Advanced Research Journal of Medical and Clinical Sciences

Received 20 Apr 2021 | Revised 4 May 2021 | Accepted 11 May 2021 | Published Online 15 May 2021

DOI: https://doi.org/10.15520/arjmcs.v7i05.311
ARJMCS 07 (05), 542−550 (2021) ISSN (O) 2455-3549 IF:1.6

ARTICLE

“Changes in Nasolabial Angle, Lip Competency And Facial Profile By

Correcting Angulation Of Maxillary Central Incisors” – A Case Report
∗
Dr. Lishoy Rodrigues 1 Dr. Shilpa Chawla Jamenis 2 Dr. Bhushan Jawale 3 Dr.
Bhagyashree Jadhav 4 Dr. Vanessa Varghese 5 Dr. Tejas Kadam 6 Dr. Chirayu Jain 7
Dr. Almas Shaikh 8
1PG Student, Dept of Orthodontics Abstract
and Dentofacial Orthopedics, Sinhgad
Dental College and Hospital, Vadgaon
This case report evaluates the management of bimaxillary dentoalveolar
Bk, Pune, Maharashtra, India protrusion in a female patient with a Class I malocclusion with conven-
2Reader,Dept of Orthodontics and
tional fixed appliance mechanotherapy. The case required extraction
Dentofacial Orthopedics, Sinhgad of 1st premolars for correction of the proclined and forwardly placed
Dental College and Hospital, upper and lower anterior teeth. However we managed it without ex-
Vadgaon Bk, Pune, Maharashtra,
tractions by correcting just the angulation of the upper central incisors
India
which drastically bought about an improvement in the patients smile,
3Professor,Dept of Orthodontics and profile and aesthetics. Clinical and cephalometric evaluation revealed
Dentofacial Orthopedics, Sinhgad
Dental College and Hospital,
skeletal Class I malocclusion with a convex facial profile, an average
Vadgaon Bk, Pune, Maharashtra, to horizontal growth pattern, an Orthognathic divergent face, increased
India overjet and average overbite, severe jetting proclination in the maxillary
4AssistantProfessor, Dept of anterior region and mild crowding in the mandibular anterior region,
Orthodontics and Dentofacial potentially incompetent lips, increased lip fullness and lip strain and a
Orthopedics, Bharti Vidhyapeet
Dental College and Hospital, Navi decreased nasolabial angle. Following fixed orthodontic treatment by
Mumbai, Maharashtra, India changing the angulation of upper central incisors and with retraction
5PG Student, Dept of Orthodontics
of anterior segment, a marked improvement in patient’s smile, facial
and Dentofacial Orthopedics, VPDC profile and occlusion was achieved and there was a remarkable increase
Dental College and Hospital, Sangli, in the patient’s confidence and quality of life. The profile changes and
Maharashtra, India
treatment results were demonstrated with proper case selection and
6
PG Student, Dept of Oral and good patient cooperation with fixed appliance therapy.
Maxillofacial Surgery, Sinhgad
Keywords: Fixed Orthodontic Mechanotherapy, Bimaxillary den-
Dental College and Hospital,
Vadgaon Bk, Pune, Maharashtra, toalveolar protrusion, Fixed Appliance Therapy, Class I malocclusion,
India Proclined maxillary central incisors, Crowding, Spacing Mesoprosopic
7
PG Student, Dept of Public
facial form, Aesthetic Improvement, Non Extraction protocol, Unaes-
health Dentistry, Sinhgad Dental thetic smile
College and Hospital, Vadgaon
Bk, Pune, Maharashtra, India Copyright : © 2021 Innovative Journal
8
Assistant Professor, Dept of
Prosthodontics,Crown, bridge and
Implantology, Govt. Dental
College and Hospital, Mumbai,
Maharashtra, India
ARJMCS 07 (05), 542−550 INNOVATIVE JOURNAL 542
1 INTRODUCTION tion by fixed appliance therapy using conventional
MBT fixed appliance mechano-therapy. The Non-

F
ixed Appliance treatment can significantly al- extraction protocol shown in this case is indicative
ter and improve facial appearance in addition of how an unaesthetic non consonant smile can be
to correcting irregularity of the teeth. Facial converted into a more aesthetic and pleasing one by
Esthetics has been in increasing demand in today’s routine fixed Orthodontic treatment without the need
century. Nowadays, patients with the slightest mis- for extracting premolars.
alignment of teeth demand Orthodontic treatment
to get it corrected and improve their smile and fa-
cial profile. Fixed Appliance treatment can signif- 2 CASE REPORT
icantly alter and improve facial appearance in ad-
dition to correcting irregularity of the teeth[1] .The 2.1 EXTRA-ORAL EXAMINATION
number of patients seeking orthodontic treatment
has increased significantly[1,19,26] . In Today’s times, A 14 year old female patient presented with the
Fixed Appliance treatment can significantly alter chief complaint of forwardly placed upper front teeth
and improve facial appearance in addition to cor- and jetting out of upper front teeth. On Extra-oral
recting irregularity of the teeth. Class I malocclu- examination, the patient had an orthognathic facial
sion is the most prevalent followed by Class II profile, grossly symmetrical face on both sides, a
and Class III malocclusion.[2−3,14−15] Over the last Mesoprosopic facial form, Dolicocephalic head form
few decades, there has been an increase in the and average width of nose and mouth, potentially
awareness about orthodontic treatment which has incompetent lips with increased lip strain , an acute
led to more and more adolescents, especially girls Nasolabial Angle with increased upper and lower
demanding high quality treatment in the shortest labial fullness. The patient had no relevant prenatal,
possible time with increased efficiency and reduced natal, postnatal history, history of habits, medical or
costs.[4,16−18] There are many ways to treat Class a family history. On Smiling, there was presence of
I malocclusions, according to the characteristics as- spacing in the maxillary anterior region and a non-
sociated with the problem, such as antero-posterior consonant reverse smile arc. The patient had a toothy
discrepancy, age, and patient compliance.[5−6,20] The smile with minimal buccal corridor space on smiling.
indications for extractions in orthodontic practice The patient was very dissatisfied with her smile.
have historically been controversial.[7−9,21] . On the
other hand, correction of Class I malocclusions in 2.2 INTRA-ORAL EXAMINATION
growing patients, with subsequent dental camouflage
to mask the skeletal discrepancy, can involve ei- Intraoral examination on frontal view shows pres-
ther retraction by non-extraction means simply by ence of congruent upper and lower dental midlines
utilizing the available spaces or by extractions of and presence of spacing in the maxillary anterior
premolars.[10−11] Lack of crowding or cephalomet- region. On lateral view the patient shows the pres-
ric discrepancy in the mandibular arch is an indi- ence of a Class II Division 1 incisor relationship and
cation of 2 premolar extraction.[12−13,22−25] Fortu- a Class I canine and molar relationship bilaterally.
nately, in some instances satisfactory results with
an exceptional degree of correction can be achieved Supplementary information The online version of
without extraction of permanent premolars. This this article (https://doi.org/10.15520/arjmcs.v7i05.3
case presents the correction of a bi-maxillary dento- 11) contains supplementary material, which is avail-
alveolar protrusion with a Class I malocclusion in able to authorized users.
an adolescent female patient with proclined max- Corresponding Author: Dr. Lishoy Rodrigues
illary anterior teeth, merely simply by executing PG Student, Dept of Orthodontics and Dentofacial
a non-extraction protocol merely by torqueing the Orthopedics, Sinhgad Dental College and Hospital,
maxillary central incisors and decreasing its angula- Vadgaon Bk, Pune, Maharashtra, India

ARJMCS 07 (05), 542−550 INNOVATIVE JOURNAL 542

 DR. LISHOY RODRIGUES ET AL.
INNOVATIVE JOURNAL

FIGURE 1: PRE TREATMENT EXTRA-ORAL FIGURE 2: PRE TREATMENTINTRA-ORAL

PHOTOGRAPHS PHOTOGRAPHS

There is mild crowding in the lower anterior region

with proclined and forwardly placed upper anterior
teeth. On occlusal view the patient shows presence of
retained deciduous right 2nd molar. The upper arch
shows the presence of a “V” shaped arch form and
lower arch shows the presence of a “U” shaped arch
form.

2.3 RADIOGRAPHIC EVALUATION

FIGURE 3: PRE TREATMENT RADIOGRAPHS
Lateral cephalogram showed presence of severely
proclined maxillary anterior dentition with an aver-
age to slightly horizontal growth pattern. OPG shows 3 DIAGNOSIS
presence of tooth buds of mandibular 3rd molars
bilaterally and absence of both tooth buds in the
This 14 year old female patient was diagnosed with
maxilla, adequate height of interdental alveolar bone
a II malocclusion on a Class I Skeletal base with
and well positioned condyles without presence of
any anomaly. OPG also shows presence of a spaced an average to horizontal growth pattern, proclined
maxillary dentition and absence of root parallelism. upper incisors with increased overjet, spacing in the
There is presence of over-retained deciduous maxil- upper anterior region and mild crowding in lower
lary right 2nd molar and impacted 15 due to obstruc- anterior region with over-retained deciduous max-
tion created by the deciduous over-retained molar. illary right 2nd molar, potentially incompetant lips
Ramal width is broad and the mandibular plane is with increased lip fullness and a reduced nasolabial
flat without presence of an antegonial notch. angle with increased lip strain.

INNOVATIVE JOURNAL ARJMCS 07 (05), 542−550 (2021) 543

“CHANGES IN NASOLABIAL ANGLE, LIP COMPETENCY AND FACIAL PROFILE BY
CORRECTING ANGULATION OF MAXILLARY CENTRAL INCISORS” – A CASE REPORT
TABLE 1: PRE TREATMENTCEPHALOMETRIC 3. To correct spacing in maxillary and crowding in
READINGS mandibular anterior teeth
PARAMETERS PRE- TREATMENT
4. To correct the decreased Nasolabial angle
SNA 84◦
SNB 82◦ 5. To correct the potentially incompetent lips
ANB 2◦
WITS 0mm 6. To decrease the lip strain
MAX. LENGTH 98mm
7. To correct the reverse smile arc
MAN. LENGTH 108mm
IMPA 94◦ 8. To achieve a Class I molar relationship
NASOLABIAL ANGLE 86◦
U1 TO NA DEGREES 46◦ 9. To maintain Class I canine and molar relation-
U1 TO NA mm 9mm ship
◦
L1 TO NB DEGREES 28
10. To achieve a pleasing smile and a pleasing
L1 TO NB mm 4mm
profile
U1/L1 ANGLE 114◦
FMA 24◦
Y AXIS 65◦ 3.3 TREATMENT PLAN
L1 TO A-POG 3mm
• Non-extraction protocol with banding, bonding
CONVEXITY AT PT. A 2mm
and fabrication of trans-palatal arch in the max-
LOWER LIP- E PLANE 2mm
illa
N-PERP TO PT A 2mm
N-PERP TO POG 0mm • Extraction of over-retained maxillary right de-
CHIN THICKNESS 12mm ciduous 2nd molar

• Fixed appliance therapy with MBT 0.022 inch

3.1 LIST OF PROBLEMS bracket slot
1. Proclined maxillary anterior dentition • Initial leveling and alignment with 0.012”,
0.014”, 0.016”, 0.018”, 0.020” Niti archwires
2. Increased overjet
following sequence A of MBT
3. Spacing in maxillary anterior region
• Torquing of maxillary incisors and correction of
4. Mild crowding in mandibular anterior region its angulation

5. Decreased Nasolabial angle • Piggy back NiTi for getting impacted 15 into
occlusion
6. Potentially Incompetant lips
• Retraction and closure of spaces by use of
7. Increased lip strain 0.019” x 0.025” rectangular NiTi followed
by 0.019” x 0.025” rectangular stainless steel
8. Reverse smile arc wires.

3.2 TREATMENT OBJECTIVES • Conservation of anchorage in the upper and

lower arch to maintain a Class I canine and
1. To correct proclined maxillary anterior denti- molar relationship
tion
• Final finishing and detailing with 0.014” round
2. To correct the increased overjet stainless steel wires

ARJMCS 07 (05), 542−550 (2021) INNOVATIVE JOURNAL 544

 DR. LISHOY RODRIGUES ET AL.
INNOVATIVE JOURNAL
• Retention by means of Hawley’s retainers along TABLE 2: MID TREATMENT CEPHALOMETRIC
with lingual bonded retainers in the upper and READINGS
lower arch.
PARAMETERS MID- TREATMENT
SNA 83◦
SNB 82◦
4 TREATMENT PROGRESS ANB 1◦
WITS 0mm
Complete bonding & banding in both maxillary MAX. LENGTH 97mm
and mandibular arch was done, using MBT- MAN. LENGTH 108mm
0.022X0.028”slot and over-retained maxillary right IMPA 93◦
deciduous 2nd molar was extracted. Initially a 0.012” NASOLABIAL ANGLE 99◦
NiTi wire was used which was followed by 0.014 U1 TO NA DEGREES 30◦
, 0.016”, 0.018”, 0.020” Niti archwires following U1 TO NA mm 4mm
sequence A of MBT. After 6 months of alignment L1 TO NB DEGREES 27◦
and leveling NiTi round wires were discontinued. L1 TO NB mm 3mm
Torquing of maxillary central incisors was done with U1/L1 ANGLE 128◦
the help of Beggs’s torquing auxillary. Retraction FMA 25◦
and closure of existing spaces was then started by Y AXIS 67◦
use of 0.019” x 0.025” rectangular NiTi followed L1 TO A-POG 2mm
by 0.019” x 0.025” rectangular stainless steel wires. CONVEXITY AT PT. A 1mm
A segmental Piggy back NiTi was run in the upper LOWER LIP- E PLANE 2mm
arch for getting impacted 15 into occlusion. Reverse N-PERP TO PT A 1mm
curve of spee in the lower arch and exaggerated N-PERP TO POG 0mm
curve of spee in the upper arch was incorporated in CHIN THICKNESS 12mm
the heavy archwires to prevent the excessive bite
deepening during retraction process. Anchorage was
conserved in the upper and lower arch by using light
retraction forces, thus constantly monitoring molar
and canine relationship. Anchorage was needed
in the upper and lower arch to maintain a Class
I canine and molar relationship. Retraction and
closure of existing spaces was done with the help
of Elastomeric chains delivering light continuous
forces and replaced after every 4 weeks due to
force decay and reduction in its activity. Finally
light settling elastics were given with rectangular
steel wires in lower arch and 0.012” light NiTi
wire in upper arch for settling , finishing, detailing
and proper intercuspation. The upper proclination
was corrected with an ideal occlusion at the end of
the fixed appliance therapy. The Nasolabial angle
improved significantly at the end of treatment and
the reverse smile arc was corrected, thus improving
the profile even further. There was improvement in FIGURE 4: MID TREATMENT EXTRA-ORAL
occlusion, lip competency and profile at the end of PHOTOGRAPHS
the treatment.

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“CHANGES IN NASOLABIAL ANGLE, LIP COMPETENCY AND FACIAL PROFILE BY
CORRECTING ANGULATION OF MAXILLARY CENTRAL INCISORS” – A CASE REPORT
fact that the adults seeks treatment more often for
esthetic reasons and hence is likely to have unreason-
able expectations about the outcome of the treatment,
is less adaptable to the appliance and is uncom-
promising in his appraisal of the treatment results.
Treatment of bi-maxillary dento-alveolar protrusion
without extraction of premolars in an adolescent
patient is challenging. A well-chosen individualized
treatment plan, undertaken with sound biomechani-
cal principles and appropriate control of orthodontic
mechanics to execute the plan is the surest way to
achieve predictable results with minimal side effects.
Class I malocclusion might have any number of a
combination of the skeletal and dental components.
Hence, identifying and understanding the etiology
and expression of Class I malocclusion and identify-
ing differential diagnosis is helpful for its correction.
The patient’s chief complaint was forwardly placed
upper front teeth and jetting out of upper front teeth
FIGURE 5: MID TREATMENT INTRA-ORAL
and seeked treatment for the same. The selection
PHOTOGRAPHS
of orthodontic fixed appliances is dependent upon
several factors which can be categorized into patient
factors, such as age and compliance, and clinical
factors, such as preference/familiarity and laboratory
facilities. The most important point to be highlighted
here is the decision to not extract the premolars.
After analyzing the case thoroughly and reading all
pretreatment cephalometric parameters along with
evaluating the patients profile clinically, a decision
was made of proceeding with the treatment without
extracting premolars as the patient presented with se-
vere maxillary anterior proclination but with proper
FIGURE 6: MID TREATMENT RADIOGRAPHS buccal root torquing of maxillary central incisors
and by appropriate application of begg’s biomechan-
5 DISCUSSION ics, the case could be managed without extractions.
Begg’s torqueing auxillary was used for the purpose
A well-chosen individualized treatment plan, un- of root uprighting of maxillary central incisors. This
dertaken with sound biomechanical principles and drastically reduced the angulation of the incisors and
appropriate control of orthodontic mechanics to exe- thus created more space for enabling retraction of the
cute the plan is the surest way to achieve predictable maxillary anterior dentition. The treatment after clo-
results with minimal side effects. In adolescents, sure of anterior spaces improved the patients profile
tooth movement is affected by growth while in adults changing the Nasolabial angle from acute to average
we deal strictly with tooth movement alone. In ad- at the end of the treatment. There was a significant
dition, orthodontic treatment in the adults is often decrease in the lip strain and lip fullness with in-
based on symptoms detected by the patient while in creased competency of lips. Successful results were
children; it is based more often on signs detected by obtained after the fixed appliance therapy within a
practitioners or parents. Of equal significance is the stipulated period of time. The overall treatment time

ARJMCS 07 (05), 542−550 (2021) INNOVATIVE JOURNAL 546

 DR. LISHOY RODRIGUES ET AL.
INNOVATIVE JOURNAL
was 16 months. After this active treatment phase, the
profile of this 14 year old female patient improved
significantly as seen in the post treatment Extra oral
photographs. Hawley’s retainers were then delivered
to the patient along with fixed lingual bonded retain-
ers in upper and lower arch. Patient was very happy
and satisfied with the results of the treatment

TABLE 3: POST-TREATMENT CEPHALOMETRIC

READINGS
PARAMETERS POST - TREATMENT
SNA 83◦
SNB 82◦
ANB 1◦
WITS 0mm
MAX. LENGTH 98mm
MAN. LENGTH 107mm
IMPA 93◦
NASOLABIAL ANGLE 107◦
U1 TO NA DEGREES 26◦ FIGURE 7: POST TREATMENT EXTRA-ORAL
U1 TO NA mm 3mm PHOTOGRAPHS
L1 TO NB DEGREES 26◦
L1 TO NB mm 2mm
U1/L1 ANGLE 133◦
FMA 25◦
Y AXIS 66◦
L1 TO A-POG 2mm
CONVEXITY AT PT. A 0mm
LOWER LIP- E PLANE 1mm
N-PERP TO PT A 1mm
N-PERP TO POG 0mm
CHIN THICKNESS 12mm

6 CONCLUSION
This case report shows how a borderline extraction
case can be managed with a Non Extraction Pro-
tocol by means of properly conserving Anchorage.
The planned goals set in the pretreatment plan were
successfully attained. Good intercuspation of the
teeth was maintained with class I incisor and Class
I canine and molar relationship bilaterally. Treatment FIGURE 8: POST TREATMENT INTRA-ORAL
of bimaxillary protrusion and localized spacing in- PHOTOGRAPHS
cluded the retraction and retroclination of maxillary
and mandibular incisors with a resultant decrease

INNOVATIVE JOURNAL ARJMCS 07 (05), 542−550 (2021) 547

“CHANGES IN NASOLABIAL ANGLE, LIP COMPETENCY AND FACIAL PROFILE BY
CORRECTING ANGULATION OF MAXILLARY CENTRAL INCISORS” – A CASE REPORT

TABLE 4: COMPARISON OF PRE, MID AND POST

TREATMENT CEPHALOMETRIC READINGS
PARAME- PRE- MID- POST-
TERS TREAT- TREATMENTTREATMENT
MENT
SNA 84◦ 83◦ 83◦
SNB 82◦ 82◦ 82◦
ANB 2◦ 1◦ 1◦ FIGURE 9: POST TREATMENT RADIOGRAPHS
WITS 0mm 0mm 0mm
MAX. 98mm 97mm 98mm
LENGTH
MAN. 108mm 108mm 107mm
LENGTH
IMPA 94◦ 93◦ 93◦
NA- 86◦ 99◦ 107◦
SOLABIAL
ANGLE
U1 TO NA 46◦ 30◦ 26◦
DEGREES
U1 TO NA 9mm 4mm 3mm
mm
L1 TO NB 28◦ 27◦ 26◦
DEGREES FIGURE 10: COMPARISON OF PRE AND POST
L1 TO NB 4mm 3mm 2mm TREATMENT PROFILES
mm
U1/L1 114◦ 128◦ 133◦
ANGLE in soft tissue lip procumbency and lip fullness. The
FMA 24◦ 25◦ 25◦ maxillary and mandibular teeth were found to be
Y AXIS 65◦ 67◦ 66◦ esthetically satisfactory in the line of occlusion. An
L1 TO 3mm 2mm 2mm ideal overjet was achieved and a normal overbite
A-POG was maintained. Patient had improved smile and
CONVEXITY 2mm 1mm 0mm Profile without the need for extractions. The cor-
AT PT. A rection of the malocclusion was achieved, with a
LOWER LIP- 2mm 2mm 1mm significant improvement in the patient aesthetics and
E PLANE self-esteem. The patient was very satisfied with the
N-PERP TO 2mm 1mm 1mm result of the treatment.
PT A
N-PERP TO 0mm 0mm 0mm
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