THE PHILIPPINE JOURNAL OF ORTHODONTICS

A PBO Phase III Case Report

Treatment of Class I Bimaxillary Protrusion

Ernesto Jose G. de Leon, DMD
Dr. Ernesto Jose G. de Leon graduated from the Centro Escolar University in 1985 and underwent the orthodontic preceptorship
under the late Dr. Luz C. Macapanpan in 1994 - 1995. He took up the MEAW Course given by the MEAW Study Club of the
Philippines from August to November 2003. He sucessfully participated in the PBO Phase III Case Presentation 2004
Examination of which the following was one of the cares presented.

A case report is presented of an Angle Class I bimaxillary protrusion with high mandibular
plane angle which was treated with four 1st bicuspids extraction and Straightwire Archwire
Mini-Wick Appliance.

Figure 1. Patient R.Y. : Pretreatment extraoral and intraoral photographs.

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Case Report Figure 2. Pre-treatment cephalogram

Patient R.Y. is a female 10 years 10 months of age.
The patient has characteristic Chinese features and
presents with a Class I, bimaxillary protrusion malocclu-
sion with protruded lips and convex profile. Mild lower
crowding is present with a moderate overbite of 4mm and
an overjet of 5.5mm. The curve of Spee is moderate as
well. Being young, a good amount of growth is expected of
this patient. It was noted that mild facial asymmetry is
present with the chin shifted to her left. (Figure 1)
Cephalometric analysis revealed a Class I skeletal re-
lationship with an ANB of 2.5 degrees and AO-BO of -.5mm.
Vertical height appears normal. (Figure 2) The maxillary Table 1 Patient R.Y. female, 10:10
and mandibular incisors are labially flared and positioned
more labial in their denture bases. The upper incisors shows Mean X Pre TX
more procumbency (U1-NA= 11.5mm and 36.5 degrees) than BA-S-N 130 deg. 136
the lower. (Table 1) SNA 84.5 deg. 76
NA-FH 90 deg. 88.5
History and Etiology: SNB 82 deg. 73.5
In this case, it is the mother who complained of her ANB 2.5 deg. 2.5
daughter’s teeth and lips of being too protruded. AO-BO -1 to 1 mm -.5
SN-MP 31.3 deg. 36.5
Treatment Plan: FMA 28.7 deg. 24.5
1. Extraction of all upper and lower 1st premolars. The UI-Apog 8.6 mm 13
first bicuspids were extracted rather than the second UI-NA 6.4 mm 11.5
because of the apparent protrusiveness of both UI-NA 24.7 deg. 36.5
upper and lower incisors. The convex profile was LI-NB 7.5 mm 9
also a major concern, particularly to the mother. LI-NB 29.8 deg. 29
2. Full upper and lower orthodontic treatment with UI-LI 122.8 deg. 112.5
.018 Mini-Wick Appliance, Alexander prescription.
LIip-Eline -2 mm +5
3. Debond/deband before retaining with upper
Hawley and lower fixed retainers. The Specific Objectives of Treatment (A-P, Transverse,
Vertical)
Maxilla:
Reduce A-P length with moderate level of
anchorage

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Maintain transverse relationship II elastics (1/4 in X 6 oz.) were started to help obtain
Minimize opening of the bite by controlling molar improved interdigitation and Class I relations.
extrusion 6. Final archwire of .017 X .025 & .016 X .022 SS
Mandible: were placed on the upper and lower arches
Reduce A-P length with moderate level of respectively.
anchorage 7. All brackets and bands were removed after 28
Maintain transverse relationship months of active treatment on October 19, 2001.
Maintain vertical relation by controlling molar 8. Retainers were delivered one week after debonding
extrusion to avoid clockwise mandibular rotation procedure.
Maxillary Dentition:
Retract and upright anterior teeth Results Achieved (A-P, Transverse, Vertical) Figure 3,4
Level and align Maxilla:
Mandibular Dentition: The A-P length was reduced
Retract anterior teeth and maintain axial inclination Transverse dimensions were controlled and
Level and align maintained.
Occlusion: Vertical relation has been maintained as well.
Achieve proper overbite and overjet Mandible:
Maintain Class I cuspid and molar relationships The A-P length was reduced
Obtain canine and incisal guidances Transverse dimensions were maintained.
Maintain dental midlines Clockwise rotation of the mandible was avoided
Facial Esthetics: by careful control of molar extrusion.
Improve facial balance Maxillary Dentition:
Improve smile esthetics The anteriors were all retracted and brought to a
more upright position.
Treatment Progress / Mechanotherapy: All teeth were leveled and aligned.
1. All four 1st premolars were extracted. (Figure 5a) Mandibular Dentition:
2. All molars were banded 2 weeks after extraction The lower incisor were retracted and their axial
procedure. Upper and lower .018 Mini-Wick inclinations were maintained
brackets were installed. Initial alignment was All teeth were leveled and aligned
carried out with .016 NiTi June 04, 1999. Occlusion:
3. Upper canines were distalized through sliding Proper overbite and overjet were obtained
mechanics using elastomeric chain on .016 SS wire. Class I cuspid and molar relations were achieved
4. Lower incisors were retracted en masse with .016 Incisal and canine guidances were established
X .022 Vari-Simplex SS Closing Loop archwire. Dental midlines were maintained
5. After space closure, arches were releveled with Facial Esthetics:
plain .016 X .022 preformed VSD archwire. Class Facial balance is very much improved.

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Patient’s profile and smile demonstrates Figure 4. Post treatment Cephalometric

tremendous improvement. (Figure 3)

Retention:
Upper and lower retainers were delivered one week
after debonding. Full-time wear was advised for 12
months and then nighttime for another 6 months.
Evaluation of third molar removal recommended to
be done one year after retention.

Figure 3. Post retention facial and intra-oral photograph

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Table 2. Patient R.Y. Female, 13:11 Final Evaluation of Treatment:

Downward and forward growth is clearly demonstrable
Mean X Post - tx in this patient. There was lengthening of the ramus due to
BA-S-N 130 deg. 136 condylar growth. The symphysis has grown down as well.
SNA 84.5 deg. 75 Composite tracing shows that the anteriors were truly retracted
NA-FH 90 deg. 87 successfully to provide soft tissue relief and establish facial
SNB 82 deg. 74 balance and harmony (Fig. 6).
ANB 2.5 deg. 1.0 Good timing and proper monitoring of this case led
AO-BO -1 to 1 mm -4.5 to successful orthodontic treatment. Comparing the post-
SN-MP 31.3 deg. 36 treatment results with the pre-treatment records reveals that
FMA 28.7 deg. 22.5 the treatment objectives set in this case were achieved. The
UI-Apog 8.6 mm 9 canines and molars were maintained in Class I. Occlusion
UI-NA 6.4 mm 9.5 obtained is stable as can been from the post-retention records
UI-NA 24.7 deg. 31.5 (Fig. 3).
LI-NB 7.5 mm 5 With orthodontic treatment, all anterior teeth were
LI-NB 29.8 deg. 30 retracted and brought to a more favorable relationship with
UI-LI 122.8 deg. 120 each other (U1-L1=112.5 deg to 122.5 deg). Upper inci-
LIip-Eline -2 mm +2 sors are more upright now (U1-NA=36.5 deg to 29 deg)
while the inclinations of the lower incisors were maintained
(Table 3).

Figure 5a. Pre-treatment panoramic radiograph Figure 5b. Post-treatment panoramic radiograph

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The patient’s smile has been greatly improved and All third molars are to be monitored every six months
patient’s profile showed big improvement by providing har- until resolved (Figure 5b).
mony as a result of treatment (Fig 3). The lower lips appear Mother and patient are very pleased with the results.
to show big improvement as well, from Llip – Eline of +5mm Prognosis for this case to be stable is excellent. Fixed re-
to 2mm and finally to 0mm (Table 3). tainer was removed when patient came back 3 months later.

Table 3. Cephalometric Summary

Area of Study 1-yr.

Measurement Standard Pre-tx Progress Post-tx Post-Tx
Age Age Age
10:10 13:11 15:4
Cranial Base BA-S-N 130 deg. 136 136 137
Maxilla to SNA 84.5 deg. 76 75 74
Cranial Base NA-FH 90 deg. 88.5 87 88.5
Mandible to SNB 82 deg. 73.5 74 72.5
Cranial Base
Maxillo- ANB 2.5 deg. 2.5 1.0 1.5
Mandibular Relations AO-BO -1 to 1 mm -.5 -4.5 -4.5
Vertical SN-MP 31.3 deg. 36.5 36 38.5
Height FMA 28.7 deg. 24.5 22.5 23.5
Maxillary UI-Apog 8.6 mm 13 9 8
And UI-NA 6.4 mm 11.5 9.5 7
Mandibular UI-NA 24.7 deg. 36.5 31.5 29
Incisor LI-NB 7.5 mm 9 5 5
Position LI-NB 29.8 deg. 29 30 28
UI-LI 122.8 deg. 112.5 120 122.5
Soft Tissue LIip-Eline -2 mm +5 +2 0

References

1. Graber TM; Vanarsdall RL, Jr: Diagnosis and Treatment

Planning in Orthodontics, Orthodontics-Current Principles
and Techniques, 1994. Mosby-Year Book, Inc.
2. Alexander RG: The Use of Elastics and Other Extra-Oral
Appliances in the Vari-Simplex Discipline, The Alexander
Discipline, 7:149-165, 1986.
Figure 6. Superimpositions of cephalometric tracings
3. Alexander RG: The Vari-Simplex Discipline - Part 3-
before and after treatment.
_________ Pre-treatment Extraction Treatment, J Clin Ortho pp. 537-547, August
______ Post-treatment 1983.