Treatment of a case of a Class III bimaxillary protrusion · PDF fileIntraoral vestibular...
Transcript of Treatment of a case of a Class III bimaxillary protrusion · PDF fileIntraoral vestibular...
Address for correspondence:
M. BELLAMINEDepartement d’Orthopedie Dento-Facialede Casablanca/[email protected]
DOI: 10.1051/odfen/2013408 J Dentofacial Anom Orthod 2014;17:108� RODF / EDP Sciences
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Article received: 05-2013.Accepted for publication: 07-2013.
C L I N I C A L C A S E
Treatment of a case of a Class IIIbimaxillary protrusion
Meriem BELLAMINE, Lahcen OUSEHAL
INTRODUCTION
This article describes a Class III maloc-clusion with bi-alveolar protrusion of the in-cisors treated by extraction of premolars
and a follow-up of 3 years post-retentionby the Dento-Facial Orthopedic Service ofthe CHU of Casablanca.
CLINICAL CASE
The patient S.F., 18 years old, came tothe Dento-Facial Orthopedic Service of theCHU of Casablanca for an esthetic problemrelated to dental crowding and an edge-to-edge occlusion of the incisors. The patientreported prior facial trauma at 11 years ofage (practicing a fighting sport).
CLINICAL EXAM
An examination of the face revealed along face with weak asymmetry, particularlyaffecting the middle third of the face withdeviation of the nasal septum to the left
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side probably due to the reportedtrauma. We also noted a flat profileline with a slightly protruded lowerlip, inverted lips relationship, astraight nasolabial angle, a faint labio-mental furrow, and a broad chin thatresembles a skeletal Class III. Verti-cally, the patient presents an in-creased lower facial height. (Figs. 1ato c).
Reviewing the intra-oral examina-tion, the patient presents with goodoral hygiene and thick periodontium.Regarding the orthodontic condition
we noted a Angle’s Class I right ca-nine and left molar relationship, witha Class III left canine and right molarrelationship, a dental shift of the inci-sor midlines, and an anterior edge-to-edge occlusion. In the maxillary archthere are disto-rotations of 12 and22, missing 24 and complete mesialdrift of the left molar sector. In themandibular arch, there is also anteriorcrowding and left posterior crowdingdue to the trapped 45 (Figs. 2 a to c,3 a & b).
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Figures 1Facial portraits, anterior, profile and smile at the start of treatment.
Figures 2 a to cIntra-oral vestibular views, right, anterior and left, at the start of treatment.
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ADDITIONAL EXAMINATIONS
A study of the models confirms allthe clinical elements we observed,notably the anterior infraclusion andthe accentuated mandibular Curve ofSpee (Fig. 4).
The functional evaluation mean-while reveals mixed breathing, atypi-cal swallowing, disturbed speech (ahiss) and unilateral right side chew-ing. No problems with the TM jointswere found upon examination.
The panoramic x-ray taken at thestart of treatment shows an incom-
plete adult dentition with 24 missing,an angulated root on 15 and no os-teolysis detectable on the four wis-dom teeth (Fig. 5).
The Steiner and Tweed Analyseswere (Figs. 6 & 7) performed. The Ce-phalometric values are displayed in ta-bles I and II. The profile Cephalometricx-ray confirms a skeletal Class III(AO-BO: -3mm) with hyperdivergenceand bimaxillary protrusion.
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Figures 3 a & bMaxillary and mandibular occlusal views, at the start of treatment.
Figure 4Photographs of models before treatment.
TREATMENT OF A CASE OF A CLASS III BIMAXILLARY PROTRUSION
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Figure 5Panoramic radiograph at the start of treatment.
Figure 6Lateral cephalometric x-ray at the start of treatment.
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Crowding
Position of i(lower incisor)
Curve of Spee
Relation of 6’s(first molars)
E space
Sub-total
Extractions
Total
Figure 7Chevrons and Steiner Box.
Table ISteiner analysis before and after treatment.
Before
treatment
After
treatment
SNA 86� 86�
SNB 84� 84�
ANB 2� 2
SND 81� 80�
I to NA 32� 24
I TO NA (mm) 6 mm 4 mm
I TO NB 32� 24�
I TO NB (mm) 6 mm 4 mm
Pog to NB (mm) 2 mm 1 mm
I to I 116� 130
Occl to SN 14� 16�
GoGn to SN 31� 35�
Table IITweed analysis before and after treatment.
Before
treatment
After
treatment
FMIA 56� 65�
FMA 30� 30�
IMPA 94� 85�
SNA 86� 86�
SNB 84� 84�
ANB 2� 2�
AO-BO �3 mm �3 mm
Occlusal Plane 11� 8�
Z Angle 72� 81�
Upper lip 8 mm 8 mm
Total chin 9 mm 9 mm
Post. facial hgt 42 mm 68 mm
Ant. facial hgt. 57 mm 40 mm
Post/ant index 0.73 0.58
TREATMENT OF A CASE OF A CLASS III BIMAXILLARY PROTRUSION
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DIAGNOSIS
In reviewing the facial examinationthe patient presents with hyperdiver-gent morphology with a stretchednose-lip-chin relationship. Based onthe skeletal pattern, there is a skele-tal Class III hyperdivergent pattern.Based on the dental pattern thepatient presents insufficient verticaloverlap, and a Class III with bimaxil-
lary protrusion. The occlusal asym-metry is reflected by an incisormidline deviation, a total loss ofspace on the left due to the missing24 allowing for maintenance of theClass I molar relationship with a verystrong left side Class III cuspid rela-tionship. The extreme crowding is re-lated to relatively large teeth.
TREATMENT OBJECTIVES
The following objectives were iden-tified:– correct the crowding;– correct the bimaxillary protrusion;– center the incisor midlines;
– re-establish Class I relationship ofthe left cuspids;
– obtain anterior guidance that isfunctionally efficient and esthetic;
– ensure long-term stability of thecorrections.
TREATMENT PLAN
To accomplish these objectives weproposed only one therapeutic optionconsisting of extraction of 14, 34,and 44 as confirmed by the Steinerbox with a total DDM of 14 mm requir-ing extractions of PM. This option al-lows for the correction of the Class IIIcanine/molar relationship as well asthe crowding while at the same time
reducing the axes of the maxillaryand mandibular incisors. One objec-tive was that the strict repositioningaccording Steiner standards that washindered by the vertical excess andthe labial contact with the protrudedlip. Secondarily, it was the manage-ment of the occlusal Class III to aClass I. The appliances utilized were
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Figures 8 a to cIntraoral vestibular views right, frontal and left, during treatment.
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Edgewise .022 x .028 inch (Figs. 8 ato c, 9 a to c) and the duration oftreatment was 22 months. Fixed re-
tention in the maxilla from 12-22 andin the mandible from 33 to 43 wasused at the end of treatment.
THERAPEUTIC STEPS
– Preparation of the arches– alignment and leveling;– canine retraction;– anchorage preparation.
– Arch correction– lower incisor retraction;– maxillary anchorage loss.
– Intercuspation finalization– Removal of appliances and begin
retention.
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Figures 9 a to cIntraoral vestibular views right, frontal and left at finish.
Figures 10 a to cPortraits frontal, profile and smile at finish.
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END OF TREATMENT
Our treatment objectives wereachieved, our patient’s profile wasnormalized, the relationship of thelips and the smile was improved(Figs. 10 a to c). For the dental plan,the left canine Class I was achievedwith symmetry of the incisor mid-lines and standard overbite and over-jet (Figs. 11 a to c, 12 a & b and 13).
The panoramic radiograph showedthe presence of significant apical rootresorption on 11 and moderately soon 21. This could be related in largepart to the use of a heavy deforma-tion of the maxillary finishing arch;i.e. essentially the forward tip and
anterior torque differential utilizedwith the goal of harmonizing the in-tra- and inter-arch relationship of theanterior guidance. This resorptionshould be the focus of a clinical andradiologic follow-up. The eruption ofthe wisdom teeth into functional oc-clusion was achieved (Fig. 14). At thesame time despite the weak tip for-ward of 15 in the finishing arch, thecrown-root angulation created an ap-parent closeness of the root in the2D image. The conserving of the 3rdmolars has yet to be decided.
The cephalometric profile (Fig. 15),the cephalometric results (Tabs. I
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Figures 11 a to cIntraoral vestibular views right, frontal and left, at the end of treatment.
Figures 12 a & bMaxillary and mandibular views at the end of treatment.
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Figure 13Photographs of the models
at the end of treatment.
Figure 14Panoramic radiograph at the end of
treatment.
Figure 15Profile cephalometric radiograph at the end of
treatment.
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and II) as well as the superimposi-tions (Figs. 16, 17a & b) have showna significant change in the dento-alveolar relationships with the in-
crease in the overlapping of the teethand the uprighting of the axis of theincisors. The Class III hyperdivergentmorphology remains undisturbed.
POST TREATMENT FOLLOW-UP
Photos taken 2 years after removalof the appliances show perfect stabi-lity of the results, despite the loss ofthe maxillary and mandibular retai-ners one year following de-banding
as reported by the patient. Thesedocuments are therefore the ‘‘postretention’’ documents (Figs. 18 ato c, 19 a & b).
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Figure 16General superimpositions (Tweed).
Figures 17 a & bLocal Tweed superimpositions of the maxilla and mandible.
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Figures 18 a to cIntraoral vestibular views right, frontal and left at two years post-treatment (1 year post-retention).
Figures 19a & bMaxillary and mandibular occlusal views
At two years post-treatment (1 year post-retention).
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