Teixeira CC a , Abdullah F b, Sangsuwon C b , Alansari S b, Oliveira SP b,c, Nervina JM b , Alikhani M b,d
Figure 1: Pre-treatment portrait and intra-oral photographs. Lateral profile portrait showed a bimaxillary protrusion with protrusive upper and lower lips. Frontal portraits showed lip competency at rest and a reverse smile line with 70% incisal display while smiling, dark buccal corridors and coincident maxillary and mandibular midlines. Intra-oral photographs revealed a high maxillary labial frenum attachment, spacing and severe anterior and posterior open bite extending to the first premolars, proclined maxillary and mandibular incisors, a constricted maxilla, marginal ridge discrepancies, gingival margin not aligned with irregular heights of contour. The mandibular third molars were present, but the maxillary third molars were absent, and the mandibular left first premolar was severely rotated.
Figure 2: Pre-treatment digital casts evaluation. Pre-treatment digital casts showed a Class I molar and Class III canine relation. The maxillary dental arch width was constricted with an inter-canine and inter-molar width of 35.3 mm, 47 mm, respectively. The mandibular dental arch width was broad with the inter-canine and inter-molar width of 37 mm, 42.4 mm, respectively. The maxillary dental arch showed a severe Curve of Spee and the mandibular arch showed a reverse Curve of Spee with two distinct occlusal planes. Spacing was observed in both arches (upper = -6 mm; lower = -10 mm) and a maxillary anterior excess Bolton discrepancy of 3.1 mm. The overjet and overbite were -3.7 mm and -10.9 mm, respectively.
Figure 3: Pre-treatment panoramic radiograph. Panoramic radiograph showed a complete dentition except for the absence of both maxillary third molars. The bone level and density were within normal limits and the maxillary sinuses were clear. Asymmetrical short condyles revealed some degree of remodeling and asymmetrical position.
Figure 4: Pre-treatment lateral cephalometric radiograph and analysis. Cephalometric analysis showed a Class III tendency (ANB= 0.9°), hyper-divergent profile (FMA= 29.1°, SN-MP= 44.4°), proclined maxillary and mandibular incisors (U1°-SN= 108.2°, IMPA= 110.9°, respectively) and a severe skeletal open bite.
Table 1: Cephalometric Analysis of Pre- and Post-treatment lateral chephalograms. Angular and linear measurements were completed between craniofacial skeletal and dental landmarks identified on pre- and post- treatment lateral cephalograms (° – degrees, mm – millimeters)
Figure 5: CTOR Intrusion-Plates (I-Plates) can be used at different stages of treatment. This CTOR Plate design is used for bilateral intrusion of posterior teeth in the upper arch. The I-Plate (A) can be easily shaped by hand or pliers to follow the patient’s palatal contour. This plate can be used in combination with buccal TADs, depending on the patient’s problem (B, intrusion forces shown as black arrows). Buttons on the lingual surface of the posterior teeth can be connected to the I-Plate using power thread or power chain (C). The design allows intrusion of several posterior teeth simultaneously. After intrusion this plate can be used for posterior anchorages during retraction of anterior teeth.
Figure 6: Post-treatment portrait and intra-oral photographs Post-treatment photographs revealed a well-balanced straight facial profile, improved smile esthetics and maxillary and mandibular lip positions. Intra-oral photographs showed maxillary arch expansion, space consolidation in the maxillary and mandibular dental arches, a Class I molar and canine occlusal relationship, correction of the anterior open bite and retroclination of incisors into an ideal overjet and overbite relation. Both maxillary and mandibular dental midlines are aligned with the facial midline. Gingival margins and heights of contour improved around the anterior teeth. The labial frenum attachment remodeled into its normal position without surgical intervention. Lingual fixed retainers are shown extending from first premolar to first premolar in both arches.
Figure 7: Post-treatment lateral cephalometric radiograph and analysis. Post-treatment cephalometric analysis showed overall improvement in maxillary and mandibular relationship (ANB= 2.3°), improved mandibular plane angle (FMA= 26.2°, SN-MP= 41.8°), correction of anterior open bite into ideal overjet, ideal overbite, improvement in the maxillary and mandibular incisor inclination (U1°-SN= 96.9°, IMPA= 80.2°, respectively) and enhanced soft tissue profile and lip position (Upper Lip to E-plane= 0.7 mm, Lower Lip to E-plane= 3,4 mm).
Figure 8: Superimposition of pre- and post- treatment cephalometric tracings. Cephalometric superimposition of pre-treatment (black tracing) and post-treatment (red tracing) on the anterior cranial-base demonstrated counter-clockwise rotation of the mandible by intrusion of the maxillary molars, Class I jaw relation, improvement of maxillary and mandibular incisor inclination, extrusion of the mandibular anterior teeth and flattening of the occlusal plane (A). Superimposition on the body of the maxilla showed molar intrusion and uprighting and incisor extrusion with retroclination (B). Superimposition on the inferior-alveolar nerve and inner profile of the mandibular symphysis revealed molar uprighting without extrusion and significant extrusion and retroinclination of the lower incisors (C).
Figure 9: Post-treatment digital casts. Post-treatment digital cast analysis showed increased maxillary arch dimensions (intermolar width increased by 1.3 mm, while inter-canine width increased by 2.2 mm), coincident dental midlines, Class I molar and canine occlusal relation, ideal overjet (1.8 mm) and overbite (0.8 mm).
Figure 10: Post-treatment panoramic radiograph. Panoramic radiograph at the end of treatment showed flatten condyles, good root parallelism and no root resorption or other pathological problems.