CASE REPORT C

A relatively minor adult case becomes significantly

complex: A lesson in humility
Mitra Derakhshan, DDS, MS,a and Cyril Sadowsky, BDS, MSb
Chicago, Ill

A 41-year-old white woman with no particular concerns about facial esthetics was first seen with bilateral Class II
molar relationship, a Class I right canine, and a Class II left canine. Overjet was 3 mm and overbite was 0.5 mm,
with no incisor contact. A maxillary right premolar was missing for unknown reasons and all 4 third molars had
previously been extracted. The maxillary midline was 2 mm to the right of the facial midline, and the mandibular
midline was 3.5 mm to the left of the maxillary midline. There was 7 mm of crowding in the maxillary arch and 6
mm of crowding in the mandibular arch, with an increased curve of Spee. The patient had a well-positioned
maxilla, a retrognathic mandible with increased convexity, a Class II denture base relationship, and a vertical facial
pattern. The treatment plan consisted of extracting the maxillary left first premolar and the mandibular left central
incisor. After 4 months of treatment, an open bite from second premolar to second premolar was noted. After 6
months of treatment, the patient expressed concern with her chin position and mentalis hyperactivity. It was
apparent that the orthodontic treatment had resulted in molar extrusion, which the musculature was not able to
withstand. Treatment continued and the case was set up for posterior maxillary impaction and mandibular
advancement surgical procedures. (Am J Orthod Dentofacial Orthop 2001;119:546-53)

I
t is particularly important for the clinician to address
the adult patient’s chief concerns when deciding on a
treatment plan. Alternate treatment plans may be pre-
sented, but the patient may only accept a treatment plan
with limited objectives. A comprehensive examination
and diagnosis is essential so potential limitations and
complications can be anticipated. When treating any
patient there is the possibility of a dual bite that may not
be obvious before treatment but may be revealed as treat-
ment progresses. Additionally, the response to mechan-
otherapy, particularly posterior tooth extrusion, has signif-
icant potential for affecting mandibular position, which
may also complicate treatment. This case report describes
an adult case that was planned for limited objectives,
responded poorly to treatment, and eventually resulted in
comprehensive treatment, including orthognathic surgery.
HISTORY
The patient was a 41-year-old white woman who
was not particularly concerned about facial esthetics
but wanted to know, “What can be done about my
From the Department of Orthodontics, College of Dentistry, University of Illi-
nois at Chicago.
aFormer resident.
bProfessor.
Reprint requests to: Cyril Sadowsky, University of Illinois at Chicago, College
of Dentistry, Department of Orthodontics, 801 S Paulina St, Chicago, IL 60680;
e-mail, cyrilsad@uic.edu.
Submitted, November 1999; revised and accepted, June 2000.
Copyright © 2001 by the American Association of Orthodontists.
0889-5406/2001/$35.00 + 0 8/4/112113
doi:10.1067/mod.2001.112113
546
teeth?” Her medical history was noncontributory; her
dental history consisted of childhood first molar
restorations. Overall, the dentition was healthy and oral
hygiene was good. A maxillary right premolar was
missing for unknown reasons and all 4 third molars had
previously been extracted. During the initial examina-
tion, there were no symptoms of temporomandibular
dysfunction, her mandibular range of motion was good,
and no mandibular functional shift was noted.
Facial analysis revealed a dolichofacial pattern and
a retrognathic profile with increased convexity (Fig 1).
Her nasal tip was deviated to the right. The maxillary
incisor to upper lip position was good, both at rest and on
smiling. She had minimal lip strain, and the lips were
retrusive to the E plane (Rickett’s esthetic plane, nose tip
to chin). Full mouth radiographs revealed normal alveolar
bone levels with a few amalgam restorations (Fig 2). The
study models showed that the right and left molars were in
a Class II relationship, the right canine was Class I and the
left canine was Class II (Fig 3). One maxillary right pre-
molar was missing. There was 3 mm of overjet and 0.5
mm of overbite with no incisor contact. The maxillary
midline was 2 mm to the right of the facial midline, and
the mandibular midline was 3.5 mm to the left of the max-
illary midline. There was 7 mm of crowding in the maxil-
lary arch, with the maxillary left lateral incisor to the
labial. The canines were asymmetric. Crowding of the
mandibular arch was 6 mm, and the curve of Spee was
increased. There was no Bolton discrepancy. The cephalo-
metric analysis showed a well-positioned maxilla and ret-
rognathic mandible resulting in increased convexity
American Journal of Orthodontics and Dentofacial Orthopedics Derakhshan and Sadowsky 547
Volume 119, Number 5

Fig 1. Pretreatment facial photographs.

Fig 2. Pretreatment full mouth radiographs.

(Table I, Fig 4). There was a Class II denture base rela-
tionship and a vertical facial pattern. Her lower face height
was increased. The maxillary and mandibular incisors
were well positioned to the A-pogonion line. The maxil-
lary incisors were retroclined, and the mandibular incisors
were slightly proclined. The primary etiologic factor was
assumed to be developmental crowding complicated by
the absence of a maxillary right premolar.
extract the mandibular left central incisor to resolve the 6
mm of crowding. Facial esthetics were of no concern; the
treatment objectives were solely dental. These objectives
were: (1) to achieve a Class I canine relationship and
maintain the Class II molar relationship, (2) align the
maxillary midline to the face, and (3) resolve the crowd-
ing in the maxillary and mandibular arches while main-
taining incisor position anteroposteriorly.

TREATMENT OBJECTIVES TREATMENT ALTERNATIVES

One maxillary right premolar was missing, the max-
illary midline was deviated 2 mm right, and there was 7
mm of maxillary crowding. Thus, it was decided to
extract the maxillary left first premolar. This would estab-
lish Class I canines, correct the midline, and resolve the
crowding. In the mandibular arch, the decision was to
Because the patient did not express concerns with
facial esthetics, an orthognathic surgical approach was
not discussed. A diagnostic wax-up was performed that
indicated satisfactory occlusal relationships, one of the
patient’s concerns. The treatment plan was presented to
the patient for acceptance.
548 Derakhshan and Sadowsky American Journal of Orthodontics and Dentofacial Orthopedics
May 2001

Fig 3. Pretreatment study models.

Table I. Cephalometric summary

Average Pretreatment Progress Posttreatment

Skeletal
SN-FH (°) 6 10 10 11
Facial angle (°) 86 81 80 83
Pog-NVert (mm) –2 –18 –22 –15
SNB (°) 77.5 70 70 70.5
A-NPog (mm) 3.5 8 8.5 9
A-NVert (mm) 0 –1 –1.5 1
SNA (°) 81 78.5 80 80
ANB (°) 3.5 8.5 10 9.5
Wits (mm) 0 –2 –4 –8
Mandibular 25.5 33 39 35
plane (°)
Y-axis (°) 60 66 64 63.5
LFH% 54 62.6 65.6 62.1
Dental
Interincisal 135.5 126 134 130
angle (°)
L1-Mandibular 94.75 100 95 95
Fig 4. Pretreatment cephalometric radiograph. plane (°)
L1-APog (mm) 2.5 3 1 2
U1-SN (°) 103 89 90 90
TREATMENT PROGRESS U1-APog (mm) 5 6.5 7.5 6
Soft tissue
Facial contour –9 –22 –23 –20
Initially, the maxillary left quadrant and full mandibu- angle (°)
lar arch were bonded (including second molars) using a Nasolabial 100 108 108 113
preadjusted .018- × .025-in fixed appliance. Initial align- angle (°)
ment was accomplished in the mandibular arch with a UL-E plane (mm) –2 –3 0 –1
LL-E plane (mm) 0 –2 0.5 1.5
spiral wire progressing to .014-in stainless steel followed
Interlabial gap (mm) 1 0.5 2 0.5
by a .016-in stainless steel archwire for space closure
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 119, Number 5
Fig 5. Progress intraoral photographs.
Fig 6. Progress cephalometric radiograph.
with elastomeric links. The maxillary arch was aligned
with a .014-in stainless steel segment, progressing to
.016-in stainless steel segment and a gable bend mesial to
the premolar to enhance anchorage. A light elastomeric
link was placed from the canine to the second molar
(maxillary left segment only) to begin canine retraction;
a .016- × 0.016-in sectional loop was used to continue
canine retraction. After 4 months, an open bite from sec-
ond premolar to second premolar was noted clinically
(Fig 5). The patient was made aware of this anterior open
bite and her tendency for a vertical facial pattern. The rest
of the maxillary arch was bonded and aligned with a
nickel-titanium archwire. The mandibular arch received a
.016- × .022-in stainless steel archwire. Short Class II
elastics were used to aid in closing the bite, followed by
anterior elastics. Four months later, the possibility of
surgery to close the bite if a better response did not occur
was discussed with the patient. After 9 months, a progress
cephalometric radiograph was taken (Fig 6). At this point,
the TMJs were still asymptomatic.
Cranial base superimposition revealed that the
mandible had rotated open 5° and anterior face height
had increased 4 mm. Maxillary superimposition revealed
that the maxillary molar had moved mesially and down-
Derakhshan and Sadowsky 549
Fig 7. Pretreatment/progress superimposition.
ward. Maxillary incisor position was unchanged.
Mandibular superimposition revealed that the mandibu-
lar molars had moved mesially and upward. The
mandibular incisors were retracted, which contributed to
the increased overjet (Fig 7).
After 6 months of treatment, the patient expressed
concern with her chin position and mentalis hyperactiv-
ity (Fig 8). She indicated that she had been having
severe gastrointestinal problems over the previous
months, with numerous vomiting episodes. This was
unrelated to the orthodontic treatment and eventually
subsided with conservative medical care. It was appar-
ent that the orthodontic treatment had resulted in molar
extrusion that the musculature was not able to with-
stand. A potential vertical facial pattern may have been
unmasked, leading to an anterior open bite. Treatment
continued and the case was set up for orthognathic
surgery. The arches were coordinated and the maxillary
second molars were aligned vertically. Sixteen months
after beginning treatment, presurgical cephalometric
radiographs and TMJ tomograms were taken, followed
by a surgical consultation. Maxillary impaction and
possible mandibular advancement surgery was planned.
The tomographic report indicated some degenerative
550 Derakhshan and Sadowsky
Fig 8. Progress facial photographs.
Fig 9. Progress/postsurgical superimposition.
changes of the condyles, including menisci dysfunction.
However, the patient was asymptomatic with no clinical
signs of a temporomandibular disorder. She was advised
accordingly and reassured not to be overly concerned.
Because of delays with insurance authorization, surgery
was performed 9 months later. After 3 months of post-
surgical stabilization, the appliances were removed,
bringing the total treatment time to 29 months. Upper
and lower Hawley retainers were delivered.
TREATMENT RESULTS
Posterior maxillary impaction and mandibular
advancement surgical procedures were performed (Figs
9 and 10). Esthetically, facial convexity had decreased,
the face became less retrognathic, and lower face height
had decreased (Fig 11). The occlusion was finished with
American Journal of Orthodontics and Dentofacial Orthopedics
May 2001
Fig 10. Postsurgical cephalometric radiograph.
Class II molar and Class I canine relationships (Figs 12-
14). The maxillary midline was centered to the face, and
the midpoint of the middle mandibular incisor was in
line with the maxillary midline. The overjet and overbite
were minimal. The arches were coordinated and sym-
metric. The maxillary intermolar and intercanine width
remained unchanged, the mandibular intercanine width
increased by 1 mm, and the intermolar width increased
by 2 mm. The compensating curve and the curve of Spee
were normal. The posttreatment panoramic radiograph
revealed a healthy dentition (Fig 15).
DISCUSSION
The original treatment objectives of this adult patient
were limited, based on the patient’s concerns, the rela-
tively mild malocclusion, and the decision to accept
American Journal of Orthodontics and Dentofacial Orthopedics Derakhshan and Sadowsky 551
Volume 119, Number 5

Fig 11. Posttreatment facial photographs.

Fig 12. Posttreatment intraoral photographs.

Fig 13. Posttreatment study models.

552 Derakhshan and Sadowsky
Fig 14. Pretreatment/posttreatment superimposition.
Fig 15. Panoramic radiograph taken 2 months before
appliance removal.
facial esthetics as presented. The diagnostic setup con-
firmed a treatment plan involving extraction of a maxil-
lary left first premolar and a mandibular left central
incisor. The anticipated treatment time was 12 to 15
months with a low degree of difficulty, which was
reflected in the treatment fee being two thirds of the usual
full fixed appliance fee.
Within a few months of commencing treatment, sig-
nificant increases in overjet, anterior open bite, anterior
face height, and excessive lip strain were noted. It
became apparent that orthodontic treatment alone would
not result in an acceptable occlusion, and the probable
need for orthognathic surgery was raised with the patient
for the first time. Patient consultations and explanations
were ongoing, and entries were made in the treatment
chart. Progress cephalometric radiograph and pho-
tographs were taken. The opening of the mandible possi-
bly occurred as anchorage was lost on the upper left side
and the second molar was extruded, particularly because
of the use of a sectional archwire rather than a continuous
American Journal of Orthodontics and Dentofacial Orthopedics
May 2001
maxillary archwire. The musculature could probably not
tolerate the extrusive forces secondary to extraction
mechanics. Also, the gastrointestinal distress and vomit-
ing that occurred during the initial stages of treatment
may have resulted in decreased occlusal function. The
curve of Spee was leveled with some mandibular incisor
intrusion and mandibular molar extrusion, which possi-
bly contributed to the open bite.
Is it possible that once tooth movement was initiated,
condylar position changed to a “more seated and normal
position” as suggested by Roth,1-3 that is, a postural
mandibular position was unmasked by initiating tooth
movement? Would articulator mounting of the initial con-
tact position have indicated a centric relation to maximum
intercuspation shift in an anteroposterior and vertical
direction? According to Roth,1-3 Roth and Ware,4 Cor-
dray,5 Utt et al,6 and others, some patients have hidden
skeletal problems that must be diagnosed before initiating
treatment. They maintain that the practitioner may not be
able to trust the occlusion observed in the mouth. A dual
bite, defined as the difference in condylar position between
maximum intercuspation/centric occlusion and centric
relation, may exist. Thus, they advocate mounting study
models in centric relation in order to detect the slide. They
maintain that occlusal disharmonies cannot be evaluated
by clinical examination alone because of overriding neu-
romuscular reflexes protecting the joint.2,3,5 Centric rela-
tion to maximum intercuspation slides can probably be
detected in most patients by mandibular manipulation. If
muscle resistance is felt clinically, occlusal splints may be
indicated for a few weeks to relax the musculature before
reevaluating the mandibular position. It is the clinical tech-
nique of identifying centric relation/initial contact position
that is important, rather than the articulator mounting. The
articulator is the instrument for recording and document-
ing the centric slide in 3 dimensions and may be of value
in that regard. Whether a dual bite would have been
detected for the patient described in this case report is
unknown. Mandibular manipulation at the initial examina-
tion did not reveal a centric slide. Utt et al6 reported that
approximately 20% of adults have centric slides that can-
not be detected by routine clinical examination.
Was this case really a vertical skeletal Class II mal-
occlusion in which orthognathic surgery should have
been a part of the treatment plan from the start—par-
ticularly if the “proper” diagnosis had been made based
on articulator-mounted casts in initial contact position
and securing TMJ tomograms? Roth2,4 maintained that
with the relief of symptoms of occlusion-related TMJ
dysfunction through the use of an occlusal reposition-
ing splint, posterior repositioning of the mandible
occurs. When the discrepancy between maximum
interdigitation of the teeth and physiologic mandibular
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 119, Number 5
position is excessive, surgery may be indicated. Roth3,4
suggested that the mandible is usually found to be in a
retruded position with premature contact in the molar
regions. TMJ tomograms taken during treatment
revealed some degenerative changes of the condyles,
including menisci dysfunction, which was asympto-
matic. It is possible that the TMJ finding was a con-
tributing etiologic factor in the development of the open
bite. There was no history of TMJ symptoms, and no
signs or symptoms of a TMJ disorder were detected at
the initial clinical examination.
Eventually, a successful treatment outcome was
achieved with the help of posterior maxillary impaction
and mandibular advancement surgery. The possible
need for surgery was not addressed at the pretreatment
consultation. However, once an adverse response to
treatment was noted, the patient was advised, the find-
ings were documented in the treatment chart, and
progress records were taken for a revised treatment
plan. The patient was intelligent, understood the prob-
lems, and began to explore coverage through her insur-
ance carrier for the anticipated surgical procedure.
This case could have resulted in litigation because
of misdiagnosis and inadequate informed consent
before treatment, particularly if the patient did not
have insurance coverage for the surgical procedure and
Derakhshan and Sadowsky 553
had limited financial resources. However, excellent
rapport and good communication existed throughout
treatment. Also, good records and documentation were
maintained. Although the patient inquired and
expected the orthodontic fee to be increased because
of the increased complexity of treatment, the original
fee was maintained.
The patient was very pleased with the final treat-
ment outcome and the improved facial esthetics, even
though she initially considered orthodontic treatment
for crowded incisors only.
REFERENCES
1. Roth RH. Functional occlusion for the orthodontist. Part I. J Clin
Orthod 1981;15:32-51.
2. Roth RH. Functional occlusion for the orthodontist. Part II. J
Clin Orthod 1981;15:100-23.
3. Roth RH. Functional occlusion for the orthodontist. Part III. J
Clin Orthod 1981;15:174-98.
4. Roth RH, Ware WH. Orthognathic treatment in patients with
temporomandibular joint pain-dysfunction. J Clin Orthod
1980;Feb:108-20.
5. Cordray FE. Centric relation treatment and articular mountings
in orthodontics. Angle Orthod 1996;66:153-8.
6. Utt TW, Meyers CE, Wierzba TF, Hondrum, SO. A three-dimen-
sional comparison of condylar position changes between centric
relation and centric occlusion using the mandibular position
indicator. Am J Orthod Dentofacial Orthop 1995;107:298-308.