management of a mixed treatment technique in a … · etiology and diagnosis ... left asymmetry...
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Address for correspondence:
Benjamin DELVALLEZ31 D rue Vaneau, 35000 [email protected]
DOI: 10.1051/odfen/2013500 J Dentofacial Anom Orthod 2014;17:207� RODF / EDP Sciences
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Article received: 14-09-2013.Accepted for publication: 29-11-2013.
C L I N I C A L C A S E
Management of a mixed treatmenttechnique in a patient with a class Ibimaxillary protrusion
B. Delvallez, O. Sorel
INTRODUCTION
Orthodontic treatment using a mixedtechnique (maxillary lingual appliance andmandibular buccal appliance) increases thedifficulties of detailing the occlusal finishing.We will see the implementation of the
various methods used to treat the followingClass I skeletal case, with dento-maxillarydiscrepancy and a previously treated period-ontal disease.
ETIOLOGY AND DIAGNOSIS
The patient came for a consultation to theRennes DFO Center in January 2008 for thepurpose of aligning her teeth and lesseningher concern about her ‘‘teeth being too farforward.’’
The diagnosis was:Functional: a slight lingual thrust in the
maxilla during swallowing. There is noproblem with breathing and she was testednegative for OSA.
Extra-oral: in the facial view note the right-left asymmetry with the right side less
developed. The smile is broad and asymme-trical. In the profile view the naso-labialangle is closed with the presence of abimaxillary protrusion (Figs. 1 and 2).
Skeletal: in the transverse direction the A-Pcephalometric xray does not indicate anyabnormality, in the sagittal direction, thecephalometric analysis shows a skeletalClass I and a bimaxillary protrusion (1/NA37� and i/NB 34� and an IMPA of 100�) (Fig. 3).
Dento-alveolar: the patient is an AngleClass I with a 2 mm Class II right canine.
Article available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2013500
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Figure 1Facial photographs before treatment: frontal, profile and smile.
Figure 2(a) Profile cephalometric xray (b) Steiner Analysis and (c) pre-treatment orthopantomogram.
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The incisal overjet is 6 mm and theoverbite is 5 mm.
There exists two local crossbitesbetween 17 and 47 in one case (17 isbuccal) and in the other case between14 and 44 in the other case (44 is inlingually tipped) (Figs. 3 and 4). There
is 6 mm lower dental crowding withabnormal crown morphology on 34and 44. In addition, the exam shows amoderate vertical alveolar bone loss(defect) due to a previously treatedperiodontal disease.
TREATMENT OBJECTIVES
It was decided to perform treatmentwith the extraction of four first pre-molars. This decision is justified by:
the maxillo-mandibular protrusion andthe desire of the patient to not haveprotrusive teeth as well as the dental
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Figure 3Intra-oral photographs before treatment.
Figure 4Study models before treatment.
MANAGEMENT OF A MIXED TREATMENT TECHNIQUE IN A PATIENT WITH A CLASS I BIMAXILLARY PROTRUSION
J Dentofacial Anom Orthod 2014;17:207. 3
crowding and the abnormal shapes of34 and 44, and finally by a weakperiodontium even though the period-ontal pathology had been treated andstabilized.
The extractions of the premolarswill enable us to create the necessaryspace for alignment with a favorablelingual and palatal tipping of themaxillary and mandibular incisors. Inorder to avoid reducing the tonguespace and to not modify the profile,
we did not use a special anchoragesystem.
The right and left excursions aredisturbed by the completely blockedout 17 that leads to a significantinterference and prematurity in open-ing and closing. Repositioning of thistooth made it possible to improveocclusal function of mastication.
It was necessary to retrain swallow-ing in parallel with exercises as de-scribed by Garliner or Fournier.
TREATMENT PROGRESSION
Treatment started in June 2008.The extractions of the 4 premolarswere done after placement of themaxillary lingual system in June 2008(Fig. 5).
The leveling and aligning phase wascompleted in 7 months. The beginningof mesialization of the mandibularsecond premolars (by sliding me-chanics using elastomeric chains)was accompanied by mesio-lingualrotations. This was due to a mechan-ical error (missing metal ligature on
the 5 elastomeric chains holding the 4tie wings of the bracket, under-sizedwire and of course a force that did notpass through the center of resistanceleading to the rotation).
During the first re-evaluation at theend of 1 year, we note: a mildretraction of the maxillary incisorswithout noticeable change in theirinclination, and a lingual tipping ofthe mandibular incisors (according tosuperimposition using the the LVDmethod as confirmed by the SteinerAnalysis) (Fig. 6).
Fortunately, we reacted quickly andchanged mechanics. Orthodontistshave to be very careful with me-chanics because the unwanted rota-tion took place in one month! Thespace closure was done with an .020Australian wire that was rigid enoughwith low friction with no control overthe inclination of the mandibular in-cisors, the object of which was toobtain a linguoversion of the incisors(Fig. 7).
We then began maxillary incisorretraction and had some difficulties in
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Figure 5Photograph of the maxillary arch after bonding.
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Figure 6(a) Steiner Analysis and (b) Superimpositions at 1 year of treatment.
Figure 7Intra-oral photographs during the closure of the mandibular spaces.
MANAGEMENT OF A MIXED TREATMENT TECHNIQUE IN A PATIENT WITH A CLASS I BIMAXILLARY PROTRUSION
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Figure 8Intra-oral photographs at the beginning of the closure of the maxillary extraction spaces.
Figure 9(a) Steiner Analysis at 2 years of treatment and (b) superimposition at 2 years of treatment.
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controlling the inclination of the max-illary incisors (Figs. 8 and 9).
Then after accelerating the maxillaryspace closure and having overcomethe friction, we incorporated retractionloops. (Fig. 10).
Class II traction elastics (thin dia-meter) were worn at night betweenthe mandibular first molars and themaxillary second premolars in order tolimit the mesialization of the maxillaryfirst molars (Fig. 11).
Thereafter, the end of the maxillaryspace closure was achieved by usingmini screw anchorage and by remov-ing the mandibular system. Since thepatient can no longer wear inter-maxillary elastics, we placed thescrews to accomplish single jawretraction. Buccal brackets becametroublesome for the retraction ofthe maxillary incisor-canine group.(Fig.12).
Criss-cross elastics were placedto reduce the crossbite of 15-25.A coronoplasty was performed on 21(on the occlusal edge) in order tomake the shape of 21 and 11 symme-trical, also on 13 and 23 to reduce thethe cuspid tip, that appeared toopronounced for a woman. The de-banding took place at the end of2011.
The superimpositions at the end oftreatment, in violet, show a little toomuch retroclination of the maxillaryincisors. The lingual tipping and theretraction of the mandibular incisorsand the mesialization of the maxillaryfirst molars. The upper and lower lips,also, retracted (Figs 13-15). Webonded a nickel-titanium braided wirein the maxilla and mandible and hadher wear a Hawley plate with the goalof avoiding any reopening of anyextraction spaces in the maxilla.
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Figure 10Intra-oral photographs during closure of the maxillary extraction spaces.
MANAGEMENT OF A MIXED TREATMENT TECHNIQUE IN A PATIENT WITH A CLASS I BIMAXILLARY PROTRUSION
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Figure 11Radiographs prior to placement of the mini screws at three years of treatment.
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Figure 12Intra-oral photographs at the end of maxillary space closure with mini-screws.
Figure 13Superimposition at the end of treatment.
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Figure 14Intra-oral photographs at the end of treatment.
Figure 15Profile and smile photographs.
Figure 16Intra-oral photographs and the end of retention.
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Figure 17Models at the end of retention.
MANAGEMENT OF A MIXED TREATMENT TECHNIQUE IN A PATIENT WITH A CLASS I BIMAXILLARY PROTRUSION
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