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An American board of orthodontics case report
American Journal of ORTHODONTICS and DENTOFACIAL ORTHOPEDICS Founded in 1915
Volume 94 Number 6 Copyright
December 1988
0 1988 by The C.V. Mosby Company
CASE REPORT
An American Board of Orthodontics case report Donald E. Snyder, DDS Fresno, Calif.
A case report is presented of a Class II, Division 1 malocclusion with severe overjet and deep overbite with crowding and irregularities of the anterior teeth. The case was treated according to the standards of the’American Board of Orthodontics. (AM J ORTHOD DENTOFAC ORTHOP 1988;94,:453-7.)
C
CASE REPORT
lass II, Division 1 malocclusion is common in orthodontic practice. Severe Class II malocclusions are often challenging problems, requiring careful planning and treatment. When combined with crowding in the nongrowing patient, they often become a most difficult malocclusion to treat.
Diagnosis
The patient, a 23-year-old woman, had a Class II, Division 1 malocclusion, severe overjet, and deep overbite (Figs. 1 and 5). The mandibular incisors had supraerupted with a resulting deep curve of Spee. Crowding and irregularities of the anterior teeth were present.
Fig. 1. A through C, Pretreatment facial photographs. D through F, Pretreatment intraoral photographs, age 23 years 5 months. 453
454
Am. J. Orthod.
Snyder
graphs,
Fig. 3. Tracing
age 25;ears
of initial
head
History and general clinical
film,
Dent&c. Orthop. December 1988
11 months.
age 23 years
5 months.
picture
The patient was in good health. Clinical examination showed a normal color and texture of the cheeks, tongue, and hard and soft palates. Oral hygiene was good and gingival tissue appeared healthy. facial appearance The facial profile was characterized by a protrusive upper lip. The lower lip was everted under the excess overjet of the maxillary incisors with a deepened mentolabial fold. The lips
Fig. 4. Cephalometric 5 months (so/id /ines), fines).
tracings at pretreatment, age 23 years and posttreatment, age 26 years (dashed
were apart at rest (Fig. 1). Mentalis and perioral muscle strain was necessary to obtain lip closure. Intraoral
radiographs
All teeth were present with impaction of the four third molars. There was an area of increased calcification of the bone between the right mandibular first and second molars. The maxillary sinus extended down between the roots of the
Volume 94 Number 6
Crde repot-r
Fig. 5. A through
Fig. 6. A through
E, Pretreatment
study
casts,
age 23 years
6 months
E. Posttreatment
study
casts.
age 25 years
11 months
maxillary first molars and second premolars, with divergence of their roots. The roots of the mandibular second molars were close to the cortical plate of the lower border of the mandible. Bone height and root length were good. SW Fig. 10. Cephalometric
findings
There was an acceptable anteroposterior position of the maxilla and mandible, with an SNA angle of 82” and SNB angle of 78”. Lower facial height was normal. The predominant component of this Class II malocclusion was dental. The maxillary dentition was protrusive. The maxillary central incisors were proclined 44” and 11 mm to the nasion-point
455
A line. The mandibular central incisors were somewhat rctruded-2 mm behind the point A-pogonion plane. See Fig. 3. Plan of treatment The extraction of maxillary first premolars was elected retraction of the maxillary anterior teeth. Maximum anchorage was to be utilized in the upper arch with use of a cervical face-bow. The mandibular curve of Spee was to be leveled by intrusion of the mandibular incisors. The prognosis was good, dependent on patient cooperation. Orthognathic surgery was a viable option. The treatment objectives were as follows: to allow
456
Am. J. Orthod.
Snyder
Dent&c. Orthop. December 1988
age 29 years 2 months.
Progress
Fig. 8. Cephalometric tracings at posttreatment, age 26 years (solidlines), and postretention, age 29 years 2 months (dashed lines).
1. Establishmentof normal facial balance 2. Correction of the maxillary dental protrusion and reduction of overjet by extraction of maxillary first premolars and retraction of the maxillary anterior teeth 3. Leveling of the mandibular curve of Speevia intrusion of incisors 4. Elimination of maxillary and mandibular dental irregularities 5. Establishmentof a good functional occlusion
of treatment
A full 0.018 x 0.025-inch edgewise appliance was placed. Maxillary first premolars and four third molars were subsequentlyextracted. The patient was askedto wear a cervical face-bow with 0.45 kg of force applied to each side 14 to 16 hours per day. Light ClassIII elasticswere worn with headgearto augment anchorageto the mandibular arch during leveling. The cervical face-bow was worn 13 months during the period of retraction of the maxillary anterior teeth. Initial leveling and bracket engagement was gained with progressiveround wires. The maxillary anterior teeth were retracted en masse with a 0.016 x 0.022-inch closing loop arch wire. The mandibular incisors were intruded with a 0.016 x 0.022-inch utility arch wire over a 0.016-inch round continuous arch wire. After leveling and space closure, 0.016 x 0.022-inch continuous arch wires bent to ideal form were placed to detail the occlusion. Crossbite elasticswere worn on the right first molars. Round twisted wires were placed and light up-down elastics were worn to settle the occlusion. Maxillary and mandibular Hawley retainers were placed for retention. The period of active treatment was 28 months. Results achieved Facial. An orthognathic face was achieved with the lips in good harmony with the chin and nose (Fig. 2). Dental assessment. The dental correction gained was good. All treatment objectives were met and a wellinterdigitated occlusion was established(Fig. 6). The occlusion functions well with anterior disclusion on right and left lateral excursionsand no TMJ symptoms evident.
Case report
Volume 94 Number 6
457
Fig. 9. A through E. Postretention study casts, age 29 years 2 months.
Fig. 10. Panoramic radiographs. A, Pretreatment, age 23 years 5 months. B, Posttreatment, age 26 years. C, Postretention, age 29 years 2 months.
Cephalometric findings. The maxillary incisors were retracted with very little anterior movement of the maxillary first molars. The mandibular incisors were intruded and tipped anteriorly to a position 2 mm anterior to the point A-pogonion plane. The mandibular first molars were retracted slightly. See Fig. 4. Secondary treatment. Maxillary and mandibular Hawley retainers were worn full-time for a period of 12 months and nightly for a 13-month period, and then discontinued.
Final evaluation The occlusion has remained relatively unchanged, with the overjet and overbite correction maintained (Figs. 7 through 10). Treatment objectives were achieved with substantial patient cooperation. Reprinf
requests
to:
Dr. Donald Snyder 6255 N. Fresno St., No. Fresno, CA 937 10
101
Volume 94 Number 6 Copyright
December 1988
0 1988 by The C.V. Mosby Company
CASE REPORT
An American Board of Orthodontics case report Donald E. Snyder, DDS Fresno, Calif.
A case report is presented of a Class II, Division 1 malocclusion with severe overjet and deep overbite with crowding and irregularities of the anterior teeth. The case was treated according to the standards of the’American Board of Orthodontics. (AM J ORTHOD DENTOFAC ORTHOP 1988;94,:453-7.)
C
CASE REPORT
lass II, Division 1 malocclusion is common in orthodontic practice. Severe Class II malocclusions are often challenging problems, requiring careful planning and treatment. When combined with crowding in the nongrowing patient, they often become a most difficult malocclusion to treat.
Diagnosis
The patient, a 23-year-old woman, had a Class II, Division 1 malocclusion, severe overjet, and deep overbite (Figs. 1 and 5). The mandibular incisors had supraerupted with a resulting deep curve of Spee. Crowding and irregularities of the anterior teeth were present.
Fig. 1. A through C, Pretreatment facial photographs. D through F, Pretreatment intraoral photographs, age 23 years 5 months. 453
454
Am. J. Orthod.
Snyder
graphs,
Fig. 3. Tracing
age 25;ears
of initial
head
History and general clinical
film,
Dent&c. Orthop. December 1988
11 months.
age 23 years
5 months.
picture
The patient was in good health. Clinical examination showed a normal color and texture of the cheeks, tongue, and hard and soft palates. Oral hygiene was good and gingival tissue appeared healthy. facial appearance The facial profile was characterized by a protrusive upper lip. The lower lip was everted under the excess overjet of the maxillary incisors with a deepened mentolabial fold. The lips
Fig. 4. Cephalometric 5 months (so/id /ines), fines).
tracings at pretreatment, age 23 years and posttreatment, age 26 years (dashed
were apart at rest (Fig. 1). Mentalis and perioral muscle strain was necessary to obtain lip closure. Intraoral
radiographs
All teeth were present with impaction of the four third molars. There was an area of increased calcification of the bone between the right mandibular first and second molars. The maxillary sinus extended down between the roots of the
Volume 94 Number 6
Crde repot-r
Fig. 5. A through
Fig. 6. A through
E, Pretreatment
study
casts,
age 23 years
6 months
E. Posttreatment
study
casts.
age 25 years
11 months
maxillary first molars and second premolars, with divergence of their roots. The roots of the mandibular second molars were close to the cortical plate of the lower border of the mandible. Bone height and root length were good. SW Fig. 10. Cephalometric
findings
There was an acceptable anteroposterior position of the maxilla and mandible, with an SNA angle of 82” and SNB angle of 78”. Lower facial height was normal. The predominant component of this Class II malocclusion was dental. The maxillary dentition was protrusive. The maxillary central incisors were proclined 44” and 11 mm to the nasion-point
455
A line. The mandibular central incisors were somewhat rctruded-2 mm behind the point A-pogonion plane. See Fig. 3. Plan of treatment The extraction of maxillary first premolars was elected retraction of the maxillary anterior teeth. Maximum anchorage was to be utilized in the upper arch with use of a cervical face-bow. The mandibular curve of Spee was to be leveled by intrusion of the mandibular incisors. The prognosis was good, dependent on patient cooperation. Orthognathic surgery was a viable option. The treatment objectives were as follows: to allow
456
Am. J. Orthod.
Snyder
Dent&c. Orthop. December 1988
age 29 years 2 months.
Progress
Fig. 8. Cephalometric tracings at posttreatment, age 26 years (solidlines), and postretention, age 29 years 2 months (dashed lines).
1. Establishmentof normal facial balance 2. Correction of the maxillary dental protrusion and reduction of overjet by extraction of maxillary first premolars and retraction of the maxillary anterior teeth 3. Leveling of the mandibular curve of Speevia intrusion of incisors 4. Elimination of maxillary and mandibular dental irregularities 5. Establishmentof a good functional occlusion
of treatment
A full 0.018 x 0.025-inch edgewise appliance was placed. Maxillary first premolars and four third molars were subsequentlyextracted. The patient was askedto wear a cervical face-bow with 0.45 kg of force applied to each side 14 to 16 hours per day. Light ClassIII elasticswere worn with headgearto augment anchorageto the mandibular arch during leveling. The cervical face-bow was worn 13 months during the period of retraction of the maxillary anterior teeth. Initial leveling and bracket engagement was gained with progressiveround wires. The maxillary anterior teeth were retracted en masse with a 0.016 x 0.022-inch closing loop arch wire. The mandibular incisors were intruded with a 0.016 x 0.022-inch utility arch wire over a 0.016-inch round continuous arch wire. After leveling and space closure, 0.016 x 0.022-inch continuous arch wires bent to ideal form were placed to detail the occlusion. Crossbite elasticswere worn on the right first molars. Round twisted wires were placed and light up-down elastics were worn to settle the occlusion. Maxillary and mandibular Hawley retainers were placed for retention. The period of active treatment was 28 months. Results achieved Facial. An orthognathic face was achieved with the lips in good harmony with the chin and nose (Fig. 2). Dental assessment. The dental correction gained was good. All treatment objectives were met and a wellinterdigitated occlusion was established(Fig. 6). The occlusion functions well with anterior disclusion on right and left lateral excursionsand no TMJ symptoms evident.
Case report
Volume 94 Number 6
457
Fig. 9. A through E. Postretention study casts, age 29 years 2 months.
Fig. 10. Panoramic radiographs. A, Pretreatment, age 23 years 5 months. B, Posttreatment, age 26 years. C, Postretention, age 29 years 2 months.
Cephalometric findings. The maxillary incisors were retracted with very little anterior movement of the maxillary first molars. The mandibular incisors were intruded and tipped anteriorly to a position 2 mm anterior to the point A-pogonion plane. The mandibular first molars were retracted slightly. See Fig. 4. Secondary treatment. Maxillary and mandibular Hawley retainers were worn full-time for a period of 12 months and nightly for a 13-month period, and then discontinued.
Final evaluation The occlusion has remained relatively unchanged, with the overjet and overbite correction maintained (Figs. 7 through 10). Treatment objectives were achieved with substantial patient cooperation. Reprinf
requests
to:
Dr. Donald Snyder 6255 N. Fresno St., No. Fresno, CA 937 10
101