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Nonextraction treatment of a Class II, Division 1 malocclusion with headgear and functional appliances
CDABO CASE REPORT
Nonextraction treatment of a Class II, Division 1 malocclusion with headgear and functional appliances Michael S. Mosling, DDS, M S , a Laura L. Fogle, DDS, b Judith Gloeckner-Demro, DDS, MS, a and Harold F. Bigelow, DDS, MS c Iowa City, Iowa [This case was chosen by the CDABO student case selection committee for publication in the American Journal of Orthodontics and Dentofacial Orthopedics.] (Am J Orthod Dentofac Orthop 1997;112:372-7.)
PATIENT HISTORY AND ETIOLOGY The patient was a healthy 8-year, 9-month-old white boy (Fig. 1). His mother stated, "He needs to see an orthodontist to straighten his teeth and to correct his jaw problem." His oral hygiene was good and no obvious cause was evident.
DIAGNOSIS The patient had a Class II, Division 1 malocclusion with 100% overbite and 10 mm of overjet (Figs. 2 and 3). The upper dental midline was 1 mm to the right of the facial midline, while the lower dental midline was centered. A bilateral posterior scisssors bite was present. Space analysis revealed approximately 1.2 mm of excess space in the maxillary arch and 3.4 mm of crowding in the mandibular arch. An interlabial gap of 6 mm existed, with the lower lip trapped beneath the maxillary incisors. Cephalometrically, the patient had an SNA angle of 83 °, an SNB angle of 78 °, an ANB angle of 5°, an SN-MP angle of 36 °, and an F M A angle of 31 ° (Fig. 4). The maxillary incisors were 8 mm anterior to the N-A line with an upper incisor to SN angle of 112 °. The mandibular incisors were 5 mm anterior to the N-B line with a lower incisor to F H angle of 57 °. These findings were consistent with a diagnosis of a Class II, Division 1 malocclusion with a bilateral posterior scissors bite, retrusive mandible, and steep mandibular plane.
TREATMENT OBJECTIVES AND INITIAL TREATMENT PLAN The treatment objectives consisted of correction of the posterior transverse problem, differential jaw growth for From The University of Iowa. aPrivate practice, former orthodontic resident. bOrthodontic resident. ~Private practice and adjunct orthodontic faculty member. Reprint requests to: Dr. Thomas Southard, Graduate Program Director, Department of Orthodontics, College of Dentistry, The University of Iowa, Iowa City, IA 52242. Copyright © 1997 by the American Association of Orthodontists. 0889-5406/97/$5.00 + 0 8/4/73338
372
profile improvement, and attainment of Class I interdigitation, with ideal overbite and overjet. The initial treatment plan included correction of the mandibular arch constriction with a Swartz appliance. Application of a high-pull headgear was recommended to achieve Class I molar and canine relationship and to improve the profile through differential jaw growth. Edgewise appliances were planned, as the permanent teeth erupted for final alignment.
TREATMENT PROGRESS The maxillary first molars were banded, the maxillary incisors bonded (0.022 slot brackets) and high-pull headgear wear begun. Space between the maxillary incisors was closed. A Swartz appliance was placed and activated for 2 months. Three months later, a transpalatal arch and an 0.018 x 0.022-inch maxillary intrusion arch wire were placed to decrease the overbite, while the headgear wear continued for another 6 months. Phase 1 treatment ended after 13 months, at which time a maxillary retainer was delivered. Ten months later, a Frankel II appliance was used for a 10-month duration. After its discontinuation, full-fixed orthodontic appliances, including a lower lingual holding arch, were placed. Maxillary canine retraction was accomplished with elastomeric chains on a 0.018 stainless steel stopped arch wire; subsequently, the maxillary incisors were retracted with closing loops. High-pull headgear was used for posterior anchorage control during retraction and for maxillary molar vertical control. The mandibular spaces were closed with elastomeric chains. Class II and vertical elastics were used for enhanced dental interdigiration for a total of 6 months. Final leveling, coordination, and detailing were completed with 0.018 × 0.025 stainless steel arch wires. The appliances were removed and retainers delivered. As a result of poor patient cooperation, fixed orthodontic appliances had to be worn for approximately 20 months.
RESULTS ACHIEVED The patient showed significant downward and forward growth of the mandible and the maxilla during the course
American Journal of Orthodontics and Dentofacial Orthopedics Volume 112, No. 4
Fig. 1. Pretreatment facial photographs.
Fig. 2. Pretreatment study casts.
Mosling et aL 373
374 Mosling et al.
American Journal of Orthodontics and Dentofacial Orthopedics October 1997
Fig. 3. Pretreatment intraoral photographs.
112
83 78 5
o
31 36
Fig. 4. Pretreatment cephalometric tracing.
American Journal of Orthodontics and Dentofacial Orthopedics Volume 112, No. 4
Fig. 5. Posttreatment facial photographs,
Fig. 6. Posttreatment study casts.
Mosling et al. 375
3"/6 Mosling et al.
American Journal of Orthodontics and Dentofacial Orthopedics October 1997
Fig. 7. Posttreatment intraoral photographs.
8O 7--6 4
Fig. 8. Posttreatment cephalometric tracing.
Mosling et aL
American Journal of Orthodontics and Dentofacial Orthopedics Volume 112, No. 4
,
-A--
,
377
,,
Fig. 9. Pretreatment and posttreatment superimposed cephalometric tracings.
of treatment (Figs. 5 to 8). The maxillary molars extruded and were protracted slightly, while the maxillary incisors were tipped lingually and extruded slightly. The mandibular molars were extruded and protracted, and the mandibular incisors were flared and extruded. Because of differential jaw growth, the profile straightened slightly during treatment, the ANB angle decreased 1°, and the FH-NPog angle increased 2° (Figs. 8 and 9, Table I). Dentally, the molars and canines finished in good Class I interdigitation. No prematurities were present. The overbite was reduced to approximately 25%, while the final overjet was approximately 2.5 ram. Radiographically, minimal root resorption was evident, and root parallelism was acceptable. The bone height was normal, and the third molars were developing. RETENTION
After appliance removal, temporary maxillary and mandibular retainers were delivered. After i month, the patient was given maxillary and mandibular Hawley retainers. The patient never returned for retention check visits. FINAL EVALUATION
Two-phase treatment aided in the realization of a final Class I occlusion without extractions. The Swartz appliances corrected the bilateral scissors bite in the initial treatment phase. The headgear and Frankel II appliance treatments improved facial esthetics through differential jaw growth.
Table
I. Summary of cephalometric analysis Measurement
SNA (degrees) FH-NA (degrees) SNB (degrees) FH-NPog (degrees) ANB (degrees) SN-MP (degrees) FMA (degrees) LFH/TFH _I:SN (degrees) I:NA (mm) I:FH (degrees) I:NB (rnm) 1:7 (degrees) ILG (mm) Mx lip:! at rest (mm)
Standard
Initial
82 90 80 88 2 32 25 55% 104 4 65 4 131 0 2
83 89 78 85 5 36 31 51% 112 8 57 5 118 9 9
[
I
Deband 80 90 76 87 4 37 27 56% 101 5 49 9 118 7 7
Mx, maxillary.
Fixed appliances were used for maxillary dentition retraction and reciprocal mandibular space closure. Despite extrusion of the posterior occlusion during treatment, a final Class I occlusion and improved facial harmony was achieved because of good differential jaw growth. We thank the following former residents for their participation in the care of this patient: Drs. Curtis Menard, John Di Giovanni, and Greg Christensen.
Nonextraction treatment of a Class II, Division 1 malocclusion with headgear and functional appliances Michael S. Mosling, DDS, M S , a Laura L. Fogle, DDS, b Judith Gloeckner-Demro, DDS, MS, a and Harold F. Bigelow, DDS, MS c Iowa City, Iowa [This case was chosen by the CDABO student case selection committee for publication in the American Journal of Orthodontics and Dentofacial Orthopedics.] (Am J Orthod Dentofac Orthop 1997;112:372-7.)
PATIENT HISTORY AND ETIOLOGY The patient was a healthy 8-year, 9-month-old white boy (Fig. 1). His mother stated, "He needs to see an orthodontist to straighten his teeth and to correct his jaw problem." His oral hygiene was good and no obvious cause was evident.
DIAGNOSIS The patient had a Class II, Division 1 malocclusion with 100% overbite and 10 mm of overjet (Figs. 2 and 3). The upper dental midline was 1 mm to the right of the facial midline, while the lower dental midline was centered. A bilateral posterior scisssors bite was present. Space analysis revealed approximately 1.2 mm of excess space in the maxillary arch and 3.4 mm of crowding in the mandibular arch. An interlabial gap of 6 mm existed, with the lower lip trapped beneath the maxillary incisors. Cephalometrically, the patient had an SNA angle of 83 °, an SNB angle of 78 °, an ANB angle of 5°, an SN-MP angle of 36 °, and an F M A angle of 31 ° (Fig. 4). The maxillary incisors were 8 mm anterior to the N-A line with an upper incisor to SN angle of 112 °. The mandibular incisors were 5 mm anterior to the N-B line with a lower incisor to F H angle of 57 °. These findings were consistent with a diagnosis of a Class II, Division 1 malocclusion with a bilateral posterior scissors bite, retrusive mandible, and steep mandibular plane.
TREATMENT OBJECTIVES AND INITIAL TREATMENT PLAN The treatment objectives consisted of correction of the posterior transverse problem, differential jaw growth for From The University of Iowa. aPrivate practice, former orthodontic resident. bOrthodontic resident. ~Private practice and adjunct orthodontic faculty member. Reprint requests to: Dr. Thomas Southard, Graduate Program Director, Department of Orthodontics, College of Dentistry, The University of Iowa, Iowa City, IA 52242. Copyright © 1997 by the American Association of Orthodontists. 0889-5406/97/$5.00 + 0 8/4/73338
372
profile improvement, and attainment of Class I interdigitation, with ideal overbite and overjet. The initial treatment plan included correction of the mandibular arch constriction with a Swartz appliance. Application of a high-pull headgear was recommended to achieve Class I molar and canine relationship and to improve the profile through differential jaw growth. Edgewise appliances were planned, as the permanent teeth erupted for final alignment.
TREATMENT PROGRESS The maxillary first molars were banded, the maxillary incisors bonded (0.022 slot brackets) and high-pull headgear wear begun. Space between the maxillary incisors was closed. A Swartz appliance was placed and activated for 2 months. Three months later, a transpalatal arch and an 0.018 x 0.022-inch maxillary intrusion arch wire were placed to decrease the overbite, while the headgear wear continued for another 6 months. Phase 1 treatment ended after 13 months, at which time a maxillary retainer was delivered. Ten months later, a Frankel II appliance was used for a 10-month duration. After its discontinuation, full-fixed orthodontic appliances, including a lower lingual holding arch, were placed. Maxillary canine retraction was accomplished with elastomeric chains on a 0.018 stainless steel stopped arch wire; subsequently, the maxillary incisors were retracted with closing loops. High-pull headgear was used for posterior anchorage control during retraction and for maxillary molar vertical control. The mandibular spaces were closed with elastomeric chains. Class II and vertical elastics were used for enhanced dental interdigiration for a total of 6 months. Final leveling, coordination, and detailing were completed with 0.018 × 0.025 stainless steel arch wires. The appliances were removed and retainers delivered. As a result of poor patient cooperation, fixed orthodontic appliances had to be worn for approximately 20 months.
RESULTS ACHIEVED The patient showed significant downward and forward growth of the mandible and the maxilla during the course
American Journal of Orthodontics and Dentofacial Orthopedics Volume 112, No. 4
Fig. 1. Pretreatment facial photographs.
Fig. 2. Pretreatment study casts.
Mosling et aL 373
374 Mosling et al.
American Journal of Orthodontics and Dentofacial Orthopedics October 1997
Fig. 3. Pretreatment intraoral photographs.
112
83 78 5
o
31 36
Fig. 4. Pretreatment cephalometric tracing.
American Journal of Orthodontics and Dentofacial Orthopedics Volume 112, No. 4
Fig. 5. Posttreatment facial photographs,
Fig. 6. Posttreatment study casts.
Mosling et al. 375
3"/6 Mosling et al.
American Journal of Orthodontics and Dentofacial Orthopedics October 1997
Fig. 7. Posttreatment intraoral photographs.
8O 7--6 4
Fig. 8. Posttreatment cephalometric tracing.
Mosling et aL
American Journal of Orthodontics and Dentofacial Orthopedics Volume 112, No. 4
,
-A--
,
377
,,
Fig. 9. Pretreatment and posttreatment superimposed cephalometric tracings.
of treatment (Figs. 5 to 8). The maxillary molars extruded and were protracted slightly, while the maxillary incisors were tipped lingually and extruded slightly. The mandibular molars were extruded and protracted, and the mandibular incisors were flared and extruded. Because of differential jaw growth, the profile straightened slightly during treatment, the ANB angle decreased 1°, and the FH-NPog angle increased 2° (Figs. 8 and 9, Table I). Dentally, the molars and canines finished in good Class I interdigitation. No prematurities were present. The overbite was reduced to approximately 25%, while the final overjet was approximately 2.5 ram. Radiographically, minimal root resorption was evident, and root parallelism was acceptable. The bone height was normal, and the third molars were developing. RETENTION
After appliance removal, temporary maxillary and mandibular retainers were delivered. After i month, the patient was given maxillary and mandibular Hawley retainers. The patient never returned for retention check visits. FINAL EVALUATION
Two-phase treatment aided in the realization of a final Class I occlusion without extractions. The Swartz appliances corrected the bilateral scissors bite in the initial treatment phase. The headgear and Frankel II appliance treatments improved facial esthetics through differential jaw growth.
Table
I. Summary of cephalometric analysis Measurement
SNA (degrees) FH-NA (degrees) SNB (degrees) FH-NPog (degrees) ANB (degrees) SN-MP (degrees) FMA (degrees) LFH/TFH _I:SN (degrees) I:NA (mm) I:FH (degrees) I:NB (rnm) 1:7 (degrees) ILG (mm) Mx lip:! at rest (mm)
Standard
Initial
82 90 80 88 2 32 25 55% 104 4 65 4 131 0 2
83 89 78 85 5 36 31 51% 112 8 57 5 118 9 9
[
I
Deband 80 90 76 87 4 37 27 56% 101 5 49 9 118 7 7
Mx, maxillary.
Fixed appliances were used for maxillary dentition retraction and reciprocal mandibular space closure. Despite extrusion of the posterior occlusion during treatment, a final Class I occlusion and improved facial harmony was achieved because of good differential jaw growth. We thank the following former residents for their participation in the care of this patient: Drs. Curtis Menard, John Di Giovanni, and Greg Christensen.