Wechsler 2012
Wechsler 2012
Wechsler 2012
This case report describes the treatment of an adult patient who had a Class II Division 1 malocclusion with
a severe overjet (13.5 mm), a deep overbite (7 mm, 100%), and spacing between the maxillary anterior teeth.
The purpose of this report is to demonstrate the importance of developing an individualized treatment plan,
tailored to the patient’s specific dental and skeletal problems, as well as to his or her needs and desires. Although
all indications pointed to a surgical intervention for this patient, her reluctance to undergo orthognathic
surgery led to an alternative treatment, which yielded a satisfactory result. (Am J Orthod Dentofacial Orthop
2012;142:95-105)
C
lass II Division 1 malocclusions are characterized DIAGNOSIS AND ETIOLOGY
primarily by the mandibular canines and molars The patient was a white woman, 51 years of age at
in distal relationships relative to the correspond- the time of consultation. Her chief complaint was the
ing maxillary teeth, as well as by protrusion of the unesthetic appearance of her smile. She also mentioned
maxillary anterior teeth. Treatment planning for such frequent irritation of her cheeks and palate, as well as
patients must take into consideration numerous factors, difficulty in chewing and maintaining proper oral hy-
including the soft-tissue profile, interlabial space, ratio giene, all of which she attributed to her malpositioned
of upper to lower face height, inclination of the occlusal teeth. She had regular checkups with her general dentist
plane, overbite, severity of the skeletal and dental Class II and, in the past, had been treated by a periodontist. She
relationships, growth potential, and posttreatment indicated some hypersensitivity of the maxillary anterior
stability. teeth to cold. She also mentioned that she had occa-
When considering orthodontic treatment for adults sional episodes of snoring, as well as some pain and
with such malocclusions, additional factors must be clicking in the area of the right temporomandibular
taken into account. Treatment goals and outcomes joint. Aside from an allergy to nuts, she was in good
might be affected by large restorations, missing teeth, health and took no medication. The etiology of her mal-
periodontal status, loss of papillae, gingival recession, occlusion appeared to be hereditary; she stated that her
and bone loss.1 An interdisciplinary approach, including father had a similar condition.
surgical intervention, is usually required. This case report The patient had a symmetrical, brachyfacial face (Fig
illustrates a severe skeletal discrepancy in an adult that 1). The profile was convex with a retrognathic mandible.
was successfully treated without orthognathic surgery. There was an increased labiomental fold of the lower lip
because of the increased overbite and diminished lower
a
Professor of orthodontics, Faculte de Medecine Dentaire, Universite de Mon- anterior face height. The chin-throat angle was ill-
treal; associate professor of orthodontics, Faculty of Dentistry, McGill University, defined. When she smiled, large buccal corridors were
Montreal, Quebec, Canada. visible.
b
Private practice, Toronto, Ontario, Canada.
c
Private practice, Montreal, Quebec, Canada. The patient had a Class II Division 1 malocclusion (Fig
d
Private practice, Lyon, France. 2). On both sides, the molars and the canines were in
The authors report no commercial, proprietary, or financial interest in the prod- Class II relationships. There were a severe, 7-mm overbite
ucts or companies described in this article.
Reprint requests to: Morris H. Wechsler, 5445 Rosedale Ave, Montreal, Quebec, and an overjet of 13.5 mm. Buccal crossbites existed bi-
H4V 2H7, Canada; e-mail, [email protected]. laterally at the level of the first and second maxillary pre-
Submitted, December 2010; revised and accepted, July 2011. molars, as well as at the level of the maxillary right third
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists. molar. The maxillary dental midline was deviated 1 mm
doi:10.1016/j.ajodo.2011.07.027 to the left, and the mandibular dental midline was
95
96 Wechsler et al
deviated 1 mm to the right. The maxillary dental arch The patient had a severe Class II skeletal malocclusion
was tapered and constricted, especially in the first molar with a retrognathic mandible and a hypodivergent pat-
area; the mandibular dental arch was also narrow, with tern (Fig 4; Table). According to the analysis of Steiner,2
lingual positioning of the mandibular second premolar. the maxilla was normally related to the cranial base
The curve of Spee was accentuated, and the maxillary (SNA, 82.5 ), whereas the mandible was severely retro-
and mandibular incisors were proclined, most marked gnathic (SNB, 72.6 ; normal, 80 ; ANB, 10 ). The McNa-
in the maxillary central incisors. There were diastemas mara analysis3 indicated that the maxilla was slightly
between the maxillary central and lateral incisors bilater- smaller than average (87.5 mm, average 91.0 mm). The
ally. effective length of the mandible was much shorter
The patient’s periodontal status was healthy, with an than average (97 mm, average 120 mm). The maxillo-
adequate band of attached gingiva and no discernible mandibular difference was 9.8 mm (average 29.2 mm).
dental mobility. Oral hygiene was adequate. Moderate The mandible was shorter than average (97 mm; nor-
generalized bone loss was observed and confirmed by ra- mal, 107 mm). The maxillomandibular difference was
diology, indicating a past history of active periodontitis. 7.5 mm (average, 22.4 mm). The Wits appraisal was
A periodontist confirmed the current healthy and stable 11.6 mm (average, 1.1 mm). The patient had a low man-
status of the periodontium. dibular plane angle (19 ). The maxillary and mandibular
All permanent teeth were present except for the max- incisors were proclined.
illary left third molar. Extensive restorations were pres-
ent on the maxillary and mandibular posterior teeth. TREATMENT OBJECTIVES
The condyles were symmetrical and appeared normal. The treatment objectives for this patient were to (1)
No pathology was noted (Fig 3). improve facial esthetics, (2) reduce the overbite and
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98 Wechsler et al
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Fig 5. Intraoral photographs during treatment, showing a removable maxillary anterior biteplate to dis-
articulate the occlusion and open the bite.
Fig 6. Intraoral photographs showing retraction of the maxillary anterior teeth via sliding mechanics.
American Journal of Orthodontics and Dentofacial Orthopedics July 2012 Vol 142 Issue 1
100 Wechsler et al
The posttreatment panoramic and periapical radio- composite resin on the mesial surfaces of the canines
graphs (Fig 9) show that there was little or no resorption and the distal surfaces of the lateral incisors. The pa-
of the roots of the maxillary and mandibular anterior tient's periodontal health remained stable throughout
teeth. The maxillary and mandibular bases remained treatment, with a healthy band of keratinized tissue.
relatively stable. The maxillary incisors were retracted The posttreatment panoramic and periapical radio-
and retroclined (Mx1-NA, 0.5 mm; Mx1-NA, 10 ), and graphs confirm that the bone levels remained stable
the mandibular teeth were advanced and proclined (Fig 9). However, there are no interdental papillae in
(Md1-NB, 8.5 mm; IMPA, 111 ) (Table; Fig 10). Com- some areas. There is evidence of an increased centric
parison of the soft-tissue profile in the pretreatment relation-centric occlusion shift.
and posttreatment cephalometric tracings indicates an As can be seen in the 3-year posttreatment photo-
improvement in the profile (Fig 11). Separate superim- graphs (Fig 13), there has been a remarkable improve-
positions of the pretreatment and posttreatment trac- ment in the occlusion after restoration of the maxillary
ings of the maxilla and the mandible show that the and mandibular posterior teeth. This seems to have
maxillary teeth appear to have been retracted palatally, helped to provide a stable result.
whereas the mandibular anterior teeth were proclined
labially (Fig 12).
At the end of treatment, some spacing remained DISCUSSION
distal to the maxillary right and left lateral incisors. The patient initially had all the classic characteristics
These spaces were reduced by the addition of of a Class II Division 1 malocclusion: hypodivergent
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American Journal of Orthodontics and Dentofacial Orthopedics July 2012 Vol 142 Issue 1
102 Wechsler et al
Fig 11. A, Superimposed initial and final cephalometric and continuously maintained mandibular advancement
tracings; B, superimposed cephalometric tracings at CC using the Herbst appliance. The mandibular advance-
(center of cranium, point of intersection of nasion-basion ment produced extensive remodeling and anterior relo-
line with facial axis line) and along the nasion-basion line. cation of the glenoid fossa; this contributed to anterior
mandibular positioning and an altered jaw relationship.
increased horizontal component of condylar growth, Voudouris et al9 stated that new bone formation in the
and anterior displacement of the mandible and the man- fossa was associated with continuous mandibular pro-
dibular dentitions. Although we cannot necessarily trusion. This was quantified by using computerized cal-
transfer the results from animal studies to humans, cified histologic sections. Again, this is unlikely in this
one could speculate that our patient's continuous patient at her age.
wearing of the Class II elastics might have acted in A third hypothesis is that some distal movement of
a similar manner to the action of functional appliances. the maxillary dentition might have occurred (Fig 11,
However, because of this patient's age, this hypothesis is B), resulting from the use of Class II elastics with sliding
unlikely. hooks against the maxillary molars.
Another hypothesis might be that the glenoid fossa Yet another explanation is based on the mesial move-
remodeled forward and downward. Woodside et al8 in- ment of the mandibular dentition from Class II elastics.
vestigated the remodeling changes in the condyle and This can be seen in the posttreatment cephalograms
glenoid fossa after a period of progressively activated (Figs 10 and 12) showing the proclination of the
July 2012 Vol 142 Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Wechsler et al 103
Fig 14. Cone-beam computed tomography scan of the bony temporomandibular joint showing the po-
sition of the right and left condyles on the posterior slope of the articular eminence with the patient in
centric occlusion, taken 3.5 years posttreatment.
mandibular incisors. Voudouris et al9 found mesial It is likely that a dual bite was produced in this pa-
movement of the mandibular arch in both experimental tient. A dual bite is present if the anteroposterior differ-
animals and human subjects. ence between centric relation and maximum intercuspal
American Journal of Orthodontics and Dentofacial Orthopedics July 2012 Vol 142 Issue 1
104 Wechsler et al
Fig 15. Cone-beam computed tomography scan of the temporomandibular joints 3.5 years posttreat-
ment: A, right joint, showing the position of the condyle on the posterior slope of the articular eminence;
B, left joint, showing the position of the condyle on the posterior slope of the articular eminence.
relation exceeds 2 mm, and if the 2 positions can be temporomandibular joints. This was done about 3.5
achieved by the patient.10 Our patient preferred to main- years after treatment. As can be seen in Figures 14 and
tain her mandible in an anterior maximal intercuspal po- 15, the condyles are positioned on the posterior slope
sition and experienced no subjective symptoms of of the articular eminence when the patient is positioned
mandibular dysfunction. The pain and clicking in the in centric occlusion (maximal intercuspation). Figure 15
right temporomandibular joint has disappeared. also shows the tomographic images of the condyles rel-
A combination of any or all of the above factors could ative to the posterior slope of the articular eminence with
have occurred. In this patient, the objectives were most the mandible in centric occlusion. The patient indicated
likely achieved by an anterior shift of the mandible as that this was the most comfortable position for her;
well as by dentoalveolar changes. There was proclination when it was attempted to manipulate the mandible pos-
of the mandibular incisors and retroclination of the teriorly, she was uncomfortable.
maxillary incisors; these brought about the reduction As can be seen in the intraoral and extraoral photo-
of the overjet. By flattening the curve of Spee, the over- graphs taken 3 years after treatment and after prosthetic
bite was reduced. restoration (Fig 13), the patient has a good functional
One last item to be considered is the remaining dia- occlusion and a pleasing esthetic result, both intraorally
stemas at the end of treatment. The difficulty in closing and facially, and the occlusion has remained stable.
the diastemas distal to the maxillary lateral incisors ap-
pears to be due to an excess of tooth width in the man- CONCLUSIONS
dibular anterior teeth relative to the maxillary anterior
The treatment option selected for this patient met her
teeth, as indicated by the Bolton anterior ratio of 81.3
esthetic expectations and gave her a pain-free, well-
(mean anterior ratio, 77.2).11 This was further exacer-
functioning (no noises from the joint), and seemingly
bated by the need for interproximal stripping of the max-
stable occlusion. It is interesting that a patient, who ini-
illary central incisors to reduce the appearance of open
tially seemed to need a treatment plan including surgical
embrasures and improve the esthetics. The open embra-
intervention, was successfully managed nonsurgically
sures might have been caused by the healthy but reduced
and without extractions. In this patient, dental compen-
periodontium.12 The contact points between the maxil-
sation permitted the achievement of a harmonious smile
lary central and lateral incisors might have been more
and a pleasing soft-tissue profile. This emphasizes the
than 5 mm from the crestal bone, thus increasing the
notion that, in some cases, responding to the patient’s
likelihood of open embrasures.13 Nevertheless, this was
chief complaint might take precedence over the clini-
a satisfactory compromise, since we achieved the main
cian’s desire to achieve ideal orthodontic goals.
objectives of treatment for this patient.
To verify which of the above proposed hypotheses is We thank Ann Wechsler for her assistance with the
correct, it was decided (with the patient’s consent) to preparation of the manuscript; Jack Turkewicz, Jean-
take cone-beam computed tomography scans of her Marc Retrouvey, and Claude Remise for reviewing the
July 2012 Vol 142 Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Wechsler et al 105
manuscript and for helpful suggestions; Howard Cytry- 7. Voudouris JC, Woodside DG, Altuna G, Kuftinec MM,
niak for his skillful prosthetic restoration; and Louis Fro- Angelopoulos G, Bourque PJ. Condyle-fossa modifications and
muscle interactions during Herbst treatment, part 1. New techno-
nenberg for his assistance in obtaining the cone-beam
logical methods. Am J Orthod Dentofacial Orthop 2003;123:
computed tomography scans; also thanks to Mourad 604-13.
Benmiloud, for his technical assistance in the prepara- 8. Woodside DG, Metaxas A, Altuna G. The influence of functional
tion of this article. appliance therapy on glenoid fossa remodeling. Am J Orthod Den-
tofacial Orthop 1987;92:181-98.
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