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A novel approach for treatment of mandibular

deficiency with vertical growth pattern

Article in International journal of orthodontics (Milwaukee, Wis.) · August 2012

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Abdolreza Jamilian
Islamic Azad University
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F E A T U R E

A Novel Approach for Treatment of Mandibular

Deficiency with Vertical Growth Pattern
By Abdolreza jamilian, DDS, Rahman Showkatbakhsh, DDS and __ Tehrani

Abstract: This case illustrates the treatment of a 10.5 year old girl with Class II Division I malocclusion and mandibular
deficiency combined with vertical growth pattern. The patient was treated by a modified R-Appliance and extraction of upper
and lower first bicuspids. Modified R-Appliance was used for 18 months followed by 17 months of Posterior bite plate, after
which favorable correction of the malocclusion was observed. The SNB angle increased by 5° and the IMPA decreased by 11°.
This case demonstrates that modified R-Appliance can be a suitable method for treatment of maxillary deficient cases with
vertical growth pattern.
Keyword: Class II Division I, Mandibular Deficiency, Vertical Growth Pattern, R-Appliance, Growth Modification.

ntroduction Restriction of the maxilla, proclination of lower

Angle Class II division 1 malocclusion has
been one of the most encountered problems in
the orthodontic practice.1 McNamara2 claimed
that underdeveloped mandible is the most frequent
skeletal problem in this malocclusion. Different functional
appliances or headgears can be used in treatment of Cl
II Div I malocclusion.3-7 Functional appliances put the
mandible in forward position, result in stretches on the
related attached muscular groups of the mandible, and
create bone remodeling and muscular adaptation.8-17
Treatment of Class II with functional appliances will
result in a headgear effect on nasomaxillary complex.18-23
It was also reported that functional appliances restrict
the growth of the maxilla.4,24-29 Incisor mandibular plane
angle is increased in all functional appliances. Treatment
of skeletal Cl II malocclusion with vertical growth pattern
and lower anterior functional compensation is very
complicated. Traditional functional appliances could not
be used to put the mandible in proper position due to
the flaring of anterior teeth. In such cases the real overjet
could not be seen because the lower anterior is flared and
there is a contact between the lower anterior and lingual
aspect of upper incisors. Treatment of vertical grower with
traditional functional appliances has many controversies.
Most of the time functional appliances are used for
horizontal and normal growth pattern patients. There is
not any literature to show the application of functional
appliance to simultaneously upright the lower anterior
flaring and put the deficient mandible in the proper
position.
anteriors and being unsuitable in treatment of vertical
growers are the main disadvantages of traditional
functional appliances. In order to overcome these
disadvantages and to upright the lower anterior combined
with vertical growth control, R-Appliance30-31 was
designed.
Case Report
A 10.5-year-old girl was referred to an orthodontic
private practice office. Her chief complaint was her long
face with the lips being too much apart. Mandibular
deficiency with increased anterior facial height, lip
incompetency and short flaccid lips were obvious in her
extraoral examination (Figures 1 and 2). Her intraoral
examination showed flaring lower incisors with normal
overjet. (Figures 3-5) The patient’s cephalogram revealed
skeletal Cl II which was compensated dentally (Figures
6 and 7). The SNA , SNB were 80° and 74° respectively
(Table 1).
Table 1 Cephalometric analysis of the patient.
Pretreatment Post treatment
SNA 80° 82°
SNB 74° 79°
ANB 6° 3°
U1 to SN 101° 104°
IMPA 110° 99°
Inter-incisal angle 108° 122°
GoGn-Sn 40° 35°
Y-Axis 78° 72°

IJO  VOL. 23  NO. 2  SUMMER 2012 23

 Treatment objective
The treatment objectives for this patient were to:
1. Correct the deficient mandible
2. Obtain an ideal profile
3. Upright the lower incisors

Treatment alternative
Mandibular advancement combined with lefort 1
was considered as an alternative treatment at the age of
18. On one hand, postponing the treatment to the age
of 18 was not advisable due to psychological aspects;
on the other hand the patient and her parents rejected
Orthognathic surgery. Use of fixed appliances was also
considered as another alternative treatment procedure.
Figures 1-2: Extraoral pretreatment photographs.
Treatment progress
The treatment plan was to extract the first and
second deciduous molars followed by extraction of the
first mandibular bicuspids in order to provide space for
uprighting the lower anterior incisors. Afterwards, a
modified R-Appliance was constructed for the patient.
The R-Appliance31 consists of buccal and lingual shields,
which were connected to each other through the occlusal
clearance during bite construction. These shields were
extended to the distal of first molars and covered the
buccal and lingual region and the depth of vestibule. The
lingual shield should be fabricated with less undercut
relieve. This relieving must be done as minimally as
possible to allow appliance settlement easily. The right and
Figures 3-5: Intraoral pretreatment photographs. left lower lingual shields were connected and reinforced
with a heavy archwire to withstand the load of muscular
activity (1mm diameter). A heavy wire (1mm diameter),
which was positioned posteriorly, connected the right
and left acrylic part on the palatal area to reinforce the
appliance. Upper and lower labial bows were constructed
Figures 6: Pretreatment
lateral cephalometric ra-
by a 0.7 mm wire extended from canine to canine with
diograph. vertical loop on the canine area. Modified R-Appliance has
both upper and lower labial bows while the R-Appliance
only has an upper labial bow.
The vertical loop of lower labial bow was activated 1
Figures 7: Pretreatment
panoramic radiograph.
mm each month on both sides. The acrylic part of lower
lingual shield on the singulum area was reduced in each
visit. Lower labial bow activation would allow the lower
incisor to be uprighted. The construction bites were
taken when the mandible was pushed anteriorly with
the occlusal clearance of 6-8 mm. The increased vertical
height of the bite block of this appliance helped to get
advantage of the isometric contraction of vertical muscles
(Figures 8-10). The patient was recommended to use the
appliance for at least 18 hours a day and the period of
treatment was 18 months. Cl II canine relationship was
established by activation of the lower labial bow and distal
movement of lower incisors and canines. At the same time,

24 IJO  VOL. 23  NO. 2  SUMMER 2012


Figures 8-10: Modified R-Appliance in the mouth.
Figure 11: Posterior bite plate in the mouth.
Figure 12: Extraoral
posttreatment photograph.
with the progress of modified R-Appliance treatment the
mandible was positioned anteriorly. After discontinuation
of R-Appliance, a lower posterior bite block was fabricated
for the patient to avoid any relapse in vertical control.
Afterwards, the patient was referred for first upper bicuspid
extraction. Posterior bite plate was used for 17 months
to control the vertical growth of the patient (Figure 11).
The patient was instructed to wear the posterior bite
plate at all times except for eating and contact sports. The
treatment used in this study was for skeletal correction.
After this treatment the facial appearance of the patient
IJO  VOL. 23  NO. 2  SUMMER 2012
Figures 13-15: Intraoral Posttreatment photographs.
Figure 16: Posttreatment lateral
cephalometric radiograph.
Figure 17: Posttreatment
panoramic radiograph.
was improved and the lip incompetency was corrected
(Figure 12). Intraoral photos and cephalograms show that
the inclination of lower incisors to mandibular plane angle
was decreased (Figures 13-17). The inclination of lower
incisors achieved in this study was different from other
functional appliances. IMPA was decrease by 11° (Table
1). The superimposition is shown in Figure 18. Space
closure and further treatment was continued with fixed
appliance therapy. Modified R-appliance can be seen in
Figure 19.
25

Figure 18: Superimposition of pre (black) and post (red)
treatment cephalometric analysis of the patient, on SN,
registered at sella.
Figure 19: Modified R-appliance.
Discussion
In this case report the lower anterior incisors were
uprighted and at the same time the mandible was
advanced to its normal position. This case was more
complex than other cases due to the vertical growth
pattern of the patient. The patient had good cooperation
and all the treatment objectives were achieved. In this
study, the thickness of bite block in modified R-Appliance
was 6 to 8 mm which was more than average. By doing
this the authors gave the role of posterior bite plate
to the bite block of modified R-Appliance, which was
very helpful in control of vertical growth. Nevertheless,
posterior bite plate was also given to patient for 17
more months for more control. After the treatment was
completed not only the lower incisors were not flared but
also they were lingually retracted without any headgear
effect on the maxilla. The increase of SNA shows that
maxilla was moved to a forward position due to the growth
of the patient. These achievements, which were shown in
previous studies of R-Appliance,30-31 were uncommon in
conventional functional appliances.
26
The treatment in this case report was a growth
modification approach which could not be fully achieved
by fixed appliances. Use of fixed appliances at the
beginning of treatment as an alternative would have caused
bimaxillary retrusion and extrusion of the dentition.
However, use of Miniplates or miniscrews with multiple
band appliances could prevent the vertical growth of the
patient.
Another alternative treatment for this case was to
postpone any kind of treatment until 18 years of age, after
which the patient would undergo presurgical orthodontics
and be prepared for bimaxillary surgery. Initially the
patient and her parents rejected Orthognathic surgery
and her parents showed greater interest in orthodontic
approach for improvement of facial appearance.
If treatment had been postponed until 18 years of age,
it would not have been acceptable for the patient from
psychosocial point of view.
References:
1. Hanandeh BA, El-Bialy AA. Evaluating the effect of Sabbagh
Universal Spring during treatment of growing class II
malocclusions. Int J Orthod Milwaukee 2010;21:13-24.
2. McNamara JA, Jr. Components of class II malocclusion in
children 8-10 years of age. Angle Orthod 1981;51:177-202.
3. Tulloch JF, Proffit WR, Phillips C. Influences on the outcome of
early treatment for Class II malocclusion. Am J Orthod Dentofacial
Orthop 1997;111:533-542.
4. Ghafari J, Shofer FS, Jacobsson-Hunt U, Markowitz DL, Laster
LL. Headgear versus function regulator in the early treatment of
Class II, division 1 malocclusion: a randomized clinical trial. Am J
Orthod Dentofacial Orthop 1998;113:51-61.
5. Ehmer U, Tulloch CJ, Proffit WR, Phillips C. An international
comparison of early treatment of angle Class-II/1 cases. Skeletal
effects of the first phase of a prospective clinical trial. J Orofac
Orthop 1999;60:392-408.
6. Wheeler TT, McGorray SP, Dolce C, Taylor MG, King GJ.
Effectiveness of early treatment of Class II malocclusion. Am J
Orthod Dentofacial Orthop 2002;121:9-17.
7. O’Brien K, Wright J, Conboy F, Sanjie Y, Mandall N, Chadwick S
et al. Effectiveness of treatment for Class II malocclusion with the
Herbst or twin-block appliances: a randomized, controlled trial.
Am J Orthod Dentofacial Orthop 2003;124:128-137.
8. Petrovic A, Stutzmann J, Lavergne J, Shaye R. Is it possible to
modulate the growth of the human mandible with a functional
appliance? Int J Orthod 1991;29:3-8.
9. Aelbers CM, Dermaut LR. Orthopedics in orthodontics: Part
I, Fiction or reality--a review of the literature. Am J Orthod
Dentofacial Orthop 1996;110:513-519.
10. Johnston LE, Jr. Functional appliances: a mortgage on mandibular
position. Aust Orthod J 1996;14:154-157.
11. Barton S, Cook PA. Predicting functional appliance treatment
outcome in Class II malocclusions--a review. Am J Orthod
Dentofacial Orthop 1997;112:282-286.
12. Morris DO, Illing HM, Lee RT. A prospective evaluation of Bass,
Bionator and Twin Block appliances. Part II--The soft tissues. Eur
J Orthod 1998;20:663-684.
13. McSherry PF, Bradley H. Class II correction-reducing patient
compliance: a review of the available techniques. J Orthod
2000;27:219-225.
IJO  VOL. 23  NO. 2  SUMMER 2012
14. McDonagh S, Moss JP, Goodwin P, Lee RT. A prospective
optical surface scanning and cephalometric assessment of the
effect of functional appliances on the soft tissues. Eur J Orthod
2001;23:115-126. Dr. Jamilian is an orthodontic specialist.
15. Jacobs T, Sawaengkit P. National Institute of Dental and He is now associate professor of Islamic
Craniofacial Research efficacy trials of bionator class II treatment: Azad University in Tehran and fellow
a review. Angle Orthod 2002;72:571-575. of Orthognathic surgery fellowship in
16. Shen G, Hagg U, Darendeliler M. Skeletal effects of bite jumping
therapy on the mandible - removable vs. fixed functional Shahid Beheshti University of Medical
appliances. Orthod Craniofac Res 2005;8:2-10. Sciences. His practice is limited to
17. McNamara JA, Jr., Carlson DS. Quantitative analysis of orthodontics. He has lectured in several
temporomandibular joint adaptations to protrusive function. Am J international congresses and has been a
Orthod 1979;76:593-611. consultant for various journals. He can be reached at info@
18. Pangrazio-Kulbersh V, Berger JL, Chermak DS, Kaczynski R,
Simon ES, Haerian A. Treatment effects of the mandibular jamilian.net.
anterior repositioning appliance on patients with Class II
malocclusion. Am J Orthod Dentofacial Orthop 2003;123:286-295.
19. Hagglund P, Segerdal S, Forsberg CM. The integrated Herbst
appliance--treatment effects in a group of adolescent males with Dr. Rahman Showkatbakhsh finished
Class II malocclusions compared with growth changes in an
untreated control group. Eur J Orthod 2008;30:120-127. his post-graduate training in the School
20. Toth LR, McNamara JA, Jr. Treatment effects produced by the of Dental and Oral Surgery, Colombia
twin-block appliance and the FR-2 appliance of Frankel compared University, New York City, in 1981.
with an untreated Class II sample. Am J Orthod Dentofacial Orthop He established the first post-graduate
1999;116:597-609. program in orthodontics at the School
21. Trenouth MJ. Cephalometric evaluation of the Twin-block
appliance in the treatment of Class II Division 1 malocclusion of Dentistry, Shahid Beheshti Medical
with matched normative growth data. Am J Orthod Dentofacial Sciences University. Currently, he is associate professor of the
Orthop 2000;117:54-59. same orthodontic department and director of Orthognathic
22. Hamilton SD, Sinclair PM, Hamilton RH. A cephalometric, surgery fellowship.
tomographic, and dental cast evaluation of Frankel therapy. Am J
Orthod Dentofacial Orthop 1987;92:427-436.
23. Kerr WJ, TenHave TR, McNamara JA, Jr. A comparison of
skeletal and dental changes produced by function regulators (FR-2
and FR-3). Eur J Orthod 1989;11:235-242. Dr. Tehrani is a post-graduate student
24. Williams S, Melsen B. Condylar development and mandibular of orthodontics in Islamic Azad
rotation and displacement during activator treatment. An implant University of Tehran. He completed
study. Am J Orthod 1982;81:322-326.
25. Woodside DG, Altuna G, Harvold E, Herbert M, Metaxas A. his undergraduate courses at the same
Primate experiments in malocclusion and bone induction. Am J university.
Orthod 1983;83:460-468.
26. Rabie AB, She TT, Hagg U. Functional appliance therapy
accelerates and enhances condylar growth. Am J Orthod
Dentofacial Orthop 2003;123:40-48.
27. Birkebaek L, Melsen B, Terp S. A laminagraphic study of the
alterations in the temporo-mandibular joint following activator
treatment. Eur J Orthod 1984;6:257-266.
28. Woodside DG, Metaxas A, Altuna G. The influence of functional
appliance therapy on glenoid fossa remodeling. Am J Orthod
Dentofacial Orthop 1987;92:181-198.
29. Voudouris JC, Woodside DG, Altuna G, Angelopoulos G,
Bourque PJ, Lacouture CY et al. Condyle-fossa modifications and
muscle interactions during Herbst treatment, Part 2. Results and
conclusions. Am J Orthod Dentofacial Orthop 2003;124:13-29.
30. Jamilian A, Showkatbakhsh R, Amiri SS. Treatment effects of the
R-appliance and twin block in Class II division 1 malocclusion.
Eur J Orthod 2010.
31. Jamilian A, Showkatbakhsh R, Kamali Z. R-appliance: a different
design in functional therapy in Class II Division I malocclusion.
Int J Orthod Milwaukee 2009;20:11-14. Look for this symbol in
Orthodontic-TMJ CE course brochures to
make sure that CE hours attended will be
credited towards IAO Tier Advancement.

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