Volume 34 Issue 1 Article 3

January 2022

Angle Class II Division 1 Malocclusion in an Adolescent Patient

Treated with Four First Premolars Extraction and Temporary
Anchorage Devices
Yu-Cheng Hsu
CSMUH

Po-Yu Yang
CSMUH

Chia-Tze Kao
CSMUH

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Recommended Citation
Hsu, Yu-Cheng; Yang, Po-Yu; and Kao, Chia-Tze (2022) "Angle Class II Division 1 Malocclusion in an
Adolescent Patient Treated with Four First Premolars Extraction and Temporary Anchorage Devices,"
Taiwanese Journal of Orthodontics: Vol. 34: Iss. 1, Article 3.
DOI: 10.38209/2708-2636.1118
Available at: https://www.tjo.org.tw/tjo/vol34/iss1/3

This Case Report is brought to you for free and open access by Taiwanese Journal of Orthodontics. It has been
accepted for inclusion in Taiwanese Journal of Orthodontics by an authorized editor of Taiwanese Journal of
Orthodontics.
Angle Class II Division 1 Malocclusion in an Adolescent Patient Treated with Four
First Premolars Extraction and Temporary Anchorage Devices

Abstract
This case report describes a successful orthodontic treatment in an Angle Class II division 1
malocclusion with severe space deficiency by temporary anchorage device (TAD) in a 15-year-old male
patient. The skeletal analysis showed mandibular retrognathism and slightly hyperdivergent growth
pattern. The treatment plan included four first premolars extractions combined with TAD application
which used for anteroposterior and vertical anchorage control. The orthodontic treatment was to achieve
the effect of counter-clockwise rotation of mandible for the patient who still has remaining growth. After
23 months of orthodontic treatment, Angle Class I molar relationship was achieved. The patient was
satisfied with his facial appearance.

Keywords
Vertical control; Class II division 1 malocclusion; Temporary anchorage devices (TADs)

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CASE REPORT

Angle Class II Division 1 Malocclusion in an

Adolescent Patient Treated with Four First Premolars
Extraction and Temporary Anchorage Devices

Yu-Cheng Hsu a,b, Po-Yu Yang a,b, Chia-Tze Kao a,c,*

a
Orthodontic Department, Chung Shan Medical University Hospital, Taichung, Taiwan
b
College of Oral Medicine, Chung Shan Medical University, Taichung, Taiwan
c
Department of Dentistry, Chung Shan Medical University, Taiwan

ABSTRACT

This case report describes a successful orthodontic treatment in an Angle Class II division 1 malocclusion with severe
space deficiency by temporary anchorage device (TAD) in a 15-year-old male patient. The skeletal analysis showed
mandibular retrognathism and slightly hyperdivergent growth pattern. The treatment plan included four first premolars
extractions combined with TAD application which used for anteroposterior and vertical anchorage control. The ortho-
dontic treatment was to achieve the effect of counter-clockwise rotation of mandible for the patient who still has
remaining growth. After 23 months of orthodontic treatment, Angle Class I molar relationship was achieved. The patient
was satisfied with his facial appearance. Taiwanese Journal of Orthodontics 2022;34(1):24e30

Keywords: Vertical control; Class II division 1 malocclusion; Temporary anchorage devices (TADs)

INTRODUCTION mandible forward and bring out chin projection as

P atients with Class II malocclusion often pre-
sent with Class II molar and canine relation-
ships and proclined incisors, usually associated
with skeletal Class II pattern with retrognathic
mandible and a convex profile.
The orthodontic treatment of adolescence involves
great attention to the growth stage recognition and
close follow up in the next few years. With prudent
evaluation, the direction and amount of skeletal and
dental growth may be modified to a more favorable
facial profile. Therefore, in adolescence patient,
unlike the treatment options including compensa-
tion treatment or treatment combined with orthog-
nathic surgery in adult patients, the crucial key to
improve the Class II skeletal relationship is to
modify the growth direction of mandible, either by
functional appliances or by fixed appliance to limit
the eruption during adolescence and achieve
intrusion of the dental arches, and rotate the
the mandible grows, by reducing the vertical
dimension with multiple methods.1
Nowadays, temporary anchorage devices (TADs)
have been used for providing a relatively simple
and directional force system to control tooth
movement and meet the treatment goal with high
success rate and more comfortable without relying
on patient's cooperation compared to traditional
anchorage methods.2e5
The present case reports an adolescence with
Class II division 1 malocclusion, treated by first
premolars extraction and TADs. The treatment
outcome was satisfied.
CASE REPORT
Clinical findings and diagnosis
A 15-year-old male patient presented chief
complaint of the crowded teeth and was dissatisfied
with the appearance. In the lateral view, a convex

Received 30 August 2021; revised 12 October 2021; accepted 18 January 2022.

Available online 31 March 2022

* Address correspondence to Professor Chia-Tze Kao: No.110, Sec. 1, Jianguo N. Road, South District, Taichung City 402, Taiwan. Fax: þ886 4 24759065.
E-mail address: ctk@csmu.edu.tw

https://doi.org/10.38209/2708-2636.1118
2708-2636/© 2022 Taiwan Association of Orthodontist. This is an open access article under the CC-BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Taiwanese Journal of Orthodontics
2022;34(1):24e30 CLASS II DIVISION 1 ADOLESCENCE TREATED WITH EXTRACTION AND TADS
profile with a retrusive chin and incompetent lips
was observed (Figure 1). No trauma or allergic his-
tory was reported.
The intraoral examination and cast analysis
showed Angle Class II division 1 malocclusion with
Class II canine and molar relationship on both sides,
with an increased overbite of 4.5 mm and an
excessive overjet of 7 mm. The maxillary dental
midline was 1 mm deviated to his left side from the
facial midline, while the mandibular dental midline
was 1 mm deviated to his right side. Both arches
exhibited severe space deficiency of 8.5 mm in the
upper dentition and 9 mm in the lower dentition.
The lateral cephalometric analysis revealed, ante-
roposteriorly, a Class II skeletal relationship with
mandibular retrognathism (ANB ¼ 6 , Nv-
Pog ¼ 9mm), and vertically, a normal yet slightly
hyperdivergent skeletal growth pattern (Y-axis ¼ 64 ,
SN-MP ¼ 34 ). The cervical vertebral maturation
stage was between CS3 to CS4, closer to CS4. Dental
analysis showed maxillary and mandibular incisors
are proclined (U1-SN ¼ 113.5 , L1-MP ¼ 106 ), and
correspondingly, the upper and lower lips are pro-
trusive relative to E-line (Figure 2, Table 1).
Figure 1. Pre-treatment photos.
25
Y.-C. HSU ET AL
Treatment objective
Treatment objectives were setup as followings:
(1) relief of crowding
(2) establishing normal incisal angle
(3) establishing normal overbite, overjet and solid
interdigitation
(4) obtaining facial profile improvement
Treatment plan
In order to accomplish the treatment objectives
listed earlier, the treatment plan included extrac-
tion of 4 first premolars to provide sufficient
space for alignment, and 4 miniscrews placement
in the upper and lower posterior area of both
sides for maximum anchorage. Meanwhile, to
reduce the skeletal anteroposterior discrepancy,
the miniscrews could also be of good use con-
trolling the vertical dimension. Throughout the
treatment, periodic panoramic film and cephalo-
metric film examination was done for growth
monitoring.
Y.-C. HSU ET AL Taiwanese Journal of Orthodontics
CLASS II DIVISION 1 ADOLESCENCE TREATED WITH EXTRACTION AND TADS 2022;34(1):24e30

cephalometric film showed the upper incisors has

drifted to a relatively less crowded yet retroclined
position, which was resulted from the habit of
pressing the lips together frequently, even when the
lips competency had improved. Once the patient
acknowledged it, the oral habit was rectified
gradually.
Before the space closure stage, 4 miniscrews were
inserted, between the roots of second premolars and
first molars in the upper arch, and between the roots
of first and second molars in the lower arch, at about
8 mm further from the arch wire to provide absolute
anchorage for space closure. The posterior segments
of the arch wires were tied firmly to the miniscrews
throughout the treatment, giving the force of
restraining the arch from eruption during growth.
To correct the inclination of incisors, other than a
compensating curve in the maxillary arch wire and a
reverse curve of Spee in the mandibular arch wire
during space closure to prevent roller coaster effect,
incisor extrusion and overbite deepening. We added
palatal root torque to the upper incisors, and
furthermore, a torquing spring on 21 at detailing
stage to achieve an appropriate incisor inclination.
Finally, after arch coordination obtained by
bracket rebonding and a series of wire bending, the
Figure 2. Pre-treatment X-rays.
fixed appliances were removed. The total treatment
duration was about 23 months. At the end of treat-
ment, wrap-around retainers for both arches was
Treatment progress delivered for retention.

At the beginning of the treatment, 4 first pre- Treatment result

molars were extracted, then the teeth were bonded
with fixed edgewise appliances except for maxillary After the treatment, the skeletal anteroposterior
and mandibular incisors, to avoid incisor flaring and discrepancy was improved, with ANB angle
round tripping from the initial leveling and align- decreased by 3 and Pog moved forward for 4.5 mm, to
ment. After canine retraction was done, the incisors a more Class I skeletal relationship. Vertically, the
were bonded with brackets, leveled and aligned by mandible has rotated forward, with the mandibular
sequential wires. At this point, the lateral plane angle decreased by 2 (Table 1 and Figures 3e5).
As for the dentition, the severe crowding of both
arches was solved and the molar and canine re-
Table 1. Cephalomatric analysis comparison and of the pre-treatment
and post-treatment results. lationships improved from Class II to Class I rela-
tionship. Furthermore, both maxillary and
Norm Initial Final
mandibular incisors were retracted under controlled
Skeletal analysis
tipping to normal incisal angulation (U1-SN ¼ 104 ,
SNA 79.4 ~82.5 81.5 80
SNB 74.6 ~77.8 75.5 77 L1-MP ¼ 93 ). The maxillary molar remained the
ANB 4.1 ~5.7 6 3 original position, and the mandibular molar
SN-MP 34.2 ~38.6 34 32 extruded for 1 mm, lesser than the usual amount of
Dental analysis tooth eruption during growth, with the facilitation of
U1-NA 3.8~7.2 mm 11.5 mm 5.5 mm
TADs.
U1-SN 103.5 ~109.1 113.5 104
L1-NB 6.1~9.5 mm 10.5 mm 6.5 mm The lateral facial profile indicated improvement of
L1-MP 91.1 ~98.3 106 93 facial profile from convex to straight, which resulted
E-line from the forward rotation of mandible and retrac-
Upper lip 0.78~3.2 mm 4 mm 0.5 mm tion of incisors. The previously protrusive and
Lower lip 1.2~4.4 mm 6.5 mm 1 mm
incompetent lips became harmonized.

26
Taiwanese Journal of Orthodontics Y.-C. HSU ET AL
2022;34(1):24e30 CLASS II DIVISION 1 ADOLESCENCE TREATED WITH EXTRACTION AND TADS

Figure 3. Post-treatment photos.

DISCUSSION interpremolar angle, the lower anterior face height.6,7

Besides, several parameters from lateral cephalo-
In this case, we presented a case of Angle Class II
metric analysis are available for determining the
division 1 malocclusion with severe space deficiency
skeletal pattern, such as Y-axis, mandibular plane
under skeletal discrepancy of mandibular retro-
angle, UFH/LFH, PFH/AFH, etc.8e12
gnathism in an adolescence. At the end of the
The other aspect of growth assessment is to assess
treatment, we achieved counter-clockwise rotation
which growth stage the patient is at, using several
of mandible with the facilitation of TADs. The
indicators, such as chronologic age,8e10 secondary
growth assessment and the vertical control are
sexual characteristics,11,12 dental age13 and skeletal
important factors in treating Class II division 1
age, including cervical vertebrae maturational
malocclusion in growing patients.
stage,14,15 hand-wrist radiographs,16,17 serial cepha-
In regarding of growth assessment, different as-
lometric radiographs.18 We may predict the amount
pects should be considered. First of all, we need to
of skeletal growth over the following years, as well
evaluate which the direction of maxillofacial growth
as the amount of dental eruption. The estimated
is. The facial pattern can be divided as hyperdivergent
amounts of mandibular growth during puberty are
or hypodivergent skeletal pattern. During the growth
3 mm/yr for ramus height and 2 mm/yr for
period, the orthodontic treatment plan needs to be
mandibular body length.19,20 Moreover, the erup-
cautioned on improving the worse growth pattern.
tion of teeth cannot be overlooked. In the maxillary
Bj€ork and Skieller presented the indicators of
arch, the approximate amounts of tooth eruption are
mandibular growth to decide either the direction is
1.2/1.4 (female/male) mm/yr in the molar area and
forward rotation or backward rotation, including the
0.9 mm/yr in the incisor area, while in the
inclination of condylar head, the curvature of
mandibular arch, the amounts of eruption are 0.5/
mandibular canal, the shape of the lower border of the
0.9 (female/male) mm/yr in the molar area and 0.5/
mandible, the inclination of the mandibular sym-
0.8 (female/male) mm/yr in the incisor area.21
physis, the interincisal angle, the intermolar and

27
Y.-C. HSU ET AL
CLASS II DIVISION 1 ADOLESCENCE TREATED WITH EXTRACTION AND TADS
Figure 4. Post-treatment X-rays.
With the estimated direction and amount of sub-
sequent growth, we are able to decide what kind of
treatment to provide the patient. For example, in
this case, the patient grew in a fairly normal yet
slightly hyperdivergent skeletal pattern, inferred
from the rather straight and backward inclined
condyle and symphysis, Y-axis (64 ), and mandib-
ular plane angle (34 ). Although the rotation of the
mandible during growth may lead to the decrease of
the mandibular plane angle by 0.3 e0.4 /yr, and the
decrease of ANB angle by slightly more than 0.2 /yr,
but the amount of decrease wouldn't be enough to
correct the retrognathic mandible.18 Besides, the age
was 15, the CVM stage was close to CS4, right after
the adolescent growth spurt, which confirmed from
the presence of the larynx enlargement, voice
change, and the facial hair on the chin and the
upper lip. Therefore, the residual growth potential
could be estimated. According to Garcia Fernan-
dez,14 there is about 10e25% of growth potential left
at CS4 (SMI7~8), about the time we initiate the
treatment. As a consequence, we decided to trans-
form the growth of the mandible to a more forward
direction to correct the Class II skeletal relationship
by means of vertical control.
The methods of controlling vertical dimension
consist of, extraoral appliance such as headgears,
28
Taiwanese Journal of Orthodontics
2022;34(1):24e30
and intraoral appliances such as TADs, bite block,
transpalatal arch, active vertical corrector, and
avoiding the use of intermaxillary elastics. TADs are
now a widely used device with the properties of
versatility, minimal invasiveness, and have been
shown to be effective in intruding teeth in a
controlled fashion and with light force.22,23 In a
previous study of growing hyperdivergent, retro-
gnathic patients, orthopedic correction occurred
after the orthodontic treatment with TADs, the SNB
angle increased by 2.1 ± 1.3 and the mandibular
plane angle decreased an average of 3.9 ± 1.8 .24,25
Thus, in this case, we used TADs to obtain absolute
anchorage.
According to the finite element analysis, the
center of resistance of maxillary dentition is
located near the mesial side of the root of second
premolar, at about 11 mm higher from cusp tip.26
The relationship between the position of TADs and
hooks makes great influences on the force direc-
tion. When the TADs were placed on a higher level
(8 mm higher from arch wire), more vertical force
could be brought into the force system.27 When
combining the use of high-position miniscrew with
short power arm, the movements in the anterior
and posterior teeth are more of bodily movement
and intrusion.27 Therefore, as presented in this
case, the four TADs could facilitate resisting the
tendency of molar eruption during adolescence,
with maxillary molar remained the original posi-
tion, and the mandibular molar only erupted for
1 mm, while the mandible grew for 3 mm in the
anteroposterior direction and 4 mm in the vertical
direction, which resulted in the counter-clockwise
rotation of the mandible, with 2 decrease in
mandibular plane angle and 3 decrease in ANB. If
the molars were to be intruded for further
decrease of vertical dimension, an active intrusive
force from TADs should be considered, and
moreover, a transpalatal arch and a lingual arch
could be utilized as to prevent the molars from
buccal tipping and stabilize the arch width.28 Be-
sides, avoid using intermaxillary elastics could
prevent extrusion, thereby, preserving the effect of
intrusive force.
CONCLUSION
When treating growing patients with retrognathic
mandible, close and continuous monitoring is
crucial to determine the growth potential and if they
exhibit desirable treatment changes.
With proper use of TADs and various methods of
vertical control, regulation of growth direction and
forward rotation of mandible, along with better chin
Taiwanese Journal of Orthodontics Y.-C. HSU ET AL
2022;34(1):24e30 CLASS II DIVISION 1 ADOLESCENCE TREATED WITH EXTRACTION AND TADS

Figure 5. Superimposition of the pre-treatment and post-treatment cephalograms. Black line, before treatment; red line, after treatment.

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Comparative evaluation of micro-implant and headgear
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FUNDING 3. Yao CC, Lai EH, Chang JZ, Chen I, Chen YJ. Comparison of
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