Total Arch Extrusion With Skeletal Anchorage To Improve Inadequate Maxillary Incisor Display in A Case of Vertical Maxillary Deficiency
Total Arch Extrusion With Skeletal Anchorage To Improve Inadequate Maxillary Incisor Display in A Case of Vertical Maxillary Deficiency
Total Arch Extrusion With Skeletal Anchorage To Improve Inadequate Maxillary Incisor Display in A Case of Vertical Maxillary Deficiency
ABSTRACT
and mandibular left third molars (Figure 3). The peri- while the mandibular incisors were upright (U1-SN:
odontal support appeared fine on the panoramic radio- 114.5°, L1-MP: 90.5°).
graph; no other pathological findings were noted. A Based on the findings, the patient was diagnosed
cephalometric radiograph revealed a skeletal Class I with a hypodivergent skeletal Class I relationship with
relationship (ANB: 2°) with a Class III tendency (A-Nv: a Class III tendency and vertical maxillary deficiency.
1.5 mm, Pg-Nv: 0 mm) and a hypodivergent craniofa- Additionally, the dental relationship was Class II with a
cial pattern (SN-MP: 17.0°) (Table 1). Vertical propor- deep overbite and large overjet. The main etiological
tions showed a reduced lower facial height (UFH: LFH ¼ factor for these conditions was determined to be
48.5%: 51.5%). The maxillary incisors were proclined, hereditary.
Figure 5. Two slanted buccal shelf miniscrews were installed for protraction of the mandibular molars.
along the guide bar, just below the circular loop. Addi- Subsequently, the bite raisers were removed, and short
tionally, a segment of NiTi open coil spring (light, Ormco interarch elastics were employed to settle the occlusion.
Corp., Orange, Calif), slightly longer than the distance Unfortunately, noticeable relapse was observed in maxil-
between the stopper and the vertical tube of the cross lary incisor display (Figure 7).
tube, was inserted around the guide bar. The treatment approach was based on the previous
To install the extrusion assembly, the guide bar was study on redirecting mandibular growth through the clock-
inserted into the vertical tube of the cross tube, with wise rotation of the maxillomandibular complex with ortho-
the circular loop hooked around the interdental minis- dontic dentoalveolar height development.7 In the 25th
crew. Flowable composite resin was applied to secure month, two anterior miniscrews were inserted again bilat-
the attachment, preventing irritation. An inward bend erally between the maxillary central and lateral incisors,
was made at the tail of the guide bar to control the while two posterior miniscrews were placed between the
desired amount of extrusion while also avoiding disar- maxillary second premolars and first molars (Figure 8).
ticulation of the extrusion assembly and irritation of the These miniscrews served as anchors for the extrusion
oral mucosa. The open coil spring could be reacti- assemblies, which were used for a period of five months
vated by adding flowable composite resin beneath the to extrude the entire maxillary dentition. The extrusion
crimpable stoppers. assemblies and miniscrews were removed in the 30th
The maxillary incisor display showed significant month of treatment. After a total of 32 months of active
improvement 2 months after the initiation of treat- treatment, all appliances were removed. Vacuum-formed
ment (Figure 7). The extrusion assembly was then clear retainers were delivered for full-time wear during the
discontinued, and the anterior miniscrews were removed. first 6 months, followed by nighttime use thereafter.
Figure 7. Maxillary incisor display at different stages: (A) Pretreatment, (B) 15th month, and (C) 25th month. Images demonstrate the
improvement achieved after using the anterior extrusion assembly for a period of 2 months. However, it also reveals the subsequent relapse
that occurred after discontinuing use of the extrusion assembly.
2. Maxillary first molars: The maxillary first molars 6. Mandibular plane rotation: Extrusion of the maxil-
exhibited distalization of 1.5 mm and extrusion of lary dentition rotated the mandible clockwise and
2.8 mm, which may have contributed to an increase increased the mandibular plane by 2.0° (SN-MP:
in the vertical dimension. 17.0° to 19.0°).
3. Mandibular incisors: Relative intrusion of the man-
dibular incisors was noted with proclination by
DISCUSSION
10.5° (IMPA: 90.0° to 100.5°) and 4.0 mm intrusion
at the incisal edge. Additionally, the mandibular Theoretically, vertical dimension has been considered
incisors moved forward by 4.3 mm. as being genetically determined and unchangeable due
4. Mandibular first molars: The mandibular first molars to the influence of muscular forces.8,9 Any increase in
experienced distalization of 1.8 mm and extrusion the vertical dimension can result in relapse over time. In
of 1.3 mm, contributing significantly to an increase cases where esthetic improvement is desired without
in the vertical dimension, specifically in the lower resorting to orthognathic surgery involving downward
anterior facial height by 3.0 mm. grafting of the maxilla, clinicians are now exploring the
5. Occlusal plane rotation: There was significant possibility of increasing the vertical dimension through
clockwise rotation of the occlusal plane by 7.5° orthodontic extrusion with the assistance of skeletal
(SN-OP: 8° to 15.5°). anchorage.
Figure 11. Posttreatment radiographs and lateral cephalogram. The Pretreatment cephalogram is traced as dotted lines.
Orthodontic extrusion of the maxillary incisors in such incisor display is to consider total arch extrusion of the
situations can be challenging, as the extruded maxillary maxillary arch, effectively increasing the vertical dimen-
incisors may interfere with the mandibular incisors, sion. It is worth noting that the stability of molar extrusion
impeding the desired extrusion.1–3,10 While improve- might be more reliable than incisor extrusion. Extruding
ments in maxillary incisor display can be achieved tem- the maxillary molars to a certain extent creates addi-
porarily, there is a tendency for relapse due to occlusal tional interarch spaces, allowing for extrusion of the
forces. One possible strategy for enhancing maxillary maxillary incisors.
In this case report, orthodontic extrusion was achieved provide interincisal clearance proves to be a more effi-
through an extrusion assembly anchored on interdental cient approach when feasible.
miniscrews. The guide bar of the extrusion assembly Another important consideration when using bite rais-
was custom-made by the clinician chairside. Extrusive ers is the influence of muscle force. Patients with a low
force was generated by de-activating a light open coil mandibular plane angle often exhibit greater muscular
spring segment of NiTi, around 100 gm. forces, leading to a common occurrence of posterior
To achieve effective extrusion of the maxillary inci- tooth intrusion when bonded with bite raisers, while the
sors, it was crucial to ensure the appropriate interin- rest of the dentition undergoes extrusion.11,12 To address
cisal clearance in overjet and overbite. To provide this, one potential approach would be to adjust the loca-
necessary interincisal clearance for the maxillary inci- tion of the bite raisers on the extruded molars in an alter-
sors to extrude, posterior bite raisers can be employed nating fashion to alleviate intrusion of those teeth.
to hinge the mandible backward. If there had been In cases where patients present with a low mandibular
contraindications for increasing facial height, intrusion angle and inadequate maxillary incisor display, injection
of the mandibular incisors could have been consid- of Botulinum toxin type A into the masseter muscle is
ered. However, the rate of intrusion is generally slower often considered.13 This can be a potential solution to
than that of extrusion. Therefore, using bite raisers to address challenges posed by strong occlusal forces and
Figure 15. Evaluation of the treatment effect and stability on maxillary incisor display after extrusion with TSADs at different stages. (A)
Pretreatment; (B) 2 months after maxillary anterior extrusion; (C) 9 months after maxillary anterior extrusion; (D) Posttreatment; (E) 2-year
follow-up. TSADs indicates temporary skeletal anchorage devices.
Figure 16. A flap was reflected to remove the broken tip of the miniscrew.
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