2013 Dental Press Journal of Orthodontics Dental Press J Orthod.

2013 May-June;18(3):150-8 150

BBO Case Report
Angle Class I malocclusion treated with lower incisor extraction
The author reports no commercial, proprietary or nancial interest in the products
or companies described in this article.
The patient displayed in this article previously approved the use of her facial and
intraoral photographs.
Contact address: Vanessa Leal Tavares Barbosa
Rua Jos Alexandre Buaiz, n 160, salas 904/906 Enseada do Su / Brazil
CEP: 29.050-545 - Vitria/ES - E-mail: [email protected]
Vanessa Leal Tavares Barbosa
1
In planning orthodontic cases that include extractions as an alternative to solve the problem of negative space dis-
crepancy, the critical decision is to determine which teeth will be extracted. Several aspects must be considered,
such as periodontal health, orthodontic mechanics, functional and esthetic alterations, and treatment stability. De-
spite controversies, extraction of teeth to solve dental crowding is a therapy that has been used for decades. Pre-
molar extractions are the most common, but there are situations in which atypical extractions facilitate mechanics,
preserve periodontal health and favor maintenance of the facial profle, which tends to unfavorably change due to
facial changes with age. The extraction of a lower incisor, in selected cases, is an efective approach, and literature
describes greater post-treatment stability when compared with premolar extractions. This article reports the clini-
cal case of a patient with Angle Class I malocclusion and upper and lower anterior crowding, a balanced face and
harmonious facial profle. The presence of gingival and bone recession limited large orthodontic movements. The
molars and premolars were well occluded, and the discrepancy was mainly concentrated in the anterior region of the
lower dental arch. The extraction of a lower incisor in the most ectopic position and with compromised periodon-
tium, associated with interproximal stripping in the upper and lower arches, was the alternative of choice for this
treatment, which restored function, providing improved periodontal health, maintained facial esthetics and allowed
fnishing with a stable and balanced occlusion. This case was presented to the Brazilian Board of Orthodontics and
Dentofacial Orthopedics (BBO), as part of the requirements for obtaining the BBO Diplomate title.
Keywords: Crowding. Lower incisor extraction. Gingival recession.
1
Specialist in Orthodontics and Dentofacial Orthopedics, State University of Rio de
Janeiro (UERJ). Diplomate of the Brazilian Board of Orthodontics and Dentofacial
Orthopedics (BBO).
* Clinical case, category 2, accepted by the Brazilian Board of Orthodontics and
Dentofacial Orthopedics, BBO.
How to cite this article: Barbosa VLT. Angle Class I malocclusion treated with
lower incisor extraction. Dental Press J Orthod. 2013 May-June;18(3):150-8.
No planejamento ortodntico de casos que incluem extraes como alternativa para solucionar o problema de discre-
pncia de espao negativa, a deciso crtica determinar quais dentes sero extrados. Devemos considerar vrios as-
pectos, como a sade periodontal, mecnica ortodntica, alteraes funcionais e estticas, e estabilidade do tratamento.
Apesar das controvrsias, a extrao de dentes para solucionar apinhamentos dentrios uma teraputica que tem
sido utilizada h dcadas. As extraes de pr-molares so as mais comuns, mas h ocasies em que extraes atpicas
facilitam a mecnica, preservam a sade periodontal e favorecem a manuteno do perfl, que tende a se alterar desfa-
voravelmente devido s modifcaes faciais decorrentes da idade. A extrao de um incisivo inferior, em casos bem
selecionados, uma abordagem efciente; e a literatura descreve maior estabilidade ps-tratamento, quando comparada
com a opo de extrao de pr-molares. O presente artigo relata um caso clnico de uma paciente com m ocluso
de Classe I de Angle e apinhamento anterior superior e inferior, face equilibrada e perfl harmonioso. Apresena de
recesses gengivais e sseas limitava grandes movimentaes ortodnticas. Os molares e pr-molares estavam bem
relacionados, e a discrepncia concentrava-se principalmente na regio anterior da arcada dentria inferior. A extrao
de um incisivo inferior em posio mais ectpica e com periodonto comprometido, associada a desgastes interproxi-
mais nas arcadas superior e inferior, foi a alternativa de escolha para o tratamento, que restabeleceu a funo, propor-
cionando melhoria da sade periodontal, manteve a esttica facial, e permitiu a fnalizao com uma ocluso estvel e
equilibrada. Esse caso foi apresentado diretoria do Board Brasileiro de Ortodontia e Ortopedia Facial (BBO), como
parte dos requisitos para obteno do ttulo de Diplomado pelo BBO.
Palavras-chave: Apinhamento. Extrao de incisivo inferior. Recesses gengivais.
2013 Dental Press Journal of Orthodontics Dental Press J Orthod. 2013 May-June;18(3):150-8 151
Barbosa VLT BBO Case Report
Figure 1 - Initial facial and intraoral photographs.
HISTORY AND ETIOLOGY
Female patient, Caucasian, searched for orthodon-
tic treatment at age 44, in good general health with no
signifcant medical history. The main complaint was
related to crowding in the upper arch, and especially in
the lower arch, as well as the gingival recessions, which
were increasing over the years (Fig 1). There was a his-
tory of caries and unsatisfactory restorations in several
teeth. No esthetic complaints were reported. In func-
tional occlusion analysis, it was found that the right
and lef lateral guides were performed by the frst upper
and lower premolars. The gingival recession of tooth
#14 was, possibly, due to occlusal overload. Despite no
functional guides were present, there were no signs or
symptoms of temporomandibular disorders. No orth-
odontic intervention had been performed before.
DIAGNOSIS
Regarding facial characteristics the following fea-
tures were present: A mesocephalic pattern, symmetri-
cal face, normal nasolabial angle, with a straight profle.
The lower lip was slightly ahead of the Steiners line and
the patient had difculty to obtain a passive lip seal. In
the intraoral evaluation, it was observed a high number
of caries, nasal breathing, Angle Class I malocclusion,
with severe lower anterior crowding (7 mm negative
discrepancy in dental arch analysis) and slight crowding
in the upper arch. A reduced overbite was present, with
less than 1/3 overlap of the lower incisors, and an almost
edge to edge anterior occlusion except in the region
of tooth #11, which had 3mm overjet, due to its protru-
sion and rotation. The upper midline was inclined. In the
transverse direction, there was a constriction of the upper
2013 Dental Press Journal of Orthodontics Dental Press J Orthod. 2013 May-June;18(3):150-8 152
Angle Class I malocclusion treated with lower incisor extraction BBO Case Report
arch in the premolars and molars region, with a tendency
to crossbite. The lower midline was shifed 1mm to the
lef side, and the upper and lower incisors and lower right
canine were projected in relation to their apical bases.
Tooth #43 was labially positioned with the long axis me-
sially displaced, and presented marked gingival recession
(Figs 1 and 2). The panoramic radiograph reported the
presence of third molars, with the lower ones mesially
tipped. Periapical radiographs revealed a regular alveolar
bone loss in the maxilla and mandible, and suggested ex-
ternal root resorption in the apical third of the teeth #31
and #41. Interproximal radiographs demonstrated excess
of restorative material in several teeth. The cephalometric
diagnosis confrmed the labial protrusion of the upper in-
cisors (1-NA = 32 and 7.5mm) as well as the lower ones
(1-NB = 25 and 7mm) (Figs 3, 4 and 5).
TREATMENT OBJECTIVES
Orthodontic treatment aimed to eliminate the ante-
rior dental discrepancy, correcting the crowding of up-
per and lower incisors, aligning and leveling the teeth
without jeopardizing the facial profle; establishing es-
thetically favorable and functionally efective overjet and
overbite, properly positioning the teeth on their apical
bases and contributing to improve periodontal health.
The extraction of premolars could result in fattening
of the facial profle, aggravated by facial changes due to
age; however, the treatment without extractions would
increase the lack of lip seal, and contribute to the wors-
ening of gingival recession and a greater tendency to re-
lapse.
8
Through the diagnostic setup the possibility of a
lower incisor extraction was evaluated, because it is one
of the most valuable orthodontic records to determine if a
lower incisor should be extracted.
1,3,11,22,24
Prior to ortho-
dontics, the patient would be referred to the periodontist
for free gingival graf in the teeth with accentuated gin-
gival recession, preventing its intensifcation and creating
a thicker marginal gingiva.
25
The shape of the upper arch
should be improved by expanding the molar and pre-
molar regions, which tended to cross, favoring a greater
flling of the buccal corridor and broadening the smile.
The occlusion key of the right and lef molars and lef ca-
nine would be kept, while the Class I relationship in the
right canine should be achieved. Inadequate restorations
would be replaced at the end of orthodontic treatment,
aiming periodontal health and occlusal stability.
Figure 2 - Initial casts.
2013 Dental Press Journal of Orthodontics Dental Press J Orthod. 2013 May-June;18(3):150-8 153
Barbosa VLT BBO Case Report
TREATMENT PLAN
Performing the diagnostic setup was essential for the
decision of the lower incisor extraction, besides help-
ing to visualize treatment outcome and determine the
amount of interproximal stripping that would be per-
formed on the upper incisors for proper intercuspa-
tion.
17,24
To indicate the treatment with incisor extrac-
tion, some requirements that applied to this case were
also considered: Class I molar relationship, mandibular
crowding greater than 4.5 mm (in this case, it was 7mm),
slight or nonexistent maxillary crowding (in this case,
it was 3 mm), balanced sof tissue profle, minimal
or moderate overbite and overjet
1,7,22,24
(Figs 1 and 2).
However, before the beginning of orthodontic treat-
Figure 3 - Initial periapical radiographs.
Figure 4 - Initial lateral cephalometric radiograph (A) and cephalometric tracing (B).
Figure 5 - Initial panoramic radiograph.
A B
2013 Dental Press Journal of Orthodontics Dental Press J Orthod. 2013 May-June;18(3):150-8 154
Angle Class I malocclusion treated with lower incisor extraction BBO Case Report
ment, thepatient would be referred to the periodontist
to control periodontal health conditions and to plan the
free graf surgery in teeth with more advanced gingival
recession (#23 and #43). Only afer 60 days these teeth
could be moved. For the maxillofacial surgeon, extrac-
tion of third molars would be required, because these
teeth were in unfavorable positions. Afer the initial
procedures with the multidisciplinary team, orthodon-
tic treatment would start with bonding the brackets on
upper and lower dental arches, Straight-Wire system,
Roth prescription, slot 0.022 x 0.028-in except in
the #43 tooth, which would not receive a bracket until
the space for its alignment in the arch was obtained. In-
terproximal stripping in the #45 and #44 teeth, which
presented excess of restorative material, were scheduled
in order to optimize the space for the tooth #43. The f-
nalization would be accomplished through coordinated
rectangular arches with ideal torques and shapes, and
the use of intermaxillary elastics for fnal intercuspation.
If necessary, it would be requested an occlusal adjust-
ment with the general dentist for occlusion refnement
and replacement of initially inadequate restorations.
TREATMENT PROGRESS
As planned, prior to orthodontics, the patient was re-
ferred to the periodontist for the control of periodontal
health and conditions and free graf in the region of teeth
#23 and #43 to increase the thickness of the marginal
gingiva because orthodontic movement could favor the
increase of gingival recession and bone fenestrations.
9,21,25

Afer 60 days, orthodontic movement in these teeth was
permitted. Third molar extraction, which were in unfa-
vorable positions, was also performed at this stage.
Then, brackets were bonded on the upper
teeth, Straight-Wire system, Roth prescription, slot
0.022 x 0.028-in, on teeth #17 to #27. Then, stripping
was performed on the upper incisors, with manual abrasive
strips, to facilitate alignment, avoid black spaces between
these teeth and achieve excellent incisal relationship, by
controlling the overbite and reducing overjet consider-
ing that the new occlusal situation would promote articu-
lation of six upper teeth with fve lower ones.
7,20,24
Align-
ment and leveling nickel-titanium 0.012-in and 0.014-in
archewires were used followed by stainless steel round and
0.014-in, 0.016-in, 0.018-in and 0.020-in archewires.
Finishing occurred with 0.019 x 0.025-in stainless steel
rectangular archwires with ideal shape and torque.
In the mandibular arch a Straight-Wire fxed orth-
odontic appliance, Roth prescription, slot 0.022x0.028-
in was placed, except in the tooth #43, which received
bracket bonding afer opening of space for its alignment
and correction of the long axis, which was markedly me-
sial. Stripping was performed for removal of restorative
material excess in teeth #45 (mesial) and #44 (distal), and
to facilitate the alignment of the tooth #43. The extrac-
tion of the lower lef lateral incisor (#32) was required
for being the incisor in the most ectopic position and
with the most unfavorable periodontal conditions.
6,14

The closure of the extraction space was conducted us-
ing a passive stainless steel 0.018-in round archwire and
through distal movement of tooth #31 and mesial move-
ment of the teeth #41 and #42 with elastomeric chain
and nickel-titanium open spring installed between the
teeth #44 and #42. Posterior anchorage in the right
and lef sides was obtained by tying together the mo-
lars and premolars with metal ligatures. Afer obtaining
space for tooth #43, bracket bonding was proceeded, a
lower 0.018x0.025-in stainless steel base archwire with
a bypass was made for this tooth and, for its alignment
and leveling, a superimposed 0.012-in nickel-titanium
sectioned archwire was initially used, followed by a
0.014-in archwire, evolving into continuous arches, for
completion of this phase. The fnishing was done with
0.018x0.025-in stainless steel rectangular archwire with
ideal form and torques, coordinated with the upper arch.
Light triangular 1/4-in intermaxillary elastics were used
in the canines and premolars region. Throughout the
treatment, the patient was accompanied by the perio-
dontist, with appointments every three months. Afer
verifying the achievement of the goals predefned in the
initial planning, the fxed orthodontic appliance was re-
moved, initiating the retention phase. A removable up-
per wraparound retainer was used as well as a bonded
lingual retainer, made with 0.038-in braided stainless
steel wire. The use of the upper retainer plate was rec-
ommended for 24 hours a day in the frst six months; 18
hours a day, in the following six months; 12 hours a day,
for more six months; and then daily use at night.
TREATMENT EVALUATION
The main treatment goals were achieved. The molar
and premolar occlusion, which was very favorable, was
maintained and the lower anterior dental crowding, pa-
tients main complaint, was corrected. The correction
2013 Dental Press Journal of Orthodontics Dental Press J Orthod. 2013 May-June;18(3):150-8 155
Barbosa VLT BBO Case Report
Figure 6 - Final intraoral and facial photographs.
of the axial inclination of the incisors resulted in sig-
nifcant improvement in dental esthetics and refected in
the facial profle, with retraction of the lower lip, from a
position 1mm forward the S line (Steiner) to 0mm, fa-
voring passive lip sealing (Table 1). In the frontal photo-
graph, the fnal smile was more harmonious. The upper
midline, which was angled, was corrected and became
coincident with the middle of the lower central incisor,
without esthetic commitment
10,24
(Fig 6).
The periodontal health was markedly improved and
the increase of overbite and overjet, which had its mea-
sures reduced, allowed the establishment of a function-
ally balanced occlusion (Fig 7).
The lef and right molars and lef canine keys of occlu-
sion were maintained and the occlusion key on the right
canine was achieved, resulting in right and lef laterality
with disocclusion in the canines and without contacts in
balance. The protrusive excursion resulted in adequate
posterior disocclusion.
Total superimposition of cephalometric tracings il-
lustrates the profle improvement with the change in the
lower lip position, which made it more pleasant (Fig10A).
The partial superimpositions of the maxilla and mandible
confrm the signifcant reduction in labial axial inclina-
tion of the upper incisors and discrete uprighting of lower
ones, with slight anchorage loss (Fig 10B).
The decision on the extraction of the lateral inci-
sor instead of a central incisor was benefcial because it
avoided the presence of an undesirable black triangle
between the middle third of the tooth and gingiva, for
the distal surface of a central incisor contacts better to
mesial surface of a canine.
16
2013 Dental Press Journal of Orthodontics Dental Press J Orthod. 2013 May-June;18(3):150-8 156
Angle Class I malocclusion treated with lower incisor extraction BBO Case Report
Figure 7 - Final casts.
Figure 8 - Final periapical radiographs.
Figure 9 - Final lateral cephalometric radiograph (A) and cephalometric tracing (B).
A B
2013 Dental Press Journal of Orthodontics Dental Press J Orthod. 2013 May-June;18(3):150-8 157
Barbosa VLT BBO Case Report
MEASURES Normal A B A/B diff.
Skeletal pattern
SNA (Steiner) 82 80 80 0
SNB (Steiner) 80 77 77 0
ANB (Steiner) 2 3 3 0
Convexity angle (Downs) 0 4 3 1
Y axis (Downs) 59 59 58 1
Facial angle (Downs) 87 86 87 1
SN-GoGn (Steiner) 32 35 33 2
FMA (Tweed) 25 28 24 4
Dental pattern
IMPA (Tweed) 90 93 98 5
1.NA (degrees) (Steiner) 22 32 27 5
1-NA (mm) (Steiner) 4 mm 7,5 mm 6 mm 1.5
1.NB (degrees) (Steiner) 25 25 27 2
1-NB (mm) (Steiner) 4 mm 7 mm 6 mm 1
1
1
-Interincisal angle
(Downs) 130 120 120 0
1-APo (mm) (Ricketts) 1 mm 5 mm 4 mm 1
Prole
Upper lip S line (Steiner) 0 mm -2 mm -2 mm 0
Lower lip S line (Steiner) 0 mm 0 mm -1 mm 1
Table 1 - Summary of cephalometric measures.
Figure 10 - Total (A) and partial (B) superimpositions of initial (black) and nal (red) tracings.
A B
Assessing the intercanine distance, it was found
that there was a 1-mm reduction, and it can be said
that the maintenance or reduction of this distance dur-
ing mechanical extraction of incisorsis advantageous
10

compared to premolars, because there is a strong re-
lationship between long-term stability of crowding
correction and intercanine distance. It is believed that
the treatment with extraction of an incisor and main-
tenance of that distance or even decreasing it, in an-
ticipation of a further natural decrease, provides bet-
ter stability for the fnal outcome.
24
However, other
authors
6,18
suggest that the simple maintenance or re-
duction of intercanine distance during treatment does
not guarantee total stability in the long-term, despite
contributing to a lower degree of relapse compared to
patients treated with premolar extractions. The gingi-
val recession of #14 tooth was improved, probably due
to the removal of occlusal trauma, since prior to the
orthodontic treatment, the right side laterality was ac-
complished by this tooth and the tooth #44.
2013 Dental Press Journal of Orthodontics Dental Press J Orthod. 2013 May-June;18(3):150-8 158
Angle Class I malocclusion treated with lower incisor extraction BBO Case Report
In the evaluation of fnal periapical radiographs it
was observed the absence of the upper and lower third
molars, which were removed; and increasing of root
apex rounding on the lower incisors (#41 and #31),
which had already been observed in the initial radio-
graphs (Fig8). The improvement in axial inclination of
#43 tooth, severely tipped mesially and out of position
before treatment, draws attention to its repositioning
in the arch and excellent periodontal recovery. The re-
placement of inadequate restorations was requested at
the end of treatment, but had not been completed yet.
FINAL CONCLUSIONS
The diagnosis and careful planning, with the help
of the diagnostic setup,
4
was essential for the decision
of treatment with extraction of a lower incisor. Refer-
ring the patient to the periodontist to perform gingival
graf before orthodontic treatment enabled orthodontic
movement more safely and without injury to teeth al-
ready compromised by periodontal recessions.
21,25
Despite the difculties or limitations that planning
of cases with incisor extraction may result during orth-
odontic treatment, provided properly conducted and
evaluated considering the particularities of each
case, it can be stated that the lower incisor extraction
contributes efectively in the treatment of certain mal-
occlusions, seeking excellence in orthodontic treatment
outcomes (maximum function, esthetics and stability).
13

The patients satisfaction by having her main complaint
resolved refected also in increased self-esteem and gain
of quality of life benefts provided by orthodontics in
the aspect of overall health.
Based on data from the literature and exemplifed by
the clinical report of this case, it can be concluded that
the extraction of a lower incisor is a very efective thera-
peutic approach in carefully selected situations.
15
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