American Journal of ORTHODONTICS and DENTOFACIAL ORTHOPEDICS Founded in 1915--Seven~'-five )'ears
Volunze 98 Number 4
October 1990
of continuous publication Copyright © 1990 by Mosby-Year Book, Inc.
CASE REPORT
An American Board of Orthodontics case report Philippe L. Angelle, DMD, MS Paris, France
A case of a Class I malocclusion with a steep mandibular plane angle, a bimaxillary protrusion, and a congenitally missing lower premolar is reported. [This case was presented to the American Board of Orthodontics in partial fulfillment of the requirements for the certification process conducted by the Board.] (AMJ ORTHODDENTOFACORTHOP 1990;98:285-91.)
I n mandibular angle cases, it is very easy, during orthodontic treatment, to elongate molars and increase vertical dimension with an unfavorable facial change resulting. The orthodontist has the ability to make dramatic 814110429
facial changes through tooth movement and growth control. Growth trend should be determined before treatment; vertical mechanics should be used with extreme caution; and mechanics involved should control vertical growth. The following case report describes the treatment of a patient with a steep mandibular plane angle, a
Fig. 1, A through E. Pretreatment study casts at 13 years 6 months.
285
286
Am. J. Orthod. Dentofac. Orthop. October 1990
Angelle
Fig. 2, A and B. Pretreatment facial photographs at 13 years 6 months.
Fig. 3, A through C. Pretreatment intraoral photographs at 13 years 6 months.
bimaxillary protrusion, and a congenitally missing lower premolar. CASE REPORT HISTORY AND GENERAL CLINICAL PICTURE
The patient was a boy 13 years 6 months of age at the start of treatment. His general health was excellent and there were no conditions present that would contraindicate treat-
ment. His childhood growth and development were apparently normal. Tonsils and adenoids were present. Oral tissues appeared to be healthy and the dentition in a good state of repair, with no carious lesions present. No detrimental habits were noted. Both parents had the appearance of a double protrusion. As a result of this observation and the fact that the boy's sister had a similar malocclusion, hereditary influence would
Voh*me 98 Number 4
Case report
287
Fig. 4, A through E. Posttreatment study casts at 15 years 5 months.
Fig. 5, A through C. Postretention facial photographs at 17 years 5 months.
be hkely. However, the anterior spacing would indicate a possible tongue thrust habit. The profile was protrusive and the lips strained on closure. An excessive vertical growth pattern was evident (Figs. 1 through 3). DIAGNOSIS The occlusion was classified as Angle Class I with bimaxillary protrusion and spacing in both mandibular and maxillary arches. The maxillary and mandibular second molars were fully erupted. The lower left second deciduous molar
was still present. There was no apparent tissue pathoses. Cephalometrically, it was evident that there was a marked protrusion of both maxillary and mandibular dentures with the resultant bimaxillary protrusion-type profile?" 3 The Angle classification was Class I with an ANB relationship of 3.5 °. The mandibular incisors were very protrusive and forward off the bony base as indicated by their position of 11.5 mm at 36 °. The mandibular plane angle was steep, with a GoGnSN angle of 39 °. Pogonion to NB was recorded at 0 mm (Fig. 10, A). The intraoral radiographs confirmed the presence of all
288
Am. J. Orthod. Dentofac. Orthop. October 1 9 9 0
Angelle
B
,
,.
,
Fig. 6, A through E. Intraoral photographs at 15 years 5 months.
Fig. 7, A through E. Postretention study casts at 17 years 5 months.
permanent teeth with the exception of the lower left second premolar and the four wisdom teeth, which were congenitally missing (Fig. 11, A). DIAGNOSTIC SUMMARY
The following clinical findings were noted: (1) Class I, (2) bimaxillary protrusion, (3) spacing in both arches, (4) lower left permanent premolar and four third molars congenitally missing, (5) steep mandibular plane, and (6) prognathic profile with protruded lip position. TREATMENT OBJECTIVE
The treatment objective was to achieve the maximum retraction of incisor teeth so as to effect the greatest profile change and control the vertical dimension.
TREATMENT PLAN
A full-banded edgewise, level-anchorage--type of appliance~ with pretorqued, preangulated 0.018 × 0.025inch bonded brackets was used to treat this malocclusion. The following treatment steps were undertaken. 1. All maxillary teeth were banded except the second molars. Leveling and correction of rotations of the maxillary arch were accomplished with nitinol round wire followed by nitinol rectangular wire. A removable transpalatal bar and high-pull face-bow were used. The maxillary arch was then stabilized with an 0.018 x 0.025-inch wire to prepare for Class III elastics. 2. The lower left deciduous second molar and right second premolar were extracted and the mandibular teeth
Volume 98 Number 4
Case report
Fig. 8, A through C. Immediate posttreatment facial photographs.
'
9'
"
.-
:
D Fig. 9, A through E. Intraoral photographs at 17 years 5 months•
.
i / ~ / j
-
/ ~.,'>-~
i~ A
'5;L:~
~~
"
c •I
B Fig. 10. Cephalometric tracings• A, Pretreatment; B, posttreatment; and C, postretention.
289
290
Am. J. Orthod. Dentofac. Orthop. October 1990
Angelle
Fig. 11. Panoramic radiographs. A, Pretreatment at 13 years 6 months; B, posttreatment at 15 years 5 months; and C, postretention at 17 years 5 months.
SUMMARY C~PHALOM[TRIC MEASUREMENTS Me~utement
Norm
A
SNA
8Z
81..5
80
79.5
SNB
80
78
77.5
77.5
ANB
2
3.5
13
C
2.`5
2
SN.h~OA
32
39
3~.`5
37
4Po.lrH
88
8.5
89.5
89
MPA
90
100
9~
89
"MA
21
2`5
23
2~
'1" to APO (ram) I to NA (Angle)
2.7
1 to NB tram)
2 27.`5
5.
`5.5
6.
26
21.`5
A
11
A
2`5
36
2.5
23
5
.5
4
11.5
4.
2.5
22
I to HA (ram)
1 to N8 (Angle)
8,5
3.
ntetinclsal angle
132
11.5
131
I:'7.5
Soil tissue lin~ (Stelner)
0/0
317.`5
-2/3
-li/-1
)c¢lusll to .~q ( / ~ l e )
14
21
18.5
11~.`5
5A (rnm)
ZIP
29
27.~,
27
5L tram}
$1
.~!
`51
51
Fig. 12. Cephalometric measurements.
7.
were banded through the second molars, except the four lower anterior teeth. Leveling of the mandibular arch was accomplished with round and rectangular nitinol wires. The curve of Spee was leveled and anchorage was prepared with reverse curve of Spee and Class III elastics. Lower canines and first premolars were retracted to predetermined anchorage space with a 0.010 x 0.040-inch open coil spring 1.5 times intercanine width onto the arch wire. The four lower anterior teeth were banded and the mandibular arch was releveled with rectangular nitinol wire. A rectangular vertical closing-loop arch wire rounded over to 0.016 inch between loops was placed, lower anterior teeth were tipped and uprighted, and anterior spaces were closed. The mandibular arch was then stabilized with an 0.018 × 0.025-inch ideal arch wire. The upper first premolars were extracted and the upper second molars were banded. The maxillary extraction spaces were closed with a vertical closing-loop arch wire. The palatal bar was removed and the headgear was discontinued. The patient was instructed to wear Class 1I elastics 24 hours a day. Occlusion, interdigitation, and finishing were completed with posterior vertical elastics.
PROGRESS OF TREATMENT
The patient was seen at 4-week intervals; during the last 3 months of treatment, appointments were scheduled for 2week intervals. Appliance breakage was nonexistent; cooperation and oral
Volume 98 ?,'umber 4
Case report
!~ \\
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t it
.,t ~
-
•
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Volunze 98 Number 4
October 1990
of continuous publication Copyright © 1990 by Mosby-Year Book, Inc.
CASE REPORT
An American Board of Orthodontics case report Philippe L. Angelle, DMD, MS Paris, France
A case of a Class I malocclusion with a steep mandibular plane angle, a bimaxillary protrusion, and a congenitally missing lower premolar is reported. [This case was presented to the American Board of Orthodontics in partial fulfillment of the requirements for the certification process conducted by the Board.] (AMJ ORTHODDENTOFACORTHOP 1990;98:285-91.)
I n mandibular angle cases, it is very easy, during orthodontic treatment, to elongate molars and increase vertical dimension with an unfavorable facial change resulting. The orthodontist has the ability to make dramatic 814110429
facial changes through tooth movement and growth control. Growth trend should be determined before treatment; vertical mechanics should be used with extreme caution; and mechanics involved should control vertical growth. The following case report describes the treatment of a patient with a steep mandibular plane angle, a
Fig. 1, A through E. Pretreatment study casts at 13 years 6 months.
285
286
Am. J. Orthod. Dentofac. Orthop. October 1990
Angelle
Fig. 2, A and B. Pretreatment facial photographs at 13 years 6 months.
Fig. 3, A through C. Pretreatment intraoral photographs at 13 years 6 months.
bimaxillary protrusion, and a congenitally missing lower premolar. CASE REPORT HISTORY AND GENERAL CLINICAL PICTURE
The patient was a boy 13 years 6 months of age at the start of treatment. His general health was excellent and there were no conditions present that would contraindicate treat-
ment. His childhood growth and development were apparently normal. Tonsils and adenoids were present. Oral tissues appeared to be healthy and the dentition in a good state of repair, with no carious lesions present. No detrimental habits were noted. Both parents had the appearance of a double protrusion. As a result of this observation and the fact that the boy's sister had a similar malocclusion, hereditary influence would
Voh*me 98 Number 4
Case report
287
Fig. 4, A through E. Posttreatment study casts at 15 years 5 months.
Fig. 5, A through C. Postretention facial photographs at 17 years 5 months.
be hkely. However, the anterior spacing would indicate a possible tongue thrust habit. The profile was protrusive and the lips strained on closure. An excessive vertical growth pattern was evident (Figs. 1 through 3). DIAGNOSIS The occlusion was classified as Angle Class I with bimaxillary protrusion and spacing in both mandibular and maxillary arches. The maxillary and mandibular second molars were fully erupted. The lower left second deciduous molar
was still present. There was no apparent tissue pathoses. Cephalometrically, it was evident that there was a marked protrusion of both maxillary and mandibular dentures with the resultant bimaxillary protrusion-type profile?" 3 The Angle classification was Class I with an ANB relationship of 3.5 °. The mandibular incisors were very protrusive and forward off the bony base as indicated by their position of 11.5 mm at 36 °. The mandibular plane angle was steep, with a GoGnSN angle of 39 °. Pogonion to NB was recorded at 0 mm (Fig. 10, A). The intraoral radiographs confirmed the presence of all
288
Am. J. Orthod. Dentofac. Orthop. October 1 9 9 0
Angelle
B
,
,.
,
Fig. 6, A through E. Intraoral photographs at 15 years 5 months.
Fig. 7, A through E. Postretention study casts at 17 years 5 months.
permanent teeth with the exception of the lower left second premolar and the four wisdom teeth, which were congenitally missing (Fig. 11, A). DIAGNOSTIC SUMMARY
The following clinical findings were noted: (1) Class I, (2) bimaxillary protrusion, (3) spacing in both arches, (4) lower left permanent premolar and four third molars congenitally missing, (5) steep mandibular plane, and (6) prognathic profile with protruded lip position. TREATMENT OBJECTIVE
The treatment objective was to achieve the maximum retraction of incisor teeth so as to effect the greatest profile change and control the vertical dimension.
TREATMENT PLAN
A full-banded edgewise, level-anchorage--type of appliance~ with pretorqued, preangulated 0.018 × 0.025inch bonded brackets was used to treat this malocclusion. The following treatment steps were undertaken. 1. All maxillary teeth were banded except the second molars. Leveling and correction of rotations of the maxillary arch were accomplished with nitinol round wire followed by nitinol rectangular wire. A removable transpalatal bar and high-pull face-bow were used. The maxillary arch was then stabilized with an 0.018 x 0.025-inch wire to prepare for Class III elastics. 2. The lower left deciduous second molar and right second premolar were extracted and the mandibular teeth
Volume 98 Number 4
Case report
Fig. 8, A through C. Immediate posttreatment facial photographs.
'
9'
"
.-
:
D Fig. 9, A through E. Intraoral photographs at 17 years 5 months•
.
i / ~ / j
-
/ ~.,'>-~
i~ A
'5;L:~
~~
"
c •I
B Fig. 10. Cephalometric tracings• A, Pretreatment; B, posttreatment; and C, postretention.
289
290
Am. J. Orthod. Dentofac. Orthop. October 1990
Angelle
Fig. 11. Panoramic radiographs. A, Pretreatment at 13 years 6 months; B, posttreatment at 15 years 5 months; and C, postretention at 17 years 5 months.
SUMMARY C~PHALOM[TRIC MEASUREMENTS Me~utement
Norm
A
SNA
8Z
81..5
80
79.5
SNB
80
78
77.5
77.5
ANB
2
3.5
13
C
2.`5
2
SN.h~OA
32
39
3~.`5
37
4Po.lrH
88
8.5
89.5
89
MPA
90
100
9~
89
"MA
21
2`5
23
2~
'1" to APO (ram) I to NA (Angle)
2.7
1 to NB tram)
2 27.`5
5.
`5.5
6.
26
21.`5
A
11
A
2`5
36
2.5
23
5
.5
4
11.5
4.
2.5
22
I to HA (ram)
1 to N8 (Angle)
8,5
3.
ntetinclsal angle
132
11.5
131
I:'7.5
Soil tissue lin~ (Stelner)
0/0
317.`5
-2/3
-li/-1
)c¢lusll to .~q ( / ~ l e )
14
21
18.5
11~.`5
5A (rnm)
ZIP
29
27.~,
27
5L tram}
$1
.~!
`51
51
Fig. 12. Cephalometric measurements.
7.
were banded through the second molars, except the four lower anterior teeth. Leveling of the mandibular arch was accomplished with round and rectangular nitinol wires. The curve of Spee was leveled and anchorage was prepared with reverse curve of Spee and Class III elastics. Lower canines and first premolars were retracted to predetermined anchorage space with a 0.010 x 0.040-inch open coil spring 1.5 times intercanine width onto the arch wire. The four lower anterior teeth were banded and the mandibular arch was releveled with rectangular nitinol wire. A rectangular vertical closing-loop arch wire rounded over to 0.016 inch between loops was placed, lower anterior teeth were tipped and uprighted, and anterior spaces were closed. The mandibular arch was then stabilized with an 0.018 × 0.025-inch ideal arch wire. The upper first premolars were extracted and the upper second molars were banded. The maxillary extraction spaces were closed with a vertical closing-loop arch wire. The palatal bar was removed and the headgear was discontinued. The patient was instructed to wear Class 1I elastics 24 hours a day. Occlusion, interdigitation, and finishing were completed with posterior vertical elastics.
PROGRESS OF TREATMENT
The patient was seen at 4-week intervals; during the last 3 months of treatment, appointments were scheduled for 2week intervals. Appliance breakage was nonexistent; cooperation and oral
Volume 98 ?,'umber 4
Case report
!~ \\
,,; ts
~,,,, )~
t it
.,t ~
-
•
"/-
