CASE REPORT
Class II malocclusion with complex problems treated with a novel combination of lingual orthodontic appliances and lingual arches Takeshi Yanagita,a Masahiro Nakamura,b Noriaki Kawanabe,c and Takashi Yamashirod Okayama and Osaka, Japan
This case report describes a novel method of combining lingual appliances and lingual arches to control horizontal problems. The patient, who was 25 years of age at her first visit to our hospital with a chief complaint of crooked anterior teeth, was diagnosed with skeletal Class II and Angle Class II malocclusion with anterior deep bite, lateral open bite, premolar crossbite, and severe crowding in both arches. She was treated with premolar extractions and temporary anchorage devices. Conventionally, it is ideal to use labial brackets simultaneously with appliances, such as a lingual arch, a quad-helix, or a rapid expansion appliance, in patients with complex problems requiring horizontal, anteroposterior, and vertical control; however, this patient strongly requested orthodontic treatment with lingual appliances. A limitation of lingual appliances is that they cannot be used with other conventional appliances. In this report, we present the successful orthodontic treatment of a complex problem using modified lingual appliances that enabled combined use of a conventional lingual arch. (Am J Orthod Dentofacial Orthop 2014;146:98-107)
L
ingual appliances are often used to correct malocclusions in adult patients who have esthetic concerns.1 Nevertheless, clinicians face some problems when working with lingual appliances, such as limited visibility during adjustment of the appliances, short distances between neighboring brackets, irregular arch forms, and complicated attaching and detaching processes.2-7 However, lingual appliances have become more convenient for orthodontists because of the introduction of self-ligating brackets, the straight-wire technique, customized brackets, and wire-bending robots.8-12 Temporary skeletal anchorage devices have also played a part in expanding the applications of
a Assistant professor, Department of Orthodontics, Okayama University Hospital, Okayama, Japan. b Clinical fellow, Department of Orthodontics, Okayama University Hospital, Okayama, Japan. c Senior assistant professor, Department of Orthodontics, Okayama University Hospital, Okayama, Japan. d Professor and chair, Department of Orthodontics and Dentofacial Orthopedics, Graduate School of Dentistry, Osaka University, Osaka, Japan. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Takeshi Yanagita, Department of Orthodontics, Okayama University Hospital, 2-5-1, Shikata-cho, Okayama City, Okayama 700-8525, Japan; e-mail, [email protected]. Submitted, April 2013; revised and accepted, August 2013. 0889-5406/$36.00 Copyright Ó 2014 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.08.022
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lingual appliances, particularly in patients with Angle Class II or Class III malocclusion.13-18 Temporary skeletal anchorage devices make it easier to perform anterior tooth retraction and achieve anchorage control to correct molar relationships.19-21 These technologic advancements have solved most of the problems associated with lingual appliances. However, one remaining problem contributes to the unsuitability of such lingual appliances in difficult cases, especially those involving transverse complications: lingual appliances cannot be used with a lingual arch appliance, a quad-helix appliance, or fixed rapid expansion appliances. The use of these appliances is desirable when treating complex problems. In this report, we describe the treatment of an adult with a Class II malocclusion and complex problems, including a second premolar crossbite resulting from a narrowed maxillary arch. The patient did not wish to undergo orthognathic surgical procedures, instead requesting orthodontic treatment with lingual appliances for esthetic reasons. Although the use of conventional lingual appliances and methods appeared difficult because of the patient's severe vertical and horizontal problems, we modified the appliance design and treatment technique to satisfy her request. The most notable point in this case was the modified design of the lingual appliances, which enabled the combined use of lingual appliances and a lingual arch,
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Fig 1. Pretreatment photographs.
successfully addressing the horizontal problems. We believe that this approach will broaden future orthodontic treatment choices. DIAGNOSIS AND ETIOLOGY
A woman, 25 years 4 months of age, consulted the outpatient clinic of Okayama University Hospital with a chief complaint of crooked teeth. She strongly desired nonsurgical treatment with an invisible appliance. Her convex profile was due to a retrognathic mandible with upper lip protrusion. Circumoral muscle strain was observed upon mouth closure. Anterior incisor deepbites with an excessive overjet of 8 mm and a deep overbite of 7 mm were observed. A severe curve
of Spee was noted in the mandibular occlusal plane (4 mm). Severe crowding was present in both arches (arch length discrepancies: maxilla, 8.6 mm; mandible, 10.9 mm). The maxillary right central incisor had a gingival recession on the distal side caused by labial malposition and mesial rotation. The amount of attachment loss of the maxillary right central incisor was 2.0 mm in contrast to the left side. Both maxillary second premolars exhibited crossbites because of palatally dislocated maxillary second premolars. The mandibular incisors were inclined lingually, and both canines were dislocated labially. The molar relationship was Angle Class II on both sides. The maxillary dental midline was deviated 3 mm toward the right of the facial midline, although the mandibular dental midline was not
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Fig 2. Pretreatment dental casts.
Fig 3. Pretreatment radiographs: A, cephalogram; B, pretreatment panoramic radiograph.
deviated from the facial midline. The dental radiographs showed normal root lengths with no horizontal or vertical bone loss (Figs 1-3). In comparison with the Japanese norm, a skeletal Class II relationship (ANB angle, 5.8 ) with mandibular retrusion (SNB angle, 74.8 ) was observed (Table).22 The body length of the mandible was small (Ar-Me, 97.7 mm). The mandibular plane angle was normal (Mp-SN, 40.9 ). The maxillary incisors were lingually inclined (U1-SN, 91.0 ), and the height of the incisors was normal (U1/PP, 30.2 mm). The mandibular incisors were
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lingually inclined (L1-Mp, 86.9 ), and the height from the mandibular plane was excessive (L1/Mp, 49.4 mm). The occlusal plane angle was average (18.2 ). TREATMENT OBJECTIVES
We diagnosed the patient with an Angle Class II malocclusion, a skeletal Class II jaw-base relationship, anterior deep bite, lateral open bite, premolar crossbite, severe maxillary and mandibular crowding, and midline deviation. The treatment objectives were to correct the
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Table. Cephalometric measurements Mean Angular analysis ( ) SNA SNB ANB Mp-SN Gonial angle U1-SN L1-Mp IIA Occlusal plane Linear analysis (mm) PTM-A/PP PTM-ANS/PP Go-Me Ar-Go Ar-Me U6/PP U1/PP L6/Mp L1/Mp Overjet Overbite
SD
Pretreatment Posttreatment
80.8 3.6 77.9 4.5 2.8 2.4 37.1 4.6 122.1 5.3 105.9 8.8 93.4 6.8 123.6 10.6 16.9 4.4 47.9 52.1 71.4 47.3 106.6 24.6 31.0 32.9 44.2 3.1 3.3
2.8 3.0 4.1 3.3 5.7 2.0 2.3 2.5 2.7 1.07 1.89
80.5 74.8 5.8 40.9 119.7 91.0 86.9 141.2 18.2
80.1 74.6 5.6 41.6 122.4 87.6 91.4 139.4 22.3
46.7 50.9 66.3 43.0 97.7 22.7 30.2 35.2 49.4 7.0 6.7
46.7 51.1 66.4 40.8 96.7 22.4 30.1 36.0 46.3 2.6 2.4
severe crowding, midline deviation, and lateral open bite; establish an ideal incisor relationship; and achieve an acceptable occlusion with a favorable functional Class I occlusion. We also planned to perform genioplasty to protrude the patient's chin, as it would be difficult to correct the convex profile using only orthodontic treatment, owing to the skeletal problems and severe dental discrepancy. Since the mandibular dental discrepancy was too severe to control the molar relationships, we planned to place temporary skeletal anchorage devices in the retromolar areas to provide skeletal anchorage to correct the molar relationships. Additionally, extractions of 4 premolars and 4 third molars were required to correct the severe crowding. Furthermore, the patient preferred to undergo lingual bracket treatment for esthetic reasons. However, it was difficult to use lingual brackets because she required highly technical tooth control in the horizontal, anteroposterior, and vertical directions. Ultimately, we decided to avoid the use of labial brackets on the maxillary incisors only.
hospitalization. Furthermore, the physical disadvantages of a surgical invasion caused her to decline this option, in addition to the fact that she was not dissatisfied with her facial profile. Therefore, we chose orthodontic treatment with premolar extraction. TREATMENT PROGRESS
The maxillary and mandibular first premolars were extracted before orthodontic treatment. The lingual arch was placed in the maxilla, and 0.018-in slot preadjusted edgewise appliances were placed in the mandible to level both arches. After initially leveling the maxilla with the lingual arch, 0.018-in slot preadjusted edgewise appliances were placed lingually on the maxillary incisors and labially on the maxillary premolars and molars (Fig 4). After the maxillary arch was leveled, a 0.016 3 0.022-in stainless steel archwire with a closing loop was positioned, and temporary anchorage devices (1.6 mm in diameter, 6 mm in length: Abso Anchor; Dentos, Taegu, South Korea) were placed in the buccal areas between the maxillary first and second molars. The maxillary molars were then retracted with nickel-titanium closing coil springs (200 g) for 12 months (Fig 5). To reduce the incisor overbite and the mandibular curve of Spee, we initially made occlusal stops on the mandibular first and second molars to create contact with the maxillary molars. The occlusal stops were made of resin cement, and their role was to prevent excessive stress on the lingual appliances placed on the maxillary incisors by the mandibular incisor ridges. We repeatedly scraped the occlusal stops in small amounts until the mandibular occlusal plane was flattened (Fig 4, C and D). The total active treatment period, including the use of the lingual arch, was 32 months. After removal of the edgewise appliances, lingual bonded retainers were positioned to retain both arches. Invisible retainers were also placed for full-time wear. After the edgewise appliances were removed, a gingivectomy of the central incisors was performed. One month after the gingivectomy, we took the oral and dental photos and the dental impressions for the dental casts. RESULTS
TREATMENT ALTERNATIVES
Two major procedures (with and without orthognathic surgery) were explored to achieve an ideal Class I occlusion and a good profile. Although mandibular and chin advancements with orthognathic surgery are considered an effective treatment method, the patient did not want to undergo surgery for social and physiologic reasons and the need for prolonged
The posttreatment records showed significant improvement of the patient's facial profile with a protruded upper lip. The strain of the circumoral musculature observed upon mouth closure disappeared (Fig 6). The severe crowding was resolved, and the anterior deepbite and lateral open bites were corrected. An Angle Class I molar relationship with ideal overjet and overbite was achieved (Figs 7-9). The occlusion exhibited
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Fig 4. Oral photographs obtained during the leveling procedure: A, start of treatment; B, 3 months after the start of treatment; C, 6 months later; D, 12 months later.
acceptable interdigitation and canine guidance. The dental midlines became consistent with the facial midline. The posttreatment cephalometric evaluation demonstrated intrusion of the mandibular incisors and retraction of the maxillary incisors. The maxillary and mandibular molars were moved mesially by 1 mm. There were no significant skeletal changes, except for the slightly increased mandibular plane angle. After the gingivectomy, the gingival discrepancy in the maxillary incisal area was corrected.
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DISCUSSION
We successfully treated our patient with modified use of a lingual appliance with additional palatal appliances. The combined use of lingual appliances and a lingual arch was enabled by the layout of the lingual appliances. The patient had a skeletal Class II jaw relationship, an Angle Class II malocclusion, an anterior deep overbite, a second molar crossbite, excessive overjet, severe crowding with a 12-mm arch length discrepancy in the
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Fig 5. Oral photographs of space closure: A, 15 months after the start of treatment; B, 21 months later; C, 24 months later.
mandibular arch, and a lateral open bite with an excessive curve of Spee in the mandible. Under such conditions, conventional camouflage treatment is usually difficult to apply because it is challenging to address the horizontal, anteroposterior, and vertical problems simultaneously. However, the patient rejected orthognathic surgery because of the need for surgical invasion and postoperative discomfort and risks as well as a prolonged hospitalization. Furthermore, she preferred lingual bracket treatment for esthetic reasons. In the past, we have discouraged the use of lingual brackets to treat such complex cases of malocclusion because this procedure poses difficulties related to incisal control, arch width coordination, space closure, and vertical control of the posterior teeth. The treatment for this patient is notable for the application of lingual appliances only on the maxillary incisors; this enabled the combined use of appliances. An anterior archwire was connected to the posterior labial arches between the canines and the second premolars.
We found that this structure had several advantages in managing this patient's complex problems. The structure made it possible to adjust the arch width with the simultaneous use of lingual arches, to conveniently control the posterior teeth, and to easily activate the closing loops and load the force from the buccally placed temporary skeletal anchorage devices. The temporary skeletal anchorage devices placed in the maxilla were used to retract the maxillary anterior teeth, with a method similar to using labial appliances as described in previous reports. In this case, space closure was achieved using closing loop mechanics because the initial maxillary incisor angle was slightly inclined lingually, and we had to prevent excess lingual inclination. We loaded the force used to retract the anterior teeth at as high a position as possible to allow for bodily movement of the maxillary incisors, since the point of action was near the resistance center when we loaded the force to prevent the tipping movement of the maxillary incisors. We also added lingual root torque
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Fig 6. Posttreatment photographs.
while retracting the incisors. From the superimposition, we could see that the tipping movement of the maxillary incisors was prevented to some extent, although it was difficult to achieve complete bodily movement. The treatment of a severe deep anterior overbite malocclusion requires careful diagnosis and selection of treatment strategies in accordance with each factor that contributes to the dental problems. Deep anterior overbites are difficult to correct and retain in patients with Class II malocclusion because of the effects of skeletal morphology.23-27 The 4 types of tooth movement that require correction of Class II anterior deepbites include posterior tooth extrusion, labial inclination of the anterior teeth in patients with lingually tipped incisors, intrusion of incisors, and surgical correction.23
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In adult patients, in particular, it is difficult to resolve deepbite problems because of fewer alveolar changes in the posterior area.28 Dermaut and De Pauw29 advocated the importance of intrusion of the incisors in adults because of unstable extruded molars. For a deepbite malocclusion, lingual appliances have a bite-plane effect that induces intrusion of the incisors.30,31 In our patient, intrusion of the maxillary and mandibular incisors was observed. Although this treatment result is reasonable with respect to the correction of the deepbite malocclusion, superimposition of the pretreatment and posttreatment images demonstrated unfavorable clockwise rotation of the mandible, regardless of the patient's retrognathic profile. Some case reports have described the treatment of adult
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Fig 7. Posttreatment dental casts.
Fig 8. Posttreatment radiographs: A, cephalogram; B, posttreatment panoramic radiograph.
deepbite malocclusions with intrusion of the maxillary or mandibular incisors with temporary anchorage devices implanted on the labial side of the incisor area. If we had used this technique, the clockwise rotation of the mandible might have been prevented.16 As an esthetic adult orthodontic treatment method, we prefer lingual appliances. We use these devices in the maxilla only or in both jaws, depending on the situation. The use of lingual appliances in the maxilla only is esthetically acceptable because the labial appliance of the maxillary arch is a particular esthetic problem. In
this patient, we used labial appliances, except on the maxillary anterior teeth. Further clinical research of the esthetic assessment is required; however, this patient was satisfied with the esthetic outcome of the treatment. One problem associated with this method is the difficulty of adjusting the arch form, especially to control the positional relationship between the canines and the second premolars because of the crossed-over bend. This problem can be solved by creating a diagnostic setup model, setup arch forms, and jigs for indirect bonding.
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Fig 9. Superimposed pretreatment (solid line) and posttreatment (dotted line) cephalometric tracings: A, superimposed on the sella-nasion plane at sella; B, superimposed on the palatal plane at ANS; C, superimposed on the mandibular plane at menton.
In this patient, although we did not use temporary skeletal anchorage devices to anchor the intrusion of the maxillary molars because of her anterior deepbite, buccally placed temporary skeletal anchorage devices can be used to intrude molars, as is the case with labially placed multibracket appliances.32-34 The minor gingivectomy was done after the orthodontic treatment to eliminate the gingival discrepancy in the maxillary incisors. The gingival margin relationships between the 4 maxillary incisors sometimes become a problem for esthetic reasons. Especially, the gingival margins of the 2 central incisors should be at the same level and positioned more apically than those of the lateral incisors.35,36 The gingivectomy produced the desired result. It might be easier to perform a gingivectomy during orthodontic treatment with lingual appliances than with labial appliances, because lingual appliances do not hamper clinicians when they assess the clinical crown lengths of the incisors and perform the gingivectomy procedure. CONCLUSIONS
We treated an adult patient with complex problems using the simultaneous application of anterior lingual appliances, a lingual arch appliance, and temporary skeletal anchorage devices after premolar extractions. After treatment, the maxillary incisors were moved distally, the maxillary and mandibular incisors were intruded,
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the premolar crossbite was corrected, the mandibular molars were uprighted, and an acceptable Class I occlusion with rigid intercuspation was achieved. Therefore, we can report successful use of a new application of lingual appliances and the combined use of a lingual arch with temporary skeletal anchorage devices. REFERENCES 1. Fujita K. New orthodontic treatment with lingual bracket mushroom arch wire appliance. Am J Orthod 1997;76:657-75. 2. Creekmore T. Lingual orthodontics—its renaissance. Am J Orthod Dentofacial Orthop 1989;96:120-37. 3. Ackerman JL. The challenge of adult orthodontics. J Clin Orthod 1978;12:43-7. 4. Geron S, Wasserstein A, Geron Z. Stability of anterior open bite correction of adults treated with lingual appliances. Eur J Orthod 2013;35:599-603. 5. Ye L, Kula KS. Status of lingual orthodontics. World J Orthod 2006; 7:361-8. 6. Geron S, Romano R, Brosh T. Vertical forces in labial and lingual orthodontics applied on maxillary incisors—a theoretical approach. Angle Orthod 2004;74:195-201. 7. Moran KI. Relative wire stiffness due to lingual versus labial interbracket distance. Am J Orthod Dentofacial Orthop 1987;92: 24-32. 8. Takemoto K, Scuzzo G. The straight-wire concept in lingual orthodontics. J Clin Orthod 2001;35:46-52. 9. Wiechmann D, Rummel V, Thalheim A, Simon JS, Wiechmann L. Customized brackets and archwires for lingual orthodontic treatment. Am J Orthod Dentofacial Orthop 2002;124:593-9. 10. Fuck LM, Wiechmann D, Drescher D. Comparison of the initial orthodontic force systems produced by a new lingual bracket system and a straight-wire appliance. J Orofac Orthop 2005;66: 363-76.
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11. Dalessandri D, Lazzaroni E, Migliorati M, Piancino MG, Tonni I, Bonetti S. Self-ligating fully customized lingual appliance and chair-time reduction: a typodont study followed by a randomized clinical trial. Eur J Orthod 2013;35:758-65. 12. Mujagic M, Fauquet C, Galletti C, Palot C, Wiechmann D, Mah J. Digital design and manufacturing of the Lingualcare bracket system. J Clin Orthod 2005;39:375-82. 13. McGuire MK, Scheyer ET, Gallerano RL. Temporary anchorage devices for tooth movement: a review and case reports. J Periodontol 2006;77:1613-24. 14. Kurz C. The use of lingual appliances for correction of bimaxillary protrusion (four premolars extraction). Am J Orthod Dentfacial Orthop 1997;112:357-63. 15. Fukui T, Tsuruta M. Invisible treatment of a Class III female adult patient with severe crowding and cross-bite. J Orthod 2002;29:267-75. 16. Kyung HM, Kim IB. Case reports of Class I malocclusion treated with lingual appliance. Korean J Orthod 1991;21:309-24. 17. Vu J, Pancherz H, Schwestka-Polly R, Wiechmann D. Correction of Class II, Division 2 malocclusions using a completely customized lingual appliance and the Herbst device. J Orofac Orthop 2012; 73:225-35. 18. Yanagita T, Kuroda S, Takano-Yamamoto T, Yamashiro T. Class III malocclusion with complex problems of lateral open bite and severe crowding successfully treated with miniscrew anchorage and lingual orthodontic brackets. Am J Orthod Dentfacial Orthop 2011;139:679-89. 19. Kawakami M, Miyawaki S, Noguchi H, Kirita T. Screw-type implants used as anchorage for lingual orthodontic mechanics: a case of bimaxillary protrusion with second premolar extraction. Angle Orthod 2004;74:715-9. 20. Nelson G, Ahn HW, Jeong SH, Kim JS, Kim SH, Chung KR. Threedimensional retraction of anterior teeth with orthodontic miniplates in patients with temporomandibular disorder. Am J Orthod Dentofacial Orthop 2012;142:720-6. 21. Itsuki Y, Imamura E, Sugawara J. Temporary anchorage device with interchangeable superstructure for mandibular tooth movement. World J Orthod 2013;2:e19-29. 22. Wada K, Matsushima K, Shimazaki S, Miwa Y, Hasuike Y, Sunami R. An evaluation of a new case analysis of a lateral cephalometric roentgenogram. J Kanazawa Med Univ 1981;6:60-70.
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23. Nanda R. Correction of deep overbite in adults. Dent Clin North Am 1997;41:67-87. 24. Sadowsky C, Sellke T. Management of overbite by controlling incisor and molar movements. Semin Orthod 2000;6:43-9. 25. Vaden JL. Alternative nonsurgical strategies to treat complex orthodontic problems. Semin Orthod 1996;2:90-113. 26. Sch€ utz-Fransson U, Bjerklin K, Lindsten R. Long-term follow-up of orthodontically treated deep bite patients. Eur J Orthod 2006; 28:503-12. 27. Ceylan I, Er€ oz UB. The effects of overbite on the maxillary and mandibular morphology. Angle Orthod 2001;71:110-5. 28. Nanda RS, Nanda SK. Considerations of dentofacial growth in long-term retention and stability: is active retention needed? Am J Orthod Dentofacial Orthop 1992;101:297-302. 29. Dermaut LR, De Pauw G. Biomechanical aspects of Class II mechanics with special emphasis in deep bite correction as part of the treatment goal. In: Nanda R, editor. Biomechanics in clinical orthodontics. Philadelphia: W. B. Saunders; 1997. p. 86-98. 30. Gorman JC, Smith RJ. Comparison of treatment effects with labial and lingual fixed appliances. Am J Orthod Dentofacial Orthop 1991;99:202-9. 31. Forsberg CM, Hellsing E. The effect of lingual arch appliance with anterior bite plane in deep overbite correction. Eur J Orthod 1984; 6:107-15. 32. Kuroda S, Katayama A, Takano-Yamamoto T. Severe anterior open-bite case treated using titanium screw anchorage. Angle Orthod 2004;74:558-67. 33. Park HS, Kwon TG, Kwon OW. Treatment of open bite with microscrew implant anchorage. Am J Orthod Dentofacial Orthop 2004; 126:627-36. 34. Yanagita T, Adachi R, Kamioka H, Yamashiro T. Severe open bite due to traumatic condylar fractures treated nonsurgically with implanted miniscrew anchorage. Am J Orthod Dentofacial Orthop 2013;143(Suppl):S137-43. 35. Kokich V, Nappen D, Shapiro P. Gingival contour and clinical crown length: their effects on the esthetic appearance of maxillary anterior teeth. Am J Orthod 1984;86:89-94. 36. Kokich VG. Esthetics: the orthodontic-periodontic restorative connection. Semin Orthod 1996;2:21-30.
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Class II malocclusion with complex problems treated with a novel combination of lingual orthodontic appliances and lingual arches Takeshi Yanagita,a Masahiro Nakamura,b Noriaki Kawanabe,c and Takashi Yamashirod Okayama and Osaka, Japan
This case report describes a novel method of combining lingual appliances and lingual arches to control horizontal problems. The patient, who was 25 years of age at her first visit to our hospital with a chief complaint of crooked anterior teeth, was diagnosed with skeletal Class II and Angle Class II malocclusion with anterior deep bite, lateral open bite, premolar crossbite, and severe crowding in both arches. She was treated with premolar extractions and temporary anchorage devices. Conventionally, it is ideal to use labial brackets simultaneously with appliances, such as a lingual arch, a quad-helix, or a rapid expansion appliance, in patients with complex problems requiring horizontal, anteroposterior, and vertical control; however, this patient strongly requested orthodontic treatment with lingual appliances. A limitation of lingual appliances is that they cannot be used with other conventional appliances. In this report, we present the successful orthodontic treatment of a complex problem using modified lingual appliances that enabled combined use of a conventional lingual arch. (Am J Orthod Dentofacial Orthop 2014;146:98-107)
L
ingual appliances are often used to correct malocclusions in adult patients who have esthetic concerns.1 Nevertheless, clinicians face some problems when working with lingual appliances, such as limited visibility during adjustment of the appliances, short distances between neighboring brackets, irregular arch forms, and complicated attaching and detaching processes.2-7 However, lingual appliances have become more convenient for orthodontists because of the introduction of self-ligating brackets, the straight-wire technique, customized brackets, and wire-bending robots.8-12 Temporary skeletal anchorage devices have also played a part in expanding the applications of
a Assistant professor, Department of Orthodontics, Okayama University Hospital, Okayama, Japan. b Clinical fellow, Department of Orthodontics, Okayama University Hospital, Okayama, Japan. c Senior assistant professor, Department of Orthodontics, Okayama University Hospital, Okayama, Japan. d Professor and chair, Department of Orthodontics and Dentofacial Orthopedics, Graduate School of Dentistry, Osaka University, Osaka, Japan. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Takeshi Yanagita, Department of Orthodontics, Okayama University Hospital, 2-5-1, Shikata-cho, Okayama City, Okayama 700-8525, Japan; e-mail, [email protected]. Submitted, April 2013; revised and accepted, August 2013. 0889-5406/$36.00 Copyright Ó 2014 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.08.022
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lingual appliances, particularly in patients with Angle Class II or Class III malocclusion.13-18 Temporary skeletal anchorage devices make it easier to perform anterior tooth retraction and achieve anchorage control to correct molar relationships.19-21 These technologic advancements have solved most of the problems associated with lingual appliances. However, one remaining problem contributes to the unsuitability of such lingual appliances in difficult cases, especially those involving transverse complications: lingual appliances cannot be used with a lingual arch appliance, a quad-helix appliance, or fixed rapid expansion appliances. The use of these appliances is desirable when treating complex problems. In this report, we describe the treatment of an adult with a Class II malocclusion and complex problems, including a second premolar crossbite resulting from a narrowed maxillary arch. The patient did not wish to undergo orthognathic surgical procedures, instead requesting orthodontic treatment with lingual appliances for esthetic reasons. Although the use of conventional lingual appliances and methods appeared difficult because of the patient's severe vertical and horizontal problems, we modified the appliance design and treatment technique to satisfy her request. The most notable point in this case was the modified design of the lingual appliances, which enabled the combined use of lingual appliances and a lingual arch,
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Fig 1. Pretreatment photographs.
successfully addressing the horizontal problems. We believe that this approach will broaden future orthodontic treatment choices. DIAGNOSIS AND ETIOLOGY
A woman, 25 years 4 months of age, consulted the outpatient clinic of Okayama University Hospital with a chief complaint of crooked teeth. She strongly desired nonsurgical treatment with an invisible appliance. Her convex profile was due to a retrognathic mandible with upper lip protrusion. Circumoral muscle strain was observed upon mouth closure. Anterior incisor deepbites with an excessive overjet of 8 mm and a deep overbite of 7 mm were observed. A severe curve
of Spee was noted in the mandibular occlusal plane (4 mm). Severe crowding was present in both arches (arch length discrepancies: maxilla, 8.6 mm; mandible, 10.9 mm). The maxillary right central incisor had a gingival recession on the distal side caused by labial malposition and mesial rotation. The amount of attachment loss of the maxillary right central incisor was 2.0 mm in contrast to the left side. Both maxillary second premolars exhibited crossbites because of palatally dislocated maxillary second premolars. The mandibular incisors were inclined lingually, and both canines were dislocated labially. The molar relationship was Angle Class II on both sides. The maxillary dental midline was deviated 3 mm toward the right of the facial midline, although the mandibular dental midline was not
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Fig 2. Pretreatment dental casts.
Fig 3. Pretreatment radiographs: A, cephalogram; B, pretreatment panoramic radiograph.
deviated from the facial midline. The dental radiographs showed normal root lengths with no horizontal or vertical bone loss (Figs 1-3). In comparison with the Japanese norm, a skeletal Class II relationship (ANB angle, 5.8 ) with mandibular retrusion (SNB angle, 74.8 ) was observed (Table).22 The body length of the mandible was small (Ar-Me, 97.7 mm). The mandibular plane angle was normal (Mp-SN, 40.9 ). The maxillary incisors were lingually inclined (U1-SN, 91.0 ), and the height of the incisors was normal (U1/PP, 30.2 mm). The mandibular incisors were
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lingually inclined (L1-Mp, 86.9 ), and the height from the mandibular plane was excessive (L1/Mp, 49.4 mm). The occlusal plane angle was average (18.2 ). TREATMENT OBJECTIVES
We diagnosed the patient with an Angle Class II malocclusion, a skeletal Class II jaw-base relationship, anterior deep bite, lateral open bite, premolar crossbite, severe maxillary and mandibular crowding, and midline deviation. The treatment objectives were to correct the
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Table. Cephalometric measurements Mean Angular analysis ( ) SNA SNB ANB Mp-SN Gonial angle U1-SN L1-Mp IIA Occlusal plane Linear analysis (mm) PTM-A/PP PTM-ANS/PP Go-Me Ar-Go Ar-Me U6/PP U1/PP L6/Mp L1/Mp Overjet Overbite
SD
Pretreatment Posttreatment
80.8 3.6 77.9 4.5 2.8 2.4 37.1 4.6 122.1 5.3 105.9 8.8 93.4 6.8 123.6 10.6 16.9 4.4 47.9 52.1 71.4 47.3 106.6 24.6 31.0 32.9 44.2 3.1 3.3
2.8 3.0 4.1 3.3 5.7 2.0 2.3 2.5 2.7 1.07 1.89
80.5 74.8 5.8 40.9 119.7 91.0 86.9 141.2 18.2
80.1 74.6 5.6 41.6 122.4 87.6 91.4 139.4 22.3
46.7 50.9 66.3 43.0 97.7 22.7 30.2 35.2 49.4 7.0 6.7
46.7 51.1 66.4 40.8 96.7 22.4 30.1 36.0 46.3 2.6 2.4
severe crowding, midline deviation, and lateral open bite; establish an ideal incisor relationship; and achieve an acceptable occlusion with a favorable functional Class I occlusion. We also planned to perform genioplasty to protrude the patient's chin, as it would be difficult to correct the convex profile using only orthodontic treatment, owing to the skeletal problems and severe dental discrepancy. Since the mandibular dental discrepancy was too severe to control the molar relationships, we planned to place temporary skeletal anchorage devices in the retromolar areas to provide skeletal anchorage to correct the molar relationships. Additionally, extractions of 4 premolars and 4 third molars were required to correct the severe crowding. Furthermore, the patient preferred to undergo lingual bracket treatment for esthetic reasons. However, it was difficult to use lingual brackets because she required highly technical tooth control in the horizontal, anteroposterior, and vertical directions. Ultimately, we decided to avoid the use of labial brackets on the maxillary incisors only.
hospitalization. Furthermore, the physical disadvantages of a surgical invasion caused her to decline this option, in addition to the fact that she was not dissatisfied with her facial profile. Therefore, we chose orthodontic treatment with premolar extraction. TREATMENT PROGRESS
The maxillary and mandibular first premolars were extracted before orthodontic treatment. The lingual arch was placed in the maxilla, and 0.018-in slot preadjusted edgewise appliances were placed in the mandible to level both arches. After initially leveling the maxilla with the lingual arch, 0.018-in slot preadjusted edgewise appliances were placed lingually on the maxillary incisors and labially on the maxillary premolars and molars (Fig 4). After the maxillary arch was leveled, a 0.016 3 0.022-in stainless steel archwire with a closing loop was positioned, and temporary anchorage devices (1.6 mm in diameter, 6 mm in length: Abso Anchor; Dentos, Taegu, South Korea) were placed in the buccal areas between the maxillary first and second molars. The maxillary molars were then retracted with nickel-titanium closing coil springs (200 g) for 12 months (Fig 5). To reduce the incisor overbite and the mandibular curve of Spee, we initially made occlusal stops on the mandibular first and second molars to create contact with the maxillary molars. The occlusal stops were made of resin cement, and their role was to prevent excessive stress on the lingual appliances placed on the maxillary incisors by the mandibular incisor ridges. We repeatedly scraped the occlusal stops in small amounts until the mandibular occlusal plane was flattened (Fig 4, C and D). The total active treatment period, including the use of the lingual arch, was 32 months. After removal of the edgewise appliances, lingual bonded retainers were positioned to retain both arches. Invisible retainers were also placed for full-time wear. After the edgewise appliances were removed, a gingivectomy of the central incisors was performed. One month after the gingivectomy, we took the oral and dental photos and the dental impressions for the dental casts. RESULTS
TREATMENT ALTERNATIVES
Two major procedures (with and without orthognathic surgery) were explored to achieve an ideal Class I occlusion and a good profile. Although mandibular and chin advancements with orthognathic surgery are considered an effective treatment method, the patient did not want to undergo surgery for social and physiologic reasons and the need for prolonged
The posttreatment records showed significant improvement of the patient's facial profile with a protruded upper lip. The strain of the circumoral musculature observed upon mouth closure disappeared (Fig 6). The severe crowding was resolved, and the anterior deepbite and lateral open bites were corrected. An Angle Class I molar relationship with ideal overjet and overbite was achieved (Figs 7-9). The occlusion exhibited
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Fig 4. Oral photographs obtained during the leveling procedure: A, start of treatment; B, 3 months after the start of treatment; C, 6 months later; D, 12 months later.
acceptable interdigitation and canine guidance. The dental midlines became consistent with the facial midline. The posttreatment cephalometric evaluation demonstrated intrusion of the mandibular incisors and retraction of the maxillary incisors. The maxillary and mandibular molars were moved mesially by 1 mm. There were no significant skeletal changes, except for the slightly increased mandibular plane angle. After the gingivectomy, the gingival discrepancy in the maxillary incisal area was corrected.
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DISCUSSION
We successfully treated our patient with modified use of a lingual appliance with additional palatal appliances. The combined use of lingual appliances and a lingual arch was enabled by the layout of the lingual appliances. The patient had a skeletal Class II jaw relationship, an Angle Class II malocclusion, an anterior deep overbite, a second molar crossbite, excessive overjet, severe crowding with a 12-mm arch length discrepancy in the
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Fig 5. Oral photographs of space closure: A, 15 months after the start of treatment; B, 21 months later; C, 24 months later.
mandibular arch, and a lateral open bite with an excessive curve of Spee in the mandible. Under such conditions, conventional camouflage treatment is usually difficult to apply because it is challenging to address the horizontal, anteroposterior, and vertical problems simultaneously. However, the patient rejected orthognathic surgery because of the need for surgical invasion and postoperative discomfort and risks as well as a prolonged hospitalization. Furthermore, she preferred lingual bracket treatment for esthetic reasons. In the past, we have discouraged the use of lingual brackets to treat such complex cases of malocclusion because this procedure poses difficulties related to incisal control, arch width coordination, space closure, and vertical control of the posterior teeth. The treatment for this patient is notable for the application of lingual appliances only on the maxillary incisors; this enabled the combined use of appliances. An anterior archwire was connected to the posterior labial arches between the canines and the second premolars.
We found that this structure had several advantages in managing this patient's complex problems. The structure made it possible to adjust the arch width with the simultaneous use of lingual arches, to conveniently control the posterior teeth, and to easily activate the closing loops and load the force from the buccally placed temporary skeletal anchorage devices. The temporary skeletal anchorage devices placed in the maxilla were used to retract the maxillary anterior teeth, with a method similar to using labial appliances as described in previous reports. In this case, space closure was achieved using closing loop mechanics because the initial maxillary incisor angle was slightly inclined lingually, and we had to prevent excess lingual inclination. We loaded the force used to retract the anterior teeth at as high a position as possible to allow for bodily movement of the maxillary incisors, since the point of action was near the resistance center when we loaded the force to prevent the tipping movement of the maxillary incisors. We also added lingual root torque
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Fig 6. Posttreatment photographs.
while retracting the incisors. From the superimposition, we could see that the tipping movement of the maxillary incisors was prevented to some extent, although it was difficult to achieve complete bodily movement. The treatment of a severe deep anterior overbite malocclusion requires careful diagnosis and selection of treatment strategies in accordance with each factor that contributes to the dental problems. Deep anterior overbites are difficult to correct and retain in patients with Class II malocclusion because of the effects of skeletal morphology.23-27 The 4 types of tooth movement that require correction of Class II anterior deepbites include posterior tooth extrusion, labial inclination of the anterior teeth in patients with lingually tipped incisors, intrusion of incisors, and surgical correction.23
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In adult patients, in particular, it is difficult to resolve deepbite problems because of fewer alveolar changes in the posterior area.28 Dermaut and De Pauw29 advocated the importance of intrusion of the incisors in adults because of unstable extruded molars. For a deepbite malocclusion, lingual appliances have a bite-plane effect that induces intrusion of the incisors.30,31 In our patient, intrusion of the maxillary and mandibular incisors was observed. Although this treatment result is reasonable with respect to the correction of the deepbite malocclusion, superimposition of the pretreatment and posttreatment images demonstrated unfavorable clockwise rotation of the mandible, regardless of the patient's retrognathic profile. Some case reports have described the treatment of adult
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Fig 7. Posttreatment dental casts.
Fig 8. Posttreatment radiographs: A, cephalogram; B, posttreatment panoramic radiograph.
deepbite malocclusions with intrusion of the maxillary or mandibular incisors with temporary anchorage devices implanted on the labial side of the incisor area. If we had used this technique, the clockwise rotation of the mandible might have been prevented.16 As an esthetic adult orthodontic treatment method, we prefer lingual appliances. We use these devices in the maxilla only or in both jaws, depending on the situation. The use of lingual appliances in the maxilla only is esthetically acceptable because the labial appliance of the maxillary arch is a particular esthetic problem. In
this patient, we used labial appliances, except on the maxillary anterior teeth. Further clinical research of the esthetic assessment is required; however, this patient was satisfied with the esthetic outcome of the treatment. One problem associated with this method is the difficulty of adjusting the arch form, especially to control the positional relationship between the canines and the second premolars because of the crossed-over bend. This problem can be solved by creating a diagnostic setup model, setup arch forms, and jigs for indirect bonding.
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Fig 9. Superimposed pretreatment (solid line) and posttreatment (dotted line) cephalometric tracings: A, superimposed on the sella-nasion plane at sella; B, superimposed on the palatal plane at ANS; C, superimposed on the mandibular plane at menton.
In this patient, although we did not use temporary skeletal anchorage devices to anchor the intrusion of the maxillary molars because of her anterior deepbite, buccally placed temporary skeletal anchorage devices can be used to intrude molars, as is the case with labially placed multibracket appliances.32-34 The minor gingivectomy was done after the orthodontic treatment to eliminate the gingival discrepancy in the maxillary incisors. The gingival margin relationships between the 4 maxillary incisors sometimes become a problem for esthetic reasons. Especially, the gingival margins of the 2 central incisors should be at the same level and positioned more apically than those of the lateral incisors.35,36 The gingivectomy produced the desired result. It might be easier to perform a gingivectomy during orthodontic treatment with lingual appliances than with labial appliances, because lingual appliances do not hamper clinicians when they assess the clinical crown lengths of the incisors and perform the gingivectomy procedure. CONCLUSIONS
We treated an adult patient with complex problems using the simultaneous application of anterior lingual appliances, a lingual arch appliance, and temporary skeletal anchorage devices after premolar extractions. After treatment, the maxillary incisors were moved distally, the maxillary and mandibular incisors were intruded,
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the premolar crossbite was corrected, the mandibular molars were uprighted, and an acceptable Class I occlusion with rigid intercuspation was achieved. Therefore, we can report successful use of a new application of lingual appliances and the combined use of a lingual arch with temporary skeletal anchorage devices. REFERENCES 1. Fujita K. New orthodontic treatment with lingual bracket mushroom arch wire appliance. Am J Orthod 1997;76:657-75. 2. Creekmore T. Lingual orthodontics—its renaissance. Am J Orthod Dentofacial Orthop 1989;96:120-37. 3. Ackerman JL. The challenge of adult orthodontics. J Clin Orthod 1978;12:43-7. 4. Geron S, Wasserstein A, Geron Z. Stability of anterior open bite correction of adults treated with lingual appliances. Eur J Orthod 2013;35:599-603. 5. Ye L, Kula KS. Status of lingual orthodontics. World J Orthod 2006; 7:361-8. 6. Geron S, Romano R, Brosh T. Vertical forces in labial and lingual orthodontics applied on maxillary incisors—a theoretical approach. Angle Orthod 2004;74:195-201. 7. Moran KI. Relative wire stiffness due to lingual versus labial interbracket distance. Am J Orthod Dentofacial Orthop 1987;92: 24-32. 8. Takemoto K, Scuzzo G. The straight-wire concept in lingual orthodontics. J Clin Orthod 2001;35:46-52. 9. Wiechmann D, Rummel V, Thalheim A, Simon JS, Wiechmann L. Customized brackets and archwires for lingual orthodontic treatment. Am J Orthod Dentofacial Orthop 2002;124:593-9. 10. Fuck LM, Wiechmann D, Drescher D. Comparison of the initial orthodontic force systems produced by a new lingual bracket system and a straight-wire appliance. J Orofac Orthop 2005;66: 363-76.
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23. Nanda R. Correction of deep overbite in adults. Dent Clin North Am 1997;41:67-87. 24. Sadowsky C, Sellke T. Management of overbite by controlling incisor and molar movements. Semin Orthod 2000;6:43-9. 25. Vaden JL. Alternative nonsurgical strategies to treat complex orthodontic problems. Semin Orthod 1996;2:90-113. 26. Sch€ utz-Fransson U, Bjerklin K, Lindsten R. Long-term follow-up of orthodontically treated deep bite patients. Eur J Orthod 2006; 28:503-12. 27. Ceylan I, Er€ oz UB. The effects of overbite on the maxillary and mandibular morphology. Angle Orthod 2001;71:110-5. 28. Nanda RS, Nanda SK. Considerations of dentofacial growth in long-term retention and stability: is active retention needed? Am J Orthod Dentofacial Orthop 1992;101:297-302. 29. Dermaut LR, De Pauw G. Biomechanical aspects of Class II mechanics with special emphasis in deep bite correction as part of the treatment goal. In: Nanda R, editor. Biomechanics in clinical orthodontics. Philadelphia: W. B. Saunders; 1997. p. 86-98. 30. Gorman JC, Smith RJ. Comparison of treatment effects with labial and lingual fixed appliances. Am J Orthod Dentofacial Orthop 1991;99:202-9. 31. Forsberg CM, Hellsing E. The effect of lingual arch appliance with anterior bite plane in deep overbite correction. Eur J Orthod 1984; 6:107-15. 32. Kuroda S, Katayama A, Takano-Yamamoto T. Severe anterior open-bite case treated using titanium screw anchorage. Angle Orthod 2004;74:558-67. 33. Park HS, Kwon TG, Kwon OW. Treatment of open bite with microscrew implant anchorage. Am J Orthod Dentofacial Orthop 2004; 126:627-36. 34. Yanagita T, Adachi R, Kamioka H, Yamashiro T. Severe open bite due to traumatic condylar fractures treated nonsurgically with implanted miniscrew anchorage. Am J Orthod Dentofacial Orthop 2013;143(Suppl):S137-43. 35. Kokich V, Nappen D, Shapiro P. Gingival contour and clinical crown length: their effects on the esthetic appearance of maxillary anterior teeth. Am J Orthod 1984;86:89-94. 36. Kokich VG. Esthetics: the orthodontic-periodontic restorative connection. Semin Orthod 1996;2:21-30.
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