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Original Article

Treatment of Class II Division 1 Malocclusion: Asymmetric Extraction

Watana Mathurasai DDS., M.D.S.,F.I.C.D,F.A.C.D.

Smorntree Viteporn DDS.,M.D.Sc., F.I.C.D.

Compromised treatment of Class II division 1 malocclusion in the adlut patient usually re-
quires extraction of the two maxillary first bicuspids so that Class I canine can be obtained.Asymmetric
extraction of one bicuspid is a treatment of choice in the patient with acceptable profile and space
deficiency is moderate . Success of the treatment depends upon clinical examination, space assess-
ment, anchorage management and biomechanics. The article presented treatment of Class II divi-
sion 1 malocclusion with lingual orthodontic mechanics by extraction one bicuspid .

The specific characteristics of Class II esthetics. Excessive space obtained from extrac-
division 1 malocclusion that is usually the major tion may end up with the uprighted incisor, deep
concern of a patient is severe protrusion of overbite, and flat facial profile due to excessive
maxillary incisors. Compromised orthodontic retraction of the anterior teeth. Otherwise treat-
treatment in the adult patient is extraction only ment planning as a nonextraction case may be
the maxillary first bicuspids so that there are not possible since it aggravates the protrusion.
enough space for correction of the protrusion and The possibility of asymmetric extraction of only
improvement of facial profile if possible. In a Class one bicuspid should be evaluated according to
II division 1 patient with acceptable profile space the aforementioned factors.
obtained from extraction of the two maxillary Clinical examination: The initial relation
first bicuspids may be redundant thus caus- between the maxillary dental midline and the
ing excessive retraction of the maxillary incisors. facial midline should be thoroughly examined to
In this case nonextraction or extraction only investigate the possibility to maintain or shift the
one bicuspid should be the treatment of choice. maxillary dental midline towards the extraction
Factors influence success of correction site. The symmetric positions of the maxillary
of dental protrusion in the patient with accept- canines when smiling has to be evaluated as well.
able facial profile are clinical examination, space Space assessment: The occlusogram (1)
assessment, anchorage management, and bio- of the maxillary denture should be scrutinized to
mechanics. Since in this case the objectives of determine final position of the anterior and pos-
the treatment do not concern only function but terior segments and to select type of anchorage.
8 J. Lingual Ortho.Th. Vol.2 No.1 Jan.-Jun 2002

Anchorage management: Space obtained the Class II division 1 case treated with
from extraction one bicuspid is utilized for cor- asymmetric extraction by lingual orthodontic
rection of protrusion by maximum retraction of the mechanics.
anterior segment (Type A anchorage), retraction Diagnosis and Etiology
of the anterior segment and protraction of the A woman aged 19 years searched for cor-
posterior segment (Type B anchorage) or pro- rection of maxillary incisor protrusion without
traction of the posterior segment (Type C anchor- changing her facial profile. Clinical examination
age)(2). In lingual orthodontics, management of (figure 1) showed acceptable facial profile, nor-
anchorage is depended upon configuration of the mal lip position and function. The maxillary dental
archwire and the amount of force. midline in relation to the facial midline was shifted
Biomechanics: Asymmetric retraction of to the right side 1 mm, the mandibular dental mid-
the anterior segment should be a treatment of line was normal. The maxillary left posterior seg-
choice if the dental protrusion cannot be ment moved forward due to disto-lingual rotation
corrected by alteration of jaw relationship. of the maxillary left canine causing severe
The objective of the article was to present

Figure 1 Pretreatment facial profile and occlusion

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Figure 2 Pretreatment cephalometric analysis

Figure 3 Oral features during treatment

10 J. Lingual Ortho.Th. Vol.2 No.1 Jan.-Jun 2002

Class II molar and canine relationship around 4 2. Indirect bonding #15, #12, #11, #21, #22, #25
mm. The maxillary right segment was slightly leveling with .014"TMA
Class II molar and canine relation 2 mm. The 3. Insert .016"TMA after extraction #24,
overbite was normal while the overjet was 6 mm. direct bonding #23 Labial brackets and retract
The Bolton analysis showed maxillary #23 with elastic chain 150 grams
anterior teeth excess 2 mm. 4.Insert .016x.016" Blue elgiloy L loop closing loop
Panoramic radiograph showed normal 5. Insert .016" NiTi after complete space closure.
development dentition. 6. Insert .017x.025" TMA archwire
Cephalometric analysis showed skeletal Lower Arch
Class I normal bite with maxillary incisor 1 Band #36, #46 direct bonding all remaining teeth
protrusion and proclination, normal facial profile leveling with .0175" Superflex
(figure 2). 2. Insert .014" stainless steel archwire
Hereditary factor should be a major 3. Insert .016" stainless steel archwire
etiological factor. 4. Insert .018" stainless steel archwire
Treatment Objectives 5. Insert .016x.022" stainless steel archwire
To correct maxillary incisor protrusion 6. Insert .017x.025" TMA archwire
while maintaining the facial profile. Final adjustment of occlusion with Class
To obtain Class I molar (right side), Class II traction 4 oz. 1/4”
II molar (left side) and Class I canine (both sides) Treatment Result (figure 4,5)
with normal overbite and overjet. Maxillary incisor protrusion and
Extraction of the maxillary left first bicus- proclination could be corrected by retraction of
pid was recommended to obtain space available the anterior teeth and protraction of the posterior
8 mm for correction of the maxillary left canine teeth so that the facial profile could be maintained.
rotation and incisor protrusion. Type B anchor- Class I canines, Class I molar (right side) Class II
age was selected to achieve the aforemen- (left side) were obtained.
tioned occlusion. Discussion
Treatment Progress (figure 3) Asymmetric retraction by lingual orthodon-
Edgewise lingual appliance was used for tic mechanics was rare since the technique is
the maxillary teeth and labial appliance was used usually performed symmetrically by utilizing
for the mandibular teeth. The .022x.028" Roth the horizontal force from elastic chain or
vertical slot edgewise appliance (Ortho Organizer) retraction loop (3)to retract the anterior segment.
were placed. The treatment sequences were as In order to achieve type B anchorage the hori-
follows: zontal force must be higher than those required
Upper Arch for retraction only the six anterior teeth. The simple
1. Band #16, #26 Impression for bracket align- mechanics likes unilateral retraction with elastic
ment with TARG system chain was not recommended as the heavy force
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Figure 4 Posttreatment cephalometric analysis

Figure 5 Posttreatment facial profile and occlusion

12 J. Lingual Ortho.Th. Vol.2 No.1 Jan.-Jun 2002

might cause distortion of the archwire thus ended References

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mize this side effect the L loop retraction archwire planning orthodontic treatment. Am J Orthod.
was used with minimal attachment to the teeth of 1976;69:655-67.
the nonextraction side. Initial retraction of the 2. Burstone CJ. The segmented arch approach
maxillary left canine with both labial and lingual to space closure. Am J Orthod.1982;82:361-78.
mechanics was necessary for controlling rotation 3. Alexander CM., Alexander RG., Gorman JC.
of the canine and enabling the perfect engage- et al. Lingual orthodontics: A status report part
ment of the canine slot to the retraction archwire. 5 lingual mechanotherapy. J Clin Orthod
Acknowledgement The authors would like to express our sincerely thanks to the patient for
her contributions as the subject of the presentation.