CASE REPORT
An American Board of Orthodontics case report A nonsurgical and nonextraction approach in the treatment of a skeletal and dental Class I I I malocclusion in a growing patient John N. Fox, DDS, MS
Poplar Bh~f, Mo. This case report is presented following the specifications of the American Board of Orthodontics. The patient had a true maxillary retrognathism, a mandibular prognathism, and a lower anterior height deficiency. She was treated with a fixed orthopedic appliance, fixed orthodontic appliances, and intermaxillary elastics. [This case was presented to the American Board of Orthodontics in partial fulfillment of the requirement for the certification 3rocess conducted by the Board.] (AM J ORTHOD DENTOFAC ORTHOP 1990;98:470-5.)
CASE REPORT DIAGNOSIS/DENTAL AND CEPHALOMETRIC FINDINGS The patient had a Class III molar relationship in bilateral crossbite. The anterior crossbite produced an underbite of 8 mm and an underjct of 3 mm. The midlines of each arch had shifted approximately 2 mm to the right of the facial median line. The mandibular arch length measured an additional 3 mm. The mandibular arch form was ovoid and tapering with a moderate curve of Spee (Fig. !). Cephalometric analysis showed a skeletal dysplasia with a midface deficiency (retrognathism) and a mandibular prog814114462
nathism (SNA and SNB of 79 ° and 83.5 °, respectively). The lower anterior facial height was deficient at 59 mm. The dentoalveolar description showed the mandibular incisors were in retrusion with a Frankfort mandibular incisor angle of 75" and were in anterior crossbite with the maxillary incisors. The upper pharynx appeared blocked with an obstruction measuring 3 ram, thus affecting the nasal passage. The soft-tissue analysis showed a profile with a prognathic mandible and a deficient maxilla (Z angle of 85 ° and E line of - 4 mm) (Fig. 2). On each side of the mandibular arch the panoral radiograph showed a retained mandibular left deciduous second molar with a second premolar erupting. All four third molars were forming. The crestal bone and the root
Fig. 1. Models at start. 470
Volume 98 Number 5
Case report
JJ
12-0
f Fig. 2. Cephalometric tracing at start.
Fig. 3. Extraoral photographs at start.
Fig. 4. Extraoral photographs (active treatment completed).
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Am. J. Orthod. Dentofac. Orthop. November 1990
Fox
Fig. 5. Models (active treatment completed).
formation of the teeth appeared to be within normal limits. The patient was in good oral health.
JJ 16- I
HISTORY/FACIAL APPEARANCE
The patient was an I 1-year-old girl in good health. Her build was mesomorphic. She weighed 115 pounds and was 5 feet 6 inches tall. She had a long, ovoid-tapering face and a mesocephalie head. Her profile appeared to be prognathic, but on a closer inspection, it appeared that there was also a maxillary deficiency (Fig. 3). The mentalis and perioral musculature was abnormal. The pattern of eruption appeared to have been normal. The patient was very concerned about her "underbite," and motivation did not seem to be a problem.
ETIOLOGY f
Fig. 6. Cephalometric tracing (active treatment completed).
Heredity was the causative factor in the growth of the patient's malocclusion.
Volume 98 Number 5
Case report
Fig. 7. Models (2 years in retention).
Fig. 8. Extraoral photographs (2 years in retention).
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Fox
maxillary arch. The patient activated the device 0.5 mm daily until the desired expansion was achieved. A series of round arch wires leveled and aligned the teeth. Crossbite and Class III elastics brought the malocclusion under control. A set of idealized 0.019 x 0.025 inch rectangular arch wires detailed the occlusion. Although the profile was not ideal, the parents were pleased with the appearance of the teeth and opted not to have the orthognathie surgery (Fig. 4). The appliances were removed, and the retention phase of treatment with a removable retainer and a cemented mandibular lingual arch was started. TREATMENT PROGRESS
Treatment progressed ahead of schedule because the correction of the malocclusion did not require orthognathic surgery. The patient cooperated at every step of treatment (i.e., activating the expander, wearing the elastics). The appointments during active treatment were weekly during expansion, then every 4 to 6 weeks. The length of active treatment was 27 months. RESULTS ACHIEVED
The attained occlusion was functionally normal (Fig. 5). The facial features were improved. The molar and cuspid relationships were correct. The facial growth of the patient was favorable for this situation. The maxilla grew vertically, with some anterior growth. This caused the mandible to autorotate downward and backward (SNB of 77.5 ° instead of 83.5°). Other cephalometric measurements were within acceptable limits. For example, the lower anterior facial height measured 65 mm instead of the original 59 mm (Fig. 6). The panoral radiograph showed some blunting of the apices of the anterior teeth.
Fig. 9. Superimposed tracings. A, 12-16 years, showing treatment changes. B, Posttreatment, 16-18 years, showing no change.
TREATMENT PLAN
On the basis of the severity of the Class III malocclusion, the available space on the mandibular arch, and the fact that the patient was going to be evaluated for possible orthognathic surgery, it was decided not to extract any teeth. The patient was placed on a longitudinal growth study, which included radiographic lateral head films and wrist films every 6 months. When the patient's growth was determined to be slowing or stopped, active treatment was to begin. The goals of treatment were expansion of the maxillary arch, alignment of the arches to fit the individual bones and not each other, and correction of the skeletal dysplasia by maxillofacial surgery. A 0.022 x 0.028 inch edgewise appliance was placed. A hygienic rapid palatal expander (RPE) was cemented to the
SECONDARY TREATMENT
After an acceptable occlusion was attained, the appliances were removed. The patient received a removable maxillary retainer to be worn 24 hours daily. A cemented canine-tocanine lingual arch was placed in the mandibular arch. The use of the maxillary retainer was to be decreased gradually over a period of 2 years to a few hours a month. The cemented lower lingual arch retainer was to be in place for 2 years. FINAL EVALUATION
The results were acceptable. The dental objectives of treatment were met without orthognathic surgery. The dental prognosis for stability was good. The maxillary arch has been out of retention for 7 months, and the mandibular arch has recently been released from retention. The overjet and overbite were judged to be excellent (Fig. 7). The tooth relationship has some rotations of second premolars (they erupted in that manner and relapsed); therefore it has been judged good. Panoral radiographic evaluation showed four impacted third molars. The patient was instructed to have these molars ex-
Volume 98 Number 5
Case report
tracted. Also, some blunting of the apices of anterior teeth was detected. The patient's facial features were more than acceptable (Fig. 8). The need for orthognathic surgery was eliminated after correction of the malocclusion (Fig. 9). The result might have been improved if the mandibular left and maxillary right
475
second premolars had been treated with a circumferential supracrestal fibrotomy. Reprint requests to: Dr. John N. Fox 1520 Highland Place Poplar Bluff, MO 63901
AAO MEETING CALENDAR
1991--Seattle, Wash., May 11 to 15, Seattle Convention Center 1992--St. Louis, Mo., May 10 to 13, St. Louis Convention Center 1993--Toronto, Canada, May 16 to 19, Metropolitan Toronto Convention Center 1994--Orlando, Fla., May 1 to 4, Orange County Convention and Civic Center 1995--San Francisco, Calif., May 7 to 10, Moscone Convention Center 1 9 9 6 n Denver, Colo., May 12-15, Colorado Convention Center
An American Board of Orthodontics case report A nonsurgical and nonextraction approach in the treatment of a skeletal and dental Class I I I malocclusion in a growing patient John N. Fox, DDS, MS
Poplar Bh~f, Mo. This case report is presented following the specifications of the American Board of Orthodontics. The patient had a true maxillary retrognathism, a mandibular prognathism, and a lower anterior height deficiency. She was treated with a fixed orthopedic appliance, fixed orthodontic appliances, and intermaxillary elastics. [This case was presented to the American Board of Orthodontics in partial fulfillment of the requirement for the certification 3rocess conducted by the Board.] (AM J ORTHOD DENTOFAC ORTHOP 1990;98:470-5.)
CASE REPORT DIAGNOSIS/DENTAL AND CEPHALOMETRIC FINDINGS The patient had a Class III molar relationship in bilateral crossbite. The anterior crossbite produced an underbite of 8 mm and an underjct of 3 mm. The midlines of each arch had shifted approximately 2 mm to the right of the facial median line. The mandibular arch length measured an additional 3 mm. The mandibular arch form was ovoid and tapering with a moderate curve of Spee (Fig. !). Cephalometric analysis showed a skeletal dysplasia with a midface deficiency (retrognathism) and a mandibular prog814114462
nathism (SNA and SNB of 79 ° and 83.5 °, respectively). The lower anterior facial height was deficient at 59 mm. The dentoalveolar description showed the mandibular incisors were in retrusion with a Frankfort mandibular incisor angle of 75" and were in anterior crossbite with the maxillary incisors. The upper pharynx appeared blocked with an obstruction measuring 3 ram, thus affecting the nasal passage. The soft-tissue analysis showed a profile with a prognathic mandible and a deficient maxilla (Z angle of 85 ° and E line of - 4 mm) (Fig. 2). On each side of the mandibular arch the panoral radiograph showed a retained mandibular left deciduous second molar with a second premolar erupting. All four third molars were forming. The crestal bone and the root
Fig. 1. Models at start. 470
Volume 98 Number 5
Case report
JJ
12-0
f Fig. 2. Cephalometric tracing at start.
Fig. 3. Extraoral photographs at start.
Fig. 4. Extraoral photographs (active treatment completed).
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472
Am. J. Orthod. Dentofac. Orthop. November 1990
Fox
Fig. 5. Models (active treatment completed).
formation of the teeth appeared to be within normal limits. The patient was in good oral health.
JJ 16- I
HISTORY/FACIAL APPEARANCE
The patient was an I 1-year-old girl in good health. Her build was mesomorphic. She weighed 115 pounds and was 5 feet 6 inches tall. She had a long, ovoid-tapering face and a mesocephalie head. Her profile appeared to be prognathic, but on a closer inspection, it appeared that there was also a maxillary deficiency (Fig. 3). The mentalis and perioral musculature was abnormal. The pattern of eruption appeared to have been normal. The patient was very concerned about her "underbite," and motivation did not seem to be a problem.
ETIOLOGY f
Fig. 6. Cephalometric tracing (active treatment completed).
Heredity was the causative factor in the growth of the patient's malocclusion.
Volume 98 Number 5
Case report
Fig. 7. Models (2 years in retention).
Fig. 8. Extraoral photographs (2 years in retention).
473
474
Am. J. Orthod. Dentofac. Orthop. November 1990
Fox
maxillary arch. The patient activated the device 0.5 mm daily until the desired expansion was achieved. A series of round arch wires leveled and aligned the teeth. Crossbite and Class III elastics brought the malocclusion under control. A set of idealized 0.019 x 0.025 inch rectangular arch wires detailed the occlusion. Although the profile was not ideal, the parents were pleased with the appearance of the teeth and opted not to have the orthognathie surgery (Fig. 4). The appliances were removed, and the retention phase of treatment with a removable retainer and a cemented mandibular lingual arch was started. TREATMENT PROGRESS
Treatment progressed ahead of schedule because the correction of the malocclusion did not require orthognathic surgery. The patient cooperated at every step of treatment (i.e., activating the expander, wearing the elastics). The appointments during active treatment were weekly during expansion, then every 4 to 6 weeks. The length of active treatment was 27 months. RESULTS ACHIEVED
The attained occlusion was functionally normal (Fig. 5). The facial features were improved. The molar and cuspid relationships were correct. The facial growth of the patient was favorable for this situation. The maxilla grew vertically, with some anterior growth. This caused the mandible to autorotate downward and backward (SNB of 77.5 ° instead of 83.5°). Other cephalometric measurements were within acceptable limits. For example, the lower anterior facial height measured 65 mm instead of the original 59 mm (Fig. 6). The panoral radiograph showed some blunting of the apices of the anterior teeth.
Fig. 9. Superimposed tracings. A, 12-16 years, showing treatment changes. B, Posttreatment, 16-18 years, showing no change.
TREATMENT PLAN
On the basis of the severity of the Class III malocclusion, the available space on the mandibular arch, and the fact that the patient was going to be evaluated for possible orthognathic surgery, it was decided not to extract any teeth. The patient was placed on a longitudinal growth study, which included radiographic lateral head films and wrist films every 6 months. When the patient's growth was determined to be slowing or stopped, active treatment was to begin. The goals of treatment were expansion of the maxillary arch, alignment of the arches to fit the individual bones and not each other, and correction of the skeletal dysplasia by maxillofacial surgery. A 0.022 x 0.028 inch edgewise appliance was placed. A hygienic rapid palatal expander (RPE) was cemented to the
SECONDARY TREATMENT
After an acceptable occlusion was attained, the appliances were removed. The patient received a removable maxillary retainer to be worn 24 hours daily. A cemented canine-tocanine lingual arch was placed in the mandibular arch. The use of the maxillary retainer was to be decreased gradually over a period of 2 years to a few hours a month. The cemented lower lingual arch retainer was to be in place for 2 years. FINAL EVALUATION
The results were acceptable. The dental objectives of treatment were met without orthognathic surgery. The dental prognosis for stability was good. The maxillary arch has been out of retention for 7 months, and the mandibular arch has recently been released from retention. The overjet and overbite were judged to be excellent (Fig. 7). The tooth relationship has some rotations of second premolars (they erupted in that manner and relapsed); therefore it has been judged good. Panoral radiographic evaluation showed four impacted third molars. The patient was instructed to have these molars ex-
Volume 98 Number 5
Case report
tracted. Also, some blunting of the apices of anterior teeth was detected. The patient's facial features were more than acceptable (Fig. 8). The need for orthognathic surgery was eliminated after correction of the malocclusion (Fig. 9). The result might have been improved if the mandibular left and maxillary right
475
second premolars had been treated with a circumferential supracrestal fibrotomy. Reprint requests to: Dr. John N. Fox 1520 Highland Place Poplar Bluff, MO 63901
AAO MEETING CALENDAR
1991--Seattle, Wash., May 11 to 15, Seattle Convention Center 1992--St. Louis, Mo., May 10 to 13, St. Louis Convention Center 1993--Toronto, Canada, May 16 to 19, Metropolitan Toronto Convention Center 1994--Orlando, Fla., May 1 to 4, Orange County Convention and Civic Center 1995--San Francisco, Calif., May 7 to 10, Moscone Convention Center 1 9 9 6 n Denver, Colo., May 12-15, Colorado Convention Center
