Camoufl age orthodontic treatment in skeletal class III malocclusion with passive self-ligating system

  Vol. 64, No. 1, Januari-April 2015 | Hal. 1-6 | ISSN 0024-9548

Camoufl age orthodontic treatment in skeletal class

  

III malocclusion with passive self-ligating system

Diah Adisty and Krisnawa Ɵ

  Department of Orthodon cs Faculty of Den stry, Universitas Indonesia Jakarta - Indonesia Correspondence

  : Diah Adisty, c/o: Departemen Ortodonsia, Fakultas Kedokteran Gigi Universitas Indonesia. Jl. Salemba Raya 4 Jakarta 10430, Indonesia. E-mail: drg_adisty@yahoo.com ABSTRACT

Background: Skeletal Class III malocclusion treatment is a di ffi cult case because jaw discrepancies are severe sometimes. However,

ft where the incisor teeth position can reach in the case of skeletal Class III malocclusion small to moderate level with functional shi tt er. In this case report, treatment of skeletal Class III edge to edge relationship in centric relation, then the prognosis will be be ft s can be done with orthodontic camoufl age, which is intended to fi xed malocclusion, eliminating malocclusion with functional shi

  Purpose: To perform factors that cause/interfere and create a good interdigitation when the mandible is in centric relation.

  Case: camoufl age orthodontic treatment in skeletal class III malocclusion in order to create a relationship of good dental occlusion.

  

Female patients, aged 17 years and 9 months old, came to the orthodontic clinic at RSGMP FKGUI with chief complaints of her

upper front teeth position more to the back of the lower front teeth. Clinical examination came with a result of negative overjet,

severe crowding in the upper jaw, asymmetry, concave profi le, deviation when jaw closed, and centric occlusion is not the same

  Case management: Treatment of skeletal Class III malocclusion is done with camoufl age treatment using with centric relation.

the self-ligating system through the anterior teeth of the upper jaw protraction. The selection of self-ligating system was based

on the various advantages, which include low friction between the bracket with archwire, an additional signifi cant and stable

  ff ect. During 15 months of treatment, the result of width in intermolar and interpremolar, and the presence of a lip bumper e

overjet becomes positive, teeth are at the arched, asymmetry was corrected, fl at profi le, and there is no deviation when jaw closed.

  

Conclusion: In the case of mild and moderate class III malocclusion, orthodontic camoufl age is o ft en selected, with or without

extraction (proclination of upper incisor and retroclination of lower incisor were recured). That condition may cause an unstable

ff ects of upper treatment results. Therefore, the use of self-ligating brackets will become an appropriate option to reduce fl aring e incisor teeth by the lateral expansion of the posterior region.

  Keywords: Camoufl age treatment; skeletal class III malocclusion; passive self ligating ABSTRAK

Latar belakang: Maloklusi kelas III skeletal merupakan suatu kasus maloklusi yang perawatannya sulit dilakukan karena seringkali

diskrepansi rahang yang terjadi sangat parah. Akan tetapi pada kasus maloklusi kelas III skeletal ringan sampai sedang dengan

ft dimana posisi gigi insisif dapat mencapai hubungan edge to edge pada relasi sentrik, maka prognosisnya adanya functional shi ft dapat menjadi lebih baik. Pada laporan kasus ini, perawatan kasus maloklusi kelas III skeletal yang disertai adanya functional shi

dilakukan secara ortodonti kamufl ase, yang ditujukan untuk memperbaiki maloklusi, mengeliminasi faktor penyebab/interfensi dan

  Tujuan: Untuk melakukan perawatan ortodonti menciptakan interdigitasi yang baik saat mandibula berada pada relasi sentrik.

  Kasus: Pasien perempuan, usia kamufl ase pada maloklusi skeletal kelas III agar tercipta suatu hubungan oklusi gigi yang baik.

  

17 tahun 9 bulan, datang ke klinik ortodonti RSGMP FKGUI dengan keluhan posisi gigi depan atas lebih ke belakang dari gigi

  Adisty and Krisnawa Ɵ : Camoufl age orthodon c treatment in skeletal class III malocclusion

  Jurnal PDGI 64 (1) Hal. 1-6 © 2015

  

III skeletal ini dilakukan dengan perawatan kamufl ase menggunakan sistem self-ligating melalui protraksi gigi-gigi anterior

rahang atas. Pemilihan sistem self-ligating dilakukan berdasarkan pertimbangan berbagai kelebihan pada sistem ini, antara lain

friksi yang rendah antara braket dengan archwire, adanya penambahan lebar interpremolar dan intermolar yang signifi kan serta

stabil, dan adanya lip bumper e ff ect. Dalam 15 bulan perawatan overjet menjadi positif, gigi-gigi berada pada lengkungnya,

asimetri terkoreksi, profi l datar, dan tidak terdapat deviasi saat penutupan rahang. Simpulan: Pada kasus maloklusi skeletal

kelas III ringan dan sedang, perawatan ortodonti kamufl ase dapat dilakukan, dengan atau tanpa ekstraksi (proklinasi dari gigi

insisif atas dan retroklinasi dari gigi insisif bawah). Kondisi ini dapat menyebabkan hasil perawatan yang tidak stabil. Oleh karena

itu, penggunaan braket self ligating akan menjadi pilihan yang tepat untuk mengurangi efek proklinasi gigi insisif atas dengan

ekspansi lateral regio posterior.

  Kata kunci: Perawatan kamufl ase; maloklusi kelas III skeletal; passive self ligating (Damon Q)

  INTRODUCTION

  contacts between the upper and lower incisor teeth, and the profi le and occlusion improvements will be Dental aspect of Class III malocclusion is achieved. characterized by the mesiobuccal cusp of the upper fi rst molar occludes with the mesiobuccal groove

  1

  of the lower fi rst molar. From skeletal aspect, class

  CASE

  III malocclusion o ft en due to abnormal growth of Female patient, student of Faculty of Medicine, the mandible (excessive bone growth), less optimal

  University of Indonesia, aged 17 years 9 months, maxillary bone growth, or a combination of both. came to the clinic RSGMP FKGUI with chief

  Class III malocclusion prevalence varies depending complaints of upper front teeth are located backward on the type of race. Mongoloid race has the greatest

  1 from the lower front teeth (Figure 1).

  prevalence in the amount of 12%.

  Extra-oral clinical examination showed that Skeletal Class III malocclusion is a case in which patient had mesofacial face, asymmetric and concave

  ffi cult because the treatment of malocclusion is di ft tissue profi le. Intra-oral clinical examination so jaw discrepancies are o ft en severe. There is bett er showed that oral hygiene and gingiva was moderate, prognosis in mild to moderate cases of skeletal there was no tooth mobility, palate and tongue was Class III malocclusion with the functional shift moderate (Figure 1). position where the incisor teeth can reach edge to edge relationship. Treatment of skeletal Class III malocclusion cases in the presence of functional shi ft s can be performed by orthodontic camoufl age, which is intended to correct malocclusion, eliminating the interference factors and creating a good interdigitation when the mandible is in centric relation.

  Self-ligating system in orthodontic treatment uses a bracket fi xed to the ligation mechanism in it, so it can be opened and closed to lock the wire in the slot without the need for wires or elastomeric ligation. This system is also provide include a low friction between the bracket to the archwire, intermolar and interpremolar additional width that more signifi cant and stable, and the presence of a

  lip bumper e This case report will discuss the treatment of

  3 ff ect.

  Class III malocclusions in the presence of functional shi ft s in female patients aged 17 years and 9 months

  Adisty and Krisnawa Ɵ : Camoufl age orthodon c treatment in skeletal class III malocclusion

  ⁰ ± 7⁰ ¹²⁸ ⁰ SN-MP ³² ⁰ ± 3⁰ ³¹ ⁰ Parameter dental Interincisal angle 130 ⁰ ± 2⁰ ¹³⁴ ⁰ UI-SN ¹⁰⁴ ⁰ ± 6⁰ ¹⁰⁸ ⁰ UI-NA 4 mm ± 2 5 mm

  Lundstrum analysis indicated a lack of space in the upper jaw of 10 mm and the lower jaw of 2.5 mm. Meanwhile, Bolton’s analysis showed that the ratio of anterior teeth with the mesiodistal width of the mandibular was excess of 3.11 mm compared to the upper jaw.

  Panoramic radiograph showed that 18 and 28 tooth germs both in vertical position, 38 and 48 are in a mesioangular position. There is a supernumerary teeth in mandibular left posterior. Alveolar bone height is normal, as well as the absence of abnormalities in the maxillary sinus, but less roots parallel alignment (Figure 3).

  Figure 3. Panoramic radiograph.

  0 mm ± 2 0 mm

  Parameter so Ō Ɵ ssue Upper lip-E line 1 mm ± 2 -6 mm Lower lip-E line

  4 mm ± 2 7 mm

  UI-Apg 4 mm ± 2 4 mm LI-Apg 2 mm ± 2 8 mm LI-MP ⁹⁰ ⁰ ± 4⁰ ⁸⁴ ⁰ LI-NB

  Parameter skeletal (ver Ɵ cal) Y-axis ⁶⁰ ⁰ ± 6⁰ ⁶⁴ ⁰ Go angle 123

  Jurnal PDGI 64 (1) Hal. 1-6 © 2015

  4 mm 0 mm

  SNA ⁸² ⁰ ± 2⁰ ⁸⁴ ⁰ SNB ⁸⁰ ⁰ ± 2⁰ ⁸⁶ ⁰ ANB ² ⁰ ± 2⁰

• ^-2 ⁰ The Wits ± 1 mm -10 mm Facial Angle
⁸⁷ ⁰ ± 3⁰ ⁹⁰ ⁰ Angle of Convexity ⁰ ± 6⁰ ^-4 ⁰ Pg-NB

  Table 1. Cephalometric analysis Mean Pa Ɵ ent Parameter skeletal (horizontal)

  III jaw relationship with the normal maxillary and mandibular prognatic, concave skeletal profile, normal mandibular growth direction, normal vertical growth of the middle and lower face, upper incisor inclination towards the lower incisor was retrusive, upper incisor inclination to the cranial base was protrusive , the lower incisor inclination of the mandibular plane was retrusive, upper lip was retrusive with normal lower lip (Figure 2 and Table 1).

  From the results of cephalometric analysis (Table 1), it can be concluded that there were class

  On functional examination, there were no abnormalities of the temporomandibular joint. There was a deviation to the le ft in the opening and closing of the mandible. There was a vertical interference in the anterior region (11, 21 to 41, 31). There was also normal pa tt ern of swallowing and speech. Patients did not have bad habits. On examination showed that Centre Occlusion was not the same as the Centre Relation.

  Right fi rst molar relationship were Class III. Both canine relationships are class III. Overjet was -3 mm, whereas overbite was 4 mm. There were deep compensation curve in the upper jaw and lower jaw, normal curve of Spee, normal midline upper teeth and lower teeth shi ft to the left 2 mm. The shape of the upper and lower dental arches were oval (Figure 1).

  All the permanent teeth have erupted perfectly, except the unerupted third molars. Le ft fi rst molar have missing and replaced with supernumerary teeth. There was no persistency of decidious teeth.

  Figure 2. Cephalometric photo.

  Adisty and Krisnawa Ɵ : Camoufl age orthodon c treatment in skeletal class III malocclusion

  Jurnal PDGI 64 (1) Hal. 1-6 © 2015 Kesling analysis was calculated by maintaining Scaling was started before bonding bracket.

  tt ached to the upper jaw fi rst. Bonding the position of the lower dental arch, to advance Bracket a 4 mm maxillary forwarding, 2 mm shi ft ing lower bracket on the lower jaw is planned to be carried dentition midline to the right. The needs of the space out if the relationship is already jumping the bite. In in the upper jaw was 0 mm and the lower jaw was this case also planned the use of early elastic since

• 2 mm (right -1,5 mm, le ft -0.5 mm). the early stages of treatment. Finishing is done to

  Skeletal factors that play a role in this case is in obtain a good interdigitation. Then the retention the direction of anteroposterior jaw relationship phase is done by essix retainer on the upper and which is class III malocclusion with mandibular lower jaw. prognati, and in the transverse directions are After 15 months of treatment is 7 times the crossbite posterior. Dental factors is the discrepancy control visit, the outcome is negative overjet of dental arch and teeth, thus causing crowding correction (anterior crossbite) from -3 mm to +2 in the maxilla and mandible. There is a vertical mm, deep overbite of +4 mm to +2 mm, severe interference in the anterior region, causing mandible crowding correction in the upper jaw and light on ft correction, canine and molar located more anteriorly in centric occlusion. mandible, midline shi Female patient, student of Faculty of Medicine, relationship from class III into class I (Figure 4). University of Indonesia, aged 17 years 9 months, with mesofacial face type, asymmetric and concave ft tissue profi le. Class III jaw relationship with so normal maxillary and mandibular prognati, concave skeletal profi le, normal mandibular growth direction, normal vertical growth of the middle and lower face, upper incisor inclination towards tt om is retrusive, upper incisor inclination the bo towards cranial base is normal, the lower incisor inclination of the mandibular plane is retrusive , upper lip retrusive and lower lip normal .Right fi rst molar relationship is Class III. Canine relationships are class III. Overjet of -3 mm, whereas overbite of 4 mm. Deep compensation curve in the upper jaw. The lower dentition midline shi ft to the left 2 mm. The need for space in the upper jaw and the lower jaw of 0 mm at -2 mm (right -1.5 mm, -0.5 mm le ft ).

  Figure 4. Photo of extraoral and intraoral patients after 15 months of treatment.

  On functional examination showed that CO and CR in these patients is not the same. CR examination showed the upper and lower incisor relationship edge to edge with overjet of 0 mm, so the camoufl age procedure will be chosen for treatment. Taking into account the advantages contained in the self- ligating bracket, it was decided to use a passive self ligating system (Damon Q). Standard torque bracket prescription is used both in the maxilla and mandible. Camoufl age procedures performed by protraction and intrusion of the maxillary anterior region by considering the inclination of the maxillary incisor.

  Cephalometric and panoramic photos of pa ents a er Figure 5.

• 2 ⁰ ⁰ The Wits ± 1 mm -10 mm -4 mm Facial Angle
• 4 ⁰ -4⁰ Pg-NB 4 mm 0 mm 5 mm

  33 ⁰ Parameter dental Interincisal angle 130 ⁰ ± 2⁰

  Treatment was preceded by bonding bracket on the upper jaw. It is intended to obtain positive overjet by proclination of incisor teeth of the maxilla. Posterior bite riser was made to free the anterior bite, so the upper incisor can easily move forward. Mandibular bracket were bonded when positive overjet had been achieved. Early elastic mechanism which is one of the advantages of self-ligating system was applied, using the class III elastic from 16-43 and 26-33. This procedure was done to get the canine and molar relationships into class I from the beginning of treatment.

  ff erent. CR examination showed that the upper and lower incisor relationship edge to edge with overjet of 0 mm. Since there is several advantages in the self-ligating bracket system, it was decided to use a passive self ligating system (Damon Q). Standart bracket prescription was used on both upper and lower jaw, due to the initial incisor position and edge to edge incisor relationship while centric relation. Camouflage procedures were performed by protraction and intrusion of the maxillary anterior region by considering the inclination of the maxillary incisors.

  Camoufl age procedurs was chosen because the functional analysis showed that CO and CR in these patients is di

  DISCUSSION

  Figure 7. Profi le photos of pa ents before and a er 15 months of treatment.

  Cephalometric superimposition picture before and a ft er 15 months treatment shows that there are change in dental, which is a signifi cant maxillary incisor proclination to obtain a normal overjet. Also the presence of mandibular rotation in a clockwise direction. Then the molar relationship of class III into class I. Good so ft tissue profi le (Fgure 6 and

  Note: The black color shows the pre-treatment cephalometric. The red color shows the cephalometric a ft er 15 months of treatment.

  Figure 6. Superimposi on cephalometric photo on SN fi eld.

  87 ⁰ LI-NB 4 mm ± 2 7 mm 5 mm Parameter so Ō Ɵ ssue Upper lip-E line 1 mm ± 2 -6 mm -2,5 mm Lower lip-E line 0 mm ± 2 0 mm 0 mm

  90 ⁰ ± 4⁰ 84 ⁰

  125 ⁰ UI-NA 4 mm ± 2 5 mm 8 mm UI-Apg 4 mm ± 2 4 mm 8 mm LI-Apg 2 mm ± 2 8 mm 6 mm LI-MP

  UI-SN 104 ⁰ ± 6⁰ 108 ⁰

  134 ⁰ 117 ⁰

  32 ⁰ ± 3⁰ 31 ⁰

  Adisty and Krisnawa Ɵ : Camoufl age orthodon c treatment in skeletal class III malocclusion

  SN-MP

  128 ⁰ 130 ⁰

  66 ⁰ Go angle 123 ⁰ ± 7⁰

  60 ⁰ ± 6⁰ 64 ⁰

  Parameter skeletal (ver Ɵ kal) Y-axis

  86 ⁰ Angle of Convexity ⁰ ± 6⁰

  87 ⁰ ± 3⁰ 90 ⁰

  2 ⁰ ± 2⁰

  ANB

  80 ⁰ ± 2⁰ 86 ⁰ 86⁰

  86 ⁰ SNB

  82 ⁰ ± 2⁰ 84 ⁰

  Mean Before treatment A Ō er treatment Parameter skeletal (horizontal) SNA

  Jurnal PDGI 64 (1) Hal. 1-6 © 2015 Table 2. Cephalometric Analysis a er 15 months of treatment

  A ft er 15 months of treatment, the fi nishing stage of treatment was achieved,with good interdigitation at the premolar region. In the cephalometric superimposition a ft er 15 months of treatment, it was seen that there were dental changes, with a

  Adisty and Krisnawa Ɵ : Camoufl age orthodon c treatment in skeletal class III malocclusion

  4. Nanda R. Biomechanics and esthetic strategies in clinical orthodontics. St. Louis: Elsevier; 2005.

  13. Harradine N. Self-ligating bracket : theory, practice and evidence. In : Graber LW, Vanarsdall RL, Vig WL, eds.

  12. Baek S, Kim K, Hwang S. New trend in orthodontics- basic priciples, biomechanics, and clinical application of Damon system. Korea: Shinhung International Inc; 2007. p. 89-118.

  11. Birnie D. The Damon passive self-ligating appliance system. Semin Orthod 2008; 14: 19-35.

  10. Graber TM, Vanarsdall RL, Vig KWL. Orthodontics: Current principles and techniques. St. Louis: Mosby; 2005. p. 753-831.

  9. Harradine N. The history and development of self- ligating brackets. Semin Orthod 2008; 14: 5-18.

  Systematic review of self-ligating brackets. Am J Orthod Dentofacial Orthop 2010; 137(6): 726.e1-726.e18.

  8. Chen SS, Greenlee GM, Kim JE, Smith CL, Huang GJ.

  7. Proffit WR, Fields HW, Sarver DM. Contemporary orthodontics. 4 ^th ed. 2007. St Louis: Elsevier; 2007.

  6. Sugawara J. Clinical practice guidelines for developing class III malocclusion. In: Nanda R, editor. Biomechanics and esthetic strategies in clinical orthodontics. St. Louis: Elsevier; 2005. p. 211-2.

  5. Chen F, Wu L, Terada K, Saito I. Longit udinal intermaxillary relationships in class III malocclusions with low and high mandibular plane angles. Angle Orthod 2007; 77(3): 397-403.

  Oxford: Blackwell Publishing Ltd; 2009. p. 19-44.

  Jurnal PDGI 64 (1) Hal. 1-6 © 2015

  3. Eliades T, Pandis N. Self-ligation in orthodontics. 1 ^st ed.

  2. Dawson PE. Functional occlusion from TMJ to smile design. 1 ^st ed. St. Louis: Elsevier; 2007. p. 17-44.

  1. Mitchell L. An introduction to orthodontics. 3 ^rd ed. New York: Oxford University Press Inc; 2007. p. 6-8, 140-145.

  REFERENCES

  ff ects of upper incisor teeth by the lateral expansion of the posterior region. Damon System also has the advantages of early torque control and a variety of mechanisms that can be done since the beginning of treatment to correct the incisor inclination and to obtain good occlusion a ft er the interference factor is eliminated with the use of early elastic and the control time interval is longer than usual.

  In the camouflage treatment of Class III malocclusion without extraction, usually proclination of upper incisor and retroclination of lower incisor were recured. That condition may cause an unstable treatment results. Therefore, the use of self-ligating brackets will become an appropriate option to reduce fl aring e

  III malocclusion is a di ff erent case due to severe jaw discrepancies. However, the prognosis is be tt er in the mild to moderate Class III malocclusion cases with incisor tooth position can reach edge to edge relationship. Therefore in the case of mild and moderate class III malocclusion, orthodontic camouflage is often selected, with or without extraction.

  The conclusion of this case report was that class

  Presence of mandibular rotation in a clockwise direction make an elevation in the lower third of the face. This likely occurred because there was no interference a ft er the upper incisor teeth had been protracted.

  be done with labial root torque by using the third order bend. Proclination incisor did not change the patient’s upper lip, probably because in the initial condition the upper right incisor tip position was at the lower incisor tip position, and the upper lip was rests on the lower lip in the initial conditions. Canine and molar relationship were changed from class III into class I. This might be due to the early use of Class III elastic at initial treatment.

  Orthodontic current principles and technique. 5 ^th ed. St. Louis: Elsevier; 2012. p. 581-614.