CDABO CASE REPORT

Treatment of a Class I malocclusion with a carious mandibular

incisor and no Bolton discrepancy

Vincent O. Kokich, Jr, DMD, MSDa

Tacoma, Wash

Occasionally orthodontists must plan treatment for a patient with extensive caries or a traumatic injury to one
mandibular incisor. If the patient has a Bolton discrepancy, one treatment option could involve extraction of the
affected mandibular incisor. However, if the patient does not have a Bolton discrepancy and a mandibular incisor
is extracted, the treatment becomes more complicated. This case report will present and discuss the ramifications
of extracting one mandibular incisor in a patient without an anterior tooth-size discrepancy. The CDABO Student
Case Selection Committee chose this case for publication. (Am J Orthod Dentofacial Orthop 2000;118:107-13)

his 34-year 6-month old white male was concerned
T with the appearance of his smile and specifically
with the alignment of his anterior teeth. His oral
hygiene was poor, and he had a significant dental his-
tory that included previous trauma to the maxillary right
central incisor. However, he was genuinely interested in
improving his overall dental health and esthetics.
DIAGNOSIS AND ETIOLOGY
Facially, the patient appeared to be symmetrical,
and he had satisfactory lip support and displayed no
maxillary gingiva when smiling (Fig 1). Skeletally, he
had a mildly retrognathic mandible with a good chin
prominence (Fig 2). Intraorally, composite resin
restorations on the maxillary central and lateral incisors
were failing. One maxillary central incisor appeared
darker than the adjacent central incisor as a result of the
previous trauma and subsequent root canal therapy. The
mandibular right lateral incisor was fractured and had
severe caries (Figs 3 and 4).
The patient had a Class I malocclusion with 5.0 mm
of overjet and 75% overbite. The arch length deficien-
cies were 2.0 mm in the maxillary arch and 9.0 mm in
the mandibular arch (Fig 3). His maxillary midline was
coincident with his facial midline, and the mandibular
midline was shifted 2.0 mm to the right (Fig 1). A
Bolton analysis showed a 1.0 mm maxillary anterior
excess. The panoramic radiograph and anterior periapi-
cal radiographs (Fig 4) also revealed the fractured and
carious mandibular right lateral incisor. Cephalometri-
aAffiliate Assistant Professor, Department of Orthodontics, University of Wash-
ington School of Dentistry.
Reprint requests to: Vincent O. Kokich, Jr, DMD, MSD, 1950 S. Cedar, Suite
E, Tacoma, WA 98466
Submitted, 2/00; accepted for publication, 3/00.
Copyright © 2000 by the American Association of Orthodontists.
0889-5406/2000/$12.00 + 0 ems 8/4/108562
doi.10.1067/mod.2000.108562
cally, the patient exhibited mild mandibular retro-
gnathia with slightly proclined maxillary incisors and
relatively upright mandibular incisors (Fig 2).
TREATMENT OBJECTIVES
Facial esthetics: Maintain upper lip support, main-
tain facial profile.
Occlusion: Maintain the Class I molar relationship,
improve the Class I canine relationship, and reduce the
overjet and overbite.
Maxillary dentition: Eliminate the arch length defi-
ciency, level the anterior gingival margins, and improve
the buccal overjet of the left first molar.
Mandibular dentition: Eliminate the arch length
deficiency, maintain a mild curve of Spee, and procline
the incisors.
TREATMENT ALTERNATIVES
The main issues involved in developing the appro-
priate treatment plan were the severely fractured and
carious mandibular right lateral incisor and the possi-
bility of a significant tooth-size discrepancy with
extraction of this tooth. Therefore, 2 treatment options
were presented to the patient. The first involved nonex-
traction orthodontic therapy and restoration of the
mandibular right lateral incisor. This would allow easy
correction of the overjet and overbite and maintain the
posterior occlusion. The second option involved extrac-
tion of the fractured mandibular incisor. This would
complicate treatment by introducing a large maxillary
tooth-size excess, which would have to be eliminated
by selective reproximation of the maxillary anterior
teeth. A diagnostic wax set-up was constructed that
showed 5.0 mm of enamel must be removed interprox-
imally from the 6 maxillary anterior teeth to produce
satisfactory overbite and overjet. Either treatment plan
could produce successful, esthetic treatment results.
107
108 Kokich
Fig 1. Pretreatment facial photographs.
A B
Fig 2. Pretreatment cephalometric (A) radiograph and (B) tracing.
However, for financial reasons, the patient chose option
2: to extract the fractured mandibular incisor.
TREATMENT PROGRESS
Appliances were placed using an indirect bonding
technique. Ormco .022 × .028-inch slot bands and brack-
ets were used. After placement of the appliances, the
mandibular right lateral incisor was extracted. Initial lev-
eling was accomplished with the use of nickel titanium
archwires over 4 months. This was followed by selective
bracket repositioning and continued leveling with .018-
inch nickel titanium and stainless steel archwires. After
leveling, the maxillary incisors were proclined, and 4.0
mm of overjet was present. According to the diagnostic
wax set-up, 5.0 mm of enamel had to be removed inter-
proximally from the maxillary anterior teeth. Therefore,
0.5 mm was reduced from each interproximal surface of
the 6 anterior teeth (10 surfaces). This was accomplished
in 2 appointments. At each appointment 0.25 mm of
enamel was removed per surface. After each reproxima-
tion, elastomeric chain was used to close the interproxi-
mal spaces with an .018-inch stainless steel archwire.
American Journal of Orthodontics and Dentofacial Orthopedics
July 2000
The mandibular incisors were proclined labially,
and a mild mandibular curve of Spee was maintained
during alignment to decrease the amount of overjet
and establish incisor contact. Vertical elastics were
worn during the final 4 months of treatment to finish
the occlusion.
A maxillary circumferential removable retainer was
used to retain the maxillary arch, and a lingual bonded
retainer from canine to canine was used to retain the
mandibular arch.
TREATMENT RESULTS
Facial esthetics: Overall facial esthetics were
maintained, and upper lip support was slightly
improved (Fig 5).
Occlusion: The Class I molar relationship was main-
tained, and the Class I canine relationship was improved.
The overjet and overbite were reduced (Figs 5, 6, and 7).
Maxillary dentition: The arch length deficiency was
eliminated. The anterior gingival margins were leveled,
and the buccal overjet of the left first molar was
improved (Fig 7).
American Journal of Orthodontics and Dentofacial Orthopedics Kokich 109
Volume 118, Number 1

Fig 3. Pretreatment dental casts.

A B
Fig 4. Pretreatment (A) panoramic and (B) periapical radiographs.

Mandibular dentition: The arch length deficiency
was eliminated, the incisors were proclined, and a mild
curve of Spee was maintained (Figs 6 and 7).
The pretreatment cephalometric radiograph (Fig 2)
and cephalometric summary (Table I) demonstrated
significant positional changes to the maxillary and
mandibular incisors. The maxillary incisors were retro-
clined during treatment from a pretreatment 1-FH
angle of 73° to a posttreatment angle of 53°. The
– DISCUSSION
mandibular incisors were proclined from an initial 1-
MP angle of 83° to a final measurement of 97°. As a
result, the interincisal angle decreased from 153° to
120°. The rest of the cephalometric evaluation
remained within the acceptable range of normal from
pretreatment to posttreatment (Fig 2, Table I).
The treatment results met all the initial objectives.
The large Bolton discrepancy created by extraction of the
mandibular right lateral incisor was eliminated by selec-
tive reproximation of the maxillary anterior teeth (Figs 7
and 8). Facial esthetics were also maintained (Fig 5), and
the patient was pleased with the overall result.
A Class I malocclusion with a significant mandibu-
lar tooth-size excess can frequently be treated by
extracting 1 mandibular incisor.1-3 Mild interproximal
110 Kokich
Fig 5. Posttreatment facial photographs.
A B
Fig 6. Posttreatment cephalometric (A) radiograph and (B) composite tracing.
reduction is typically necessary to establish satisfac-
tory overbite and overjet. However, extraction of 1
mandibular incisor in a Class I malocclusion with
no Bolton discrepancy decreases the chances of
obtaining proper overbite and overjet. Therefore, this
would be considered an unconventional treatment
unless it was unavoidable or the alternatives unaf-
fordable. Removing 5.0 mm of tooth structure intro-
duces a far more difficult treatment situation. There-
fore, the decision to extract must be confirmed with a
diagnostic wax set-up that simulates the eventual
treatment outcome.
Certain principles should be evaluated before mak-
ing this decision. These include:
1. Size of the Bolton discrepancy
2. Shape of the maxillary and mandibular incisor
crowns
3. Width of the maxillary incisor roots
4. Amount of interproximal enamel on the maxillary
incisor crowns
American Journal of Orthodontics and Dentofacial Orthopedics
July 2000
5. Inclination of the maxillary and mandibular incisors
6. Health of the mandibular incisors
7. Congenital absence of teeth
8. Stability
A mandibular tooth-size excess greater than 1.6
mm, as determined by the Bolton analysis, is consid-
ered significant4 and can typically be handled in 1
of 3 ways: interproximal reduction, extraction, or
restoration. Appropriate case selection is critical.
First, the width of the mandibular incisor crowns can
be narrowed by reducing a predetermined amount
from each interproximal contact point. The ideal
crown shape for reproximation is tapered toward the
gingival margin. This allows for easy interproximal
reduction and improvement of the overall crown
shape. The appropriate amount of enamel reduction is
determined from anterior periapical radiographs and
the pretreatment diagnostic wax set-up. The amount
of available interproximal enamel must measure more
than the required amount of reduction per interproxi-
American Journal of Orthodontics and Dentofacial Orthopedics Kokich 111
Volume 118, Number 1

Table I. Cephalometric summary

Area of study Measurement Standard (A-1) (A-2)

Cranial base
S-N Length 73-81 mm 82 mm 82 mm
SN-FH 0°-11° 2° 2°
Maxilla to cranial base
SNA 75°-87° 86° 88°
Na-FH 84°-96° 88° 88°
Mandible to cranial base
Facial angle 82°-95° 85° 85°
SNB 72°-87° 82° 84°
Maxillomandibular relationships
ANB 1°-5° 4° 4°
AB Plane-Npo 0°-(–9)° –6° –8°
Vertical height
Y Axis-SN 61°-72° 63° 65°
MnPl-FH 18°-30° 24° 28°
MnPl-SN 22°-42° 27° 29°
Maxillary and mandibular incisor position
1-NA 3°-31° 12° 25°
1-NA (mm) (-2)-8 mm 3.5 mm 5 mm
–
1 -FH 53°-78° 73° 53°
–
1 -MP 81°-97° 83° 97°
–
1 -NB (mm) 1-10 mm 3.5 mm 7 mm
Soft tissue
Holdaway angle 8° 14° 14°
“O” meridian (mm) 0 mm –7.5mm –7mm
Other
% Nasal ht 40%-46% 44% 44%
–
1-1 130°-150° 153° 120°
Occl Pl-FH 1°-14° 6° 7°
Holdaway ratio 3:2 3.5:1.5 7:1.5

mal contact point. If too much enamel is removed,
dentin can be exposed, significantly increasing the
risk for caries and tooth sensitivity.1
Width of the maxillary incisor roots is also important
when determining the appropriate amount of interproxi-
mal enamel reduction. It, too, should be evaluated by
studying the incisor periapical radiographs. Maxillary
incisors with wide mesiodistal dimensions at the cervical
portion of the root do not allow for substantial interprox-
imal reduction due to the potential for root proximity
problems after space closure. These issues should be con-
sidered when performing the initial treatment planning
and diagnostic wax set-up. The achievable alterations are
then transferred to the patient during interproximal reduc-
tion in the finishing stages of orthodontic treatment.
Another option involves extraction of 1 mandibular
incisor. This is generally done in patients with Bolton
discrepancies greater than 2.0 mm. The decision to
extract should be supported by the initial records, diag-
nostic wax set-up, and clinical experience. Additional
information, such as Bolton analysis, shape of the max-
illary incisor crowns, and amount of interproximal
enamel is also important.
The third alternative involves restoration of the
maxillary lateral incisors. The cause of the Bolton dis-
crepancy in these patients is often a narrow or “peg-
shaped” maxillary lateral incisor crown. Therefore,
the ideal treatment is to restore one or both of these
teeth to their natural proportional width, approxi-
mately two thirds of the width of the adjacent central
incisors. A diagnostic set-up on which the maxillary
lateral incisor crowns have been restored with wax
will confirm this. This is important information to
have available at the time of restoration.
Each of the 3 aforementioned treatment modalities
can be used alone or in conjunction with the other 2.
Proper case selection as well as diagnostic protocol and
treatment choice are important issues when evaluating
patients with significant Bolton discrepancies, small
maxillary lateral incisors, and/or a congenitally miss-
ing, fractured, or carious mandibular incisor.
There are specific instances when treatment of Class
I malocclusions with no Bolton discrepancy could
require lower incisor extraction. These include trauma,
severe caries, or congenital absence of one of the
mandibular incisors. In these patients, the easiest treat-
112 Kokich American Journal of Orthodontics and Dentofacial Orthopedics
July 2000

Fig 7. Posttreatment dental casts

A B

Fig 8. Posttreatment (A) panoramic and (B) periapical radiographs.

ment plan would be to extract the affected tooth or
accept the absence of a congenitally missing incisor—
the least expensive option for the patient. However, the
easiest and least expensive alternative is not always in
the best interest of the patient. Therefore, it is imperative
to evaluate the other diagnostic criteria: Bolton analysis,
crown shape, amount of interproximal enamel, and root
width, before making the extraction decision. What may
seem the easiest treatment plan often becomes more dif-
ficult and time consuming than originally anticipated.
The final principle that should be assessed in
patients requiring a single mandibular incisor extrac-
tion is the inclination of the maxillary and mandibular
incisors. Upright maxillary incisors and proclined
mandibular incisors decrease the amount of maxillary
interproximal reduction necessary to establish occlusal
contact between the incisors. This is important because
it maintains protrusive guidance and eliminates poste-
rior interferences in protrusive function.1
Also important when evaluating a patient for
extraction or reproximation of the mandibular incisors is
the issue of stability. Studies have investigated the long-
term stability of patients treated with lower incisor
extraction2,3 or selective reproximation of the mandibular
incisors.5 Reidel et al2 evaluated the pretreatment, post-
treatment, and 10-year postretention records of 42
patients. Each patient had 1 or 2 mandibular incisors
extracted before complete orthodontic treatment. They
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 118, Number 1
compared the overall stability of patients treated with
premolar extractions and those treated with extraction of
1 mandibular incisor. They found more acceptable
mandibular incisor alignment in those patients treated
with a single incisor extraction at postretention (29%).
The premolar extraction cases demonstrated 70% unac-
ceptable incisor alignment at postretention.
Canut3 also found better stability in patients who had
1 mandibular incisor extracted when compared with
patients requiring premolar extraction. He evaluated the
pretreatment, posttreatment, and 5- to 8-year postreten-
tion records of 26 patients. He used Little’s irregularity
index6 to determine a net mean improvement in align-
ment of 3.91 from pretreatment to postretention.
Gilmore and Little5 evaluated incisor dimensions
and stability by evaluating the postretention records of
134 patients who had undergone orthodontic treatment
at the University of Washington. They found a weak
tendency for narrower incisors to be associated with
improved alignment. However, their results indicated
that narrower mesiodistal widths of the mandibular
incisor crowns did not guarantee better long-term sta-
bility of lower incisor alignment.
Kokich 113
Mandibular incisor extraction can be an effective
treatment choice for the appropriate malocclusion.
However, several factors must be considered before
making the final treatment decision. In addition, eval-
uation of a diagnostic wax set-up will allow the ortho-
dontist to predict the success of the proposed treat-
ment plan. Finally, research has shown that lower
incisor alignment after single mandibular incisor
extraction is significantly more stable than after pre-
molar extraction.
REFERENCES
1. Kokich VG, Shapiro PA. Lower incisor extraction in orthodontic
treatment. Angle Orthod 1984;54:139-53.
2. Riedel RA, Little RM, Bui TD. Mandibular incisor extraction:
postretention evaluation of stability and relapse. Angle Orthod
1991;62:103-16.
3. Canut JA. Mandibular incisor extraction: indication and long-
term evaluation. Eur J Ortho 1996;18:485-9.
4. Bolton WA. Disharmony in tooth size and its relation to the analy-
sis and treatment of malocclusion. Angle Orthod 1958;28:113-30.
5. Gilmore CA, Little RM. Mandibular incisor dimensions and
crowding. Am J Orthod 1984;85:493-63.
6. Little RM. The irregularity index: a quantitative score of
mandibular anterior alignment. Am J Orthod 1975;68:554-63.