IJOI 36 iAOI CASE REPORT

Full Cusp Class II Malocclusion

with a Deep Overbite

SUMMARY
A skeletal and dental Class II malocclusion in a adolescent male with incompetent lips was managed with non-extraction
orthodontics treatment. The impinging deep overbite was resolved with an anterior bite turbo. The skeletal and dental Class II
relationships were corrected with Class II elastics and miniscrews that were inserted as anchorage in the infrazygomatic crests
bilaterally. A tooth positioner was used to finish the occlusion. Overall, this moderately difficult malocclusion (DI=20) was
finished in an excellent result (CRE=24) in ~21 months, but there were some side effects associated with rapidly opening the
bite.(Int J of Othod Implantol 2014;36:72-86)

Key word: Class II, deep overbite, miniscrews, tooth positioner.

History and Etiology

A 13-year-11-month-old boy was referred by his
dentist for orthodontic consultation ( Fig. 1 ). The
chief concern was an impinging deep overbite
(Figs. 2 and 3). A diastema was noted between the
upper central incisors ( Fig. 2 ). No known habits
contributing to the malocclusion were reported.
However, hypermentalis activity associated with lip
closure (Fig. 1) suggests the malocclusion is primarily Fig. 2:
Pre-treatment intraoral photographs show an impinging
environmental, secondary to a moderate lip trap deep overbite that obscures the view of the lower anterior
teeth.

Fig. 1:
Pre-treatment facial photographs show strained lips on
closure: flat chin contour in the profile view, dimpled chin
pattern due to hypermentalis activity in the frontal view.
Note that the chin dimpling disappears when the lips are
opened for the smiling view. Fig. 3: Pre-treatment study models (casts)

72
 Full Cusp Class II Malocclusion with a Deep Overbite IJOI 36

Dr. Sheau-Ling Lin,

Instructor, Beethoven Orthodontic Course (left)
Chris Chang, DDS, PhD.
Founder, Beethoven Orthodontic Center
Publisher, International Journal of Orthodontics & Implantology (Middle)
W. Eugene Roberts, Consultant,
International Journal of Orthodontics & Implantology (Right)

when the lips are in repose. The patient was treated

to an acceptable result as documented in Fig. 4-9.

Diagnosis

Skeletal:
Fig. 4: • Skeletal Class II (SNA 85°, SNB 79°, ANB 6°)
Post-treatment facial photographs show lip strain on closure.
• Normal mandibular plane angle ( SN-MP 29°,
FMA 21°)

Dental:

• Bilateral Class II molar relationship, full cusp

discrepancy on the left side (Fig. 3)
• 100% impinging deep overbite with lingual
recession of the gingiva on the Mx central
incisors (Figs. 2 & 3)
Fig. 5: • Overjet (OJ) 5 mm (Fig. 10)
Post-treatment intraoral photographs document that the
deep overbite was successfully resolved. • Mild crowding of about 2 mm in upper arch,
and 1 mm in the lower arch
• Diastema <1.0 mm between maxillary central
incisors (Fig. 11)
• Maxillary dental midline 1 mm to the right of
the facial midline
• Deep Curve of Spee (Fig. 12)

Facial:

• Mild convex profile with protrusive lips Lip strain

on closing, as evidenced by a dimple pattern on
the chin due to hypermentalis activity
Fig. 6: Post-treatment study models (casts)

73
IJOI 36 iAOI CASE REPORT

Fig. 7: Fig. 8:
Pre-treatment cephalometric and panoramic radiographs Post-treatment cephalometric and panoramic radiographs
reveal a deep overbite and increased curve of Spee. document the correction of the deep overbite the excessive
curve of Spee

Fig. 9:
Superimposed tracings document retraction of maxillary anterior teeth and posterior rotation of the mandible. The mandibular
molars were extruded and the lower incisors were slightly flared.

74
 Full Cusp Class II Malocclusion with a Deep Overbite IJOI 36

The ABO Discrepancy Index (DI) was 20 as shown in

the subsequent worksheet.

Specific Objectives of Treatment

Maxilla (all three planes):

• A - P: Retract
• Vertical: Allow for normal expression of growth
Fig. 10:
Pre-treatment a 100% deep impinging overbite is associated
• Transverse: Maintain
with distal out rotation of the maxillary central incisors.
Mandible (all three planes):

• A - P: Allow for normal expression of growth

• Vertical: Allow for normal expression of growth
• Transverse: Maintain

Maxillary Dentition

• A - P: Retract the entire maxillary arch

• Vertical: Maintain the molars and intrude the incisors

CEPHALOMETRIC
Fig. 11: SKELETAL ANALYSIS
Pre-treatment and intra-oral frontal photographs reveals a PRE-Tx POST-Tx DIFF.
maxillary midline diastema.
SNA° 85° 83° 2°
SNB° 79° 78° 1°
ANB° 6° 5° 1°
SN-MP° 29° 30° 1°
FMA° 21° 22° 1°
DENTAL ANALYSIS
U1 TO NA mm 6 mm 3 mm 3 mm
U1 TO SN° 110° 108° 2°
L1 TO NB mm 7 mm 9 mm 2 mm
L1 TO MP° 98° 102° 4°
FACIAL ANALYSIS
E-LINE UL 2 mm -0.5 mm 2.5 mm
E-LINE LL 5 mm 3 mm 2 mm
Fig. 12:
An open-mouth frontal view of the dentition shows the deep ██ Table 1: Cephalometric summary
curve of Spee.

75
IJOI 36 iAOI CASE REPORT

• Inter-molar Width: Increase corrected dentition. Removal of the four 3rd molars
• Inter-canine Width: Maintain at the age of 18 is recommended.

• Buccolingual Inclination: Maintain

A 0.022” slot Damon Q bracket system (Ormco) was
Mandibular Dentition used. The maxillary arch was bonded with high
torque brackets on the anteriors, and low torque
• A - P: Maintain the molars and incisors
brackets for the mandibular arch ( Fig. 13 ). The
• Vertical: Maintain the molars and intrude the incisors
archwire sequences for both arches was .014 CuNiTi,
• Inter-molar Width: Increase
.016 CuNiTi, .014 x .025 CuNiTi, and .017 x .025 TMA.
• Inter-canine Width: Maintain Class II elastics (early-short-light) were used to correct
• Buccolingual Inclination: Maintain the A-P discrepancy during the .014 CuNiTi archwire
stage.
Facial Esthetics: Correct incompetent

Other: Correct Curve of Spee by intruding the lower

incisors

Treatment Plan
A non-extraction treatment plan included correcting
the deep overbite, leveling the Curve of Spee,
coordinating the arches, and normalizing the soft 1M
tissue profile. Both arches will be bonded with a Fig. 13:
full fixed orthodontic appliance, with bite turbos High torque brackets were bonded on the maxillary incisors,
and low torque brackets were used for the mandibular
placed on the lingual surface of both central incisors incisors.
to correct the deep bite and curve of Spee. Class II
molar relationship was to be corrected with early-
In the 5th month of treatment, the composite resin
light-short elastics (2 oz). Miniscrews were planned
bite turbos were placed on the palatal surface of
bilaterally in the infrazygomatic crests for retracting
the upper central incisors to open the bite and
the maxillary arch to correct the Class II relationship.
allow the molars to erupt in order to correct the
Up & down elastics (2 oz) were prescribed to detail
impinging deep bite situation1 (Fig. 14). In the 11th
the occlusion before removing the fixed appliances,
month of active treatment, reshaping the contour
and then the final occlusion was to be achieved with
of all the mandibular central and the lateral incisors
a positioner. An upper clear retainer and both upper
was carried out so the irregular surface of the teeth
and lower fixed retainers were planned to retain the
that would not disturb the alignment ( Figs. 15-

76
 Full Cusp Class II Malocclusion with a Deep Overbite IJOI 36

16 ). One month later, two miniscrews ( 2x12 mm,

OrthoBoneScrew®, Newton's A, Inc. ) were inserted
bilaterally in the infrazygomatic crests1,2 to serve as
anchorage to retract the entire maxillary dentition
(Fig. 17 A & B). When both arches were in the .017 x
.025 TMA archwire stage, elastometric chains were
attached from the upper canines to the miniscrews,
and class III elastics were used from the lower
canines to the miniscrews.
5M

Fig. 14:
Composite resin bite turbos were bonded on the lingual
surface of the maxillary central incisors.

Before reshaping

13M
Fig. 17-A:
10M Miniscrews, inserted bilaterally in the infrazygomatic
crests, were subsequently used to anchor Class III elastics,
Fig. 15: extending to drop-in hooks on the lower cuspids.
At 10 months of treatment, the lower incisors required
reshaping.

After reshaping

10M

Fig. 16: Fig. 17-B:

The lower incisors were reshaped, and the spaces were A lateral view shows the Class III elastics between the lower
subsequently closed with elastomeric chains. canines and the upper posterior miniscrews.

77
IJOI 36 iAOI CASE REPORT

Bracket repositioning was performed as indicated

by sequential panoramic films during several
appointments, and wire bending was performed
for detailing the occlusion during the final stages of
the treatment. In the 19th month of treatment, up
and down elastics were applied on the 2 nd molars
to settle the tip-back side effect, which had been
caused by retraction of the maxillary arch using 21M
miniscrews for anchorage.
Fig. 18:
At 21 months, a mouthguard-type tooth positioner was
A tooth positioner was prescribed to establish an delivered to finish the occlusion.

optimal functional occlusion. At the appointment

prior to removing the fixed appliances, impressions
and a wax bite registration were taken and sent to a
commercial orthodontic laboratory to fabricate the
tooth positioner. The patient was informed that the
braces would be removed at the next appointment
and a positioner would be used to finish the
occlusion.

Fig. 19:
After 21 months of active treatment, all the
Post-treatment photograph of the frontal view of the maxilla
appliances were removed and a mouthguard- shows the final alignment.
type tooth positioner was delivered (Fig. 18 ). The
patient was instructed to wear it four hours a day Results Achieved
for the first two weeks, during which the patient
was asked to repeatedly clench into the positioner Maxilla (all three planes):
and then release. The patient was instructed to • A - P: Retracted
perform this “ exercise ” for 15 minutes every hour
• Vertical: Increased
while wearing the appliance. After two weeks of
• Transverse: Expanded
the tooth positioner application, the treatment
was finished and the retainers were delivered (Fig. Mandible (all three planes):
19). Post-treatment cephalometric and panoramic
• A - P: Retracted
radiographs (Fig. 8), as well as superimpositions of
cephalometric tracings (Fig. 9) document the final • Vertical: Increased
result. • Transverse: Expanded

78
 Full Cusp Class II Malocclusion with a Deep Overbite IJOI 36

Maxillary Dentition teeth from returning to pre-treatment positions

( rotation & spacing ). The upper and lower clear
• A - P: Retracted maxillary arch
overlay retainers were delivered. The patient was
• Vertical: Maintained
instructed to wear them full time for the first 6
• Inter-molar Width: Increased
months and nights only thereafter. In addition, the
• Inter-canine Width: Maintained patient was instructed in the proper home hygiene
care and maintenance of the retainers.
Mandibular Dentition

• A - P: Maintained
• Vertical: Increased Final Evaluation of Treatment
• Inter-molar Width: Increased Critical assessment of this case with the ABO Cast-

• Inter-canine Width: Decreased Radiograph Evaluation and IBOI Pink & White
score resulted in scores of 24 and 2 respectively, as
Facial Esthetics: documented on the forms appearing later in this

• Lower lip profile was improved but the lips report. The major discrepancies were in the occlusal

were still incompetent. Chin dimples were still relationships ( 8 points ), marginal ridges ( 5 points ),

noted in the frontal photograph of the face alignment/rotations (3 points), and occlusal contacts

(Fig. 4) because of mentalis muscle contraction (2 points). The patient's chief concern (deep impinging

when the lips are closed. overbite ) was successfully treatment, and his lip
profile has been improved but the lip incompetence
Superimpositions: remained. The patient was satisfied with the

• As the maxilla extruded, it was retracted, but treatment outcome (Fig. 20).

the mandible was rotated posteriorly.

Upper incisors were retracted bodily and slightly

extruded, but the lower incisors were flared.
Extrusion of the lower molars was attributed to the
extensive use of Class II elastics.

Retention
After two weeks of tooth positioner application, a
fixed retainer was bonded on the lingual surface Fig. 20:
Post-treatment photograph shows the patient with Dr. Chris
of the two maxillary central incisors to prevent the Chang.

79
IJOI 36 iAOI CASE REPORT

Discussion Anchorage is considered the most critical factor

when correcting a Class II Division 1 malocclusion.
Angle Class II Division 1 malocclusions represents
To reinforce anchorage, various auxiliaries can be
a large proportion of the average orthodontist's
used, including headgear, lingual arch, transpalatal
caseload. 3 There are multiple approaches for
arch, Nance holding arch and intermaxillary
managing Class II Division 1 malocclusion. The
elastics. However, anchorage control that
diagnosis and treatment plan should carefully
requires patient compliance may be problematic.
consider facial profile, skeletal pattern, growth
Dental implants, miniscrews, and miniplates are
potential, and severity of the malocclusion. The
increasingly popular for skeletal anchorage that
treatment protocol as well as the malocclusion
does not depend on compliance. These devices
severity can influence the efficiency of orthodontic
can provide stationary anchorage for various
treatment.4 Therapeutic options include removable
types of tooth movement7 without active patient
functional appliances, fixed functional appliances,
cooperation. According to the retrospective study
headgear, intermaxillary elastics and/or tooth
by Yao et al., 8 skeletal anchorage has achieved
extractions. Removable functional appliances are
better control than other options in both the
usually best suited to patients in the late mixed
anteroposterior and vertical directions during
dentition, while fixed functional appliances are best
treatment of maxillary dentoalveolar protrusion.
in the early permanent dentition. 5 However, the
Correction of Class II malocclusion is facilitated
effectiveness of functional appliances on enhancing
by greater retraction of the maxillary incisors, less
mandibular growth in the short term remains
posterior anchorage loss, and counterclockwise
controversial. 6 Since the current patient had a
mandibular rotation, especially for patients with
major Class II discrepancy and his growth potential
a hyperdivergent face. 8 Among the devices
was questionable, a dentoalveolar correction was
available, miniscrews as temporary anchorage
indicated to achieve the most efficient treatment for
devices (TADs) are commonly used because of the
a full cusp Class II malocclusion as rapidly as possible.
following advantages:4
Extractions were not a good option due to mild
crowding and convex profile. Excessive retraction
1. Easy placement and removal
of the anterior teeth may increase the nasolabial
angle and decrease incisal inclination, which could
2. A variety of maxillary and mandibular locations are
increase the severity of the deep bite. Therefore,
available for placement
a non-extraction treatment protocol was chosen,
utilizing a full fixed appliance, Class II elastics and
3. Minimal operation and postoperative discomfort 9
maxillary posterior miniscrews.

80
 Full Cusp Class II Malocclusion with a Deep Overbite IJOI 36

4. No need for complicated clinical and laboratory and low torque brackets for the lower incisors.
procedures to facilitate precise implant placement Despite this precaution, lower incisor angulation to
the mandibular plane increased from 98° to 102°. In
5. Can be immediately loaded Correction of deep retrospect, it may have been better to treat this case
overbite can be accomplished in different ways with miniscrews and a lower base arch to intrude
depending on the treatment goals chosen for the mandibular incisors.10 However, miniscrews can
individual patients. 10,11 There are four general also produce unwanted side effects, such as tip-back
12
treatment options to consider: of the molars and a posterior open bite. However
these side effects can be at least partially controlled
1. Extrude the posterior segment by using a lighter force and extending the treatment
time.
2. Intrude the maxillary incisors
The patient was found to have an unconscious
3. Intrude the mandibular incisors bruxism habit that was evidenced by generalized
wear facets on multiple teeth (Fig. 21). The etiology
4. Flare the maxillary and/or mandibular incisors appeared to be a predisposition to nocturnal
bruxism that was manifest after the deep impinging
For the present patient, anterior bite turbos were overbite was relieved. Attrition can occur with
placed to allow posterior teeth to extrude. This
method is advantageous for correcting the deep
bite, creating interocclusal space and eliminating the
intercuspal locking. All of these effects facilitate the
correction of the Class II relationship.13,14 Bite turbos
and Class II elastics are a good combination to solve
Class II deep bite problem, but there are risks if the
patient does not have good growth potential for
froward rotation of the mandible. These mechanics
rotate the mandible posteriorly (clockwise), extrude
the mandibular molars, and increase the axial Fig. 21:
inclination of the lower incisors. Taking the side Following the opening of the occlusion with bite turbos,
generalized wear facets were noted on multiple teeth in the
effects on the anterior teeth into consideration, high maxillary arch (circles). The facets were distinguished as less
torque brackets were chosen for the upper incisors (blue circles) or more (red circles) severe.

81
IJOI 36 iAOI CASE REPORT

normal masticatory function but it is usually a According to Yongjong et al., 18 wearing a tooth
manifestation of parafunctional habits such as positioner improves alignment and rotation, overjet,
15
nocturnal bruxism. Parafunction is thought to have occlusal relationship, inter-proximal contact, and
a multifactorial etiology: occlusal, psychological root angulation. For the present patient, improved
16
or originating within the central nervous system. occlusal relationships, closure of inter-proximal
15
However, Caroline et al. found no relationship contacts, proper overbite and optimal overjet were
between bruxism and orthodontics; neither the all achieved. However, good patient compliance is
need for nor the provision of orthodontic treatment needed and that is the most important consideration
contributes to increased tooth wear. Parafuction in determining the efficacy of the method.18
can lead to mobility of the dentition, severe
occlusal wear, displacement of the aligned arches In addition to a successful outcome, a treatment
and sometimes pain. Recommended treatment protocol must also provide good long-term stability
includes the medication Klonopin® ( clonazepam ) of the dental relationships. Long-term changes in
1mg one hour prior bedtime, reduction of acidity in tooth alignment can occur, so Niall et al.19 suggest
the diet which softens tooth structure, fabrication that it is not appropriate to evaluate final treatment
of an occlusal nightguard to protect the teeth, results at the end of active treatment. Long-term
and restoration of the damaged tooth structure as follow-up evaluation is an important consideration
15
necessary. for all patient treatment outcomes.

The purpose of the tooth positioner for the present

patient was to establish an optimal functional Conclusion
occlusion. Using a tooth positioner, rather than Class II Division 1 with a deep bite is a common
final finishing with archwires, is purported to have 3 malocclusion. The choice of treatment should
advantages : consider the patient's facial profile, skeletal
pattern, growth potential, and severity of the
1. It allows the fixed appliances to be removed malocclusion. Bite turbos and Class II elastics are
sooner. a good combination for rapidly resolving a severe
Class II deep bite malocclusion. This method may
2. It improves articulation of the teeth and massages
be advantageous for patients who have competent
the gingiva, which is usually swollen after
lips, but limited growth potential; however, opening
comprehensive orthodontic treatment.
the bite may also lead to unintended consequences
3. It helps develop lip competence and facial muscle such as flaring of the lower incisors, lingual tipping
tone. of the upper incisors, and incompetent lips. Overall,

82
 Full Cusp Class II Malocclusion with a Deep Overbite IJOI 36

extra-alveolar skeletal anchorage, miniscrews buccal 9. Shingo K et al. Clinical use of miniscrew implants as
orthodontic anchorage: Succes rates and postoperative
to the maxillary molars, may achieve better control
discomfort. Am J Orthod Dentofacial Orthop 2007;131:9-15.
of Class II correction in three dimensions, particularly 10. Charles JB. Biomechanics of deep overbite correction. Semin
for patients with incompetent lips. Orthod 2001;7:26-33.
11. Hsu YL et al. ABO case report: A Class II deep bite case. New
& Trends in Orthodontics 2009;vol 15:56-63.
12. David MS. Soft-tissue-based diagnosis and treatment planning.
Acknowledgment Clinical Impression 2005;14:1:21-26.
Thanks to Teacher Paul Head, Dr. Hsin Yin Yeh and 13. Samir EB. Class II malocclusion: Diagnostic and clinical
considerations with and without treatment. Semin Orthod
Ben Lin for proofreading this article.
2006; 12:11-24.
14. Jeff K. Honing Damon system mechanics for the ultimate in
efficiency and excellence. Clinical Impression 2008;16:1:23-28.
References 15. Harpenau LA et al. Diagnosis and management of dental wear.
J Calif Dent Assoc. 2001Apr;39(4):225-231
1. Cozza P, Baccetti T, Franchi L, De Toffol, McNamana JA
16. Nissani M. A bibliographical survey of bruxism with special
Jr. mandibular changes produced by functional appliances
emphasis on non-traditional treatment modalities. J Oral Sci
in Class II malocclusion: a systematic review. Am J Orthod
2011 Jun;43(2):73-83.
Dentofacial Orthop 2006;129:599.e1-12.
17. Caroline WM et al. Relationship between malocclusion,
2. Marsico E, Gatto E, Burrascano M, Matarese G, Cordasco
orthodontic treatment, and tooth wear. Am J Orthod
G. Effectiveness of orthodontic treatment with functional
Dentofacial Orthop 2009;136:529-535.
appliances on mandibular growth in the short term. Am J
Orthod Dentofacial Orthop. 2011;139:24-36. 18. Yongjong P et al. Tooth positioner effects on occlusal contacts
and treatment outcomes. Angle Orthod 2008;78:1050-1056.
3. C h a n g C H . B a si c D a m o n C o u rs e No. 3 : D a n o m +
OrthoBoneScrew I, Beethoven Podcast Encyclopedia in 19. Niall JP McG et al. Long-term occlusal and soft-tissue profile
Orthodontics 2011, Newton's A Ltd, Taiwan. outcomes after treatment of Class II Division 1 malocclusion
with fixed appliances. Am J Orthod Dentofacial Orthop
4. Lin JJ. A new method of placing orthodontic bone screws in
2011;139:362-368.
IZC. New & Trends in Orthodontics 2009;vol 13:4-7.
5. Zhang N, Bai Y, and Li S. Treatment of a Class II Division
1malocclusion with miniscrew anchorage. Am J Orthod
Dentofacial Orthop 2012;141:e85-e93.
6. Moschos AP. Orthodontic treatment of Class II malocclusion
with miniscrew implants. Am J Orthod Dentofacial Orthop
2008;134:604.e1-604.e16.
7. Shingo K et al. Class II malocclusion treated with miniscrew
anchorage : Comparison with traditional orthodontic
mechanics outcomes. Am J Orthod Dentofacial Orthop
2009;135:302-309.
8. Yao CC Jane et al. Comparison of treatment outcomes between
skeletal anchorage and extraoral anchorage in adults with
maxillary dentoalveolar protrusion. Am J Orthod Dentofacial
Orthop 2008;134:615-624.

83
IJOI 36 DISCREPANCY
iAOI CASE REPORT INDEX WORKSHEET
EXAM YEAR 2009
CASE # 1 P(Rev. 9/22/08) CHAO-YUEN CHIU
ATIENT ABO ID# 96112

Discrepancy Index Worksheet LINGUAL POSTERIOR X-BITE

1 pt. per tooth Total = 00

DISCREPANCY
3.1 Ð 5 mm. INDEX
= 2WORKSHEET
pts. EXAM YEAR 2009
5.1 Ð 7 mm. = 3 pts. BUCCAL POSTERIOR
C7.1
ASEÐ 9# mm. 1
P(Rev.
ATIENT CHAO-YUEN CHIU
= 9/22/08) 4 pts.
ABO ID# 96112 X-BITE
T>OTAL
9 mm.D.I. SCORE = 2025 5 pts.
2 pts. per tooth Total = 20
Negative OJ (x-bite) 1 pt. per mm. per tooth =
OVERJET LINGUAL POSTERIOR X-BITE
CEPHALOMETRICS (See Instructions)
0 mm. (edge-to-edge) = 1 pt.
1 Ð 3 mm.Total == 0 pts. 5 1 pt. per tooth Total = 0
3.1 Ð 5 mm. = 2 pts.
ANB ≥ 6¡ or ≤ -2¡ 0 = 4 pts.
OVERBITE
5.1 Ð 7 mm. = 3 pts. BUCCAL POSTERIOR
Each degree < -2¡ X-BITE
x 1 pt. =
7.1 Ð 9 mm. = 4 pts.
0 Ð 3
> 9 mm. mm. = = 5 0pts.
pts.
3.1 Ð 5 mm. = 2 pts. 2 pts.
Eachperdegree
tooth > 6¡ Total = x 1 pt. = 2
5.1 Ð 7 mm. = mm. per
3 pts. 0
Negative OJ (x-bite) 1 pt. per tooth =
Impinging (100%) = 5 pts. SN-MP
CEPHALOMETRICS (See Instructions)
Total
Total
=
= 25 5 ANB
≥ 38¡
6¡ or ≤> -2¡
= 2 pts.
≥ degree
Each 38¡ x 2 pts. = 4 pts.
=
OVERBITE
Each degree < -2¡ x 1 pt. =
≤ 26¡ = 1 pt.
0ANTERIOR
Ð 3 mm. OPEN BITE= 0 pts.
3.1 Ð 5 mm. = 2 pts. Eachdegree
Each degree> <6¡26¡ 4 x 1xpt.
1 pt.
= = 4
5.1 Ð 7 mm.
0 mm. (edge-to-edge), 1= pt. per3tooth
pts.
Impinging
then 1 pt. (100%)
per additional=full mm.
5 pts.
per tooth 1 to MP ≥ 99¡
SN-MP = 1 pt.
≥ 38¡ x 1 pt. = 2 pts.2
=
Total
Total == 55 0 Each degree > 99¡
Each degree > 38¡
2
x 2 pts. =

≤ 26¡ Total = = 1 pt. 84

LATERAL OPEN
ANTERIOR OPEN BITE
BITE
Each degree < 26¡ 4 x 1 pt. = 4
02mm.
pts. (edge-to-edge),
per mm. per tooth
1 pt. per tooth OTHER (See Instructions)

then 1 pt. per additional full mm. per tooth 1 to MP ≥ 99¡ teeth
Supernumerary =x 1 pt.
1 pt.=
Total = 0 Ankylosis of perm. teeth x 2 pts.
Each degree > 99¡ 2 x 1 pt. = 2=
Total = 00 Anomalous morphology x 2 pts. =
CROWDING (only one arch) Impaction (except 3rd molars) x 2 pts. =
Midline discrepancy (≥3mm) 0
1 Ð 3 mm. OPEN BITE =
LATERAL 1 pt. Total =@ 2 pts.8 =
Missing teeth (except 3rd molars) x 1 pts. =
3.1 Ð 5 mm. = 2 pts. Missing teeth, congenital x 2 pts. =
25.1
pts.Ðper mm. per tooth =
7 mm. 4 pts. OTHER (See Instructions) 2
Spacing (4 or more, per arch) x 2 pts. =
> 7 mm. = 7 pts. Spacing 2
(Mx cent. diastema ≥ 2mm)
Supernumerary teeth x [email protected] pts.
= =
Total
Total =
= 0
0
1
Tooth transposition
Ankylosis of perm. teeth x 2 pts. = =
x 2 pts.
Skeletal asymmetry (nonsurgical tx) 3 pts.
x 2@pts. =2 =
2
Anomalous morphology
CROWDING (only one arch) Addl. treatment complexities
rd
Impaction (except 3 molars) x 2 pts. = =
x 2 pts.

Identify: Lip Incompetence

Midline discrepancy (≥3mm) @ 2 pts. =
1OCCLUSION
Ð 3 mm. = 1 pt. Missing teeth (except 3rd molars) x 1 pts. =
3.1 Ð 5 Imm.
Class to end on == 2 0pts.
pts. Missing teeth, congenital x 2 pts. =
= = 422
5.1
EndÐ 7onmm.
Class II or III = = 4 2pts.
pts. per side pts. Spacing (4 or more, per arch) Total x 2 pts.
>Full
7 mm.Class II or III == 7 4pts.
pts. per side pts. 2
Beyond Class II or III = 1 pt. per mm. pts. IMPLANT
Spacing SITE ≥ 2mm)
(Mx cent. diastema @ 2 pts. =
Tooth transposition x 2 pts. =
Total = 1
1 additional Skeletal asymmetry (nonsurgical tx)
3
@ 3 pts. =
6
Total = 0 Addl. treatment complexities x 2 pts. =
OCCLUSION Identify:
Class I to end on = 0 pts. 8
End on Class II or III = 2 pts. per side 2 pts. Total = 4
Full Class II or III = 4 pts. per side 4 pts.
Beyond Class II or III = 1 pt. per mm. pts.
additional

Total = 6
0

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IBOI Cast-Radiograph Evaluation Occlusal Contacts
Full Cusp Class II Malocclusion with a Deep Overbite IJOI 36

Occlusal Contacts
Cast-Radiograph Evaluation 2

Total Score: 24
Alignment/Rotations

1 1
3
1

Marginal Ridges

Occlusal Relationships
Marginal Ridges

5 Occlusal Relationships
11

1 1 1
1 1
1
1
1 1 1 1 1 1 1 1
Buccolingual Inclination
Interproximal Contacts
Interproximal Contacts
Buccolingual Inclination
1
2 1

1 1

Overjet
Overjet Root Angulation
1 2
1

1 1

1 1
INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter
in the white box. Mark extracted teeth with ÒXÓ. Second molars should be in occlusion.
INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter
in the white box. Mark extracted teeth with ÒXÓ. Second molars should be in occlusion.

85
IJOI 36 iAOI CASE REPORT

IBOI Pink & White Esthetic Score

Total Score: = 2
1. Pink Esthetic Score
Total = 1
1. M & D Papillae 0 1 2

6 2. Keratinized Gingiva 0 1 2
6 5
5 4 3. Curvature of Gingival Margin 0 1 2
2 3 14
62 3 1 4. Level of Gingival Margin 0 1 2
6
5
5 4 5. Root Convexity ( Torque ) 0 1 2
4
2 3 1
2 3 1 6. Scar Formation 0 1 2

1. M & D Papillae 0 1 2
1 2. Keratinized Gingiva 0 1 2
1
3. Curvature of Gingival Margin 0 1 2
1 4. Level of Gingival Margin 0 1 2
1

5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2
2. White Esthetic Score ( for Micro-esthetics )
2. White Esthetic Score ( for Micro-esthetics )
2. White Esthetic Score ( for Micro-esthetics )
2. White
White Esthetic
Esthetic Score
Score ( for Micro-esthetics )
Total = 1
2. ( for Micro-esthetics )
1 1. Midline 0 1 2
1
2. Incisor Curve 0 1 2
4 3
3 5 6
4 1 5 3. Axial Inclination (5°, 8°, 10°) 0 1 2
1 6
2
4.Contact Area (50%, 40%, 30%) 0 1 2
2
4 3
4 3 5 6 5. Tooth Proportion (1:0.8) 0 1 2
5 6
2 6. Tooth to Tooth Proportion 0 1 2
2

1. Midline 0 1 2

2. Incisor Curve 0 1 2

3. Axial Inclination (5°, 8°, 10°) 0 1 2

4. Contact Area (50%, 40%, 30%) 0 1 2

5. Tooth Proportion (1:0.8) 0 1 2

6. Tooth to Tooth Proportion 0 1 2

86