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University J Dent Scie 2015; No. 1, Vol. 3

Abstract: We are presenting this case report to evaluate the management of skeletal Class II division 1 malocclusion in non-growing patient without extraction of upper first premolars. Clinical and cephalometric evaluation revealed skeletal Class II division 1 malocclusion with severe maxillary incisor proclination, convex profile, average mandibular plane angle, incompetent lips, increased overjet and overbite.Following fixed orthodontic treatment marked improvement in patient's smile, facial profile and lip competence were achieved and there was a remarkable increase in the patient's confidence and quality of life

1 2 3 4Sanjeev K. Verma1, Sanjay N. Gautam, Sandhya Maheshwari, Fehmi Miyan1,2 3Professor, JRIII, Department of Dental Orthopedics and Orthodontics,4Professor, Department of Orthodontics, Dental College, Azamgarh

INTRODUCTION : Class II div 1 malocclusion is more

prevalent than any type of malocclusion after Class I

malocclusion.[1-2]Over the last few decades, there are

increased number of adults who have become aware of

orthodontic treatment and are demanding high quality

treatment, in the shortest possible time with increased

efficiency andreduced costs[3]Class II div.1 malocclusions

can be treated by several means, according to the

characteristics associated with the problem, such as

anteroposterior discrepancy, age, and patient compliance.[4-

5]The indications for extractions in orthodontic practice have

historically been controversial.[6-8]On the other hand,

correction of Class II div.1 malocclusions in nongrowing

patients, with subsequent dental camouflage to mask the

skeletal discrepancy, can involve extractions of 2 maxillary

premolars.[9-10]The extraction of only 2 maxillary

premolars is generally indicated when there is no crowding or

cephalometric discrepancy in the mandibular arch.[11-

12]But fortunately some time with suitable mechanotherapy,

satisfactory results with an amazing degree of correction can

be achieved without extraction of permanent premolars.

CASE REPORT :

A 20 year old female reported to the Department Orthodontic

& Dentofacial Orthopedics at Dr. Z.A Dental College &

Hospital AMU Aligarh, with multiple complaints “My teeth

always stick out”, “I am unable to close my lips” “I feel

embarrassed when I laugh”.

Figure-1, Pretreatment Photographs

Figure-2, Pretreatment radiographs

CONSERVATIVE MANAGEMENT OF CLASS II DIV.1 MALOCCLUSION WITH SEVERELY PROCLINED MAXILLARY ANTERIOR IN A NONGROWING PATIENT

Journal of Dental Sciences

University

Keywords :ClassII div.1 malocclusion, severely proclined incisors Conservative management, Nongrowing patients

Source of support : NilConflict of Interest : None

OriginalResearch

Paper

PRETREATMENT ASSESSMENT :

Extra oral examination revealed an apparently Symmetrical,

Europrosopic face, convex hard and soft tissue profile, lip trap

and an acute nasolabial angle. The patient showed a good

range of mandibular movements and no TMJ symptoms. (Fig. 1)

Intra oral examination revealed that the patient had an End on

to Class II molar and canine relationship bilaterally,

excessively proclined maxillary incisors with an overjet of

11mm and overbite of 70%. (Fig. 1)

Cephalometric examination revealed Class II skeletal relation

with severe maxillary incisor proclinationwith

Normodivergent growth pattern. Although the underlying

sagittal jaw discrepancy was moderate with protrusive soft

tissue profile (fig.2 & table1)

The selective extraction of two permanent maxillary first

premolar teeth was considered acceptable. Our treatment

objective focused on the chief complaint of the patient, and

the treatment plan was individualized based on the specific

treatment goals

DIAGNOSIS :

Skeletal Class II division 1 malocclusion with severe

maxillary incisor proclination&spacing, convex profile,

average mandibular plane angle, lip trap, incompetent lips,

increased overjet & deep overbite.

PROBLEM LIST

1. Severely Proclined maxillary central incisors with

spacing

2. End on to class II molar and canine relation bilaterally

3. Increased overjet and overbite

4. Incompetent and protruded lips

5. Lip trap and deep mentolabial sulcus

6. Asymmetrical maxillary & mandibular arches

7. Class II Skeletal base

TREATMENT OBJECTIVES :

1. Correction of severely proclined maxillary incisors &

spacing.

2. Achieve lip competence and reduce the labiolmental

fold.

3. Develop an optimum overjet & overbite.

4. Alignment & leveling of upper & lower arches

5. Achieve occlusal intercuspation with a Class I molar &

canine relationship

6. Final settling of the occlusion and arch coordination.

7. Improve the soft tissue profile and facial esthetics.

Treatment alternatives

1. Because of this patient's stage of development, she did

not have significant maxillomandibular growth potential

left to assist in reaching the treatment goals with growth

modifications

2. Orthodontics with extraction of premolars, would help

camouflage some skeletal and dental aspects of the

malocclusion, improving esthetics and function

3. Conservative Nonextraction fixed mechanotherapy with

the help of utility arches and finishing elastics

TREATMENT PLAN :

After considering the findings, Nonextraction fixed

mechanotherapy was planned using MBT 0.022” slot

Preadjusted appliance, along with Rickets bioprogressive

therapy, using utility arches in the beginning of the treatment

to intrude as well as retract the severely proclined maxillary

CIs simultaneously.

TREATMENT PROGRESS :

Complete bonding & banding in both maxillary and

mandibular arch done, using MBT-0.022X0.028”slot.

Initially a 0.016X0.022” TMA wire is used to form a

customized utility arch to engage the brackets of maxillary

CIs, and in rest of the maxillary arch by using segmental arch

mechanics,a segmented 0.012 niti wire is placed for

alignment and leveling which was followed by 0.014 and

0.016 niti wires, a scheduled activation of utility arch was

done, after sufficient amount of retraction and intrusion of

maxillary CIs, a continuous 0.016 niti wire is placed in the

maxillaryarch along with 0.017X0.025” TMA wire utility

arch providing a single point contact between the CIs, for

further retraction and intrusion. After 6 month of alignment

and leveling utility arch and niti wires was stopped, 0.018

SS”wires are placed in both maxillary and mandibular

archfollowed by0.016X0.022”SS, 0.017X0.025”SS&

0.019X0.025”SS wires andclass II (1/4”blue) elastics were

given along with rectangular steel wiresto correct the molar

and canine relation followed by settling elastics for finishing,

detailing and proper intercuspation. Treatment is still

continued for further finishing & detailing.

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University J Dent Scie 2015; No. 1, Vol. 3

Figure-3 post treatment photograph

Figure -4 post treatment radiographs

POST TREATMENT ASSESSMENT

Extraoral examination reveals, Lip competence and a straight

profile were achieved,correction of lip trap and an increased

nasolabial angle was observed, improving the patient's facial

appearance. (fig.3)

Intraoral examination shows, A functional occlusion with

normal overjet and overbite; Class I molar and canine

relationship wasachieved along with correction of severely

proclined maxillary central incisors (fig.3)

Cephalometric analysis shows there is marked reduction in

the maxillary CIs proclination, improvement in the soft tissue

profile (fig.4 & table1)

Duration of the treatment was 18 months. The patient and her

parent were very happy with completesatisfaction.

Table-1 cephalometric findings

DISCUSSION

Patient had improved soft tissue profile and smile after

orthodontic treatment without undergoing extraction of any

teeth. Upper incisors were retracted to achieve normal

incisorinclinations, all the changes occurred because of

change in the position of point-A & point-B, after retraction of

maxillary CIs, position of point-A shifted more anteriorly,

changing SNA from 810 TO 820, ANB is decreased from 40

to 30.maxillary central incisors inclination and position

changes drastically as Mx1-NA linear & Mx1-NA angular

changes from 12mm to 7.2mm & 480 to 320respectively.

Marked change can be noticed in soft tissue profile of the

patient as protrusion of the lips is corrected as E-line & S-line

values are decreased, lip strain is relieved, nasolabial angle is

increased from 850 to 920making face more balance and

pleasant. Bilateral Class I molar and canine relationwas

achieved with maximum intercuspation. The case

wassuccessfully managed by contemporary orthodontic

technique.

Conclusion: Treatment of Class II malocclusion in adults

without extractions of premolars is challenging. A well-

chosen individualized treatment plan, undertaken with sound

biomechanical principles and appropriate control of

orthodontic mechanics to execute the plan is the surest way to

achieve predictable results with minimal side effects.

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