Bimaxillary protrusion treated without extraction

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Bimaxillary protrusion treated without extraction

  1. 1. P.33-38 Celli:CR_Celli 1/10/07 2:48 PM Page 33 ©2007 JCO, Inc. May not be distributed without permission. www.jco-online.com CASE C S REPORT O Bimaxillary Protrusion Treated Without Extractions DANIEL CELLI, MD, DDS, MSC, PHD DANIELE GARCOVICH, DDS, MSC ENRICO GASPERONI, DDS ROBERTO DELI, MD, DDS B imaxillary protrusion in ado- lescent patients has tradition- ally been treated by extracting with mild or moderate bimaxillary protrusion, as the following case demonstrates. proclination, the parents refused premolar extraction treatment. Therefore, a protocol involving the four first premolars and the removal of only the lower third retracting the anterior teeth.1,2 molars was chosen. Diagnosis and Although this approach is less Treatment Plan complex than nonextraction treat- Treatment Progress ment and can produce a good An 11-year-old female pre- occlusal result, it also tends to sented with a Class II maloc- After the third molar extrac- retrude the lips and reduce the clusion (Fig. 1). The patient’s tions, the upper arch was bonded, convexity of the face.3-6 lips were incompetent and and leveling and alignment were In cases with severe incisor procumbent, and the nasolabial carried out with an .016" heat- protrusion, facial convexity, lip angle was closed. Cephalomet- activated nickel titanium wire. incompetence, or crowding, pre- ric analysis (Table 1) showed a Bendbacks and lacebacks were molar extractions may be marked bimaxillary protrusion added to preserve arch length and unavoidable. In our opinion, how- (L1-GoGn = 106 ° ; U1-ANS/ avoid worsening the incisor pro- ever, a nonextraction approach PNS = 126°). clination. A combi headgear was can be more esthetic in patients Despite the extreme incisor worn to the upper first molars 16 Dr. Celli is a Visiting Professor, Dr. Gasperoni is a postgraduate stu- dent, and Dr. Deli is Professor and Director, Postgraduate Program (School of Specialization) in Orthodontics, Università Cattolica del Sacro Cuore, Largo F. Vito 4, 00100 Rome, Italy. Drs. Celli, Garcovich, Gasperoni, and Deli are also in the private practice of orthodontics in Pescara, Cervteri, Rimini, and Rome, Italy, respec- tively. E-mail Dr. Celli at info@ celliortho.it. Dr. C Celli Dr. G Garcovich Dr. G Gasperoni Dr. Deli VOLUME XLI NUMBER 1 © 2007 JCO, Inc. 33
  2. 2. P.33-38 Celli:CR_Celli 1/10/07 2:49 PM Page 34 Bimaxillary Protrusion Treated Without Extractions Fig. 1 11-year-old female patient with dental and skeletal Class II mal- occlusion and bimaxillary protrusion before treatment. 34 JCO/JANUARY 2007
  3. 3. P.33-38 Celli:CR_Celli 1/10/07 2:49 PM Page 35 Celli, Garcovich, Gasperoni, and Deli A A Fig. 2 A. Patient after 26 months of treatment. B. Superimposition of cephalometric tracings before and after treatment. VOLUME XLI NUMBER 1 35
  4. 4. P.33-38 Celli:CR_Celli 1/10/07 2:49 PM Page 36 Bimaxillary Protrusion Treated Without Extractions hours per day. Treatment Results the chin.9-11 This will maintain a Seven months later, the more esthetic profile over the long After 26 months of treat- lower arch was banded and bond- term, especially in ethnic groups ment, the patient showed a Class ed, except for the four incisors. An where moderate lip protrusion is I occlusal relationship with nor- .016" heat-activated nickel titani- a desirable feature. mal overbite and overjet control um wire with bendbacks and lace- Most cephalometric and pro- (Fig. 2). The axial inclination of backs was used in conjunction file standards are derived from the upper incisors was controlled, with a lightly activated open-coil North American and northern as shown by a 6° reduction in spring from canine to canine. European samples of Caucasian U1-ANS/PNS (Table 1). The Light Class III elastics were worn patients.12-17 In recent years, how- Class II correction was achieved only when the headgear was in ever, researchers have begun to mainly by maxillary retraction, place. After 11 months of treat- develop norms for ethnic sub- while the mandibular plane ment, both archwires were groups that may have different remained essentially stable, changed to .019" ✕ .025" heat- esthetic concerns.18-23 Specifically, despite the limited use of Class III activated nickel titanium, still with Bowman and Johnston proposed elastics. The lower incisor incli- bendbacks and lacebacks. that the lips should be 2-3mm in nation was clearly reduced; the Further alignment was car- front of the E-plane in African mandibular superimposition ried out using .019" ✕ .025" stain- Americans, as opposed to 2-3mm demonstrated that the entire arch less steel archwires with tiebacks behind the E-plane in Cau- was tipped back. The profile was for torque control, followed by casians.24 In our experience, the improved, lip prominence was .014" Australian* wires for fin- Italian norm for lip protrusion is reduced, the nasolabial angle ishing. Class II elastics were used somewhere in between. remained stable, and the facial to optimize intercuspation. Several studies have found convexity was reduced (Fig. 3). that the general public associates a fuller, more protrusive dentofa- Discussion cial pattern with a youthful TABLE 1 appearance. 25-27 Some authors CEPHALOMETRIC DATA Several factors must be have stated that premolar extrac- taken into account when planning tions cause a narrowing of the Pre- Post- the treatment of a patient with arches, producing dark buccal cor- treatment Treatment moderate bimaxillary protrusion. ridors in smiling28,29—although The clinician has to consider not this view has been contradicted by SNA 88.0° 84.5° only the outcome of treatment at recent reports.30,31 To improve the SNB 81.0° 80.0° debonding, but also how the post-extraction smile, Zachrisson ANB 7.0° 4.5° results will change throughout the has recommended adding buccal SN-ANS/PNS 11.0° 11.0° growth and aging process. crown torque to lingually inclined SN-GoGn 34.0° 35.0° While the subject is contro- canines and premolars.32 ANS/PNS- versial, excessive incisor procli- In severe skeletal Class II GoGn 23.0° 24.0° nation has been correlated with cases, facial esthetics generally U1-ANS/PNS 126.0° 120.0° periodontal recession and bony tend to worsen when extractions defects.7,8 Moderate incisor pro- are performed, even if a good L1-GoGn 106.0° 98.0° clination, on the other hand, can occlusion is achieved.33-35 Accor- L1-APo 5.0mm 4.5mm improve lip support. In addition, ding to Proffit and Field, Class II Nasolabial a slight protrusion will help bal- angle 121.0° 121.0° ance the tendency of the profile to Lower lip flatten due to continuing growth of *G&H Wire Company, P.O. Box 248, Green- to E-line 5.0mm –2.0mm the nose and forward rotation of wood, IN 46142; www.ghwire.com. g 36 JCO/JANUARY 2007
  5. 5. P.33-38 Celli:CR_Celli 1/10/07 2:49 PM Page 37 Celli, Garcovich, Gasperoni, and Deli Fig. 3 Patient one year after treatment. extraction treatment can result in method for controlling anchorage was designed for borderline cas- a more prominent nose and a defi- in extraction treatment. 48 Our es of bimaxillary protrusion, in ciency in the middle and lower results show that these mechan- which nonextraction treatment thirds of the face.33 This was a ics can also correct a skeletal may produce more esthetic results concern in the present case, espe- Class II relationship by means of than can be achieved with pre- cially if mandibular growth turned maxillary growth inhibition or molar extractions. out to be insufficient. retraction. Mandibular growth Various nonextraction op- will assist in the Class II cor- REFERENCES tions were considered for this rection, while Class III elastics 1. Lew, K.: Profile changes following patient, including anterior inter- can control or retrocline the orthodontic treatment of bimaxillary proximal enamel reduction.36,37 lower incisors. Alveolar bone protrusion in adults with the Begg appli- Although the stripping proce- remodeling of the mandibular ance, Eur. J. Orthod. 11:375-381, 1989. 2. Farrow, A.L.; Zarrinnia, K.; and Azizi, dure is considered safe and reli- arch, supported by planned K.: Bimaxillary protrusion in black able,38-43 we preferred to maintain extractions of the lower third Americans: An esthetic evaluation and the patient’s Bolton Index44 and molars, will further improve the treatment considerations, Am. J. Orthod. 104:240-250, 1993. dental integrity.42,45-47 incisor inclination.49 3. Koch, R.; Gonzales, A.; and Witt, E.: The combination of head- Profile and soft tissue changes during gear with light Class III elastics and after orthodontic treatment, Eur. J. Conclusion Orthod. 1:193-199, 1979. has been previously described 4. La Mastra, S.J.: Relationships between by McLaughlin and Bennett as a The protocol described here changes in skeletal and integumental VOLUME XLI NUMBER 1 37
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