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Two-phase treatment of a hypodivergent

skeletal Class II patient with a missing
maxillary canine.

Article in Journal of clinical orthodontics: JCO · May 2014

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CASE REPORT
Two-Phase Treatment of a
Hypodivergent Skeletal Class II Patient
with a Missing Maxillary Canine
ELIE W. AMM, DCD, DES
EDMOND A. CHAPTINI, DCD, DUO, DEA
JIM C. BOLEY, DDS, MS

N on-syndromic congenital
absence of the canines in the
permanent dentition is rare, with
a reported incidence of .01-2.1%.
Although studies have reported
more of a preponderance in the
maxillary arch and among fe-
males and Asian populations,1-4
most reports on the prevalence of
hypodontia do not even mention
the permanent canines.5-12
On the other hand, a Class
II, division 1 malocclusion is one
of the most common situations in
everyday practice. When a young
child presents with a skeletal
Class II condition, the orthodon-
tist is faced with the question of
whether to treat the patient early
or to wait until the permanent
dentition stage. Most clinical tri-
als and a systematic review sug-
gest that two-phase orthodontic
treatment of young children with
mild-to-severe Class II, division
1 malocclusions is no more effec-
tive than one-phase treatment.13-15
There are other advantages to
two-phase treatment, however,
that may lead the clinician to rec-
ommend early intervention.16-19
This report describes the
two-phase treatment of a young
patient with a severe Class II,
division 1 malocclusion and agen-
esis of the upper left canine.

Dr. Amm Dr. Chaptini Dr. Boley

Dr. Amm is a Clinical Assistant Professor and Dr. Chaptini is a Senior Lecturer, Department of Orthodontics, School of Dental Medicine, St. Joseph
University, Beirut, Lebanon. Dr. Amm is also in the private practice of orthodontics in Byblos and Beirut, Lebanon. Dr. Chaptini is also in the private
practice of orthodontics in Jounieh, Lebanon, and Dubai, United Arab Emirates. Dr. Boley is a Professor, Department of Orthodontics, Baylor
College of Dentistry, Dallas, and in the private practice of orthodontics in Richardson, TX. Contact Dr. Amm at Maria Center, N.D. des Secours
Hospital Road, Mar Geryes, Jbeil 4503-3003, Lebanon; e-mail: elieamm@hotmail.com.

VOLUME XLVIII  NUMBER 5 ©  2014 JCO, Inc. 303

Two-Phase Treatment of a Hypodivergent Skeletal Class II Patient
Diagnosis
A 10-year-old male present-
ed with the chief complaint of
prominent and spaced upper front
teeth. Clinical examination
showed a retrusive chin, a men-
talis strain consistent with lip
incompetence at rest, the lower lip
trapped behind the upper incisors,
and an excessive posterior gingi-
val display (6mm) in smiling
(Fig. 1). The maxillary arch was
in the mixed dentition stage and
the mandibular arch in the late
mixed dentition. While there
were diastemas between all the
upper incisors, there was 1mm of
crowding in the lower incisor
region. The upper midline was
shifted 2mm to the left, and the
curve of Spee was 2mm deep.
The molars were in a full Class II
relationship, with a 15mm overjet
and a 60% overbite.
The panoramic radiograph
confirmed the late mixed denti-
tion stage, as well as the absence
of the upper left permanent
canine. The second molars were
unerupted, and the germs of the
four third molars were present.
Cephalometric analysis in-
dicated a skeletal Class II maloc-
clusion with a hypodivergent
pattern. The upper incisors were
protrusive, but the lower incisors
were slightly retrusive. The E-line
was consistent with a convex pro-
file and a protrusive upper lip.
Treatment Plan
Treatment objectives were
to improve the skeletal discrep-
ancy and harmonize the profile,
control the gingival display,
retract the protruded upper inci-
304
sors, correct the severe overjet,
close the diastemas, and resolve
the issue of the missing upper left
canine.
Five treatment alternatives
were proposed. Three involved
delaying comprehensive treat-
ment until the early permanent
dentition and either maintaining
the canine space with a Maryland
bridge until the patient was old
enough for a permanent implant;
extracting the upper right first
premolar, closing the canine
space, and finishing the occlusion
in a Class II camouflage on both
sides; or closing the canine space
with asymmetrical mechanics.
Two other options involved an
immediate first phase of high-
pull headgear to control the verti-
cal dimension and correct the
skeletal Class II, followed by a
second phase including either
maintenance of the canine space
with a Maryland bridge until
maturation and implant place-
ment or closure of the canine
space to finish with a Class I
occlusion on the right and Class
II camouflage on the left.
Because the parents were
not enthusiastic about a future
implant placement and the patient
was extremely self-conscious
about his protrusive incisors, the
final treatment option was chosen.
Treatment Progress
The upper first molars were
banded with double tubes, and a
high-pull headgear was pre-
scribed to be worn 14 hours per
day. The outer arms of the face-
bow were cut shorter and reposi-
tioned in front of the centers of
resistance of the molars to prevent
distal tipping. This first phase of
treatment lasted 12 months (Fig.
2, Table 1).
After a latent period of six
months while awaiting the com-
pletion of the permanent denti-
tion, .022" standard edgewise
brackets were bonded first in the
maxillary arch and four months
later in the mandibular arch.
Class III elastics were applied for
leveling, and lingual crown torque
was added to the lower incisors to
maintain their positions.
Following seven months of
leveling, alignment, and space
management, there were wider
spaces distal to the upper left lat-
eral incisor than distal to the
upper right lateral incisor. We
then decided to close the space of
the missing upper left canine uni-
laterally. The mandibular arch
was stabilized with an .020" ×
.025" stainless steel wire, and an
.020" × .025" stainless steel clos-
ing wire with bull loops distal to
the lateral incisors was placed in
the upper arch, including the sec-
ond molars. This closing archwire
was activated progressively, with
Class II elastics worn only on the
right side to maintain the midline
correction.
After nine months of space
closure, a final upper .020" ×
.025" stainless steel archwire was
placed, and the occlusion was
settled with elastics.
Fixed appliances were re-
moved after 30 months of Phase
II treatment, and 3-3 mandibular
and maxillary 2-2 lingual retain-
ers were bonded. A thermo-
formed removable maxillary
retainer was fabricated to be
JCO/MAY 2014
 Amm, Chaptini, and Boley

Fig. 1 10-year-old male patient with

Class II malocclusion, prominent and
spaced upper incisors, retrusive chin,
and congenitally missing upper left
permanent canine before treatment.

VOLUME XLVIII  NUMBER 5 305

Two-Phase Treatment of a Hypodivergent Skeletal Class II Patient

TABLE 1 favorable mandibular response to

CEPHALOMETRIC ANALYSIS the headgear therapy, as well as
the amount of growth. Changes in
Pre- After Post- the Wits appraisal and ANB con-
Norm treatment Phase I Treatment firmed this skeletal improvement
(Table 1). The upper and lower
SN 75.0mm 66.3mm 67.4mm 70.1mm
incisors remained in their initial
SNA 82.0° 79.8° 79.6° 75.3°
positions, but the upper molars
SNB 80.9° 72.6° 74.5° 73.6° exhibited distal root and mesial
N-A-Pog 2.6° 9.2° 6.0° –2.8° crown tipping along with vertical
Wits appraisal –1.0mm 6.7mm 2.0mm –1.5mm intrusion.
ANB 1.6° 7.2° 5.1° 1.8° The post-treatment extra-
Co-ANS 91.3mm 81.7mm 82.9mm 82.8mm oral photographs demonstrated a
Co-Pog 113.0mm 99.1mm 102.6mm 110.6mm balanced and harmonious profile
ANS-Me 68.6mm 59.4mm 58.3mm 63.3mm with an improved chin-to-lip con-
FMA 24.5° 22.7° 21.0° 20.3° tour and lip competence, and no
N-ANS 64.3mm 46.5mm 49.1mm 52.5mm mentalis strain. The smile arc
ANS-Me 68.6mm 59.4mm 58.3mm 63.3mm was in harmony with the lower
lip, and the gingival display was
UAFH/LAFH 80.0% 78.3% 84.2% 83.2%
reduced, showing normal ante-
L1-MP 39.0mm 33.5mm 32.9mm 35.0mm
rior-to-posterior distribution.
U1-PP 28.0mm 26.8mm 26.0mm 27.3mm While the intraoral photographs
U1-FH 111.0° 125.5° 124.7° 107.4° confirmed proper alignment, a
U1-NA 22.8° 34.9° 33.6° 19.0° 1mm midline discrepancy per-
U1-NA 4.3mm 7.1mm 6.2mm 1.8mm sisted. Treatment ended with
Interincisal angle 130.0° 115.8° 118.5° 135.0° Class I canine and molar relation-
L1-NB 25.3° 22.1° 22.9° 24.2° ships on the right side and a Class
L1-NB 4.0mm 2.5mm 1.3mm 2.3mm I first-premolar and Class II
IMPA 95.0° 96.0° 95.9° 97.3° molar relationship on the left
L1-APo 2.7mm –3.7mm –3.2mm –1.2mm side. The final panoramic radio-
U1-StS 2.0mm 7.9mm 5.8mm 6.8mm graph showed root parallelism
and sufficient space for eruption
UL-E plane –4.8mm –1.2mm –1.2mm –5.4mm
of the upper left third molar.
LL-E plane –2.0mm –2.3mm –3.7mm –5.2mm
The final cephalometric
analysis and overall superimposi-
tion substantiated the profile
worn full time for one month and gear and intermaxillary elastics, improvement and growth expres-
then at night only. but not in oral hygiene. Both the sion (Wits appraisal, ANB, UL-E
patient and his parents expressed plane), as well as an increase in
satisfaction with his facial appear- the interincisal angle to a more
Treatment Results
ance, profile, and smile. functional relationship (Fig. 3B,
All objectives were achieved At the end of Phase I, the Table 1). The palatal superimpo-
after a total 42 months of active upper molars were still in a Class sition showed no distal movement
treatment and six months between II relationship, and their crowns of the molars, but merely upright-
the two phases (Fig. 3, Table 1). were mesially tipped (Fig. 2). ing of the upper incisors (U1-FH,
The patient showed excellent Superimposition of the initial and U1-NA). The mandibular super-
compliance in wearing his head- progress tracings illustrated the imposition confirmed control of

306 JCO/MAY 2014

 Amm, Chaptini, and Boley

the lower incisors and the favor-
able growth response.
One year after treatment,
the patient exhibited a slight
opening of spaces distal to the
upper lateral incisors (Fig. 4). He
admitted that he had worn his
thermoformed retainer for only
the first month after the debond-
ing appointment.
Discussion
The literature suggests that
canine agenesis is attributable
more to genetic than to systemic
or environmental factors.1-4,20 In
Class II patients with bilateral
missing canines, space-closure
mechanics are no different from
those used in first-premolar-
extraction cases.20,21 The best
option for a patient with a unilat-
eral missing canine, however, is
still considered to be replacement
with a dental implant.22,23 Although
unilateral space closure can be
achieved with skeletal anchorage,
the present case demonstrates a
satisfactory, stable outcome with
no side effects using asymmetrical
conventional mechanics.
The remaining midline dis-
crepancy in this case—due to a
tooth-size discrepancy and
mesiodistal arch-length differ-
ence between the right canine
and left first premolar—was im-
perceptible to the patient and did
not affect occlusal function. The
spaces that appeared distal to the
upper lateral incisors one year
after treatment were caused by a
lack of compliance with retainer
wear and also by an undiagnosed
Bolton discrepancy. The absence
of the canine on the left side
allowed enough space for erup-

A
Fig. 2 A. Patient after 12 months of Phase I
treatment. B. Superimposition of pretreatment
and post-Phase I cephalometric tracings. B

VOLUME XLVIII  NUMBER 5 307

Two-Phase Treatment of a Hypodivergent Skeletal Class II Patient

Fig. 3  A. Patient after 42 months of

active Phase I and Phase II treat-
ment (continued on next page).

308 JCO/MAY 2014

 Amm, Chaptini, and Boley

Fig. 3 (cont.)  B. Superimposition of

pre- and post-treatment cephalo-
metric tracings.

Fig. 4  Patient one year after debonding.

VOLUME XLVIII  NUMBER 5 309

Two-Phase Treatment of a Hypodivergent Skeletal Class II Patient
tion of the third molar on the
same side. After the retention
period, the patient was referred
to his dentist for optional cos-
metic restorations to close the
maxillary spaces and to reshape
the left first premolar so it would
more closely resemble the contra-
lateral canine. A periodontal
evaluation was also recommend-
ed for oral-hygiene instruction,
treatment of the hypertrophic
periodontal tissues, and a poten-
tial gingivoplasty to harmonize
the gingival margins.
The first phase of treatment
was started relatively early for
esthetic reasons, after a lengthy
discussion with the patient and his
parents about the advantages and
disadvantages of such a decision.
The parents believed that respond-
ing promptly to their child’s con-
cerns would enhance his self-
esteem and prevent teasing by
schoolmates. That opinion is sup-
ported by short-term studies
showing varying degrees of
enhanced well-being when chil-
dren and adults receive ortho-
dontic treatment, as well as by
others demonstrating that early
orthodontic treatment results in
improved perceptions of facial
attractiveness.19,24,25 On the other
hand, longer-term studies have
concluded that children who
receive orthodontic treatment
show better tooth alignment and
greater satisfaction, but that ortho-
dontics has little impact on their
psychological health and quality
of life in adulthood.26 Of course,
our patient was already seeking
help at the initial consultation.
310
Even though this patient’s
facial pattern was hypodivergent,
we prescribed a high-pull head-
gear in an attempt to control
the vertical dimension and to
promote optimal mandibular
response during the first phase
of treatment, especially consid-
ering the posterior gingival dis-
play in smiling. Holberg and
colleagues found that the effects
of headgear therapy are primar-
ily dentoalveolar, with a more
questionable skeletal effect re-
sulting from the inhibition of
sutural growth.27 In our patient,
the superimposition of initial and
post-Phase I tracings showed that
the maxilla continued to grow
while the upper molar was
intruded, confirming that the
sagittal enhancement was at-
tributable mainly to mandibular
growth. The final superimposi-
tions provided no evidence of a
skeletal treatment effect on the
maxilla: the maxilla continued
to grow, while the upper first
molars were mesialized but not
extruded and the upper incisors
were uprighted. The mandible
expressed vertical and horizontal
growth, but the lower incisors
were well controlled.
Conclusion
The results shown in this
patient with a congenitally miss-
ing canine suggest that our treat-
ment plan could also be an
acceptable compromise in cases
with severely impacted maxillary
canines whose successful retriev-
al is dubious.
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