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15
Resumo
Treatment of a Class II division 1 case with
straight wire technique and fnalization
with Multiloop Edgewise Arco-Wire
Tratamento de um caso de Classe II diviso 1
com a tcnica de straight wire e fnalizao
com Multiloop Edgewise Arco-Wire
Neste caso clnico descreve-se o tratamento de uma Clas-
se II diviso 1 com um padro facial hiperdivergente, mas
pela anlise efectuada pelo mtodo de Kim trata-se de uma
malocluso de Classe I, com apinhamento. Numa primeira
fase, foi utilizada a tcnica de arco recto, que possibilitou
alinhar e nivelar durante 14 meses e, numa segunda etapa,
o plano oclusal foi modicado e a mandbula reposiciona-
da com Multiloop Edgewise Arco-Wire (MEAW), que foi
utilizado durante oito meses. Neste caso a extraco de
pr-molares no seria o mais recomendado, devido ao
paciente apresentar um ngulo naso-labial aberto. A verti-
calizao dos segmentos posteriores e a vestibularizao
dos sectores laterais que apresentavam um torque muito
negativo, permitiram a correco do apinhamento dent-
rio e o restabelecimento de uma boa ocluso sem agrava-
mento da inclinao do incisivo inferior.
This clinical case describes a treatment of a Class II division
1 malocclusion with a hyperdivengent facial pattern, but a
Class I malocclusion by Kim method analysis, with crowd-
ing. In a rst stage it was used a straight-wire technique
which made possible to align and to level for fourteen
months and, in the second stage, the occlusal plane was
modied and the mandible repositioned with Multiloop
Edgewise Arch-Wire (MEAW), which was used for seven
months. In this case premolars extractions wouldnt be
the most recommended due to the open naso-labial angle
exhibited. The uprighting of mesially tipping posterior seg-
ments and vestibular tipping in all lateral teeth offered cor-
rection of crowding and good occlusion was established
without worsening the lower incisor inclination.
Palavras chave: Classe II diviso 1 / Plano oclusal / Straight wire / MEAW
Keywords: Class II div 1 / Occlusal plane / Straight wire / MEAW
Abstract
Prof. Doutora Teresa Pinho
Professora Auxiliar de Ortodontia e Odontopediatria do ISCSN
Doutorada em Ortodontia e Odontopediatria pela UP, em 2004
Prtica exclusiva em ortodontia desde 2000
Certificado de excelncia na prtica clnica ortodntica, Board Francs de Ortodontia
terpinho@netcabo.pt teresa.pinho@iscsn.cespu.pt
16
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O desenvolvimento de um quadro de Classe II esquelti-
ca est relacionado com a extenso da base craniana que
causa uma rotao anterior do complexo maxilar. O plano
oclusal o componente mais importante que influencia a
dimenso vertical do tero inferior da face
1,2
.
importante compreender as caractersticas morfolgicas
de malocluso, a fim de reconstruir uma ocluso funcio-
nal. As caractersticas da malocluso de Classe II tornam
especialmente difcil de a corrigir
1
.
O usual tipo de malocluso de Classe II geralmente ca-
racterizado por um plano oclusal ngreme. Este tipo de
problema de Classe II resultou do fracasso da mandbula
para se adaptar anteriormente
1,2
. No entanto, em pacien-
tes com suporte oclusal suficiente devido ao excelente
crescimento vertical do ramo mandibular, a maxila gira an-
teriormente permitindo a adaptao oclusal. O plano oclu-
sal neste caso plano
3
.
A correco do plano oclusal, controlando a dimenso ver-
tical extremamente importante no tratamento da malo-
cluso de Classe II
1
.
Os melhores tratamentos, nos pacientes hiperdivergentes,
so aqueles que fornecem uma rotao anterior da man-
dbula e um aumento do crescimento vertical condilar
2,4-7
.
Um dos procedimentos mais utilizado para obter uma
rotao anterior da mandbula a intruso ou o controle
vertical de dentes molares
7-10
. Alguns autores
2,5,6,11-14
tm
tratado numerosos pacientes com malocluses esquel-
ticas de mordida aberta, de Classes II ou Classes III sem
interveno cirrgica, recorrendo alterao do plano
oclusal usando a tcnica de multiloop edgewise arch wire
(MEAW).
O tratamento ortodntico da malocluso de Classe II mor-
dida aberta centra-se na extruso dos molares superiores
e intruso dos molares inferiores para um aplanamento do
plano oclusal. A mecnica para essa correco consiste
em tip back bends moderados no arco MEAW maxilar e
fortes tip back bends no arco MEAW mandibular. Els-
ticos verticais curtos de Classe II so usados nos loops
anteriores. Assim, permite-se fechar uma malocluso de
Classe II mordida aberta aplanando o plano oclusal acen-
tuado proporcionando a adaptao da mandbula para
frente
1,2,14
.
Na mordida de Classe II profunda a incapacidade da man-
dbula se adaptar anteriormente devido a interferncias
na regio posterior que leva sua retruso. O apoio oclusal
igualmente insuficiente por causa do bom crescimen-
to vertical do ramo mandibular, levando a uma adaptao
oclusal, permitindo maxila rodar anteriormente. A mec-
nica para essa correo consiste em eliminar primeiro as
interferncias oclusais, como causas funcionais da retru-
so mandibular (correco da curva de Spee excessiva).
Depois de aplanar o plano oclusal e, a fim de obter um
apoio suficiente oclusal dos molares superiores e inferio-
res, estes so supra erupcionados para aumentar a dimen-
so vertical
1,2,14
.
The development of a Class II skeletal frame is related to
the extension of the cranial base that causes anterior ro-
tation of the maxillary complex. The occlusal plane is the
most important component influencing the vertical dimen-
sions of the lower face
1,2
.
It is important to understand the morphological features
of malocclusion in order to reconstruct a functional occlu-
sion. The features of Class II malocclusion make them es-
pecially difficult to correct
1
.
The common type of Class II malocclusion is usually char-
acterized by a steep occlusal plane. This type of Class II
problem resulted from the failure of the mandible to adapt
anteriorly
1,2
. However, in patients with sufficient occlusal
support due to the excellent vertical growth of the mandibu-
lar ramus, the maxilla rotates anteriorly allowing occlusal
adaptation. The occlusal plane in this case is flat
3
.
The occlusal plane correction by controlling the vertical
dimension is extremely important in the treatment of Class
II malocclusions1.
In hyperdivergent patients, the best treatments are those
that provide an anti-clockwise rotation of the mandible
and an increase in the condilar vertical growth
2,4-7
. One of
the most used procedures to obtain an anterior rotation
of the mandible is the intrusion or the vertical control of the
molar teeth
7-10
. Some authors
2,5,6,11-14
have treated numerous
patients with skeletal malocclusion like open bite, Class
II or Class III without surgical intervention, using the
occlusal plane alteration with the Multiloop Edgewise Arch
Wire (MEAW).
The orthodontic treatment of class II open bite malocclu-
sion focuses on extrusion of the maxillary molars and intru-
sion of the mandibular molars for flattening the occlusal
plane. The mechanics for this correction consist of mod-
erate tip back bends in the maxillary MEAW and strong
tip back bends in the mandibular MEAW. Vertical or short
class II elastics are used at the anterior loops. This way
allows closing a class II open bite malocclusion flattening
the occlusal plane steep providing the adaptation of the
mandible forward
1,2,14
.
In the Class II deep bite the inability of the mandible to
anteriorly adapt is due to interference in the posterior re-
gion leading to its retrusion. The oclusal support is also
insufficient because of the good vertical growth of the
mandibular ramus, leading to occlusal adaptation, allow-
ing the maxilla to anteriorly rotate. The mechanics for this
correction consist of eliminate first the cuspal and occlusal
interferences, functional causes of the mandibular retru-
sion (correcting the excessive curve of spee). After flatten
occlusal plane and in order to get a sufficient occlusal sup-
port the upper and lower molars are supra-erupted to in-
crease vertical dimension
1,2,14
.
Introduo
Introduction
(Fig.1)
Fotografias pr-tratamento,
frontal, perfil facial e sorriso e intra-orais
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17
Caso Clnico
Clinical Case
(Fig.1)
Fotografias pr-tratamento,
frontal, perfil facial e sorriso e intra-orais
(Fig.1)
Pre-treatment frontal,
facial profile, smile and intra-oral photos
Motivo da consulta: A razo principal foi o mau posicio-
namento dentrio do arco superior e inferior (Fig1).
Idade: 12 anos e 11 meses.
Sexo: Masculino
Reason for consultation: The first reason is due to the
bad dental position of upper and lower arch (Fig. 1).
Age: 12 years and 11 months.
Sex: Male
Documentos pr-tratamento:
Pre-treatment documents:
Diagnstico:
Anlise extra-oral (Fig 1): perfil convexo, lbio superior
retrudo com ngulo naso-labial aberto, mandbula recuada e
linha do sorriso normal.
Exame funcional: Sem parafunes ou disfunes. O
exame e histria clnica no revelaram problemas da ATM.
Exame intra-oral (Fig. 1) e anlise de modelos (Fig 2):
Todos os dentes estavam presentes. O paciente apresentava
uma relao de Classe II molar e canina do lado esquerdo e
no lado direito uma relao de Classe I molar (devido me-
sializao do 36) e Classe II canina. A linha mdia dentria
maxilar estava centrada. Apinhamento dentrio considervel
na maxila (13, 12, 22, 23) e na mandbula (32, 31, 41, 42, 45).
Overbite de 3,4mm e overjet de 7,6mm.
Diagnosis:
Extra-oral analyze (Fig. 1): convex profile, retruding up-
per lip with open naso-labial angle, retruded chin and bal-
anced smile.
Functional examination: No parafunction or dysfunction.
The examination and history disclosed no TMJ disorder.
Intra-oral examination and Cast analyze (Fig.1 and 2):
All the teeth were present. The patient exhibited a molar
and canine left Class II and in the right side a Class I molar
(due to 36 mesialization) and a canine Class II. The midline
was centered. Considerable crowding was present in the
maxilla (13, 12, 22, 23) and in the mandible (32, 31, 41, 42,
45). Overbite of 3.4mm and overjet of 7.6 mm.
(Fig.2)
Fotografias dos modelos iniciais
(Fig.2)
Photos of initial dental casts
Radiograa panormica (Fig 3):
Todos os terceiros molares estavam presentes.
Panoramic x-ray:
The four 3
rd
molars were presented (Fig.3).
(Fig.3)
Radiografia panormica
antes do tratamento
(Fig.3)
Pre-treatment
panoramic x-ray
Anlise cefalomtrica (Fig 4, 5 e tabela 1): TClasse II
esqueltica com maxila normal e retruso mandibular (ANB
= 6, SNA = 81,5 and SNB = 75,5) com Ao-Bo (0,4mm).
A dimenso vertical exibida uma hiperdivergncia (FMA =
29,7). Os incisivos superiores no apresentavam compen-
sao para o padro esqueltico (UI/NA = 20,1) mas os
incisivos inferiores tinham uma considervel pr inclinao
(IMPA = 97,7). ngulo interincisal diminudo (I/I = 119,8),
overbite 3,4mm e overjet 7,6mm. Mordida cruzada entre
os dentes 16 e 46, e uma inclinao lingual significativa em
todos os dentes dos sectores laterais dos arcos maxilar e
mandbular. Curva de Spee moderada.
O indicador de sobremordida profunda (ODI) consiste de
dois ngulos, um entre FH e PP e outra entre AB e MP.
Neste caso, o valor ODI foi normal, revelando uma mordi-
da esqueltica normal (Tabela 2).
O indicador de displasia ntero-posterior (APDI) consiste
de trs medidas angulares (FH-PP, AB-NPG, FH-NPG), mas
corresponde ao ngulo PP-AB, revelando neste caso, uma
Classe I esqueltica (Tabela 3).
Cephalometric analyze (Fig. 4, 5 and Table 1): These
reveled a skeletal Class II with normal maxillary and man-
dibular retrognathism (ANB = 6, SNA = 81.5 and SNB =
75.5) correlated to Ao-Bo (0.4mm). The vertical dimension
displayed a hiperdivergent (FMA = 29.7). There wasnt
upper incisor compensation for the skeletal pattern (UI/NA
= 20.1) but the lower incisor had a considerable pro-incli-
nation (IMPA = 97.7). The interincisal angle was lower (I/I
= 119.8), the deep bite measured 3.4 mm and the overjet
7.6mm. There was a crossbite between 16 and 46, and a
significant lingual tipping in all lateral teeth of maxillary and
mandibular archs. The Spee curve was moderate.
The overbite depth indicator (ODI) consists of two angles,
the one between FH and PP and the other one between AB
and MP. In this case, the ODI value was normal, revealing a
normal skeletal bite (Table 2).
The anteroposterior dysplasia indicator (APDI) consists of
three angular measurements (FH-PP, AB-NPg, FH-NPg) but
corresponds to the angle PP-AB, revealing in this case a
skeletal Class I (Table 3).
18
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(Fig.3)
Pre-treatment
panoramic x-ray
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(Fig.4)
Telerradiografia em incidncia
lateral antes do tratamento
(Fig.4)
Pretreatment
cephalometric radiogram
Cephalometric
Analyse
Norm Before T AfterT Retention
FMIA 67 +/- 3 52.6 53 52.1
FMA 25 +/- 3 29.7 29.5 29.4
IMPA 88 +/- 3 97.7 97.5 98.5
SNA 82 +/- 2 81.5 78.4 78.1
SNB 80 +/- 2 75.5 72.7 73.1
ANB 1 - 5 6 5.7 5mm
A B 2mm +/- 2 0.4mm 1.7mm 1.7mm
UI/NA 22 +/- 2 20.1 18.3 19
Occlusal Plan 8 - 12 10.9 11.4 10.3
Angle Z 75 +/- 5 69.9 60.5 64.4
Post Facial Ht 45mm 43.2mm 45.5mm 46.9mm
Ant Facial Ht 65mm 63.4mm 80.9mm 82.5mm
Index Post Ant 0,69 0.6 0.6 0.6
Evol. Rap. 2 / 1 17 20.8 19.6
Overjet 2.5mm +/- 2.5 7.6mm 4mm 3.6mm
Overbite 2.5mm +/- 2.5 3.4mm 3.4mm 2.4mm
Interincisal Angle 126 +/- 10 119.8 124.7 123.6
(Tabela 1)
Medidas cefalomtricas
iniciais, finais e 1 ano aps
o final do tratamento
(Table 1)
Cephalometric analyse
(Marrifield-Tweed,) before,
conversion, after and
retension treatment
Objectivos de tratamento:
Treatment aims:
Correco da dimenso transversal para descruzar 16 - 46
e expanso dento-alveolar para melhorar significativamen-
te a inclinao lingual de todos os dentes laterais do arco
maxilar e mandibular. Correco da Classe II dentria, com
overjet e overbite normalizados. No aumento da verso
labial dos incisivos inferiores.
Correction of the transverse dimension which should allow
uncross 16 - 46 and dento-alveolar expansion to improve
the significant lingual tipping in all lateral teeth of maxillary
and mandibular arch. Correction of dental Class II, with a
good overjet and overbite. No augmentation of mandibu-
lar incisors labial version.
(Fig.5)
Traado cefalomtrico
antes do tratamento
(Fig.5)
Pretreatment
cephalometric tracing
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Plano de tratamento:
Treatment Plan:
Recuperar a dimenso transversal, alinhamento e nivela-
mento, articulao dentria estvel, alinhamento de am-
bas as linhas mdias dentrias com a linha mdia facial,
boa relao de overjet e de overbite.
Explicao das extraces:
18, 28, 38, 48 no sentido de corrigir a discrepncia poste-
rior. A retruso do lbio superior com ngulo naso-labial
aberto no permitia a extraco de pr-molares superio-
res. Na mandbula, a extraco de pr-molares, mesmo
que do 35 e 45, no era necessria, devido existncia
de uma significativa lingualizao de todos os dentes dos
sectores laterais nos arcos maxilar e mandibular.
Tipo de aparelho:
Aparelho fixo bimaxilar, bandas e braquetes Straight wire
verso Roth, com um slot 0,022 x 0,028.
Recuperating transverse width, alignment, leveling and
create a stable dental articulation, both of the midlines
aligned with the facial midline, good overjet and overbite
relationship.
Choose of possible extractions, explications:
18,28,38,48, in order to correct posterior discrepancy.
Retrusive upper lip with open naso-labial angle does not
argue for extraction of maxillary premolars. In the mandi-
ble, the extraction of premolars, even 35 and 45, was not
necessary due to a significant lingual tipping in all lateral
teeth of maxillary and mandibular archs.
Type of appliance:
Bimaxillary fixe appliance, Straight wire bands and brack-
ets with a slot of 0.022 x 0.028.
Tratamento:
Treatment:
Primeiro aplicao de um expander (Fig. 6), devido mordida
cruzada entre 16 e 46. Devido desarmonia dento-maxilar
negativa (DDM) na maxila e mandbula e ao torque corono-
lingual significativo em todos os dentes laterais dos arcos
maxilar e mandibular, foi decidido alinhar e nvelar, com uma
sequncia de arcos de nquel titnio 0,014, 0,018, 0,016 x
0,022, 0,019 x 0,025 e arcos de ao com omegas 0,018 x
0,025 e 0,019 x 0,025) (Fig. 7).
First use of an expander (Fig. 6), due to the crossbite be-
tween 16 and 46. Due to the dento-maxillary negative dis-
harmony (DDM) in the maxilla and mandible and the sig-
nificant lingual tipping in all lateral teeth of maxillary and
mandible arches, it was decided to align and level with
a sequence of 0.014, 0.018, 0,016 x 0,022, 0,019 x 0,025
inches nickel titanium arches, and stell wire with omegas
0,018 x 0,025 and 0,019 x 0,025 inch (Fig. 7).
(Fig.6)
Colocao
do expander
(Img.6)
Placement
of the expander
(Fig.7)
Fotos Oclusais da maxila e da mandbula
durante o alinhamento e nivelamento
coronrio e radicular
(Fig.7)
Occlusal maxillary and mandible photos
during the coronary alignment and the
radicular levelling
Uma mola helicoidal aberta gradualmente activada foi utili-
zada para criar o espao adequado para o alinhamento do
canino superior direito e o segundo pr-molar inferior.
Catorze meses aps o incio do tratamento, foi aplicado
o MEAW (Multiloop Edgewise Arco-Wire) confeccionado
com arco de ao 0,016 x 0,022 com activaes tpicas de
Classe II e elsticos intermaxilares verticais curtos de Clas-
se II em ambos os lados durante 8 meses (1 loop superior
ao 2 loop inferior) (Fig. 8 e 9).
An open coil spring gradually activated was used for cre-
ated adequate space for aligning the upper right canine
and the lower second premolar.
Fourteen months after the beginning of the treatment,
MEAW (Multiloop Edgewise Arch-Wire): 0.016 x 0.022 inch
steel wire was applied with a typical Class II activations
and short intermaxillary vertical Class II elastics in both
sides during 8 months (Fig. 8 and 9).
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(Fig.8)
Fotos intra-orais no incio da aplicao do MEAW
(Fig.8)
Intra-oral photos at the beginning of the use of MEAW
(Fig.9)
Fotos intra-orais no final das activaes do MEAW
(Fig.9)
Intra-oral photos at the end of the use of MEAW
Progresso do tratamento com MEAW
Etapa 1: Eliminao de interferncias oclusais, atravs de
tipback progressivo de 5 desde os prmolares at aos mola-
res e elsticos de Classe II (3/16, 6oz) nos dentes anteriores.
Etapa 2: Estabelecer a posio mandibular, depois de eli-
minadas as interferncias oclusais, a posio mandibular
foi guiada mesialmente atravs da diminuio da dimen-
so vertical na rea dos molares. Aplicou-se um step down
e um step up na rea dos pr-molares superiores e inferio-
res respectivamente, para obter uma intercuspidao de
Classe I nos pr-molares.
Etapa 3: Reconstruo do plano oclusal, nesta etapa
removeu-se o tipback na rea dos molares e a dimenso
vertical na rea dos prmolares foi melhorada e obteve-se
uma posio mandibular fisiologicamente estvel.
Etapa 4: Obteno de uma ocluso siolgica, a melhoria da
guia oclusal e uma boa intercuspidao foi ento obtida.
Para as activaes do MEAW neste caso, devido ao ODI e
APDI se encontrarem normais, na finalizao optou-se por
aplanar os arcos, devido ao paciente no ter um sorriso
gengival, tpico dos casos de Classe II ngulo alto.
Progress of the MEAW treatment
Stage 1: Elimination of occlusal interferences, through
progressive tipback of 5 from premolars to the molar area
and with the subsequent use of Class II elastics (3/16, 6 oz)
in the anterior teeth.
Stage 2: Establishing mandibular position, after eliminat-
ing the occlusal interferences, the mandibular positioning
was mesialy guided by reducing the vertical dimension in
the molar area. Step down and step up was applied respec-
tively in the upper and lower premolar area, to achieved
the class I intercuspidation in the premolars.
Stage 3: Reconstruction of the occlusal plane, in this
stage tipback was removed in the molar area and the verti-
cal dimension in the premolar area was improved. A physi-
ologically stable mandibular position was obtained.
Stage 4: Achieving a physiological occlusion, the im-
provement of the occlusal guide and a good intercuspa-
tion was obtained.
For MEAW activations in this case, because of ODI and
APDI normal values, at the end we decided to flatten the
MEAW arches, because the patient does not have a gum-
my smile, typical of Class II high angle cases.
Durao do tratamento: 22 meses. Duration of treatment: 22 months.
Reteno:
Aparelho removvel superior para ser usado durante a noi-
te e retentor lingual fixo colocado nos incisivos e caninos
inferiores (Fig. 10).
Retention:
Maxillary wrap-around to be worn at night and bonded lin-
gual wire on the lingual surfaces of the lower incisors and
canines (Fig. 10).
22
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(Fig.10)
Fotografias frontal, perfil
facial e sorriso e intra-orais no
final do tratamento ortodontico
(Fig.10)
Extra and
intra-oral photos after
the orthodontic treatment
Documentos ps-tratamento (14A 8M)
Analise extra-oral: O perfil permaneceu convexo, mas
uma melhoria na esttica facial foi observada. O nariz e
queixo cresceu consideravelmente, contudo o sorriso fi-
cou harmonioso (Fig. 10).
Exame funcional: ocluso dinmica balanceada.
Exame intra-oral (Fig. 10) e anlise de modelos (Fig. 11):
Articulao estvel com uma ocluso dentria balanceada
com relao bilateral de Classe I molar e canina. Ambas as
linhas mdias centradas entre si e com a linha mdia facial,
e a relao normal de overjet e overbite foram obtidas.
Post-treatment documents (14Y 9M)
Extra-oral analyze: The perfil remained convex, but we can
observe an improvement in facial esthetics. The noise had
grown considerably but the smile was pleasant (Fig. 10).
Functional examination: Balanced dynamic occlusion.
Intra-oral examination and Cast analyze (Fig. 10 and11):
the improvement of the occlusal guide and a good inter-
cuspation was obtained.
(Fig.11)
Fotografias dos modelos finais
(Fig.11)
Dental casts after treatment
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(Fig.12)
Radiografia panormica
no final do tratamento
(Fig.12)
Post-treatment
panoramic x-ray
Anlise cefalomtrica (Fig. 13, 14 e Tabela 1): No sentido
ntero-posterior, a Classe II manteve-se inalterada (ANB =
5,7 mas Ao-Bo aumentou de 0,4 para 1,7mm), contudo o
SNA diminuiu de 81,5 para 78,4 mas o SNB diminuiu de
75,5 a 72,7. Na dimenso vertical, podemos observar o
bom controlo do plano oclusal, o padro esqueltico ao
nvel do FMA manteve-se inalterado mantendo-se hiperdi-
vergente (FMA = 29,5).
Compensaes dento-alveolar: A inclinao do incisivo su-
perior (UI / NA) diminuiu de 20,1 para 18,3. O IMPA no
alterou mantendo-se 97,5, reduo do overjet de 7,6mm
para 4mm e o overbite manteve-se inalterado, abertura do
ngulo interincisal de 119,8 para 124,7 permitindo melhor
correco da tendncia mordida aberta.
Cephalometric analyze (Fig. 13, 14 and Table1): In the an-
teroposterior dimension, the Class II was unchanged in
ANB = 5.7 but Ao-Bo increased from 0.4 to 1.7mm), how-
ever the SNA decreased from 81.5 to 78.4 but the SNB
decreased from 75.5 to 72.7. In vertical dimension, we
can observe good control of occlusal plane, the skeletal
pattern of FMA was unchanged remained hyperdivergent
(FMA = 29.5).
Dento-alveolar compensations: Upper incisor inclination
(UI/NA) with decreased from 20.1 to 18.3. IMPA was
unchanged remained 97.5, reduction of the overjet from
7.6mm to 4mm and the overbite was unchanged remained
3.4, opening the interincisal angle from 119.8 to 124.7 giv-
ing better correction of the open bite tendency.
(Fig.13)
Telerradiografia em incidncia
lateral no final do tratamento
(Fig.13)
Post-treatment
cephalometric radiogram
Anlise das sobreposies:
Sobreposio geral (Fig. 15): Desenvolvimento anteropos-
terior significativo em todos os nveis da face. Crescimen-
to nasal e do queixo cutneo.
Analysis of superposition:
General superposition (Fig. 15): There was very significant
anteroposterior development at all levels of the face. We
observed nasal and cutaneous chin growth.
Radiograa panormica (Fig.12): Bom posicionamen-
to radicular e a extraco dos terceiros molares foram
efectuadas.
Panoramic x-ray (Fig.12): Good root positioning. Proposed
extraction of wisdom teeth was done.
(Fig.14)
Traado cefalomtrico
no final do tratamento
(Fig.14)
Post-treatment
cephalometric tracing
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Sobreposio Maxilar (Fig. 16): O eixo do incisivo superior
diminuiu alterando o torque. Retruso do ponto A.
Sobreposio Mandibular (Fig.16): Podemos notar alguma
resposta do crescimento mandibular, mesmo com a diminui-
o do SNB o eixo do incisivo inferior permaneceu inalterado.
Na dimenso vertical, podemos observar o bom controle
do plano oclusal.
Maxillary local superposition (Fig. 16): Changed upper in-
cisor axis decreased the torque. Point A retrusion.
Mandibular local superposition (Fig. 16): We can note
some mandibular growth response even with the decreas-
ing SNB the axis of lower incisor was unchanged.
In the vertical dimension, we can observe good control of
occlusal plane.
(Fig.16)
Sobreposies cefalomtricas
locais do inicio e do final do tratamento
(Fig.16)
Pretreatment and post-treatment
cephalometric tracings local superimposed
Documentos no final da reteno (15Y 10M) (Fig. 17-21)
Um ano e um ms aps o tratamento, temos uma oclu-
so dentria estvel e um sorriso agradvel.
End of retention documents (15Y 10M) (Fig. 17-21)
One year and one month posttreatment, we have a stable
dental occlusion and pleasant smile.
(Fig.17)
Fotografias 1 ano
aps o final do tratamento
(Fig.17)
Frontal, smile, facial profile
and intra-oral photos one year
after the orthodontic treatment
(Fig.15)
Sobreposio cefalomtrica geral do inicio
e do final do tratamento, sela-nasio na sela
(Fig.15)
Pretreatment and post-treatment geral su-
perimposed on sella-nasion plane at sella
Radiograa panormica (Fig.12): Bom posicionamen-
to radicular e a extraco dos terceiros molares foram
efectuadas.
Panoramic x-ray (Fig.12): Good root positioning. Proposed
extraction of wisdom teeth was done.
25
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(Fig.16)
Sobreposies cefalomtricas
locais do inicio e do final do tratamento
(Fig.17)
Frontal, smile, facial profile
and intra-oral photos one year
after the orthodontic treatment
(Fig.18)
Fotografias dos
modelos 1 ano aps
o final do tratamento
(Fig.18)
Dental casts
one year after the
orthodontic treatment
(Fig.19)
Radiografia panormica 1 ano
aps o final do tratamento
(Fig.19)
Panoramic x-ray, one year
after the orthodontic treatment
(Fig.20)
Telerradiografia em incidncia lateral
1 ano aps o final do tratamento
(fig.20)
Cephalometric radiogram, one year
after the orthodontic treatment
Discusso
Discussion
Tm sido discutidas de vrias maneiras as desvantagens
da terapia de extraco de pr-molares na repercusso da
face e dentio. Tem sido apontado que as desvantagens
incluem uma linha sorriso de dentes estreita, um arco me-
nor, com idades e aparncia mais avanadas, perda de
dimenso vertical, e distrbios temporomandibulares de-
vido ao deslocamento posterior do cndilo
15
. Neste caso
as extraces de pr-molares no seriam recomendadas,
The disadvantages of premolar extraction therapy have
been argued for the effect on the face and dentition in sev-
eral ways. It has been pointed out that the disadvantages
include a narrower smile line of teeth, a smaller overall
arch, an aged and sunken-in appearance,loss in vertical di-
mension, and temporomandibular disturbance due to pos-
terior displacement of the condyle
15
. In this case premo-
lars extractions wouldnt be the most recommended due
(Fig.21)
Traado cefalomtrico 1 ano
aps o final do tratamento
(Fig.21)
Cephalometric tracing, , one year
after the orthodontic treatment.
26
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Antes T
Before T
Depois T
AfterT
MP-AB 75.5 75.4
HF-PP + + ><OK XX
HF-PP -0.2 1 > Close bite
ODI (74,5+/-6) = 75.3 = 76.4 < Open bite
MP-AB = ngulo do plano mandibular e plano AB
HF-PP = ngulo do plano de Frankfort e plano Palatino
(Tabela 2) (Table 2)
ODI - Indicador de profundidade de sobremordida vertical, antes e final do tratamento ortodntico
ODI - Overbite depth indicator, cephalometric measurements, and after orthodontic treatment
HF-PF = ngulo do plano de Frankfort e plano facial (N-Po)
PF-AB = ngulo do plano facial e plano AB
(Tabela 3) (Table 3)
APDI (Indicador de displasia antero-posterior ) antes e final do tratamento ortodntico
APDI - anterior-posterior dysplasia indicator, cephalometric measurements, before, and
after orthodontic treatment
Antes T
Before T
Depois T
AfterT
HF-PF 86.9 85
PF-AB + +
PF-AB -8.2 -8.3
=78.7 =76.7
HF-PP + + < Cl I XX
HF-PP -0.2 1 < Cl II
= 78.5 = 77.7 > Cl III
APDI (81,4+/-3,7)
devido ao ngulo de abertura naso-labial exibido pelo pa-
ciente e do significativo torque lingual em todos os dentes
laterais do arco maxilar e mandibular, assim o sorriso no
final do tratamento sem extraces ficou mais agradvel
(Fig. 10 e 17). Embora o paciente tivesse um apinhamen-
to dentrio grande, foi possvel trat-lo sem extraco de
pr-molares, utilizando a verticalizao dos segmentos
posteriores e a vestibularizao dos sectores laterais que
apresentavam um torque muito negativo, permitindo a
correco do apinhamento dentrio e o restabelecimento
de uma boa ocluso
16
sem agravamento do IMPA.
No presente caso, tendo em conta a DDM negativa exis-
tente no arco superior e o facto de no haver inteno por
parte da paciente de usar os elsticos intermaxilares, du-
rante todo o tratamento activo, o uso da tcnica de arco
recto na primeira fase, durante catorze meses, tornou-se
essencial para o alinhamento e o nivelamento coronrio /
radicular. Este procedimento permitiu o uso de Multiloop
edgewise arch-wire apenas durante sete meses e desta
forma o uso de elsticos curtos de Classe II nos dentes
anteriores tornou-se mais fcil.
A discrepncia posterior influncia a dimenso vertical da
ocluso, que na verdade mais importante porque envol-
ve a sustentao dentria nas alteraes dinmicas do
crescimento esqueltico
14
. Tambm importante notar
que sempre que houver uma discrepncia anterior, uma
discrepncia posterior existe tambm
16
. No caso apresen-
tado, o doente teria beneficiado da extraco mais cedo
dos terceiros molares, mas esta indispensvel abordagem
foi efectuada no final do tratamento.
to the open naso-labial angle exhibited by the patient and
the significant lingual tipping in all lateral teeth of maxil-
lary and mandibular arch, so the smile at the end of treat-
ment without extraction was more pleasant (Fig. 10 e 17).
Although the patient had a high crowded occlusion, it was
possible to treat him with a non-premolar extraction, utiliz-
ing the uprighting of mesially tipping posterior segments
and vestibular tipping in all lateral teeth offered correction
of crowding and good occlusion was established
16
without
worsening the IMPA.
In the present case considering the negative DDM existent
in the upper arch and the fact that there is no intention of
the patient to use the intermaxillary elastics during all ac-
tive treatment, the use of straight wire technique in the first
stage for twelve months became essential for the coronary
alignment and the radicular levelling allowing the lingual tip-
ping correction in all lateral teeth of maxillary and mandibular
arch. This procedure allowed the use of Multiloop Edgewise
Arch-Wire only for seven months and the use of short Class
II elastics in the anterior teeth became easier.
The posterior discrepancy influenced the vertical dimen-
sion of occlusion, which is actually more important be-
cause it involves tooth support of the dynamic skeletal
growth changes
14
. It is also important to notice that when-
ever there is an anterior discrepancy, a posterior discrep-
ancy exists as well
16
. In the case presented, the patient
would have benefited from the earlier extraction of the
third molars, but this approach was made at the end of
the treatment.
27
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A camuflagem ortodntica nas malocluses esquelticas
pretende dissimular a anomalia, no colocando desse
modo as bases sseas maxilares de acordo com a estrutu-
ra craneana individual existente. A partir do momento em
que a resoluo do caso obriga a compromissos estticos
faciais e dentrios, ocluso-funcionais e periodontais, que
ponham em causa a estabilidade dos resultados terapu-
ticos, ser prefervel a opo por um tratamento ortodon-
tico-cirurgico
17,18
, esta opo a nica forma de corrigir
correctamente as alteraes esquelticas e dentrias
3,18
.
No presente caso, a opo de camuflagem ortodntica foi
uma escolha razovel com base nos valores normais do
indicador inicial da sobremordida profunda (ODI)
11
e o indi-
cador ntero-posterior de displasia (APDI), que revelavam
respectivamente a nvel esqueltico uma mordida e uma
relao de Classe I normais, apesar da dimenso verti-
cal exibir um bitipo hiperdivergente (FMA = 29,7 ) e a
esttica facial no era desfavorvel, apesar da bi-retruso
maxilar existente.
The orthodontic camouflage of the skeletal malocclusion
attempts to reduce the anomaly, not placing the maxillary
cranial base in accordance with the existing individual cra-
nial structure. So from the moment that the resolution of
the case calls for an aesthetic facial and dental, functional
occlusion and periodontal commitment, that can com-
promise the stability of the therapeutic results, the ortho-
dontic-surgical treatment option would be preferable
17,18
,
because its the only way to properly correct the skeletal
and dental changes
3,18
. In the present case the orthodontic
camouflage option was a reasonable choice based on the
initial overbite depth indicator (ODI)
11
and anteroposterior
dysplasia indicator (APDI) values that were normal, reveal-
ing a skeletal normal bite and Class I relationship respec-
tively, despite the vertical dimension displayed a hyperdi-
vergent biotype (FMA = 29.7) and the facial esthetics was
not unpleasant, despite the existing bi-maxillary retrusion.
Em concluso, no final do tratamento foram alcanados
os objectivos propostos. H um bom prognstico para o
tratamento realizado com a melhoria funcional e dentria
sem prejuzo da esttica facial.
In conclusion, at the end of the treatment the proposed ob-
jectives were achieved. There is a good prognostic for the
accomplished treatment, considering the functional and
dental improvement without loss facial aesthetics.
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occlusal plane control. Bull Kanagawa Dent Col 1995;23:63-68.
3. Pinho T, Figueiredo A. An Orthodontic-Orthognathic surgical treatment in a Class II subdivision: occlusal plan alteration. Am J Orthod
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Angle Orthod 2004;74:454-464.
9. Saito I, Yamaki M, Hanada K. Nonsurgical treatment of adult open bite using edgewise appliance combined with high-pull headgear and
class III elastics. Angle Orthod 2005;75:277-283.
10. Xun C, Zeng X, Wang X. Microscrew anchorage in skeletal anterior open-bite treatment. Angle Orthod 2007;77:47-56.
11. Kim YH. Overbite depth indicator with particular reference to anterior open-bite. Am J Orthod 1974;65:586-611.
12. Kim YH. Anterior openbite and its treatment with multiloop edgewise archwire. Angle Orthod 1987;57:290-321.
13. Sato S, Dennis CL. The development of openbite as a result of posterior discrepancy and its treatment approach using MEAW. Inter
Journal of MEAW Tecnic and Res Foundation 1998;5:5-15.
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15. Slavicek R. Compulsory diagnostic measures bef the indication of extraction. What kind of diagnosis do we need to decide: extraction
or nonextraction? In Extraction versus Non-extraction, Bolender C.J., Bounoure G.M., Barat, Y. (Eds) SID Publisher Inc; 1995.
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Orthod 2002;72:265-274.
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