Journal of Orthodontics
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The William Houston Gold Medal of the Royal
College of Surgeons of Edinburgh 2009
Helen E Flint
To cite this article: Helen E Flint (2010) The William Houston Gold Medal of the Royal
College of Surgeons of Edinburgh 2009, Journal of Orthodontics, 37:4, 279-292, DOI:
10.1179/14653121043218
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Journal of Orthodontics, Vol. 37, 2010, 279–292
INVITATION The William Houston Gold Medal of
TO SUBMIT
the Royal College of Surgeons of
Edinburgh 2009
Helen E. Flint
Coffs Harbour Orthodontic Group, Australia
As part of the Membership in Orthodontics examination, candidates are required to present five treated cases. Two of the
cases treated by one of the winners of the William Houston Gold Medal from the MOrth diet of the Royal College of Surgeons
of Edinburgh in 2009 are described.
Key words: MOrth, class II division 1
Received 29th January 2010; accepted 12th June 2010
Introduction Intra-oral examination (Figure 1e–i)
The William Houston Gold Medal is awarded to the The patient was in the permanent dentition and had
candidate(s) who achieved the most outstanding perfor- good oral hygiene. There were restorations present in all
mance in the Membership in Orthodontics examination four first molars, LR5 and LR7. The restorations were
of the Royal College of Surgeons of Edinburgh. As part all clinically sound and there was no evidence of active
of the examination, the candidate must present five caries. The mandibular arch was U-shaped and moder-
personally treated cases, upon which they are verbally ately crowded, whereas the maxillary arch was V-shaped
examined. A mark is also awarded for the written and mildly crowded. The upper incisors appeared
presentation of the cases. Details of two of the treated clinically to be proclined relative to the Frankfort plane.
cases, which were jointly awarded the medal in 2009, are In occlusion, the overjet measured 12 mm, and there
presented in this paper. was a 2 mm anterior open bite, extending from UR1 to
UL2. The molar and canine relationships were a full
unit class II bilaterally. The upper and lower dental
Case report 1 centrelines were coincident with one another, and with
the midfacial axis. There was a crossbite without
A female patient presented at the age of 14 years and displacement affecting the UR5 and LR5.
0 months complaining that her top teeth ‘stuck out’ and The dental health component (DHC) of the Index of
were crooked. She had a class II division 1 malocclusion, Orthodontic Treatment Need (IOTN) was 5a, and the
on a class II skeletal base, with increased vertical aesthetic component (AC) was 8.
proportions.
Radographic examination (Figure 2a,b)
Extra-oral examination (Figure 1a–d)
The DPT demonstrated that the maxillary third molars
Extra-orally the patient was a severe class II skeletal were present; however, the mandibular third molars
base with mandibular retrusion and a convex profile. were congenitally absent. The DPT also confirmed the
She had an increased Frankfort-mandibular planes presence of restorations, as noted clinically. There were
angle, with an increased lower face height proportion. deep restorations in the lower first molars; however,
Frontal examination revealed no transverse asymmetry, there was secondary dentine formation and no evidence
and the upper dental centreline was coincident with the of periapical pathology.
midfacial axis. Soft tissue examination demonstrated The cephalometric analysis confirmed the clinical
incompetent lips and an obtuse naso-labial angle. impression of a severe class II skeletal base relationship,
Address for correspondence: Helen E. Flint, Coffs Harbour
Orthodontic Group, Coffs Harbour, NSW 2450, Australia.
Email:
[email protected]# 2010 British Orthodontic Society DOI 10.1179/14653121043218
280 Flint Invitation to Submit JO December 2010
Figure 1 (a–i) Case 1. Pre-treatment extra- and intra-oral photographs
Figure 2 (a,b) Case 1. Pre-treatment radiographs
JO December 2010 Invitation to Submit William Houston Gold Medal 281
Figure 3 (a–c) Case 1. Upper and lower MBT pre-adjusted edgewise appliances with 0.014-inch nickel titanium archwires
with an ANB difference of 8u (Table 1). The maxillary– 6. crossbite without displacement affecting UR5 and
mandibular planes angle was increased at 40u and the LR5;
lower face height proportion was also increased at 60%. 7. bilateral class II molar relationship.
The upper incisors were found to be proclined at 122u,
while the lower incisors were at an inclination of 86u.
This indicated that the lower incisors were 6u proclined Aims and objectives
for the maxillary–mandibular planes angle.
1. maintenance of good oral hygiene;
Problem list 2. relief of crowding;
3. reduce overjet;
1. class II skeletal discrepancy, with mandibular 4. increase overbite;
retrusion; 5. correction of the crossbite involving UR5 and LR5;
6. finish to class I incisor, canine and molar relation-
2. increased vertical skeletal proportions;
ships within a stable soft tissue environment,
3. increased overjet;
maintaining the lower incisors in their pre-treat-
4. anterior open bite;
ment position.
5. upper and lower arch crowding;
Table 1 Case 1. Pre-treatment cephalometric analysis. Treatment plan
Variable Pre-treatment Normal 1. fit high pull headgear to bands on the upper first
SNA (u) 81 82 (SD 3)
molars for vertical and antero-posterior anchorage
SNB (u) 73* 79 (SD 3) control. The headgear was to be worn for 12 hours
ANB (u) 8* 3 (SD 1) per day, with a force of 400 g per side;
SN to maxillary plane (u) 7 8 (SD 3) 2. assess compliance with headgear wear;
Wits appraisal (mm) z5* 0 3. extraction of maxillary first premolars and man-
Upper incisor to maxillary 122* 108 (SD 5) dibular second premolars;
plane angle (u) 4. fit upper and lower pre-adjusted edgewise appli-
Lower incisor to mandibular 86* 92 (SD 5)
ances with MBT prescription;
plane angle (u)
5. retention using upper and lower vacuum formed
Interincisal angle (u) 114* 133 (SD 10)
Maxillo-mandibular planes angle (u) 40* 27 (SD 5)
retainers.
Upper anterior face height (mm) 51
Lower anterior face height (mm) 75
Treatment progression (Figures 3–7)
Face height ratio (%) 60* 55
Lower incisor to APo line (mm) 21* 0–2 Compliance with high pull headgear wear was excellent,
Lower lip to Ricketts E Plane (mm) 0* 22
and after 3 months of wear, the molar relationship had
Naso-labial angle (u) 102 95 (SD 10)
improved to a K unit class II bilaterally. At this stage
Jarabak ratio (%) 56* 62 (SD 3)
Bjork’s polygon (u) 407* 396 (SD 4)
the extractions were carried out and upper and lower
MBT prescription fixed appliances were bonded. The
*Denotes values greater than 1 standard deviation from the average headgear continued to be worn to provide antero-
Caucasian values. posterior and vertical anchorage control. Lacebacks
282 Flint Invitation to Submit JO December 2010
Figure 4 (a–c) Case 1. Upper and lower 0.01960.025-inch stainless steel archwires and 9 mm nickel titanium coil springs for space
closure
were placed in all four quadrants, and 0.014-inch nickel
titanium archwires were placed to commence aligning
and levelling (Figure 3).
After 7 months of treatment, customized co-ordinated
0.01960.025-inch stainless steel archwires were placed
and space closure was commenced using 9 mm nickel
titanium coil springs (Figure 4). At this stage, the
headgear was discontinued, and anchorage was rein-
forced using class II elastics. It was hoped that the
inclination of the lower incisors would be maintained by
the counteraction of the tendency for these teeth to
upright during space closure by the proclining effect of
the class II elastics. If any significant change to their pre-
treatment inclination were to be identified on the pre-
finish lateral cephalogram this would be dealt with by
Figure 5 Case 1. Pre-finish lateral cephalogram
Figure 6 (a–c) Case 1. Second molars bonded and upper and lower 0.01960.025-inch stainless steel archwires with 7u labial crown torque
to the upper incisors
Figure 7 (a–c) Case 1. Finishing and detailing with upper 0.09160.025-inch TMA and lower 0.01960.025-inch braided stainless steel
archwires, with class II box elastics
JO December 2010 Invitation to Submit William Houston Gold Medal 283
application of appropriate torque to the archwire during discrepancy was severe, the incisor relationship could be
finishing and detailing. corrected by uprighting and bodily retraction of the
Once space closure was completed, a pre-finish lateral upper incisors. Functional appliance treatment was not
cephalogram was taken and analyzed (Figure 5 and considered to be appropriate in this patient in view of
Table 2). This demonstrated that the lower incisor her age and the increased vertical skeletal relationship.
inclination had been maintained at 85u; however, the Extractions were considered to be necessary in both
upper incisors had been uprighted considerably to 97u. the upper and lower arches. Mandibular extractions
The second molars were bonded and aligned, and then a were required to relieve the moderate crowding in the
0.01960.025-inch stainless steel archwire with 7u labial lower arch, without further proclining the lower
crown torque in the upper incisor region was placed in incisors. This would have further reduced the overbite,
order to correct their inclination (Figure 6). Following and potentially moved the lower incisors into an
5 months of torque expression, the upper incisors were unstable position. The lower second premolars were
at a more appropriate inclination. Finishing and chosen as these would provide sufficient space to relieve
detailing of the occlusion was then undertaken utilizing the crowding, and also provide appropriate anchorage
a 0.01960.025-inch braided stainless steel archwire in balance to reduce the likelihood of retraction of the
the mandibular arch, while maintaining a 0.01960.025- lower labial segment during space closure. In the
inch titanium molybdenum alloy archwire in the maxillary arch, extractions were required to relieve
maxillary arch. Box elastics with a class II vector were the crowding and allow overjet reduction. The upper
used for vertical settling (Figure 7). After 25 months of first premolars were chosen to provide the most effective
active treatment the appliances were debonded and means of allowing retraction of the canines to a class I
upper and lower vacuum formed retainers were fitted. relationship.
High pull headgear was also required in order to
Case 1 assessment (Figure 8) reinforce antero-posterior and vertical anchorage. The
canines were in a bilateral class II relationship, therefore
Case 1 presented with a severe class II skeletal retraction to class I required significant posterior
discrepancy with increased vertical proportions. The anchorage reinforcement. The high pull vector was
upper incisors were significantly proclined, while the chosen in order to reduce extrusion of the upper first
lower incisors were slightly proclined for the maxillary– molars during treatment and so increase the chances of
mandibular planes angle. achieving a positive overbite.
An orthodontic camouflage approach was considered There were minimal skeletal effects during treatment,
appropriate, as although the antero-posterior skeletal as demonstrated by the cephalometric superimposition
Table 2 Case 1. Near end of treatment cephalometric analysis.
Variable Pre-treatment Pre-finish Change
SNA (u) 81 79 22
SNB (u) 73* 74* z1
ANB (u) 8* 5* 23
SN to maxillary plane (u) 7 10 z3
Wits appraisal (mm) z5* z3* 22
Upper incisor to maxillary plane angle (u) 122* 97* 225
Lower incisor to mandibular plane angle (u) 86* 85* 21
Interincisal angle (u) 114* 143 z29
Maxillary–mandibular planes angle (u) 40* 38* 22
Upper anterior face height (mm) 51 52 z1
Lower anterior face height (mm) 75 77 z2
Face height ratio (%) 60* 60* 0
Lower incisor to APo line (mm) 21* z1 z2
Lower lip to Ricketts E plane (mm) 0* 22 22
Naso-labial angle (u) 102 110* z8
Jarabak ratio (%) 56* 54* 22
Bjork’s polygon (u) 407* 407* 0
*Denotes values greater than 1 standard deviation from the average Caucasian values.
284 Flint Invitation to Submit JO December 2010
Figure 8 (a–i) Case 1. Post-treatment extra- and intra-oral photographs
(Figure 9). SNA decreased slightly, but this is likely to inclination. The overbite was improved by uprighting
be due to remodelling of A point following significant of the upper incisors, and also due to some limited
upper incisor movement rather than a true change in extrusion of the upper incisors as the increased curve of
skeletal base relationship. There was a 2u reduction in Spee in the maxillary arch was levelled.
the maxillary–mandibular planes angle, suggesting there Lip competence was achieved during treatment, and
may have been some restraint of posterior maxillary so stability of overjet reduction should be improved as
growth. However, this small change is unlikely to affect the soft tissue environment is more favourable. The
future stability of the occlusion. Most of the changes naso-labial angle increased slightly due to the retraction
achieved were dento-alveolar. The upper incisors were of the upper incisors. However, the facial appearance at
significantly uprighted to 97u, although the addition of the end of treatment was much improved.
labial crown torque to the upper archwire during The prognosis for the long term stability of the
finishing will have improved their inclination. The upper occlusion is reasonably good. Well interdigitated class I
incisors were also bodily retracted to reduce the overjet. buccal segments were achieved, which will aid main-
The lower incisors maintained their pre-treatment tenance of the sagittal relationship. The removal of the
JO December 2010 Invitation to Submit William Houston Gold Medal 285
present and no evidence of active caries. There was a
mesio-incisal edge fracture of the UL1 extending into
enamel only, caused by previous trauma. The UL1 was
asymptomatic and responsive to vitality testing with
ethyl chloride. The mandibular arch was u-shaped, and
there was 2 mm of crowding present. There was also an
increased curve of Spee which measured 5 mm at its
deepest point. The maxillary arch was u-shaped with
2 mm of crowding present. The upper central incisors
appeared clinically to be proclined relative to the
Frankfort plane.
In occlusion, the overjet measured 11 mm, and the
overbite was increased and complete to the palate, but
was atraumatic. The right canines were in a class II
relationship, and the right molar relationship was L
unit class II. The left canines were in a K unit class II
relationship, and the left molar relationship was also K
unit class II. The upper and lower dental centrelines
Figure 9 Case 1. Cephalometric superimposition
were coincident with each other, and with the midfacial
axis.
The IOTN DHC was 5a and the AC was 10. The
soft tissue lip trap will also aid maintenance of the clinical and radiographic findings led to the develop-
incisor relationship. Further growth may compromise ment of the following problem list:
the stability of the overbite, as it is likely to continue in a
mostly vertical direction. The patient is aware of the
need for long term retention. Radiographic examination (Figure 11a,b)
The DPT demonstrated the presence of developing
Case report 2 UR8, UL8 and LR8. The LL8 appeared to be
congenitally absent; however, the other third molars
A male patient presented at the age of 12 years and were at a very early stage of development and so it was
7 months complaining that his upper teeth ‘stuck out’. too early to be certain that the LL8 was missing. There
He had a class II division 1 malocclusion on a class II was no evidence of caries or any other pathology.
skeletal base, with average vertical proportions. The lateral cephalometric analysis showed an ANB
difference of 8u, which confirmed the clinical impression
Extra-oral examination (Figure 10a–d) of a severe class 2 skeletal base (Table 3); however, the
Extra-orally the patient was a moderate-severe class II SNA value was increased at 86u, but the Eastman
skeletal base, with mandibular retrusion and a convex correction could not be performed as the SN-Maxillary
profile. The lower anterior face height and Frankfort- planes angle was outside the normal range at 4u. The
mandibular planes angle were average. On frontal Wits analysis of z3 mm also suggested a class 2 skeletal
examination, there was no facial asymmetry, and the pattern. The maxillary–mandibular planes angle was
upper dental centreline was coincident with the mid- within normal limits at 26u, as was the lower anterior
facial axis. Soft tissue examination demonstrated face height proportion of 55%.
incompetent lips with a lip trap related to the upper The upper incisors were proclined at 120u and the
central incisors. There was a deep labio-mental fold with aetiology of this was probably related to the action of
eversion of the lower lip, and the naso-labial angle was the lower lip trap. The lower incisors were also proclined
average. at 101u and the lower incisor crown tip lay 2 mm ahead
of the APo line. The inter-incisor angle was reduced at
Intra-oral examination (Figure 10e–i) 114u, reflecting the proclination of the upper and lower
incisors. The soft tissue relationships could not be
The patient was in the permanent dentition with a below accurately interpreted from the cephalogram, as the
average standard of oral hygiene, particularly around patient had postured his lips when the radiograph was
the upper lateral incisors. There were no restorations exposed.
286 Flint Invitation to Submit JO December 2010
Figure 10 (a–i) Case 2. Pre-treatment extra- and intra-oral photographs
Figure 11 (a,b) Case 2. Pre-treatment radiographs
JO December 2010 Invitation to Submit William Houston Gold Medal 287
Figure 12 (a–c) Case 2. Twin Block functional appliance
Problem list 3. reduce overbite;
4. reduce overjet;
1. below average oral hygiene; 5. finish to class I incisor, canine and molar relation-
2. class II skeletal pattern with mandibular retrusion; ships within a stable soft tissue environment and
3. increased overjet; with competent lips.
4. increased overbite;
5. crowding;
6. incompetent lips with lip trap affecting the upper Treatment plan
central incisors; A two-stage treatment plan was developed as follows:
7. bilateral class II molar relationship.
1. oral hygiene instruction;
2. correct overjet and overbite using a modified Clark
Aims and objectives Twin Block appliance;
3. reassess requirements for phase 2 treatment;
1. improvement of oral hygiene; 4. extraction of all four second premolars;
2. relief of crowding; 5. fit upper and lower pre-adjusted edgewise appli-
ances with MBT prescription;
Table 3 Case 2. Pre-treatment cephalometric analysis. 6. retention using upper and lower vacuum formed
retainers.
Variable Pre-treatment Normal
SNA (u) 86* 82 (SD 3)
Treatment progression (Figures 12–18)
SNB (u) 78 79 (SD 3)
ANB (u) 8* 3 (SD 1) There was a good response to oral hygiene instruction,
SN to maxillary plane angle (u) 4* 8 (SD 3) and so a Twin Block functional appliance was fitted and
Wits appraisal (mm) z3* 0
worn full time for 5 months (Figure 12). After
Upper incisor to maxillary 120* 108 (SD 5)
5 months, an edge-to-edge incisor relationship was
plane angle (u)
Lower incisor to mandibular 101* 92 (SD 5)
achieved, the buccal segment relationships were over-
plane angle (u) corrected, and full records, including post-functional
Interincisal angle (u) 114* 133 (SD 10) cephalometric radiograph were taken (Figure 13).
Maxillo-mandibular planes angle (u) 26 27 (SD 5) Reassessment of the space and anchorage require-
Upper anterior face height (mm) 45 ments following the functional appliance phase of
Lower anterior face height (mm) 56 treatment necessitated an extraction approach. All four
Face height ratio (%) 55 55 second premolars were extracted in order to provide
Lower incisor to APo line (mm) z2 0–2 space for the relief of the crowding, and to allow
Lower lip to Ricketts E plane (mm) z3* 22 uprighting of the lower incisors which had been further
Naso-labial angle (u) 118* 95 (SD 10)
proclined during the functional phase of treatment.
Jarabak ratio (%) 67* 62 (SD 3)
Following the extractions, the upper and lower arches
Bjork’s polygon (u) 393 396 (SD 4)
were bonded with an MBT prescription pre-adjusted
*Denotes values greater than 1 standard deviation from the average edgewise appliance, with the exception of the lingually
Caucasian values. displaced LL2. Lacebacks were placed in all four
288 Flint Invitation to Submit JO December 2010
Figure 13 (a–g) Case 2. Post-functional appliance occlusion and lateral cephalogram
quadrants, and a ‘steep and deep’ inclined bite plane was After 6 months of fixed appliance treatment, upper
fitted for evenings and night time wear to maintain the and lower 0.01960.025-inch customized and co-ordi-
class II correction. Alignment and levelling was com- nated stainless steel archwires were placed. At this stage,
menced with the placement of 0.014-inch nickel titanium the ‘steep and deep’ inclined bite plane was discon-
archwires (Figure 14). tinued, and class II elastics were commenced full time.
Space was created for the lingually displaced LL2 After four weeks, elastomeric tie-backs were placed in
using a push coil on a 0.018-inch stainless steel archwire. all four quadrants to commence space closure, and class
Once there was adequate space, the LL2 was bonded, II elastics were continued on a night time only basis
and aligned using a 0.014-inch nickel titanium auxiliary (Figure 16).
archwire, with a 0.018-inch stainless steel base archwire Once space closure was completed, a pre-finish lateral
(Figure 15). cephalogram was taken and analyzed (Figure 17 and
JO December 2010 Invitation to Submit William Houston Gold Medal 289
Figure 14 (a–c) Case 2. Upper and lower MBT pre-adjusted edgewise appliances with 0.014-inch nickel titanium archwires and ‘steep and
deep’ inclined bite plane
Figure 15 (a–c) Case 2. Bracket bonded LL2 and 0.014 nickel titanium auxiliary archwire
Figure 16 (a–c) Case 2. Upper and lower customized co-ordinated 0.01960.025-inch stainless steel archwires with elastomeric tiebacks in
all four quadrants
Table 2). This demonstrated that the incisors were at
acceptable inclinations. The second molars were bonded,
and bracket repositioning was undertaken as necessary,
and 0.01860.025-inch neo sentalloy archwires were
placed. Finishing and detailing was then carried out
using a lower 0.01960.025-inch braided stainless steel
archwire, an upper 0.01960.025-inch stainless steel
archwire, and class II box elastics (Figure 18). After
24 months of active treatment, the appliances were
debonded, and the incisal edge of UL1 was restored.
Upper and lower vacuum formed retainers were pro-
vided, to be worn on a night time only basis (Figure 19).
Case 2 assessment (Figure 19)
Case 2 presented with a moderate-severe class II skeletal
base discrepancy, with average vertical proportions. The
Figure 17 Case 2. Pre-finish lateral cephalogram upper incisors were proclined, probably due to the
290 Flint Invitation to Submit JO December 2010
Figure 18 (a–c) Case 2. Finishing and detailing with upper 0.01960.025-inch stainless steel and lower 0.01960.025-inch braided stainless
steel archwires, and class II box elastics
action of the lower lip trap. The lower incisors were also Functional appliance treatment was felt to be appro-
proclined, in an attempt to compensate for the under- priate in this case as the patient was likely to be
lying skeletal base discrepancy. approaching a period of rapid growth. The functional
Figure 19 (a–i) Case 2. Post-treatment extra- and intra-oral photographs
JO December 2010 Invitation to Submit William Houston Gold Medal 291
appliance would therefore allow dentoalveolar tipping
movements to correct the class II occlusion, with the
possibility of some enhancement of mandibular forward
growth. Early correction of the incisor, canine and
molar relationships simplified anchorage requirements
during the fixed appliance phase of treatment, by
creating a class I occlusion with crowding.
During the functional appliance phase of treatment,
the ANB difference decreased by 2u due to an increase in
the value of SNB (Table 4). This suggests that some
forward mandibular growth took place during this
phase of treatment. The main changes during the
functional appliance phase of treatment were dentoal-
veolar. The upper incisors were retroclined by 8u and the
lower incisors were proclined by 6u.
Following the functional appliance phase of treat-
ment, extractions were required to allow alignment of
the upper and lower arches and also to upright the lower
incisors following their proclination by the functional Figure 20 Case 2. Cephalometric superimposition
appliance. Upper and lower second premolars were
selected for extraction, as these provided adequate
space for alignment of the teeth, without compromising of the alveolus following tooth movement. There was no
anchorage balance during space closure. significant change in the vertical relationships.
Overall, there was a reduction in ANB difference of 5u, Both the upper and lower incisors were corrected to
as demonstrated by cephalometric superimposition more normal inclinations. The majority of the change in
(Figure 20). This was due to an increase in SNB of 3u and the inclination of the upper incisors occurred during the
a decrease in SNA of 2u. These changes are likely to be due functional appliance treatment, whereas, the lower
to a combination of favourable growth and remodelling incisors were uprighted using the fixed appliances. Lip
Table 4 Case 2. Near end of treatment cephalometric analysis.
Variable Pre-treatment Post-functional Pre-finish Change
SNA (u) 86* 86* 84 22
SNB (u) 78 80 81* z3
ANB (u) 8* 6* 3 25
SN max. (u) 4* 6 5 z1
Wits appraisal (mm) z3* 0 21 24
Upper incisor to maxillary plane angle (u) 120* 112 107 213
Lower incisor to mandibular plane angle (u) 101* 107* 91 210
Interincisal angle (u) 114* 118* 140 z26
Maxillary–mandibular planes angle (u) 26 25 25 21
Upper anterior face height (mm) 45 48 45 0
Lower anterior face height (mm) 56 60 62 z6
Face height ratio (%) 55 56 58 z3
Lower incisor to APo line (mm) z2 z5* z2 0
Lower lip to Ricketts E plane (mm) z3* 0 22 25
Naso-labial angle (u) 118* 107* 105 213
Jarabak ratio (%) 67* 68* 70* z3
Bjork’s polygon (u) 393 389* 387* 26
*Denotes values greater than 1 standard deviation from the average Caucasian values.
292 Flint Invitation to Submit JO December 2010
competence, and removal of the lower lip trap, was as instructed. The upper incisors have been brought
achieved with the functional appliance. Correction of within the control of the lower lip, creating a favourable
the lip trap also allowed unfurling of the lower lip and a soft tissue environment for maintenance of the class I
general improvement in the facial appearance. occlusion. Any further growth is likely to be favourable
The prognosis for the long term stability of the for continued correction of the skeletal relationship
occlusion is good, provided that the retainers are worn towards class I.
