Cl II case - Metal allergy, multiple missing teeth

Hello all,

I have an case in treatment, she is now approx 16-17 years old, she has Nickel allergy, missing 17, 32, and 42, peg 22. I informed her about Nickel allergy requires oxidation for her to become reactive but she still wants to limit any use of SS appliances (she hasn't reacted to stainless steel k-ties), I replaced 18 for 17. Upper 4s extracted. These are the things I want to achieve but having a difficult time figuring out how and if I can do it:
1) Cl II canine with only 1mm to distalize canine, not enough space to make them Cl I
2) Narrow transverse in area of Upper 5's and Upper 6s
3) Rotated 12 - distal out
4) Creating space for 22 build up
5) Some anterior OJ 2-3mm
6) rotated 36 distal in and rotated 37 mesial in

I'm considering:
-TMA Horseshoe arch for expansion on upper and TMA LLHA to derotate LL6 - but don't have a place to attach it, do they have bondable hinge caps?
-Distalizing U3s by 1mm with rigid extensions on the buccal and buttons on the lingual
-V bend b/t 11 and 12 in the center (G VI) to help with rotation of 12, 11 may be slightly rotated mesial out
-Overaly wire or rectangular wire to correct 37 position after 36 corrected

I'm a bit stuck and confused, she is not an easy patient to work on too. A bit sensitive and tiny tiny mouth with limited opening.

Hi Ann!

Are there any calculations and x-rays?

I think this is due to a mismatch in the Bolton index. 3.2 and 4.2 are much smaller than 3.3 and 4.3. Therefore, the lower premlars and molars cannot shift mesial to Cl I.

Hi Matthew, thank you for your response. I think you are right that there is definitely a Bolton discrepancy, UL2 is also a small peg lateral. I'll take a look at the Bolton discrepancy, this case has been a struggle for me.