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U n i v e r s i t y J D e n t S c i e 2 0 1 5 ; N o . 1 , V o l . 3 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 U n i v e r s i t y J o u r n a l o f D e n t a l S c i e n c e s , A n O f f i c i a l P u b l i c a t i o n o f A l i g a r h M u s l i m U n i v e r s i t y , A l i g a r h . I n d i a 1 0 U n i v e r s i t y J D e n t S c i e 2 0 1 5 ; N o . 1 , V o l . 3 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. U n i v e r s i t y J o u r n a l o f D e n t a l S c i e n c e s , A n O f f i c i a l P u b l i c a t i o n o f A l i g a r h M u s l i m U n i v e r s i t y , A l i g a r h . I n d i a 1 1 U n i v e r s i t y J D e n t S c i e 2 0 1 5 ; N o . 1 , V o l . 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 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 aetiological factors. Journal of Oral Health, Vol. 2 No. 2 April 1996 3. Khan RS, Horrocks EN. A study of adult orthodontic patients and their treatment. Br J Orthod,18(3):183–194; 1991. 4. Salzmann JA. Practice of orthodontics. Philadelphia: J. B. Lippincott Company; p. 701-24;1966. 5. McNamara, J.A.: Components of Class II malocclusion in children 8 10 years of age, Angle Orthod, 51:177-202; 1981. 6. Case C S. The question of extraction in orthodontia. American Journal of Orthodontics, 50: 660–691; 1964. 7. Case C S. The extraction debate of 1911 by Case, Dewey, and Cryer. Discussion of Case: the question of extraction in orthodontia. American Journal of Orthodontics, 50: DISCUSSION 900–912; 1964. Patient had improved soft tissue profile and smile after 8. Tweed C. Indications for the extraction of teeth in orthodontic treatment without undergoing extraction of any U n i v e r s i t y J o u r n a l o f D e n t a l S c i e n c e s , A n O f f i c i a l P u b l i c a t i o n o f A l i g a r h M u s l i m U n i v e r s i t y , A l i g a r h . I n d i a 1 2 U n i v e r s i t y J D e n t S c i e 2 0 1 5 ; N o . 1 , V o l . 3 orthodontic procedure. American Journal of Orthodontics 30: 405–428; 1944. 9. Cleall JF, Begole EA. Diagnosis and treatment of Class II Division 2 malocclusion. Angle Orthod 52:38-60; 1982. 10. Strang RHW. Tratado de ortodoncia. Buenos Aires: Editorial Bibliogra´fica Argentina; 1957. p. 560-70, 65771. 11. Bishara SE, Cummins DM, Jakobsen JR, Zaher AR. Dentofacial and soft tissue changes in Class II, Division 1 cases treated with and without extractions. Am J Orthod Dentofacial Orthop 107:28-37; 1995. Rock WP. Treatment of Class II malocclusions with removable appliances. Part 4. Class II Division 2 treatment. Br Dent J 168:298-302; 1990. U n i v e r s i t y J o u r n a l o f D e n t a l S c i e n c e s , A n O f f i c i a l P u b l i c a t i o n o f A l i g a r h M u s l i m U n i v e r s i t y , A l i g a r h . I n d i a 1 3