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.

MERIEM BELLAMINE, LAHCEN OUSEHALCAS

2 BELLAMINE M., OUSEHAL L. Treatment of a case of a Class III bimaxillary protrusion

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

J Dentofacial Anom Orthod 2014;17:108. 3

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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



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.



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.



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.



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).



Treatment of a case of a Class III bimaxillary protrusion · PDF fileIntraoral vestibular...

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