Management of A Growing Skeletal Class II Patient: A Case Report
Management of A Growing Skeletal Class II Patient: A Case Report
Management of A Growing Skeletal Class II Patient: A Case Report
5005/jp-journals-10005-1187
Narendra Shriram Sharma
CASE REPORT
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TREATMENT PROGRESS
Treatment began with a bite for the twin block appliance
with a 7 mm sagittal advancement and a 5 mm vertical
opening in the premolar region (Fig. 4). The twin block
appliance was fabricated with a maxillary expander placed
Fig. 3: A positive VTO on the maxillary arch. The patient was instructed to wear
the appliance full-time except during meals and contact
This was to be followed by fixed-appliance therapy for sports. After 6 months of wear, the pterygoid response was
simultaneous intrusion and retraction of the anterior teeth achieved and trimming was started.
and finishing and detailing of the occlusion. The specific After 11 months of good compliance, the patient showed
treatment objectives were to (1) correct the skeletal AP a class I molar relationship with no dual bite and a
discrepancies with improvement of the soft-tissue profile, considerably improved facial profile. After removal of the
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appliance, we noted a class I molar relationship, an overjet The fixed appliances were debonded for a total treatment
of 2 mm, and increases of 2 and 1.5 mm in the maxillary time of 14 months (Fig. 6). The total treatment time was
intercanine and intermolar widths respectively. The approximately 25 months. The retainers were the
increased arch width in the canine regions had removed the thermoplastic type and used full-time, except during meals
occlusal interferences and settled the canines into a class I and brushing, for the first 12 months. After this period, the
relationship with adequate buccal clearance. She practiced retainers were switched to nocturnal use only for another
upper-lip exercises and an active anterior lip seal throughout 12 months.
the orthopedic treatment period.
MBT-prescription 0.018" brackets were then bonded. TREATMENT RESULTS
For the first 7 months of fixed-appliance therapy, we used All treatment objectives were achieved. The anterior lip trap
a removable transpalatal arch to maintain the vertical was corrected, and satisfactory dental alignment, normal
anchorage and sagittal expansion at the maxillary first overjet and overbite, and ideal class I molar and canine
molars, as well as 4.5 oz class II elastics to retain the sagittal relationships on both sides were established. The overall
correction. A utility arch was placed to intrude and retract facial balance was greatly improved. The post-treatment
the maxillary anterior teeth, closing the spaces. A Marcotte extraoral photographs showed a relaxed lip closure and an
3-piece intrusion arch was placed to intrude and retract the esthetically pleasing smile with a favorable smile arc. The
mandibular anterior teeth, closing the spaces (Fig. 5). After patient was satisfied with her teeth and profile.
10 months of fixed appliance treatment, the patient was In the panoramic radiograph (Fig. 7), root parallelism
highly satisfied with the treatment results. was good, and no apical resorption was observed. The
mandibular third molars were well-developed and movement of the chin, resulting in a harmonious basal
positioned. The cephalometric analysis (Table 2) indicated relationship (Fig. 8). Other factors contributing to the correction
that the AP relationship of the basal bone was improved. included sagittal and vertical maintenance of the maxillary
Superimposition of the cephalometric tracings revealed molars, intrusion and retraction of the maxillary anterior
a restriction in maxillary growth and considerable forward teeth and counterclockwise rotation of the occlusal plane.
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DISCUSSION
Class II malocclusions might have any number of
combinations of skeletal and dental components. So,
identifying and understanding the etiology and expression
of a class II malocclusion and forming the correct differential
diagnosis are essential for its correction, whether it is
orthodontic, orthopedic, surgical or a combination of these
modalities. From an etiologic perspective, few
malocclusions have one specific cause; more often, they
are the result of a combination of many factors in the inherent
predetermined growth potential of each patient. Thus, for
any malocclusion, especially a skeletal malocclusion,
multiple-factor treatment is superior to that of a single factor.
Previous studies regarding morphologic characteristics of
skeletal class II malocclusion present various and
contradicting opinions. But it is generally believed that a
skeletal class II malocclusion is often caused by some
combination of mandibular deficiency and maxillary excess.
The success of combination therapy (distal jet and Jasper
jumpers) in class II malocclusion suggests that the problem
is not concentrated in a single jaw (maxilla or mandible),
so a bimaxillary treatment design might achieve a better
result. Here, we treated a developing skeletal class II patient
with combination therapy using a twin block and SWA.
In this patient, the satisfactory occlusal and esthetic
results were due to significant dentoalveolar compensation Fig. 8: Superimposition of maxilla and mandible
and excellent patient compliance with the twin block. The 3. Tollaro L, Baccetti T, Franchi L, Tanasescu CD. Role of
changes contributing most to the correction of the initial posterior transverse interarch discrepancy in class II division l
malocclusion during the mixed dentition phase. Am J Orthod
dental and skeletal AP discrepancy were forward mandibular
Dentofacial Orthop 1996;110(4):417-422.
growth, maxillary incisor retroclination and distal en masse 4. Bacceti T, Franchi L, McNamara JA Jr, Tollaro I. Early
movement of the maxillary dentition with concurrent dentofacial features of class II malocclusion: a longitudinal study
alveolar remodeling. These changes produced a from the deciduous through the mixed dentition. Am J Orthod
counterclockwise rotation of the occlusal plane as expected Dentofacial Orthop 1997;111(5):502-509.
and improved the soft-tissue profile, with retrusion of the 5. Pancherz H, Hagg U. Dentofacial orhtopedics in relation to
upper lip and slight protrusion of the lower lip. Although somatic maturation. An analysis of 70 consecutive cases treated
with the Herbst appliance. Am J Orthod 1985;88(4):273-287.
the mandible rotated slightly clockwise (1.0°) still resulted
6. Hagg U, Pancherz H. Dentofacial orhtopaedics in relation to
in a class I occlusion. Although the upper anterior intrusion chronological age, growth period and skeletal development: An
and increased tonicity of the upper lip reduced the incisal analysis of 72 male patients with class II division 1 malocclusion
exposure, a complete passive lip seal could not be achieved. treated with the Herbst appliance. Eur J Orthod 1988;10(3):
On retrospective analysis, however, the treatment plan was 169-176.
justified by the results achieved. 7. McNamara JAJ; Brudon WL. Orthodontics and orthopedic
treatment in the mixed dentition. Ann Arbor: Needham Press;
CONCLUSION 1993.85-88 p.
8. McNamara JAJ, Peterson JEJ, Alexander RG. Three-
A good esthetic and functional result was achieved for this dimensional diagnosis and management of class II malocclusion
patient. This was achieved by employing a stepwise in the mixed dentition. Semin Orthod 1996;2(2):114-137.
functional advancement and two phase treatment protocol 9. Stockli PW, Teuscher UM. Combined activator headgear
that was tailored specifically to this patient’s needs. During orthopedics. In: Graber TM, Swain BF, editors. Orthodontics:
the treatment, oral hygiene was continually reinforced and Current principles and techniques. St. Louis: Mosby Company;
1985. 405-483 p.
treatment mechanics adjusted to simplify oral hygiene.
10. Mills CM, Mc Culloch KJ. Treatment effects of the twin block
This approach took advantage of the patient’s pubertal appliance: A cephalometric study. Am J Orthod Dentofacial
growth spurt to achieve a sagittal correction that otherwise Orthop 1998;114(1):15-24.
would have been a missed opportunity. Our case exemplifies 11. Antonarakis GS, Kiliaridis S. Short-term anteroposterior
the need for individualized treatment planning rather than treatment effects of functional appliances and extraoral traction
a cook-book approach in the management of dentofacial on class II malocclusion: A meta-analysis. Angle Orthod
2007;77(5):907-914.
deformities.
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