Camouflage Treatment of a Class II Divison 1 Malocclusion

This case report demonstrates treatment of an adult patient with pre-adjusted edgewise mechanotherapy. Clinical and cephalometric evaluation revealed Class II Skeletal pattern, high mandibular plane angle, incompetent upper lip and everted lower lip, increasedoverjet and deep overbite. The goal of treatment was to bring about maximum retraction of upper anterior teeth. The case was successfully managed by extraction of all first Premolars and fixed appliance therapy using preadjusted edgewisemechanics. Stable esthetic results were attained at the end of the treatment.

INTRODUCTION

Awareness and demand for high quality orthodontic treatment for adult patients has increased. A growing patient with class II malocclusion can be treated by orthopedic appliance, myo-functional appliance or with inter-maxillary class II elastics and fixed appliance therapy. Otherwise for a non-growing patient, treatment options remain as camouflage or orthognathic surgery. However, to accept orthognathic surgery as a treatment modality is not easy for every patient.On the other hand, camouflage treatmentoffers patient satisfaction similar to that achieved with surgery1. This article shows camouflage treatment of class II division 1 malocclusion.

CASE-REPORT

A 19-year-old patient presented with a Class II division 1 malocclusion witha high angle between the maxillary and mandibular planes. The patient requested orthodontic treatment to improve her dental appearance. She had no relevant medical history. Extra oral examination revealed convex profile, high mandibular plane angle andincompetent upper lip. Intraoral examination revealed end on molar and canine relation, curve of spee of 1.5 mm, lower midline deviated to the right by 2 mm, poor oral hygiene, inflamed soft tissues, increasedoverjet and deep overbite (figure 1).

TREATMENT OBJECTIVES

• Retraction of Upper and Lower anteriors
• Improvement in facial profile and achieving lip competence
• AttainingClass I molar and canine relation
• Establish normal overjet and overbite

Correction of lower midline

TREATMENT PLAN

• Extraction of all first Premolars
• Fixed appliance therapy using Pre-adjusted edgewise mechanics.

TREATMENT PROGRESS

Treatment involved the extraction of first premolars in the upper and lower arch to correct the proclination and achieve angle’s Class-I molar and canine relation. Treatment started with the placement of 0.022˝ preadjusted edgewise brackets and molar tubes (Victory series, 3M, UNITEK, Monrovia, CA, USA). In the upper arch banding was done on first molar and molar tube with head gear slot was placed on upper first molar to facilitate head gear use. Patient was asked to wear a high pull head gear with a force of 400 gms for 8 hours daily throughout the treatment period.

Treatment began with leveling and alignment with 0.016˝ NiTiarchwire(d-tech, Wagholi, Pune, India)and well-coordinated 0.018˝ stainless steel (S.S.) arch wires (A.J. Wilcock Premium Plus Australian arch wire, Whittlesea, Victoria, Australia). Individual canine retraction was started and finished with an elastic chain (3M, UNITEK, Monrovia, CA, USA) on 0.019x0.025” stainless steel wire. Class II elastics were given simultaneously to burn the anchorage and correct the molar relation (figure 2).

Fig 1: Pretreatment intraoral and extraoral photographs.

Fig 2: Canine retraction with class II elastics.

After canine retraction, 0.019 × 0.025˝ S.S. T loop archwires (Truforce, Ortho Technology, Inc., Tampa, USA) were placed in both arches (figure 3).Patient was recalled every 6 weeks for reactivation of loops and to check the progress.Settling was done with triangular elastics on upper and lower 0.016˝ S.S. wire, after which the appliance was debonded.

RESULTS

The first molar was successfully brought into a Class-I relationship. Treatment time was 2 years. Endof treatment, a proper overjet and overbite was establishedwith coincident midlines and no opening of mandibular plane angle. Mandibular plane was maintained with the high pull head gearand a profile change was noted at the end of treatment (figure 4, 5).

Fig 3: Anterior retraction with T loop stainless steel arch wire

Fig 4: Post treatment intraoral and extraoral photographs.

Figure 5- Profile comparison.

DISCUSSION

A paradigm shift is noted in the present era with more emphasis on soft tissue appearance rather than the ideal cephalometric values. Mihaliket al2 compared patients’ perceptions of outcomes with orthodontic and the surgical groups and found results with both the options as highly positive. The orthodontics-only (camouflage) patients reported fewer temporomandibular joint problems and had similar satisfaction asthe surgical patients, but patients who had surgery had significantly more positive dentofacial images.In our case, an acceptable soft tissue profile was achieved and patient was satisfied with the treatment results. More improvement in chin, nose and lip relation was observed by Saelenset al3 with extraction protocol than non-extraction method.In this case, all first premolars were extracted to improve the patient’s profile and achieve lip competence. Individual canine retraction was performed on the 0.019x0.025” stainless steel wire with elastic chain. The force was kept in the range of 50-100 grams to avoid canine tipping4. This was assisted with class II elastic wear which corrected the molar relationship by anchorage loss. Also, the placement of elastic chain made oral hygiene maintenance better. Thus, individual canine retraction and head gear in the upper arch reinforced upper anchorage. Anterior retraction was started on 0.019x0.025” stainless steel wire with a T loop. The advantage of using T loop is a better moment to force ratio5.The overall duration of treatment was 2 years with no adverse effects. Upper and lower incisors were retracted to achieve normaloverjet and overbite.

Table: Comparison of cephalometricvariables

CONCLUSION

Camouflage treatment of Class II divison 1 malocclusion yields stable esthetic results with proper diagnosis and sound mechanics.
NOTE: There is no conflict of interest. This patient was treated after her approval to go ahead with the orthodontic treatment. The patient was informed about all the advantages, disadvantages and limitations before the start of the treatment. Patient also consented to taking pre, post and ongoing stage photographs during the course of treatment.

REFERENCES