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University
Journal of
Dental Sciences
CONSERVATIVE MANAGEMENT OF CLASS II
DIV.1 MALOCCLUSION WITH SEVERELY PROCLINED
MAXILLARY ANTERIOR IN A NONGROWING PATIENT
Original
Research
Paper
1
Sanjeev K. Verma1, 2Sanjay N. Gautam, 3Sandhya Maheshwari, 4Fehmi Miyan
Professor, 3JRIII, Department of Dental Orthopedics and Orthodontics,
4
Professor, Department of Orthodontics, Dental College, Azamgarh
1,2
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
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.[45]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.[1112]But fortunately some time with suitable mechanotherapy,
satisfactory results with an amazing degree of correction can
be achieved without extraction of permanent premolars.
Keywords :
ClassII div.1 malocclusion,
severely proclined incisors
Conservative management,
Nongrowing patients
Source of support : Nil
Conflict of Interest : None
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
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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 &
6.
7.
1.
2.
3.
canine relationship
Final settling of the occlusion and arch coordination.
Improve the soft tissue profile and facial esthetics.
Treatment alternatives
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
Orthodontics with extraction of premolars, would help
camouflage some skeletal and dental aspects of the
malocclusion, improving esthetics and function
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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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
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 wellchosen 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.
References :
1. Hossain MZ et al, Prevalence of malocclusion and
treatment facilities at Dhaka Dental College and
Hospital. Journal of Oral Health, vol: 1, No. 1, 1994
2. Ahmed N et al, Prevalence of malocclusion and its
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April 1996
3. Khan RS, Horrocks EN. A study of adult orthodontic
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4. Salzmann JA. Practice of orthodontics. Philadelphia: J.
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5. McNamara, J.A.: Components of Class II malocclusion
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Patient had improved soft tissue profile and smile after
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