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Teresa Pinho
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Introduction: Asymmetry and deep bite malocclusions provide management difficulties for clinicians and the combination invites
special concern.
Aim: The purpose of the present paper is to describe a clinical case presenting with an asymmetric deep bite, a canted occlusal
plane, a Class II canine relationship on the right side and a Class III canine relationship on the left side, with deviations of
both dental midlines to the right. A lower right premolar impaction contributed to the asymmetry and a left first maxillary molar
extraction was required for endodontic reasons.
Methods: A straight-wire technique was used for eighteen months to achieve second molar mesialisation, as well as dental
levelling and alignment. To unravel the mandibular arch, resolve the deep bite and manage the canted the lower occlusal plane,
two bite turbos were attached to the palatal surface of the maxillary central incisors. In addition, a sectional Multiloop Edgewise
Arch-Wire (MEAW) was placed on the left side and maintained for nine months. Different lower MEAW activation (lateral left
lower extrusion) and tip-back control on the posterior teeth were essential mechanics to increase vertical dimension on the lower
left side and allow for Class III dental correction. Short Class II vertical elastics on the right side and Class III elastics on the left
side were applied.
Conclusion: The asymmetric mechanics allowed the case to be treated to a stable sagittal and vertical occlusal result.
(Aust Orthod J 2013; 29: 115-122)
Introduction
An asymmetric malocclusion may be corrected using
a variety of treatment mechanics directed at the
aetiological factor(s) which produce the asymmetric
characteristics of the malocclusion.1-8 The correction
of an anterior deep bite can be achieved by incisor
intrusion, incisor proclination or molar extrusion.9
However, orthodontic treatment and orthognathic
surgery may be required when the dental discrepancy
is unable to be corrected by orthodontic mechanics
alone, or when facial aesthetics might be unduly
compromised.7
To maximise the potential for smile improvement,
maxillary anterior teeth must be moved vertically to
enhance aesthetics.10 A previous report has speculated
Australian Society of Orthodontists Inc. 2013
115
PINHO
Case report
A 13-year-old female patient presented with a chief
complaint of malaligned teeth associated with an
anterior asymmetric deep bite. Extra-oral photos
revealed a symmetrical face and a low smile line
(exposing less than 75% of the anterior maxillary
teeth) (Figure 1). Intra-orally, a Class II and Class
III dental relationship was evident on the right and
left side, respectively. The occlusal plane was canted
upward on the right side. Both dental midlines were
displaced to the right with the mandibular midline
displaced 3 mm more than the maxillary midline. Mild
crowding was present in the maxillary arch which had
suffered a recent upper left molar extraction. There
was moderate crowding in the mandibular arch which
contained an impacted right second premolar. Lingual
tipping of the upper anterior teeth and a deep bite
(overbite of about 7 mm on the left side) was evident.
116
Treatment plan
An initial stage of treatment aimed at levelling and
alignment of the upper arch with a straight wire
appliance, the intrusion of the upper left incisors and
the movement of the upper second molar into the first
molar extraction space. Secondly, in order to relieve
the mandibular crowding, resolve the asymmetric
deep bite and manage the canted occlusal plane, two
bite turbos were to be attached to the palatal face of
the maxillary central incisors. A sectional Multiloop
Edgewise Arch-Wire (MEAW) was planned for the
left side.
Treatment
A fixed appliance with an 0.022 inch bracket slot was
placed on the maxillary and mandibular arches. Due
to the crowding, lingual tipping and the asymmetric
vertical position of the maxillary incisors, the dental
levelling and alignment were achieved with a sequence
of 0.014 inch and 0.018 inch nickel titanium arch
wires. These were followed by rectangular nickel
titanium arch wires (0.016 x 0.022 inch and 0.019 x
0.025 inch), leading to 0.019 x 0.025 inch and 0.020
x 0.025 inch stainless steel arch wires to control the
second molar in its mesial movement (Figure 4).
Treatment results
The extra-oral photographs showed a symmetric and
balanced relationship of the facial soft tissues, an
improved profile and a pleasant smile. A significant
improvement in the occlusion was achieved,
highlighted by a molar and canine Class I relationship.
The upper midline was co-incident with the facial
midline, and overjet and overbite were normal. The
aims of increasing the vertical dimension as well as
relieving the deep overbite were achieved. The goal of
levelling and proclining the maxillary and mandibular
incisors was also achieved. The post-treatment
panoramic radiograph (Figure 9) confirmed that there
was good root positioning following the mesial bodily
movement of the maxillary second molar.
A cephalometric analysis (Figure 10) identified that
ANB decreased from 5 to 2.2 whilst maintaining the
underlying skeletal Class I relationship. SNA decreased
from 84.6 to 82.1 due to the root torque applied
to the upper incisors, but SNB remained the same.
Australian Orthodontic Journal Volume 29 No. 1 May 2013
117
PINHO
Figure 4. Intra-oral photos at the end of the crown alignment and the root levelling with second molar mesialised in the first molar position.
Figure 5. Two bite turbos placed in palatal face of both central incisors; nitinol open coil spring, in third and fourth quadrant.
Figure 6. End of the crown alignment and the root levelling with space recuperation on the fourth quadrant for second premolar eruption; Class II elastics
on the right side and Class III on the left side.
Figure 7. Sectional Multiloop Edgewise Archwire technic on the lower left side; Short Class II vertical elastics on the right side and Class III on the
left side.
118
Discussion
No discernable mandibular lateral deviation was
identified in the presented case, but there was
dentoalveolar distortion indicated by non-coincidence and displacement of the dental midlines and
an asymmetric deep bite. The asymmetry of the upper
Australian Orthodontic Journal Volume 29 No. 1 May 2013
119
PINHO
Figure 11. Cephalometric superposition pre- (grey line) and post- (black line) treatment (Bjork method); general,
maxillary, mandibular and perfil superimpositions.
Figure 12. Intra-oral photos one year after the orthodontic treatment.
Figure 13. Smile before and one year after orthodontic treatment.
Table I. Cephalometric analysis before and after treatment.
Cephalometric
analysis
Normal
Before treatment
After treatment
FMIA (degrees)
67 3
75.8
69.1
FMA (degrees)
25 3
23.8
21.9
IMPA (degrees)
88 3
80.4
89.0
SNA (degrees)
82 2
84.6
82.1
SNB (degrees)
80 2
79.6
79.9
ANB (degrees)
1 5
5.0
2.2
22
1.4
22 2
10.0
30.0
10.4
7.3
77.0
80.6
Ao Bo (mm)
UI/NA (degrees)
Occlusal plane (degrees)
Angle Z (degrees)
8 12
75 5
Overjet (mm)
2.5 2.5
5.4
3.7
Overbite (mm)
2.5 2.5
7.3
2.7
155.4
129.6
126 10
121
PINHO
Conclusion
This clinical case shows that, in a young patient,
orthodontic correction of an asymmetric deep
bite, the restoration of a canted occlusal plane to a
stable dental articulation with optimal aesthetic and
functional results, can be achieved.
Corresponding author
Dr Teresa Pinho
Centro de Investigao Cincias da Sade (CICS),
Instituto Superior de Cincias da Sade-Norte/CESPU
Rua Central de Gandra, 1317
4585-116 Gandra,PRD
Portugal
Email: teresa.pinho@iscsn.cespu.pt
122
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