An Innovative Treatment Approach with Atypical Orthodontic Extraction Pattern in Bimaxillary Protrusion Case

JIOS
The Journal of Indian Orthodontic Society, January-March 2013;47(1):39-43 39
An Innovative Treatment Approach with
Atypical Orthodontic Extraction Pattern in
Bimaxillary Protrusion Case
1
Anil Miglani,
2
Reena R Kumar,
3
Ashish Chopra,
4
Sangeeta Sunda
CASE REPORT
Received on: 16/2/12
Accepted after Revision: 24/7/12
ABSTRACT
This case report describes the treatment of a 23-year-old female with severe bimaxillary dentoalveolar protrusion and missing left mandibular first
molar. Her chief concern was significant facial convexity. Generally treatment plan of such cases involves extraction of first premolars but
absence of first molar complicates situation with problem of space management, anchorage requirement and post-treatment occlusion. This
case report introduces thought provoking treatment approach of selecting atypical teeth for orthodontic extraction without compromising the
quality of treatment outcomes. However, three first bicuspids were extracted while the mandibular left second premolar was distalized into the
missing molar space and used as an abutment for replacement of the missing first molar by prosthesis. Despite the unusual asymmetric
extraction of teeth, superimposition of the pretreatment and post-treatment cephalometric tracings shows excellent treatment outcomes and
reduction of facial convexity by maximum retraction of the anterior teeth.
Keywords: Atypical orthodontic extraction, Missing mandibular molar, Bimaxillary dentoalvelar protrusion.
How to cite this article: Miglani A, Kumar RR, Chopra A, Sunda S. An Innovative Treatment Approach with Atypical Orthodontic Extraction
Pattern in Bimaxillary Protrusion Case. J Ind Orthod Soc 2013;47(1):39-43.
1,2
Professor,
3
Reader,
4
Postgraduate Student
1-4
Department of Orthodontics, DJ College of Dental Sciences, Ghaziabad
Uttar Pradesh, India
Corresponding Author: Anil Miglani, Professor, Department of
Orthodontics, DJ College of Dental Sciences, Modi Nagar, Ghaziabad
Uttar Pradesh, India, e-mail: anilmiglani@yahoo.com
INTRODUCTION
Bimaxillary dentoalveolar protrusion is a condition
characterized by proclined upper and lower incisors with
increased procumbency of the lips.
1
Hence, the goals of
orthodontic treatment include the retraction of both maxillary
and mandibular incisors to decrease soft tissue procumbency
and facial convexity.
2
The common treatment approach would
involve extraction of first four premolars with maximum
anchorage mechanics.
3
The treatment plan becomes
complicated when the patients present with extracted first
molar and even more complex when third molars are
congenitally missing or unfavorably positioned.
This case report describes the innovative treatment
approach for the patient with bimaxillary dentoalveolar
protrusion with missing mandibular first molar.
CASE REPORT
Diagnosis
A 23-year-old female patient presented with the chief complaint
of forward placement of upper front teeth. The patient
exhibited a convex profile with marked protrusion of lips (Figs
1A to D). Intraorally, she had a Class I canine and molar
relationship with minor crowding (Figs 1E to I). The
panoramic radiograph confirmed the history of prior
extraction of mandibular left first molar and revealed the
absence of mandibular left third molar and a need for
endodontic treatment of second molar on the same side (Fig.
1J). The lateral cephalogram showed a Class I skeletal pattern
with hypo-divergent jaw bases as evidenced by the ANB angle
of 30 and FMA of 14. The IMPA was 121 and L1 to NB
values of 38 and 8.5 mm and U1 to NA 38 and 8 mm
confirmed the proclination of the upper and lower incisors
(Fig. 1K). There were no significant signs or symptoms of
temporomandibular disorders.
Treatment Objectives
Treatment objectives included the following: (1) Level and
align the teeth in upper and lower arch, (2) achieve ideal overjet
and overbite relationships, (3) obtain a pleasing facial profile
and (4) replace the mandibular left first molar.
Treatment Alternatives
The first alternative was extraction of the four first premolars
and retraction of the maxillary and mandibular anterior teeth
by using maximum anchorage. However, this would require
the replacement of the molar by either an implant or a 3 unit
conventional bridge. This adjunctive expenditure would be an
additional burden to the patient.
The second alternative was extraction of mandibular first
molar on the right side to create symmetric spaces and
thereafter protract second molar using microimpalnt to end
10.5005/jp-journals-10021-1127
Anil Miglani et al
40
JAYPEE
Figs 1A to I: (A) Pretreatment profile at rest, (B) pretreatment frontal at rest, (C) pretreatment frontal dynamic smile, (D) pretreatment oblique on
smile, (E) pretreatment right buccal dental photograph, (F) pretreatment frontal centered dental photograph, (G) pretreatment left buccal dental
photograph, (H) pretreatment maxillary occlusal dental photograph, (I) pretreatment mandibular occlusal dental photograph
Fig. 1J: Pretreatment lateral cephalogram
Fig. 1K: Pretreatment OPG
in Class II molar relationship. Due to the absence of
mandibular third molars this would have resulted in a small
occlusal table with only one molar in the mandibular arch.
Moreover, there will be no antagonist to the upper second
molar.
The third alternative was extraction of first premolars
except in the mandibular left quadrant. It was planned that in
mandibular left quadrant missing molar space would be utilized
for anterior retraction and as well for partial distalization of
the mandibular left second premolar. The second premolar
along with endodontically treated second molar could then
serve as abutment for a joint first and second molar prosthesis.
This would not only prevent extraction of a healthy premolar
but would also negate the need of three unit bridge.
Benefits and disadvantages of each were explained to the
patient and the patient choose the third treatment option.
An Innovative Treatment Approach with Atypical Orthodontic Extraction Pattern in Bimaxillary Protrusion Case
JIOS
The Journal of Indian Orthodontic Society, January-March 2013;47(1):39-43 41
Figs 2A to E: (A) Midtreatment right buccal dental photograph, (B) midtreatment frontal centered dental photograph, (C) midtreatment left buccal
dental photograph, (D) midtreatment maxillary occlusal dental photograph, (E) midtreatment mandibular occlusal dental photograph
Treatment Progress
The treatment plan involved sliding mechanics in the both
arches and banding of second molar for anchorage control
after the extraction of the maxillary first premolars and the
mandibular right first premolar.
After the extractions, fixed preadjusted appliance with
MBT Prescription (0.022 0.028-inch slot) was placed. After
due leveling and aligning, 0.017 0.025-inch S-S archwire
with crimpable hooks distal to lateral incisors was placed in
3 quardants except the mandibular left quadrant where the
crimpable hook was placed distal to canine, and the anterior
teeth were retracted simultaneously. After space closure, it
was observed that mandibular dental midline was shifted toward
the right. To achieve correction of the same 0.019 0.025
inch S-S wire was placed in upper arch and 0.018 inch S-S
wire in the lower arch along with double strength Class II
elastic on right side and single strength on left side. After
en masse movement, directional force control was used to
retract mandibular second premolar to move in place of first
molar (Figs 2A to E). After distal movement 2 mm of space
was present mesial and distal to second premolar for prosthetic
replacement. The treatment was completed with ideal
archwires and cusp seating elastics. Lingual bonded retainer
was placed in the mandibular arch and Hawleys retainer was
delivered for maxillary arch. The total treatment time was 18
months. After orthodontic treatment prosthodontic
rehabilitation was done for replacement of first and second
molar.
Treatment Results
The patients facial profile had significantly improved, and the
dental occlusion was maintained with symmetric Class I molar
and canine relationship on both sides with optimal overjet and
overbite (Figs 3A to K). Superimposition of pre- and post-
treatment cephalometric tracings (Fig. 4) confirmed the
maximum retraction of the anterior teeth by controlled tipping
with no positional change of the maxillary molars in any
direction (Table 1).
Fig. 2F: Midtreatment lateral cephalogram Fig. 2G: Midtreatment OPG
Anil Miglani et al
42
JAYPEE
Figs 3A to I: (A) Post-treatment profile at rest, (B) post-treatment frontal at rest, (C) post-treatment frontal dynamic smile, (D) post-treatment oblique
on smile, (E) post-treatment right buccal dental photograph, (F) post-treatment frontal centered dental photograph, (G) post-treatment left buccal
dental photograph, (H) post-treatment maxillary occlusal dental photograph, (I) post-treatment mandibular occlusal dental photograph
Fig. 3J: Post-treatment lateral cephalogram Fig. 3K: Post-treatment OPG
Table 1: Pre- and post-treatment cephalometric data
SNA SNB ANB FMA U1 to NA U1 to NA L1 to NB L1 to NB S-line
(angle) (linear) (angle) (linear) to U/L lip
Pretreatment 81 78 3 14 38 8 mm 38 8.5 mm 1/4 mm
Post-treatment 80 77 3 15 24 5 mm 29 4 mm 0/2 mm
DISCUSSION
Bimaxillary dentoalveolar protrusion cases with missing molar
are a challenge for the orthodontist. Conventional treatment
plan involves extraction of premolars to achieve facial changes,
but absence of molar in any quadrant creates a dilemma for
the orthodontist, i.e. whether to extract the premolar of same
An Innovative Treatment Approach with Atypical Orthodontic Extraction Pattern in Bimaxillary Protrusion Case
JIOS
The Journal of Indian Orthodontic Society, January-March 2013;47(1):39-43 43
quadrant or to utilize the available space of the extracted molar.
This case report introduces an innovative solution to the above
problem by utilizing the extracted molar space for retraction
and also using second premolar as an abutment for molar
prosthesis to finish the case in Class I molar relation on both
sides.
Though there was high anchorage demand, microimplants
were not used for retraction as the patient had severe horizontal
growth pattern so there were minimal chances of anchorage
loss and secondly second molar were used as anchorage.
4
In the maxillary arch en masse retraction was done using
sliding mechanics on both sides. In the mandibular arch also
sliding mechanics were used but the presence of space at
asymmetric location created concerns which were resolved
with changes in mechanics. The left mandibular segment
required retraction of 5 units (from central incisor to second
premolar) this shifted the center of resistance of these teeth
distally in between canine and first premolar. Hence, the
crimpable hook for retraction was placed distal to canine on
left side. The mandibular midline was shifted toward right side
during treatment, this could have happened because we had
used same levels of force on both sides with different number
of units to be retracted, i.e. 3 units on right side as compared
to 5 units on left side. According to Chung et al this could
have been prevented by using different force levels on right
and left sides.
5
However, in present case midline was later
matched using asymmetric Class II elasticsdouble on right
side and single on left side.
After en masse retraction of lower anterior segment
mandibular second premolar was distalized to bring it in the
center of first molar space so that it can be used as abutment
for first molar prosthesis. Postdistalization premolar was
maintained in upright position to allow occlusal forces to pass
along the long axis. Dieddrich et al
6
studied the distal
movement of premolar to serve as posterior abutment for
missing molar on 24 patients (32 premolars) for a period of
Fig. 4: Superimposition of cephalometric tracings pretreatment
(black) and post-treatment (red)
average 9.6 years. All 32 distalized premolars were functioning
efficiently as bridge abutment and showed minimal mobility
of 0.2. They also revealed that all teeth remained vital with
low measured probing depth and sulcus bleeding indices. They
concluded that premolar as a posterior bridge abutment is
prognostically favorable alternative to an implant.
Mandibular left second molar was endodontically treated
and required crown for rehabilitation. In order to distribute
the functional load and to follow Antes law it was decided to
make a joint unit for mandibular left first and second molar.
As per Antes law for prosthetic rehabilitation, the
abutment teeth should have a combined pericemental area equal
to or greater in pericemental area than the tooth or teeth to be
replaced. A ratio of abutment to pontic of 1:1 or greater would
satisfy Antes law. The average pericemental area of second
bicuspid is 207 26.6 mm
2
, for first molar is 431 59.5
mm
2
and for second molar is 426 69.7 mm
2
.
7
In the present
case premolar and second molar (with average pericemental
area of 207 mm
2
and 426 mm
2
respectively with a total of
633 mm
2
) were used as abutment for a first molar pontic
(431 mm
2
), the above makes abutment to pontic ratio of
approximately 1.46:1. Instead of a joint unit the other
alternative was to place two separate units for first and second
molar but that would not had sufficed Antes law, because that
makes the abutment to pontic ratio of 0.48:1.
Even if the second molar is vital it would be prudent to
include the second molar in prosthesis to match the Antes law
ratio.
At the end of treatment, good facial esthetics and Class I
molar and canine relation was achieved on both sides.
CONCLUSION
This innovative approach conserved a healthy tooth by avoiding
the extraction of the sound bicuspid and an additional
prosthetic replacement was prevented.
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