THE UNIVERSITY OF THE WEST INDIES

DD 5330

CASE HISTORY

DATE OF EXAMINATION: April-May, 2013

CANDIDATE NUMBER: 808100046

PATIENT INITIALS: A.S

CASE SUMMARY

AS is a 9 year, 3 month old female of African descent in late mixed dentition exhibiting a Class I

malocclusion on a Class I skeletal base. Overjet was increased while there was severe

crowding in the upper and lower arches. Clinical examination revealed a microdont of an upper

right lateral incisor while plain film radiography revealed unerupted permanent canines with the

lower right permanent canine occupying a transposed position with the lower right permanent

lateral incisor. AS was treated with fixed space maintenance appliances (lingual arch and Nance

appliance), a sectional appliance and is due to enter a fixed treatment phase.

pg. 2

Table of Contents SECTION 1: PRE TREATMENT ASSESSMENT ...................................................................................... 3

PATIENT DETAILS ...................................................................................................................... 3

PATIENT COMPLAINTS ............................................................................................................. 3

RELEVANT MEDICAL HISTORY .................................................................................................. 3

DENTAL HISTORY ...................................................................................................................... 3

SOCIAL HISTORY ....................................................................................................................... 3

CLINICAL EXAMINATION: EXTRA-ORAL FEATURES ................................................................... 4

CLINICAL EXAMINATION: INTRA- ORAL FEATURES ................................................................... 5

PRE-TREATMENT PHOTOGRAPHS: EXTRA-ORAL ...................................................................... 7

GENERAL RADIOGRAPHIC EXAMINATION .............................................................................. 10

DIAGNOSTIC SUMMARY ......................................................................................................... 13

PROBLEM LIST ........................................................................................................................ 13

AIMS AND OBJECTIVES OF TREATMENT ................................................................................. 13

TREATMENT PLAN .................................................................................................................. 14

TREATMENT PROGRESS ......................................................................................................... 15

KEY STAGES IN TREATMENT PROGRESS ................................................................................. 15

SECTION 3. POST-TREATMENT ASSESSMENT ................................................................................. 17

OCCLUSAL FEATURES: ............................................................................................................ 17

COMPLICATIONS ENCOUNTERED DURING TREATMENT........................................................ 17

ADDITIONAL ANALYSIS ........................................................................................................... 18

POST-TREATMENT PHOTOGRAPHS: INTRA-ORAL .................................................................. 19

CRITICAL APPRAISAL ............................................................................................................... 28

CONCLUSION .......................................................................................................................... 28

REFERENCES ................................................................................................................................... 29

pg. 3

SECTION 1: PRE TREATMENT ASSESSMENT

PATIENT DETAILS

Initials: AS

Sex: Female

Date of birth: 03.04.03

Age of start of treatment: 9 years 3 months

PATIENT COMPLAINTS

AS’s mother noticed that the lower teeth were rotated and thought that the primary teeth were

being lost too early. AS’s mother is keen on intercepting any orthodontic complications that may

arise as AS continues to grow.

RELEVANT MEDICAL HISTORY

AS occasionally suffers from allergic rhinitis. Symptomatic bouts occur especially in the morning

time. Her symptoms are managed with Ventolin® which she has used twice for the year thus

far. Otherwise she is fit and well.

DENTAL HISTORY AS's attendance at UWI Child Dental Health Unit started at the age of three. She received

routine dental examination and active treatment. She has had an atraumatic dental experience

with a history of prophylaxis, fissure sealants, composite restorations and multiple extractions.

SOCIAL HISTORY

AS’s attends primary school but is available for monthly appointments. There was no previous

orthodontic treatment in family.

pg. 4

CLINICAL EXAMINATION: EXTRA-ORAL FEATURES Extra oral examination revealed a palpable, non-tender, mobile left submandibular lymph node.

ORTHODONTIC

Skeletal: Class I Skeletal pattern

Prognathic maxilla and mandible

Reduced lower face height

Average MMPA

Mild Bimaxillary Proclination

Soft tissue: Incompetent Lips

Lower lip: In front

Upper lip: Normal

Reduced Naso-Labial Angle

Habits: Tongue thrust

TMJ: No problem

pg. 5

CLINICAL EXAMINATION: INTRA- ORAL FEATURES

Soft tissues: WNL

Palpation: Bulges palpated on the gingival buccal aspect in the lower canine

regions.

Oral hygiene: Moderate plaque deposit identified mostly within the gingival third

of the posterior teeth.

Erupted teeth present:

6 E 4 C 2 1 1 2 C 4 5 6

6 E 4 2 1 1 2 4 E 6

General dental condition:

Resin based sealants were noted on 6 6

E E

4 is partially erupted.

1 has an uncomplicated enamel fracture on its mesio-incisal edge.

A wear facet was found on the occlusal edge of C.

CROWDING/SPACING

Maxillary arch: Severe crowding

Mandibular arch: Severe crowding

pg. 6

OCCLUSAL FEATURES

Incisor relationship: Class I

Overjet (mm): 6 6

Overbite: Normal

Centerlines: Coincident with each other and both upper and lower were

coincident with the face.

Left buccal segment relationship: ¼ unit Class II

Right buccal segment relationship: ¼ unit Class II

Displacements: Nil

Crossbites: Nil

Other occlusal features: The canines are unerupted and thus there is no canine

relationship to report.

pg. 7

PRE-TREATMENT PHOTOGRAPHS: EXTRA-ORAL

pg. 8

PRE-TREATMENT PHOTOGRAPHS (13.07.12): INTRA-ORAL Labial segment

PRE-TREATMENT PHOTOGRAPHS (13.07.12): INTRA-ORAL Right and left buccal segments

pg. 9

PRE-TREATMENT PHOTOGRAPHS (13.07.12): INTRA-ORAL Upper and lower occlusal arches

pg. 10

GENERAL RADIOGRAPHIC EXAMINATION

Pre-treatment radiographs taken:

1. Right and left bitewings: No interproximal caries.

2. Periapicals of upper right and left canine regions.

3. Periapical of lower anterior sextant.

4. Orthopantomogram: Unerupted canines with 3, erupting in a potentially

transposed position with 2. Note: errors in patient positioning were found;

namely the patient was positioned too far forward as well as asymmetrically in

the focal trough, resulting in tooth size discrepancies (anterior segment being

narrowed and left buccal segments being larger than the right).

5. Upper standard occlusal

6. Lower 45° occlusal

Unerupted teeth:

8 7 5 3 3 7 8

8 7 5 3 3 5 7 8

Teeth absent: Nil

Teeth of poor prognosis: Nil

Other relevant radiographic findings: The upper standard occlusal and periapical

radiographs were utilized to localize the upper canines using the phenomenon

of horizontal parallax. The 3 was found to be in the line of the arch. The 3 was

found to be buccally displaced with minimal resorption of the right deciduous

canine root. After viewing the lower 45° occlusal radiograph along with the

DPT, the radiology department advised that 3 seemed to be lingually placed

or at least the tip of the crown is lingually placed. Note that the same tooth is

occupying a transposed position and is rotated. At a subsequent visit a right

and left lower periapical was taken to verify the position of the lower canines.

There was no change in position of the 3 when comparing the lower 45°

occlusal with the periapical suggesting that this tooth is erupting in the line of

the arch.

pg. 11

PRE-TREATMENT RADIOGRAPHS (13.07.12): Bitewings

PRE-TREATMENT RADIOGRAPHS: Periapicals of right and left upper canine regions (13.07.12) and

periapical of lower anterior sextant (12.12.12)

pg. 12

PRE-TREATMENT RADIOGRAPHS: Orthopantomogram (21.06.12)

PRE-TREATMENT RADIOGRAPHS: Upper standard occlusal and lower 45° occlusal (13.07.12)

pg. 13

DIAGNOSTIC SUMMARY

AS is a 9 year, 3 month old female of African descent in late mixed dentition exhibiting Class I

malocclusion on a Class I skeletal base. A normal overbite was identified along with a 6mm OJ

on both the right and left incisors. AS’s upper and lower arches were severely crowded.

PROBLEM LIST 1. Moderate oral hygiene.

2. Localized Microdontia.

3. Upper and lower arch crowding.

4. Impaction of all canines.

5. Transposition.

6. Proclined upper incisors.

7. Increased OJ.

8. ¼ unit Class II molars on the right and left.

AIMS AND OBJECTIVES OF TREATMENT

1. Ensure good oral hygiene.

2. Manage the aesthetic challenge of the peg lateral.

3. Relieve crowding in both arches.

4. Maintain available space (leeway space and that which is gained by extraction) in both

arches during transition into permanent dentition.

5. Manage the aesthetic challenge of transposed 3 and 2 (upon the canine’s eruption).

6. Retract upper incisors.

7. Level and align both arches.

8. End in Class I incisal and molar relationships.

9. Ensure adequate retention.

pg. 14

TREATMENT PLAN (19.7.12)

Extractions:

E C 2 C 4

E 4 4 E

Appliances:

1. Nance Appliance

2. Lingual Arch

3. Fixed Appliances

I. Sectional appliance (modified treatment plan12/12/12) from 2 to 6

II. Full fixed appliances

Minor adjunctive surgery: Nil

Additional dental treatment: Aesthetic re-contouring of upper and lower

permanent canines to the likeness of a permanent lateral incisor and the

upper right first premolar and lower right lateral incisor to the likeness of a

permanent canine

Proposed retention strategy: Tentative

Prognosis for stability: Good

pg. 15

SECTION 2. TREATMENT

TREATMENT PROGRESS

Start of treatment: 27.07.12

Age at start of active treatment: 9 years 3months

KEY STAGES IN TREATMENT PROGRESS

DATE STAGE

1. 19.07.12 Extraction of E 4

2. 25.07.12 Extraction of E C

3. 25.07.12 First molar band fitting for fabrication of Nance

appliance and lingual arch (including

accompanying alginate impressions)

4. 27.07.12 Placement/cementation (Fugii 1) of Nance

appliance and lingual arch

5.

10.09.12

Extraction of E

First molar band fitting for fabrication of a

new lingual arch

6.

26.09.12

Extraction of 4

Lingual arch cementation

7.

07.11.12

Extraction of 4

8. 12.12.12 Bonding of a sectional appliance, placement

of brackets on 6 5 2 and application of 0.014”

Ni-Ti arch wire and lacebacks. (TransbondTM

XT light cure adhesive)

9. 16.01.13 Insertion of 0.018” SS archwirwe into

appliance

pg. 16

MID-TREATMENT PHOTOGRAPHS: Nance appliance, lingual arch and sectional appliance with

lacebacks in place. Note composite placed on occlusal of the lower permanent first molars for

dis-occlusion.

pg. 17

SECTION 3. POST-TREATMENT ASSESSMENT

OCCLUSAL FEATURES:

Incisor relationship: Class 1

Overjet (mm): 6 6

Overbite: Normal, incomplete

Centerlines: Coincident to the face and to each other

Left buccal segment relationship: ¼ Class II

Right buccal segment relationship: Class I

Crossbites: Nil

Displacements: Nil

Functional occlusal features: Group function

COMPLICATIONS ENCOUNTERED DURING TREATMENT

1. De-bonding of the lingual arch a few hours after first insertion and 1 month post second

insertion.

2. De-bonding of lingual arch resulting in complete warping after AS bit down on it. A new

lingual arch had to be fabricated.

3. Reluctance (to the point of tears) to extract the peg lateral. This tooth remains in situ to

date.

4. Loss of Ni-Ti wire archwire before review appointment after little brother manipulated it

during play.

pg. 18

ADDITIONAL ANALYSIS

With the development of AS’s reluctance to extract the peg lateral it was decided that an

attempt might be made to include it in the fixed appliance phase even though it seems too

diminutive to receive a standard orthodontic bracket. This would lead to the need for restorative

treatment planning for that tooth prior to final alignment.

pg. 19

POST-TREATMENT PHOTOGRAPHS: INTRA-ORAL

Note prominent bulge of completely formed crown of upper right permanent canine directly over

diminutive lateral.

pg. 20

POST-TREATMENT PHOTOGRAPHS: INTRA-ORAL

Note eruption of the upper left permanent canine and Nance appliance still in place

pg. 21

SECTION 4: DISCUSSION

Recall agreed upon treatment plan:

Alignment of involved teeth in their transposed positions and cosmetic re-shaping; fixed

appliance treatment facilitated by extraction and space maintenance pre- treatment.

RATIONALE FOR FIXED SPACE MAINTENANCE

AS’s case was deemed an urgent one for utilizing interceptive orthodontic techniques due to

the anticipation of a crowded permanent dentition. The choice of space maintenance in the

use of the Lingual arch and Nance appliance as an adjunct to relief of crowding was

indicated due to the intention to remove multiple teeth and the presence of the permanent

lower incisors and permanent first molars. The protocol chosen was based on the following

considerations:

1. Eruption of permanent maxillary canines after the eruption of the first premolars

increases the likelihood of crowding.

2. Buccal displacement of permanent canines (85%) is often a manifestation of crowding in

the upper arch (Jacoby, 1983) (Radiographic report revealing a buccally displaced

unerupted right maxillary canine).

3. With the permanent canines being the last to erupt anterior to the first permanent

molars, space loss is an inevitable feature (Millett & Welbury, 2005).

The selected space maintainers achieve the objective by moving onto an anterior stop

(lower permanent incisors and the palatal vault when there is movement in a mesial

direction as a result of the eruption of the permanent second molars. In this way the spaces

for the premolars are maintained.

pg. 22

F/S p/e F/S

6 E D C B 1 A B C D E 6

6 E D C B 1 1 B C D E 6

p/e F/S F/S GIC pit F/S F/S p/e

RATIONALE FOR FIXED APPLIANCES

Interceptive orthodontics is aimed at recognizing a developing malocclusion and the provision of

treatment which aims to minimize or eliminate more complex treatment. However, AS’s case

does require more complex detailing including residual space closure and thus requires fixed

appliances. A sectional appliance was used during the interceptive phase to begin distalization

of the lower right permanent incisor to allow the transposed permanent canine to erupt. An

0.014” NiTi arch wire was used and a laceback (0.009” soft stainless steel ligature wire) applied

to protect the thin aligning archwire.

A BRIEF LOOK AT THE COURSE OF AS’s DENTAL DEVELOPMENT

History of the development of AS’s dentition is critical in reviewing the factors that may have

contributed to its present state. This section would therefore attempt to explore these factors by

investigating previous entries into AS’s patient notes:

1. DEVELOPMENT OF THE EARLY MIXED DENTITON

Notes dated 31.11.09 reported that primate spaces were visible in both arches and that a large

fleshy frenum was spotted between the upper permanent central incisors.

AS was 6 years and 7 months at this time. The charting revealed that the chronological age

indeed correlated with her dental age as all first permanent molars and central incisors with the

exception of A (which in fact demonstrated grade 2 mobility).

Charting recorded at 6 years 7 months

Key: F/S - Fissure sealant

p/e - Partially erupted

GIC - Glass Ionomer

restoration

At this point it can be said that AS’s dental development was on track with no expectation of

crowding occurring in the permanent dentition.

pg. 23

2. RETAINED DECIDUOUS TEETH

Notes dated 25.08.10 reported that B B were over- retained. Her age at this time was 7 years

and 4months.

Although it is accepted that lower permanent incisors erupt around 7-8 years (Millett & Welbury,

2005), it is my view that the practitioner who attended to AS at this time considered the history

of eruption in order to come to this conclusion. Dental sequence can show subtle inter-patient

variability. However, intra-patient variability may raise red flags. With such considerations in

mind, it would be prudent to recall that the same author (see Table) suggests that permanent

upper central incisors erupt at age 7-8 years while AS’s charting revealed an already erupted 1

and a mobile A at only 6 years and 7 months. Therefore, as a watchful practitioner, I would

suggest that AS’s eruption sequence started off at least a year ahead and that the rest of the

permanent dentition was expected to follow suit.

A simpler route to a conclusion would be to insist that the eruption of permanent lower lateral

incisors usually coincide with that of the permanent upper central incisors regardless of inter-

patient eruption variability.

Table: Eruption Sequences (Adapted from Clinical Problem-Solving in Orthodontics and Paediatric Dentistry,

pg2)

These observations have thus resulted in my agreeing that the deciduous lower lateral incisors

were indeed over-retained. The notes further reported that a decision was made to extract the

said lateral incisors to allow the eruption and alignment of the permanent successors.

pg. 24

3. DEVELOPMENT OF LOWER INCISOR CROWDING AND RETAINED DECIDUOUS TEETH IN

THE EARLY MIXED DENTITION (recurring phenomenon)

Notes dated 16.02.11 reported that AS who was 7 years and 10 months of age at the time, had

undergone extraction of C.

Rationale was not given for this but it can be speculated that an attempt was made at

commencing serial extraction as the following note entry would suggest; (At this time the

permanent lower incisors would have been erupting. The classical technique of serial extraction

advocates the extraction of the deciduous canines as the incisors are erupting (Kjellgren)).

Notes dated 29.06.11 reported extraction of C when AS was 8 years and 2 months of age.

The dental student attending to AS at this time went on to classify the extraction as a serial

extraction. Thus mitigation of developing lower incisor crowding was most likely the rationale for

these extractions.

AS’s next visit highlighted her presenting clinical intra-oral features (that which is under scutiny

in this report). It suffices to say that the following steps in the classical technique for serial

extraction were not followed through after extraction of C C:

1. Extraction of the first deciduous molars when their roots were half resorbed

2. Extraction of the first premolars on eruption.

Therefore, space loss (for permanent canines) in the lower arch was the unfortunate result.

At this same visit 2 2 were reported to have been erupting palatally to the over- retained

predecessors. The B was subsequently extracted at this same appointment and B was

delivered at a following visit. AS’s age at this extraction was 8 years and 5 months.

pg. 25

A BRIEF INSIGHT INTO AS’s PRESENTING DENTAL ANOMALIES

LOCALIZED MICRODONTIA

Although crowding has been suggested as the possible reason for the buccal displacement of

the 3, another issue surrounding AS’s dentition is worthy of mention. The peg shaped lateral (2)

is a possible contributing factor to the observed displacement, keeping in mind that palatal (not

buccal as in AS’s case) displacement is usually associated with such an anomaly. It has been

suggested that the reduction in size of the tooth especially it’s root, results in a lack of guidance

during eruption. Its association with an autosomal dominant mode of inheritance has been

documented (Regezi).

TRANSPOSITION

The rare anomaly of transposition is almost exclusive to the canine tooth when it occurs. It is

the positional interchange between two adjacent teeth, the occurrence of which also has a

genetic component (Peck S, 2002). While a definite etiology remains speculative the condition is

associated with concurrent dental anomalies including hypodontia, peg-shaped maxillary lateral

incisors and retained primary teeth.

Studies found that unilateral transposition was by far the most common type and that

transposition affected the maxillary far more frequently than the mandibular dentition with the

maxillary canine and first premolar being more commonly involved. When occurring in the

mandible the most commonly affected teeth were most commonly transposed were the

mandibular canine and lateral incisor (Nicola J. E et al 2006). AS showed unilateral, right sided

mandibular canine and lateral incisor transposition (Mn.I2C) with a concomitant peg lateral. The

same study also found that in females the majority of unilateral cases occur on the right side. In

addition biplot analysis allowed the visualization of a weak association between Mn.I2C and peg

shaped maxillary incisors and a weak association between the gender and the presence of the

pg. 26

peg shaped incisor. Although it is thought that microdontia results from a weaker penetrance of

the same gene expression for hypodontia, the latter dental anomaly was poorly associated. This

may suggest that environmental factors may also play a role.

Peck et al 1998 examined the nature of Mn.I2.C transposition and its associated features. Two

stages of transposition were identified; early-stage and mature-stage transposition. The author

found that early-stage transposition occurred in the age category of 7-10years of age and

characterized by early distal tipping, coronal displacement and severe mesiolingual rotation (60-

120 degrees) of the mandibular lateral incisor. The crowns are transposed but the roots are not

yet in transposed positions. These characteristics save the crown and root positions were not

yet evident in AS’S case until later radiographic examination. Peck went on to observe the

female preponderance for the condition as well as a preference for right sidedness, keeping in

mind that a moderate sex bias may exist in orthodontic patients.

ALTERNATIVE TREATMENT PLANS

The treatment plan described here is not meant to serve as a definitive treatise on how to

handle dental transposition. As such, alternative treatment plans were offered to AS’s mother.

These may involve:

1. Non acceptance of transposition

a. Treat with fixed appliances to move the transposed teeth into correct positions.

It is essential to carefully consider initial root positions and inclinations and adequacy of

bone in which to move the transposed teeth (Doruk 2006). As such this option carries

with it the risk of tooth resorption, loss of vitality and damage to the periodontium.

b. Surgically reposition.

This option requires general anaesthesia and also carries the risk of tooth resorption

(and ankylosis) and loss of vitality. AS’s mother objected to surgery.

c. Extraction of the most displaced tooth of the two followed by orthodontic alignment.

This option would result in loss of centerline coincidence and symmetry in the arch.

Alignment will place an incisor at the midline which is unaesthetic. There was also

objection to this option.

pg. 27

2. Acceptance of transposition

a. With some limitation, alignment with removable appliances.

The transposed canine would be left to erupt in that position and the erupting forces

used to distalize the lateral incisor. A removable appliance fitted with an appropriate

spring could then be used to improve the rotation of the canine. The two teeth can then

be re-contoured to resemble each other.

Position of the erupting permanent mandibular right canine

Intra-oral view of the removable appliance with a labiolingual spring

Advantages of this treatment option include cheaper cost than fixed appliances.

However it is limited by the fact that proper torqueing and uprighting movements, if

needed, are unachievable with this type of movement.

pg. 28

CRITICAL APPRAISAL

The left upper canine has since erupted into the arch following extraction of the predecessor.

Thus a close watch on the unerupted contralateral canine is warranted as it is nearing the end

of its eruption potential. Besides presenting an aesthetic challenge the peg lateral is impeding

the canine’s eruption and a decision concerning its extraction must be made soon to avoid

surgery.

In the fixed appliance phase the space afforded by the Lingual Arch and Nance Appliance will

be used to distalize the buccal segment teeth and canines (and lower right lateral incisor) and

retract the upper incisors. During treatment the use of the space maintenance was quickly

obsolete as the eruption of the upper and lower second premolars (except for the upper left

which was already erupted) was expedited (This has been attributed to a clearance of the path

of eruption) while the lower right permanent second molar had barely erupted.

It is worthy to note that AS is exhibiting secondary sexual characteristics and her mother has

commented on the rate at which she is currently changing clothes sizes. This will impact on the

timing of her treatment. It may afford a quicker start and relatively earlier end to full fixed

appliance therapy.

The administration of proper care instructions of appliances should have been given to AS and

her mother to avoid the mishaps involving the lingual arch and sectional appliance. This would

have included instructions to return to the clinic as soon as possible if any appliance were to de-

bond or fall out.

CONCLUSION AS is still in the early stages of treatment (at the end of her interceptive phase) and as such the

full success of the treatment protocol chosen has not yet been realized. However based on

clinical examination and radiographic analysis a good outcome is expected as the transposition

was detected before the canine erupted. No detrimental responses to treatment have arisen

thus far and satisfactory and stable results are expected.

pg. 29

REFERENCES Doruk, C. B. (2006, January). Correction of a mandibular lateral incisor-canine transposition. American

Journal of Orthodontics and Dentofcial Orthopaedics, pp. 65-72.

Ely, N. J., Sheriff, M., & Cobourne, M. T. (2006, April). Dental transpostion as a disorder of genetic origin.

European Journal of Orthodontics, pp. 145-151.

Gill, D. S., & Naini, F. B. (2011). Orthodontics, Principles and Pratcice. West Sussex: Wiley-Blackwell,

Dental Update.

Houghton, N., & Morris, D. (2004, November). Mandibular Lateral Incisor-Canine Transposition: A Case

Report. Dental Update, pp. 548-550.

Hoyte, T. Lecture Notes in Orthodontics. UWI Dental School.

Millett, D., & Welbury, R. (2005). Clinical Problem Solving in Orthodontics and Paediatric Dentistry.

Oxford: Elsevier Churchill Livingstone.

Mitchell, L. (1998). An Introduction to Orthodontics. New York: Oxford University Press.

Peck S, P. L. (2002). Concomitant occurrence of canine malposition and tooth agenesis: Evidence of

orofacial generic fields. AM J Orthod Dent Orthop 122, 657-660.

Peck, S., Peck, L., & Kataja, M. (1998, October). Mandibular lateral incsior-canine transposition,

concomitant dental anomalies, and genetic control. The Angle Orthodontist, pp. 455-466.

Proffit, W. R. (2007). Contemporary Orthodontics. St. Louis: Elsevier.