JUNE 2008

CASE REPORT
Frank K. Marasa, B.Sc., D.M.D. Surrey, British Columbia, Canada

Non-Extraction Treatment of a Crowded Class II Skeletal, Class I Dental Patient

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 does orthodontics. 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. CHIEF COMPLAINT The patient was a Class I molar, Class II canine dentally. She had a neutral profile but the upper lip appeared short and slightly retruded. Her upper midline was 2 mm to the left of her facial midline. The lower right first premolar was tipped lingual into crossbite. There was severe crowding in the anterior regions. The incisors had a normal angulation. There was an 80% overbite with minimal overjet. Her Ponts measurement was 33.0 and she was short of Ponts in all areas, with the largest being almost 10 mm in the lower first premolar area. (See Table 1) No deviation of the mandible was noted on opening and closing. No clicking noises could be detected. She could open 45 mm vertically and 9 mm horizontally which falls within the normal range of motion for an adult female. Also the condyles appeared normal on the Panelipse radiograph. Her diagnostic casts showed a 1 mm lateral side shift, to the right, from CR to CO. (Fig 10 14) The deflection appeared to be off of her left lateral incisors. The Kernott Analysis showed her to be relatively symmetrical. TREATMENT OBJECTIVES 1. Treat non-extraction. 2. Develop the dentition to Ponts to gain room to reduce the crowding and use the inclined plane action to increase the vertical. 3. Further reduce crowding by flaring the anterior teeth forward. This would also help with the retruded upper lip and 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 a Class I relationship. 8. Reduce the lateral side shift and make CR = CO.

MEDICAL HISTORY

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

DENTAL HISTORY

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

The patient had some routine amalgam restorations placed on her molar teeth. Her wisdom teeth had been removed, at age 18, with no significant complications. She had been referred for orthodontic treatment, as early as age 11, for her crowding problem. The orthodontist had recommended 1st premolar extractions to correct her tooth size - arch length discrepancy. Her parents decided not to proceed with treatment. ETIOLOGY There was a history of previous clicking noises in her TMJs, however this had not led to any painful symptoms.

The patient did not appear to have any airway problems. There may have been a myofunctional problem, as the Masseter and Anterior Digastric muscles were weak with swallowing; however no anterior tongue thrust could be detected. Other members of her family had a Class II malocclusion and crowding so heredity was probably a factor. DIAGNOSIS

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

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

APPLIANCES AND TREATMENT PLAN 1. Standard body wire Crozat appliances would be used to start the arch development. However the lingual arms would initially only engage the upper and the lower left second premolars and the lower right first premolar. These teeth were leaning lingually and needed the most arch development. The arches would be developed to Ponts. It was hoped that the crossbite would be corrected in this stage. 2. Possible use of a bite opening splint, on the maxillary teeth, 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 would hopefully improve with the alignment of the more significantly crowded left lateral and canine. 4. Hawley retainers 5. Occlusal equilibration, if necessary, to eliminate any CR to CO discrepancies.

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

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6 PROGRESS OF TREATMENT Treatment was started with the standard Crozat appliances, as previously discussed. (Fig 15, 16) Light forces were used to develop the dentition towards Ponts. After 8 months of treatment, the premolar crossbite was corrected. It was unnecessary to use a bite opening splint as the crossbite corrected without it. The upper second molars were expanding 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.

More arch length could be gained by rotating the upper first molars with the TPA and molar rotation is much easier to accomplish with a TPA than with a Crozat appliance. (Fig 17) Also the molar arch width could be maintained. The SWA could now be used to align the anterior teeth. By maintaining the width of the first molars (with the TPA), the second molars could now be brought lingually as they would move against the locked in first molars. Roth Rx. brackets were used and the upper arch was banded and bracketed from the 2nd molars forward. (Fig 18) The mandibular left canine

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

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

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

Figure 18 - Leveling and aligning the maxillary teeth.

Figure 19 - Only the left mandibular canine needed 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.

Figure 20 - Leveling and aligning the mandibular teeth.

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

RETENTION

was lingually inclined and thus a recurve was added to the lower Crozat appliance to tip the tooth to the labial. An arm was placed on the occlusal of the lower right 2nd molar to try and prevent the reciprocating forces that will occur, causing molar extrusion and tip back, from the lingual recurve to the canine. (Fig 19) Once the lower left canine was aligned into the arch, the lower Crozat appliance was left in place and brackets were placed from the 2nd premolars forward on the lower arch. (Fig 20) A .018 x .025 SE Nitinol wire was placed in the upper arch and a .014 Nitinol wire was placed on the lower arch. Arch wires progressed to a .020 SS upper and a .018 SS lower as the teeth aligned. A Class II elastic was used, for a short period of time, on the right side from the upper canine bracket to the lower Crozat appliance hook. Treatment was completed after 17 months. (Fig 21 28)

It was felt that this would be better myofunctionally, in case there had been any tongue thrust problems that were undiagnosed. The maxillary body wire would guide the tongue to the roof of the mouth. The Crozat appliances were revamped and a labial bow was soldered to the buccal strut of the upper appliance. A .018 braided wire was also bonded to each lower anterior tooth, from canine to canine, to prevent any relapse of the lower anterior region. RESULTS ACHIEVED

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

The patient did not wear her maxillary retainer faithfully. She was eager to be out of her SWA and did not wish to show any wire, in public, after treatment was completed. She stopped wearing the lower retainer after 2 years. The Ponts measurements that were achieved with Crozat arch expansion held up remarkably well 7 years after treatment was completed (Table 1 and Fig 29). All treatment objectives were met reasonably well. There appeared to be no skeletal increase in vertical. Thus the decreased overbite was the result of incisor flaring. (Fig 30, 31)

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

Figure 30 - Final Sassouni Plus cephalometric analysis. Notice improvement from a Class II to a Class I tendency

Figure 31 - Kernott Analysis slope measurement. Notice the decrease in the slope from the flaring of the maxillary anterior teeth.

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

Occlusal equilibration was unnecessary as CR = CO at the completion of treatment. The upper second molars tipped back initially as a response to the distal driving of the upper Crozat. (Fig 32 36) Seven years post treatment, they had settled back into function. This initial tipping back may tend to prevent them from becoming an occlusal interference. That may be one of the reasons for CR = CO in this case. The slight rotation of the upper right lateral incisor did not concern the patient. FINAL EVALUATION

more coronal on the frontal photograph. (Fig 24) Also the maxillary occlusal photograph shows different torque between the two lateral incisors. (Fig 25) However the photographs taken seven years after treatment was completed show this largely corrected. (Fig 37 44) Since mechanics werent used, the only explanation for its correction can be function. The action of the lips on the incisal edge of the upper lateral incisor fulcruming against the incisal edges of the lower anterior teeth was enough (over time) to correct the incisor torque. Thus function helped to correct position. Improved tongue function and an improved swallowing habit can explain the maintenance of the expanded arch widths. Thus improvement of form and position lead to improvement of function for this patient. .

The root of the upper left lateral incisor was lingually displaced before treatment started. This was not recognized during treatment and no allowance was made for its correction. The final photos show the attached gingiva

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

Table 1 - Ponts Measurements (33.0) Upper 6s Ideal Initial Final 7 yrs 51.5 44.5 50.0 48.8 Lower 6s 50.5 44.0 50.0 48.7 + 4.7 Upper 4s 41.0 37.0 41.3 41.3 + 4.3 Lower 4s Upper 3s 36.0 26.2 34.7 35.2 + 9.0 38.0 35.5 36.5 36.3 + 0.8 Lower 3s 30.0 25.8 28.8 28.5 + 2.7

Change + 4.3

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