CASE REPORT

Correcting severe scissor bite in an adult

Un-Bong Baik,a Yunji Kim,b Junji Sugawara,c Christine Hong,d and Jae Hyun Parke
Seoul, Korea, Sendai, Japan, Los Angeles, Calif, and Mesa, Ariz

Scissor bite often remains unnoticed by patients although it can adversely affect facial symmetry, jaw growth,
and mastication. This case report illustrates the efficacy of temporary skeletal anchorage devices (TSADs)
and a modified lingual arch in correcting severe scissor bite. A 28-year-old woman presented with severe scissor
bite in the mandibular right posterior segment. To treat this condition, TSADs were used for maxillary posterior
intrusion and a modified lingual arch for buccally uprighting mandibular posterior teeth. Long-term retention re-
cords demonstrate stable treatment results. (Am J Orthod Dentofacial Orthop 2019;156:113-24)

S
cissor bite is a rare malocclusion caused by a rela- suggested, including a maxillary constriction plate, in-
tively large maxillary dental arch compared with termaxillary elastics, quad helix, and transpalatal arch
its mandibular counterpart.1 Scissor bite remains appliance.4,5 Although these methodologies may be
a clinical challenge for orthodontists. People with scissor considered as noninvasive alternatives to surgical
bite may have discrepancies in facial symmetry and dif- treatment, their limitations include excessive extrusive
ficulties in lateral excursive movements owing to exces- force requirements on the anchor teeth and a need for
sive buccal eruption of maxillary posterior teeth and patient compliance.6
lingual tipping of mandibular posterior teeth.2 Previous To avoid these dental side-effects in scissor bite
studies have sought to determine the exact etiology of correction, temporary skeletal anchorage devices
scissor bite. Possible causes include familial inheritance, (TSADs) have begun to be used in recent years. Previous
excessive sucking behavior, and mouth breathing.3 case reports revealed their efficacy in alleviating trans-
Despite these findings, the cause remains unknown, verse discrepancies and scissor bite, thereby affirming
and the challenge in correcting such a malocclusion is TSADs as a favorable alternate appliance.1,4,7 Because
further compounded by the fact that few patients are TSADs can be placed in various anatomic locations,
diagnosed with the condition. they can serve as anchors for both maxillary and
Conventional therapies for the treatment of scissor mandibular arches.8-10 Furthermore, TSADs have
bite often involve surgical procedures combined with become widely accepted in the orthodontic community
fixed appliance orthodontics.3 Although surgical treat- because they are biomechanically favorable and cost-
ment is often required for ideal repositioning of the efficient, and they eliminate the need for patient compli-
maxilla and mandible, many patients do not readily ance.1,7,8 Given these favorable characteristics, TSADs
accept a surgical approach, because it is invasive, expen- hold great promise for treating scissor bite and
sive, and carries associated risks. Other orthodontic correcting skeletal discrepancies in order to achieve
treatments for correcting scissor bite have been functional occlusion.
In the present case report, we demonstrate the suc-
a cessful treatment of scissor bite with the combined use
Smilewith Dental Clinic, Seoul, Korea.
b
Department of Orthodontics, Korea University Anam Hospital, Seoul, Korea. of TSADs for maxillary posterior intrusion and modified
c
SAS Orthodontic Center, Ichiban-Cho Dental Office, Sendai, Japan. lingual arch for mandibular posterior uprighting.
d
Section of Orthodontics, Division of Growth and Development, UCLA School of
Dentistry, Los Angeles, Calif.
e
Postgraduate Orthodontic Program, Arizona School of Dentistry and Oral DIAGNOSIS AND ETIOLOGY
Health, A.T. Still University, Mesa, Ariz, and International Scholar, Graduate
School of Dentistry, Kyung Hee University, Seoul, Korea. A 28-year-old woman was referred with a chief
All authors have completed and submitted the ICMJE Form for Disclosure of Po- complaint of buccal crossbite of the mandibular right
tential Conflicts of Interest, and none were reported. posterior segment. She presented with a convex profile
Address correspondence to: Jae Hyun Park, Postgraduate Orthodontic Program,
Arizona School of Dentistry and Oral Health, A.T. Still University, 5835 East Still and facial asymmetry. Her lips were protrusive and
Circle, Mesa, AZ 85206; e-mail, [email protected]. incompetent at rest. Her maxillary dental midline was
Submitted, September 2017; revised and accepted, November 2017. 1.0 mm to the right of the facial midline, and her
0889-5406/$36.00
Ó 2019 by the American Association of Orthodontists. All rights reserved. mandibular dental midline was 2.0 mm to the right of
https://doi.org/10.1016/j.ajodo.2017.11.047 the facial midline. When smiling, the patient showed
113
114 Baik et al

Fig 1. Pretreatment facial and intraoral photographs.

disharmonious gingival contours on her anterior denti- not report any muscle or joint pain or other symptoms
tion (Fig 1). typically associated with temporomandibular disease.
Intraoral and dental cast examination revealed a All 4 of her third molars were impacted. Her dentition
Class I molar relationship on the left side. Molar rela- showed generally short roots, especially on the anterior
tionship could not be determined on the right side dentition, due to proclination and pointed or dilacerated
due to severe lingual tilting of the mandibular poste- root shapes.
rior teeth. She had 5 mm overjet and 30% overbite Lateral cephalometric analysis indicated a skeletal
on her left central incisors. The maxillary arch had Class II (ANB 4.0 ) with a hyperdivergent growth
moderate crowding with proclined incisors, and the pattern (SN-MP 45.5 ). Even though she had a skel-
mandibular arch had severe crowding with a lingually etal Class II pattern, her Wits measurement was low
displaced right posterior segment. When her mandible (Wits 3.0 mm) due to the clockwise rotation of
was guided into centric relation, a functional shift occlusal plane.11 Her maxillary and mandibular inci-
was detected due to unilateral Brodie bite on the sors were proclined (U1-SN 120.5 , IMPA 96.5 ). Her
right side (Figs 1 and 2). lips were protrusive relative to the E-line (Table I;
A routine periodontal examination was performed Fig 3).
which included assessment of probing depths. Localized
pocket depths were \3 mm on the mandibular right
segment. A panoramic radiograph showed slightly TREATMENT OBJECTIVES AND PLAN
different right and left condylar heads, but during the The following treatment objectives were established:
temporomandibular joint evaluation, the patient did (1) relieve crowding in both arches, (2) correct the scissor

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Fig 2. Pretreatment dental casts.

would have to be primarily on the right side while the

Table I. Cephalometric measurements occlusion on the left side is maintained,12 but the patient
6-Year declined the surgical option.
Measurement Norm Pretreatment Posttreatment retention TSADs were considered to be a useful treatment
SNA ( ) 82.0 81.0 81.0 81.0 option in this case. The extruded maxillary right molars
SNB ( ) 80.0 77.0 77.5 77.0 could be intruded and the lingually displaced mandibular
ANB ( ) 2.0 4.0 4.5 4.0
Wits (mm) 0.1 3.0 3.5 4.0
right segment could be uprighted with the use of TSADs.7
SN-MP ( ) 34.0 45.5 46.0 46.0 While correcting the crossbite, a removable plate could be
FMA ( ) 28.2 40.0 41.5 41.0 delivered on the maxillary arch to open the posterior
LFH (ANS-Me/N- 55.0 55.0 55.8 55.8 segment so that the mandibular posterior teeth could
ANS) (%) be uprighted buccally. After correcting the unilateral
U1 to SN ( ) 104.0 120.5 97.0 98.0
U1 to NA ( ) 22.0 35.6 16.1 17.3
buccal crossbite, her maxillary anterior teeth could be re-
IMPA ( ) 90.0 96.5 86.0 87.0 tracted with the use of TSADs after extraction of premo-
L1-NB ( ) 25.0 39.3 24.1 24.2 lars to reduce lip protrusion and overjet.
U1/L1 ( ) 124.0 100.0 130.0 128.0
Upper lip (mm) 1.2 5.0 1.0 1.5
Lower lip (mm) 2.0 5.0 2.0 2.5 TREATMENT ALTERNATIVES
Because her maxillary right molars were lingually dis-
placed, we could use an expander containing 2 anchor
bite, (3) maintain Class I dental relationship on the left teeth (first molars) rather than 4 teeth (first molars and
side and establish it on the right side, (4) obtain normal first premolars).14 We also could solder an extension
overjet and overbite, (5) improve the deviation on open- arm on the distolingual side of the maxillary right first
ing and correct the dental midline, (6) obtain a stable molar band to expand the right second molar. To pre-
occlusal relationship, (7) improve facial and dental es- vent transverse widening of the normal side, 1 miniscrew
thetics by establishing an esthetic smile, and (8) improve could be installed on the left posterior palatal slope or
facial profile. paramedian palatal region to maintain left-side occlu-
Because she was an adult patient with skeletal prob- sion during expansion. The patient was an adult, so
lems, orthognathic surgery was considered. Her mandib- we also considered slow expansion. After expansion,
ular constriction and unilateral Brodie bite could be while using heavy rectangular wire, we could use inter-
corrected with the use of a Le Fort I and posterior maxillary crossbite elastics to upright lingually tilted
segmental osteotomy along with mandibular symphy- mandibular right posterior teeth. During this procedure,
seal distraction.7,12,13 Because there was unilateral we would prevent lingual tipping of the maxillary poste-
buccal crossbite, the mandibular transverse widening rior teeth while using crossbite elastics. However, there

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Fig 3. Pretreatment radiographs and lateral cephalometric tracing.

was some concern about extruding and tipping the molars buccally. While correcting the crossbite, a remov-
maxillary right molars after expansion. able plate was delivered on the maxillary arch to open
the posterior segment so the mandibular posterior teeth
could be uprighted buccally (Fig 4).
After 7 months, the maxillary right molars were
TREATMENT PROGRESS intruded and the mandibular right molars were buccally
Because the patient wanted to retract her upper lip as uprighted. The patient was then referred for the extrac-
much as possible, the plan was to extract her premolars tion of her maxillary first premolars and mandibular
to relieve crowding and reduce her overjet. Because she second premolars to relieve the crowding and reduce
did not want to extract all premolars and third molars at her anterior overjet efficiently. Full fixed 0.018-inch
the same time, she was referred to an oral surgeon to metal twin brackets (Dentsply GAC, York, Pa) were
extract her right third molars first. While extracting her placed and bonded in both arches. After leveling and
right third molars, 2 TSADs (6.0 mm length, 1.5 mm alignment, an additional miniscrew was installed on
diameter; Orlus, Seoul, Korea) were installed on the the maxillary arch between maxillary left second premo-
interdental space between maxillary molars buccally lar and first molar for maximum anchorage. In the
and palatally, and elastic chains were engaged from mandibular arch, during space closing, an
the buccal to palatal TSADs. To secure the elastic chains 0.017 3 0.025-inch TMA intrusion archwire was used
and wire passing through the contact, composite was to prevent bite deepening. After space closure, final
cured on the occlusal surfaces of the 2 adjacent molars. detailing of the occlusion was accomplished with the
Two months later, the maxillary molars were intruded use of 0.016 3 0.022-inch steel archwires (Fig 5). Fixed
and maxillary occlusal plane flattened. A modified retainers were attached on the maxillary anterior teeth
lingual holding arch with soldered hooks was then and mandibular anterior teeth and first premolars.
used on the mandibular arch to tip the lingual tilted Wraparound removable retainers were also delivered to

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Fig 4. Maxillary right molar intrusion with the use of TSADs and buccal uprighting of mandibular right
molars with the use of elastics.

Fig 5. Progress intraoral photographs of the TSADs for space closing in the maxillary arch and an intru-
sion archwire for mandibular anterior teeth.

secure the stability of both arches. Total treatment time improved lip closure. The unilateral buccal crossbite
for this patient was 3 years. After her orthodontic treat- on the patient's right posterior segment was corrected.
ment, she was referred to surgeons to evaluate the The crowding in both arches was relieved, acceptable
extraction of her left third molars and gingival graft of overbite and overjet were achieved, and her dental
the mandibular anterior segment. midlines were improved. A Class I dental relationship
was maintained on the left side and a Class I dental
relationship was established on the right side (Figs 6
TREATMENT RESULTS and 7).
Posttreatment records showed that the treatment The posttreatment panoramic radiograph showed
objectives were achieved. Facial photographs showed proper space closure and acceptable root parallelism.

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Fig 6. Posttreatment facial and intraoral photographs.

Fig 7. Posttreatment dental casts.

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Baik et al 119

Fig 8. Posttreatment radiographs and lateral cephalometric tracing.

Although she developed more root resorption on her individual is often unaware that they possess a scissor
mandibular anterior segment, there were no significant bite. The scissor bite is not corrected spontaneously
signs of bone or root resorption compared with the pre- and progressively worsens as maxillary teeth continue
treatment panoramic radiograph. Posttreatment lateral to overerupt and occlude on the buccal surfaces of the
cephalometric analysis and superimposition showed no mandibular posterior teeth.15 Occlusion itself causes
significant skeletal changes (ANB 4.5 , SN-MP 46.0 ). tipping of maxillary posterior teeth buccally and
The maxillary and mandibular incisor showed retroclina- mandibular posterior teeth lingually.3 If this condition
tion (U1-SN 97.0 , IMPA 86.0 ). The patient's facial pro- persists, mandibular posterior teeth can become
file, especially the protrusion of her lips and smile completely tipped lingually and the alveolar bone may
esthetics, were improved (Table I; Figs 8 and 9). At the be severely affected as well.5
6-year retention examination, the records showed no Untreated scissor bite in younger patients can lead to
significant relapse and the patient had a stable occlusion aberrant jaw growth and the development of facial
(Figs 10-12). asymmetry. Furthermore, as a patient ages and growth
of the mandible slows, the correction of scissor bite be-
comes more challenging. For younger patients, more
DISCUSSION treatment options are available including constriction
Scissor bite is a rare phenomenon in the general of maxilla and expansion of mandible before growth is
population, with an estimated occurrence of 1.5% of completed.16 This early interceptive treatment can
the general population,12 and even fewer cases during shorten the treatment time and decrease the complexity
the primary dentition period. However, such reported in later stages of orthodontic treatment.3,15 As such,
prevalence may be underestimated because an afflicted early treatment of scissor bite is critical.

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Fig 9. Cephalometric superimposition showing profile improvement. Black, pretreatment; red, post-
treatment.

In the present case, our patient exhibited a scissor study showing that intruded posterior teeth may conse-
bite with supraerupted maxillary posterior teeth quently experience a relapse rate as high as 30%.19
occluding on the buccal surface of lingually tipped Therefore, overcorrection of molar intrusion was neces-
mandibular posterior teeth. We began the treatment by sary to achieve sufficient molar intrusion in our patient.
intruding her supraerupted maxillary posterior teeth. In addition, previous studies reported that intrusion with
There are multiple treatment mechanisms available for heavy force can cause pulpal damage and interradicular
intruding posterior teeth, such as headgear and posterior root resorption,23,24 so we limited the magnitude of
bite blocks.17,18 These treatment modalities, however, force to 250 g per molar to prevent further root
require stringent patient cooperation, thus compelling resorption.24 Fortunately, in our case, molar intrusion
us to turn to other favorable alternatives, such as for maxillary posteriors was achieved successfully
TSADs. TSADs have been shown to be very effective in without any of the aforementioned complications.
molar intrusion. Sugawara et al demonstrated that In severe cases of unilateral Brodie bite, as with our
TSAD-facilitated molar intrusion can achieve intrusion patient, treatment options including mandibular sym-
of 1.7 mm for the mandibular first molar and 2.8 mm physeal distraction and TSADs have been shown to be
for the mandibular second molar.19 Intrusion with the effective. Distraction osteogenesis, a procedure
use of TSADs is efficient as intrusive forces can be involving osteotomy and a distractor to gradually stretch
applied in a stable manner and immediately after the callus,12,25 has been shown to be successful in
TSAD placement.20 Furthermore, varying numbers of expanding mandibular basal bone for the correction of
TSADs can be incorporated in molar intrusion tech- true unilateral scissor bite. It is important to note,
niques. In our case, we used the minimum number however, that distraction osteogenesis is most effective
necessary for efficient intrusion to maximize patient in younger patients with growth potential.2 Therefore,
comfort.21 We placed 2 TSADs on both buccal and less invasive procedures such as TSADs are particularly
palatal sides for balanced biomechanics, because tilting suitable for treatment of severe scissor bite in adult pa-
of the tooth during apical displacement can occur if tients. The TSAD system allows the force to be applied
force is only applied to just one side.22 closer to the center of resistance of the tooth, thereby
One of the complications associated with TSAD- producing translatory movement and allowing extensive
facilitated molar intrusion was highlighted in a previous tooth displacement.8 In this case, because buccal TSAD

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Baik et al 121

Fig 10. Six-year posttreatment facial and intraoral photographs.

Fig 11. Six-year posttreatment dental casts.

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Fig 12. Six-year posttreatment radiographs and lateral cephalometric tracing.

placement was able to facilitate mandibular right poste- while simultaneously preventing unwanted extrusion
rior uprighting, we initially considered using TSADs as a of the maxillary posterior teeth.1,4,28 Although it is also
treatment option. However, with severely tilted buccal possible to place bite resin on individual teeth,
alveolar bone as seen in our patient, buccal insertion undesirable extrusion of teeth that did not have bite
of TSADs could have caused significant patient discom- resin might occur.7 Our patient was receptive and
fort. In addition, TSADs placed in the mandible are compliant to the full-time application of the bite plate,
known to have higher failure rates.26,27 To avoid which may have contributed in facilitating our treatment
potential complications with TSAD use, we decided to progress.
use a modified lingual holding arch for molar As seen from 6-year retention records, this case had
uprighting in the mandible. We designed a modified excellent posttreatment stability. After a year of full-
buccal extension arm on the lingual holding arch. To time retainer wear, retainers were used infrequently.
maximize anchorage on the lingual arch, we placed Once scissor bite is corrected, the lingual incline of the
bands on a larger number of teeth and performed buccal cusp of the maxillary teeth and the lingual incline
mandibular premolar extraction after the buccal of the lingual cusp of the mandibular teeth occlude
uprighting of the mandibular right posteriors. Molar properly so that the occlusion itself functions as a
uprighting progressed successfully and scissor bite was retainer to prevent scissor bite from reoccurring,29 but
significantly improved in just 7 months. it is important to note that scissor bite treatment stability
During the initial 7 months, we used a maxillary bite is often compromised owing to treatments involving
plate to facilitate the treatment of scissor bite. The dental expansion. It has been shown that the expansion
reason for this was to prevent occlusal interference of basal bone relative to alveolar bone is critical in estab-
when the mandibular posterior teeth moved buccally lishing long-term stability.12,30 In this case, the

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Baik et al 123

mandibular constriction was isolated to the right 10. Ryu JH, Park JH, Thu TVT, Bayome M, Kim YJ, Kook YA. Palatal
quadrant with excessive dental tipping. By uprighting bone thickness compared with cone-beam computed tomography
in adolescents and adults for mini-implant placement. Am J
the mandibular right posterior teeth, we were able to
Orthod Dentofacial Orthop 2012;142:207-12.
reposition the alveolar housing as well and achieve 11. Jacobson A. The “Wits” appraisal of jaw disharmony. Am J Orthod
long-term stable results. Dentofacial Orthop 2003;124:470-9.
12. King JW, Wallace JC. Unilateral Brodie bite treated with
CONCLUSION distraction osteogenesis. Am J Orthod Dentofacial Orthop
2004;125:500-9.
A specially designed lingual holding arch used in this 13. Baeg S, On S, Lee J, Song S. Posterior maxillary segmental osteot-
study was able to provide sufficient anchorage and pa- omy for management of insufficient intermaxillary vertical space
tient comfort to buccally upright lingually tilted and intermolar width discrepancy: a case report. Maxillofac Plast
Reconstr Surg 2016;38:28-33.
mandibular posterior teeth. The integrated approach of
14. Lamparski DG, Rinchuse DJ, Close JM, Sciote JJ. Comparison of
TSADs for maxillary intrusion and a lingual holding skeletal and dental changes between 2-point and 4-point rapid
arch for mandibular uprighting could be an effective palatal expanders. Am J Orthod Dentofacial Orthop 2003;123:
way to orthodontically treat severe scissor bite in adult 321-8.
patients. 15. Grippaudo C, Pantanali F, Paolantonio EG, Saulle R, Latorre G,
Deli R. Orthodontic treatment timing in growing patients. Eur J
Paediatr Dent 2013;14:231-6.
ACKNOWLEDGMENTS 16. Favero V, Sbricoli L, Favero L. Scissor bite in a young patient
The authors thank Andrew Serrano, Ju Myung Kim, treated with an orthodontic-orthopedic device. Eur J Paediatr
Dent 2013;14:153-5.
and Jaime Tran for their help with the preparation of
17. Proffit WR, Fields HW. Orthodontic treatment planning: limita-
the manuscript. tions, controversies, and special problems. In: Proffit WR, editor.
Contemporary orthodontics. 3rd ed. Saint Louis: Mosby; 2000.
SUPPLEMENTARY DATA p. 268-9.
18. Iscan HN, Sarisoy L. Comparison of the effects of passive posterior
Supplementary data to this article can be found bite-blocks with different construction bites on the craniofacial
online at https://doi.org/10.1016/j.ajodo.2017.11.047. and dentoalveolar structures. Am J Orthod Dentofacial Orthop
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