JOURNAL CLUB

DR. RICHA AHLAWAT

JR - III
DEPARTMENT OF ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS
 INTRODUCTION
. Tooth transposition is the proportional interchange of 2 adjacent permanent
teeth or the development or eruption of one tooth into a position occupied by a
non-adjacent tooth.

. It is a rare condition occurring in approximately 0.3% to 0.4% of the general

population and is more frequently seen unilaterally in the maxilla.

. According to Peck, the distribution of lateral incisor – central incisor

transposition is 3% of the maxillary transposition’s.

. Despite its low prevalence, treating this condition presents a major challenge to
orthodontists.

. To obtain the best aesthetic and optimal function, it should be orthodontically

aligned back into their normal position.
. Segmented archwire technique with cantilever or loops in rectangular
wires is commonly used to achieve these results. Using this technique, the
moving and anchor parts are clearly divided, and the force system is well
controlled.

. However, this approach requires precise lab work and sometimes creates
discomfort for the patient.

. Herein, they introduced a novel method that demonstrated the successful

correction of a complete maxillary central incisor - lateral incisor
transposition using continuous archwire orthodontic treatment to bypass
the transposed teeth.

. At the end of the treatment, the patients dental aesthetic and function
was successfully restored. This technique is significantly easier and faster.

. It's biomechanics and detailed orthodontic procedures, and a four year

follow-up records are demonstrated and discussed in the case report.
DIAGNOSIS
AND
ETIOLOGY
AGE: 8 years and 10 months
SEX: Male
CHIEF COMPLAINT: Spaced and tipped front
teeth
MEDICAL AND DENTAL HISTORY: No relevant
history
CHILDHOOD HISTORY: No childhood trauma or
other reasons for the delayed eruption.

The patient had a well-balanced face with good facial

symmetry and a straight facial profile.
 A mixed dentition with bilateral Class I molar relationship.
Maxillary left central incisor was transposed with the maxillary lateral
incisor, and both of their crowns were mesially tipped.
Normal overjet and overbite.
 The maxillary dental midline deviated 2.0 mm to the left.
The mandibular dental midline was centered with the facial midline.
Both maxillary and mandibular dental arches had ovoid shapes.
The maxillary right primary molars had dental caries.
The maxillary left central and maxillary lateral incisors were
completely transposed.

All permanent tooth germs (except the third molars) were

present in all 4 quadrants.
 This radiograph was taken when
appliances were initially bonded.

The maxillary and mandibular incisors

were normally inclined.
 CEPHALOMERTIC
MEASUREMENTS

. Class I Skeletal relationship.

. Vertical growth pattern.

. Retrusive upper and lower lip.

. Retroclined lower incisors.

 DIAGNOSIS

Angle’s Class I malocclusion with complete

transposition of the maxillary left central incisor
and lateral incisor.
 TREATMENT OBJECTIVES

(1) Correct the transposed maxillary incisors

(2) Close the space in the maxillary anterior segment

(3) Correct the angulation of the maxillary incisors

(4) Correct the dental midline

(5) Maintain dental and skeletal Class I relationships and achieve normal

overbite and overjet

(6) Maintain facial balance.

 TREATMENT ALTERNATIVES

Nonextraction treatment Orthodontic treatment Nonextraction treatment

and alignment of the with autotransplantatio and correction of the
teeth in the transposed of the maxillary central transposition to a
order incisor normal tooth sequence
Nonextraction treatment and alignment of the teeth
in the transposed order

Given that both the crown and the root were transposed in the maxillary left
central incisor and lateral incisor, aligning the teeth in the transposed order would
probably require a shorter treatment time than correcting the transposition.
However, future prosthetic restorations were necessary for better esthetic,
arch form, mastication, and speech.
Considering that the patient had not yet experienced a puberty growth spurt,
this approach might have also impaired the patient's anterior alveolar bone growth
and facial profile in the future.
Orthodontic treatment with autotransplantation of
the maxillary central incisor

Autotransplantation combined with orthodontic treatment of the maxillary central

incisor is relatively easy for orthodontists but risky for oral surgeons.
The recipient site for the maxillary central incisor is prepared by distally moving
the lateral incisor to regain the space and the necessary bone graft for adequate
alveolar bone support.
The autotransplantation prognosis and further complications could not be
neglected.
Meanwhile, the patient's family would have been burdened with extra costs for
operation procedure and endodontic treatment.
 Nonextraction treatment and correction of the
transposition to a normal tooth sequence
Thus, correcting the transposition to a normal tooth sequence seemed to be the
best alternative, and the patient strongly desired to have his teeth aligned in
their correct positions.
This plan might provide the maximum esthetic with functional occlusion
while maintaining the patient's facial profile.
However, it poses a high risk, and bone grafting is highly suggested to
restore the anterior alveolar bone volume. Moreover, accurate tooth movement
and anchorage selection were carefully considered.
This plan requires a longer treatment time and effort from both the patient and
the clinician.
The boy and his parents were well informed about the
advantages and disadvantages of all 3 treatment plans.
They rejected any surgical treatment, including bone
grafting.
Meanwhile, they were informed that root resorption and
gingival recession were inevitable regardless of which
plan they chose.
After a detailed discussion, decision was made to attempt
the treatment that corrects the transposition to achieve a
functional Class I canine and molar relationship.
TREATMENT PROGRESS
 Bonding the maxillary incisors using 0.022
× 0.028-in slot straight-wire appliances.
(Smartclip, 3M Unitek, Monrovia, Calif).

For a maximum anchorage, transpalatal arch

(TPA) with molar bands was used.
A 0.019 × 0.025-in stainless steel (SS) archwire with omega stop loop was
applied to preserve the maxillary arch form, whereas a 0.012- in nickel-
titanium (NiTi) archwire was placed through the brackets of transposed
teeth in a continuous form to palatally bypass the lateral incisor.

The central incisor was

mesially pulled by the power
chain and labially restricted
by the SS archwire.
The power chain were applied
for approximately 50 g of
pulling force and were
replaced every month.
They noticed a slightly gingival submersion of the NiTi wire while distally
moving the lateral incisor.
After 3 months, when the lateral incisor moved palatally, the SS archwire
and TPA were removed.
To initially level the maxillary teeth, another 0.012-in NiTi arch- wire was
used.
 Then, the lateral incisor was moved distally,
with approximately 50 g of force applied by
the power chain for 1 month.

The position of the maxillary central incisor was maintained by an open-coil

spring between the maxillary central incisor and maxillary first premolar.
After bypassing the lateral incisor, tandem wires (0.012-in NiTi + 0.014-in
NiTi) were applied to align the teeth while maintaining the maxillary arch
form.

To eliminate the possible

occlusion interference,
occlusal pads were used.
 Furthermore, open-coil springs were placed to regulate the space between the
first molar, first premolar, and lateral incisor.

Once the lateral incisor was initially aligned, a 0.017 × 0.025-in NiTi rectangular
Panoramic radiographs were periodically taken to monitor the position of
transposed teeth.
In the following appointments, the initial force for the mesial movement of
the central incisor was from the counteracting force of the distal moving
lateral incisor; after that, the force was exerted from the NiTi open-coil
spring in the first premolar and first molar, which served as the main
abutment for central incisor movement.
Palatal root torque was augmented for the central incisor, whereas labial
root torque was applied to the lateral incisor.
Panoramic radiographs were periodically taken to monitor the position of
The central and lateral incisors were mesially positioned by the force of
open-coil springs to leave a space for canine eruption.
Panoramic radiographs were periodically taken to monitor the position of
transposed teeth.
The correction of the transposed central and lateral incisors lasted for
approximately 22 months. After that, the brackets were bonded to the rest
of the maxillary teeth and mandibular dentition.
During the finishing stage, 0.019 × 0.025-in SS rectangular wires were used
to obtain correct intercuspation, normal torque, and root parallelism.
After 44 months of active treatment, when the patient was 12 and a half
years old, the fixed orthodontic appliance was removed.
Hawley's removable retainer and fixed lingual splint retainer were inserted
for both the maxilla and mandible.
TREATMENT RESULTS
At the end of the treatment, the boy had a
pleasant facial profile.
Bilateral Class I molar and canine relationship of
Both the maxillary and mandibular dental arches were leveled and
aligned, with normal overbite and overjet.
The crowns and roots of the transposed maxillary central and lateral incisors
were corrected and were in their proper positions.
A functional occlusion was established with stable posterior support and proper
anterior guidance.
In addition, the keratinized gingival tissue of the incisors was normal.
Nevertheless, the maxillary left central incisor had a slight gingival recession.
The OPG after debonding showed that the entire dentition had a normal dental
sequence and well-paralleled roots, including the transposed central incisor
and lateral incisor. The alveolar bone level was also normal, but the maxillary
 CEPHALOMERTIC
MEASUREMENTS

. The lateral cephalometric

measurements met the
Chinese norms.
4 YEAR FOLLOW-UP
The records of fourth-year follow-up showed a
stable result.
The periodontal status of the anterior teeth and occlusal relationships
remained healthy and stable over the years.
 CEPHALOMERTIC
MEASUREMENTS

. Superimposition revealed
a normal growth pattern.

. The position of the

maxilla and mandible
relative to the cranial
base did not significantly
change, but the maxillary
incisors were
approximately 4 degree
proclined.
DISCUSSION
Treating tooth transposition can be challenging for orthodontists, especially in complete
transposition.
Although the main goal of treatment of all transposition abnormalities is to correct the
position of transposed teeth, many factors that affect the treatment results must be
considered; these factors include esthetics, occlusion, root apex position, treatment
length, patient cooperation, periodontal support, and patient's age.
Age is the most noticeable factor; it directly correlates with tissue regeneration.
Periodontal support is another important factor that determines the physiological limits
of transposed teeth. 1

In the current case, the boy suffered a collapsed anterior alveolar ridge, but with care to
control all the negative factors, the transposed teeth were successfully reversed into a
normal sequence. His young age was the greatest advantage.
When individualised and controlled movements of teeth are required, fixed
appliances such as customised fabricated loops or cantilever are widely applied.
In the current case, with the combination of 0.012-in NiTi archwire and 0.019 ×
0.025-in SS archwire, a continuous archwire technique was employed to bypass
the lateral incisor palatally.
The 0.012-in NiTi archwire moved the transposed teeth away from each other
initially, whereas the 0.019 × 0.025-in SS archwire served as a fulcrum to prevent
the labial movement of the central incisor.
 Once the lateral incisor moved from the mesial side of the central incisor to its
palatal side, aligning them back to a normal tooth sequence was considerably
easier in the following treatment.

The segmented archwire technique involves a more “controlled” movement for

the transposed teeth.
In continuous archwire technique, the transposed teeth were moved by an extremely light force with great flexibility. Thus, the continuous

archwire technique implies more of a “free” movement.

 BIOMECHANICS OF THE
CONTINUOUS ARCHWIRE
TECHNIQUE
Transposed teeth move away
from each other in a vertical
direction, without any horizontal
movement.

The round NiTi archwire formed a

2- couple orthodontic appliance
system.
It worked as a transformed “step
bend,” which moved the
transposed teeth away from each
other initially and aligned them
ultimately.
Transposed teeth move away
from each other in a horizontal
direction, without any vertical
movement in between.
Transposed teeth move
toward each other in the
final stage.
Clock-wised moments are
applied throughout the
entire process to transposed
teeth, which are balanced by
their adjacent teeth.
The rotation moments of the transposed incisors were eliminated by their
adjacent teeth.
When a round NiTi wire is applied, the main disadvantage of the continuous
archwire technique is that it cannot produce torque alone for the transposed
teeth. This approach is recommended for the initial bypassing of transposed
teeth.
Meanwhile, both of the transposed teeth were moved simultaneously in the
continuous archwire technique. If only one of them needs to be moved, the
other tooth should be restricted to minimize the undesired tooth movement.
In this case, an active force was applied to the central incisor to enhance the
movement of the transposed teeth, resulting in unwanted tipping of the central
incisor.
During the treatment course, drawbacks such as fully erupted transposed
teeth, distally tilted central incisor, left-shifted maxillary midline, and collapsed
anterior alveolar bone were encountered; nevertheless, the best esthetic and
optimal function were finally met.
Meanwhile, no maximum anchorage, such as temporary anchorage devices, was
used during the treatment. TPA was used only in the first 3 months to stabilize
the horizontal dimension.
The final result, which relies on the full understanding of the biomechanics in
orthodontic treatment and the highly professional skills of the orthodontist,
was satisfactory for both the patient and the orthodontist.
Correcting the transposed central and lateral incisors lasted for approximately
22 months, which was a relatively longer treatment time than expected but still
acceptable, given the complexity of this case.
However, considering that the patient had mixed dentition, the eruption of all
permanent teeth took a long time, thereby prolonging the whole treatment
length to 44 months.
Nevertheless, root resorption was noticed on the transposed teeth after the
treatment, possibly because of the long root movement range, long treatment
time, and narrowed alveolar ridge. Meanwhile, biological limits should also be
respected to prevent root resorption and periodontal support impairment.
Within the 4 years of follow-up, the central incisor slightly proclined. SN-U1
unexpectedly increased from 109.2 to 113.6, probably because of the collapsed
anterior alveolar ridge impairing the maxillary growth. 21

Regrettably, the cone-beam computed tomography, which is the current gold

standard for transposed teeth, was unavailable for this patient. The root
22

relation of the transposed teeth was monitored by panoramic radiographs

periodically. Angulation technique was also suggested to determine their
spatial relation. If more detailed information about the alveolar bone and teeth
was available, the treatment would be more precise, and the results would be
better.
CONCLUSION
In this case report, a continuous archwire technique, which was proven to be easy
and efficient, was used to bypass the transposed teeth.

No temporary anchorage reinforcement, such as temporary anchorage devices,

was used during the treatment.

However, several factors should be considered before starting the treatment.

In addition, orthodontists need to follow the biomechanical principles to facilitate

the treatment and avoid potential negative outcomes.
THANK YOU