A 20-year-old female was referred to the Orthodontics Department of the School of Dentistry, National University of San Marcos. Her chief complaint was the anterior crossbite, crowded teeth, and a large jaw. She presented a good general state of health and no history of systemic disease. The extraoral frontal examination revealed a mesofacial aspect, a lower prognathic third, and a symmetrical face. The smile showed adequate gingival exposure with upper dental crowding. In the lateral view, a total and concave lower third profile was observed, an apparent lack of development in the sub nasal region, and a protruding lower lip. Intraorally, she had a class III molar and canine relationship, with a negative overjet and overbite of -1 mm and -3 mm, respectively. The space deficiency of the upper arch was -3 mm and -6 mm in the lower arch. The lower midline was 0.5 mm shifted to the left. In the lower arch, the incisors showed a severe lingual inclination and the premolars and molars showed an increased mesial inclination (Figures 1 and 2). No symptoms of temporomandibular joint dysfunction were detected during jaw function and palpation.
The panoramic X-ray (Figure 3) revealed the presence of the four third molars, and endodontic treatment on the upper right central incisor (11) and the left upper pre-molar (25), with no presence of caries. It was identified the presence of a supernumerary tooth between the left lower canine and the first premolar (33 and 34). The condyles were morphologically asymmetrical. The cephalometric analysis revealed a slight maxillary retrusion (SNA: 79 ) and mandible protrusion (SNB: 82 ), resulting in a skeletal class III (ANB: -3 ; Wits: -11 mm). Facial growth was hypodivergent (FMA: 20.50) and the occlusal plane showed clockwise rotation (Occlusal-SN plane: 22.5 ) indicating a deficiency in maxillary posterior vertical dimension.
Cephalometric radiography also showed an increased distal angulation of the maxillary molars and upper and lower incisors retroinclined (1-NA: 15  and 1-NB: 17 ) (Figure 3, Table 1).
The overall goals of the treatment plan were to achieve a good skeletal relationship, improve the profile, and establish a stable occlusion. The specific objectives were (1) to correct the sagittal skeletal relationship, (2) promote a counterclockwise rotation of the occlusal plane to incorporate the correct vertical dimension of the maxilla, (3) achieve a clockwise rotation of the jaw to improve facial profile, (4) establish a correct overbite and overjet, (5) establish a class I molar and canine relationship, (6) to eliminate the negative tooth discrepancy, (7) correct the deviation of the lower midline, (8) extraction of the supernumerary tooth, and (9) improve the smile.
Initially, an orthosurgical treatment was presented for the patient. This would consist of a maxillary Lefort I advancement and a ramus sagittal osteotomy to achieve mandibular clockwise rotation and setback. Due to economic constrains and fear, the surgery was rejected. Therefore, an orthodontic camouflage was considered as an alternative, based on five biomechanics options: (1) teeth extractions (lower first premolars and upper second premolars); (2) intermaxillary Class III elastics; (3) miniplates; (4) extraalveolar miniscrews; and (5) Multiloop Edgewise Archwire (MEAW) technique.
The patient has not accepted extractions apart from third molars nor the use of skeletal anchorage. Thus, the MEAW technique was the chosen option as the occlusal plane could be rigorous controlled. The patient was aware of the need for collaboration regarding the use of intermaxillary elastics and of the need of third molars extractions.
Treatment began with third molar extractions to facilitate distal movements of the upper and lower second and first molars. A cone-beam computed tomography (CBCT) scan was performed to assess the area of the supranumerary tooth; an initial segmentation of the compromised teeth was performed and showed no contact or damages to the adjacent teeth (Figures 4 and 5). The distances between the teeth measured in the tomography were in a range from 0.55 to 1.30 mm. Extraction of the supernumerary tooth was requested but the patient refused the proposal due to unsuccessful previous extraction attempting procedure. Therefore, it was decided to keep the supernumerary tooth as long as annual controlling exams were performed. Full-fixed appliance was placed in both dental arches (0.022 x 0.028-inch slot, 3 M Unitek). First and second molars were banded with prescription tubes MBT 0.022 x 0.028-inch slot (3 M Unitek). Treatment with MEAW arches was divided into five phases, as proposed by Kim and Sato: (1) Alignment and Leveling, where the 0.016-inch, 0.018-inch, and 0.016" x 0.022-inch slot Nickel-Titanium (NiTi) (Unitek-3 M) arches were installed. Short intermaxillary 3/16 in elastic, 2.5 oz of upper canine to lower canine was placed to avoid excessive buccal inclination of the lower incisors. The objectives were to correct rotations, coordinate the upper and lower arches, and facilitate the insertion of the MEAW arch (Figure 6(a)); (2) Elimination of Interferences, which was initially performed by installing an upper MOAW (Modified Offset Arch Wire) arch, made with 0.016 x 0.0022-inch blue elgiloy (RMO) wire. It was used to produce intrusion and buccal inclination of the upper incisors facilitating the crossbite correction (Figure 6(b)). To eliminate dental interference from the posterior segments, upper and lower MEAW arches with 0.016 x 0.022-inch blue elgiloy (RMO) wires were installed. Step-up bends for the upper and lower molars associated with tip-back bends for molar and lower premolar verticalization and class III (3/16-in, 6.5 oz) intermaxillary elastics were incorporated. (Figure 6(c)); (3) Mandibular displacement, with downward and backward rotation, helped achieving an adequate molar and canine Class I relationship, as well as correcting the overbite and overjet (Figure 6(c)); (4) Reconstruction of the Occlusal Plane, modification of the posterior occlusal plane by incorporating a step down of the upper molars and a tip-back of the lower molars. In this phase, the occlusal plane was rotated (counterclockwise) increasing the vertical dimension of the maxilla (Figure 6(d) and 7(b)); and (5) Obtaining a Physiological Occlusion, with the use of a 0.020-inch stainless steel (SS) continuous arch and class III intermaxillary elastics, to achieve a good intercuspation (Figure 6(e)).
After 15 months of MEAW mechanics, the treatment continued with a 0.020-inch and 0.018 x 0.025-inch rectangular stainless steel arches and Class III elastics (3/16 in, 4.5 oz) to extrude the upper molars and continue increasing the posterior occlusal dimension. Treatment was completed within 24 months. A Hawley removable appliance associated to bonded canine to canine lower lingual wire were used as retainers (0.7 mm SS), supervised from 3 to 3 months.
The final registries showed that the majority of treatment targets were accomplished. Extraoral photographs indicated significant improvement of the facial profile and lip position. The lack of development in the subnasal region, and the protrusion of the lower lip were camouflaged. The smile became more aesthetic, and the patient reported great satisfaction with the results. Intraorally, the anterior crossbite was corrected, a Class I Canine and a Class III molar functional relationship was achieved, with adequate overjet and overbite. The dental arches were aligned and leveled and the upper and lower dental midlines were coincident (Figure 8). Panoramic X-ray showed a verticalization of the upper and lower molars and premolars, with acceptable parallelism and no signs of significant bone or root resorption (Figure 9). In order to reevaluate the position of the remaining, a CBCT was required and the area segmented using ITK-SNAP 3.8 (USA) (Figure 10). There was no contact nor damages between the extra tooth and neighbouring teeth. Final Cephalometric radiography:taken immediately before appliance removal:(Figure 9, Table 1) revealed an improved skeletal relationship (ANB: 1 , SNA: 81.5 , SNB: 80.5 , Wits: -5 mm). Regarding the dentoalveolar changes, it is possible to observe the protrusion of the upper and lower incisors (1-NA: 34 , 1-NB: 23  and IMPA: 83 ) and a decrease in the inclination of the occlusal plane (Occ. Plane-SN: 14 ), which reflected an increase in the vertical dimension of the maxilla (Figure 7). Cephalometric superposition revealed the improvement of the facial profile with a slight increase in facial height (as shown in Table 1: FMA: 23 ).
The upper and lower molars were uprighted and the upper extruded as well resulting in an anticlockwise rotation of the occlusal plane (OccPlane-SN: 14 ). The vestibuloversion of the upper and lowers incisors can be observed (Figure 11). Three-dimensional (3D) superposition of the jaws was performed using Geomagic Qualify 2013 (USA), highlighting the extrusion of the upper molars and the vestibuloversion of the upper incisors (Figure 12). In the 3D superposition of the mandible, no extrusion of the lower molars and mild vestibuloversion of the lower incisors was observed (Figure 13).
After three years of posttreatment, the position of the lips was maintained and profile remained straight. The patient underwent nasal plastic surgery, with a significant improvement of the facial profile. Functional molar Class III and canine Class I were maintained, although the patient lost the lower retention after24 months of control. A slight relapse was observed in the lower incisors; however, an occlusion with acceptable stability was observed (Figure 14).