Journal of Advanced Clinical & Research Insights ● Vol. 6:1 ● Jan-Feb 2019 27

Journal of Advanced Clinical & Research Insights (2019), 6, 27–31

C A S E R E P O R T

Catch-up growth after skeletal maturity - A case reportN. V. Hridaya1, Amrita Ashok2

1Department of Orthodontics and Dentofacial Orthopaedics, Midac Prime, Mathottam, Calicut, Kerala, India, 2Department of Orthodontics and Dentofacial Orthopaedics, KMCT Dental College, Kerala University of Health Sciences, Calicut, Kerala, India

Introduction

Orthodontic problems of a cleft lip and palate patient can be associated with soft tissue, skeletal, or dental defects. Some cleft orthodontic problems have a direct relationship to the cleft deformity, whereas others occur secondary to surgery to repair the defects.[1] A small mandible may prevent the downward relocation of the tongue which may mechanically prevent palatal fusion. This is probably the pathogenic mechanism of the cleft palate in the Pierre Robin syndrome characterized by mandibular hypoplasia.[2] This article describes non-surgical management of a repaired cleft palate with transverse arch deficiency and Class II malocclusion in a vertically growing patient, past the active phase of mandibular growth.

Case Report

A 13-year-old female patient presented with a repaired median cleft of the palate, Class II malocclusion with upper and lower anterior crowding, palatally placed maxillary right and left lateral incisors, constricted upper arch, and mandibular incisors locked behind palatally placed upper lateral incisors.

A review of her medical history showed that she was diagnosed as a case of Pierre Robin syndrome at the time of birth and had undergone palatoplasty for the cleft palate at 2 years. She also

had undergone ear surgery since her hearing was impaired. She had attained puberty 1 year back.

The patient had a symmetric face and convex profile with incompetent lips [Figure 1a-d]. The clinical examination showed that the patient was in mixed dentition stage with 55 and 65. She presented with Class II malocclusion with full cusp Class II molar and class II canine relationships, overjet of 12 mm, and overbite of 5 mm [Figure 1e-h]. Upper and lower dental midlines were coincident with the facial midline. The interpremolar width and intermolar width in the maxillary arch were 18 and 30 mm, respectively.

The panoramic radiograph showed that the patient had missing 25 [Figure 2a]. A cephalometric evaluation showed a skeletal Class II relationship with mandibular retrusion and increased mandibular plane angle [Figure 2b and Table 1]. The maxillary incisors were proclined, and the mandibular incisors were retroclined.

Treatment objectives

The treatment objectives of this study are as follows:• To expand the narrow maxillary arch and the mandible from

obstruction caused by palatally placed lateral incisors to enable the full potential of mandibular growth.

• To camouflage the dentoskeletal disharmony by extraction of the two upper premolars and class II elastics.

AbstractClass II malocclusions in adolescent patients are often managed using functional appliances or orthodontic camouflaging. The aim of this article is to describe the skeletal changes in mandible when factors causing mandibular growth restriction were removed orthodontically in a patient past the active mandibular growth spurt.

Keywords: Catch-Up growth, class II Malocclusion, cleft palate, condyle-fossa remodeling, dental camouflage

Correspondence: Dr. N. V. Hridaya, Sahriaa, Near Driving Test Ground, Chevayur, Calicut–673 017, India. Phone: +91- 9446062167. E-mail: drhridayaortho@gmail.com

Received: 15 January 2019; Accepted: 24 February 2019

doi: 10.15713/ins.jcri.253

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• To achieve a stable, functional occlusion and class I canine relationship.

• To achieve a pleasing smile and lip competence.

Treatment plan

After discussion with parents, the following treatment plan was selected.• Quad helix appliance on the upper arch for expanding

constricted upper arch and to provide space for palatally blocked upper laterals.

• Relieve occlusal interference caused by the palatally placed lateral incisors which lock the mandible, by fixed appliance therapy with 022 slot MBT prescription brackets.

• Extraction of two upper premolars to camouflage the skeletal discrepancy.

• Use of class II elastics to encourage the catch-up growth of the mandible.

Method

It was decided to correct the transverse discrepancy and remove the occlusal interference caused by palatally placed lateral incisors as priority.[3,4] Quad helix appliance with long outer arms was adapted to touch the palatally placed lateral incisors [Figure 3a]. The appliance was expanded to 6 mm, followed by subsequent reactivations at 6 week intervals. Expansion was considered adequate when the occlusal aspect of the maxillary lingual cusp of primary second molar contacts the occlusal aspect

Figure  2: (a) Pre-treatment panoramic radiograph, (b) Pre-treatment cephalometric radiograph

b

a

Figure 1: Pre-treatment photographs

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h

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g

b

f

a

e

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Journal of Advanced Clinical & Research Insights ● Vol. 6:1 ● Jan-Feb 2019 29

of the mandibular facial cusp of the primary second molar. The teeth were bonded with 0.022 slot MBT prescription brackets, since our priority was to relieve the mandible from the occlusal interference caused by palatally placed lateral incisors to facilitate the remaining growth potential to express. After initial alignment with 0.016 NiTi wires, 55 and 65 were extracted and 15 was surgically removed. It was decided to extract second premolars instead of first premolars because 25 was found missing in the panoramic radiograph [Figure 3b]. A case was considered as a high anchorage case, and upper second molars were banded

and TPA was placed. Class II elastics were used to facilitate mandibular growth and reduction of overjet [Figure 3c]. The patient was cooperative and fixed appliance was removed in a span of 1½ years, followed by fixed retainers in both the upper and lower arches.

Treatment Results

Significant improvement in facial esthetics and balance notable changes in lip profile was attained after treatment [Figure 4a-d]. The arches were well aligned [Figure 4e-h]. Proclination and facial convexity decreased. Normal overbite (3 mm) and overjet (2 mm) and Class I canine relationships were attained. Increase in effective length of the mandible was achieved. A significant counter clockwise rotation of the mandibular plane was observed. Increase in the Bolton’s ratio indicates a comparative increase in vertical growth of the mandibular ramus. There was a change inthe position of upper and lower incisors [Figure 5a,b]. In addition, the soft-tissue profile improved. There was a marked improvement in nasolabial angle.

When the changes in maxilla were studied by superimposing on Ba-Na and registering at nasion,[5] point A was found to move posteriorly after treatment [Figure 6a]. Superimposition on corpus axis, by taking PM as registration point, shows a forward movement of mandibular molars and incisors, bone deposition in the mandibular anterior alveolar region above PM, condylar fossa remodeling in anterior direction and an increase in length of mandibular ramus [Figure 6b]. By superimposing on the palatal plane and by registering at ANS, retraction and intrusion of maxillary incisors, forward movement of molars, and posterior displacement in position of point A were noted [Figure 6c]. Superimpositions [Figure 6d][6] showed a reduction of the forward growth of the maxilla and downward rotation of the anterior part of the palatal plane. The mandible showed a favorable growth in mandibular ramus area and anticlockwise rotation of mandible resulted in improvement in profile. Regional superimpositions on the stable structures[5] showed the dentoalveolar changes in the molar and incisor along with

Figure 3: (a) After delivery of quad helix, (b) After expansion and alignment, (c) Retraction with active tiebacks and Class II elastics

c

ba

Table 1: Cephalometric valuesMeasurement Mean Pre-treatment Post-treatmentMaxilla

SNA 82±2° 78° 76

Na per to point A ±2 mm −7 mm −5 mm

Co to point A 80 mm 82 mm

Mandible

SNB 80±2° 73° 71

Na per Pog −2 - 2mm −21 mm −20 mm

Co-Gn 102 mm 104 mm

Max-mand relation

ANB 2° 5° 5°

WITS −1 mm −1 mm

McNAMARA diff 22 mm 22 mm

Vertical

FMA 25±3° 29° 25°

SN to Go-Gn 31° 37° 34°

Sum of posterior angles 396±4° 403° 402°

Jarabak ratio 62–65 61 62

Dental

U1 to N-A (angle) 22° 29° 12°

U1 to N-A (mm) 4 mm 9 mm 2 mm

U1 to SN 102° 107° 89°

L1 to N-B (mm) 4 mm 2 mm 8 mm

L1 to N-B (angle) 25° 17° 30°

L1 to A-Pog (mm) 1–2 mm 1 mm 3 mm

L1 to A-Pog (angle) 22° 13° 28°

Interincisal angle 131° 128° 132

IMPA 90° 84° 101°

U6 to Pt V 17±3 mm 27 mm 29 mm

Soft tissue

E line to the lower lip −2 - 2mm 7 mm 5 mm

S line to the upper lip 0 mm 6 mm 3 mm

S line to the lower lip −2 mm 7 mm 6 mm

Nasolabial angle 110° 90° 101°

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remodeling of bony bases.

Discussion

Choices for treating Class II malocclusions generally comprise surgical correction or camouflage the skeletal discrepancy by dental compensation.[7,8] Here, the patient was not willing for surgical correction. Treatment began during CVMI, CS6 stage. CS3 stage was considered to be the ideal time for the treatment of Class II malocclusion due to mandibular deficiency.[9] The patient had attained puberty 1 year back and

Figure  5: (a) Post-treatment panoramic radiograph, (b) Post-treatment cephalometric radiograph

b

a

Figure 4: Post-treatment photographs

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h

c

g

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f

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e

Figure 6: Cephalometric superimpositionsdc

ba

Growth of mandible after skeletal maturity Hridaya and Ashok

Journal of Advanced Clinical & Research Insights ● Vol. 6:1 ● Jan-Feb 2019 31

so the circumpubertal growth period was almost over. However, But a catch-up growth of mandible was mostly seen when the interference to mandibular growth was removed.[10,11]

The presence of repaired cleft palate and palatally placed laterals made quad helix the appliance of choice in this case. In cleft palate patients, the palatal suture system is disturbed and either irregular or absent and permits an orthopedic response to quad helix expansion.[12-15] Furthermore, the skeletal resistance to expansion is less in cleft palate patients.[12] In this case, adequate expansion was achieved in 2 months’ time.

In Angle’s Class II Division 1 cases with large overjets, treatment with two premolar extractions gave a better occlusal success rate than treatment with four premolar extractions.[16] Extractions in the mandibular arch are often contraindicated in Class II Division 1 cases with severe skeletal discrepancies since any uprighting of the lower incisors can increase the distance that the upper anterior teeth need to be retracted to correct the overjet.[17] Need for anterior movement of mandibular teeth, retrusive mandibular incisors, and presence of at least a minimal mandibular growth potential made use of class II elastics appropriate in this case.[7]

A mesial movement of the mandibular teeth may have triggered a condylar response as said in the studies of Voudouris and Kuftinec.[18] The reduction of the mandibular plane angle can be attributed an increase in ramus length[19] and counterclockwise rotation of mandible. Change in occlusion would have contributed to this.[20] A catch-up growth of the mandible was evident when conditions became favorable in this case even after the active phase of mandibular growth (CS6 stage).

Conclusions

• A thorough case history, clinical examination, and cephalometric analysis assisted in the diagnosis and successful correction of the deformity.

• A successful correction of proclination was achieved by dental camouflage using extraction and Class II elastics.

• Mandibular skeletal changes were brought about by the expansion of maxillary arch and use of Class II elastics.

• A change in the position of maxillary dental arch has triggered a growth at lower anterior dentoalveolar region and growth at condyles.

References

1. Pradip S. Update on treatment of patients with cleft timing of orthodontics and surgery. Semin Orthod 2016;22:45-51.

2. Crispan S. Oxford Handbook of Applied Dental Sciences. New York: Oxford University Press; 2002. p. 415-21.

3. Tollaro L, Baccetti T, Franchi L, Tanasescu CD. Role of posterior transverse interarch discrepancy in class II division l malocclusion during the mixed dentition phase. Am J Orthod

Dentofacial Orthop 1996;110:417-22.4. Bacceti T, Franchi L, McNamara JA Jr., Tollaro I. Early

dentofacial features of class  II malocclusion: A  longitudinal study from the deciduous through the mixed dentition. Am J Orthod Dentofacial Orthop 1997;111:502-9.

5. Ricketts RM. Bio-progressive therapy part  4: The use of superimposition areas to establish treatment design. J  Clin Orthod 1977;11:820-34.

6. Enlow DH. Handbook of Facial Growth. 2nd  ed. Philadelphia, PA: WB Saunders; 1982.

7. Bishara SE. Textbook of Orthodontics. London: Saunders; 2001. p. 324-68.

8. Cope JB, Sachdeva RC. Nonsurgical correction of a class  II malocclusion with a vertical growth tendency. Am J Orthod Dentofacial Orthop 1999;116:66-74.

9. Baccetti T, Franchi L, McNamara JA. The cervical vertebral maturation (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics. Semin Orthod 2005;11:119-29.

10. Mitani H. Recovery growth of the mandible after chin cup therapy: Fact or fiction. Semin Orthod 2007;13:186-99.

11. Bütow KW, Zwahlen RA, Morkel JA, Naidoo S. Pierre Robin sequence: Subdivision, data, theories, and treatment Part  3: Prevailing controversial theories related to Pierre Robin sequence. Ann Maxillofac Surg 2016;6:38-43.

12. Vasant M, Menon S, Kannan S. Maxillary expansion in cleft lip and palate using quad helix and rapid palatal expansion screw. Med J Armed Forces India 2009;65:150-3.

13. Cassi D, Di Blasio A, Gandolfinini M, Magnifico M, Pellegrino F, Piancino MG. Dentoalveolar effects of early orthodontic treatment in patients with cleft lip and palate. J Craniofac Surg 2017;28:2021-6.

14. Ruel WB. The quad helix appliance. Semin Orthod 1998;4:231-7.15. Prakash A, Tandur AP, Rai S. Slow expansion in cleft patient

with quad helix. Indian J Dent Adv 2012;4:772-5.16. Janson G, Brambilla Ada C, Henriques JF, de Freitas MR,

Neves LS. Class II treatment success rate in 2- and 4-premolar extraction protocols. Am J Orthod Dentofacial Orthop 2004; 125:472-9.

17. Bishara SE. Class  II malocclusions: Diagnostic and clinical considerations with and without treatment. Semin Orthod 2006; 12:11-24.

18. Voudouris JC, Kuftinec MM. Improved clinical use of twin-block and herbst as a result of radiating viscoelastic tissue forces on the condyle and fossa in treatment and long-term retention: Growth relativity. Am J Orthod Dentofacial Orthop 2000;117:247-66.

19. Neilson IL. Vertical malocclusions: Etiology, development, diagnosis and some aspects of treatment. Angle Orthod 1991; 61:247-55.

20. Carlson DS. Theories of craniofacial growth in the postgenomic era. Semin Orthod 2005;11:172-83.

How to cite this article: Hridaya NV, Ashok A. Catch-up growth after skeletal maturity - A case report. J Adv Clin Res Insights 2019;6:27-31.

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