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CLINICAL DENTISTRY AND RESEARCH 2013; 37(3): 49-56 Case Report

Correspondence

Hande Grc Cokuner, DDSDepartment of Orthodontics,

Faculty of Dentistry,

Hacettepe University,

Shhye, 6100, Ankara / Turkey

Phone : +90 312 305 22 90

Fax : +90 312 309 11 38

E-mail: [email protected]

Hande Grc Cokuner, DDSResearch Assistant, Department of Orthodontics,

Faculty of Dentistry, Hacettepe University,

Ankara, Turkey

lken Kocadereli, DDS, PhDProfessor, Department of Orthodontics,

Faculty of Dentistry, Hacettepe University,

Ankara, Turkey

NONEXTRACTION TREATMENT OF AN ADULT WITH CLASS IIDIVISION 2 MALOCCLUSION

ABSTRACT

This case report describes the treatment of an adult with

Class II division 2 malocclusion. The patient had class II molar

and class II canine relationships, retroclined upper and lower

incisors, excessive deep bite and severe crowding. The patient

was treated by incisor protrusion and use of xed functionalappliance. An optimal molar and canine relationship was

achieved in 14 months.

Key words:Class II Division 2 Malocclusion, Fixed Functional

Appliance, Non-Extraction Treatment

Submitted for Publication:02.04.2013

Accepted for Publication :

10.07.2013


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CLINICAL DENTISTRY AND RESEARCH 2013; 37(3): 49-56 Olgu Bildirimi

Sorumlu Yazar

Hande Grc CokunerHacettepe niversitesi, Di Hekimlii Fakltesi,

Ortodonti Anabilim Dal

Shhiye, 6100, Ankara/Trkiye

Telefon: +90 312 305 22 90

Faks: +90 312 309 11 38

e-mail: [email protected]

Hande Grc CokunerAratrma Grevlisi, Hacettepe niversitesi Di Hekimlii Fakltesi,

Ortodonti Anabilim Dal,

Ankara, Trkiye

lken Kocadereli,Prof. Dr., Hacettepe niversitesi, Di Hekimlii Fakltesi,

Ortodonti Anabilim Dal,Ankara, Trkiye

SINIF II DVZYON 2 MALOKLZYONLU BR ERKNN EKMSZTEDAVS

ZET

Bu olgu raporunda Snf II divizyon 2 maloklzyona sahip erikin

hastann tedavisi anlatlmaktadr. Hastada snf II molar ve snf

II kanin ilikisi, diklemi st ve alt insizrler, ar deep bite ve

ciddi apraklk bulunmaktayd . Hastada insizr protrzyonu

ve sabit fonksiyonel aperey ile tedavi yapld. Optimum molar vekanin ilikisi 14 ayda saland.

Anahtar Kelimeler: Snf II Divizyon 2 Maloklzyon, Sabit

Fonksiyonel Aparey, ekimsiz Tedavi

Yayn Bavuru Tarihi : 04.02.2013

Yayna Kabul Tarihi :07.10.2013

50


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TREATMENT OF AN ADULT WITH CLASS II DIVISION 2 MALOCCLUSION

INTRODUCTION

Epidemiologic investigations have shown that in a

population 2-5% of individuals have Class II division 2

malocclusion.1,2 Retrusion of maxillary incisors is one of

the main characteristics of class II division 2 malocclusion.3

Therefore, rst step in the treatment strategy is to procline

the upper incisors by removable plates or protrusion

utility arches and converting Class II division 2 to a Class II

division 1. Later, class 2 mechanics are used for correction.4

In prepubertal or pubertal period, removable functional

appliances can be used but in postpubertal period usually

xed functional appliances are preferred.

CASE REPORT

23 year 1 month old white girl referred to Hacettepe

University, Faculty of Dentistry, Department of

Orthodontics with a chief complaint that she did not like hersmile because of the crowding of her anterior teeth. Her

medical and dental histories were unremarkable.

Extraoral examinations showed concave prole

with prominent chin and deep labiomental sulcus. In

anteroposterior projection no asymmetry was noticed.

Her lips were competent (Figure 1). Intraorally she had

class II molar and class II canine relationships in the right

and left segments (Figure 2). Mandibular dental midline

was centered relative to facial midline but maxillary dental

midline was 2 mm deviated to the right of facial midline.

The maxillary arch was square shaped with 8 mm crowding

(Figure 3). In mandibular arch there was 6 mm crowding inthe anterior region (Figure 4).

The panoramic x-rays showed no caries and no pathologies.

All permanent teeth were present, right maxillary and both

mandibular third molars were impacted (Figure 5).

Cephalometric examinations showed that both maxilla and

mandible were retrusive and mandible was more retrusive

with an ANB angle of 6. Lower anterior facial height was

in normal values with 46. Dentally, both the maxillary and

mandibular incisors were retroclined relative to cranial and

apical bases and there was excessive deepbite (Figures

6-8).Treatment Objectives

Our goals were to improve the patients facial esthetics and

to provide functional occlusion. According to Ricketts soft

tissue analysis, lower lip should be 2 mm behind E line. In

our case lower lip was -4 mm to Ricketts E line. To improve

Figure 1. Pretreatment facial photographs

Figure 2. Pretreatment intraoral photographs


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CLINICAL DENTISTRY AND RESEARCH

Figure 3. Pretreatment maxillary arch

Figure 6. Initial cephalometric radiograph

Figure 7. Initial cephalometric tracing

Figure 8. Initial cephalometric tracing-Ricketts

Figure 4. Pretreatment mandibular arch

Figure 5. Initial panoramic radiograph


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facial esthetics, we should make lips more prominent and

therefore, we planned nonextraction treatment strategy.

Dental treatment objectives included correction of class

II molar and canine relations, correction of deep bite

and correction of crowding by protrusion of incisors and

expansion of dental arches.

Treatment Alternatives

First treatment option was mandibular surgery after the

extraction of right and left mandibular rst premolars for

crowding and coordination of dental arches by expansion

and upper incisor proclination. Because of prominent chin,

after mandibular surgery genioplasty could be necessary.

The patient was not willing for surgical treatment.

Second treatment option was extraction treatment with

the extraction of upper rst premolar and lower second

premolar. In that case correction of crowding and class II

molar canine relationship would be easier but prole of

patient would worsen and correction of deep bite would be

dicult.

In non-extraction treatment crowding can be solved by

expansion of the arches and proclination of upper and

lower incisors. This would improve esthetics and correction

of deep bite would be easier so we decided to apply non-

extraction treatment.

Treatment Progress

After evaluation of the diagnostic records; the patient history

and the decision of the patient non-extraction orthodonticcorrection was chosen as the treatment strategy.

Expansion was started with the application of a quad-helix

appliance. Then, upper incisors were bonded and after

leveling with a utility arch, protrusion utility arch was placed

which has 45 intrusion bends. Concurrently mandibular

teeth were bonded and banded. After upper incisor

protraction, upper premolar and canines were bonded.

Later, for both upper and lower arches, 0,014 inch Ni-Ti,

0,016 inch Ni-Ti, 0,016x0,016 inch Ni-Ti and 0,016x0,016

stainless steel wires are used respectively. When upper and

lower leveling completed, 0.016x0.022 inch stainless steelwires were placed and Forsus Fatigue Resistant Device

(3M Unitek 2724 South Peck Road Monrovia, CA 91016

USA) was used. Five months later, Class I molar and canine

relationships were achieved. Forsus FRD was removed

and for occlusal settling intermaxillary elastics was used.

2 months later, after 14 months from the beginning of

treatment, patient was debonded.

During treatment, patient was instructed for extraction of

third molars, so all third molars were extracted in nishing

phase. For retention; Hawley retainers were placed above

upper and lower bonded lingual retainers and the patient

was instructed to wear them full time for one year. After

one year patient was called for periodic evaluation.

Treatment Results

Favorable facial changes were obtained (Figure 9). Lower

lip was forwarded 2 mm according to E plane. Ideal tooth

aspect was gained on full smile. Intraorally, deepbite was

resolved and ideal overjet and overbite relationships were

achieved. Maxillary and mandibular dental midlines were

coincident with facial midline and class 1 molar and canine

relationships were established (Figures 10, 11,12).

Cephalometrically, ANB angle decreased to 4 from 6 and

lower anterior facial height changed to 47 from 46. Upper

and lower incisors were proclined relative to cranial and

apical bases, and this proclination also helped the correction

of deepbite (Figures 13, 14, 15). In nal panoramic

radiograph, all third molars were extracted (Figure 16).

DISCUSSION

Usually, when treating patients who have 6 mm or more

crowding in the mandibular arch, we consider extraction.

But in the treatment of Class II division 2 malocclusion,

extraction would make the correction of deep bite dicult

and worsen the prole. In a case report, Asakawa et al. 5

treated a girl with Class II division 2 malocclusion who has

8 mm mandibular crowding without extraction. They stated

that if the patient was treated with premolar or incisor

extraction, proper overjet and overbite couldnt be obtained.

For the reasons mentioned above and to improve facial

prole we decided to treat the patient without extraction.

After leveling of maxillary and mandibular arches, we

corrected Class II molar and canine relationships by using

Forsus FRD. One of the main dental eects of Forsus

FRD is protrusion and intrusion of mandibular incisors

with labial tipping.6,7In our case both eects are seen and

also protrusion and intrusion of mandibular incisors had

favorable eect on correction of deepbite.

Proclination of lower incisors are considered to be a major

factor for gingival recession. In a study, Melsen et al.8

concluded that the risk of periodontal damage secondary to

protrusion of incisors is small. Also, Hasund et al.9noted that

mandibular incisors could be proclined more in the patients

with hypodivergent skeletal patterns and prominent chins.


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Figure 9. Posttreatment facial photographs

Figure 12.Posttreatment intraoral photographs

Figure 10.Posttreatment maxillary arch Figure 11.Posttreatment mandibular arch

In treatment of a Class II division 2 female, Asakawa et al. 5

also proclined upper and lower incisors signicantly, but at

the end of the treatment no periodontal damage was noted.

By proclination of upper and lower incisors, interincisal angle

decreased. In deepbite cases, it is chosen to achieve narrow

interincisal angle for stability. Riedel 10 proposed that at the

end of treatment, large interincisal angle is associated with

relapse of deep overbite.

Our treatment lasted in 14 months. If we take a look at

treatment durations of Class II division 2 malocclusions,

we see prolonged durations. Chen et al.11 treated a 42-

year old male with Class II division 2 malocclusion, deep


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deep bite and deep bite was corrected by incisor intrusion.

A 12 year old Class II division 2 male was also treated without

extraction and treatment duration was 14 months.16It was

similar with our treatment duration.

According to Prot 17; if Class II traction has proclined the

lower incisors more than 2 mm, permanent retention is

required. Usually patients are instructed to wear Hawley

retainers full time for one year, at night for an additional

year and later, return for periodic evaluation.11,16 In our

patient we used bonded lingual retainers and Hawley

retainers for retention.

CONCLUSIONS

Correction of Class II malocclusion without extraction

was achieved in 14 months. Class I molar and canine

Figure 13.Final cephalometric radiograph

Figure 14.Final cephalometric tracing

Figure 15. Final cephalometric tracing-Ricketts

Figure 16.Final panoramic radiograph

overbite and some missing teeth. The total treatment time

was 30 months. One of the reasons of excessive treatment

duration could be the age of the patient. There are

limited publications considering the relationship between

treatment duration and patient age.12,13 But in recent

articles comparing treatment duration no dierence was

found between adults and adolescents.14,15 Another reason

for prolonged treatment time in that patient could be incisor

intrusion for correction of deepbite. In our case by incisor

protrusion and using Forsus FRD, deepbite was resolved

and no other eort was taken for correction of deepbite.

In another case report, 14 year old Class II division 2 female

with severe crowding was treated without extraction.5

Treatment duration was 24 months. She also had severe


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relationships were obtained; favorable changes were seen

in patients prole, smile and aesthetics. Lower lip was

forwarded according to E plane so improvement in prole

was achieved. Upper arch was expanded and incisors were

proclined so patients smile was fulled and these results

improved her aesthetics.

REFERENCES

1.Ast DH, Carlos JP, Cons NC. The prevalence and characteristics of

malocclusion among senior high school students in upstate New

York. Am J Orthod 1965; 51: 437-445.

2. Ingervall B, Seeman L, Thilander B. Frequency of malocclusionand need of orthodontic treatment in 10-year old children in

Gothenburg. Sven Tandlaek Tidskr 1972; 65: 7-21.

3.Bishara SE. Class II Malocclusions: Diagnostic and Clinical

Considerations With and Without Treatment. Semin Orthod 2006;

12: 11-24.

4.Von Bremen J, Panscherz H. Eciency of Class II Division 1 and

Class II Division 2 Treatment in Relation to Dierent Treatment

Approaches. Semin Orthod 2003; 9: 87-92.

5.Asakawa S, Al-Musaallam T, Handelman CS. Nonextraction

treatment of a Class II deepbite malocclusion with severe

mandibular crowding: Visualized treatment objectives for selecting

treatment options. Am J Orthod Dentofacial Orthop 2008; 133:

308-316.

6. Aras A, Ada E, Saracolu H, Gezer NS, Aras I. Comparison of

treatments with the Forsus fatigue resistant device in relation

to skeletal maturity: A cephalometric and magnetic resonance

imaging study. Am J Orthod Dentofacial Orthop 2011; 140: 616-

625.

7. Jones G, Buschang PH, Kim KB, Oliver DR. Class II Non-Extraction

Patients Treated with the Forsus Fatigue Resistant Device Versus

Intermaxillary Elastics. Angle Orthodontist 2008; 78-2: 332-338.

8.Melsen B, Allais D. Factors of importance for the development

of dehiscences during labial movement of mandibular incisors: A

retrospective study of adult orthodontic patients. Am J Orthod

Dentofacial Orthop 2005; 127: 552-561.

9.Hasund A, Ulstein G. The position of incisors in relation to thelines NA and NB in dierent facial types. Am J Orthod 1970; 57:

1-14.

10. Riedel RA. A review of retrusion problem. Angle Orthod 1960;

30: 179-194.

11.Chen YJ, Yao CCJ, Chang HF. Nonsurgical correction of skeletal

deep overbite and Class II Division 2 malocclusion in an adult

patient. Am J Orthod Dentofacial Orthop 2004; 126: 371-378.

12.Chiappone RC. Special considerations for adult orthodontics. JClin Orthod 1976; 10: 535-545.

13. Barrer HG. The adult orthodontic patient . Am J Orthod 1977;

72: 617-640.

14.Robb SI, Sadowsky C, Schneider BJ, BeGole EA. Eectivenessand duration of orthodontic treatment in adults and adolescents.

Am J Orthod Dentofacial Orthop 1998; 113: 383-386.

15. Becker A, Chaushu S. Success rate and duration of orthodontic

treatment for adult patients with palatally impacted maxillary

canines. Am J Orthod Dentofacial Orthop 2003; 124: 509-514.

16. Ferreira SL. Class II Division 2 deep overbite malocclusion

correction with nonextraction therapy and Class II elastics. Am J

Orthod Dentofacial Orthop. 1998; 114: 166-175.

17. Prot WR. Retention. In: Prot WR, Fields HW Jr, editors.

Contemporary orthodontics. St. Louis: Mosby Year Book; 1993. P.

534-535.

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