CASE REPORT

Nonsurgical treatment of an adult with a skeletal

Class II Division 1 malocclusion and a severe
overjet
Morris H. Wechsler,a Bradley Lands,b Chantal Gauthier,c and Cedric Cardonad
Montr
eal, Qu
ebec, and Toronto, Ontario, Canada, and Lyon, France

This case report describes the treatment of an adult patient who had a Class II Division 1 malocclusion with
a severe overjet (13.5 mm), a deep overbite (7 mm, 100%), and spacing between the maxillary anterior teeth.
The purpose of this report is to demonstrate the importance of developing an individualized treatment plan,
tailored to the patient’s specific dental and skeletal problems, as well as to his or her needs and desires. Although
all indications pointed to a surgical intervention for this patient, her reluctance to undergo orthognathic
surgery led to an alternative treatment, which yielded a satisfactory result. (Am J Orthod Dentofacial Orthop
2012;142:95-105)

C
lass II Division 1 malocclusions are characterized
primarily by the mandibular canines and molars
in distal relationships relative to the correspond-
ing maxillary teeth, as well as by protrusion of the
maxillary anterior teeth. Treatment planning for such
patients must take into consideration numerous factors,
including the soft-tissue profile, interlabial space, ratio
of upper to lower face height, inclination of the occlusal
plane, overbite, severity of the skeletal and dental Class II
relationships, growth potential, and posttreatment
stability.
When considering orthodontic treatment for adults
with such malocclusions, additional factors must be
taken into account. Treatment goals and outcomes
might be affected by large restorations, missing teeth,
periodontal status, loss of papillae, gingival recession,
and bone loss.1 An interdisciplinary approach, including
surgical intervention, is usually required. This case report
illustrates a severe skeletal discrepancy in an adult that
was successfully treated without orthognathic surgery.
a
Professor of orthodontics, Facult
e de M
edecine Dentaire, Universite de Mon-
tr
eal; associate professor of orthodontics, Faculty of Dentistry, McGill University,
Montr
eal, Qu
ebec, Canada.
b
Private practice, Toronto, Ontario, Canada.
c
Private practice, Montr
eal, Qu
ebec, Canada.
d
Private practice, Lyon, France.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Morris H. Wechsler, 5445 Rosedale Ave, Montr
eal, Qu
ebec,
H4V 2H7, Canada; e-mail, morris.wechsler@mcgill.ca.
Submitted, December 2010; revised and accepted, July 2011.
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2011.07.027
DIAGNOSIS AND ETIOLOGY
The patient was a white woman, 51 years of age at
the time of consultation. Her chief complaint was the
unesthetic appearance of her smile. She also mentioned
frequent irritation of her cheeks and palate, as well as
difficulty in chewing and maintaining proper oral hy-
giene, all of which she attributed to her malpositioned
teeth. She had regular checkups with her general dentist
and, in the past, had been treated by a periodontist. She
indicated some hypersensitivity of the maxillary anterior
teeth to cold. She also mentioned that she had occa-
sional episodes of snoring, as well as some pain and
clicking in the area of the right temporomandibular
joint. Aside from an allergy to nuts, she was in good
health and took no medication. The etiology of her mal-
occlusion appeared to be hereditary; she stated that her
father had a similar condition.
The patient had a symmetrical, brachyfacial face (Fig
1). The profile was convex with a retrognathic mandible.
There was an increased labiomental fold of the lower lip
because of the increased overbite and diminished lower
anterior face height. The chin-throat angle was ill-
defined. When she smiled, large buccal corridors were
visible.
The patient had a Class II Division 1 malocclusion (Fig
2). On both sides, the molars and the canines were in
Class II relationships. There were a severe, 7-mm overbite
and an overjet of 13.5 mm. Buccal crossbites existed bi-
laterally at the level of the first and second maxillary pre-
molars, as well as at the level of the maxillary right third
molar. The maxillary dental midline was deviated 1 mm
to the left, and the mandibular dental midline was
95
96
Fig 1. Pretreatment facial and intraoral photographs.
deviated 1 mm to the right. The maxillary dental arch
was tapered and constricted, especially in the first molar
area; the mandibular dental arch was also narrow, with
lingual positioning of the mandibular second premolar.
The curve of Spee was accentuated, and the maxillary
and mandibular incisors were proclined, most marked
in the maxillary central incisors. There were diastemas
between the maxillary central and lateral incisors bilater-
ally.
The patient’s periodontal status was healthy, with an
adequate band of attached gingiva and no discernible
dental mobility. Oral hygiene was adequate. Moderate
generalized bone loss was observed and confirmed by ra-
diology, indicating a past history of active periodontitis.
A periodontist confirmed the current healthy and stable
status of the periodontium.
All permanent teeth were present except for the max-
illary left third molar. Extensive restorations were pres-
ent on the maxillary and mandibular posterior teeth.
The condyles were symmetrical and appeared normal.
No pathology was noted (Fig 3).
July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Wechsler et al
The patient had a severe Class II skeletal malocclusion
with a retrognathic mandible and a hypodivergent pat-
tern (Fig 4; Table). According to the analysis of Steiner,2
the maxilla was normally related to the cranial base
(SNA, 82.5 ), whereas the mandible was severely retro-
gnathic (SNB, 72.6 ; normal, 80 ; ANB, 10 ). The McNa-
mara analysis3 indicated that the maxilla was slightly
smaller than average (87.5 mm, average 91.0 mm). The
effective length of the mandible was much shorter
than average (97 mm, average 120 mm). The maxillo-
mandibular difference was 9.8 mm (average 29.2 mm).
The mandible was shorter than average (97 mm; nor-
mal, 107 mm). The maxillomandibular difference was
7.5 mm (average, 22.4 mm). The Wits appraisal was
11.6 mm (average, 1.1 mm). The patient had a low man-
dibular plane angle (19 ). The maxillary and mandibular
incisors were proclined.
TREATMENT OBJECTIVES
The treatment objectives for this patient were to (1)
improve facial esthetics, (2) reduce the overbite and
Wechsler et al 97

Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment panoramic and periapical radiographs.

American Journal of Orthodontics and Dentofacial Orthopedics July 2012  Vol 142  Issue 1
98 Wechsler et al

Fig 4. Pretreatment lateral cephalometric radiograph and tracing.

3. Use Class II mechanics without extractions; if un-

Table. Cephalometric values successful, extract the first premolars, but this
Measurement Standard Initial Final would steepen the occlusal plane and procline the
SNA angle ( ) 82 82.5 81 mandibular anterior teeth even farther.
SNB angle ( ) 80 72.6 73
ANB angle ( ) 2 9.9 8 After extensive discussions with the patient, the non-
Wits (mm) 1 11.6 6 extraction approach was selected.
SN-Go-Gn ( ) 32 30.2 33.5
MP to FH ( ) 25 19 21
U1 to NA ( ) 22 22 10
TREATMENT PROGRESS
U1 to NA (mm) 4 2.4 0.5 Treatment began with the placement of edgewise
L1 to NB ( ) 25 23 37 brackets (0.022-in slot) on all maxillary and mandibular
L1 to NB (mm) 4 4.4 8.5
L1 to MP ( ) 90 104 111
teeth for leveling and aligning. A removable anterior bi-
U1 to L1 ( ) 130 125 124 teplane was used to disarticulate the posterior teeth and
Pog to NB (mm) 1 0 3 start the bite opening (Fig 5). Once that was achieved
and the spaces between the maxillary anterior teeth
overjet, (3) close the diastemas between the maxillary were closed, beta-titanium alloy archwires with closing
anterior teeth, and (4) place the buccal segments in an loops and an accentuated curve of Spee were placed in
Angle Class I relationship. the maxillary arch to retract the incisors. To maintain in-
TREATMENT ALTERNATIVES cisor torque and coordinate the dental arches, rectangu-
lar stainless steel wires were placed in the mandibular
Because this patient was an adult with no clinically arch to stabilize it for anchorage purposes.
significant growth potential to assist in establishing Class II elastics were used on sliding hooks against
the treatment goals with orthodontics alone, orthog- the molars and on anterior hooks distal to the maxillary
nathic surgery was proposed. Although this approach lateral incisors throughout the treatment to help in the
would allow for the correction of the skeletal discrep- correction of the anteroposterior disharmony (Figs 5
ancy, achieve an ideal occlusion, and maximize the es- and 6). Asymmetrical elastics were used to align the den-
thetic result, she refused the surgical plan. The tal midlines. Interproximal reduction of the maxillary
remaining options included the following. central incisors was performed to minimize the appear-
1. Extract the maxillary first premolars to reduce the ance of the open embrasures between the maxillary an-
overjet and improve the canine relationship. However, terior teeth. Retention consisted of bonded lingual wires
this would only reduce the protrusion of the maxilla on the maxillary and mandibular anterior teeth, and
without affecting the position of the mandible. a maxillary Hawley retainer was given to maintain the in-
2. Extract the maxillary second molars and retract all tegrity of the maxillary arch. In addition, 2 Essix retainers
maxillary teeth to establish a Class I relationship. (Raintree Essix Inc., Metairie, La) were given to the pa-
This would also be a lengthy procedure. tient as a backup in case a lingual wire debonded.

July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Wechsler et al 99

Fig 5. Intraoral photographs during treatment, showing a removable maxillary anterior biteplate to dis-
articulate the occlusion and open the bite.

Fig 6. Intraoral photographs showing retraction of the maxillary anterior teeth via sliding mechanics.

TREATMENT RESULTS relationship and a slight Class II canine relationship

The posttreatment photographs show a mesofacial
appearance, and the profile now appears more orthog-
nathic (Fig 7). The decrease in lower lip prominence
and the increase in the lower anterior facial third both
contributed to the improved facial esthetics. The smile
is wider and follows the lower lip arc. Intraorally, an ac-
ceptable overbite of 2 mm and an overjet of 3 mm were
established (Fig 8). The posterior occlusal relationships
were improved. On the left side, a Class I molar
were obtained; on the right side, slight Class II molar
and canine relationships can be observed at the end of
treatment. However, prosthetic restorations would later
be performed, and these would improve the molar and
canine relationship on both sides. The occlusal views
show good forms in both arches. The maxillary dental
midline now coincides with the facial midline; however,
the mandibular dental midline remained deviated 1 mm
to the right.

American Journal of Orthodontics and Dentofacial Orthopedics July 2012  Vol 142  Issue 1
100
Fig 7. Posttreatment facial and intraoral photographs.
The posttreatment panoramic and periapical radio-
graphs (Fig 9) show that there was little or no resorption
of the roots of the maxillary and mandibular anterior
teeth. The maxillary and mandibular bases remained
relatively stable. The maxillary incisors were retracted
and retroclined (Mx1-NA, 0.5 mm; Mx1-NA, 10 ), and
the mandibular teeth were advanced and proclined
(Md1-NB, 8.5 mm; IMPA, 111 ) (Table; Fig 10). Com-
parison of the soft-tissue profile in the pretreatment
and posttreatment cephalometric tracings indicates an
improvement in the profile (Fig 11). Separate superim-
positions of the pretreatment and posttreatment trac-
ings of the maxilla and the mandible show that the
maxillary teeth appear to have been retracted palatally,
whereas the mandibular anterior teeth were proclined
labially (Fig 12).
At the end of treatment, some spacing remained
distal to the maxillary right and left lateral incisors.
These spaces were reduced by the addition of
July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Wechsler et al
composite resin on the mesial surfaces of the canines
and the distal surfaces of the lateral incisors. The pa-
tient's periodontal health remained stable throughout
treatment, with a healthy band of keratinized tissue.
The posttreatment panoramic and periapical radio-
graphs confirm that the bone levels remained stable
(Fig 9). However, there are no interdental papillae in
some areas. There is evidence of an increased centric
relation-centric occlusion shift.
As can be seen in the 3-year posttreatment photo-
graphs (Fig 13), there has been a remarkable improve-
ment in the occlusion after restoration of the maxillary
and mandibular posterior teeth. This seems to have
helped to provide a stable result.
DISCUSSION
The patient initially had all the classic characteristics
of a Class II Division 1 malocclusion: hypodivergent
Wechsler et al 101

Fig 8. Posttreatment dental casts.

convex facial profile, severely retrognathic mandible, re-

duced lower anterior facial height, proclined maxillary
anterior teeth, and increased overjet and overbite. As
noted above, at the end of treatment, a Class I relation-
ship of the molars, premolars, and canines was obtained
on both sides. It is pertinent to consider the mechanism
whereby this was achieved.
There are several hypotheses to explain this result.
One possibility is that the condyle was remodeled up-
ward and backward under the influence of Class II elas-
tics, which placed the condylar process under tension.
This seems to be supported by the findings of McNamara
and Carlson4 in nonhuman primates, showing an in-
crease of condylar cartilage in the posterior and superior
direction after the placement of an appliance to advance
the mandible. Similarly, Rabie et al5 found that func-
tional appliance therapy accelerated and enhanced con-
dylar growth by promoting the differentiation of
mesenchymal cells into chondrocytes in experiments
on rats. In a later article, Rabie et al6 showed that the
numbers of replicating mesenchymal cells were highest
in the posterior regions of the condyle and glenoid fossa.
These findings were corroborated by Voudouris et al7
working with nonhuman primates; they showed that
the placement of a Herbst-block appliance led to an Fig 9. Posttreatment panoramic and periapical radiographs.

American Journal of Orthodontics and Dentofacial Orthopedics July 2012  Vol 142  Issue 1
102
Fig 10. Posttreatment lateral cephalometric radiograph and tracing.
Fig 11. A, Superimposed initial and final cephalometric
tracings; B, superimposed cephalometric tracings at CC
(center of cranium, point of intersection of nasion-basion
line with facial axis line) and along the nasion-basion line.
increased horizontal component of condylar growth,
and anterior displacement of the mandible and the man-
dibular dentitions. Although we cannot necessarily
transfer the results from animal studies to humans,
one could speculate that our patient's continuous
wearing of the Class II elastics might have acted in
a similar manner to the action of functional appliances.
However, because of this patient's age, this hypothesis is
unlikely.
Another hypothesis might be that the glenoid fossa
remodeled forward and downward. Woodside et al8 in-
vestigated the remodeling changes in the condyle and
glenoid fossa after a period of progressively activated
July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Wechsler et al
Fig 12. Separate superimpositions of the maxilla and the
mandible.
and continuously maintained mandibular advancement
using the Herbst appliance. The mandibular advance-
ment produced extensive remodeling and anterior relo-
cation of the glenoid fossa; this contributed to anterior
mandibular positioning and an altered jaw relationship.
Voudouris et al9 stated that new bone formation in the
fossa was associated with continuous mandibular pro-
trusion. This was quantified by using computerized cal-
cified histologic sections. Again, this is unlikely in this
patient at her age.
A third hypothesis is that some distal movement of
the maxillary dentition might have occurred (Fig 11,
B), resulting from the use of Class II elastics with sliding
hooks against the maxillary molars.
Yet another explanation is based on the mesial move-
ment of the mandibular dentition from Class II elastics.
This can be seen in the posttreatment cephalograms
(Figs 10 and 12) showing the proclination of the
Wechsler et al 103

Fig 13. Three-year posttreatment facial and intraoral photographs.

Fig 14. Cone-beam computed tomography scan of the bony temporomandibular joint showing the po-
sition of the right and left condyles on the posterior slope of the articular eminence with the patient in
centric occlusion, taken 3.5 years posttreatment.

mandibular incisors. Voudouris et al9 found mesial It is likely that a dual bite was produced in this pa-
movement of the mandibular arch in both experimental tient. A dual bite is present if the anteroposterior differ-
animals and human subjects. ence between centric relation and maximum intercuspal

American Journal of Orthodontics and Dentofacial Orthopedics July 2012  Vol 142  Issue 1
104
Fig 15. Cone-beam computed tomography scan of the temporomandibular joints 3.5 years posttreat-
ment: A, right joint, showing the position of the condyle on the posterior slope of the articular eminence;
B, left joint, showing the position of the condyle on the posterior slope of the articular eminence.
relation exceeds 2 mm, and if the 2 positions can be
achieved by the patient.10 Our patient preferred to main-
tain her mandible in an anterior maximal intercuspal po-
sition and experienced no subjective symptoms of
mandibular dysfunction. The pain and clicking in the
right temporomandibular joint has disappeared.
A combination of any or all of the above factors could
have occurred. In this patient, the objectives were most
likely achieved by an anterior shift of the mandible as
well as by dentoalveolar changes. There was proclination
of the mandibular incisors and retroclination of the
maxillary incisors; these brought about the reduction
of the overjet. By flattening the curve of Spee, the over-
bite was reduced.
One last item to be considered is the remaining dia-
stemas at the end of treatment. The difficulty in closing
the diastemas distal to the maxillary lateral incisors ap-
pears to be due to an excess of tooth width in the man-
dibular anterior teeth relative to the maxillary anterior
teeth, as indicated by the Bolton anterior ratio of 81.3
(mean anterior ratio, 77.2).11 This was further exacer-
bated by the need for interproximal stripping of the max-
illary central incisors to reduce the appearance of open
embrasures and improve the esthetics. The open embra-
sures might have been caused by the healthy but reduced
periodontium.12 The contact points between the maxil-
lary central and lateral incisors might have been more
than 5 mm from the crestal bone, thus increasing the
likelihood of open embrasures.13 Nevertheless, this was
a satisfactory compromise, since we achieved the main
objectives of treatment for this patient.
To verify which of the above proposed hypotheses is
correct, it was decided (with the patient’s consent) to
take cone-beam computed tomography scans of her
July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Wechsler et al
temporomandibular joints. This was done about 3.5
years after treatment. As can be seen in Figures 14 and
15, the condyles are positioned on the posterior slope
of the articular eminence when the patient is positioned
in centric occlusion (maximal intercuspation). Figure 15
also shows the tomographic images of the condyles rel-
ative to the posterior slope of the articular eminence with
the mandible in centric occlusion. The patient indicated
that this was the most comfortable position for her;
when it was attempted to manipulate the mandible pos-
teriorly, she was uncomfortable.
As can be seen in the intraoral and extraoral photo-
graphs taken 3 years after treatment and after prosthetic
restoration (Fig 13), the patient has a good functional
occlusion and a pleasing esthetic result, both intraorally
and facially, and the occlusion has remained stable.
CONCLUSIONS
The treatment option selected for this patient met her
esthetic expectations and gave her a pain-free, well-
functioning (no noises from the joint), and seemingly
stable occlusion. It is interesting that a patient, who ini-
tially seemed to need a treatment plan including surgical
intervention, was successfully managed nonsurgically
and without extractions. In this patient, dental compen-
sation permitted the achievement of a harmonious smile
and a pleasing soft-tissue profile. This emphasizes the
notion that, in some cases, responding to the patient’s
chief complaint might take precedence over the clini-
cian’s desire to achieve ideal orthodontic goals.
We thank Ann Wechsler for her assistance with the
preparation of the manuscript; Jack Turkewicz, Jean-
Marc Retrouvey, and Claude Remise for reviewing the
Wechsler et al
manuscript and for helpful suggestions; Howard Cytry-
niak for his skillful prosthetic restoration; and Louis Fro-
nenberg for his assistance in obtaining the cone-beam
computed tomography scans; also thanks to Mourad
Benmiloud, for his technical assistance in the prepara-
tion of this article.
REFERENCES
1. Proffit WR, Fields HW, Sarver DM. Contemporary orthodontics. 4th
ed. St Louis: Mosby Elsevier; 2007.
2. Steiner C. Cephalometrics in clinical practice. Angle Orthod 1959;
29:8.
3. McNamara JA. A method of cephalometric evaluation. Am J Or-
thod 1984;86:449-69.
4. McNamara JA, Carlson D. Quantitative analysis of temporoman-
dibular joint adaptations to protrusive function. Am J Orthod
1979;76:593-611.
5. Rabie ABM, H€agg U, She TT. Functional appliance therapy enhances
condylar growth. Am J Orthod Dentofacial Orthop 2003;123:40-8.
6. Rabie ABM, Wong L, Tsai M. Replicating mesenchymal cells in the
condyle and the glenoid fossa during mandibular forward posi-
tioning. Am J Orthod Dentofacial Orthop 2003;123:49-57.
American Journal of Orthodontics and Dentofacial Orthopedics
105
7. Voudouris JC, Woodside DG, Altuna G, Kuftinec MM,
Angelopoulos G, Bourque PJ. Condyle-fossa modifications and
muscle interactions during Herbst treatment, part 1. New techno-
logical methods. Am J Orthod Dentofacial Orthop 2003;123:
604-13.
8. Woodside DG, Metaxas A, Altuna G. The influence of functional
appliance therapy on glenoid fossa remodeling. Am J Orthod Den-
tofacial Orthop 1987;92:181-98.
9. Voudouris JC, Woodside DG, Altuna G, Angelopoulos G,
Bourque PJ, Lacouture CY. Condyle-fossa modifications and mus-
cle interactions during Herbst treatment, part 2. Results and con-
clusions. Am J Orthod Dentofacial Orthop 2003;124:13-29.
10. Egermark-Eriksson I, Carlsson GE, Ingervall B. Function and dys-
function of the masticatory system in individuals with dual bite.
Eur J Orthod 1979;1:107-17.
11. Bishara SE. Textbook of orthodontics. Philadelphia: Saunders;
2001. p. 520-1.
12. Kurth JR, Kokich VG. Open gingival embrasures after orthodontic
treatment in adults: prevalence and etiology. Am J Orthod Dento-
facial Orthop 2001;120:116-23.
13. Tarnow DP, Magner AW, Fletcher P. The effect of the distance
from the contact point to the crest of bone on the presence or
absence of the interproximal dental papilla. J Periodontol
1992;63:995-6.
July 2012  Vol 142  Issue 1