Is traditional treatment a good option for an adult with a Class II deepbite malocclusion? Catia Cardoso Abdo Quint~ ao, a Jose Augusto Mendes Miguel, a Ione Portela Brunharo, a Gustavo Zanardi, b and Daniela Feu c Rio de Janeiro, Brazil The Tweed-Merrifield directional force technique is a useful treatment approach for a patient with a Class II mal- occlusion with dentoalveolar protrusion. The purpose of this case report was to present the diagnosis and treat- ment descriptions of a patient with an Angle Class II malocclusion complicated by tooth losses, severe dentoalveolar protrusion, and skeletal discrepancy. Treatment involved extraction of the maxillary first premo- lars, high-pull headgear to enhance anchorage, and high-pull J-hook headgear to retract and intrude the max- illary anterior segments. A successful outcome was achieved with traditional orthodontic treatment in this borderline surgical case. (Am J Orthod Dentofacial Orthop 2012;141:105-12) T he diagnosis and orthodontic treatment of Class II Division 1 malocclusions in an adult patient with a brachyfacial skeletal pattern and impinging deepbite can be challenging for the practitioner. The tendency for downward and backward mandibular ro- tation in response to orthodontic forces of inappropri- ate magnitude or direction must be minimized. When correcting a Class II deepbite, an important clinical goal is to reduce the amount of overbite. 1 However, when this malocclusion is associated with lip protrusion and significant tooth display, it is also necessary to maximize the anchorage of the posterior teeth during retraction. 2 Extraoral appliances, such as the J-hook headgear, are effective in both controlling anchorage during ante- rior tooth retraction 3 and achieving effective intrusion of the incisors, even though a high level of patient cooper- ation is necessary. 3,4 In patients with deepbite and excessive tooth display, even in the resting lip position, intrusion of the maxillary incisors is required rather than extrusion of the molars. 4 The J-hook headgear gives excellent control of extrusion of the maxillary pos- terior teeth. 2 The amount and direction of force of the J-hook headgear should be considered because it will change the movement of the incisors in both the vertical and horizontal directions. 3 The use of the J-hook headgear in the appropriate direction (high pull) can provide direc- tional forces that will place the teeth in harmonious re- lationships with their environment and create stable anchorage. However, the intrusion effect might vary, since it depends on complete patient cooperation. 5,6 With the increasing popularity of skeletal anchorage, titanium screws have been used in many clinical situa- tions such as intrusion and en-masse retraction of the anterior teeth without the critical problem of patient compliance. 2 However, traditional effective treatment might be considered for patients who do not want sur- gical or any other invasive intervention. 7 DIAGNOSIS AND ETIOLOGY The patient was a 21-year-old man of normal weight and stature with no relevant medical history. His main complaints were lip protrusion and the diastema be- tween the maxillary central incisors. The facial photo- graphs showed a convex facial profile with marked lip protrusion and an everted lower lip, mentalis muscle strain, and a proportionally shorter lower anterior facial height. The temporomandibular joints were clinically normal. He had 2 mm of anterior mandibular dental crowding and a 1-mm diastema distal to each mandib- ular canine. The mandibular discrepancy was zero. There was a 5-mm diastema between the maxillary central incisors. A space was also evident between From Rio de Janeiro State University, Rio de Janeiro, Brazil. a Adjunct professor, Department of Orthodontics, Rio de Janeiro State University, Brazil. b Specialist in Orthodontics and MSc student, Rio de Janeiro State University, Brazil. c PhD student; specialist and MSc in Orthodontics, Department of Orthodontics, Rio de Janeiro State University, Brazil. The authors report no commercial, proprietary, or financial interest in the products or companies described in this article. Reprint requests to: Daniela Feu, R. Moacir Avidos, number 156/apto 804, Praia do Canto, Vitoria, E.S., Cep: 29055-350, Brazil; e-mail, [email protected]. Submitted, December 2009; revised and accepted, February 2010. 0889-5406/$36.00 Copyright Ó 2012 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2010.02.041 105 CASE REPORT
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CASE REPORT
Is traditional treatment a good option for an adultwith a Class II deepbite malocclusion?
Catia Cardoso Abdo Quint~ao,a Jose Augusto Mendes Miguel,a Ione Portela Brunharo,a Gustavo Zanardi,b
The Tweed-Merrifield directional force technique is a useful treatment approach for a patient with a Class II mal-occlusion with dentoalveolar protrusion. The purpose of this case report was to present the diagnosis and treat-ment descriptions of a patient with an Angle Class II malocclusion complicated by tooth losses, severedentoalveolar protrusion, and skeletal discrepancy. Treatment involved extraction of the maxillary first premo-lars, high-pull headgear to enhance anchorage, and high-pull J-hook headgear to retract and intrude the max-illary anterior segments. A successful outcome was achieved with traditional orthodontic treatment in thisborderline surgical case. (Am J Orthod Dentofacial Orthop 2012;141:105-12)
The diagnosis and orthodontic treatment of Class IIDivision 1 malocclusions in an adult patient witha brachyfacial skeletal pattern and impinging
deepbite can be challenging for the practitioner. Thetendency for downward and backward mandibular ro-tation in response to orthodontic forces of inappropri-ate magnitude or direction must be minimized. Whencorrecting a Class II deepbite, an important clinicalgoal is to reduce the amount of overbite.1 However,when this malocclusion is associated with lip protrusionand significant tooth display, it is also necessary tomaximize the anchorage of the posterior teeth duringretraction.2
Extraoral appliances, such as the J-hook headgear,are effective in both controlling anchorage during ante-rior tooth retraction3 and achieving effective intrusion ofthe incisors, even though a high level of patient cooper-ation is necessary.3,4 In patients with deepbite andexcessive tooth display, even in the resting lip position,intrusion of the maxillary incisors is required ratherthan extrusion of the molars.4 The J-hook headgear
Rio de Janeiro State University, Rio de Janeiro, Brazil.nct professor, Department of Orthodontics, Rio de Janeiro State University,.ialist in Orthodontics and MSc student, Rio de Janeiro State University,.student; specialist and MSc in Orthodontics, Department of Orthodontics,Janeiro State University, Brazil.uthors report no commercial, proprietary, or financial interest in thects or companies described in this article.t requests to: Daniela Feu, R. Moacir Avidos, number 156/apto 804, Praia do, Vit�oria, E.S., Cep: 29055-350, Brazil; e-mail, [email protected], December 2009; revised and accepted, February 2010.5406/$36.00ight � 2012 by the American Association of Orthodontists..1016/j.ajodo.2010.02.041
gives excellent control of extrusion of the maxillary pos-terior teeth.2
The amount and direction of force of the J-hookheadgear should be considered because it will changethe movement of the incisors in both the vertical andhorizontal directions.3 The use of the J-hook headgearin the appropriate direction (high pull) can provide direc-tional forces that will place the teeth in harmonious re-lationships with their environment and create stableanchorage. However, the intrusion effect might vary,since it depends on complete patient cooperation.5,6
With the increasing popularity of skeletal anchorage,titanium screws have been used in many clinical situa-tions such as intrusion and en-masse retraction of theanterior teeth without the critical problem of patientcompliance.2 However, traditional effective treatmentmight be considered for patients who do not want sur-gical or any other invasive intervention.7
DIAGNOSIS AND ETIOLOGY
The patient was a 21-year-old man of normal weightand stature with no relevant medical history. His maincomplaints were lip protrusion and the diastema be-tween the maxillary central incisors. The facial photo-graphs showed a convex facial profile with markedlip protrusion and an everted lower lip, mentalis musclestrain, and a proportionally shorter lower anterior facialheight. The temporomandibular joints were clinicallynormal. He had 2 mm of anterior mandibular dentalcrowding and a 1-mm diastema distal to each mandib-ular canine. The mandibular discrepancy was zero.There was a 5-mm diastema between the maxillarycentral incisors. A space was also evident between
the maxillary central and lateral incisors, distally to themaxillary canines. The mandibular dental midline wasdisplaced about 1 mm to the patient’s right. On lipclosure, the maxillary central incisors were exposed,as well as with the lips at rest. Both mentalis and max-illary lip strain were observed (Figs 1 and 2).
The tooth roots appeared normal radiographically, allamalgam fillings were satisfactory, and both mandibularand maxillary first molars had been extracted because ofcaries (Fig 3). Oral hygiene was adequate, and the gingi-val tissues were healthy.
Analysis of the lateral cephalogram (Fig 4) confirmedthe skeletal problem. The patient had a brachyfacial skel-etal pattern with a low mandibular plane angle (FMA,17�; SN-GoGN, 22�) and a severe Class II malocclusion(SNA, 95�; SNB, 86�; ANB, 9�; Wits, 16 mm). He hada dentoalveolar Class II Division 1 malocclusion witha 14-mm overjet, an impinging deepbite, and a vestibularposterior crossbite. The maxillary and mandibular centralincisors were excessively proclined (1.NA, 41�; 1-NA, 12mm; 1.NB, 35�; 1-NB, 11.5 mm; IMPA, 113�).
TREATMENT OBJECTIVES
The treatment goals were to (1) align and level theteeth in both arches and establish a functional occlusion,(2) maintain the Class II molar relationship of the secondmolars with a Class I canine relationship, (3) achieve nor-mal overjet and overbite, (4) obtain a balanced facialprofile, and (5) improve facial esthetics.
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TREATMENT ALTERNATIVES
The first alternative was orthognathic surgery. Afterspace closure, 2-jaw surgery including counterclockwisedifferential impaction of the maxilla and concurrentmandibular advancement surgery would be performedto correct the skeletal discrepancy. Genioplasty wouldbe necessary to advance the chin along the facial mid-line. However, the patient declined surgical treatment.
The second alternative was orthodontic treatmentconsisting of the extraction of the 2 maxillary first pre-molars and directional force technology with microim-plant anchorage. The microimplant could provideabsolute anchorage, not only to achieve maximum re-traction of the maxillary anterior teeth, but also to im-prove their intrusion. A genioplasty would be necessaryto advance the chin to obtain a balanced facial profile.However, the patient declined both the microimplantand the genioplasty surgery but accepted the treatmentplan involving the Tweed-Merrifield directional force,with extraction of the 2 maxillary first premolars andthe high-pull J-hook headgear as anchorage controlduring anterior tooth retraction and with an active intru-sion force on the incisors.
TREATMENT PROGRESS
A 0.022 3 0.028-in no-tip, no-torque edgewise ap-pliance was placed in both arches. An initial 0.016-instainless steel wire was used in the maxillary arch. For
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Fig 2. Pretreatment dental casts.
Abdo Quint~ao et al 107
the uprighting of the mandibular left and right third mo-lars, a 0.017 3 0.025-in beta-titanium cantilever anda 0.019 3 0.025-in passive stainless steel mandibulararchwire were used. The mandibular incisor intrusionwas obtained by using tripart mechanics (Burstone intru-sionmechanics). Therewas continuous leveling and align-ing of the mandibular arch starting with a stainless steel0.016-in wire. Subsequently, larger wires were used tolevel the mandibular and maxillary arches, and crossbitecorrection was achieved by using symmetric and coordi-nated archwires. In the 0.018 3 0.025-in maxillary arch,the first premolars were extracted. The patient was in-structed to use the high-pull headgear for at least 12 to14 hours per day tomaintain the anchorage during the re-traction of the maxillary canines. A force gauge was usedmonthly to check and maintain a 300-g force per side.
After retraction of the maxillary canines, a closing0.019 3 0.021-in archwire with bull loops was placed.Maxillary anterior retraction was conducted by activat-ing the closing loop supported by the high-pull J-hookheadgear. This contributed toward torque control,bodily movement, and intrusion of the maxillary anteriorteeth. The J-hook headgear was adapted to the closingloop archwire at 100 g per side (average, 109.2 g; SD,15 g), and the patient was instructed to use it at least14 hours per day. The force was checked monthly to
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adjust and keep it continuous. Anterior retraction wasconducted for 8 months.
The interincisal angle decreased gradually after thefirst 2 months of tooth retraction. The extraction spacewas closed while the posterior occlusal relationshipwas maintained. The treatment was completed withideal archwires and cusp-seating elastics. Additionally,a bilateral Class II elastic force was applied to the hookon the maxillary archwire from the mandibular posteriormolars to finish the occlusion.
After 36 months of treatment, space consolidationand ideal occlusion were achieved. Root parallelismwas confirmed on the panoramic radiograph, and theappliances were removed. Retention was provided bymaxillary and mandibular lingual bonded retainers.
TREATMENT RESULTS
After 36 months of treatment, the teeth were aligned.A Class I canine relationship with midline coincidenceand proper occlusion were obtained. Ideal overjet, over-bite, and facial balance were also achieved. A Class IImolar relationship was achieved as planned. The maxil-lary and mandibular second molars replaced the firstmolars, and the third molars acted as the second molars(Figs 5 and 6). The posttreatment facial photographsshowed improvement in the incisor procumbency, and
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Fig 3. Pretreatment periapical radiographs.
Fig 4. Pretreatment lateral cephalogram and cephalometric analysis.
108 Abdo Quint~ao et al
a well-balanced face was produced by the retraction ofthe upper lip and the reduction of the mentalis musclestrain. An ideal profile could have been achieved if thepatient had accepted a genioplasty to advance the chin.
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Periapical radiographs (Fig 7) showed good root par-allelism and no root resorption. Periodontal conditionswere acceptable with symmetric and normal gingivalmargins, normal bone crest height, and intact lamina
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Fig 5. Posttreatment photographs.
Fig 6. Posttreatment dental casts.
Abdo Quint~ao et al 109
dura, periodontal ligament, and trabecular bone in theperiapical area with normal levels upon probing.
The cephalometric analysis (Figs 8 and 9) shows themaintenance of FMA, the reduction of ANB during
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treatment from 9� to 4�, and the intrusion and retractionof themaxillary anterior teeth (1.NA, 41�-22�; 1-NA, 12-5mm). As expected, the mandibular incisors were alignedand showed no retraction (1.NB, 35�-36�; 1-NB, 11.5-6
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Fig 7. Posttreatment periapical radiographs.
Fig 8. Posttreatment lateral cephalogram and cephalometric analysis.
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mm; IMPA, 113�-114�). The interincisal angle was im-proved up to the normal range (97�-116�). The cephalo-metric superimposition confirmed bodily retraction, and
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retroinclination and intrusion of the maxillary anteriorteeth. The maxillary posterior teeth were intruded andmoved slightly mesially. A small chin advancement was
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Fig 9. Cephalometric superimpositions.
Abdo Quint~ao et al 111
obtained by the auto-rotation of the mandible, throughvertical control of the dentition and some growth at po-gonion.
The treatment results were within acceptable limits,and the patient was satisfied with the final result. Lingualbonded retainers were placed on the mandibular anteriorteeth and also on the maxillary anterior teeth because themidline diastema reopened during treatment.
DISCUSSION
The Tweed-Merrifield directional force technology isuseful, particularly for dentoalveolar protrusion andClass II malocclusion corrections when the patient doesnot agree to a surgical solution. In this patient, a 7-mm decrease in the amount of overbite was observed.The reduction of the overbite was due to either maxillaryand mandibular incisor intrusion or extrusion of the mo-lars. There was a reduction in SN to themandibular planewith no additional clockwise rotation of the mandible,indicating almost no reciprocal effect on the posteriorsegments. Therefore, it was suggested that ideal intru-sion of the incisors should be accomplished. The litera-ture has shown that the longer the J-hook headgearis used, the better the effect of intrusion. Patient coop-eration is the key to successful incisor intrusion with theJ-hook headgear mechanics.
However, especially with adult treatment, it is chal-lenging to obtain the patient’s compliance to con-stantly wear a headgear. Therefore, not all patientsare eligible to be treated with this technique.
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Miniscrews can also be used as orthodontic anchorageto effectively intrude the incisors.3,5,8 The mostsignificant advantage is that the mechanics do notrely on the patient’s cooperation.3 Furthermore, mini-screws have been routinely used as an option for cor-recting a Class II deepbite to obtain excellent resultsand, in some cases, to avoid maxillary surgery.9,10
In this patient, the malocclusion was corrected, anda balanced and harmonious facial profile was achievedwith a traditional treatment protocol without the needfor an invasive procedure. This shows that, with patientcooperation, a traditional treatment protocol remains anexcellent and effective option. The patient was highlysatisfied, and this was confirmed by an oral health-related quality-of-life questionnaire completed beforeand after treatment.
Vertical dimension control during treatment in-hibited the increase in anterior facial height and pro-moted an acceptable gain in the horizontal mandibulardimension in response to the Class II correction. Chin en-hancement and Z-angle improvement contributed togood facial results. The patient also showed a reductionof A-point horizontally. This might have occurred by theremodeling of the bone at A-point after prolonged ap-plication of the retraction force near the center of resis-tance of the maxillary anterior segment by the J-hookheadgear.
Intraorally, the success of a traditional treatment pro-tocol depends on the control of vertical dimensionthrough anchorage preparation. Since the horizontal
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movement of the dentition determines how the verticaldimension of themaxillomandibular complex is managed,vertical control can make horizontal correction possible.
The use of the J-hook headgear also induces procli-nation of the incisors when compared with implant an-chorage. This is because the force application of theminiscrew is more labially positioned from the centerof resistance than the force exerted by the J-hook head-gear.3 Therefore, the axial inclination correction and theretraction of the incisors with the J-hook headgear wasthe best option for this patient and allowed for a greateramount of horizontal correction. Nevertheless, a disad-vantage of this treatment protocol was the maintenanceof the mandibular incisor projection.
There is no significant difference between the timeneeded to intrude teeth with miniscrews or J-hook head-gear anchorage.2,3 In both techniques, it takes about 7months to complete this movement, assuming reliablepatient cooperation with the J-hook headgear. In thispatient, intrusion and retraction of the 4 anterior teethwere done at the same time of closing loop activation,supported by the high-pull J-hook headgear to reducetreatment time and develop a more precise treatmentprotocol.
CONCLUSIONS
The traditional treatment protocol for treating den-toalveolar protrusion and a Class II malocclusion is stilla viable option to achieve a balanced occlusion and
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a harmonious face when a cooperative patient desiresless-invasive treatment or is unwilling to pay for a surgi-cal approach to treatment.
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3. Deguchi T, Murakami T, Kuroda S, Yabuuchi T, Kamioka H,Takano-Yamamoto T. Comparison of the intrusion effects on themaxillary incisors between implant anchorage and J-hook head-gear. Am J Orthod Dentofacial Orthop 2008;133:654-60.
4. Proffit WR, Fields HW. Contemporary orthodontics. 3rd ed.St Louis: Mosby Year Book; 2000. p. 200-2.
5. Chae J. A new protocol of Tweed-Merrifield directional force tech-nology with microimplant anchorage. Am J Orthod DentofacialOrthop 2006;130:100-9.
6. Melsen B, Agerback N, Markestam G. Intrusion of incisors in adultpatients with marginal bone loss. Am J Orthod Dentofacial Orthop1989;96:232-41.
7. Thiruvenkatachari B, Ammayappan P, Kandaswamy R. Comparisonof rate of canine retraction with conventional molar anchorageand titanium implant anchorage. Am J Orthod Dentofacial Orthop2008;134:30-5.
8. Kanomi R. Mini-implant for orthodontic anchorage. J Clin Orthod1997;31:763-7.
9. Ohnishi TY, Yasuda Y, Takada AK. Mini-implant for orthodonticanchorage in a deep overbite case. Angle Orthod 2005;75:393-401.
10. Kuroda S, Katayama A, Takano-Yamamoto T. Severe anterioropen-bite case treated using titanium screw anchorage. AngleOrthod 2004;74:558-67.
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