Journal of Advanced Clinical and Research Insights

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Catch-up growth after skeletal maturity - A case report
  JCRI
CASE REPORT
Catch-up growth after skeletal maturity - A case report
N. 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
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
 
ABSTRACT
Class 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
How to cite this article: Hridaya NV, Ashok A. Catch-upgrowth after skeletal maturity - A case report. J Adv Clin ResInsights 2019;6:27-31.
 
 

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 alsohad 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.
  • To achieve a stable, functional occlusion and class I caninerelationship.
  • To achieve a pleasing smile and lip competence.

Journal of Advanced Clinical & Research Insights, January-February, Vol 6, 2019 27

Hridaya and Ashok Growth of mandible after skeletal maturity

Catch-up growth after skeletal maturity - A case report
Figure 1: Pre-treatment photographs

Catch-up growth after skeletal maturity - A case report
Figure 2: (a) Pre-treatment panoramic radiograph, (b) Pretreatmentcephalometric radiograph

 
Treatment plan

After discussion with parents, the following treatment plan wasselected.
  • Quad helix appliance on the upper arch for expandingconstricted upper arch and to provide space for palatallyblocked upper laterals.
  • Relieve occlusal interference caused by the palatally placedlateral incisors which lock the mandible, by fixed appliancetherapy with 022 slot MBT prescription brackets.
  • Extraction of two upper premolars to camouflage the skeletaldiscrepancy.
  • Use of class II elastics to encourage the catch-up growth ofthe mandible.

Method

It was decided to correct the transverse discrepancy and removethe occlusal interference caused by palatally placed lateralincisors as priority.[3,4] Quad helix appliance with long outerarms was adapted to touch the palatally placed lateral incisors[Figure 3a]. The appliance was expanded to 6 mm, followedby subsequent reactivations at 6 week intervals. Expansion wasconsidered adequate when the occlusal aspect of the maxillarylingual cusp of primary second molar contacts the occlusal aspectof the mandibular facial cusp of the primary second molar. Theteeth were bonded with 0.022 slot MBT prescription brackets,since our priority was to relieve the mandible from the occlusalinterference caused by palatally placed lateral incisors to facilitatethe remaining growth potential to express. After initial alignmentwith 0.016 NiTi wires, 55 and 65 were extracted and 15 wassurgically removed. It was decided to extract second premolarsinstead of first premolars because 25 was found missing in thepanoramic radiograph [Figure 3b]. A case was considered as ahigh anchorage case, and upper second molars were bandedand TPA was placed. Class II elastics were used to facilitatemandibular growth and reduction of overjet [Figure 3c]. Thepatient was cooperative and fixed appliance was removed in aspan of 1½ years, followed by fixed retainers in both the upperand lower arches.

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Growth of mandible after skeletal maturity Hridaya and Ashok

Table 1: Cephalometric values
Catch-up growth after skeletal maturity - A case report

 
Catch-up growth after skeletal maturity - A case report
Figure 3: (a) After delivery of quad helix, (b) After expansion andalignment, (c) Retraction with active tiebacks and Class II elastics

Treatment Results

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

When the changes in maxilla were studied by superimposingon Ba-Na and registering at nasion,[5] point A was found tomove posteriorly after treatment [Figure 6a]. Superimpositionon corpus axis, by taking PM as registration point, shows aforward movement of mandibular molars and incisors, bonedeposition in the mandibular anterior alveolar region above PM,condylar fossa remodeling in anterior direction and an increasein length of mandibular ramus [Figure 6b]. By superimposingon the palatal plane and by registering at ANS, retraction andintrusion 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 reductionof the forward growth of the maxilla and downward rotation ofthe anterior part of the palatal plane. The mandible showed afavorable growth in mandibular ramus area and anticlockwiserotation of mandible resulted in improvement in profile.Regional superimpositions on the stable structures[5] showedthe dentoalveolar changes in the molar and incisor along withremodeling of bony bases.

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Hridaya and Ashok Growth of mandible after skeletal maturity

Catch-up growth after skeletal maturity - A case report
Figure 4: Post-treatment photographs

Catch-up growth after skeletal maturity - A case report
Figure 5: (a) Post-treatment panoramic radiograph, (b) Posttreatmentcephalometric radiograph

 
Catch-up growth after skeletal maturity - A case report
Figure 6: Cephalometric superimpositions

Discussion

Choices for treating Class II malocclusions generally comprisesurgical correction or camouflage the skeletal discrepancy bydental compensation.[7,8] Here, the patient was not willingfor surgical correction. Treatment began during CVMI,CS6 stage. CS3 stage was considered to be the ideal time forthe treatment of Class II malocclusion due to mandibulardeficiency.[9] The patient had attained puberty 1 year back andso the circumpubertal growth period was almost over. However,But a catch-up growth of mandible was mostly seen when theinterference to mandibular growth was removed.[10,11]

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Growth of mandible after skeletal maturity Hridaya and Ashok

The presence of repaired cleft palate and palatally placedlaterals made quad helix the appliance of choice in this case. Incleft palate patients, the palatal suture system is disturbed andeither irregular or absent and permits an orthopedic response toquad helix expansion.[12-15] Furthermore, the skeletal resistance toexpansion is less in cleft palate patients.[12] In this case, adequateexpansion was achieved in 2 months' time.

In Angle's Class II Division 1 cases with large overjets, treatmentwith two premolar extractions gave a better occlusal success ratethan treatment with four premolar extractions.[16] Extractions in themandibular arch are often contraindicated in Class II Division 1 caseswith severe skeletal discrepancies since any uprighting of the lowerincisors can increase the distance that the upper anterior teethneed to be retracted to correct the overjet.[17] Need for anteriormovement of mandibular teeth, retrusive mandibular incisors, andpresence of at least a minimal mandibular growth potential madeuse of class II elastics appropriate in this case.[7]

A mesial movement of the mandibular teeth may havetriggered a condylar response as said in the studies of Voudourisand Kuftinec.[18] The reduction of the mandibular plane angle canbe attributed an increase in ramus length[19] and counterclockwiserotation of mandible. Change in occlusion would havecontributed to this.[20] A catch-up growth of the mandible wasevident when conditions became favorable in this case even afterthe active phase of mandibular growth (CS6 stage).

Conclusions
  • A thorough case history, clinical examination, andcephalometric analysis assisted in the diagnosis and successfulcorrection of the deformity.
  • A successful correction of proclination was achieved bydental camouflage using extraction and Class II elastics.
  • Mandibular skeletal changes were brought about by theexpansion of maxillary arch and use of Class II elastics.
  • A change in the position of maxillary dental arch has triggereda growth at lower anterior dentoalveolar region and growth atcondyles.

References
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