Department of orthodontics and

Dentofacial orthopedics

JOURNAL CLUB PRESENTATION

PRESENTED BY
KEERTHANA.S
CRRI
Nonsurgical treatment of an adult with skeletal Class III
malocclusion, anterior crossbite, and an impacted canine
-A case Report
 About The Journal And The Author

AMERICAN JOURNAL OF ORTHODONTICS AND DENTOFACIAL

ORTHOPEDICS

PUBLISHED ON: April 2021

AUTHORS: Carlos Bellot-Arcıs,

Veronica Garc ıa-Sanz,
Vanessa Paredes-Gallardo
DIAGNOSIS AND ETIOLOGY:
CASE REPORT:
Age:34 years
Gender:Male
Chief complaint: I have a tooth in my palate, and I don't like the gap.” He did not mention his anterior crossbite
at all and said it did not concern him “in the slightest.”
He did not mention his anterior crossbite at all and said it did not concern him “in the slightest.”
Facial photographs showed a well-proportioned face, symmetrical, with a slightly enlarged lower third.
The patient's smile exposed almost all the maxillary incisors without any gum.
facial profile-straight
Lip: slightly everted lower lip.
Slight malar projection was also noted, a common finding in patients with maxillary hypoplasia
Intraoral photographs and study models showed a bilateral Class III molar relationship with retroclined
mandibular incisors and proclined maxillary incisors.
In addition, the patient presented posterior crossbite in the premolar area, and complete anterior crossbite, as
well as increased overbite (4 mm).
There was a mild tooth size-arch length discrepancy in the maxillary anterior arch (3 mm) and moderate
discrepancy in the mandibular arch (4 mm).
 Both the maxillary and mandibular dental midlines were centered in relation to each other and the face.
There was a mild tooth size-arch length discrepancy in the maxillary anterior arch (3 mm) and moderate
discrepancy in the mandibular arch (4 mm).

The maxillary incisors presented some wear derived from the crossbite, whereas the mandibular incisors showed no
wear. The maxillary right canine was palatally impacted, and the maxillary left second premolar had been extracted
because of caries

. Periodontal assessment observed that the patient initially presented poor oral hygiene, with active periodontitis, 4
mm pockets in the posterior regions, and 24% bleeding, which improved significantly after periodontal treatment

Cephalometric analysis identified a skeletal Class III (ANB 4.3; Wits 10.2 mm)

The maxillary and mandibular incisors were retroclined (SN-U1 5 101.2; IMPA 5 86.0) .
Functional analysis observed that in centric relation, the patient reduced the anterior crossbite, reaching
slight incisal edge-to-edge contact . No lateral shift was observed.

A panoramic radiograph showed an impacted maxillary right canine, and the absence of the maxillary left
second premolar. Both left third molars were impacted.
Cone-beam computed tomography images showed the superficial palatally impacted position of the maxillary right
canine, this being a favorable position for traction .

The mandibular third molars and maxillary right third molar were extracted before treatment because of
caries and periodontal reason

DIAGNOSIS:
skeletal Class III of maxillary origin, anterior crossbite with functional component and posterior
crossbite, augmented overbite, and a palatally impacted maxillary right canine.
 Treatment Objectives
The treatment objectives were to expose the palatally impacted canine, establish a
dental and skeletal Class I relationship, obtain adequate overjet and overbite, as well as
maxillary and mandibular incisor torque, and correct facial harmony and esthetic

TREATMENT ALTERNATIVES:

The first treatment option considered was a surgical approach using LeFort I
advancement, but this was rejected by the patient.
To correct the sagittal problem, we considered treatments both with and without
extractions. To avoid extractions, bearing in mind that the third molars had already been
extracted, we performed distalization of the mandibular arch with miniscrews, placed distally to
the mandibular second molars.
This approach allowed the amount of distalization and anchorage to be better controlled.
Open exposure was performed to correct the impacted maxillary canine, allowing its
spontaneous eruption
Open exposure can only be performed in adult patients when the canine is positioned
superficially, after which the canine will erupt spontaneously in due course.2
 Because of the state of the maxillary right second premolar, placement of a provisional crown was
discussed, but this was rejected by the patient because of cost; this was to be restored with a zirconia
crown after orthodontic treatment. It was decided to replace the missing maxillary left second premolar with an implant or bridge after
orthodontic treatment.

TREATMENT PROGRESS:
First, exposure surgery of the maxillary right canine was performed, eliminating all the tissue surrounding
the crown and placing provisional cement to prevent the open exposure from closing. Three months later, the canine erupted
spontaneously. At this point, composite stops were placed on the maxillary first molars to open the bite and avoid debonding of the
maxillary anterior brackets. Then, Tip-Edge Plus 0.022 3 0.028-in brackets were bonded on the maxillary arch.

Because of the favorable position of the canine, direct traction to a nickel-titanium (NiTi) 0.016-in archwire was applied
using transparent elastics applying very soft forces.
Afterward, a 0.016 3 0.022-in NiTi archwire was used to bring the canine into the arch

Two miniscrews were placed distal to the mandibular second molars (length, 12 mm; diameter 1.3 mm; Tubes were placed on
the buccal surface of the mandibular molars together with a 0.017 3 0.025-in titanium molybdenum alloy sectional archwire and
buttons on the lingual surface of the first molars Distal traction was carried out with elastic chains from the miniscrews.
Three months after initiating distalization, spaces between teeth in the
mandibular arch began to appear, and at this moment, Tip-Edge Plus 0.022 3 0.028-in bracket appliances were
placed on the mandibular arch.
 Molar intrusion was not desired in the present case because the patient presented deep overbite, and the
clockwise rotation of the mandible favored the correction of the Class III malocclusion. Initially, light forces were used,
increasing to 100 g of force after 4 weeks.
To avoid molar rotations, we performed traction both buccally and lingually using a titanium molybdenum alloy
0.017 3 0.025-in sectional archwire , being the distalization 50 g of force per side.

Alignment and leveling were achieved using NiTi 0.016-in, 0.016 3 0.025-in, and 0.021 3 0.025-in archwires,
whereas stainless steel 0.019 3 0.025-in and 0.021 3 0.028-in archwires were used to finish leveling and compensate
anterior dental torque

Class III elastics were not used at any time during treatment, thus avoiding proclination of the maxillary incisors. The
correction of the malocclusion was obtained by distalizing the mandibular arch.
To achieve good interdigitation, we made compensation bends were made as well as selective enamel
reduction in both arches. The duration of treatment was 24 months.

After removing the appliances, fixed lingual retention was placed from canine to canine on the mandibular arch
and lateral to lateral in the maxillary arch. In addition, thermoplastic retainers were supplied to the patient to be worn at
night.
After orthodontic treatment, esthetic reconstructions were placed on maxillary central and lateral incisors. The
maxillary right second premolar was reconstructed with a zirconia crown.
Rehabilitation of the edentulous space at the maxillary left second premolar had been planned, but this was
postponed to a later date for economic reasons
 Treatment Results:
Because of the distalization of the mandibular arch, achieved through the use of
miniscrews, the patient's malocclusion improved considerably within a reasonable treatment
time.
Spontaneous eruption of the (favorably positioned) impacted maxillary canine in
this adult patient was achieved within an acceptable treatment time.

Posttreatment images and models showed a good finish and correct interdigitation. A
Class I molar and canine relationship and an acceptable intercisal relation were obtained
 maxillary incisors were proclined (SN-U1) and slightly retroclined in the
mandibular arch (IMPA from 86 to 84). The mandible underwent clockwise rotation,
changing the
mandibular plane (FMA]
The panoramic radiograph showed the distal uprighting of mandibular molars due to the
distalization of the mandibular arch
 Postretention cephalometric analysis showed no changes after posttreatment
analysis . A postretention panoramic radiograph also showed no changes after
treatment

show pretreatment, posttreatment, and postretention cephalometric

analyses superimposed, showing that the corrected malocclusion was due to
distalization of the mandibular arch and mandibular posterior rotation and that most
changes remained stable after the 2-year retention period
 After 24 months of retention, it can be observed that the occlusion reached at the end of
treatment remained stable. The patient had the worn maxillary incisors reconstructed and a c
placed on the maxillary right second premolar
Discussion:
the first therapeutic option was orthognathic surgery. However, this was rejected by the patient who preferred the
dentoalveolar compensation alternative
Providing the patient is able to achieve an edge-to-edge bite; the malocclusion can be treated by dentoalveolar
compensation.

When this occurs, either premolar extractions in the mandibular arch may be considered or distalization of the whole
mandibular arch using direct skeletal anchorage using miniscrews placed distal to the mandibular molars.

In the present case, the latter option was more conservative as the third molars had been extracted previously for
nonorthodontic reasons, so the further extraction of premolars would involve a lack of occlusal contact with the maxillary second
molars.

treatment started with the impacted canine, and when this had been brought to a more favorable position, treatment of the
mandibular arch began.

the malocclusion was treated by distalizing the mandibular arch using miniscrews to achieve adequate incisor inclination and
satisfactory smile esthetics.

Although a significant increased in the proclination of the maxillary incisors occurred, this change did not severely harm the
facial esthetics because the maxillary incisors were initially retroclined, so we actually minimized their proclination by distalizing the
mandibular arch when correcting the anterior crossbite

Rejecting the option of mandibular premolar extractions avoided excessive retroclination of the mandibular incisors.

Skeletal Class III malocclusion involves maxillary hypoplasia in all 3 axes (vertical, sagittal, and transverse).
The patient presented posterior crossbite, with his maxillary intermolar width being 5.88 cm.
 This crossbite was corrected as far as the sagittal discrepancy could be corrected by distalization of the
mandibular arch because the mandibular teeth were moved posteriorly (due to both miniscrew mechanics
and clockwise rotation of the mandible) to positions where the maxillary arch is wider .

To upright the mandibular molars and move them distally, miniscrews can be placed in the retromolar
area or the ramus. Another available option for mandibular arch distalization is the placement of ramal plates in the
retromolar fossa area.
Miniscrew insertion tends to be more complicated and uncomfortable in the mandibular arch than in the
maxillary, sometimes requiring flap releasing.

When placing miniscrews after mandibular third molar extraction, it is advisable to wait several months until the
bone has healed and presents sufficient density to allow traction, although it may be possible to place them during the
same surgical session providing it is anatomically possible and that the bone defect produced by the extraction can be
avoided

One of the dangers when using skeletal anchorage is that the forces applied can lead to root resorption,
although in the present case, this did not occur

In this case, treatment with skeletal anchorage proved stable after the 2-year retention period, as affirmed in
other case reports.

Finally, to obtain an adequate esthetic outcome, composite reconstructions were placed on maxillary central
and lateral incisors.

The maxillary right second premolar was rehabilitated with a zirconia crown and the maxillary left second
premolar was to be rehabilitated with an implant in the future (this was postponed by the patient for economic
reasons).
The results obtained were very satisfactory and remained stable after a reasonable retention period
CONCLUSION:

One of the most important aspects of the present case report was the diagnosis;
in this type of patient, correct treatment will always depend on the diagnosis.

The use of direct skeletal anchorage for treating skeletal Class III malocclusion
and anterior crossbite made it possible to treat the malocclusion successfully
without extraction of the mandibular premolars.

Torque control of the maxillary incisors was also crucial for achieving harmonious
smile esthetics