A European Board of Orthodontics case report. Case category: severe skeletal discrepancy.

OBJECTIVES: this 18.1 year-old girl presented with a chief complaint of progressive worsening of facial and dental esthetics, crowding, headache and facial pain.

MATERIALS AND METHODS: clinically, she was at the end of her growth and exhibited a severe facial asymmetry, but with normal sagittal and vertical cranial relationships. Clicking in the right TMJ was evident. This was accompanied by a deviation upon opening, and pain in the joint. The pain she experienced during jaw movement, and upon palpation, was significant. There was a shift to the right from centric relation to intercuspal position. Intraorally, the tissues were normal, with mild tetracycline staining, still present primary canines, impacted third molars and upper permanent canines. Her first molars had fillings. Orthodontically, her occlusion was a severe Class III subdivision left, with a severe right-side crossbite, lower midline deviation to the right 6 mm, and a 1 mm lateral shift in intercuspal position. She also exhibited severe crowding and asymmetry in both arches. The sequence of her treatment was as follows: (a) extraction of primary canines and impacted third molars, surgical exposure of impacted canines, (b) lower occlusal splint for TMJ dysfunction and an upper arch fixed appliance for ideal alignment and leveling, (c) upper occlusal splint for the maintenance of TMJ function and lower arch fixed appliance for ideal alignment and leveling, (d) surgical skeletal correction, (e) post-surgical orthodontic finishing, (f) post-treatment retention.