## 2 Case Presentation
### Treatment Alternatives  
The patient had an AOB and inadequate incisor display upon smiling with the compromised periodontitis at the maxillary incisors. The patient needed improvement in the bimaxillary dental proclination, lower incisor protrusion and subsequent lower lip protrusion, along with cessation of the tongue thrusting habit. Therefore, to achieve these treatment goals, the preferred primary treatment options were to reposition the tongue more posteriorly and consider extraction of the mandibular first premolars and, based on the diagnostic set-up, decide on either of the following:  
1. Extraction of U1s and substituting U1s with maxillary lateral incisors (U2s), U2s with maxillary amines (U3s) and U3s with maxillary first premolars (U4s), with future cosmetic restorations and periodontal treatment of the maxillary anterior teeth as needed.
2. Extraction of U4s and U1s (with forced extrusion of U1s during treatment) where U1s would be replaced with pontics during treatment, if they became significantly mobile, and with final prosthetic restorations (with or without implants) after treatment.  
Such options require continuous multidisciplinary collaboration before, during and after treatment to maintain periodontal condition and restore the missing maxillary incisors with pontics and an implant-supported prosthesis or a Maryland bridge. More importantly, it requires the patient's consent to receive extraction and financial ability to afford prosthodontic treatment. This option (with its subsequent scenarios) was discussed in detail with the patient with direct input from a periodontitis and prosthodontist, but the patient refused such scenarios due to financial and psychological constraints. A non-orthodontic treatment was also presented, but the patient declined this option.  
To achieve what was mentioned under the treatment objectives section, the selected treatment option was comprehensive nonsurgical non-extraction treatment with inter-proximal reduction using fixed metal appliances, miniscrews, a transpalatal arch (TPA)  
\begin{table}
\begin{tabular}{c c c c} \hline
**Measurement** & **A (Initial)** & **B (Final)** & **Difference (A-B)** \\ \hline SNA\({}^{\circ}\) & 89.6 & 89.3 & 0.3 \\ \hline SNB\({}^{\circ}\) & 84.7 & 84.6 & 0.1 \\ \hline ANB\({}^{\circ}\) & 4.9 & 4.7 & 0.2 \\ \hline SN-MP\({}^{\circ}\) & 38.7 & 37.5 & 1.2 \\ \hline FMA\({}^{\circ}\) & 26.3 & 25.3 & 1.0 \\ \hline UI TO NA mm & 6.8 & 5.7 & 1.1 \\ \hline UI TO SN\({}^{\circ}\) & 119.6 & 115.1 & 4.5 \\ \hline LI TO NB mm & 11.0 & 10.5 & 0.5 \\ \hline LI TO MP\({}^{\circ}\) & 97.8 & 96.0 & 1.8 \\ \hline U Lip to E-Line & \(-1.3\) & \(-1.3\) & 0.0 \\ \hline L Lip to E-Line & 2.7 & 2.5 & 0.2 \\ \hline SNA, sella-nasion–A point; SNB, sella-nasion–B point; ANB, A point-nasion–B point; SN-MB, sella–nasion–mandibular plane; FMA; Frankfort–mandibular plane angle; UI, upper incisor; SN, sella–nasion; NA, nasion–A point; NB, nasion–B point; L1, lower incisor; U, upper; L, lower. \\ \end{tabular}
\end{table}
Table 1: Cephalometric measurements before and after treatment.  
and a lower lingual holding arch (LLHA) with soldered lingual spurs. Such an approach was expected to achieve the following: (1) reposition the tongue more posteriorly, (2) intrude the maxillary posterior teeth and relatively extrude the maxillary anterior teeth and (3) maintain the vertical position of mandibular posterior teeth. The treatment was planned for segmental leveling and alignment of the maxillary arch, continuous leveling and alignment and interproximal reduction at the mandibular arch and the use of inter-arch elastics. This patient-centered option was chosen considering several factors, including the patient's strong desire not to lose a single tooth for as long as possible, compromised periodonium and financial constraints. Before commencing treatment, she fully understood that this option is a camouflage treatment and better (including long-term) esthetic and functional results could be obtained through the previously mentioned options.