A Tale of Two Cases by Dr. Daniel J. Grob

by Dr. Daniel J. Grob

• 11-year-old female with the chief concern of severe protrusion of the teeth (Fig. 1).
• No thumb- or finger-sucking, although it appeared as if lip-sucking was present.
• Nasal and mouth breathing were utilized.
• Etiology of the malocclusion was hereditary with some environmental influences.

Fig. 1

• Class II Division 1.
• Crowding and irregularities were moderate to severe in the maxillary arch with a tapering arch form (Fig. 2).
• Crowding in the mandibular arch was moderate to severe with a rounded arch form.
• Overbite and overjet were both excessive.
• Panoramic radiograph indicated all teeth were present and accounted for and that development of the unerupted teeth was slightly delayed for age and gender (Fig. 3).
• The cephalometric radiograph showed good symmetry. The airway appeared adequate (Fig. 4).
• The cephalometric analysis indicated a Class II skeleton because of maxillary protrusion relative to the cranial base and the occlusal plane.
• The temporomandibular joints functioned without noise and with an acceptable range of motion.
• The photographs indicated lip incompetence at rest with a slight strain during forced closure.
• An acceptable amount of gingiva was displayed during a broad smile.
• The periodontal tissues were healthy, pink and firm.

Fig. 2

Fig. 3

Fig. 4

• Reduce the severe maxillary dental and skeletal protrusion with a removable functional appliance.
• Remove the influence of the lower lip on the malocclusion.
• Eliminate crowding.
• Create a better arch form in the maxilla for proper tongue placement.
• Develop a Class I mutually protected occlusion.
• Create better facial balance and relaxed musculature.
• Because of the patient’s age, a one-phase treatment plan was utilized.

• A Bionator removable functional appliance was utilized for approximately 12 months full time to reduce protrusion, allow for mandibular growth and assist in developing lip seal during closure (Fig. 5).
• All four second bicuspids were removed to help alleviate the remaining crowding and protrusion.
• An .022 slot straight wire appliance was placed.
• Round and rectangular wires through .018 x .025 were utilized to align, level and coordinate the arches.
• Class II elastics and a transpalatal bar were utilized to back up anchorage in the maxilla and complete correction of the anterior-posterior discrepancy.
• Spaces were closed with elastic chain.
• .018 round and .017 x .025 braided rectangular wires were utilized to finish and detail the occlusion.

Fig. 5

• The treatment objectives were met with the help of a very cooperative patient (Fig. 6).
• Tooth alignment is excellent (Figs. 7 and 8).
• Facial balance is appropriate for the skeletal pattern (Fig. 9).
• Superimpositions indicate favorable mandibular growth and slippage of anchorage in the mandibular arch (Fig. 10).
• The maxillary incisors were retracted (and slightly under-torqued) while the mandibular incisors essentially remained in the same position.
• Favorable mandibular growth appears to have assisted in this nice result.

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Fig. 10

• Patient is a 7.5-year-old female with chief concern protrusion of the teeth (Fig. 11).
• There was a history of thumb- or finger-sucking (Fig. 12).
• Nasal and mouth breathing were utilized.
• Based on the clinical examination and the family history, it was postulated that the etiology of the malocclusion was hereditary with oral habit influences.

Fig. 11

Fig. 12

• The angle classification of the malocclusion was Class II Division 1.
• Crowding and protrusion were moderate to severe in the maxillary arch with a tapering arch form.
• Crowding in the mandibular arch was minimal with a rounded arch form.
• Overbite and overjet were both excessive.
• The panoramic radiograph indicated that all teeth were present and accounted for.
• Development of the unerupted teeth was age appropriate (Fig. 13).
• The cephalometric radiograph showed good symmetry (Fig. 14).
• The cephalometric analysis indicated a slight Class II skeleton because of mandibular retrusion and maxillary flared teeth (Fig. 15).
• The temporomandibular joints functioned without noise and with an acceptable range of motion.
• Large adenoids were visualized (Fig. 16).
• The photographs indicated lip incompetence at rest with a slight strain during forced closure.
• An acceptable amount of gingiva was displayed during a broad smile.
• The periodontal tissues were healthy, pink and firm.

Fig. 13

Fig.14

Fig. 15

Fig.16

• A two-phase treatment plan was utilized.
• The first phase was to develop width and arch coordination (Fig. 17).
• The second phase was to eliminate the retrusion and protrusion with a fixed Herbst appliance and orthodontic brackets and wires (Fig. 18).
• Create a better arch form in the maxilla for proper tongue placement.
• Develop a Class I mutually protected occlusion. Create better facial balance and relaxed musculature.

Fig. 17

Fig.18

• The first phase utilized a Haas expander followed by limited brackets and wires for approximately 18 months.
• A period of 14 months of in-between awaiting the eruption of the lower first bicuspids.
• A Herbst appliance was placed for one year followed by self-ligating brackets and wires for a total time of 2.5 years.
• Round and rectangular wires through .019 x .025 were utilized to align, level and coordinate the arches.
• Elastics were utilized along the way to settle and perfect the occlusion.

• The maxillary incisors were retracted while the mandibular incisors essentially remained in the same position (Fig. 19).
• Tooth alignment is excellent (Figs. 20 and 21).
• Facial balance is appropriate for the skeletal pattern (Fig. 22).
• Favorable mandibular growth appears to have assisted in this nice result (Fig. 23).
• The adenoids have regressed as well as the minimal cross section airway space improving (Fig. 24).
• The superimposition indicates forward and downward growth and maxillary incisor retraction (Fig. 25).

Fig. 19

Fig. 20

Fig. 21

Fig. 22

Fig.23

Fig. 24

Fig.25

Dr. Daniel J. Grob completed his dental, orthodontic and prosthodontic schooling at the Marquette University School of Dentistry. He has practiced in Tucson and Phoenix, Arizona, for more than four decades.
Grob is a diplomate of the American Board of Orthodontics, a member of the American Association of Orthodontics and the American Dental Association, and the former editorial director of Orthotown magazine. Grob is a member of the Orthotown editorial advisory board.