8/13/2019 51924210orto.pdf

1/7

JUNE 2008

4

CHIEF COMPLAINT

T he patient was seeking treatment for esthetic reasons.Her main complaint was that her upper left caninestuck out when she smiled. She was alsoconcerned with her crooked teeth. (Fig 1 8)

MEDICAL HISTORY

The patient was a 22 year, 11 month old female of SouthAsian descent. She had no significant medical history other than an allergy to Erythromycin.

DENTAL HISTORY

The patient had some routine amalgam restorations placedon her molar teeth. Her wisdom teeth had been removed, atage 18, with no significant complications. She had beenreferred for orthodontic treatment, as early as age 11, for her crowding problem. The orthodontist had recommended 1stpremolar extractions to correct her tooth size - arch lengthdiscrepancy. Her parents decided not to proceed withtreatment.

There was a history of previous clicking noises in her TMJs,however this had not led to any painful symptoms.

ETIOLOGY

The patient did not appear to have any airway problems.There may have been a myofunctional problem, as theMasseter and Anterior Digastric muscles were weak withswallowing; however no anterior tongue thrust could bedetected. Other members of her family had a Class IImalocclusion and crowding so heredity was probably afactor.

DIAGNOSIS

On the Cephalometric radiograph the patient traced out ashaving a Class II skeletal problem, as she was 4 mm on theA-B arc and +6 on the Wits analysis. She had a tendencytowards a deep bite pattern. (Fig 9)

The patient was a Class I molar, Class II canine dentally.She had a neutral profile but the upper lip appeared shortand slightly retruded. Her upper midline was 2 mm to theleft of her facial midline. The lower right first premolar wastipped lingual into crossbite. There was severe crowding inthe anterior regions. The incisors had a normal angulation.There was an 80% overbite with minimal overjet. Her Pontsmeasurement was 33.0 and she was short of Ponts in allareas, with the largest being almost 10 mm in the lower firstpremolar area. (See Table 1)

No deviation of the mandible was noted on opening andclosing. No clicking noises could be detected. She could

open 45 mm vertically and 9 mm horizontally which fallswithin the normal range of motion for an adult female. Alsothe condyles appeared normal on the Panelipse radiograph.Her diagnostic casts showed a 1 mm lateral side shift, to theright, from CR to CO. (Fig 10 14) The deflectionappeared to be off of her left lateral incisors. The KernottAnalysis showed her to be relatively symmetrical.

TREATMENT OBJECTIVES

1. Treat non-extraction.

2. Develop the dentition to Ponts to gain room to reduce thecrowding and use the inclined plane action to increase thevertical.

3. Further reduce crowding by flaring the anterior teethforward. This would also help with the retruded upper lipand the deep overbite.

4. Correction of the dental crossbite.

5. Correction of the upper midline.

6. Level and align the teeth.

7. Maintain the Class I molar and couple the canines in aClass I relationship.

8. Reduce the lateral side shift and make CR = CO.

C ASE R EPORT Non-Extraction Treatment of a Crowded Class II Skeletal, Class I Dental Patient Frank K. Marasa, B.Sc., D.M.D.Surrey, British Columbia, Canada

Presented in partial satisfaction for Diplomate in the AAGO.

Dr. Marasa took the first series of AAGO courses in 1993. He practices with his wife, Ingrid Emanuels, who also doesorthodontics. He has presented table clinics and lectured to the AAGO and other professional organizations. Dr. Marasa is a frequent contributor to the Journal and had a case report published in the Journal of Clinical Orthodontics.

8/13/2019 51924210orto.pdf

2/7

JUNE 2008

5

Figures 1-8 - Initial Photos. Patient concerned with protruding maxillary left canine.

Figure 9 - Initial Sassouni Plus cephalometric analysis showing a Class II tendency.

APPLIANCES AND TREATMENT PLAN

1. Standard body wire Crozat appliances would be used tostart the arch development. However the lingual armswould initially only engage the upper and the lower leftsecond premolars and the lower right first premolar. Theseteeth were leaning lingually and needed the most archdevelopment. The arches would be developed to Ponts. Itwas hoped that the crossbite would be corrected in thisstage.

2. Possible use of a bite opening splint, on the maxillaryteeth, if it became difficult to correct the crossbite.

3. A Transpalatal Arch (TPA) and a Straight Wire Appliance(SWA) to level and align teeth. The upper midline wouldhopefully improve with the alignment of the moresignificantly crowded left lateral and canine.

4. Hawley retainers

5. Occlusal equilibration, if necessary, to eliminate any CRto CO discrepancies.

8/13/2019 51924210orto.pdf

3/7

JUNE 2008

6

PROGRESS OF TREATMENT

Treatment was started with the standard Crozat appliances, aspreviously discussed. (Fig 15, 16) Light forces were used todevelop the dentition towards Ponts. After 8 months of treatment, the premolar crossbite was corrected. It wasunnecessary to use a bite opening splint as the crossbitecorrected without it. The upper second molars wereexpanding too far. No direct force was being placed on them;they seemed to be simply carried along with the first molars.Thus it was decided to proceed with the TPA and the SWA.

Figures 15-16 - Initial Crozat appliances on insertion. Notice that the lingual armsengage only the premolars that are in the most lingual position.

More arch length could be gained by rotating the upper firstmolars with the TPA and molar rotation is much easier toaccomplish with a TPA than with a Crozat appliance. (Fig 17)Also the molar arch width could be maintained. The SWAcould now be used to align the anterior teeth. By maintaining

the width of the first molars (with the TPA), the secondmolars could now be brought lingually as they would moveagainst the locked in first molars. Roth Rx. brackets wereused and the upper arch was banded and bracketed from the2nd molars forward. (Fig 18) The mandibular left canine

Figures 10-14 - Initial study models mounted in CR.

Figure 17 - TPA to maintain width and torotate upper 1st molars

Figure 20 - Leveling and aligning themandibular teeth.

Figure 18 - Leveling and aligning themaxillary teeth.

Figure 19 - Only the left mandibular canineneeded development. A recurve wire was

placed on the occlusal surface, of the right 2nd molar, to prevent the reciprocal effect of it being distalized and tipped back when activating the recurve wire on the canine.

8/13/2019 51924210orto.pdf

4/7

JUNE 2008

7

Figures 21-28 - Final Photos. Notice the poor torque on the maxillary left lateral incisor.

was lingually inclined and thus a recurve was added to thelower Crozat appliance to tip the tooth to the labial. An armwas placed on the occlusal of the lower right 2nd molar to tryand prevent the reciprocating forces that will occur, causingmolar extrusion and tip back, from the lingual recurve to thecanine. (Fig 19) Once the lower left canine was aligned intothe arch, the lower Crozat appliance was left in place andbrackets were placed from the 2nd premolars forward on the

lower arch. (Fig 20) A .018 x .025 SE Nitinol wire wasplaced in the upper arch and a .014 Nitinol wire was placedon the lower arch. Arch wires progressed to a .020 SS upper and a .018 SS lower as the teeth aligned. A Class II elasticwas used, for a short period of time, on the right side from theupper canine bracket to the lower Crozat appliance hook.Treatment was completed after 17 months. (Fig 21 28)

RETENTION

The patient was debracketed and impressions were takenfor her retainers. It was decided to use her Crozatappliances, instead of the Hawley appliances, for retainers.

It was felt that this would be better myofunctionally, in casethere had been any tongue thrust problems that wereundiagnosed. The maxillary body wire would guide thetongue to the roof of the mouth. The Crozat applianceswere revamped and a labial bow was soldered to the buccalstrut of the upper appliance. A .018 braided wire was alsobonded to each lower anterior tooth, from canine to canine,to prevent any relapse of the lower anterior region.

RESULTS ACHIEVED

The patient did not wear her maxillary retainer faithfully.She was eager to be out of her SWA and did not wish toshow any wire, in public, after treatment was completed.She stopped wearing the lower retainer after 2 years. ThePonts measurements that were achieved with Crozat archexpansion held up remarkably well 7 years after treatmentwas completed (Table 1 and Fig 29). All treatmentobjectives were met reasonably well. There appeared to beno skeletal increase in vertical. Thus the decreased overbitewas the result of incisor flaring. (Fig 30, 31)

8/13/2019 51924210orto.pdf

5/7

JUNE 2008

8

Figures 32-36 - Final study models mounted in CR.

Figure 31 - Kernott Analysis slopemeasurement. Notice the decrease in the

slope from the f laring of the maxillary anterior teeth.

Figure 29 - Kernott Analysis showing symmetry. Green is ideal; Red is initial;

Blue is Final.

Figure 30 - Final Sassouni Pluscephalometric analysis. Notice

improvement from a Class II to aClass I tendency

Occlusal equilibration was unnecessary as CR = CO at thecompletion of treatment. The upper second molars tippedback initially as a response to the distal driving of the upper Crozat. (Fig 32 36) Seven years post treatment, they hadsettled back into function. This initial tipping back maytend to prevent them from becoming an occlusalinterference. That may be one of the reasons for CR = COin this case.

The slight rotation of the upper right lateral incisor did notconcern the patient.

FINAL EVALUATION

The root of the upper left lateral incisor was linguallydisplaced before treatment started. This was not recognizedduring treatment and no allowance was made for itscorrection. The final photos show the attached gingiva

more coronal on the frontal photograph. (Fig 24) Also themaxillary occlusal photograph shows different torquebetween the two lateral incisors. (Fig 25) However thephotographs taken seven years after treatment wascompleted show this largely corrected. (Fig 37 44) Sincemechanics werent used, the only explanation for itscorrection can be function. The action of the lips on theincisal edge of the upper lateral incisor fulcruming againstthe incisal edges of the lower anterior teeth was enough(over time) to correct the incisor torque. Thus functionhelped to correct position.

Improved tongue function and an improved swallowinghabit can explain the maintenance of the expanded archwidths. Thus improvement of form and position lead toimprovement of function for this patient.

.

8/13/2019 51924210orto.pdf

6/7

JUNE 2008

9

Table 1 - Ponts Measurements (33.0)

Upper 6s Lower 6s Upper 4s Lower 4s Upper 3s Lower 3s

Ideal 51.5 50.5 41.0 36.0 38.0 30.0

Initial 44.5 44.0 37.0 26.2 35.5 25.8Final 50.0 50.0 41.3 34.7 36.5 28.8

7 yrs 48.8 48.7 41.3 35.2 36.3 28.5

Change + 4.3 + 4.7 + 4.3 + 9.0 + 0.8 + 2.7

Figures 37-44 - Recall photos taken 7 years after finishing. Notice the improved torque on the maxillary left lateral incisor.

8/13/2019 51924210orto.pdf

7/7

Copyright of Journal of the American Academy of Gnathologic Orthopedics is the property of American

Academy of Gnathologic Orthopedics and its content may not be copied or emailed to multiple sites or posted

to a listserv without the copyright holder's express written permission. However, users may print, download, or

email articles for individual use.