# Nonextraction Orthodontic Treatment of Severely
## 2 Case Presentation
### Treatment Alternatives  
Several key clinical factors had to be considered before the most viable treatment alternative could be considered [19; 20]. The large maxillary arch length deficiency and the deeply impacted right canine could increase the treatment time and complicate the application of biomechanics. Additionally, the presence of the initial mandibular asymmetry and edge-to-edge bite combined with a skeletal Class III growth pattern would make it difficult to predict the future impact of her pubertal growth spurt that was expected to occur during the active treatment phase. The first treatment option was to extract the patient's four first premolars. The extraction space could be utilized to align the impacted canines, correct the dental midlines, establish Class I molar and canine relationships, and correct the overjet and overbite. The second alternative was to extract only the maxillary first premolars. With this more conservative approach, the goal was to distalize the posterior segment of the mandibular arch rather than to take advantage of the premolar extraction space. The third alternative plan was somewhat unconventional. It was similar to the second option but dissimilar in that the impacted maxillary right canine was to be extracted, while the adjacent first premolars would remain substitutes for the missing canine. The fourth treatment alternative did not involve permanent tooth extractions, as space for the impacted canine would be created through the distalization of the maxillary posterior teeth. Also, the impacted maxillary right canine would be surgically transplanted into the desired position within the arch. In addition, this approach would divide the active treatment into two phases. The goal of the first phase was to gain space in the maxillary arch, align the impacted canines, and monitor the mandibular growth during the patient's pubertal growth spurt before the second phase. The second phase aimed at retracting the mandibular arch to reach the post-treatment occlusion with improved overbite and overjet \begin{table}
\begin{tabular}{l l l l l l} \hline \hline  & **Norms** & \begin{tabular}{l} **1 st Phase** \\ **Pretreatment** \\ \end{tabular} & \begin{tabular}{l} **1 st Phase** \\ **Post-Treatment** \\ \end{tabular} & \
\begin{tabular}{l} **2 nd Phase** \\ **Pretreatment** \\ \end{tabular} &
\begin{tabular}{l} **2 nd Phase** \\ **Post-Treatment** \\ \end{tabular} \\ \hline \multicolumn{5}{l}{_Dental analysis_} \\ \hline U1-NA (mm) & \(3.9\pm 2.1\) & \(2.7\) & \(4.8\) & \(4.9\) & \(4.7\) \\ \hline U1-NA (\({}^{\circ}\)) & \(24.0\pm 4.0\) & \(23.5\) & \(26.4\) & \(27.9\) & \(25.6\) \\ \hline U1-SN (\({}^{\circ}\)) & \(108.2\pm 5.4\) & \(107.1\) & \(109.4\) & \(109.0\) & \(107.1\) \\ \hline L1-NB (mm) & \(6.6\pm 2.8\) & \(6.1\) & \(7.1\) & \(6.8\) & \(5.8\) \\ \hline L1-NB (\({}^{\circ}\)) & \(25.0\pm 5.0\) & \(25.7\) & \(27.8\) & \(28.7\) & \(22.0\) \\ \hline L1-MP (\({}^{\circ}\)) & \(96.8\pm 6.4\) & \(78.1\) & \(82.3\) & \(84.3\) & \(77.8\) \\ \hline U1-L1 (\({}^{\circ}\)) & \(124.2\pm 8.0\) & \(128.9\) & \(124.1\) & \(121.5\) & \(129.7\) \\ \hline \multicolumn{5}{l}{_Facial analysis_} \\ \hline E-line/UL (mm) & \(-1.1\pm 2.2\) & \(0.4\) & \(0.8\) & \(-0.4\) & \(-0.4\) \\ \hline E-line/LL (mm) & \(0.5\pm 2.5\) & \(5.1\) & \(6.0\) & \(6.1\) & \(5.2\) \\ \hline \end{tabular}
\end{table} 
Table 1: _Cont._in a Class I molar-canine relationship. Table 2 summarizes the pros and cons of the four treatment alternatives. Of the available treatment alternatives, our patient selected the fourth one. The first option was rejected due to the required extraction of four healthy permanent premolars. We advised against the second option due to the severity of the maxillary right canine impaction, making establishing proper alignment difficult, even with premolar extraction.