9.

Treatment of Class II Deep Overbite 87

9.Treatment of Class II Deep Overbite

(Atsush i Matsu moto)

88 9. Treatment of Class IIDeep Overbite

I. General Characteristics
of Class II Deep Overbite

This is classified as a type of maloccl u sion where the vertical growth of

the maxilla is insufficient. Beca use of this, the vertical dimension in the molar
area is insufficient resulting to the d isharmony of its rel ationship to the vertical
growth of t h e mandible. Though t h ere is not much of a problem wit h the
anteroposto ri or diameter of the maxilla, there is a ch aracteri stic sud den
tipping of the occlusal plane in the molar area. With the steepen i ng of the
occlusa l plane in t he posterior, the mandible can not adapt anteriorly. fin
stead it adapts posterior l y due to the occlusal i nterference in the molar area.

II. Morphological Characteristics

of Class II Deep Overbite

l. L i p incompetence
2. The reverse rotation of the lower lip du ri ng the resti ng phase
3. Excessively small vertical dimension
4. Insuffic ient eruption of the molar teeth (infraeruption)
5. Accentuated Curve of Spee
6. Two occlusal p lanes
• Flat occlusal p lane in the u pper anterior area
• Steepening of the occlusal plane in the u pper posterior area
7. Discrepancy in the upper and lower den ta l arch \Width
8. Labial ti ppi ng of the u pper anterior teeth
9. Occlusal interference in the molar area I
0. Insufficient occlusal support
I I . Functional failure due to poor a nterior guidance

Ill. Treatment Objectives for Class II Deep Overbite

I . Habit modifica tion like tongue thrusting and abnormal swa llowing.
2. For patients with respiratory problems , t reatment of enlarged pharynx and
tonsils, oral respiration, allergic rhinitis and other otorhinologicrelated
diseases.
 9. Treatment of Class II Deep Overbite 89

3. E l i m i na te t h e funct i on al factor and obtain a ph ysiolog ic condy l ar

and mand i bu lar posi tion.
4. I ncrease th e max illary hei ght and vertical d imension
5. Eli m i nate the d iscrepa ncy i n the u pper and l ower dental arch width th
rough latera l expans ion of th e max i l l a.
6. Improve the class JI mola r rela tions h i p by retraction of the u pper den ta l
arch to i ts appropriate posi tion .
7. lf the pati ent seeks trea tm en t d u ring th e grow th period, obtain a n
terior posi tion of the mandible th rough growth guidance.
8. Al ign every sing le tooth based on the appropriate curve of Spee. And
finally, flatten the occlusal pla ne i n th e molar area.
9. Increa e the vertical dimension t h rough upper and lower molar erupt i
on . Obtai n an occlusal support.
I 0. I m prove overbi te (deep bi te).
11. Obtain an a ppropri ate occlusal and anterior gu idance.
12. Obta i n normal intercuspation.
13. Atta i n an excellent profi l e.
14. Consider rel apse as over-correct ion.

IV.
Treatment Procedures for
Class II Deep Overbite

1 . Patien t's History

Age: 1 6 y/o Sex: M a le
Chief complain ts: Protrusion o:f th e anter i or teeth
Facia l profile: Brachycephal ic and convex profi le, overjet is + l l 111111,
overbi te i s + I I mm (fig 9-2).
Pa nora mic x-ray: a l l the four yct mola r teeth are i mpacted ( fi g 9-3).
Ceph a lometric radiogra ph ic find ings: Based on th e l atera l v iew
there i s a sl igh t an terior pos i ti on of th e maxi lla , and posterior pos i t i
on of t he m a n d i b l e. Man dib u l ar an gl e i s sm al l beca u se of th e
excess i vel y l ow mand i b u la r height. Th i s i s a l so classi fi ed as bra
ch ycepha lic faci a l type (fig 9-4) . It was observed t h rou gh the latera l
cephalomet ric traci ngs th at Lh ere was a severe curve o f Spee sh ow i
ng a steepen i ng of the occlu sa l p l a n e i n the molar area a nd a
remarkable la bi a l ti ppi ng of th e occl u sa l pl ane i n th e upper anter
ior teeth (fig 9-5). Fig 9-6 shows the fron tal v iew cephalom et1ic rad i
ogra m.
90 9. Treatment of Class II Deep Overbite

Fig. 9-2 Intra-oral pictures during the initial examination

Fig. 9-3 Panoramic x-ray during the first examination

 9 . Treatment of Class II Deep Overbite 91

Fig. 9-4 Lateral cephalometr ic Fig. 9-5 Lateral cephalomet ric tracings during the initial examination
radiogram during the initial examina
tion

Fig. 9-6 Frontal view cephalometric radiogram

during the initial examination
92 9. Treatment of Class II Deep Overbite

Fig. 9-7 Illustration of the tooth movement and treatment plan for class II deep overbite condition

2. Diagnosis and Treatment Plan

ln this pa tien t i t was noted tha t the curve of Spee was deep with
steep occl usal p l ane i n the molar area, showin g an i nterference in the
posterior region. Th erefo re i t resu l ted to class II beca use of th e i n ab i l i ty
o f t h e m an d i b l e to anteriorly adapt leading to its retrusion. The occl usal
support i s also i nsufficien t beca u se of t he excellent vertical grow th of the
m and i bu l ar ra mus, l eadi ng to occlusal adaptati on, al lowing the maxi lla
to an ter i orly rota te.
I n cl ass 11 deepbite, the anterior rota tion of the mand i b le through
occlusal recon struction i s best desired. Fi rst, it i s im porta n t to el i m ina te
the funct ional causes of the mand ibular retrusion (cuspal and occl u sa l
i n terference) . ln thi s case, a ph ysio l ogic condylar and mandibular posi tion
can be attained. With this, posterior mo l ar i n terference i s elimin ated w i th
the a l ignm ent o f the lower 2"d mol ar correcting the excessive curve of Spee.
Second ly, i t serves to flatten th e occl usa l p l ane i n the u pper molar area.
Tn order Lo get a suffi cien t occl usal support, the u pper and l ower molar
teeth are supra-eru pted to i ncrease vertical d i m en sion. W ith this process,
the class 11 m ol ar rel ati onship i s i mprov ed due to the appropriate
maxillary po sition th ro ugh a l i gn men t and retraction of th e max i l l ary d
en t i ti on . Fig 9-7 shows th e i ll ustrat i on of th e t reatment pla n an d tooth
movem ent.
 9. Treatment of Class 11 Deep Overbite 93

Fig. 9-8 Intra-oral pictures a month following the start of treatment

Fig. 9-9 Intra-oral pictures 5 months following the start of lreatmen l

3. Progress of Treatment
Step 1 : Correction of the Upper Dental Arch/Reconstruction of the
Occlusal Plane in the Lower Posterior segment

Fig 9-8 shows the in tra-oral pi ctures a mon th followi ng th e start of

treatment. A Quad helix was used to lateral l y expand the maxi llary denta l
arch width. An 0.016-inch round A ustralian wire was p l aced i n the mandi
ble and el iminati on of the curve of Spee was started. Retraction of the u pper
anterior teeth has not yet started_
Fig 9-9 shows the in tra-oral pictures 5 mont hs fol lowing the sta rt of
treat ment. The intercani ne width of the max i Ila was expanded th rough the use
of Quad hel ix. Retrusion of the upper anterior area has not yet started. Brackets
were bonded and leveli ng was stmted. An 0.016-inch round Australian wire and
a Uti lity arch made from an 0.016 x 0.0 1 6 inch b lue elgi loy was used i n
lhe
94 9. Treatment of Class II Deep Overbite

Fig. 9-10 Intra-oral pictures 10 months after start of treatment

Fig. 9-11 Intra-oral pictures 15 months after start of treatment

ma nd ib le for bi te ri sing and el i m i n at ion of th e curve of Spee as well as

for closu re of spaces. (Note: At th is stage, the use of MEA W i n t he mand i
ble i s also possi ble).

Step 2: Closure of Space and Occl usal Plane Reconstruction in the Upper
and Lower Molar Area
F i g. 9- 1 0 shows the i n traora l p i ctures l 0 m on t h s followi ng the start
of treatment. A con sol idat i on arch of 0.0 1 6 i nch green elgi loy was used to
close the spaces i n the max i lla. I m provemen t for the excessi ve cu rve of Spee
i n the ma ndibula r arch was continued. A reverse curve was done i n the 0.0 1 6
x 0.01 6 inch bl ue elgi loy app l ied i n the ma nd i ble. (Note: At tbis stage, the
use of MEA W i n the mand ible is a l so possi bl e).
Fig. 9-1 I shows the intra -ora l p i ctu res 1 5 mon th s fol low i ng the sta
rt of trea tmen t. M EA W (Mu l ti loop edge\:v i se archwi rc: 0.0 1 6 x 0.022 i
nch , bl ue e l gi loy) was appl i ed to the ma x i ll a for spa ce closure, a l ign m
en t of the denta l
 9. Treatment of Class II Deep Overbite 95

Fig. 9- 12 Intra-oral pictures 19 months fo llowing the start of treatment

Fig. 9-13 Intra-oral pictures 24 months following the start of treatment

arch , and bi te ri sing. Improvemen t of the curve of Spee i n the mandi bula r
den tal arch was con ti n ued . A reverse curve was clon e i n th e 0.0 16 x 0.01 6 i
nch b l ue elgi loy appl i ed i n the mand i bl e. Th e space i n th e mand ible has
almost closed. (Note: At th i. stage, the use of M EAW i n the mandi b l e is also
possi ble).

Step 3: Bite Raising I Molar Relat ion ship Corred:ion

Fig. 9- 1 2 show s th e i n tra-ora l pictu res 19 mon t hs following the start
of trea tm ent. A step down bend was done i n the M EAW (0.0 1 6 x 0.022 inch
bl ue elgiloy wire) for maxilla ry bi te ri sing. A reverse curve was done i n the
0 .0 1 6 x 0.0 16- i nch b l ue elgi loy wire i n the mandi ble. Space i n the mandible
has closed and the mandibular arch h as been aligned. (Note: At th is stage, the use
of MEA W i n the mandibl e is also possibl e).
F i g. 9-13 shows the i n t ra -ora l pi ctures 24 mon th s fo l lowing th e start
of treatmen t. A DAW (double arch w i re) of 0.016 x 0.016-inch blu e elgiloy
was
96 9. Treatment of Class II Deep Overbite

Fig. 9-14 Intra-oral pictures 27 months following the start of treatment

Fig. 9- 15 Intra-oral pictures 32 months following the start of treatment

Fig. 9- 16 Intra-oral pictures during the completion of the dynamic treatment, 34 months following the start of treatment
 9. Treatment of Class II Deep Overbite 97

applied for bi te risi ng i n the maxillary denta l arch . A step down bend was
done in the horizonta l loop of the upper ri ght ca n i ne (upper sectional arch 3-
5). A p l ain MEA W (Multilo op edgew i se arch wi re: 0.0 1 6 x 0.022 inch bl ue
elgiloy w i re) was applied to the mandi ble to simul tan eousl y align th e
dentition.

Step 4: Bite Rising I Detailing

Fig . 9- 14 shows the intra-oral p ictures 27 mon ths fol low i ng the start
of treatmen t. Th e four u pper anterior teeth hav e intruded . Step down bend was
don e to simul taneously al ign th e den ti tion. In the mandibl e, a step up bend
and reverse curve was done to the MEAW for bite risi ng.
f i g. 9- 15 shows the i nt ra-oral pictures 32 months following t11e start
of treatment. A step down bend was done i n the MEA W of the maxilla for
bi te ri si ng. In the mandi bl e, a step dow n bend was don e i n the MEA W (Mu
lti-loop edgewise arch wirc : 0.0 16 x 0 .022 inch , bl ue elgi l oy w i re) for b
i te rising.
Fig. 9-16 shows the i n tra-oral pict ures 34 mon ths foll owing the start
of treatmen t. MBA of the upper and lower jaw was removed.

Fig. 9-17 Panoramic x-ray during the dynamic treatment

Fig. 9-18 Lateral cephalometric Fig. 9-19 P-A cephalometric
radiogram during the dynamic treatment radiogram during the dynamic
treatment
98 9. Treatment of Class II Deep Overbite

b
Fig. 9-20 Lateral cephalometr ic radiogram tracing after
the completion of the dynamic treatment

4. Treatment Results
The dyna m i c treatment per i od lasted
for 34 mon ths. The u se of Quad helix in the
max i l l a lasted for 7 mon ths, DAW was 3
mon t hs, and MEAW was 1 7 months. In the
mand i b le, utility arch was used for 5 mon ths
and 1 6 months for MEAW. The use of i n
termaxil lary el astic lasted for 24 months.

Fig. 9-17 shows the panoramic x-ray dw- molar toot h

Lng the dynam ic treatment. Fig 9- 18, and 9- 1
9 show the l ateral and frontal cephalometric
rad iogram respectively. Based on the
cephalometr ic traci ngs, the vertica l dimen sion
has increased (fig 9-20). The SLtperi m posed
tracings of the pre and post treatment (fig 9-21
a) show a corrected mand ibular posi ti on wi t
h a 6rn m-i ncrease of the vertica l dimen sion
through the movement of the occl usal system.
Based on the superimposed traci ngs of the
maxillary pal atal p lane, the upper mol ar teeth
h ave m oved an teroposteriorly wi t h a
3111111 el ongation. The incisal edge of the cen
tral incisors has retrnded by l 2 111m and
extruded by 4 mm (fig 9-21b). The center of
Fig. 9-22 Facial profile after the dynamic treatment
alignment was t he 2°d premola r teet h i n th e
lower denti tion as shown
i n the ma n d i bu l a r p l ane of the superi m
posed t rac i ngs . Th i s m ea n s tha t th ere
wa s n o an teroposterior movemen t of th e
Fig. 9-21 Superimposed tracings of the pre and post treatment
 9. Treatment of Class II Deep Overbite 99

cmwn . I nstead, i t al i gned whi leelongating by 3mm . Moreover, the lower

anterior teeth were i n truded by 31mn (fig 2 1 c). As a resul t, th e steep occl u
sal plane i n the mola r a rea, has flattened and th e d u al occl usal pla ne, wh
ich was causin g the deep curve of Spee, was improved. Overjet was +3111111
and overbi te was
+S mm. A stabl e occlusion was atta i n ed as well as the excellent facia l profi l
e due to t he correction of m an d i bu la r posi tion (fig 9-22).

A Begg type reta i ner was used for retention at daytime and a bionator (to
open) was u sed at ni gh t, wh ich l asted for a year. Si nce there was no s i gn
of relapse, the pa ti en t was subj ected to a periodic exam inat i on . Fig 9-23 sh
ows th e facial profile 5 years later and fig 9-24 shows the in tra-ora l p i ctures
confirm i n g a stable occlusi on. Fig 9-25 is the pa noramic x-ray and fig 9-26, 9-
27 shows th e la teral an d fronta l cepha lometr i c rad i ogram respect i vel y. Resu
lts of th e cephal ometric an alysis are shovvn i n chart 9-1 .

Fig. 9-23 Facial profile 5 years post retention

Fig 9-24 Intra-oral pictures 5 yea rs post retention

100 9. Treatment of Class II Deep Overbite

Fig. 9-25 Panoramic x-ray 5 yea rs post retention

Fig. 9-26 Lateral cephalometr ic

radiogram 5 years post retention Fig. 9-27 Frontal cephalometric
radiogram 5 yea rs post retention
 9. Treatment of Class II Deep Overbite 101

Chart 9-1 Results of the lateral cephalometric radiogram

I Completion of Latest
exam. First examination
or the case
I treatment
Parameters 16y.o. 18y 4mos old 23y 4mos old
SNA 82.0 82.0 82.0
SNB 78.0 80.0 80.0
ANB 4.0 2.0 2.0
FMIA 53.5 62.0 60.0
U1-SN 126.5 101.0 101.0
Facial Axis 92.5 94.0 94.0
Facial Depth 89.5 91.5 91.0
Mandibular Plane 14.0 11.5 11.0
Lower Facial Ht. 39.5 43.0 43.0
Mandibular Arc 44.5 44 .5 44.5
Convexity 2 .5 0.0 0.0
1-APO (mm) 3.5 1.5 2.0
1-APO (deg.) 32.5 29.5 29.5
6-PTV 27.0 25.5 26.0
Lower Lip-E Plane 3.5 -0 .5 1.0
upper OP (1-6) 2.0 1.5 3.0
upper OP (6-7) 14.0 1.5 3.0
001 79.0 75.0 76.0
APDI 73.0 81.5 79.5
CF 152.0 156.5 155.5

5. Treatmen t Method Used and Some I m porta nt Points to Consider in the

Treatmen t of Class II Dee pbite M aloccl usion
l . Remove the function a l cause and obtai n a physi ologic concl yl ar and
mand i bu l a r position . To do tha t , i t is im portan t to de fi ne the pl
ans for habi t mod ification. Furthermore, the use of myofunctional thera
py (MFT) restores the function of oral l ip closure and tra i ns the
masticatory m uscles i nclud ing th e tongue and the m uscles su rrou nd
i ng th e oral cav i ty. Th is
sti mulates the adaptat ional capacity of the ma ndi ble to rotate an teriorly .
2. Expect an terior mand i bular rota tion (During the grow th period ,
obtai n anterior ma nd i bul ar positi on th rough growth guidance).
3. Con trol the vertica l d i m ensi on i n the den tu re frame and flatten
the occlusa l pl ane i n the mol ar area.

4. I mprove the dental arch through a maxi I l ary lateral expa nsion dev i ce
in case the pat ien t i s ma n i festi ng i n appropri ate maxi l lary dental
arch and retrus i on of the m and i bl e. Th i s wi ll allow more leewa y for
mand i bul ar movement, obtai n i ng a ph ysiologic mandi bul a r posi tion.
(Com b i nation of T\IBA and Mul l igan arch, Quad hel ix, expa nsion
screw p l ate appl iance used for bi te risi ng, Rapid expansi on)
102 9. Treatment of Class II Deep Overbite

5. Jn rai sing the bi te, erupt the molar teeth and i n trude the u pper and
lower anterior teeth . A Dou ble Archw i re can be used at th is ti me.
General ly , the i ntermediate tooth is extracted to i ncrea se the vertical d
imension however this has been know n to be d ifficu l t. It is best to
always refrai n from doi ng a premolar xtract ion.

6. In occlusa l reconstruction , el i minate the curve of Spee and flatten the

occlusa l plane i n the molar area. Sim u l ta neous ly al i gn each tooth
tlu·ougb th e u se of MEA W . At th is point, bi te raisi ng was al so accom p
l ished (tip back bend, step bend , Reverse MEA W etc).
7. In t he retract i on of th e ma x i l l a ry den tition , i m prove th e class 11
mo l ar rel a t ion h i p by usi ng the en t i re mand ibu lar den ta l arch as
an anchorage u n i t with the use of i n terma x i l l ary elastics. I n case of
severe max i ll ary protrusion or absence of mand ibu lar growth, extrusion
of the u pper posterior teeth and d istal movemen t can be done. At this poi n
L, an extraoral anchorage appli ance can be used (MOAW, M EAW,
Headgear, J-hook , GMD, pend u lum ,
.Jones j ig).
8. Obta i n occlusal su pport and stabi l ize occl u sion .
9. Obtai n an appropriate occl u sal and an terior gui dance.
 11. Treatment of Crowding 115

11.Treatment of Crowding

(Sadao Sato)
116 11. Treatment of Crowding

I. General Characteristics of Crowding

Crowding is an abnormality of the dentition that frequently occurs in

malocclusion. The degree of crowding vaiies from one patient to another. Nmmally,
this problem arises due to discrepancy in the size of the teeth and the alveolar bone.
The most affected part of crowding starts from the molaT area, lower anterior teeth,
upper canine area and the upper and lower premolar area. The degree of crowdi ng
can be easily dete1mined through a mere dental exai11ination. However,
malocclusion cannot be diagnosed that easily. It is important to be cautious about
selecting the tooth to be extracted, that is, opting to extract the premolars,
almost routinely. [n cases of severe crowding, mesial tipping is usually present in
the premolar
and molar area. Elimination of crowding through the al ignmen t in these areas
is also possi ble. Though there is a possi bili ty that the tTeah11en t of crowding
in the molar area is overlooked, it is important to note that the treatment of
crowding in the molar area (poste1ior discrepancy) is more important than the
crowding in the anterior teeth.

II. Morphological Characteristics of Crowding

All types of malocclusion are associated with crowding. Therefore the skeletal
characteristics of crowding are not well defined. However, in general, crowding
i n high angle open bite and maxilloma ndi bular protrusion is not common. It is
because crowding is closely related to the vertical dimension (occlusal support)
in the molar area. The increase of vertical dimension in the molar area leads to the
anterior tippi ng of the entire dentition and wi l l result to an anterior open bite or
maxillomandibular protrusion to prevent the aggravation of crowding. Therefore
it is said that there is a close relationship bel:\veen an open bite or maxillomandibular
protrusion and crowding.
(Morphological Characteristics)

l. Skeletal type is usually Class I. In Class III maloccl usion, crowding is

not frequentl y seen in the mandibular dentition. On the other hand,
crowding is not common in the maxillary dentition in Class 11 cases.
2. The upper ante1ior teeth are aligned and usually a steep anterior guidance
path is observed.
3. Occlusal plane i.s usually flat.
4. Impaction or emption of the 3rd molar is usually difficult.
 11. Treatment of Crowding 117

Ill. The General Treatment Objectives for Crowding

l n pl an ni ng the treatment for th i s type of pati ent, i t i s i mportant to

determine i n i tial l y the benefi t of doing a labia l li ppi ng of th e anterior
teeth. In case of a teepen i ng of the a n teri or teet h gu i dance pat h , a l
ignmen t start i ng from th e posteri or teeth i s importan t. This u sually
affects the im prov ement of the an terior teeth. It i s because there i s a b i g
possi bi l i ty tha t du r ing the treat ment process, mola r al ign m en t could cau
e open bi te in the anteri or teeth . H owever th i s i s not a problem a t a l l.
Since al t h i s poi n t, th e ve1tica l d imension i n the mola r area i s su rficie n
t, mand i bu l ar d i sp l acemen t and TMJ compressi on i s not observed due to a
h i gh vertica l dimension, then the second pa rt of treatment can be done, wh
i ch is the imp rovem ent of the open bi te t hrough t h e con h·ol of occlusa l pl
an e. This wi l l lead to the a tta i n ment of a su ffi c i ent occlu sal support resu
lt i ng to a stable occl usion post treatmcn l. Long term reten tion i s needed i n
cases o f" severe tooth rotation to i m prove crowd ing or abn orma l tooth posi
ti on . However, T n cases of moderat e crowd i ng, retention i s simi la r to other
ty pes of patien ts. I n either case, post treatment stabi l i ty i s greatl y
dependent on the functional clement. So the mosl i mportan t factor i s to gel
a stab l e occlusa l su pport t h rou gh an appropri ate occl u sa l gui dance an
d an occlusion w i t h the absence of cuspal i nterference.

IV. Treatment Procedures for Crowding

1 . Bond t he brackets a nd bucca l tu bes to the en t i re d en t i t ion except for *.

Start leveling wi th the u se of a 0.0 1 4 i n ch rou nd wi re.

2. . R epl ace the rou nd wire wi th a 0.0 1 6 ,izc round w i re and i nsert a coi l
spri ng i n lo th e area wi thout brack ets. Start the a l i gnmen t of the .

3. Bond t he bracke ts to th e t.jt. Start t he al ign men t of t by i n serti n g a coi l

spri ng i n to the 4
4. Appl y M EA W to the upper and lower den t i ti ons and do a t ip back
bend to al i gn lh e entire molar area .

5. Once the m olar a re aligned , remove the M EA W i m medi ate l y and re-ti
e the rou nd wi re to e l i m i nate t he crowd i ng i n t he an teri or area .

6. Once the crowd i ng ha s been en t i rely e l i m inated , a fin a l adjustm en t i n

the MEA W i s done to con tro l th e toot h ax i s (torq u e control ) i m prov i
ng the i ntercu spation .
118 11. Treatment of Crowding

Fig. 11-1 Facial profile pre-treatmen t

Fig. 11-2 Occlusal condition pre-treatment

1 . Patient's history

Age: 24y I 0 mos_ old Sex: Fem ale

Ch i e f Compla i nts: Teeth crowding as well as pai n and cl icking i n the
TMJ (fig 1 1-1).
Intra-oral find i ngs: Occl usi on i n the mo l ars is Class II angle, crowd i
ng i n t he u pper and lower an ter ior area i s severe, pa l atoversion of the u
pper
11
r igh t 2 c p rem ol a r, b l ocked ou t upper l eft can i ne as well a s the l ower
l eft 1st premolar (fig 1 1-2) were observed. Occlusion in the upper and lower
anterior teeth is edge to edge with a crossbi te from the l eft la teral i nci sor to
the premo lar area.
rd
Pan oram i c x-ray : All t h e fou r 3 m ol ars were p resen t bu t were
a ll impacted excepl for the 3 rd molar in the upper right side (fig l 1-3).
 11. Treatment of Crowding 119

Fig. 11-3 Panoramic x-ray pre-treatment

:
Fig . 1 1-4a Cephalometr ic t racing pre-treatment Fig. 11-4b Cephalometric tracing post-treatment

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Fig. 11-4c Superimposed tracings of the pre-treatment DJ. l -2. 20
'"· 12' o. ol '!l g. 34 a.8' ? O.'' o.g1

" nu . -z. g 7 !5. 1 1

(dotted line) and post-treatment (solid line) 12 . •1 0.01 5e. J' •O. "2
72. 20
I . JS
a 0 1 .
-. 69. 72 D. A !5 1. 79 -1. ::.t7 o. 77
7 " 85 U o. 47. 09 -1. 3 GO. 50 0. 39
a :. to7 '7
-o. '2'
•• :H. ie '36 o. 01, AO
55.0•
-2. \;? 6•. 05 H, QO
03. 80 a.ea
· I.gi
"
61.Q.A '58 4 1 . IZ -o. 0 1 -0. 2.C

.
'" -2. 3• O. lS >< '". n •• 0 1.3 " ""
Fig. 11-5 The mandibular condyle during the mouth
opening and closing movement (axiograph)
120 11. Treatment of Crowding

Cephalometric radiogram analysis: A remarkable skel etal d isplacem en

t was not observed. SN A was 86.5°, and SNB was 82.5°. With a FI-I-MP of
31°, ODI of 67° and APDI of 86°, these shows a high angle class Ill type. A
CF of 153 suggests the importance of tooth extracti on. Discrepancy wa very
evident because either th e Stei n er or Tweed test, a test to determine the i
mportance of tooth extractio n , shows positive results (fig l l -4a-c).
Axiogra ph : Mand ibular movem en t to the anterior and l ateral d irection
i s l im ited . There was no apparent difficu l ty duri ng the mou th open ing and
closure exerc ises bu t the re was an asym m etry i n th e cond y la r path
(fi g 11-5).

2. Diagnosis an d Treatment Plan

Jn thi s patient, the reason for th e crowd i ng and the functiona l abnorma
l i ty of th e TM.J was the di screpancy i n th e s ize of the tooth and t h e
alveolar base. There are also the fol lowi ng signs o f a steep u pper an ter i or
guidance, mesial ti ppi ng i n the premol ar and mol ar teeth and retruded mand
i bul ar position. As part of the treatment pla n , a m i ld anterior movemen t of
the ma nd i ble through correction i n th e occlusal plane i s n ecessary wh ich
w i ll evade th e need for premolar extraction . The upper and lower 3rd molars
were extracted to eliminate d iscrepa ncy and obta i n an appropr iate occl u sal
guida nce an d occlusa l support.
3. Treatment Progress
Step I : An edgewise bracket app l iance system was app l i ed to the entire
11
denti tion except to the Ist molars. Bucca l tu bes were bonded onto the 2 dmolars.
11
To align the 2 c1 mol a rs, an open coi l spr ing was attached to th e area of the l
st molar and leveling was started th rou gh t h e use of a 0. 0 1 4-i nch a ustrali an

w i re (fig 1 1 -6, l 1 -7). Two mon th s l ater, the curren t wi re was repl aced with
11
a 0.0 1 6 a ustrnlian wire to con ti n ue the align men t of the 2 d mola rs. Th ree
months later,
1
ban ds were a ttached to the lower 1 molars and the coi l spri ngs were removed .
Leveli ng wa done. Th i s process conseq uen tl y l ed to an an teri or open bi te.

Fig. 11-6 Intra-oral pictures during the start of leveling

 11. Treatment of Crowding 121

Fig. 11-7 Force system of leveling. Alignment of 2nd molar through the use of coil spring.

Fig. 11-Ba 4 months since the start of treatment

Fig. 11-Bb 7.5 months since the start of treatment

Fig. 11-Bc A year since the start of treatment

122 11. Treatment of Crowding

Step 2: 4 month s l ater, MEAW was applied to both the u pper and lower
dentitions to align the premo lar and molar teeth (fig 11-8a-c). The MEAW in
the rnaxilla was especially modified for t h e distal movement of the molars (fig
l l -9a,b). On the right premolar area a com b i nation loop wa · i ncorpora ted. A
11
vertical loop i n the distal area of the 2 d premo lar was placed to allow i ts distal
movement. Vertical elastics were used in the upper and lower MEAW . 9 month s
later, the palatoversion of the upper right premolar has been corrected, the space
for the left can ine as well as the closure of the open bi te condi tion i n the anterior
area has been attained (fig 11-lOa-k, I 1-1 I)-

I[ n
s
Is I
««
Fig. 11-9 The use of combination loop to create space

Fig. 11-1Oa Occlusal plane during the start of leveling

 11. Treatment of Crowding 123

Fig. 11-10b 1.5 months following the start of treatment

Fig. 11-1Oc 4 months follow ing the start of treatment

Fig. 11-1Od 6 months following the start of treatment

Fig. 11- 10e 7.5 months following the start of treatment

124 11. Treatment of Crowding

Fig. 11-1Of 11 months following the start of treatment

Fig. 11-1Og 1 year and 1 month following the start of treatment

Fig. 11-1 Oh 1 year and 4 months following the start of treatment

Fig. 11-1Oi 1 year and 8 months following the start of treatment

 11. Treatment of Crowding 125

Fig. 11- 10j 1 year and 11 months following the start of treatment

Fig. 11-1Ok 2 years and 1 month following the start of treatment

Fig. 11-11 1 year and 4 months following the start of treatment

Step 3: I year and Imonth l ater, the upper left cani nes were wel l wit hi n
the dental arch. However, the space needed for the righ t 2 1 d premolar was qu ite
insufficien t so a 0.0 1 6-inch Au tra l ia n wi re was replaced i nto the max i l l a ry
dentition and wi th the use of a coi l spri ng, a space was obtained . At 1 yea r and
8 months since the start treatmen t, the entire denti tion was aligned (fig 1 1. - 1 Oi ,
fig I1- 1 I).
126 11. Treatment of Crowding

Fig. 11-12a 1 year and 11 months following the start of treatment

Fig. 11-12b 2 years following the start of treatment

Fig. 11-13a Occlusal condition post orthodontic treatment (2 years and 4 months since the start of treatment)

Fig. 11-13b 10 months post orthodontic treatment

Step 4: [n the last stage of the orthodontic occl usal treatment, a 0.016
i nch round austral ian wire was used to create the idea l arch for both the upper
and l ower den ti tion. At th is poin t, spl i cing was done in the adjacent surfa ce
of each tooth from t he I st mola r to the lst premolar teeth of the upper and l
ower dentition. A J-book type headgear and a short class III elastic were used
on ly i n the even ing to improve the l ab i al t ippi ng o:fthe an teri or teeth (fig l
l - l 2a, b). The said force was appl i ed for 4 mon ths. Two yea rs and four mo
n ths after, a ll the appl ia nce was removed and the treatmen t was com pl eted
. (fig 1 1 -13, 1 1-14). Retention with the use of a H awley type l asted for 6
months (fig
1 1 -1 3).
 11. Treatment of Crowding 127

Fig. 11- 14 Facial profile post treatment (10 months post orthodontic treatment)

Fig. 11-15 Intra-oral pictures post treatment (1 year and 1 month post orthodontic treatment)

4. Treatment Results
Though the crowding was severe, the molar area was al igned through the
extraction of the 3rd mola rs. The space needed for the alignmen t of teeth and
d istal movement was acquired. Duri ng the final stage of the treatment , the use
of J-hook headgear and splicing on the adjacent surface was done. The l abial
tipping in the anterior teeth was improved and a fine occlusion was attained (fig
1 ] -13, 11-15). In the superi m posed t raci ngs of the pre and post treat ment
cephalometric radiogram, the improvement of tbe anterior teeth overlap due to
the labial tipping of the upper an terior teeth was evident. There was an apparent
d i stal movement of the molars and no remarkable skeletal changes were
observed (fig l l -4c).
128 11. Treatment of Crowding

In the treatm en t of a patient suffering from crowd i n g, open bi te in the

an terior area may arise in the middle of the treatment process especially during
the tooth alignment period. This shou ld be considered as an essential open bi te
i n the treatm en t of thi s condition. This explains the camouflage effect due to
the vertical factor i n crowding. Therefore, alignment of the molars as well as
the tooth level ing conseq uen tly ind uce open bi te i n th e anteri or teeth. It i
s impo1tant that the pati ent is well infonned about thi s fact before treatment
begins. This symptom of open bite is improved th rough the alteration of
occlusal plane i n th e upper and lower dentition. So even if th i s condition ari ses
i n the midd le of the treatme nt, this i s not consi dered a pro blem at al l.