CASE REPORT

Orthodontic correction of severe Class II

malocclusion in a patient with
Prader-Willi syndrome
Yoshihito Ishihara,a Yasuyo Sugawara,a Ei Ei Hsu Hlaing,b Miho Nasu,b Tomoki Kataoka,b Naoya Odagaki,b
Teruko Takano-Yamamoto,c Takashi Yamashiro,d and Hiroshi Kamiokab
Okayama, Sendai, and Suita, Japan

Prader-Willi syndrome (PWS) is a complex disorder that affects multiple systems and may cause craniofacial
and dentofacial abnormalities. However, there is still a lack of evidence in the literature regarding the progress
of orthodontic treatment in patients with PWS. This case report describes the successful orthodontic treatment of
a patient with PWS. A girl, 9 years 0 months of age, who had been diagnosed with PWS had protruding maxillary
incisors and a convex profile. Her malocclusion was due to the posteriorly positioned mandible. Screening tests
for sleep apnea syndrome showed that she had sleep-disordered breathing, including obstructive sleep apnea
and bruxism. We also observed an excessive overjet of 10.0 mm, a deep overbite of 6.8 mm, and the congenital
absence of the mandibular second premolars. The patient was diagnosed with an Angle Class II malocclusion
and a skeletal Class II jaw-base relationship with a deep overbite. Functional appliance therapy with mandibular
advancement, which can enlarge the upper airway and increase the upper airspace, was performed to prevent
further deterioration of the patient's obstructive sleep apnea. An acceptable occlusion with a proper facial profile
and functional excursion were achieved without interference after comprehensive 2-stage treatment that incor-
porated orthodontic therapy for the patient's excessive overjet and deep overbite. The resulting occlusion was
stable, and the occlusal force and the contact area gradually increased over a 2-year retention period. These
results suggest that orthodontic treatment offers the opportunity to greatly improve the health and quality of
life of people with PWS. (Am J Orthod Dentofacial Orthop 2018;154:718-32)

P
rader-Willi syndrome (PWS; OMIM 176270) is a by the syndrome.2 In Japan, the estimated prevalence
complex genetic disorder that arises from pater- rate has been reported to be in this range.3,4 Most
nally inherited imprinted genes on the chromo- persons with PWS have neonatal and infantile
some 15q11-q13 region.1 It develops when the hypotonia, obesity, hypogonadism, childhood-onset hy-
paternal alleles are defective, missing, or silenced. The perphagia, a high pain threshold, small hands and feet,
prevalence of PWS is 1 in 10,000 to 30,000 live births, and learning and behavioral problems.1,2 With regard
and 350,000 to 400,000 people in the world are affected to the craniofacial features, PWS is characterized by
short stature—associated with growth hormone
a
(GH) deficiency—almond-shaped eyes with upslanted
Department of Orthodontics, Okayama University Hospital, Okayama, Japan.
b
Department of Orthodontics, Graduate School of Medicine, Dentistry and Phar-
palpebral fissures, bitemporal narrowing, and
maceutical Sciences, Okayama University, Okayama, Japan. strabismus.5 Sleep abnormalities, including narcolepsy
c
Division of Orthodontics and Dentofacial Orthopedics, Graduate School of and cataplexy, are also common features of PWS that
Dentistry, Tohoku University, Sendai, Japan.
d
Department of Orthodontics and Dentofacial Orthopedics, Graduate School of
may be related to narrowing of the upper airway.6
Dentistry, Osaka University, Suita, Japan. Thus, there is a high prevalence of obstructive sleep ap-
All authors have completed and submitted the ICMJE Form for Disclosure of Po- nea (OSA) among PWS patients.7-9 The oral
tential Conflicts of Interest, and none were reported.
Supported in part by Grants-in-Aid for Scientific Research (16K11787) from the
manifestations of PWS have been reported to include
Japan Society for the Promotion of Science. soft tooth enamel, thick saliva, high caries activity,
Address correspondence to: Hiroshi Kamioka, Department of Orthodontics, periodontal disease, and extreme tooth wear caused by
Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical
Sciences, 2-5-1 Shikata-Cho, Kita-ku, Okayama 700-8525, Japan; e-mail,
clenching and bruxism.10
kamioka@md.okayama-u.ac.jp. These features indicate that special precautions should
Submitted, December 2016; revised and accepted, May 2017. be taken when orthodontists treat patients with PWS;
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved.
however, there is still little information in the literature
https://doi.org/10.1016/j.ajodo.2017.05.040 regarding the progress of orthodontic treatment in these
718
Ishihara et al 719

Fig 1. Pretreatment records: A, facial photographs; B, intraoral photographs; C, lateral cephalogram;

D, panoramic radiograph.

patients. We report the successful orthodontic treatment mandibular second premolars. This case provides further
of a patient with PWS who had a skeletal Class II malocclu- evidence of the benefits of orthodontic treatment in pa-
sion with a deep overbite and congenitally missing tients with PWS and highlights some functional insights.

American Journal of Orthodontics and Dentofacial Orthopedics November 2018  Vol 154  Issue 5
720
Fig 2. Pretreatment dental casts.
DIAGNOSIS AND ETIOLOGY
A girl, 9 years 0 months of age, visited the outpatient
dental clinic of Okayama University Hospital in
Okayama, Japan, with chief complaints of protruding
maxillary incisors and a convex profile (Figs 1 and 2).
She had been clinically diagnosed with PWS by a pedia-
trician. The characteristic facial features of PWS, short
stature, small hands and feet, and hyperphagia were
observed (Figs 1 and 3).11 She had circumoral muscula-
ture strain on lip closure. Her facial photographs showed
a symmetrical face, a convex profile, an acute nasolabial
angle, and protruded and incompetent lips. An excessive
overjet of 10.0 mm with Angle Class II molar relation-
ships on both sides and a deep overbite of 6.8 mm
were observed. The canine relationship was also Class
II, whereas the incisor relationship was Class II Division
1. The maxillary dental midline almost coincided with
the facial midline; however, the mandibular dental
midline was shifted 3.0 mm toward the left. A dental
panoramic tomogram confirmed the absence of the
mandibular second premolars and showed no pathologic
problems in the root structure or the periodontal condi-
tion (Fig 1, D). The patient showed no significant symp-
toms of temporomandibular disorder. The interincisal
distance on maximal opening without pain was
39 mm. The occlusal force and the occlusal contact
area were calculated to be 564 N and 9.8 mm2, respec-
tively, using an occlusal-force recording system (Dental
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Ishihara et al
Prescale & Occluzer; Fujifilm, Tokyo, Japan) (Table I).
A screening sleep study with a polysomnography
recorder (Apnomonitor III; Chest M.I., Tokyo, Japan)
confirmed the airway collapse with decreased oxygen
level and habitual snoring, with arousal from sleep
indicating obstructive sleep apnea (OSA). The
apnea-hypopnea index is used to evaluate the severity
of OSA, and an apnea-hypopnea index score of more
than 5 events per hour of sleep is considered to be
diagnostic of OSA. According to the American Academy
of Sleep Medicine, it is categorized as mild (5-15 events),
moderate (15-30 events), or severe (.30 events). The
patient's apnea-hypopnea index score was 9.3 events
per hour, classified as mild OSA.
Compared with Japanese norms, the patient's cepha-
lometric analysis showed a skeletal Class II jaw relation-
ship due to the relatively posterior position of the
mandible (ANB, 9.2 ; SNA, 76.9 ; SNB, 67.7 ) and a
steep mandibular plane angle (FMA, 34.5 ) (Fig 1, C;
Table II).12 The maxillofacial features included reduction
of the maxilla, the ramus of the mandible, the mandib-
ular body, and the anterior and posterior facial heights.
The maxillary and mandibular incisor angles were within
the normal ranges (103.3 and 99.8 , respectively). The
patient's lower facial height ratio was slightly small
(N-Me, 118.4 mm; Me/PP, 60.2 mm), and the upper
and lower lips protruded against the esthetic E-line (up-
per, 5.0 mm; lower, 5.0 mm). An optoelectronic
Ishihara et al 721

Fig 3. Characteristic features of PWS in our patient included A-C, small hands and feet, and D and E,
longitudinal changes in height and body weight. Bar: 50 mm.

Table I. Longitudinal change in occlusal function during orthodontic treatment

Postretention Postretention Postretention Postretention
Pretreatment Pre-edgewise Posttreatment (1 mo) (3 mo) (6 mo) (2 y)
Occlusal force (N) 564 467 435 426.7 553.1 603.6 657.7
Occlusal contact area (mm2) 9.8 8.3 6.8 7.3 9.8 11.1 12.5
Maximum opening (mm) 39 40.5 39 - - - -

jaw-tracking system (gnathohexagraph system, version
1.31; Ono Sokki, Kanagawa, Japan), which can record
jaw movements with 6 degrees of freedom, indicated
that the movement of the mandible and both sides of
the condylar heads were not stable during the maximum
opening and closing of the jaw.13-15 Irregular patterns of
movement were also observed in a chewing test using a
hard gummy jelly (Fig 4).
TREATMENT OBJECTIVES
Based on these findings, the patient was diagnosed
with skeletal Class II, Angle Class II malocclusion, high
mandibular plane angle with a deep overbite, and
congenitally missing mandibular second premolars. In
the first phase of treatment, a functional appliance
was used to promote growth of the mandible in the an-
teroposterior and vertical planes, with the expectation
that it would enlarge the upper airway and improve
the patient's OSA. The second phase of treatment aimed
to camouflage the anteroposterior skeletal discrepancy,
improve the facial esthetics, correct the deep overbite
and the dental midline discrepancy, and create a func-
tional and esthetic occlusion by retracting the maxillary
incisors. The maxillary first premolars and mandibular
deciduous second molars were extracted to achieve the
treatment objectives. We planned to use combination
headgear and a transpalatal arch (TPA) to achieve
maximum anchorage reinforcement because of the
complexity of the patient's problems—specifically the
Class II malocclusion with a deep overbite and an exces-
sive overjet.
TREATMENT ALTERNATIVES
As the ANB angle increases, a Class II malocclusion
becomes more difficult to treat. The alternative treat-
ments for such patients include the use of distraction

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722 Ishihara et al

Table II. Summary of cephalometric findings

Variable Japanese norms (woman) SD Pretreatment Preedgewise Posttreatment Postretention
Angular ( )
ANB 2.8 2.44 9.2 6.5 8.0 8.0
SNA 80.8 3.61 76.9 75.5 76.0 76.0
SNB 77.9 4.54 67.7 69.0 68.0 68.0
FMA 30.5 3.60 34.5 33.9 33.7 33.7
UI-FH 112.3 8.26 103.3 103.1 90.6 91.5
LI-Mp 93.4 6.77 99.8 101.9 96.0 96.5
Interincisal angle 123.6 10.64 122.3 121.1 139.7 138.0
Occlusal plane to SN 18.0 3.50 29.8 28.6 30.0 30.0
Gonial angle 122.2 5.29 121.5 120.9 117.2 117.2
Linear (mm)
S-N 67.9 3.65 68.5 71.7 71.8 71.8
N-Me 125.8 5.04 118.4 122.9 127.2 127.2
Me/PP 68.6 3.71 60.2 62.5 66.5 66.5
Go-Me 71.4 4.14 59.4 65.1 67.6 67.6
Ar-Me 106.6 5.74 87.6 93.4 95.9 95.9
Ar-Go 47.3 3.33 38.7 39.7 41.9 41.9
Overjet 3.1 1.07 10.0 6.0 1.5 3.0
Overbite 3.3 1.89 6.8 5.5 2.0 3.5
UI/PP 31.0 2.34 28.7 29.5 28.0 30.0
U6/PP 24.6 2.00 17.4 19.1 20.9 20.9
LI/Mp 44.2 2.68 44.2 44.7 44.5 44.5
L6/Mp 32.9 2.50 32.7 33.9 37.8 37.8
E-line to upper lip -2.5 1.9 5.0 2.0 0 0
E-line to lower lip 0.9 1.9 5.0 2.0 -1.5 -1.5

Fig 4. Pretreatment condylar movement and incisal paths recorded with 6 degrees of freedom jaw
movement recording system: A, opening and closing movements; B, chewing movements. The red
lines indicate the opening phase, and the blue lines indicate the closing phase.

osteogenesis or a combination of comprehensive or-
thodontic treatment and orthognathic surgery for
mandibular advancement. The treatment of choice
would have been invasive surgery to correct the severe
skeletal disharmony caused by mandibular hypoplasia
and relieve the patient's OSA.16 However, her family
wished to avoid orthognathic surgery because they
considered this approach to be too aggressive and
invasive. After a thorough discussion, the patient and
her family decided on the conservative treatment of
mandibular growth modification with orthodontic
camouflage treatment.

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Ishihara et al 723

Fig 5. Records at the end of the first phase of treatment: A, facial photographs; B, intraoral photo-
graphs; C, lateral cephalogram; D, posteroanterior cephalogram; E, panoramic radiograph.
TREATMENT PROGRESS patient's susceptibility to caries and periodontal condi-
Klammt's elastic open activator was used to improve tion. Dietary treatment for the prevention of weight
the anteroposterior jaw-base relationship by encour- gain was taught, supervised, and adapted by a pediatri-
aging forward growth of the mandible for 40 months.17 cian.
Simultaneously, a professional mechanical tooth- After the first phase of treatment, the facial photo-
cleaning program, which included the use of a graphs showed a slight forward movement of the
fluoride-containing dentifrice/paste, improved the mandibular position and improvements in the patient's

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724
Fig 6. Dental casts at the end of the first phase of treatment.
upper and lower lip protrusions (Fig 5). Although the
excessive overjet and lip protrusion were both reduced
(Table II), the patient continued to exhibit a
skeletal Class II and Angle Class II malocclusion on the
right side with a deep overbite (Figs 5 and 6). The
patient's maxillary right third molar and mandibular
second premolars were congenitally missing. The
cephalometric superimposition showed significant
growth of the mandible in the forward and downward
directions (Fig 7). More balanced patterns of chewing
movement was observed in the right side (Fig 8).
The second phase of orthodontic treatment began
when the patient was 13 years 2 months of age. Initially,
combination headgear and a transpalatal arch were
placed and fitted in the maxillary arch to provide
anchorage reinforcement. Safety instructions and diary
sheets were provided for wearing the headgear. After
extraction of the maxillary first premolars and mandib-
ular right deciduous second molar, an 0.018-in slot
preadjusted edgewise appliance with a 0.014-in nickel-
titanium wire in the maxillary arch was placed to initiate
leveling. Two months later, an 0.018-in preadjusted
edgewise appliance with a 0.016-in nickel-titanium
wire was placed in the mandibular arch. Simultaneously,
the maxillary wire was changed to a 0.016 3 0.022-in
nickel-titanium archwire. Five months after leveling
and alignment, a 0.016-in stainless steel archwire was
installed to start the retraction of the maxillary canines.
The mesial movement of the mandibular first molars
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Ishihara et al
began after the leveling and alignment of the mandibular
arch using nickel-titanium open-coil springs with a force
of 100 g. After the maxillary canine retraction, a
0.017 3 0.025-in stainless steel archwire was installed
to intrude the maxillary incisors and induce closure of
the extraction spaces with simultaneous closing-loop
mechanics. Detailing was initiated with 0.017 3 0.025-
in stainless steel wires in both arches. The patient's over-
jet and overbite were overcorrected in anticipation of po-
tential relapse. The total second phase treatment period
was 29 months. After debonding and debanding, a
lingual fixed retainer combined with a wraparound
type of retainer was placed in the maxillary arch, with a
canine-to-canine lingual bonded retainer in the mandib-
ular arch.
TREATMENT RESULTS
The first phase orthodontic treatment corrected the
patient's skeletal discrepancy and occlusal relationships.
The favorable growth of the mandible reduced the ANB
angle by 2.8 (Table II). Longitudinal observation of the
patient's body weight showed a decrease in the relative
weight gain from 9 years of age, which was possibly
associated with the dietary treatment (Fig 3, E). The
functional appliance treatment resulted in relief of the
patient's snoring and OSA events (determined in an
interview with her family). The second phase of ortho-
dontic treatment resulted in improvement of the
Ishihara et al 725

Fig 7. Superimposition of cephalometric tracings from pretreatment (black) and end of the first phase
of treatment (blue): A, sella-nasion plane at sella; B, palatal plane at ANS; C, mandibular plane at
menton.

Fig 8. The condylar movement and incisal paths at the end of the first phase of treatment recorded with
the 6 degrees of freedom jaw movement recording system: A, opening and closing, protrusive, and
lateral excursive movements; B, chewing movements. The red lines indicate the opening phase,
and the blue lines indicate the closing phase.

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726 Ishihara et al

Fig 9. Posttreatment records: A, facial photographs; B, intraoral photographs; C, lateral cephalogram;

D, posteroanterior cephalogram; E, panoramic radiograph.

patient's facial profile, with notable changes in lip
posture and balance from retraction of the upper and
lower lips (Fig 9). The posttreatment casts showed
well-aligned arches and good interdigitation of the
teeth. Class I canine and molar relationships were estab-
lished on both sides with an overcorrected overjet of
1.5 mm and an overbite of 2.0 mm (Fig 10). The
posttreatment cephalometric analysis showed a slight
decrease of the SNB angle due to the correction of the
deep overbite by rotating the mandible downward.
Vertical growth continued throughout the treatment,
confirmed by the overall superimposition, and equated
to a 4-mm increase in lower anterior face height
(Me/PP, 66.5 mm) (Fig 11). The maxillary incisors were

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Ishihara et al 727

Fig 10. Posttreatment dental casts.

Fig 11. Superimposition of the cephalometric tracings obtained at the end of the first phase of treat-
ment (blue) and after the completion of treatment (red): A, sella-nasion plane at sella; B, palatal plane
at ANS; C, mandibular plane at menton.

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728 Ishihara et al

Fig 12. Posttreatment condylar movement and incisal paths recorded with the 6 degrees of freedom
jaw movement recording system: A, opening and closing, protrusive, and lateral excursive movements;
B, chewing movements. The red lines indicate the opening phase, and the blue lines indicate the clos-
ing phase.

inclined lingually by 12.5 due to a camouflage skeletal
Class II cranial relationship and had been intruded by
1.5 mm. The mandibular incisors were also inclined
lingually by 5.9 . Acceptable root paralleling was
observed on a panoramic radiograph. Only slight apical
root resorption was observed, especially in the maxillary
central incisors (Fig 9, E).
Evaluation of the patient's jaw movement showed
that the movements of both sides of the condylar heads
during protrusive and lateral excursion were stable with
a good locus (Fig 12, A). A chewing test demonstrated
increases in the range of motion of both condyles and
a stabilized pattern of movement during chewing on
both sides (Fig 12, B). After 26 months of retention,
her occlusion was stable. The good facial esthetics
achieved by the treatment were maintained (Fig 13).
Intraoral photographs and the study models also
showed that the molar and canine relationships had
been maintained (Figs 13 and 14). Overjet and overbite
were slightly increased because the maxillary incisors
were slightly extruded (Table II). The ratio of the
tongue area to the intermaxillary space during ortho-
dontic treatment was assessed as described previ-
ously.18 From the results, the ratio of her tongue area
to the intermaxillary space was dramatically decreased
from 89.5% to 68.6% after functional appliance treat-
ment. This favorable change was almost maintained
during phase 2 treatment and retention (Table III).
The occlusal force and contact area gradually increased
throughout a 2-year retention period (Table I). The
patient and her family were satisfied with the treatment
results.
DISCUSSION
We described the case of a 9-year-old girl with PWS.
To the best of our knowledge, this study is the first report
of orthodontic treatment for a patient with PWS with a
longitudinal assessment of the stomatognathic func-
tion. Proper stability of the occlusion with a satisfactory
functional excursion was achieved after comprehensive
2-stage treatment. The posttreatment photographs
showed a significant and positive change in the facial
balance compared with the pretreatment photographs.
The protrusion of the maxillary incisors and the convex
profile had been reduced, and the patient had a more
pleasing profile. The evaluations of her stomatologic
functions showed that her condylar movement and
incisal pathway of protrusive lateral excursion and chew-
ing had slightly improved after orthodontic treatment
(Figs 4, 8, and 12). These functional improvements
might be explained by correction of the excessive overjet
and deep overbite that were likely to create an ideal
canine protected occlusion, thereby producing a more
stable jaw movement. Previously, authors have debated
the criteria for functional occlusion; however, there is no
single predominant type of functional occlusion in na-
ture, and thus no evidence-based studies support this
argument.19
Patients with PWS have a different craniofacial
morphology with reductions in some maxillofacial

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Ishihara et al 729

Fig 13. Postretention recordings: A, facial photographs; B, intraoral photographs; C, lateral cephalo-
gram; D, posteroanterior cephalogram; E, panoramic radiograph.

skeletal dimensions.11 Schaedel et al20 reported that to-
tal mandibular length, length of the ramus and the
body of the mandible, maxillary length, posterior facial
height, and midfacial height were reduced. General
skeletal abnormalities were found, including short stat-
ure, small hands and feet, and decreased growth veloc-
ity.21 Orthodontists should be aware of these
characteristic skeletal features in patients with PWS
when formulating an individualized orthodontic treat-
ment plan.22 Regarding the pretreatment cephalometric
analysis of our patient, both the ramus and the body of
the mandible were reduced in size, and the lower facial
height ratio was slightly small, which might have pre-
disposed her to OSA.

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730 Ishihara et al

Fig 14. Postretention dental casts.

Table III. Cephalometric evaluation of intermaxillary space areas

Variable Mean SD Pretreatment Preedgewise Posttreatment Postretention
Intermaxillary space area index (IMA) (mm2) 2670 216 2585 3030 3297 3288
Tongue shadow area (TA) (mm2) 1930 161 2314 2077 2425 2283
Ratio of TA/IMA (%) 73.1 6.6 89.5 68.6 73.5 69.4

Sleep-disordered breathing, including OSA and cen-
tral hypoventilation during sleep, is a common compli-
cation of PWS.6 These problems can lead to functional
impairments and may also contribute to sudden death
in infants and young children with PWS who are
treated with growth hormones.23 Functional appliance
therapy is an obvious treatment choice for mandibular
deficiencies, since it stimulates and enhances the
downward and forward growth of the mandible during
correction of Class II skeletal malocclusion.24,25 In our
patient, the elastic open activator was also used to
increase the airway space and achieve stable anterior
positions of the mandible and tongue, and the
forward movement of the soft palate with a resultant
increase in the oropharyngeal airway space. This
increase in airway space made it considerably less
likely for oropharyngeal tissue to collapse due to
negative inspiratory pressure.26 The assessment of the
patient's OSA during treatment was determined by in-
quiry with her family. The patient's mother told us that
she found the relief of patient's OSA after wearing the
elastic open activator and without any deteriorated
symptom from phase 2 treatment to the retention
period. This information was consistent with the results
of the ratio of the tongue area to the intermaxillary
area. All of these findings indicated that our functional
appliance treatment resulted in relief of her OSA.
This case demanded high anchorage. Thus, the
anchorage was reinforced with combination headgear
and a transpalatal arch. However, the pretreatment
and posttreatment cephalogram tracings illustrated the
extrusion and mesial movement of the maxillary first
molars. In recent years, implant-anchored orthodontics
has become widely used to provide sufficient anchorage
for various tooth movements. This method also enables
sufficient anchorage to retract the anterior teeth, even in
patients who are uncooperative with regard to wearing
orthodontic appliances.27 Although this patient was
cooperative with wearing headgear, such an approach
might be considered effective.

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Ishihara et al
Many researchers have described the important rela-
tionship between vertical dimension control and the
successful treatment of Class II malocclusion. The pa-
tient's vertical discrepancies were improved during the
second phase of orthodontic treatment, which can be
explained by the intrusion of both incisors and the rela-
tively favorable growth of the mandible compared with
the maxilla. A deep overbite tends to worsen in the pre-
pubertal stage and improve once the permanent denti-
tion is established.28,29 The treatment of a deep
overbite at puberty therefore results in significantly
more favorable outcomes compared with those
observed in patients with mixed dentition.30 Although
acceptable occlusion and a satisfactory facial profile
were obtained, the treatment outcome led to a slight
molar extrusion and subsequent clockwise rotation of
the mandible (Fig 11). Using a segmented arch
minimizes extrusion of the posterior teeth and might
be a more stable approach for deepbite correction than
the continuous archwire technique when arch leveling
by incisor intrusion is indicated.31
Posttreatment stability is another concern after
correction of excessive overjet and deep overbite. A pos-
itive correlation has been reported between the amount
of correction and the incidence of relapse, as well as
among the degrees of initial and postretention
changes.32,33 Thus, overjet and overbite were slightly
overcorrected in our patient. The treatment results
were relatively stable during the 26-month retention
period. However, further observation is required
because of the difficulties associated with oral self-care
by patients with PWS. Both physicians and dentists
will be involved in maintaining the care of this patient,
with early intervention and long-term follow-up.
CONCLUSIONS
This report described the longitudinal orthodontic
treatment of a patient with a severe skeletal Class II
malocclusion and PWS. The treatment results were sta-
ble after 26 months, and an improved functional
outcome was achieved. Our findings suggest that an or-
thodontic approach can significantly contribute to
improving the health and quality of life of patients
with PWS.
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