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This clinical case reports the treatment of an Angle Class II malocclusion in a young woman with a balanced face
affected by agenesis of second and third mandibular molars and subsequent extrusion of second maxillary molars.
The atypical and peculiar occlusal anomaly led to individualized treatment proposed in order to normalize dental
malpositions, with subsequent rehabilitation of edentulous areas by means of a multidisciplinary approach. This case
was presented to the Brazilian Board of Orthodontics and Dentofacial Orthopedics (BBO) in partial fulfillment of the
requirements for obtaining the title of certified by the BBO.
Keywords: Angle Class II malocclusion. Partial anodontia. Corrective Orthodontics. Dental implant.
INTRODUCTION DIAGNOSIS
A female patient presented for initial examination She had a rather well-balanced mesofacial pat-
at the age of 14 years and three months and was found tern without any serious neuromuscular function-
to be in good general health. No significant informa- al changes, as well as a slightly convex profile and
tion was found in her past medical and dental records. slightly protrusive maxillary and mandibular lips
She did not have, nor did she report having, any del- (UL-S line = 3mm LL-S line = 2 mm). This feature
eterious oral habits. As chief complaint she reported seemed fully compatible with the patient’s age group
that some mandibular teeth were missing, which re- (Fig 1 and Table 1).
sulted in the presence of spaces, rotations and diffi- Dental analysis (Figs 1 and 2) disclosed Angle Class II
culty chewing in the posterior region. She had little malocclusion, subdivision right, aggravated by the ab-
growth potential, as she reported that her menarche sence of second and third mandibular molars, distal mi-
had occurred when she was about 12 years old. While gration of mandibular posterior teeth, and extrusion of
in many subjects the hereditary component is in- second maxillary molars. In addition to the aforemen-
volved in determining partial anodontia, this aspect tioned teeth, tooth #18 was also missing. She presented
was not investigated in this case. asymmetry of maxillary canines in the anteroposterior
» The author reports no commercial, proprietary or financial interest in the prod- How to cite this article: Tavares RR. Angle Class II, subdivision, with
ucts or companies described in this article. agenesis of mandibular second molars and extrusion of maxillary second mo-
lars. Dental Press J Orthod. 2015 Mar-Apr;20(2):110-8. DOI: http://dx.doi.
Submitted: February 9, 2015 - Revised and accepted: February 27, 2015. org/10.1590/2176-9451.20.2.110-118.bbo
© 2015 Dental Press Journal of Orthodontics 110 Dental Press J Orthod. 2015 Mar-Apr;20(2):110-8
Tavares RR BBO case report
direction and no coincidence between maxillary and only tooth #28 was going through early stages of forma-
mandibular midlines and the midsagittal plane. The max- tion, about Nolla stage 4, with all other teeth missing.
illary midline was shifted to the left while the mandibu- Profile cephalometric radiograph and cephalometric
lar one was shifted to the right.1,2 She had an increased tracing (Fig 4) revealed good maxillomandibular rela-
overbite with sharp incisal disocclusion and well-adjusted tionship in the vertical (SN-GoGn = 31o; FMA = 26o),
anterior centric stop. In the mandibular dental arch, there and anteroposterior direction, with Class I skeletal pat-
was generalized diastema, pronounced in the region be- tern (SNA = 78o; SNB = 76o; ANB = 2o). Maxillary and
tween canines and first premolars. mandibular incisors were slightly upright (1.NA = 17o;
Panoramic radiograph (Fig 3) revealed good root 1.NB = 20o), thereby increasing the interincisal angle
formation of all teeth, in addition to absence of teeth (1/1 = 145o). These and other cephalometric values are
#37 and 47. As regards third molars, it was observed that shown in Table 1.
© 2015 Dental Press Journal of Orthodontics 111 Dental Press J Orthod. 2015 Mar-Apr;20(2):110-8
BBO case report Angle Class II, subdivision, with agenesis of mandibular second molars and extrusion of maxillary second molars
© 2015 Dental Press Journal of Orthodontics 112 Dental Press J Orthod. 2015 Mar-Apr;20(2):110-8
Tavares RR BBO case report
A B
Figure 4 - Initial profile cephalometric radiograph (A) and cephalometric tracing (B).
© 2015 Dental Press Journal of Orthodontics 113 Dental Press J Orthod. 2015 Mar-Apr;20(2):110-8
BBO case report Angle Class II, subdivision, with agenesis of mandibular second molars and extrusion of maxillary second molars
of a Hawley retainer in the anterior region, Adams first molars, premolars and canines distally; more
clasps on the first molars and bilateral screws to dis- so on the right side, to ensure symmetry between
talize teeth #17 and 27 (Fig 5). These teeth were kept homologous teeth. A 0.016 x 0.022-in TMA arch-
encapsulated in the acrylic to prevent further extru- wire with T loops was used to intrude and level the
sion during distalization. The appliance also featured second molars.
a hook on the right side for Class II elastics. The pa- Then, 0.016 x 0,016-in and 0.016 x 0,022-in Elgil-
tient was instructed to wear the appliance full time, oy archwires were used for both maxillary and man-
removing it only to eat, engage in extreme sports and dibular arches, while intrusive steps4 were incorporat-
learn foreign languages. The recommended activa- ed to second molars (Fig 6). At this treatment stage,
tion was ¼ of a turn, in each screw, every five days. Class II elastics were used bilaterally to finish the
To ensure better vertical control, the maxillary sec- relationship between molars and canines in an ideal
ond molars were replenished with self-curing acrylic occlusion. After obtaining the interocclusal space
resin every six weeks. needed for rehabilitation with dental implants osseo-
Orthodontic bands were placed on the mandibular integrated in the region of mandibular second molars,
first molars, and Roth prescription brackets with the appliance was kept passive. It is noteworthy that
0.018 x 0.030-in slots were bonded to all other teeth. implant surgery was delayed by about six months in
Alignment and leveling were then achieved using up order to make it coincide, as much as possible, with
to 0.016-in round stainless steel archwires. Class II the end of patient’s growth. After the osseointegra-
elastics were thereafter introduced to be worn on the tion period, the prosthetic phase was performed con-
right side, anchored on the removable appliance. currently with the removal of the fixed orthodontic
After creating spaces between first and second appliance.
molars, maxillary fixed orthodontic appliance (Roth A removable plate with a Hawley retainer was
prescription, 0.018 x 0.030-in slot) was bonded after used for retention in the maxillary arch in the ante-
alignment and leveling, using the same sequence of rior region, and a fixed intercanine retainer made of
round stainless steel archwires. All teeth received a round 0.028-in stainless steel wire was used in the
mesial stop after distalization to progressively move mandibular arch.
© 2015 Dental Press Journal of Orthodontics 114 Dental Press J Orthod. 2015 Mar-Apr;20(2):110-8
Tavares RR BBO case report
© 2015 Dental Press Journal of Orthodontics 115 Dental Press J Orthod. 2015 Mar-Apr;20(2):110-8
BBO case report Angle Class II, subdivision, with agenesis of mandibular second molars and extrusion of maxillary second molars
© 2015 Dental Press Journal of Orthodontics 116 Dental Press J Orthod. 2015 Mar-Apr;20(2):110-8
Tavares RR BBO case report
A B
Figure 10 - Final profile cephalometric radiograph (A), and final cephalometric tracing (B).
A B
Figure 11 - Total (A) and partial (B) superimpositions of initial (black) and final (red) cephalometric tracings.
© 2015 Dental Press Journal of Orthodontics 117 Dental Press J Orthod. 2015 Mar-Apr;20(2):110-8
BBO case report Angle Class II, subdivision, with agenesis of mandibular second molars and extrusion of maxillary second molars
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© 2015 Dental Press Journal of Orthodontics 118 Dental Press J Orthod. 2015 Mar-Apr;20(2):110-8
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