The patient had crowding, three lower incisors and crossbite in the molar area. TMD was suspected because of large CO-CR discrepancies and pronounced fatigue when chewing. TMD was resolved with sprint therapy, while an open bite developed due to significant changes in condylar position. Based on the diagnosis and treatment planning from the stabilized mandibular position, orthodontic treatment was carried out successfully to obtain functional occlusion, healthy periodontium and stable results.

Age at initial visit: 14y7m
Gendar: Female
Chief complaint: Want straight teeth
Medical history: Jaw fatigue
Family history: N/A

The patient presented with a Class II malocclusion and a retrognathic mandible, along with an open bite. The jaw was difficult to manipulate during bite registration in the initial examination, and radiographs revealed condylar resorption. Splint therapy designed to stabilize the mandibular position unmasked an additional open bite, resulting in an increased open bite. It was therefore decided to combine orthodontic treatment with surgical impaction of the posterior maxilla, mandibular advancement and genioplasty. Functional occlusion, healthy periodontium and pleasing facial profile were achieved with the combined treatment.

Age at initial examination: 16y3m
Sex: Female
Chief complaint: Anterior openbite
Patient history: N/A
Family history: N/A

The patient showed facial asymmetry with mandibular deviation to the right side and a scissors bite in the left posterior area. She also had temporomandibular joiont problems. Mandibular position was stabilized with a splint for final diagnosis and treatment planning. Although a surgical option was considered, a decision was made after careful evaluation to treat the case by orthodontics alone. Occlusal improvements were made with good vertical control for closure of the facial axis, along with orthodontic tooth movement designed to correct the transverse prpblem associated with asymmtry.

Age at initial visit: 24y11m
Sex: Female
Medical history: N/A
Family history: N/A

The patient complained of protruded upper and lower front teeth and difficulty in closing the lips. Although no subjective or objective TMJ symptoms were noted, there were large CO-CR discrepancies and mild flattening of the right condyle on a tomogram. Splint therapy was performed to stabilize condylar position, resulting in an open bite. Pleasing facial profile was obtained with orthodontic treatment based on the diagnosis and treatment plan made from the stabilized jaw position.

Age at initial examination: 15y7m
Sex: Female
Chief complaint: Difficulty in closing the lips due to protruded upper and lower front teeth
Patient history: N/A
Family history: Both her elder and younger sisters had large CO-CR discrepancies.

The patient showed no TMD symptoms, but had small CO-CR discrepancies. In addition, her father had a history of TMD. Splint therapy was thus carried out to stabilize mandibular position for definitive diagnosis. A good occlusion was obtained with orthodontic treatment following the extraction of the upper first and lower second premolars. Both the maxilla and mandible showed significant amounts of vertical growth.

Age at initial visit: 11y9m
Gender: Female
Chief complaint: Anterior crowding
Medical history: N/A
Family history: The father had a history of TMD Treatment

The patient presented with unstable occlusion and dull pain in the chewing muscles. She also showed large CO-CR discrepancies, mild flattening of the left condyle and muscle tightness during jaw manipulation. Orthodontic treatment was performed based on the diagnosis and treatment plan made in the stable mandibular position achieved with splint therapy to produce a functional occlusion and a pleasing profile.

Age at initial examination: 29y3m
Sex: Female
Chief complaint: Unstable occlusion and midline shift to right
Patient history: Slight, dull pain in bilateral masseter muscles since several years ago
Family history: N/A

This case was a boy who had undergone orthodontic treatment for mandibular prognathism from age 7 to 15 with TMJ disorder (noise, locking and pain) and facial asymmetry since age 13. This case well illustrates the importance of the TMJs. Treatment performed without due consideration to TMJs, particularly in growing children, may result in severe skeletal discrepancies. Mere alignment of teeth makes no sense, a good lesson for practicing orthodontists.

The orthodontist needs to find out patient chief complaints. This patient first listed TMJ problem, followed by facial asymmetry and difficulty closing the lips due to protruded upper and lower teeth. Logical and precise treatment procedures are required to treat these problems. Highly-advanced clinical skills and knowledge are called for to satisfy all the goals for facial profile, TMJs, occlusion and periodontal tissues. Excellent results were attained.

This Angle Class I case, which appeared simple at an initial glance, turned to be a unique and quite complicated case. From a traditional orthodontic point of view, the case could be approached simply with expansion, stripping, or bicuspid extraction to align and occlude upper and lower teeth as well as achieve Class I molar relationship.

However, a careful examination and clinical records revealed that the condyles were displaced from the fossae (mandibular posturing) with significant remodeling. Mandibular position had to be checked with splint to disclose concealed problems beneath the "simplicity" in order to achieve treatment results consistent with Roth Philosophy.

Here is the lesson learned: Do not believe what you see in the mouth. Be sure to perform a careful examination to list up all possible problems and determine if the problems are related to occlusion. Make a treatment plan accordingly and then proceed with treatment efficiently towards the goals, as taught by Dr. Roth.