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Class II correction in a growing patient with hyperdivergent growth patterns

and severe overjet

Article  in  World journal of orthodontics · December 2010

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Jae Hyun Park, DMD, MSD,
MS, PhD1 CLASS II CORRECTION IN A GROWING
PATIENT WITH HYPERDIVERGENT
GROWTH PATTERNS AND SEVERE OVERJET
In general, the success of Class II treatment depends as much on the skill
of the orthodontist as it does on a favorable facial-growth pattern. Lack
of sufficient favorable growth during treatment will make it difficult to
correct the skeletal malrelationship or significantly improve the facial
profile. The case report presents the treatment of a patient with a Class II,
Division 1 malocclusion with severe overjet and a hyperdivergent
growth pattern. World J Orthod 2010;11:e35–e44.

Key words: Class II treatment, severe overjet, hyperdivergent growth pattern

1Associate Proessor and Chair, Post-

graduate Orthodontic Program,
Arizona School of Dentistry & Oral
Health, A.T. Still University, Mesa,
Arizona, USA; International Scholar,
Graduate School of Dentistry, Kyung
Hee University, Seoul, Korea.
CORRESPONDENCE
Dr Jae Hyun Park
Arizona School of Dentistry & Oral
Health
5855 East Still Circle
Mesa, AZ 85206
Email: jpark@atsu.edu
n correcting a Class II relationship with
I a retrognathic mandible, mandibular
growth is critical. If the mandible grows
unfavorably, the Class II relationship will
be more difficult to correct and the facial
profile will not be improved. The case
report shows an unfavorable growth pat-
tern in a patient presenting with a Class
II, Division 1 malocclusion and severe
overjet.
CASE HISTORY
A Hispanic boy, 12 years 8 months of
age, presented for evaluation of his
esthetic dental appearance. His chief
goal was to straighten his teeth. The
patient’s medical history showed no
signs of disease. He presented with no
history of dental trauma. His oral hygiene
was good, and his mandibular move-
ments were normal with no symptoms of
temporomandibular joint dysfunction.

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 Park WORLD JOURNAL OF ORTHODONTICS

Fig 1 Pretreatment facial photographs.

Fig 2 Pretreatment intraoral

photographs.

Diagnosis and etiology 50% overbite. The mandibular midline

The patient presented with an oval, sym-
metrical face and a convex profile. When
smiling, he had a 60% display of maxillary
incisors and 0 mm of gingiva was shown
(Fig 1). Intraoral examination revealed a
Class I molar and an end-on Class II
canine relationship, 9.5 mm overjet, and
deviated 2 mm to the right. The maxillary
arch had mild crowding with slight con-
striction bilaterally at the premolars. The
mandibular arch had severe anterior
crowding with a deep curve of Spee and
extrusion of the mandibular incisors.
Bolton analysis was normal (Fig 2).

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VOLUME 11, NUMBER 4, 2010 Park

Fig 3 Pretreatment panoramic

radiograph.

Fig 4 Pretreatment
cephalometric radiograph.

The panoramic radiograph showed no Treatment objectives

caries or pathologies. The maxillary and
mandibular third molars were developing The treatment objectives were to obtain
(Fig 3). a normal overjet and overbite, establish a
Cephalometric analysis revealed the Class I canine relationship, maintain a
patient had a skeletal Class II (ANB 6 Class I molar relationship, correct the
degrees) with a hyperdivergent growth pat- mandibular midline shift, relieve the
tern (SN-MP 45 degrees). The maxillary crowding on both arches, and level the
incisors were slightly proclined (U1-SN 108 curve of Spee.
degrees), and the mandibular incisors
showed normal inclination (IMPA 91
degrees) (Fig 4). The etiology of the maloc-
clusion was determined to be a combina-
tion of heredity and environmental factors.

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 Park
Treatment plan
The patient’s parents declined the ideal
treatment plan—to promote mandibular
growth prior to fixed appliances—there-
fore, an alternative treatment plan was
carried out. The complexity of this case
arises in the Class I molar relationship
with a Class II canine relationship with
severe overjet. Initially, both arches were
leveled and aligned with no extractions
for therapeutic diagnosis, although round-
tripping of the incisors was possible. After
6 months, the patient was reevaluated for
extraction of the four first or second pre-
molars on both arches to relieve crowding
and achieve a bilateral Class I canine rela-
tionship with an ideal overbite, overjet,
and lower midline correction. Because of
skeletal discrepancies and an unfavor-
able growth pattern, surgical treatment,
including genioplasty, was a future option
after the patient’s growth was complete.
This option was discussed. Developing
maxillary and mandibular third molars will
be monitored.
Treatment alternatives
Since the patient was still growing, the
primar y treatment objective was to
reduce the overjet by skeletal improve-
ment to promote mandibular growth. If
the functional appliances could reposi-
tion the mandibular growth forward and
improve the overjet, nonextraction or
extraction treatment would be consid-
ered after using functional appliances.
Details of these alternatives were pre-
sented to the patient and his parents;
however, they declined using functional
appliances1–4 or a Herbst appliance5,6
prior to a fixed appliance.
Treatment progress
Full-fixed 0.022 self-ligation In-Ovation
(GAC International) appliances were
placed on both arches. It was observed
that Class II canine relationship and the
mandibular midline shift did not improve
after 6 months of treatment of the level-
ing and alignment stage. The patient had
e38
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WORLD JOURNAL OF ORTHODONTICS
no crowding on the maxillary arch and
maintained a Class I molar relationship.
However, minor crowding on the mandibu-
lar arch with 4-mm overjet remained. The
patient and his parents were concerned
about mandibular incisor proclination.
Four second premolars were extracted to
establish a Class I canine relationship,
maintain a Class I molar relationship, cor-
rect the mandibular midline shift, and
level the curve of Spee. To establish
proper anchorage preparation for Class II
mechanics, a Nance appliance was
placed on the maxillary arch. To bilaterally
improve the end-on Class II canine occlu-
sion, the maxillary canines were retracted
with elastomeric chains from the maxil-
lary first molars to the maxillary canines
with a 0.016 × 0.022-inch stainless steel
wire. After the maxillary canines were in a
Class I relationship, a 0.016 × 0.022-inch
stainless steel wire with T-loops was
placed on the maxillary arch between the
maxillary lateral incisors and canines to
close the remaining spaces. To reduce
the overjet, Class II elastics, 3/16-inch
light (2 oz) (3M Unitek), were engaged
from the T-loops to the mandibular sec-
ond molars only at night. The self-ligating
bracket systems are advantageous in that
they decrease plaque retention when
compared to elastomeric ties. 7–9 This
patient showed poor oral hygiene through-
out treatment (Fig 5). During the finishing
stage, cosmetic recontouring of the maxil-
lary central incisors and mandibular
incisors was achieved using a 0.016 ×
0.022-inch stainless steel archwire.
Total treatment time was 31 months.
Due to the patient’s poor oral hygiene,
maxillary and mandibular Essix retainers
were delivered instead of a fixed canine-
to-canine retainer on the maxillary and
mandibular arch. The patient was
instructed to wear them 24 hours per day
for 1 year and then only at night after 1
year. Recall visits for retainer checks
were given at 1, 3, and 6 months for the
first year. To ensure continued satisfac-
tory posttreatment alignment of the
mandibular and maxillary anterior denti-
tion, the use of fixed or removable retain-
ers was recommended indefinitely.10 This
was emphasized to the patient and his
parents.
VOLUME 11, NUMBER 4, 2010
Fig 5 Midtreatment intraoral
photographs showing poor oral
hygiene despite minimizing the
use of plaque-retentive conven-
tional ligatures.
Fig 6 Posttreatment facial photographs.
RESULTS
Posttreatment records revealed that
treatment objectives were achieved.
Facial photographs showed improved
smile esthetics and profile (Fig 6). Class I
canine and molar relationships were
established with a canine-protected
occlusion. Dental midlines were aligned
with the facial midline, and ideal overbite
and overjet were achieved (Fig 7). After
the treatment, the curve of Spee was
successfully leveled (Fig 8).
A posttreatment panoramic radi-
ograph showed proper space closure and
acceptable root parallelism, with no signs
of bone or root resorption (Fig 9). Post-
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Park
treatment lateral cephalometric analysis
and superimposition revealed no signifi-
cant skeletal changes in the maxilla. The
slight decrease observed in SNB angle
might have been due to the backward
rotation of the mandible. The relatively
convex profile following the treatment
was associated with a slight increase in
mandibular body length (Go-Me 76 to
76.5 mm) and a slight increase in gonial
angle (ArGoMe 122 to 123 degrees).11 To
reduce the overjet, the maxillary anterior
teeth were retracted lingually and the
mandibular incisors were slightly pro-
clined. Ideal overbite and overjet relation-
ships were established (Figs 10 and 11,
Table 1).
e39
 Park WORLD JOURNAL OF ORTHODONTICS

Fig 7 Posttreatment intraoral

photographs.

Fig 8 Dental casts

showing the correction
of a deep curve of
Spee (a) before and
(b) after treatment.

a b

Fig 9 Posttreatment panoramic radiograph.

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VOLUME 11, NUMBER 4, 2010 Park

Fig 10 Posttreatment cephalometric radiograph. Fig 11 Superimposition of cephalometric tracings.

Pretreatment, solid line; posttreatment, dashed line.

Table 1 Cephalometric measurements

Area Measurement Norm A1 (pretreatment) B (posttreatment) Difference A1–B

Cranial base S-N (mm) 83.0 73.0 75.0 2.0

Maxilla to cranial base SNA (degrees) 82.0 76.0 76.0 0.0
Mandible to cranial base SNB (degrees) 80.0 70.0 69.0 1.0
Maxillo-mandibular ANB (degrees) 2.0 6.0 7.0 1.0
vertical height Wits (mm) 0.0 3.5 3.5 0.0
SN-MP 32.0 45.0 46.0 1.0
FH-MP 25.0 32.0 33.0 1.0
LFH (%) 55.0 55.0 58.0 3.0
(ANS-Me/N-Me)
Maxillary and mandibular U1 to SN (degrees) 103.0 108.0 91.0 17.0
incisor position U1 to NA (degrees) 22.0 32.0 15.0 17.0
IMPA (°) 90.0 91.0 93.0 2.0
L1 to NB (°) 25.0 24.0 27.0 3.0
U1/L1 (degrees) 131.0 116.0 130.0 14.0
Upper lip (mm) –4.0 1.0 –1.5 2.5
Soft tissue Esthetic plane
Lower lip (mm) –2.0 2.0 2.0 0.0

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 Park
DISCUSSION
Growing skeletal Class II growing patients
who have high mandibular planes are dif-
ficult to treat.12 The difficulty increases
when a patient has severe overjet. This
complex skeletal Class II, Class I molar,
and end-on Class II canine malocclusion
patient was treated successfully. A
proper diagnosis, logical extraction deci-
sion, and patient cooperation were cru-
cial for a successful treatment. In the
treatment of malocclusion, Tweed13 intro-
duced that mandibular incisors must be
positioned in a normal relation to their
basal bones to improve stability of the
dentition and to achieve the maximum
balance and harmony of facial lines. If
the premolars had been extracted at the
beginning of the treatment to avoid
unnecessary mandibular incisor proclina-
tion, the overall treatment time of 31
months could have been reduced.
There has been increased use of the
self-ligating bracket for both nonextrac-
tion and extraction treatment. The
bracket hygiene improvement in the self-
ligating bracket relates to the elimination
of elastic modules. Moreover, it is advan-
tageous to reduce chair time when
changing archwires.7–9 Although bracket
types and experimental methods are dif-
ferent, many studies have demonstrated
significant decreases in friction with self-
ligating bracket compared to conven-
tional bracket designs.14–16 Eberting et
al17 reported that self-ligating brackets
had significantly reduced treatment
times. They also reported that self-ligat-
ing brackets had significantly higher
American Board of Orthodontics (ABO)
scores than those treated with conven-
tional twin brackets.
In a clinical trial of 54 nonextraction
patients, Pandis et al,18 compared the
time required to complete the alignment
of crowded mandibular anterior teeth
with a conventional edgewise and self-lig-
ating brackets. Additionally, the effects of
alleviation of crowding on mandibular
incisor inclination and intercanine and
intermolar widths were investigated. The
result of this study suggests that self-lig-
ating brackets are not efficient in terms
of treatment time in resolving severe
e42
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WORLD JOURNAL OF ORTHODONTICS
anterior mandibular crowding than con-
ventional edgewise brackets. However,
they were faster than conventional appli-
ances in alleviating moderate crowding.
Although the overall expansion of the
mandibular arch was relatively small, the
intermolar width increased in self-ligating
brackets when compared to conventional
brackets. Also, both bracket groups
showed no difference in the mandibular
incisor proclination.
During the treatment of a patient with
a high-angle Class II malocclusion, it is
very important to avoid extrusion of the
maxillary and mandibular posterior teeth
with Class II force.
Another consideration when treating
this patient was the correction of a deep
overbite. To correct deep overbite, for
example, leveling of a mandibular curve
of Spee can be achieved by extrusion of
posterior teeth. However, extrusion of pre-
molars and molars will result in
increased lower facial height, steepening
of the occlusal plane, and downward and
backward rotation of the mandible with a
worsening of the Class II skeletal relation-
ship.19 The long-term stability of such a
correction is questionable unless favor-
able growth occurs. Intrusion of the max-
illary anterior teeth to correct a deep
overbite may be indicated in patients
when excessive maxillary incisors are not
esthetic at rest. 20 However, when the
patient is showing the ideal smile arc,
any maxillary incisor intrusion should be
carefully monitored during treatment to
avoid flattening of the smile arc.21
When smiling, the patient displayed
60% of his maxillary incisors and did not
show gingiva. To control the vertical
dimension, intrusion of the maxillary
anterior teeth was not indicated for this
patient. Instead, during the leveling
stage, the mandibular utility archwire was
used. With the mandibular utility arch-
wire, the intrusive forces are applied to
the mandibular incisors labial to the cen-
ter of resistance. It produces a labial
crown moment that would result in procli-
nation of the mandibular incisors.22 To
prevent this effect, 5 degrees of labial
root torque was included in the incisor
region of the mandibular utility archwire.
Some mandibular anterior crowding was
VOLUME 11, NUMBER 4, 2010
present; therefore, the archwire was
cinched further distally rather than imme-
diately distal to the molar bands.23 This
caused labial proclination prior to the
extraction phase. During space closure of
the canines and incisor retraction, axial
inclination of the maxillary anterior teeth
was controlled by placing a mild curve of
Spee in the maxillary archwire and a
reverse curve of Spee in the mandibular
archwire to control deep overbite.
The mandibular first molar moved
mesially and bodily into the extraction
space. The possibility of molar extrusion
in the final result was a combination of
uprighting the molar by a utility archwire
on the mandibular arch and eruption of
the mandibular posterior teeth during
growth (Fig 11). One method of leveling a
mandibular arch with an excessive curve
of Spee is relative intrusion. This is
achieved by preventing eruption of the
incisors while growth provides vertical
space into which the posterior teeth
erupt.24
To control the adverse effect of reac-
tive units, the posterior anchorage unit,
the patient wore an occipital headgear
14 hours a day. An occipital headgear
with the force directed anterior to the
center of resistance of the posterior
anchorage unit can negate the moment
on the maxillary first molars. The second
adverse effect is produced by the equal
and opposite extrusive force on the buc-
cal segments. This force will produce a
moment on the molar to tip the buccal
segment lingually with the roots moving
buccally. This was prevented by the use
of a Nance appliance.20 The patient was
recommended to wear light Class II elas-
tics to correct a Class II canine relation-
ship and to reduce overjet. However, to
minimize extrusion of the posterior
mandibular teeth, the patient wore the
elastics only at night.
Improved bite opening with overjet cor-
rection was established, and smile
esthetics was enhanced. A bilateral
canine Class I relationship and guidance
were achieved with good interdigitation.
The importance of retainers was stressed
to the patient. To correct the retrognathic
chin, genioplasty was recommended
after growth was complete.
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Park
CONCLUSION
The successful treatment of a patient
with a dolichofacial skeletal pattern is a
challenging task. Insufficient favorable
growth during treatment will make it diffi-
cult to correct the skeletal malrelation-
ship or significantly improve the profile.
Proper treatment of a skeletal Class II
patient with severe overjet and a clock-
wise growth pattern depends on sagittal,
vertical, and transverse control.
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WORLD JOURNAL OF ORTHODONTICS
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