ว.ลิงกัวล์.ออร์โท.ไทย. ปีท่ี 2 ฉบับที่ 1 ม.ค.-- มิ.ย.

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Original Article

Treatment of Class II Division 1 Malocclusion: Asymmetric Extraction

Watana Mathurasai DDS., M.D.S.,F.I.C.D,F.A.C.D.

Smorntree Viteporn DDS.,M.D.Sc., F.I.C.D.

Abstract
Compromised treatment of Class II division 1 malocclusion in the adlut patient usually re-
quires extraction of the two maxillary first bicuspids so that Class I canine can be obtained.Asymmetric
extraction of one bicuspid is a treatment of choice in the patient with acceptable profile and space
deficiency is moderate . Success of the treatment depends upon clinical examination, space assess-
ment, anchorage management and biomechanics. The article presented treatment of Class II divi-
sion 1 malocclusion with lingual orthodontic mechanics by extraction one bicuspid .

The specific characteristics of Class II
division 1 malocclusion that is usually the major
concern of a patient is severe protrusion of
maxillary incisors. Compromised orthodontic
treatment in the adult patient is extraction only
the maxillary first bicuspids so that there are
enough space for correction of the protrusion and
improvement of facial profile if possible. In a Class
II division 1 patient with acceptable profile space
obtained from extraction of the two maxillary
first bicuspids may be redundant thus caus-
ing excessive retraction of the maxillary incisors.
In this case nonextraction or extraction only
one bicuspid should be the treatment of choice.
Factors influence success of correction
of dental protrusion in the patient with accept-
able facial profile are clinical examination, space
assessment, anchorage management, and bio-
mechanics. Since in this case the objectives of
the treatment do not concern only function but
esthetics. Excessive space obtained from extrac-
tion may end up with the uprighted incisor, deep
overbite, and flat facial profile due to excessive
retraction of the anterior teeth. Otherwise treat-
ment planning as a nonextraction case may be
not possible since it aggravates the protrusion.
The possibility of asymmetric extraction of only
one bicuspid should be evaluated according to
the aforementioned factors.
Clinical examination: The initial relation
between the maxillary dental midline and the
facial midline should be thoroughly examined to
investigate the possibility to maintain or shift the
maxillary dental midline towards the extraction
site. The symmetric positions of the maxillary
canines when smiling has to be evaluated as well.
Space assessment: The occlusogram (1)
of the maxillary denture should be scrutinized to
determine final position of the anterior and pos-
terior segments and to select type of anchorage.
8 J. Lingual Ortho.Th. Vol.2 No.1 Jan.-Jun 2002
Anchorage management: Space obtained
from extraction one bicuspid is utilized for cor-
rection of protrusion by maximum retraction of the
anterior segment (Type A anchorage), retraction
of the anterior segment and protraction of the
posterior segment (Type B anchorage) or pro-
traction of the posterior segment (Type C anchor-
age)(2). In lingual orthodontics, management of
anchorage is depended upon configuration of the
archwire and the amount of force.
Biomechanics: Asymmetric retraction of
the anterior segment should be a treatment of
choice if the dental protrusion cannot be
corrected by alteration of jaw relationship.
The objective of the article was to present
Figure 1 Pretreatment facial profile and occlusion
the Class II division 1 case treated with
asymmetric extraction by lingual orthodontic
mechanics.
Diagnosis and Etiology
A woman aged 19 years searched for cor-
rection of maxillary incisor protrusion without
changing her facial profile. Clinical examination
(figure 1) showed acceptable facial profile, nor-
mal lip position and function. The maxillary dental
midline in relation to the facial midline was shifted
to the right side 1 mm, the mandibular dental mid-
line was normal. The maxillary left posterior seg-
ment moved forward due to disto-lingual rotation
of the maxillary left canine causing severe
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Figure 2 Pretreatment cephalometric analysis

Figure 3 Oral features during treatment

10 J. Lingual Ortho.Th. Vol.2 No.1 Jan.-Jun 2002
Class II molar and canine relationship around 4
mm. The maxillary right segment was slightly
Class II molar and canine relation 2 mm. The
overbite was normal while the overjet was 6 mm.
The Bolton analysis showed maxillary
anterior teeth excess 2 mm.
Panoramic radiograph showed normal
development dentition.
Cephalometric analysis showed skeletal
Class I normal bite with maxillary incisor
protrusion and proclination, normal facial profile
(figure 2).
Hereditary factor should be a major
etiological factor.
Treatment Objectives
To correct maxillary incisor protrusion
while maintaining the facial profile.
To obtain Class I molar (right side), Class
II molar (left side) and Class I canine (both sides)
with normal overbite and overjet.
Extraction of the maxillary left first bicus-
pid was recommended to obtain space available
8 mm for correction of the maxillary left canine
rotation and incisor protrusion. Type B anchor-
age was selected to achieve the aforemen-
tioned occlusion.
Treatment Progress (figure 3)
Edgewise lingual appliance was used for
the maxillary teeth and labial appliance was used
for the mandibular teeth. The .022x.028" Roth
vertical slot edgewise appliance (Ortho Organizer)
were placed. The treatment sequences were as
follows:
Upper Arch
1. Band #16, #26 Impression for bracket align-
ment with TARG system
2. Indirect bonding #15, #12, #11, #21, #22, #25
leveling with .014"TMA
3. Insert .016"TMA after extraction #24,
direct bonding #23 Labial brackets and retract
#23 with elastic chain 150 grams
4.Insert .016x.016" Blue elgiloy L loop closing loop
5. Insert .016" NiTi after complete space closure.
6. Insert .017x.025" TMA archwire
Lower Arch
1 Band #36, #46 direct bonding all remaining teeth
leveling with .0175" Superflex
2. Insert .014" stainless steel archwire
3. Insert .016" stainless steel archwire
4. Insert .018" stainless steel archwire
5. Insert .016x.022" stainless steel archwire
6. Insert .017x.025" TMA archwire
Final adjustment of occlusion with Class
II traction 4 oz. 1/4”
Treatment Result (figure 4,5)
Maxillary incisor protrusion and
proclination could be corrected by retraction of
the anterior teeth and protraction of the posterior
teeth so that the facial profile could be maintained.
Class I canines, Class I molar (right side) Class II
(left side) were obtained.
Discussion
Asymmetric retraction by lingual orthodon-
tic mechanics was rare since the technique is
usually performed symmetrically by utilizing
the horizontal force from elastic chain or
retraction loop (3)to retract the anterior segment.
In order to achieve type B anchorage the hori-
zontal force must be higher than those required
for retraction only the six anterior teeth. The simple
mechanics likes unilateral retraction with elastic
chain was not recommended as the heavy force
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Figure 4 Posttreatment cephalometric analysis

Figure 5 Posttreatment facial profile and occlusion

12 J. Lingual Ortho.Th. Vol.2 No.1 Jan.-Jun 2002

might cause distortion of the archwire thus ended References

up with asymmetric arch form. In order to mini- 1. Marcotte MR. The use of occlusogram in
mize this side effect the L loop retraction archwire planning orthodontic treatment. Am J Orthod.
was used with minimal attachment to the teeth of 1976;69:655-67.
the nonextraction side. Initial retraction of the 2. Burstone CJ. The segmented arch approach
maxillary left canine with both labial and lingual to space closure. Am J Orthod.1982;82:361-78.
mechanics was necessary for controlling rotation 3. Alexander CM., Alexander RG., Gorman JC.
of the canine and enabling the perfect engage- et al. Lingual orthodontics: A status report part
ment of the canine slot to the retraction archwire. 5 lingual mechanotherapy. J Clin Orthod
1983;17:99-115.
Acknowledgement The authors would like to express our sincerely thanks to the patient for
her contributions as the subject of the presentation.