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Combined treatment methods in a severe Angle Class II, Division 1 malocclusion with lower incisor crowding
Combined treatment methods in a severe Angle Class II, Division I malocclusion with lower incisor crowding T. I. McCartney, D.Orth. Belfast,
Northern
M.D.S.,
L.D.S.,
D.D.O.,*
and
Andrew
Richardson,
M.Sc.,
Ireland
c
urrent orthodontic treatment methods have been evolved by highly skilled and experienced orthodontists throughout the world, and these various methods have come to be associated with names which are permanent on the orthotlontic* SCPI~~.Students trained by these strong and persuasive personalities often become so imbued with one man’s philosoph;v and treatment method that they specialize ill one technique to the exclusion of all others. Consequently, the mechanical treatment of Class II, Division 1 malocclusion has a geographic tlistribntion, tlcprnding more on the trailling, experience, and skills of the orthotlontist than on the precise nature OS the malocclusion to be treated. Up to the most recent past, the Class II, Division 1 malocclusion in Central Europe or Scandinavia would probably have been treated with a functional appliance1-3 ; in North America, with the edgewise mechanism4; in Australia, with Begg technique” ; and, in Britain, with removable appliances.” NOlY! rcv?ntly, ho\vcvtT, with the increasing interchange of personnel and i(lcas, orthotlontists in c.ountrics where functional and removable appliances i~n\-(a Latin the principal trt>atment methotl are coming to appreciate the ad~niltapcs of fixccl api)lianccs,+. 1 and there is stmrnt~c>\-idcnrc~that- the cxc*bange of i&as is also optrati1ig in the oppositck clirc~ction,” All philosophies and treatment proccclures have advantages and disad: antages, and therta BW signs that orthotlontists throughout the world are seeking out and applying the best features of more than one system in treating any one maloc~~lusion.‘” Semantically, the concept of combined treatment methods is not new. Fogel “Senior
Tutor,
Orthodontici
tkpartment,
The
QUWII’R
University
of
Belfast. 581
Awe. J. Orthod. Jww 1973
tech~liqzcc to dewribe a method anti Jlagill,1’ ha\-cl cwillecl the town combit/rrtio)l which, the>- belicrc, brings together the best features of the edgewise and Begg tc~chniqucs. The use of double buccal tubes on the molars and combination brackc~ts on the remaining teeth permits round and edgewise arch wires to be usccl at tliffercnt stages. The combinctl treatment to be described in this article brings together two treatment methods which differ fundamentally in their conception and ideology, one being a functional technique and t,he other a fixed applianrc tecliniquc. In the final analysis, the objective of treatment in Class 11, Division 1 malocelusion is reduction of the incisal overbite and overjet to improve function and appearance. Some authorities also stress the importance of correcting the occlusion of the posterior teeth, but others believe that a discrepancy in posterior occlusal relations is acceptable, provided the interdigitation is good.12 In eliminating ovcrjet, the upper incisors should be retracted but not retroc1ined.l” This is usually impossible to achieve with removable appliances in the severe malocclusion, since these appliances tend to tip teeth rather than move t’hem bodily. Thus, the extreme overjet, treated with removable appliances alone, tends to finish with either a residual overjet, which may jeopordize stability, or overretroclination of upper incisors which may be esthetically unsatisfactory. Fixed appliances, which offer the facility of apical control and root torque, are better suited to this procedure when palatal bodily movement of incisors is required but they suffer from the disadvantage that they involve greater chairside time and they pose greater problems of anchorage control and oral hygiene. Another approach to the extreme overjet is the functional appliance. These appliances can bring about a dramatic improvement which some authorities believe can be associated with a straightening of the profile or an improvement in the dental base relationship. 14-17 The possibility of such a change is denied by others who maintain that the changes are limited to the dentoalveolar structures.18l jy The voluble literature on the subject would suggest that, when excellent results are produced with this appliance, there must be a tendency for an improvement in the skeletal relationship of the jaws during growth while the appliance is being used. The possibility that a favorable change in skeletal pattern may occur in some cases as a bonus over and above dentoalveolar changes makes the functional appliance a useful part of the orthodontist’s armamentarium in treating the severe Class II, Division 1 irregularities. Among orthodontists who use the functional appliance as part of a combined treatment approach, there exists a deep philosophical schism. A few authoritieszO correctly point out that functional appliances of the Andresen type seem to work best in postnormal occlusions with two good arches ; on this basis, they direct their attention first to the correction of crowding and individual tooth positions, using the functional appliance at the end of treatment to adjust the occlusion. This is sometimes given the paradoxical label of ‘Lactive retention.“21 This program of combined treatment suffers from two grave disadvantages. First, we believe that it is a mistake to align arches perfectly, perhaps with fixed
Combined
Fig. 1. A, Severe Class II, Division 1 mabcchsion before proved molar relationship following preliminary treatment appliance. C, Final results following first premolar extraction technique. Retainers had been removed 19 months before
treatment
methods
583
treatment was started. 6, Imwith an Andresen removable and treatment with the Begg the final casts were secured.
appliances, and then run the risk of crowding the lower arch with the Andresen appliance which has a strong element of intermaxillary traction in its action. It seems preferable to use the functional appliance first (allowing the lower arch crowding to develop), safe in the knowledge that lower arch extraction and multiband therapy are to follow. Second, there is a strong body of opinion, if not evidence, that functional appliances work best during the parapubertal period when the growth spurt is taking place. IS extraction and multiband therapy are to precetle treatment with functional appliances, the dates of eruption of the permanent teeth dictate that functional appliances cannot be inserted before the age of 13 or 14 years--sometime after the pubertal growth spurt has begun. For this reason, it is preferable to use functional appliances as the initial treatment method. The following comhinccl treatment concerns a severe Angle Class II, IXvision 1 malocclusion with lower incisor crowding. It was treated first with an Andresen appliance. The final correction was achieved with multiband therapy using the Begg technique.
584
McCartney
Fig. 2. Occlusal dresen therapy.
and Richardson
views of the casts C, Nineteen months
Am.
J. Orthod. June 1973
illustrated in Fig. 1. A, Before treatment. B, After Anafter removal of retainers following Begg treatment.
Fig. 3. A, B, and C, Photographs of the Andresen appliance used in the preliminary ment of the case shown in Fig. 1. D, E, and F, Functional position of the Andresen nf-,ra nn rL- -1. -. _--.4 .“1 I:4c l~~~~~~~~urn ettect on the teeth and dental arches.
treatappti-
Combined
Fig.
4.
this
patient
Intraoral
for
views
Stage
illustrate Ill
in the
the
Begg
arch
wires
technique
and
after
auxiliary
removal
treatment
attachments
of
the
methods
as
four
first
applied
585
on
premolars.
Miss A. F., :~ged 11 years, had an Angle Cl:~s II, Division 1 malocclusion with a full unit. postnormality. The overjet measured 14 mm. The overbite was incomplete, the teeth wzrc Ixrgr, and tl~cr~ ~:IS crowding in both arches. There was an active tongue thrust On swallowing, an intrrdentnl sigmxtism, and a history Of thumbsucking. ‘I’hc oral hygiene {\-as poor, and the periodontal condition was only fnir. Figs. 1, A and 2, *4 show motlrl~ Iwfow treatment was started.
Mod& preynrwl 21 months later show the improwd in&01 and molar occlusal rt~lations ( Pig. 1, I<). Fig. 5, 1 ~hO\w tracings of the pretreatment cc@mlometric film and tlw film taken :rt the end of AAndrrsen trrntmtwt. It was suptrimposed on De Caster’s line. Two months 1ntcx1 all four first l)renlolnrs were extracted ant1 negg Stag-c> I arch wires were inserted after full I~anding. Six months later the patinrt was put into Stag<, II. This stage lasted only 3 months, as most of the cxtrnftion spaces had been used in treating the incisor crowding. Stage I11 lasted 8 months. Fig. -L, A and 7: sllO\w St?ge I1 T arch wires, tllc. upper mlterior auxiliary torquing arch, and the premolarand c:nninP-uprigliting springs in place. The patient
Ann. J. Orthod. June 1973
Fig.
5.
C,
Over-all
ment.
A,
Tracing changes
Continuous
illustrates for lines,
the both
effects
Andresen
of and
Andresen
therapy.
Begg
treatment.
8,
Effects
Interrupted
of
Begg lines,
therapy. pretreat-
posttreatment.
wore upper and lower removable retainers for 5 months. Figs. 1, C and 2, C show records 1 year 7 months following the removal of all retainers. Fig. 5, B and C shows superimposed tracings of the effects of Begg treatment over-all change.
the and
final the
Discussion
When Patient A. F. was seen at the age of 11 years with a gross Class II, Division 1 malocclusion, fixed appliance therapy was contraindicated by the poor oral hygiene and periodontal conditions. While extraction of four premolars, followed by Begg treatment, was envisioned from the start, the initial use of the Andresen appliance allowed time for the patient to adjust to orthodontic treatment and to attend to primary aspects of dental care. The improvement in occlusal relations that occurred while the Rntlresen appliance was being worn transformed a gross and challenging malocclusion into one which could be treated easily to a favorable eondlusion by the definitive fixed appliance therapy which followed. REFERENCES
1. Stockfish, H.: Possibilities and limitations of the Kinetor bimaxillary appliance, Trans. Eur. Orthod. Sot., pp. 317-328, 1971. 2. FrPnkel, R.: The guidance of eruption without extraction, Trans. Eur. Orthod. Sot., pp. 303-315, 1971. 3. Andresen, V., and H&upl, Ii.: Funktions-Kiefer orthopadie, Die Grundlagen des Norwegischen systems, ed. 3, Leipzig, 1942, Hermnnn Meusser. 4. Angle, E. H.: Malocclusion of the teeth, ed. 6, Philadelphia, 1900, S. S. White Dental Manufacturing Company. 5. Begg, P. R., and Kesling, P. C.: Begg orthodontic theory and technique, ed. 2, Philadelphia, 1971, W. B. Saunders Company. 6. Adams, C. P.: The design and construction of removable orthodontic appliances, ed. 4, Bristol 1970, John Wright & Sons, Ltd. 7. Dixon, D. A.: The evolution of the fixed appliance in orthodontic practice, Dent. Pmet. Dent. Rec. 22: 320-328, 1972. 8. Hill, C. V.: Controlled tooth movement, Dent. Pratt. Dent. Rec. 5: 2-13, 1954. 9. Adams, C. P.: Orthodontic doctrine and mechanical treatment methods, AM. J. ORTHOU. 46: 811.825, 1960.
10. Usiskin, L. A., and Webb, W. G.: A comprehensive treatment of the severe Class II, Div. 1 malocclusion, Dent. Pratt,. Dent. Rec. 21: 137-448, 1971. 11. Fogel, M. S., and 3lagil1, J. MM.: The combination technique, Aiw. J. ORTHOD. 49: 801-825,
1963. 12. Hovell, 5.: Is correction of postnormal occlusion in Class II cases necessary! Trans. Eur. O&hod. Rot., pp. 294-297, 1962. 13. Orton, H.: Some cases showing deliberate labial mowment of the upper incisor npiccs during the reduction of the owrjet, Trans. Br. Poe. Orthod., pp. 65.T4, 1966. 14. Gresham, H.: Mandibular changes in Andresrn treatment of Angle Class Tl malocclusion, N. 2. Dent. J. 48: 10-36, 1952. 15. Moss, J. I-‘.: Cephalometric changes during functional spplinnre therapy, Trans. Eur. Orthod. Sot., pp. 327-341, 1962. 16. Hawser, E.: Possibilities of functional treatment, Trans. Eur. Orthod. Sot., pp. 283291, 1969. 17. Trayfoot, J., and Richardson, A. : Angle Class 11, Div. 1 malocclusions treated by the Andresen method, Br. Dent. J. 124: 516-519, 1968. 18. Bjb;rk, A.: The principle of the Andresen method of orthodontic treatment, a discussion based on cephalometric x-ray analysis of treated casrs, AM. J. ORTHOD. 37: 437-458, 1951. 19. Parkhouse, R. C.: A cephalometric appraisal of cases of Angles Class II, Div. I malocclusion treated by the Andresen appliance, Dent. Pratt. Dent. Rec. 19: 425434, 1969. 20. Clinch, L.: Personal communication. 21. Demoge, P. H.: Symposium on multiband appliances, Trans. Br. Sot. Orthod., pp.
83-98. 1965. Grosvenor Rd.
Northern
M.D.S.,
L.D.S.,
D.D.O.,*
and
Andrew
Richardson,
M.Sc.,
Ireland
c
urrent orthodontic treatment methods have been evolved by highly skilled and experienced orthodontists throughout the world, and these various methods have come to be associated with names which are permanent on the orthotlontic* SCPI~~.Students trained by these strong and persuasive personalities often become so imbued with one man’s philosoph;v and treatment method that they specialize ill one technique to the exclusion of all others. Consequently, the mechanical treatment of Class II, Division 1 malocclusion has a geographic tlistribntion, tlcprnding more on the trailling, experience, and skills of the orthotlontist than on the precise nature OS the malocclusion to be treated. Up to the most recent past, the Class II, Division 1 malocclusion in Central Europe or Scandinavia would probably have been treated with a functional appliance1-3 ; in North America, with the edgewise mechanism4; in Australia, with Begg technique” ; and, in Britain, with removable appliances.” NOlY! rcv?ntly, ho\vcvtT, with the increasing interchange of personnel and i(lcas, orthotlontists in c.ountrics where functional and removable appliances i~n\-(a Latin the principal trt>atment methotl are coming to appreciate the ad~niltapcs of fixccl api)lianccs,+. 1 and there is stmrnt~c>\-idcnrc~that- the cxc*bange of i&as is also optrati1ig in the oppositck clirc~ction,” All philosophies and treatment proccclures have advantages and disad: antages, and therta BW signs that orthotlontists throughout the world are seeking out and applying the best features of more than one system in treating any one maloc~~lusion.‘” Semantically, the concept of combined treatment methods is not new. Fogel “Senior
Tutor,
Orthodontici
tkpartment,
The
QUWII’R
University
of
Belfast. 581
Awe. J. Orthod. Jww 1973
tech~liqzcc to dewribe a method anti Jlagill,1’ ha\-cl cwillecl the town combit/rrtio)l which, the>- belicrc, brings together the best features of the edgewise and Begg tc~chniqucs. The use of double buccal tubes on the molars and combination brackc~ts on the remaining teeth permits round and edgewise arch wires to be usccl at tliffercnt stages. The combinctl treatment to be described in this article brings together two treatment methods which differ fundamentally in their conception and ideology, one being a functional technique and t,he other a fixed applianrc tecliniquc. In the final analysis, the objective of treatment in Class 11, Division 1 malocelusion is reduction of the incisal overbite and overjet to improve function and appearance. Some authorities also stress the importance of correcting the occlusion of the posterior teeth, but others believe that a discrepancy in posterior occlusal relations is acceptable, provided the interdigitation is good.12 In eliminating ovcrjet, the upper incisors should be retracted but not retroc1ined.l” This is usually impossible to achieve with removable appliances in the severe malocclusion, since these appliances tend to tip teeth rather than move t’hem bodily. Thus, the extreme overjet, treated with removable appliances alone, tends to finish with either a residual overjet, which may jeopordize stability, or overretroclination of upper incisors which may be esthetically unsatisfactory. Fixed appliances, which offer the facility of apical control and root torque, are better suited to this procedure when palatal bodily movement of incisors is required but they suffer from the disadvantage that they involve greater chairside time and they pose greater problems of anchorage control and oral hygiene. Another approach to the extreme overjet is the functional appliance. These appliances can bring about a dramatic improvement which some authorities believe can be associated with a straightening of the profile or an improvement in the dental base relationship. 14-17 The possibility of such a change is denied by others who maintain that the changes are limited to the dentoalveolar structures.18l jy The voluble literature on the subject would suggest that, when excellent results are produced with this appliance, there must be a tendency for an improvement in the skeletal relationship of the jaws during growth while the appliance is being used. The possibility that a favorable change in skeletal pattern may occur in some cases as a bonus over and above dentoalveolar changes makes the functional appliance a useful part of the orthodontist’s armamentarium in treating the severe Class II, Division 1 irregularities. Among orthodontists who use the functional appliance as part of a combined treatment approach, there exists a deep philosophical schism. A few authoritieszO correctly point out that functional appliances of the Andresen type seem to work best in postnormal occlusions with two good arches ; on this basis, they direct their attention first to the correction of crowding and individual tooth positions, using the functional appliance at the end of treatment to adjust the occlusion. This is sometimes given the paradoxical label of ‘Lactive retention.“21 This program of combined treatment suffers from two grave disadvantages. First, we believe that it is a mistake to align arches perfectly, perhaps with fixed
Combined
Fig. 1. A, Severe Class II, Division 1 mabcchsion before proved molar relationship following preliminary treatment appliance. C, Final results following first premolar extraction technique. Retainers had been removed 19 months before
treatment
methods
583
treatment was started. 6, Imwith an Andresen removable and treatment with the Begg the final casts were secured.
appliances, and then run the risk of crowding the lower arch with the Andresen appliance which has a strong element of intermaxillary traction in its action. It seems preferable to use the functional appliance first (allowing the lower arch crowding to develop), safe in the knowledge that lower arch extraction and multiband therapy are to follow. Second, there is a strong body of opinion, if not evidence, that functional appliances work best during the parapubertal period when the growth spurt is taking place. IS extraction and multiband therapy are to precetle treatment with functional appliances, the dates of eruption of the permanent teeth dictate that functional appliances cannot be inserted before the age of 13 or 14 years--sometime after the pubertal growth spurt has begun. For this reason, it is preferable to use functional appliances as the initial treatment method. The following comhinccl treatment concerns a severe Angle Class II, IXvision 1 malocclusion with lower incisor crowding. It was treated first with an Andresen appliance. The final correction was achieved with multiband therapy using the Begg technique.
584
McCartney
Fig. 2. Occlusal dresen therapy.
and Richardson
views of the casts C, Nineteen months
Am.
J. Orthod. June 1973
illustrated in Fig. 1. A, Before treatment. B, After Anafter removal of retainers following Begg treatment.
Fig. 3. A, B, and C, Photographs of the Andresen appliance used in the preliminary ment of the case shown in Fig. 1. D, E, and F, Functional position of the Andresen nf-,ra nn rL- -1. -. _--.4 .“1 I:4c l~~~~~~~~urn ettect on the teeth and dental arches.
treatappti-
Combined
Fig.
4.
this
patient
Intraoral
for
views
Stage
illustrate Ill
in the
the
Begg
arch
wires
technique
and
after
auxiliary
removal
treatment
attachments
of
the
methods
as
four
first
applied
585
on
premolars.
Miss A. F., :~ged 11 years, had an Angle Cl:~s II, Division 1 malocclusion with a full unit. postnormality. The overjet measured 14 mm. The overbite was incomplete, the teeth wzrc Ixrgr, and tl~cr~ ~:IS crowding in both arches. There was an active tongue thrust On swallowing, an intrrdentnl sigmxtism, and a history Of thumbsucking. ‘I’hc oral hygiene {\-as poor, and the periodontal condition was only fnir. Figs. 1, A and 2, *4 show motlrl~ Iwfow treatment was started.
Mod& preynrwl 21 months later show the improwd in&01 and molar occlusal rt~lations ( Pig. 1, I<). Fig. 5, 1 ~hO\w tracings of the pretreatment cc@mlometric film and tlw film taken :rt the end of AAndrrsen trrntmtwt. It was suptrimposed on De Caster’s line. Two months 1ntcx1 all four first l)renlolnrs were extracted ant1 negg Stag-c> I arch wires were inserted after full I~anding. Six months later the patinrt was put into Stag<, II. This stage lasted only 3 months, as most of the cxtrnftion spaces had been used in treating the incisor crowding. Stage I11 lasted 8 months. Fig. -L, A and 7: sllO\w St?ge I1 T arch wires, tllc. upper mlterior auxiliary torquing arch, and the premolarand c:nninP-uprigliting springs in place. The patient
Ann. J. Orthod. June 1973
Fig.
5.
C,
Over-all
ment.
A,
Tracing changes
Continuous
illustrates for lines,
the both
effects
Andresen
of and
Andresen
therapy.
Begg
treatment.
8,
Effects
Interrupted
of
Begg lines,
therapy. pretreat-
posttreatment.
wore upper and lower removable retainers for 5 months. Figs. 1, C and 2, C show records 1 year 7 months following the removal of all retainers. Fig. 5, B and C shows superimposed tracings of the effects of Begg treatment over-all change.
the and
final the
Discussion
When Patient A. F. was seen at the age of 11 years with a gross Class II, Division 1 malocclusion, fixed appliance therapy was contraindicated by the poor oral hygiene and periodontal conditions. While extraction of four premolars, followed by Begg treatment, was envisioned from the start, the initial use of the Andresen appliance allowed time for the patient to adjust to orthodontic treatment and to attend to primary aspects of dental care. The improvement in occlusal relations that occurred while the Rntlresen appliance was being worn transformed a gross and challenging malocclusion into one which could be treated easily to a favorable eondlusion by the definitive fixed appliance therapy which followed. REFERENCES
1. Stockfish, H.: Possibilities and limitations of the Kinetor bimaxillary appliance, Trans. Eur. Orthod. Sot., pp. 317-328, 1971. 2. FrPnkel, R.: The guidance of eruption without extraction, Trans. Eur. Orthod. Sot., pp. 303-315, 1971. 3. Andresen, V., and H&upl, Ii.: Funktions-Kiefer orthopadie, Die Grundlagen des Norwegischen systems, ed. 3, Leipzig, 1942, Hermnnn Meusser. 4. Angle, E. H.: Malocclusion of the teeth, ed. 6, Philadelphia, 1900, S. S. White Dental Manufacturing Company. 5. Begg, P. R., and Kesling, P. C.: Begg orthodontic theory and technique, ed. 2, Philadelphia, 1971, W. B. Saunders Company. 6. Adams, C. P.: The design and construction of removable orthodontic appliances, ed. 4, Bristol 1970, John Wright & Sons, Ltd. 7. Dixon, D. A.: The evolution of the fixed appliance in orthodontic practice, Dent. Pmet. Dent. Rec. 22: 320-328, 1972. 8. Hill, C. V.: Controlled tooth movement, Dent. Pratt. Dent. Rec. 5: 2-13, 1954. 9. Adams, C. P.: Orthodontic doctrine and mechanical treatment methods, AM. J. ORTHOU. 46: 811.825, 1960.
10. Usiskin, L. A., and Webb, W. G.: A comprehensive treatment of the severe Class II, Div. 1 malocclusion, Dent. Pratt,. Dent. Rec. 21: 137-448, 1971. 11. Fogel, M. S., and 3lagil1, J. MM.: The combination technique, Aiw. J. ORTHOD. 49: 801-825,
1963. 12. Hovell, 5.: Is correction of postnormal occlusion in Class II cases necessary! Trans. Eur. O&hod. Rot., pp. 294-297, 1962. 13. Orton, H.: Some cases showing deliberate labial mowment of the upper incisor npiccs during the reduction of the owrjet, Trans. Br. Poe. Orthod., pp. 65.T4, 1966. 14. Gresham, H.: Mandibular changes in Andresrn treatment of Angle Class Tl malocclusion, N. 2. Dent. J. 48: 10-36, 1952. 15. Moss, J. I-‘.: Cephalometric changes during functional spplinnre therapy, Trans. Eur. Orthod. Sot., pp. 327-341, 1962. 16. Hawser, E.: Possibilities of functional treatment, Trans. Eur. Orthod. Sot., pp. 283291, 1969. 17. Trayfoot, J., and Richardson, A. : Angle Class 11, Div. 1 malocclusions treated by the Andresen method, Br. Dent. J. 124: 516-519, 1968. 18. Bjb;rk, A.: The principle of the Andresen method of orthodontic treatment, a discussion based on cephalometric x-ray analysis of treated casrs, AM. J. ORTHOD. 37: 437-458, 1951. 19. Parkhouse, R. C.: A cephalometric appraisal of cases of Angles Class II, Div. I malocclusion treated by the Andresen appliance, Dent. Pratt. Dent. Rec. 19: 425434, 1969. 20. Clinch, L.: Personal communication. 21. Demoge, P. H.: Symposium on multiband appliances, Trans. Br. Sot. Orthod., pp.
83-98. 1965. Grosvenor Rd.