Angle Class II, subdivision, with agenesis of mandibular second molars and extrusion of maxillary second molars*
Identifieur interne : 000135 ( Pmc/Corpus ); précédent : 000134; suivant : 000136Angle Class II, subdivision, with agenesis of mandibular second molars and extrusion of maxillary second molars*
Auteurs : Rubens Rodrigues TavaresSource :
- Dental Press Journal of Orthodontics [ 2176-9451 ] ; 2015.
Abstract
This clinical case reports the treatment of an Angle Class II malocclusion in a young woman with a balanced face affected by agenesis of second and third mandibular molars and subsequent extrusion of second maxillary molars. The atypical and peculiar occlusal anomaly led to individualized treatment proposed in order to normalize dental malpositions, with subsequent rehabilitation of edentulous areas by means of a multidisciplinary approach. This case was presented to the Brazilian Board of Orthodontics and Dentofacial Orthopedics (BBO) in partial fulfillment of the requirements for obtaining the title of certified by the BBO.
Url:
DOI: 10.1590/2176-9451.20.2.110-118.bbo
PubMed: 25992995
PubMed Central: 4445233
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Angle Class II, subdivision, with agenesis of mandibular second molars
and extrusion of maxillary second molars<xref ref-type="fn" rid="fn01"><sup>*</sup></xref></title><author><name sortKey="Tavares, Rubens Rodrigues" sort="Tavares, Rubens Rodrigues" uniqKey="Tavares R" first="Rubens Rodrigues" last="Tavares">Rubens Rodrigues Tavares</name><affiliation><nlm:aff id="aff1">Specialist in Orthodontics and Facial Orthopedics, Universidade Paulista (UNIP). Certified by the Brazilian Board of Orthodontics and Dentofacial Orthopedics (BBO)</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25992995</idno><idno type="pmc">4445233</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4445233</idno><idno type="RBID">PMC:4445233</idno><idno type="doi">10.1590/2176-9451.20.2.110-118.bbo</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000135</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000135</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Angle Class II, subdivision, with agenesis of mandibular second molars
and extrusion of maxillary second molars<xref ref-type="fn" rid="fn01"><sup>*</sup></xref></title><author><name sortKey="Tavares, Rubens Rodrigues" sort="Tavares, Rubens Rodrigues" uniqKey="Tavares R" first="Rubens Rodrigues" last="Tavares">Rubens Rodrigues Tavares</name><affiliation><nlm:aff id="aff1">Specialist in Orthodontics and Facial Orthopedics, Universidade Paulista (UNIP). Certified by the Brazilian Board of Orthodontics and Dentofacial Orthopedics (BBO)</nlm:aff></affiliation></author></analytic><series><title level="j">Dental Press Journal of Orthodontics</title><idno type="ISSN">2176-9451</idno><idno type="eISSN">2177-6709</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>This clinical case reports the treatment of an Angle Class II malocclusion in a young
woman with a balanced face affected by agenesis of second and third mandibular molars
and subsequent extrusion of second maxillary molars. The atypical and peculiar
occlusal anomaly led to individualized treatment proposed in order to normalize
dental malpositions, with subsequent rehabilitation of edentulous areas by means of a
multidisciplinary approach. This case was presented to the Brazilian Board of
Orthodontics and Dentofacial Orthopedics (BBO) in partial fulfillment of the
requirements for obtaining the title of certified by the BBO.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Sing, G" uniqKey="Sing G">G Sing</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bruhn, C" uniqKey="Bruhn C">C Bruhn</name></author><author><name sortKey="Hofrath, H" uniqKey="Hofrath H">H Hofrath</name></author><author><name sortKey="Korkhaus, G" uniqKey="Korkhaus G">G Korkhaus</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Roriz, Nb" uniqKey="Roriz N">NB Roriz</name></author><author><name sortKey="Tavares, Rr" uniqKey="Tavares R">RR Tavares</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Langlade, M" uniqKey="Langlade M">M Langlade</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ainamo, J" uniqKey="Ainamo J">J Ainamo</name></author><author><name sortKey="Talari, A" uniqKey="Talari A">A Talari</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bjork, A" uniqKey="Bjork A">A Bjork</name></author><author><name sortKey="Skieller, V" uniqKey="Skieller V">V Skieller</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Brugnolo, E" uniqKey="Brugnolo E">E Brugnolo</name></author><author><name sortKey="Cordioll, G" uniqKey="Cordioll G">G Cordioll</name></author><author><name sortKey="Majzoub, Z" uniqKey="Majzoub Z">Z Majzoub</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bernard, Jp" uniqKey="Bernard J">JP Bernard</name></author><author><name sortKey="Schatz, Jp" uniqKey="Schatz J">JP Schatz</name></author><author><name sortKey="Christou, P" uniqKey="Christou P">P Christou</name></author><author><name sortKey="Belser, U" uniqKey="Belser U">U Belser</name></author><author><name sortKey="Kiliaridis, S" uniqKey="Kiliaridis S">S Kiliaridis</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Thilander, B" uniqKey="Thilander B">B Thilander</name></author><author><name sortKey="Odman, J" uniqKey="Odman J">J Odman</name></author><author><name sortKey="Grondahl, K" uniqKey="Grondahl K">K Gröndahl</name></author><author><name sortKey="Friberg, B" uniqKey="Friberg B">B Friberg</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Thilander, B" uniqKey="Thilander B">B Thilander</name></author><author><name sortKey="Odman, J" uniqKey="Odman J">J Odman</name></author><author><name sortKey="Lekholm, U" uniqKey="Lekholm U">U Lekholm</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mota, Ps" uniqKey="Mota P">PS Mota</name></author><author><name sortKey="Freitas, Jf" uniqKey="Freitas J">JF Freitas</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Dental Press J Orthod</journal-id><journal-id journal-id-type="iso-abbrev">Dental Press J Orthod</journal-id><journal-id journal-id-type="publisher-id">dpjo</journal-id><journal-title-group><journal-title>Dental Press Journal of Orthodontics</journal-title></journal-title-group><issn pub-type="ppub">2176-9451</issn><issn pub-type="epub">2177-6709</issn><publisher><publisher-name>Dental Press International</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25992995</article-id><article-id pub-id-type="pmc">4445233</article-id><article-id pub-id-type="doi">10.1590/2176-9451.20.2.110-118.bbo</article-id><article-categories><subj-group subj-group-type="heading"><subject>BBO Case Report</subject></subj-group></article-categories><title-group><article-title>Angle Class II, subdivision, with agenesis of mandibular second molars
and extrusion of maxillary second molars<xref ref-type="fn" rid="fn01"><sup>*</sup></xref></article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Tavares</surname><given-names>Rubens Rodrigues</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><aff id="aff1"><label>1</label>Specialist in Orthodontics and Facial Orthopedics, Universidade Paulista (UNIP). Certified by the Brazilian Board of Orthodontics and Dentofacial Orthopedics (BBO)</aff></contrib-group><author-notes><corresp id="c01"><bold>Contact address:</bold> Rubens Rodrigues Tavares Rua 6, no 370, sala 907,
Edifício Empire Center, Setor Oeste, Goiânia (GO) Brazil, CEP:74115-070 - E-mail:
<email>rubensrtavares@uol.com.br</email></corresp></author-notes><pub-date pub-type="epub-ppub"><season>Mar-Apr</season><year>2015</year></pub-date><pmc-comment>Fake ppub date generated by PMC from publisher
pub-date/@pub-type='epub-ppub' </pmc-comment>
<pub-date pub-type="ppub"><season>Mar-Apr</season><year>2015</year></pub-date><volume>20</volume><issue>2</issue><fpage>110</fpage><lpage>118</lpage><history><date date-type="received"><day>09</day><month>2</month><year>2015</year></date><date date-type="accepted"><day>27</day><month>2</month><year>2015</year></date></history><permissions><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an Open Access article distributed under the terms of the Creative
Commons Attribution Non-Commercial License, which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the
original work is properly cited.</license-p></license></permissions><abstract><p>This clinical case reports the treatment of an Angle Class II malocclusion in a young
woman with a balanced face affected by agenesis of second and third mandibular molars
and subsequent extrusion of second maxillary molars. The atypical and peculiar
occlusal anomaly led to individualized treatment proposed in order to normalize
dental malpositions, with subsequent rehabilitation of edentulous areas by means of a
multidisciplinary approach. This case was presented to the Brazilian Board of
Orthodontics and Dentofacial Orthopedics (BBO) in partial fulfillment of the
requirements for obtaining the title of certified by the BBO.</p></abstract><trans-abstract xml:lang="pt"><p>O presente caso clínico relata o tratamento de uma má oclusão de Classe II de Angle,
em uma jovem com face harmoniosa, porém agravada por agenesias de segundos e
terceiros molares inferiores e consequente extrusão dos segundos molares superiores.
A anomalia oclusal atípica e peculiar levou a uma proposta de tratamento
individualizada, visando normalizar os maus posicionamentos dentários e uma posterior
reabilitação das áreas edêntulas, por meio de uma abordagem multidisciplinar. O
presente caso foi apresentado à Diretoria do Board Brasileiro de Ortodontia e
Ortopedia Facial (BBO), como parte dos requisitos para a obtenção do título de
Diplomado pelo BBO.</p></trans-abstract><kwd-group><kwd>Angle Class II malocclusion</kwd><kwd>Partial anodontia</kwd><kwd>Corrective Orthodontics</kwd><kwd>Dental implant</kwd></kwd-group><counts><fig-count count="11"></fig-count><table-count count="1"></table-count><equation-count count="0"></equation-count><ref-count count="11"></ref-count><page-count count="9"></page-count></counts></article-meta></front><body><sec sec-type="intro"><title>INTRODUCTION</title><p>A female patient presented for initial examination at the age of 14 years and three
months and was found to be in good general health. No significant information was found
in her past medical and dental records. She did not have, nor did she report having, any
deleterious oral habits. As chief complaint she reported that some mandibular teeth were
missing, which resulted in the presence of spaces, rotations and difficulty chewing in
the posterior region. She had little growth potential, as she reported that her menarche
had occurred when she was about 12 years old. While in many subjects the hereditary
component is involved in determining partial anodontia, this aspect was not investigated
in this case.</p></sec><sec><title>DIAGNOSIS</title><p>She had a rather well-balanced mesofacial pattern without any serious neuromuscular
functional changes, as well as a slightly convex profile and slightly protrusive
maxillary and mandibular lips (UL-S line = 3mm LL-S line = 2 mm). This feature seemed
fully compatible with the patient's age group (<xref ref-type="fig" rid="f01">Fig
1</xref> and <xref ref-type="table" rid="t01">Table 1</xref>).</p><p><fig id="f01" orientation="portrait" position="float"><label>Figure 1 -</label><caption><title>Initial facial and intraoral photographs.</title></caption><graphic xlink:href="dpjo-20-02-00110-gf01"></graphic></fig></p><p><table-wrap id="t01" orientation="portrait" position="float"><label>Table 1 -</label><caption><title>Initial (A) and final (B) cephalometric values.</title></caption><table frame="hsides" rules="groups" style="border-top: 1px solid black; border-bottom: 1px solid black; width: 100%"><thead><tr><th rowspan="1" colspan="1"></th><th rowspan="1" colspan="1"> Measurements</th><th rowspan="1" colspan="1"></th><th rowspan="1" colspan="1"> Normal</th><th rowspan="1" colspan="1"> A</th><th rowspan="1" colspan="1"> B</th><th rowspan="1" colspan="1"> Dif. A/B</th></tr></thead><tbody><tr><td rowspan="8" colspan="1"> Skeletal <break></break> pattern</td><td rowspan="1" colspan="1"> SNA</td><td rowspan="1" colspan="1"> (Steiner)</td><td rowspan="1" colspan="1"> 82°</td><td rowspan="1" colspan="1"> 78°</td><td rowspan="1" colspan="1"> 78°</td><td rowspan="1" colspan="1"> 0</td></tr><tr><td rowspan="1" colspan="1"> SNB</td><td rowspan="1" colspan="1"> (Steiner)</td><td rowspan="1" colspan="1"> 80°</td><td rowspan="1" colspan="1"> 76°</td><td rowspan="1" colspan="1"> 76.5°</td><td rowspan="1" colspan="1"> 0.5</td></tr><tr><td rowspan="1" colspan="1"> ANB</td><td rowspan="1" colspan="1"> (Steiner)</td><td rowspan="1" colspan="1"> 2°</td><td rowspan="1" colspan="1"> 2°</td><td rowspan="1" colspan="1"> 1.5°</td><td rowspan="1" colspan="1"> 0.5</td></tr><tr><td rowspan="1" colspan="1"> Angle of convexity</td><td rowspan="1" colspan="1"> (Downs)</td><td rowspan="1" colspan="1"> 0°</td><td rowspan="1" colspan="1"> 2°</td><td rowspan="1" colspan="1"> 1°</td><td rowspan="1" colspan="1"> 1</td></tr><tr><td rowspan="1" colspan="1"> Y axis</td><td rowspan="1" colspan="1"> (Downs)</td><td rowspan="1" colspan="1"> 59°</td><td rowspan="1" colspan="1"> 61°</td><td rowspan="1" colspan="1"> 62°</td><td rowspan="1" colspan="1"> 1</td></tr><tr><td rowspan="1" colspan="1"> Facial angle</td><td rowspan="1" colspan="1"> (Downs)</td><td rowspan="1" colspan="1"> 87°</td><td rowspan="1" colspan="1"> 87°</td><td rowspan="1" colspan="1"> 87°</td><td rowspan="1" colspan="1"> 0</td></tr><tr><td rowspan="1" colspan="1"> SN-GoGn</td><td rowspan="1" colspan="1"> (Steiner)</td><td rowspan="1" colspan="1"> 32°</td><td rowspan="1" colspan="1"> 31°</td><td rowspan="1" colspan="1"> 30°</td><td rowspan="1" colspan="1"> 1</td></tr><tr><td rowspan="1" colspan="1"> FMA</td><td rowspan="1" colspan="1"> (Tweed)</td><td rowspan="1" colspan="1"> 25°</td><td rowspan="1" colspan="1"> 26°</td><td rowspan="1" colspan="1"> 24°</td><td rowspan="1" colspan="1"> 2</td></tr><tr><td rowspan="7" colspan="1"> Dental <break></break> pattern</td><td rowspan="1" colspan="1"> IMPA</td><td rowspan="1" colspan="1"> (Tweed)</td><td rowspan="1" colspan="1"> 90°</td><td rowspan="1" colspan="1"> 85°</td><td rowspan="1" colspan="1"> 89°</td><td rowspan="1" colspan="1"> 4</td></tr><tr><td rowspan="1" colspan="1"><underline>1</underline>.NA (degrees)</td><td rowspan="1" colspan="1"> (Steiner)</td><td rowspan="1" colspan="1"> 22°</td><td rowspan="1" colspan="1"> 17°</td><td rowspan="1" colspan="1"> 18°</td><td rowspan="1" colspan="1"> 1</td></tr><tr><td rowspan="1" colspan="1"><underline>1</underline>-NA (mm)</td><td rowspan="1" colspan="1"> (Steiner)</td><td rowspan="1" colspan="1"> 4 mm</td><td rowspan="1" colspan="1"> 3.5 mm</td><td rowspan="1" colspan="1"> 2 mm</td><td rowspan="1" colspan="1"> 1.5</td></tr><tr><td rowspan="1" colspan="1"><underline>1</underline>.NB (degrees)</td><td rowspan="1" colspan="1"> (Steiner)</td><td rowspan="1" colspan="1"> 25°</td><td rowspan="1" colspan="1"> 20°</td><td rowspan="1" colspan="1"> 20°</td><td rowspan="1" colspan="1"> 0</td></tr><tr><td rowspan="1" colspan="1"><underline>1</underline>-NB (mm)</td><td rowspan="1" colspan="1"> (Steiner)</td><td rowspan="1" colspan="1"> 4 mm</td><td rowspan="1" colspan="1"> 3.5 mm</td><td rowspan="1" colspan="1"> 3 mm</td><td rowspan="1" colspan="1"> 0.5</td></tr><tr><td rowspan="1" colspan="1"> - Interincisal angle</td><td rowspan="1" colspan="1"> (Downs)</td><td rowspan="1" colspan="1"> 130°</td><td rowspan="1" colspan="1"> 145°</td><td rowspan="1" colspan="1"> 147°</td><td rowspan="1" colspan="1"> 2</td></tr><tr><td rowspan="1" colspan="1"><underline>1</underline>-APo</td><td rowspan="1" colspan="1"> (Ricketts)</td><td rowspan="1" colspan="1"> 1 mm</td><td rowspan="1" colspan="1"> 0.5 mm</td><td rowspan="1" colspan="1"> 0 mm</td><td rowspan="1" colspan="1"> 0.5</td></tr><tr><td rowspan="2" colspan="1"> Profile</td><td rowspan="1" colspan="1"> Maxillary lip — S-line</td><td rowspan="1" colspan="1"> (Steiner)</td><td rowspan="1" colspan="1"> 0 mm</td><td rowspan="1" colspan="1"> 3 mm</td><td rowspan="1" colspan="1"> 2.5 mm</td><td rowspan="1" colspan="1"> 0.5</td></tr><tr><td rowspan="1" colspan="1"> Mandibular lip — S-line</td><td rowspan="1" colspan="1"> (Steiner)</td><td rowspan="1" colspan="1"> 0 mm</td><td rowspan="1" colspan="1"> 2 mm</td><td rowspan="1" colspan="1"> 1 mm</td><td rowspan="1" colspan="1"> 1</td></tr></tbody></table></table-wrap></p><p>Dental analysis (<xref ref-type="fig" rid="f01">Figs 1</xref> and <xref ref-type="fig" rid="f02">2</xref>) disclosed Angle Class II malocclusion, subdivision right,
aggravated by the absence of second and third mandibular molars, distal migration of
mandibular posterior teeth, and extrusion of second maxillary molars. In addition to the
aforementioned teeth, tooth #18 was also missing. She presented asymmetry of maxillary
canines in the anteroposterior direction and no coincidence between maxillary and
mandibular midlines and the midsagittal plane. The maxillary midline was shifted to the
left while the mandibular one was shifted to the right.<xref rid="B01" ref-type="bibr">1</xref><sup>,</sup><xref rid="B02" ref-type="bibr">2</xref> She had an increased overbite with sharp
incisal disocclusion and well-adjusted anterior centric stop. In the mandibular dental
arch, there was generalized diastema, pronounced in the region between canines and first
premolars.</p><p><fig id="f02" orientation="portrait" position="float"><label>Figure 2 -</label><caption><title>Initial casts.</title></caption><graphic xlink:href="dpjo-20-02-00110-gf02"></graphic></fig></p><p>Panoramic radiograph (<xref ref-type="fig" rid="f03">Fig 3</xref>) revealed good root
formation of all teeth, in addition to absence of teeth #37 and 47. As regards third
molars, it was observed that only tooth #28 was going through early stages of formation,
about Nolla stage 4, with all other teeth missing.</p><p><fig id="f03" orientation="portrait" position="float"><label>Figure 3 -</label><caption><title>Initial panoramic radiograph.</title></caption><graphic xlink:href="dpjo-20-02-00110-gf03"></graphic></fig></p><p>Profile cephalometric radiograph and cephalometric tracing (<xref ref-type="fig" rid="f04">Fig 4</xref>) revealed good maxillomandibular relationship in the vertical
(SN-GoGn = 31<sup>o</sup>; FMA = 26<sup>o)</sup>, and anteroposterior direction, with
Class I skeletal pattern (SNA = 78<sup>o</sup>; SNB = 76<sup>o</sup>; ANB =
2<sup>o)</sup>. Maxillary and mandibular incisors were slightly upright (1.NA =
17<sup>o</sup>; 1.NB = 20<sup>o)</sup>, thereby increasing the interincisal angle
(1/1 = 145<sup>o)</sup>. These and other cephalometric values are shown in <xref ref-type="table" rid="t01">Table 1</xref>.</p><p><fig id="f04" orientation="portrait" position="float"><label>Figure 4 -</label><caption><title>Initial profile cephalometric radiograph (A) and cephalometric tracing
(B).</title></caption><graphic xlink:href="dpjo-20-02-00110-gf04"></graphic></fig></p></sec><sec><title>TREATMENT PLAN</title><p>Due to dental asymmetry, treatment planning aimed to produce a distal movement of
maxillary molars on the right side and, at the same time, maintain vertical control of
maxillary second molars already extruded due to absence of antagonists. This could allow
retraction of the maxillary right quadrant so as to correct the anteroposterior
asymmetry of canines and gain space to correct the deviation in the maxillary midline.
As anchorage, one alternative would be to use mini-implants, which would allow a more
effective control of distalization of maxillary teeth. However, the patient's legal
guardians rejected this alternative, perhaps because it was not popular at that time. A
removable appliance was therefore used encapsulating teeth #17 and 27 to prevent
extrusion, along with an expansion screw for distalization (<xref ref-type="fig" rid="f05">Fig 5</xref>). A hook was also placed on the right side to deploy Class II
mechanics as soon as the mandibular arch had been leveled. Thereafter, a fixed
orthodontic appliance would be placed with a stop on the already distalized posterior
teeth, and mechanics applied to retract tooth #13, thereby achieving symmetry with its
antagonist and space for midline correction.</p><p><fig id="f05" orientation="portrait" position="float"><label>Figure 5 -</label><caption><title>Occlusal and right lateral views of the removable orthodontic
appliance.</title></caption><graphic xlink:href="dpjo-20-02-00110-gf05"></graphic></fig></p><p>In the mandibular arch, the fixed orthodontic appliance would allow not only the
leveling of the occlusal plane, a necessary step to correct severe overbite, but also
the mesialization of posterior teeth, especially on the right side, to correct the most
distal position of the right canine relative to the left. As a result, diastemata would
be eliminated, providing ideal canine and first molar occlusion and adjusting the spaces
for rehabilitation with dental implants osseointegrated in the region of second molars,
in addition to correcting the mandibular midline.</p></sec><sec><title>TREATMENT PROGRESS</title><p>Treatment began eight months after completion of the initial examination, when the
patient was almost 15 years old. This waiting time was meant to postpone, albeit
slightly, the completion of treatment, bringing it a little closer to the end of
patient's overall growth, when other rehabilitation resources, including dental
implants, would be available.</p><p>For the maxillary arch, a removable orthodontic appliance was fabricated and
installed.<xref rid="B03" ref-type="bibr">3</xref> It consisted of a Hawley retainer
in the anterior region, Adams clasps on the first molars and bilateral screws to
distalize teeth #17 and 27 (<xref ref-type="fig" rid="f05">Fig 5</xref>). These teeth
were kept encapsulated in the acrylic to prevent further extrusion during distalization.
The appliance also featured a hook on the right side for Class II elastics. The patient
was instructed to wear the appliance full time, removing it only to eat, engage in
extreme sports and learn foreign languages. The recommended activation was 1/4 of a
turn, in each screw, every five days. To ensure better vertical control, the maxillary
second molars were replenished with self-curing acrylic resin every six weeks.</p><p>Orthodontic bands were placed on the mandibular first molars, and Roth prescription
brackets with 0.018 x 0.030-in slots were bonded to all other teeth. Alignment and
leveling were then achieved using up to 0.016-in round stainless steel archwires. Class
II elastics were thereafter introduced to be worn on the right side, anchored on the
removable appliance.</p><p>After creating spaces between first and second molars, maxillary fixed orthodontic
appliance (Roth prescription, 0.018 x 0.030-in slot) was bonded after alignment and
leveling, using the same sequence of round stainless steel archwires. All teeth received
a mesial stop after distalization to progressively move first molars, premolars and
canines distally; more so on the right side, to ensure symmetry between homologous
teeth. A 0.016 x 0.022-in TMA archwire with T loops was used to intrude and level the
second molars.</p><p>Then, 0.016 x 0,016-in and 0.016 x 0,022-in Elgiloy archwires were used for both
maxillary and mandibular arches, while intrusive steps<xref rid="B04" ref-type="bibr">4
</xref>were incorporated to second molars (<xref ref-type="fig" rid="f06">Fig 6</xref>).
At this treatment stage, Class II elastics were used bilaterally to finish the
relationship between molars and canines in an ideal occlusion. After obtaining the
interocclusal space needed for rehabilitation with dental implants osseointegrated in
the region of mandibular second molars, the appliance was kept passive. It is noteworthy
that implant surgery was delayed by about six months in order to make it coincide, as
much as possible, with the end of patient's growth. After the osseointegration period,
the prosthetic phase was performed concurrently with the removal of the fixed
orthodontic appliance.</p><p><fig id="f06" orientation="portrait" position="float"><label>Figure 6 -</label><caption><title>Bite-wing radiograph. Note intrusive step on the archwire in teeth #17 and
27.</title></caption><graphic xlink:href="dpjo-20-02-00110-gf06"></graphic></fig></p><p>A removable plate with a Hawley retainer was used for retention in the maxillary arch in
the anterior region, and a fixed intercanine retainer made of round 0.028-in stainless
steel wire was used in the mandibular arch. </p></sec><sec sec-type="results"><title>RESULTS</title><p>In assessing the patient's final records (<xref ref-type="fig" rid="f07">Figs
7</xref>-<xref ref-type="fig" rid="f10">10</xref>) it is clear that all intended
objectives were achieved. Given that the patient did not grow during this period and no
significant changes were implemented in the anterior region, only subtle facial changes
were noted. In correcting the dental problems, such as intrusion of maxillary second
molars and correction of the curve of Spee, the occlusal plane was leveled. Ideal
occlusion was achieved between canines and molars at the expense of distal migration of
maxillary teeth, and especially the mesial migration of mandibular teeth, particularly
on the right side. Correction of maxillary and mandibular canine asymmetry in the
anteroposterior direction, midline deviations, extrusion of mandibular second molars,
reduced overbite, closing of mandibular spaces, and rotations were all solved in stages
by means of specific mechanics.</p><p><fig id="f07" orientation="portrait" position="float"><label>Figure 7 -</label><caption><title>Final facial and intraoral photographs</title></caption><graphic xlink:href="dpjo-20-02-00110-gf07"></graphic></fig></p><p><fig id="f08" orientation="portrait" position="float"><label>Figure 8 -</label><caption><title>Final casts.</title></caption><graphic xlink:href="dpjo-20-02-00110-gf08"></graphic></fig></p><p><fig id="f09" orientation="portrait" position="float"><label>Figure 9 -</label><caption><title>Final panoramic radiograph.</title></caption><graphic xlink:href="dpjo-20-02-00110-gf09"></graphic></fig></p><p><fig id="f10" orientation="portrait" position="float"><label>Figure 10 -</label><caption><title>Final profile cephalometric radiograph (A), and final cephalometric tracing
(B).</title></caption><graphic xlink:href="dpjo-20-02-00110-gf10"></graphic></fig></p><p><fig id="f11" orientation="portrait" position="float"><label>Figure 11 -</label><caption><title>Total (A) and partial (B) superimpositions of initial (black) and final
(red) cephalometric tracings.</title></caption><graphic xlink:href="dpjo-20-02-00110-gf11"></graphic></fig></p><p>By correcting deep overbite, the mandible was probably moved to a more anterior
position, thus contributing to a mild improvement in facial harmony and providing,
cephalometrically, a slight decrease in the value of the ANB angle (Steiner) from 2 to
1.5° (<xref ref-type="table" rid="t01">Table 1</xref>).</p></sec><sec><title>FINAL CONSIDERATIONS</title><p>As previously mentioned, treatment was deliberately delayed by approximately eight
months. However, it was later found that this delay should have lasted longer, given
that in the final phase, in agreement with the implant dentist, it proved more advisable
to wait another six months before performing surgery, which increased treatment time
unnecessarily. On the other hand, delaying the process might probably mean increased
extrusion of maxillary second molars.<xref rid="B05" ref-type="bibr">5</xref><sup>-</sup><xref rid="B11" ref-type="bibr">11</xref></p><p>Despite treatment time increase, patients and legal guardians were very pleased with the
end result, especially with regard to pleasant smile and balanced face. The goals
initially set were met especially thanks to proper planning and use of biomechanical and
rehabilitation resources based on individualized and thorough diagnosis as required by
all atypical cases. Treatment of these cases should not follow predetermined classical
protocols, but rather prompt professionals to hone their diagnostic skills in planning
and carrying out a treatment tailored to suit individual peculiarities.</p></sec></body><back><fn-group><fn fn-type="other"><p>» Patients displayed in this article previously approved the use of their facial and
intraoral photographs.</p></fn><fn fn-type="other"><p>» The author reports no commercial, proprietary or financial interest in the products
or companies described in this article.</p></fn><fn id="fn01" fn-type="other"><label>*</label><p> Case report, approved by the Brazilian Board of Orthodontics and Dentofacial
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