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To cite this article: Rafflenbeul F, et al.

First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion


with skeletal Class II: A case report. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.017

International Orthodontics 2019; //: ///

Websites:
www.em-consulte.com
www.sciencedirect.com

Case Report
First premolar extractions in an adolescent
presenting a Class I biprotrusion
malocclusion with skeletal Class II:
A case report§

Frédéric Rafflenbeul 1, Hadrien Bonomi-Dunoyer 2, Thibaut Siebert 3, Yves Bolender 4

Available online: 1. Assistant hospitalier-universitaire, ancien interne, université de Strasbourg,


hôpitaux universitaires de Strasbourg, faculté de chirurgie dentaire, sous-section
d'orthopédie dento-faciale, 8, rue Sainte-Elisabeth, 67000 Strasbourg, France
2. Ancien assistant hospitalier-universitaire, université de Strasbourg, hôpitaux
universitaires de Strasbourg, faculté de chirurgie dentaire, sous-section
d'orthopédie dento-faciale, 8, rue Sainte-Elisabeth, 67000 Strasbourg, France
3. Attaché des hôpitaux universitaires, université de Strasbourg, hôpitaux
universitaires de Strasbourg, faculté de chirurgie dentaire, sous-section
d'orthopédie dento-faciale, 8, rue Sainte-Elisabeth, 67000 Strasbourg, France
4. Maître de conférence des universités - praticien hospitalier, université de
Strasbourg, hôpitaux universitaires de Strasbourg, faculté de chirurgie dentaire,
sous-section d'orthopédie dento-faciale, 8, rue Sainte-Elisabeth,
67000 Strasbourg, France

Correspondence:
Frédéric Rafflenbeul, Université de Strasbourg, hôpitaux universitaires de
Strasbourg, faculté de chirurgie dentaire, sous-section d'orthopédie dento-faciale, 8,
rue Sainte-Elisabeth, 67000 Strasbourg, France.
frederic.rafflenbeul@gmail.com

Keywords Summary
Case report
Orthodontics This case report shows the orthodontic treatment of four first premolar extractions of a 14-year-old
First premolar extraction teenager presenting a dental Class I malocclusion with a severe retrognathic mandible. It reflects
Angle Class I malocclusion conflicting views on objectives between the orthodontist who takes into account the facial balance
Skeletal Class II and the patient who only desires a tooth alignment.

Mots clés Résumé


Cas clinique
Orthodontie Traitement par avulsion de premières prémolaires chez un adolescent présentant une
Extraction de première Classe I biproalvéolie avec Classe II squelettique : cas clinique
prémolaire
Ce cas clinique montre le traitement d'un patient de 14 ans présentant une malocclusion de
Malocclusion de Classe I
Classe I sur un schéma de Classe II squelettique avec rétrognathie mandibulaire marquée. Il
d'Angle
illustre la divergence entre les objectifs de l'orthodontiste de tenir compte de l'équilibre facial et
Classe II squelettique
celui du patient qui a comme seul motif de consultation son alignement dentaire.

§
This case was accepted in category 3, Class I malocclusion, by the European Board of Orthodontists (EBO) examiners 2018, as part of the application for provisional membership of the
EBO. It was also selected to be put on exhibit during the European Orthodontic Society (EOS) congress in Edinburgh.

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https://doi.org/10.1016/j.ortho.2019.08.017
© 2019 CEO. Published by Elsevier Masson SAS. All rights reserved.

ORTHO-426
To cite this article: Rafflenbeul F, et al. First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion
with skeletal Class II: A case report. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.017

F. Rafflenbeul, H. Bonomi-Dunoyer, T. Siebert, Y. Bolender


Case Report

Introduction was everted, his labiomental sulcus was normal, the mandible
This patient seeked initially treatment at the Department of was severely retruded and he lacked chin prominence. Patient
Orthodontics, Strasbourg University Hospitals, at age 14. His displayed a broad smile (figure 1) , no buccal corridors and a
chief complaints were the misaligned maxillary and mandibular consonant smile arc. Patient displayed 80% of his maxillary
incisors and canines, but he was not concerned by his facial incisors and 30% of his mandibular incisors upon smiling. Upper
esthetics. Neither his medical nor his dental past histories were and lower dental midlines were centred with the midsagittal
contributory. plane.

Functional examination
Clinical examination
The patient breathed through his nose and did not present any
Extraoral examination habit, any lingual dysfunction nor any swallowing anomaly.
The frontal examination at rest (figure 1), showed a symmetrical There were no TMJ symptoms reported and no centric relation –
and oval face, with a narrow mouth associated with thick and centric occlusion discrepancy could be identified.
competent lips. Nose and chin were aligned with the midsagittal
plane and horizontal lines were all parallel. Lower anterior facial Intraoral examination
height was decreased. Soft tissue profile was convex (figure 1). Patient had a fully erupted permanent dentition to the excep-
Maxillary projection was normal and nasolabial angle (1158) tion of 37 which was erupting and the four third molars. He
was slightly increased due to a vertical upper lip. His lower lip presented a 2-year delayed dentition (figure 1). There was no

Figure 1
Pre-treatment clinical records
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To cite this article: Rafflenbeul F, et al. First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion
with skeletal Class II: A case report. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.017

First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion with skeletal Class II:
A case report

Case Report
decay nor restoration, only slightly fissure infiltrations on 27. protrusion and a decreased interincisal angle. Overjet was
Oral hygiene was medium and the gingival biotype was thin on slightly increased and overbite was normal.
the lower incisors and canines, with Miller Class I recessions
already present on 31-41-33-43 (figure 1). Overall diagnosis
Patient presented a convex profile with an excessive lower lip
Dental casts projection and a severe retruded mandible and chin. Cephalo-
Maxillary arch (figure 2) was V-shaped and symmetrical. Maxil-
metric analysis revealed skeletal Class II jaw relationship due to
lary crowding was 3 mm and 26 was rotated mesiopalatally.
a retrognathic mandible, a normodivergent facial pattern and
Mandibular arch (figure 2) was U-shaped and symmetrical, with
upper and lower dento-alveolar protrusion. Intraoral examina-
a 4 mm crowding. Little Irregularity Index was 12.1 mm and
tion revealed a Class I malocclusion with an increased overjet,
Bolton Index (6 teeth) 78.9%, which was just slightly above
moderate arch length discrepancies in the upper and lower
normal limits (77.4%) and not clinically significant. Curve of
arches and gingival recessions on 31-33-41-43. The discrepancy
Spee depth was 1.5 mm. Inter-arch relationships showed bilat-
between the skeletal and dental relationships contributed to the
eral Class I molar and canine relationships and 4 mm overjet as
difficulty of the treatment strategy.
measured on tooth 11. The 1.5 mm overbite was normal. Upper
and lower dental midlines were centred with the midsagittal
plane and patient presented no transversal jaw discrepancy
Treatment
(figure 2). Treatment objectives
Treatment objectives were to correct the skeletal Class II and
Radiographic analysis enhance facial aesthetics, resolve maxillary and mandibular arch
The panoramic radiograph (figure 3) presented an artefact on length discrepancies (chief complaint), reduce the dento-alve-
the lower incisor and canine roots due to a downward head olar protrusion, maintain the bilateral Class I molar and canine
position which represented an out-of-plane deformation. Man- relationships, reduce the overjet, maintain the upper lip projec-
dibular condyles were symmetrical and there was no visible tion and reduce the lower lip projection, without aggravating
pathology of the maxillary sinuses, maxilla nor mandible. All the gingival recessions on 31-41-33-43.
permanent teeth were present. Tooth buds of 38 and 48 were
mesially tipped and their position were to be reassessed during Treatment alternatives
treatment. Root parallelism was good and there were no root Two treatment alternatives were presented to the patient:
 combined orthodontic and surgical treatment (bilateral sagit-
dilacerations.
The lateral skull radiograph (figure 3) showed clear upper air- tal split osteotomy for mandibular advancement  advancing
ways and sinuses. Patient's Cervical Vertebral Maturation Score genioplasty) after decompensation of the Class I dental rela-
(CVMS) was graded as stage 4. The initial cephalometric analysis tionships to create full Class II molar and canine relationships
(figure 3, table I) revealed a severe Class II sagittal jaw relation- with upper second and lower first bicuspid extraction. This
ship due to a retrognathic mandible (SNPog = 728), a normo- option would allow an enhancement of facial aesthetics by
divergent pattern, upper and severe lower dento-alveolar correcting the retrognathic mandible, but would require

Figure 2
Pre-treatment dental casts
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tome xx > 000 > xx 2019


To cite this article: Rafflenbeul F, et al. First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion
with skeletal Class II: A case report. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.017

F. Rafflenbeul, H. Bonomi-Dunoyer, T. Siebert, Y. Bolender


Case Report

Figure 3
Pre-treatment radiographic records

TABLE I
Pre-treatment cephalometric assessment

Norm / Mean Pre-treatment

Sagittal skeletal relationships S-Na-A8 828  3.58 798

S-Na-Pog8 808  3.58 728

A-Na-Pg8 28  2.58 78

Vertical skeletal relationships S-N / ANS-PNS8 88  38 118

S-Na / Go-Gn8 338  2.58 338

ANS-PNS / Go-Gn8 258  68 238

Dento-skeletal relationships I / ANS-PNS8 1108  68 1168

i / Go-Gn8 948  78 1148

i / A-Pog (mm) 22 8 mm

Dental relationships Overjet (mm) 3.5  2.5 5 mm

Overbite (mm) 2  2.5 2 mm

i / I8 1328  68 1088
4

tome xx > 000 > xx 2019


To cite this article: Rafflenbeul F, et al. First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion
with skeletal Class II: A case report. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.017

First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion with skeletal Class II:
A case report

Case Report
Figure 4
Intraoral photographs during space closure

considerable biomechanical skills and proper management of treatment. Extractions were required because the moderate
anchorage needs during decompensation; crowdings were associated with a severe dento-alveolar pro-
 orthodontic treatment with upper and lower first bicuspid trusion and the presence of gingival recessions in the lower
extraction + potential advancing genioplasty at the end of arch. Upper and lower second bicuspids could have been

Figure 5
Post-treatment clinical records
5

tome xx > 000 > xx 2019


To cite this article: Rafflenbeul F, et al. First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion
with skeletal Class II: A case report. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.017

F. Rafflenbeul, H. Bonomi-Dunoyer, T. Siebert, Y. Bolender


Case Report

Figure 6
Post-treatment dental casts

extracted instead of the first bicuspids, but dento-alveolar thus considered unnecessary and the lower anterior segment
protrusion correction would have been more limited. was levelled and aligned. The following archwire sequence was
The first treatment option was rejected by the patient and his used: .014 NiTi, .016 NiTi, .016  .016 NiTi, .016  .022 NiTi and
parents who were not motivated by his facial aesthetics. An .016  .022 Stainless Steel. Five months after the onset of
isolated advancing genioplasty at the end of treatment would treatment, 14 and 24 were extracted and space closure was
reduce the convexity of the profile, be less invasive than a started with four group A mechanics (maximum molar anchor-
surgical advancement of the mandible and would be indepen- age) .017  .025 TMA T-loops (figure 4). Posterior anchorage
dent of orthodontic treatment. It should be undertaken early to was reinforced by .032  .032 Stainless Steel transpalatal and
allow a better outcome in terms of bone remodelling [1]. The lingual arches (figure 4). A 458 pre-activation tip-back bend was
upper lip being already vertical and the maxillary crowding incorporated in the posterior legs of the T-loops , delivering
moderate, one could expect a slight upper lip retraction, but different anterior and posterior M/F ratios and thus opposing a
a recent systematic review found that extraction of four pre- posterior translationagainst an anterior controlled tipping [3,4].
molars would not be detrimental to facial attractiveness [2]. Initial activation was 6 mm, loops were then reactivated every
Finally, patient opted for the second treatment plan with first other appointment in order to obtain and maintain favourable
bicuspid extractions. M/F ratios during space closure [4].
Treatment sequences Extraction spaces were closed after five months. A lateral skull
Extraction of 34 and 44, full braces with .018'' slot brackets, radiograph was taken at that stage and incisor uprighting was
segmental levelling and alignment of both arches. deemed unnecessary. Both arches were levelled by continuous
Separate lower canine retraction with segmented mechanics. archwires (.016, .016  .016 and .016  .022 NiTi) until
Extraction of 14 and 24 after lower canine retraction, then .016  .022 Stainless Steel working archwires could be inserted
segmental en masse space closure of upper and lower anterior for finishing. Class II and triangular intermaxillary elastics were
segments. used to correct a slight maxillary anchorage loss.
Incisor uprighting phase if necessary.
Finishing and detailing with continuous archwires. Treatment results
Retention. Patient was debanded and debonded after one year and ten
months of active treatment. Six-stranded 0.215 lingual retainers
Treatment progress were bonded from 33 to 43 and from 12 to 22 for long-term
After extracting 34 and 44, both arches were levelled and retention of anterior alignment. A removable Hawley retainer
aligned by a segmental approach without initially inserting a was used in the upper arch at night-time, every day for the first
wire in the lower incisor and canine brackets to prevent detri- 6 months and then gradually discontinued.
mental roundtripping. 33 and 43 spontaneously migrated in a Our initial treatment objectives were met. Regarding facial
distal direction and contributed to the correction of the lower aesthetics (figure 5), upper lip inclination was maintained
incisor crowding. A separate lower canine retraction phase was and lower lip projection was slightly reduced. Patient kept his
6

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To cite this article: Rafflenbeul F, et al. First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion
with skeletal Class II: A case report. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.017

First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion with skeletal Class II:
A case report

Case Report
Figure 7
Post-treatment radiographic records

convex profile because of the weak sagittal mandibular growth. displayed a good parallelism and there were no visible apical
He presented a slight gummy smile at the end of treatment, root resorptions on the final panoramic radiograph (figure 7).
probably because of a broader and more spontaneous smile 38 and 48 uprighted slightly but still needed to be monitored.
compared to the initial records. Upper and lower crowdings and The final lateral radiograph (figure 7) showed adequate posi-
dento-alveolar protrusion were reduced without any increase in tioning of the incisors but the soft tissue profile revealed a
the inter-canine width or aggravation of the lower gingival mentalis muscle contraction.
recessions (figures 5 and 6). The bilateral Class I molar and The final cephalometric assessment (figure 7, table II) showed
canine relationships were maintained (figures 5 and 6). Roots that the sagittal and vertical jaw relationships were not
7

tome xx > 000 > xx 2019


To cite this article: Rafflenbeul F, et al. First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion
with skeletal Class II: A case report. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.017

F. Rafflenbeul, H. Bonomi-Dunoyer, T. Siebert, Y. Bolender


Case Report

TABLE II
Post-treatment cephalometric assessment

Norm / Mean Pre-treatment Post-treatment

Sagittal skeletal relationships S-Na-A8 828  3.58 798 778

S-Na-Pog8 808  3.58 728 708

A-Na-Pg8 28  2.58 78 78

Vertical skeletal relationships S-N / ANS-PNS8 88  38 118 158

S-Na / Go-Gn8 338  2.58 338 368

ANS-PNS / Go-Gn8 258  68 238 208

Dento-skeletal relationships I / ANS-PNS8 1108  68 1168 1128

i / Go-Gn8 948  78 1148 1058

i / A-Pog (mm) 2  2 mm 8 mm 3 mm

Dental relationships Overjet (mm) 3.5  2.5 mm 5 mm 4 mm

Overbite (mm) 2  2.5 mm 2 mm 2 mm

i / I8 1328  68 1088 1208

Figure 8
Final superimpositions
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To cite this article: Rafflenbeul F, et al. First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion
with skeletal Class II: A case report. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.017

First premolar extractions in an adolescent presenting a Class I biprotrusion malocclusion with skeletal Class II:
A case report

Case Report
significantly improved by growth neither treatment and the Regarding third molar impaction, Livas et al. [7] found limited
mandible rotated clockwise (+38 for SN/GoGn angle). Dento- evidence that orthodontic extractions can potentially benefit
alveolar protrusion, overjet and overbite were reduced and third molar development and their uprighting. Behbehani
interincisal angle was increased, even if the final value was et al. [8] found that increased retromolar space at the end of
still below the norm. The general superimposition (figure 8) treatment reduced third molar impaction. Bicuspid extraction
showed a downward- and backward growth of the maxilla and was indicated in our patient, who then presented a slight
the mandible, with an increase in lower anterior face height and uprighting of 38 and 48 and an increased retromolar space
a clockwise matrix rotation. Maxillary superimposition revealed due to a 2 mm mesial molar movement during space closure.
extrusion of molars and incisors, one third of molar anchorage Despite those small favourable changes, impaction of 38 and
loss and two thirds of incisor retraction during space closure. 48 is nonetheless likely and could finally lead to extraction of
Mandibular superimposition showed vertical growth of the con- two additional mandibular teeth. These latter should be moni-
dyle, extrusion of incisors and molars, and a space closure by tored annually during the post-retention phase.
one third molar anchorage loss and two thirds incisor retraction. Early functional genioplasty could have increased the symphysis
thickness and bone apposition at B point [1,9], and improved the
Discussion lip competency at rest without strain of the mentalis muscle
We were in favour of extracting first bicuspids instead of sec- [10]. Unfortunately, the patient did not want to undergo this
onds to maximize incisor retraction. We did not intend to procedure at the end of treatment, which in this case of den-
change the growth pattern. General superimposition showed toalveolar compensation would have improved the chin projec-
that despite the first bicuspid extractions and the lingual incisor tion and facial aesthetics.
repositioning, the mandibular rotation worsened without sag-
ittal growth. A recent study [5] and systematic review [6] also Disclosure of interest: The authors declare that they have no competing
found no statistically nor clinically significant changes in the interest.
vertical skeletal dimension with orthodontic extractions.

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