The current concept for effective and efficient treatment of skeletal Class II malocclusion prescribes that interceptive approach should be delivered during the pubertal growth stage. However, psychosocial issues and a greater risk of dental trauma are also factors that should be addressed when considering early Class II therapy. This paper reports a case of a patient that sought orthodontic treatment due to aesthetic discomfort with the incisors’ protrusion. Two previous treatments failed because patient’s collaboration with removable appliances was inadequate. Given his history of no collaboration and because the patient was in the prepubertal stage, it was decided to try a different approach in the third attempt of treatment. Traumatic injury protective devices were used during the prepubertal stage and followed by Herbst appliance and fixed multibrackets therapy during the pubertal stage, resulting in an adequate outcome and long-term stability.
Class II malocclusion is highly prevalent worldwide [
This paper describes the comprehensive orthodontic treatment of a child with a severe Class II malocclusion associated with mandibular deficiency. The patient’s parents reported a lack of collaboration in previous orthodontic treatment. The current concepts for efficiency and effectiveness on Class II treatment were followed and a discussion on the importance of Class II treatment timing in the search of excellence is also offered.
The 10-year-old boy was referred to orthodontic treatment by his pediatric dentist. The chief complaint was “the frontal teeth are too much advanced.” The patient had a marked convex and unaesthetic facial profile due to the severe mandibular deficiency. He also had a great exposure of maxillary incisors, the absence of passive lip seal, and an increased lower anterior facial height (Figure
Pretreatment extraoral and intraoral photographs.
During the first consultation interview, it was reported that the patient was mouth breathing, lip trapping, and tongue thrusting. Previously two treatments with interceptive orthodontic appliances (Balters Bionator and Headgear) had been performed unsuccessfully. However, the treatments’ failure in achieving an adequate outcome was associated with the lack of patient collaboration in the use of the prescribed devices.
Intraoral examination showed late mixed dentition, a complete Class II division 1 malocclusion, 15 mm of overjet, deep overbite (100%), and no dental crowding. The lower incisors impinged on the palate mucosa during occlusion (Figure
The lateral cephalometric radiograph showed a skeletal mandibular Class II relationship (SNA, 77.6°; SNB, 67.5°; ANB, 10.1°) and vertical growth pattern (SNGoGn°, 40.1°). The incisors were proclined (1.NA, 27°; 1.NB, 33°; IMPA, 101.4°). Based on the cervical vertebrae maturation method (CVM) (stage CS1) and on the hand-wrist radiographic method (HWR) (absence of sesamoid bone), the patient was prepubertal (Figure
Pretreatment lateral cephalometric radiography; cephalogram; and hand-wrist radiography.
At this point, the orthodontic treatment could be carried out using a headgear or several types of functional appliances (Bionator, Twin Block, Bimler, and Frankel, e.g.). However, due to the reported lack of collaboration, an alternative treatment plan using a fixed orthopedic jumping device (Herbst appliance, HA) was presented to patient and parents.
In order to achieve greater efficiency and effectiveness the treatment was postponed to the patient’s pubertal stage of maturation. While waiting for the patient’s pubertal growth spurt, traumatic injury protection devices were implemented, as a 0.40′′ plastic retainer during sports activities and a lip-bumper to avoid lower “lip trap.” When the patient reached 11 years and 4 months (CS3 stage of skeletal maturation), the HA was installed (Figure
Herbst appliance immediately after insertion.
Telescopic Herbst appliance design. Hyrax expander and a heavy wire lingual arch add stability and increase the dental anchorage. Please note that this image is not from the reported case.
The simultaneous occurrence of excessive overjet, severe skeletal discrepancy, and the ongoing pubertal growth maturation was the determining factor on the decision for choosing two phases of sagittal activation. Each one comprised of 8 months of HA. The HA was removed for 4 months between the two active activations to allow the patient a treatment break. The cephalometric superimposition displayed significant mandibular growth during HA therapy. By this time, the patient was finishing his pubertal stage (CS4) (Figure
Lateral cephalometric radiography at the end of Herbst appliance phase, and superimposition tracings between pretreatment and the end of Herbst appliance phase.
Posttreatment extraoral and intraoral photographs.
Lateral cephalometric radiography at the end of treatment, and superimposition tracings between the end of the Herbst appliance phase and fixed appliance phase.
From aesthetical and myofunctional perspectives, the treatment achieved good results, improving the initial profile, decreasing the incisors exposure during rest, and reaching a passive lip seal (Figure
After braces removal, the patient was instructed to a night use of removable plastics retainers. Five years after debonding, great stability and no relapses were observed. The patient reported no use of the removable retainers since brackets were removed (Figures
5-year postretention photographs.
Lateral cephalometric radiography at 5 years after retention, and superimposition tracings between the end of fixed appliance phase and 5 years after retention.
Current evidence-based guideline on the treatment timing of Class II malocclusion defines that skeletal maturation, psychosocial aspects, and the risk of traumatic injuries must be considered [
The treatments of malocclusions that rely on the patient’s collaboration are less likely to achieve good results. Several aspects are associated with the patient’s compliance, as the age and gender of the patient [
We believe that the successful outcome of the presented case report might be associated with three aspects: (1) an orthopedic therapy performed during the pubertal period; (2) the end of the treatment that occurred after the completion of the pubertal maturation; and (3) the use of fixed appliances, excluding the patient collaboration.
Several evaluative methods have been proposed to assess the biological age [
The literature has showed that Class II malocclusion subjects present the mandibular growth pattern similar to Class I peers during the prepubertal and the postpubertal periods. However, during the pubertal growth stage, Class II adolescents have a significant smaller mandibular length (Co-Gn) gain than Class I subjects [
Patient’s complaint from the tremendous discomfort immediately after HA installation is very common. But a natural adjustment will follow, and an increase in the treatment adherence after the first week is expected. In the present case, as the patient’s self-esteem greatly improved after the appliance installation, it may have contributed to the collaboration to therapy. There was no breakage of the device or emergency visits during treatment, which are one of the complicating factors in this type of treatment [
A comprehensive treatment plan, not only including the concepts of effectiveness and efficiency, but also considering the psychosocial and traumatic injury risks, should be addressed when a skeletal Class II malocclusion is diagnosed. HA therapy is an alternative way when the expected patient collaboration is low.
The authors declare that there is no conflict of interests regarding the publication of this paper.
The authors deeply appreciate the collaborative efforts of Mr. Gabriel S. Richardson in the language editing of the paper. The authors also like to thank the stipends provided by the Pontifical Catholic University of Minas Gerais (Grant no. 2014/8545-S1) supporting the scientific development of the undergraduate students involved in the present project.