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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 51  |  Issue : 3  |  Page : 192-199

Indian Board of orthodontics case report – Dr.Prem Prakash Memorial Award


Prof, Department of Orthodontics and Dentofacial Orthopedics, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Submission16-Jun-2017
Date of Acceptance20-Jun-2017
Date of Web Publication17-Jul-2017

Correspondence Address:
V K Shakeel Ahmed
Department of Orthodontics and Dentofacial Orthopedics, Ragas Dental College and Hospital, 2/102 East Coast Road, Uthandi, Chennai - 600 119, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jios.jios_129_17

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  Abstract 


This case report was adjudged one of the best-treated cases displayed in the Indian Board of Orthodontics after the board certification process. The summary of the treatment and various records are reprinted here with minimal editing and reformatting so that the presentation resembles the actual documents submitted to the board.

Keywords: Class III malocclusion, Indian Board of Orthodontics case report, MARPE, nonsurgical treatment


How to cite this article:
Ahmed V K. Indian Board of orthodontics case report – Dr.Prem Prakash Memorial Award. J Indian Orthod Soc 2017;51:192-9

How to cite this URL:
Ahmed V K. Indian Board of orthodontics case report – Dr.Prem Prakash Memorial Award. J Indian Orthod Soc [serial online] 2017 [cited 2019 Jan 20];51:192-9. Available from: http://www.jios.in/text.asp?2017/51/3/192/210903




  Introduction Top


Transverse maxillary deficiency in an adult patient is a challenging problem, especially when it is combined with a severe anteroposterior jaw discrepancy. Some authors claim that conventional expansion of the maxillary arch in mature patients is not possible.[1],[2] Proffit [3] reports that “by the late teens, interdigitation and areas of bony bridging across the suture develop to the point that maxillary expansion becomes impossible,” a belief based on Melsen's study on histological suture appearance.[4] Hence, surgically assisted rapid palatal expansion (SARPE) has been the treatment of choice for correcting transverse maxillary deficiency in adults. Maxillary constriction combined with severe anteroposterior discrepancy is challenging, because it usually requires 2 surgeries: SARPE followed by orthognathic surgery. Since many patients are reluctant to undergo multiple surgical procedures, the demand for nonsurgical expansion in adults has increased. Recent evidence indicates that miniscrew assisted rapid palatal expansion can be used without surgery in young adults.[5] This case report shows the treatment effects of miniscrew assisted rapid palatal expansion in a young adult who had transverse maxillary deficiency, followed by comprehensive orthodontic treatment and miniscrew facilitated en masse protraction of maxillary dentition using a modified transpalatal arch to correct anterior crossbite.


  Case Report Top


NID a 20-year-old female patient presented with chief complaint of backwardly placed and irregularity of upper front teeth. She had ClassIII skeletal pattern due to maxillary deficiency, anterior and posterior crossbite associated with constricted maxillary arch and orthognathic mandible. Upper lip was retrusive. Upper incisors were proclined and crowded, whereas lower incisors were upright with mild crowding. Maxillary dental midline was shifted to left by 1mm, and mandibular midline was coincident with facial midline. There was Class III molar and canine relationship bilaterally with a reverse overjet of 3 mm and overbite of 2 mm with no functional shift. There was 7 mm arch length discrepancy(crowding) in the maxillary arch.

Nonsurgical treatment plan involved correction of bilateral posterior crossbite using miniscrew assisted rapid palatal expansion, followed by comprehensive orthodontic treatment and miniscrew facilitated en masse protraction of maxillary dentition using a modified transpalatal arch to correct anterior crossbite, ClassIII molar and canine relationship, to achieve coinciding midlines, ideal overjet and overbite. Mandibular third molars were extracted since maxillary third molars were congenitally missing and for uprighting the mandibular posterior segments. Preadjusted edgewise appliance(MBT prescription, 0.022″ × 0.025″ slot) was used to correct the malocclusion. The retention protocol involved upper wraparound and lower lingual bonded retainer.

Section 1: Pretreatment assessment

Patient details

  • Initials: NID
  • Sex: Female
  • Date of birth: October 11, 1992
  • Age at start of treatment: 20years
  • Patient's complaint: Backwardly placed and irregularity of upper front teeth
  • Relevant medical/dental history: Glass ionomer restorations in 16, 26, 36, 46, 47.


Clinical examination: Extra-oral features

  • Head form: Dolichocephalic
  • Face form: Leptoprosopic
  • Facial profile: Concave
  • Facial divergence: Anterior divergence
  • Facial symmetry: Apparently symmetrical
  • Nasolabial angle: Obtuse
  • Mentolabial sulcus: Average
  • Smile type: Cuspid type
  • Smile arc: Nonconsonant
  • Lips: Competent lips [Figure 1].
Figure 1: Pretreatment extraoral photographs: (a) Frontal view with lips at rest, (b) right profile view, and (c) frontal view with smile

Click here to view


Clinical examination: Intra-oral features

Soft tissues: No abnormality detected

Oral hygiene: Fair

All the permanent teeth were erupted except the third molars.

General dental condition:

  • Mild white spots in relation to upper and lower anterior and posterior teeth
  • Dental caries in 17
  • Permanent restoration in 16, 26, 36, 46, 47.


Crowding/spacing

Maxillary arch: V-shaped, symmetrical with crowding in relation to upper anterior teeth.

  • Total tooth material(5-5) = 77mm
  • Arch perimeter(5-5) = 70mm
  • Discrepancy(crowding) = 7mm.


Mandibular arch: U-shaped, symmetrical with mild crowding present of lower anterior teeth [Figure 2].
Figure 2: Pretreatment intraoral photographs: (a) Right buccal view, (b) anterior view, (c) left buccal view, (d) maxillary occlusal view, and (e) mandibular occlusal view

Click here to view


Occlusal features

Incisor relationship: Class III

Overjet(mm): −3 mm

Overbite: 2 mm

Centerlines:

  • Upper dental midline shifted to left by 1 mm
  • Lower dental midline coinciding with facial midline.


Left buccal segment relation: Class III molar and ClassIII canine relation.

Right buccal segment relation: Class III molar and ClassIII canine relation.

Crossbites: Bilateral posterior and anterior crossbite [Figure 3].
Figure 3: Pretreatment study models showing various occlusal features: (a) Right buccal view, (b) anterior view, (c) left buccal view, (d) maxillary occlusal view, and (e) mandibular occlusal view

Click here to view


Displacements: Buccally displaced 17, 27. Mesio-labial rotation-11, 13, 14, 24, 34, 44. Disto-labial rotation-23.

Other occlusal features: Marginal ridge discrepancy between 13 and 14; 16 and 17; 23 and 24; 26 and 27; 36 and 37 and 46 and 47.

  • Tapered maxillary arch and ovoid mandibular arch
  • Bolton discrepancy


    • Overall-90.7%(normal-91.3%)
    • Anterior-79.1%(normal 77.2%)(approximately 0.9mm mandibular teeth material excess and 0.5mm overall maxillary excess).


General radiographic examination

Pretreatment radiographs recorded:

Figure 4: Pretreatment radiographs: (a) Lateral cephalogram with teeth in occlusion, (b) orthopantomogram, (c) occlusal radiograph, (d) cone beam computed tomography images, axial slice through the midpalatal suture

Click here to view


Maxillary third molars were congenitally missing and mandibular third molar were unerupted.

Other relevant radiographic findings:

  • Congenitally missing maxillary thirds molars


Other special tests/analyses: Cone-beam computed tomography(CBCT):

  • To assess the mid-palatal suture morphology and palatal bone depth[Figure4]d.


Pretreatment cephalometric findings and their interpretation

Various pretreatment cephalometric findings are described in [Table1]. The maxillary base is retrognathic and, mandible is orthognathic (SNA=77°, SNB=82°) in relation to the anterior cranial base. The ANB angle is low (ANB = −5°) suggesting ClassIII skeletal base relation. Wits appraisal(BO-AO=7mm) and other parameters for sagittal maxillomandibular relation also suggest a ClassIII skeletal base relation due to decreased maxillary length (maxillary length=49mm), mandibular length higher end normal, mandibular plane was at higher end, average lower anterior facial height.
Table 1: Cephalometric findings at various stages of orthodontic treatment


Click here to view


Maxillary incisors were proclined, whereas mandibular incisors were upright with the average interincisal angle. Reverse overjet of−3mm and overbite of 2mm. The position of upper and lower lips is slightly retrusive in relation to the esthetic line(E-line). The nasolabial angle is normal. Cervical vertebrae maturation index (CVMI) shows stage-6 of skeletal maturation (completion stage-growth considered to be complete).

Diagnostic summary

A 20 year old female patient had Angle's class III malocclusion on a Class III skeletal base. The maxilla was retrognathic in all three planes of space. She has bilateral posterior and anterior crossbite with constricted maxillary arch. Maxillary incisors were proclined and crowded, whereas mandibular incisors were upright with mild crowding. Upper midline was shifted to left by 1mm, and lower midline was coincident with facial midline. Upper lip was retrusive and competent lips. Overjet of-3mm and overbite of 2mm was present with no functional shift.

Problem list

  1. ClassIII skeletal relationship(maxillary deficiency)
  2. Concave profile with retrusive upper lip
  3. Bilateral posterior and anterior crossbite
  4. ClassIII molar and canine relation
  5. Crowding of upper anterior teeth
  6. Reverse overjet of−3 mm
  7. Upper midline was shifted to left by 1mm.


Aims and objectives of treatment

  1. Correction of maxillary deficiency, bilateral posterior and anterior crossbite
  2. Establish proper buccal occlusion
  3. Achieve classI molar and canine relation on the both sides
  4. Achieve normal overjet and overbite
  5. Matching upper dental midline to the facial midline
  6. Achieve pleasing profile and consonant smile.


Treatment plan

  • Nonsurgical expansion of maxillary arch using miniscrew assisted rapid palatal expansion
  • Appliances: 0.022″ × 0.028″(MBT preadjusted edgewise appliance)
  • En masse protraction of maxillary dentition using miniscrews and modified transpalatal arch with distal facing hooks.


Achieve ideal dental relationships of overbite, overjet, ClassI molars and canines. Retain the dentoalveolar correction to improve facial esthetics and smile.

Special anchorage requirements: Miniscrew assisted expansion and en masse protraction of maxillary dentition using miniscrews and modified transpalatal arch.

Minor adjunctive surgery

  1. Miniscrew placed adjacent to midpalatal suture for miniscrew assisted expansion of maxillary arch
  2. Miniscrew placed in anterior palate for en masse protraction of maxillary dentition
  3. Surgical removal of 38, 48.


Major adjunctive surgery: None.

Additional dental treatment: None.

Proposed retention strategy:

  • Maxillary arch-wraparound retainer to be worn full time for a year
  • Mandibular arch - lingual fixed bonded retainer (canine to canine).


Additional notes on treatment plan: There were two treatment options suggested to correct transverse deficiency and maxillary retrognathism.

  • Option 1: Surgically assisted rapid maxillary expansion followed by orthodontic decompensation and maxillary advancement. However, surgically assisted rapid palatal expansion and maxillary advancement cannot be performed simultaneously, patient would require two surgeries.
  • Option 2: Nonsurgical miniscrew assisted rapid maxillary expansion, followed by orthodontic treatment and en masse protraction of maxillary dentition using miniscrews.


Since the patient and her parents were reasonably happy with her profile and they were not willing for any form of orthognathic surgery. She and her parents opted for the 2ndoption.

Prognosis for stability: Good.

Section 2: Treatment

Treatment progress

  • Start of active treatment: July 17, 2013
  • Age at start of active treatment: 20years
  • End of active treatment: November 3, 2015
  • Age at the end of active treatment: 22years
  • Active treatment time: 2years and 4month
  • End of retention: Patient is on active retention. Upper wraparound retainer and lower bonded retainer.


Key stages in treatment progress

Treatment commenced on July 17, 2013; with miniscrew assisted rapid palatal expansion.

Date stage

  • Miniscrew assisted expansion appliance framework was cemented, and four miniscrews were inserted under local anesthesia(2% lignocanine with adrenaline)–July 17, 2013
  • Expansion was achieved and considered adequate with appearance of midline diastema and when the maxillary lingual cusp of the permanent first molar contacted mandibular buccal cusp of the permanent first molar; extraoral photographs, intraoral photographs, maxillary occlusal radiographs, lateral cephalogram, and CBCT images are recorded[Figure5] and [Figure6]–August 13, 2013
  • After active expansion, miniscrew-assisted expansion was maintained for 6months for retention–February 17, 2014
  • Banding and bonding of the mandibular arch–February 1, 2014
  • Banding and bonding of the maxillary arch–February 25, 2014
  • Leveling and aligning achieved–September 4, 2014
  • Two miniscrew were placed in anterior palate under local anesthesia(2% lignocanine with adrenaline); intraoral photographs recorded–September 23, 2014 [Figure7]
  • Initiation of en masse protraction of maxillary dentition using miniscrew and modified transpalatal arch with distal facing hooks–October 7, 2014
  • Surgical removal of 38, 48
  • En masse protraction of maxillary dentition achieved–June 9, 2015
  • U/L archwires were sectioned for settling elastics–June 9, 2015
  • End of settling–November 5, 2015
  • Review and debonding was done-U/L impression made; OPG, lateral cephalogram, extra-and intral-oral photographs were recorded: November 12, 2015 [Figure8] and [Figure9]
  • Lower fixed bonded retainer(Canine to canine)–November 12, 2015
  • Upper wraparound retainer–November 13, 2015.
Figure 5: Intraoral maxillary occlusal photographs and maxillary occlusal radiographs with miniscrew assisted rapid palatal expansion: (a) Before expansion, (b) after expansion (c) before expansion, (d) after expansion, and (e) cone beam computed tomography images, axial slice showing parallel opening of the mid-palatal suture

Click here to view
Figure 6: Intraoral photographs, Extraoral photographs and Lateral cephalogram after miniscrew assisted rapid maxillary expansion: (a) Right buccal view, (b) anterior view, (c) left buccal view, (d) frontal view, (e) right profile view, and (d) lateral cephalogram

Click here to view
Figure 7: Intraoral photographs of miniscrew assisted protraction of the maxillary dentition: Before dentoalveolar protraction: (a) Right buccal view, (b) anterior view, (c) left buccal view, (d) maxillary dentoalveolar protraction using anterior palatal miniscrew anchorage. After dentoalveolar protraction: (e) Right buccal view, (f) anterior view, (g) left buccal view

Click here to view
Figure 8: Posttreatment extraoral photographs: (a) Frontal view with lips at rest, (b) right profile view (c) frontal view with smile

Click here to view
Figure 9: Posttreatment intraoral photographs: (a) Right buccal view, (b) anterior view, (c) left buccal view, (d) maxillary occlusal view, (e) mandibular occlusal view with fixed bonded retainer from canine to canine

Click here to view


Post-expansion cephalometric findings and their interpretation

Various cephalometric finding at the end of skeletal maxillary expansion are described in [Table1]. There was a significant improvement in facial profile and ClassIII skeletal relationship improved with a change in ANB angle of −2° and a significant increase in maxillary length by 2mm. The mandible rotated marginally in downward and backward direction. Mandibular plane was at higher end, increase in lower anterior face height with mild proclination of maxillary anterior teeth. Reverse overjet reduced to −1mm and 0mm overbite. Soft tissue relationship improved with significant improvement in upper lip.

Section 3: Post-treatment assessment

Occlusal features

Various occlusal features at the end of orthodontic treatment are shown in [Figure10].
Figure 10: Posttreatment study models showing various occlusal features: (a) Right buccal view, (b) anterior view, (c) left buccal view, (d) maxillary occlusal view, and (e) mandibular occlusal view

Click here to view


  • Incisor relationship: ClassI
  • Overjet(mm): 2 mm
  • Overbite: 2 mm
  • Centrelines: Coinciding midlines
  • Left buccal segment relationship: ClassI molar relation and ClassI canine relation
  • Right buccal segment relationship: ClassI molar relation and ClassI canine relation
  • Crossbites: None
  • Displacements: None
  • Functional occlusal features: Mutually protected occlusion. Optimal overjet and overbite. No premature occlusal contacts during mandibular movements
  • Other occlusal features: None
  • Complications encountered during treatment–nil.


Radiographs recorded towards/at end of treatment

  • Radiographs recorded:


    • Lateral cephalogram with teeth in occlusion[Figure11]
    • Orthopantomogram posttreatment–to assess root paralleling[Figure11]


  • Relevant findings:


    • Analysis of OPG revealed acceptable root paralleling at the end of treatment. Lateral cephalogram showed the normal inclination of upper and lower incisor. However, mild band space was seen between 26, 27.
Figure 11: Posttreatment radiographs: (a) Lateral cephalogram with teeth in occlusion (b) orthopantomogram

Click here to view


Post-treatment cephalometric finding and their interpretation

Various posttreatment cephalometric finding is described in [Table1]. The sagittal position of maxilla and effective maxillary length significantly increased over the treatment period. The sagittal position of the maxilla improved by 3° and effective maxillary length increased by 4mm due to skeletal expansion of maxilla and protraction of the maxillary dentition. There was minimal downward and backward rotation of the mandible of 3° over the treatment period. Vertical changes during maxillary expansion and protraction of maxillary dentition produced changes in occlusal plane or clockwise rotation of the maxillomandibular complex which reduced the chin prominence. However, FMA, SN-GoGn, basal plane angle, and lower anterior facial height increased during the treatment. Upper incisors bodily moved forward and lower incisors are upright to establish optimal overjet and overbite. Anterior crossbite was corrected. Nasolabial angle was average. The position of upper lip significantly improved during the treatment.

ClassI skeletal pattern achieved.

  • Posterior crossbite correction was achieved with buccal corridor fullness
  • Anterior crossbite correction achieved with good maxillary incisor display
  • Buccal occlusion established
  • Upper and lower anterior teeth crowding resolved
  • Upper and lower midline coinciding with the facial midline
  • Clockwise rotation of maxillomandibular complex provided an improvement in facial profile, good maxillary incisor exposure, enhanced smile arch, smile esthetics, and improved facial balance [Table 2] and [Table 3].
Table 2: Index of treatment need


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Table 3: Model analysis


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Comparison of pretreatment, postexpansion, and posttreatment results showed a clinical improvement in soft tissue profile, normal overbite and overjet, ClassI molar, ClassI canine relation on both sides and coinciding upper and lower midlines. Acanine-guided occlusion as present on both sides. The pretreatment, postexpansion, and posttreatment cephalometric superimpositions are shown in [Figure12].
Figure 12: The pretreatment (blackline), postexpansion (blue), and posttreatment (red) cephalometric superimpositions on Sella-nasion plane at sella. (a) Point A changes after expansion (b) maxillary dental changes, palatal plane at ANS, (c) mandibular dental changes, mandibular plane at menton (d) overall superimposition

Click here to view


Section 4: Critical appraisal

Overall, a satisfactory occlusion and facial esthetics was achieved. Miniscrew assisted rapid maxillary expansion and en masse protraction of maxillary dentition using miniscrew significantly improved the ClassIII skeletal jaw relationship and ClassIII molar relationship. The effective maxillary length was increased by 4mm during the treatment. Although mandibular rotation and lower anterior facial height slightly increased, there was a clinical improvement in soft tissue profile. Normal overbite and overjet, ClassI canine and ClassI molar relationship on both sides were achieved. Functional aspects of the occlusion were acceptable. Acanine-guided occlusion was present on both sides without any occlusal interference. However, mild band space was observed in relation to 26, 27. Mild white spots lesions in relation to upper and lower anterior and posterior teeth were observed.

Declaration of patient consent

The author certify that he has obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bishara SE, Staley RN. Maxillary expansion: Clinical implications. Am J Orthod Dentofacial Orthop 1987;91:3-14.  Back to cited text no. 1
    
2.
McNamara JA, Brudon WL. Treatment of tooth-size/arch-size discrepancy problems. In: Orthodontic and orthopedic treatment in the mixed dentition. Michigan: Needham Press; 1993. p. 67-93.  Back to cited text no. 2
    
3.
Profitt WR. The biological basis of orthondontic therapy. In: Contemporary orthodontics. 3rd ed. St. Louis: Mosby, Inc; 2000. p. 296-325.  Back to cited text no. 3
    
4.
Melsen B. Palatal growth studied on human autopsy material. A histologic microradiographic study. Am J Orthod 1975;68:42-54.  Back to cited text no. 4
    
5.
Lee KJ, Park YC, Park JY, Hwang WS: Miniscrew-assisted nonsurgical palatal expansion before orthognathic surgery for a patient with severe mandibular prognathism, Am J Orthod Dentofacial Orthop 2010;137:830-9.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure4], [Figure5], [Figure6], [Figure7], [Figure8], [Figure9], [Figure10], [Figure11], [Figure12]
 
 
    Tables

  [Table1], [Table 2], [Table 3]



 

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