Download MANAGEMENT OF CLASS II MALOCCLUSION

Romanian Journal of Oral Rehabilitation
Vol. 5, No. 1, January - March 2013
MANAGEMENT OF CLASS II MALOCCLUSION - ORTHODONTIC
CAMOUFLAGE TREATMENT: CASE REPORT
Raluca Maria Mocanu, Cristian Romanec*, Andreea Ionescu, Irina Nicoleta Zetu
Department of Dentoalveolar and Oro-Maxillofacial Surgery, Faculty of Dental Medicine
*
Corresponding author:
Cristian Romanec, DMD, PhD
Department of Dentoalveolar and Oro-Maxillofacial Surgery
Faculty of Dental Medicine
University of Medicine and Pharmacy "Grigore T. Popa" - Iasi, Romania
0115
E-mail: [email protected]
ABSTRACT
In Class II malocclusion, a variety of treatment modalities have been presented in the literature. The camouflage
orthodontic is a treatment alternative, involving extraction of premolars. In the absence of an important
mandibular crowding, the interdental relations can be obtained by numerical reduction in the upper arch,
resulting in a Class II molar and a Class I canine relationship. It is important to choose ideal maxillary incisor
position over Class I posterior occlusion. This case report presents one such case of a 15 year old female, having
a skeletal Class II malocclusion with labial ectopic upper canines. The selective extraction of maxillary first
premolar was considered an acceptable compromised. Following treatment, great improvement in the aspect of
profile and smile were achieved and there was an
Key words: therapeutic class II occlusion, camouflage treatment.
obtain proper functional occlusion despite the
skeletal discrepancy) treatment and surgical
repositioning of the jaws [4]. The methods for
correcting class II malocclusion include:
extraoral appliances, functional appliances and
fixed appliances associated with class II
mechanics [5].
The camouflage treatment in class II
malocclusion includes extractions of 2
maxillary premolars or 2 maxillary and 2
mandibular premolars, depending on the
dento-alveolar characteristics [6, 7].
INTRODUCTION
Class II malocclusions represent a great
percentage of skeletal discrepancies. The
prevalence reported in literature varies:
Emrich and Brodie - 14% among children
who are between 12 and 14 years of age [1].
The treatment of these disorders depends on
diagnostic, age (growing or non-growing
patients), the skeletal pattern and patient
compliance [2].
Increasing number of adult patients has
become aware of their orthodontic problem
and is demanding quality treatment, in the
shortest possible time with increased
efficiency and reduced costs [3].
The main possible approaches to treat a
skeletal Class II malocclusion are: modification
of growth, camouflage (displacing the teeth to
CASE REPORT
A 15 year old female reported to the
Orthodontic Clinic with the chief complaint
of ectopic maxillary canines. No relevant
medical history was reported.
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Romanian Journal of Oral Rehabilitation
Vol. 5, No. 1, January - March 2013
The extra-oral examination (Fig.1)
revealed an oval shape of the figure, a
mesocephalic head shape, a mesoprosopic
asymmetrical face, a mild convex profile, an
acute naso-labial angle. The smile was
unaesthetic. The patient showed a good range
of mandibular movements and no temporomandibular-joint symptoms.
The intraoral examination revealed that the
patient had a Class II molar relationship (half
cusp on the left and full cusp on the right), an
increased overbite and labial displacement of
the maxillary canine.
The space for the canine alignment was
decreased. Both upper and lower arches were
asymmetric. The discrepancy in the upper
arch was 6 mm and in the lower arch was 4
mm.
Fig. 1. Extraoral aspect- before treatment
Fig. 2. Intraoral aspect- before treatment
Radiological examination revealed a
sagittal discrepancy (ANB = 5 ), with a
retrognatic mandible (SNB = 77 ) and the
proclination of lower incisors (IMPA = 100 ).
The soft tissue cephalometric analysis
(Arnett method) indicated: soft tissue A-TVL
= 0 mm, upper lip anterior-TVL = 3 mm,
lower lip anterior- TVL = 1 mm, soft tissue
B- TVL = -8 mm, soft tissue Pog-TVL = -5
mm and MX1-TVL = 9 mm (Fig. 3).
Treatment goals were: obtaining good
Fig. 3. Cephalometry- before treatment
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Romanian Journal of Oral Rehabilitation
Vol. 5, No. 1, January - March 2013
facial balance, obtaining optimal static and
functional occlusion and stability. The
treatment objectives which would lead to an
overall improvement of the hard- and softtissue profile and the facial aesthetics were: to
correct the canine displacement, to correct the
upper incisors long axis, to achieve an ideal
overjet and overbite, to achieve a flat occlusal
plane, to achieve an adequate functional
occlusal intercuspidation with a Class II
molar and a Class I canine relationship.
Treatment plan:
- Extraction of maxillary first premolars
- Alignment and leveling of the arches
- Closing the extraction space by retraction
of the maxillary canines followed by the
incisors
- Levelling the curve of Spee
- Settling the occlusion
- Retention
For anchorage control it was used a
transpalatal bar with Nance plate in the upper
arch and in the lower arch first molars were
banded. Both arches, from second premolar to
second premolar were bonded with a Roth slot
.022x .028 inch preadjusted fixed appliance.
arch. When correcting Class II malocclusion
in the permanent dentition, close attention
should be paid to three aspects: the A-P
horizontal relationship of the maxillary
incisor, the transverse midline relationship of
the maxillary incisor, the vertical position of
the maxillary incisor. The A-P horizontal
relationship of the maxillary incisor is
advocated by Arnett (1999) in the soft tissue
cephalometric analysis (STCA) [11]. The
position of maxillary incisor should be at 9
mm (female) and 12 mm (male) reported to
the true vertical line (TVL) in order to obtain
a proper facial aesthetic profile. Regarding
transverse midline relationship of the
maxillary incisor (Kokich 1999), a small
midline deviation (1-2mm) can be acceptable
as long as the midline is vertical and a canted
midline is unacceptable even if coincident
with the facial midline [12].
In the case being reported it was decided
to hide the mild skeletal discrepancy by
extracting the maxillary first premolars and
retracting the anterior teeth to improve the
profile of the patient and to obtain proper
functional occlusion. When taking the
decision to extract the following aspects were
evaluated: the current position of the
maxillary incisor 9mm from TVL, maxillary
crowding: 6mm.
The predicted movement in order to align
and level the upper arch was 3mm forward
resulting in a predicted maxillary incisor
position of 6mm from TVL which was
considered unacceptable. Because of the facts
mentioned before and because of the mild
crowding in the lower arch the decision was
to extract only the first two upper premolars.
The changes with the treatment developed
where achieved just a result of dental and
accompanying soft tissue profile changes and
there was no skeletal change (Fig. 4, Fig. 5,
Fig. 6).
The problem to discus in the cases with
extraction is the stability of the treatment
DISCUSSIONS
Treatment of a Class II patient requires
careful diagnosis and a treatment involving
aesthetic,
occlusal
and
functional
considerations [8]. When comparing the
alternative treatment plans, it also is
important to evaluate treatment efficiency,
determined by whether and to what extent the
treatment goals were met by improving dental
relationship and dento-facial aesthetics [9].
One of the camouflage options available is
the extraction of the maxillary premolars,
correcting the canine to a normal class I
relationship, leaving the molars in a class II
relationship [10].
In the absence of an important mandibular
crowding, the interdental relations can be
obtained by numerical reduction in the upper
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Romanian Journal of Oral Rehabilitation
Vol. 5, No. 1, January - March 2013
result. G Janson (2004) reports that treatment
with two maxillary premolar extractions gives
a better occlusal result than treatment with
four premolars extractions [10].
A number of studies undertaken in recent
years have led to the common conclusion that
the extractions of premolars in any sequence,
if undertaken after a thorough individual
diagnosis, are unlikely to lead to negative
profile effect [13, 14, 15, 16].
Fig. 4. Cephalometry- after treatment
Fig. 6. Extraoral aspect- before treatment
Fig. 6. Extraoral aspect- after treatment
profile changes and an overall satisfactory
facial aesthetics.
3. It is very important to evaluate the
aesthetic of the soft tissues and to choose
ideal maxillary incisor position over Class
I posterior occlusion.
CONCLUSIONS
1. Orthodontic treatment goals usually
include obtaining good facial balance,
optimal static and functional occlusion and
stability of the treatment results.
2. Extraction of premolars, if undertaken
after a complete diagnosis, leads to good
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Romanian Journal of Oral Rehabilitation
Vol. 5, No. 1, January - March 2013
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