Multidisciplinary case: The Lingual Orthodontic treatment of a comlex Peridontal- prosthetic problem

Sophia Papanikolaou D.D.S. Evangelia Stamou D.D.S, Greece, Silvia Geron D.M.D., M.Sc Israel

www.lingualnews.com Vol 1 No 4, November 2003

Abstract
This case report depicts the unique problems and interdisciplinary solutions presented by a specific patient desirous of a high quality of care.  Patient ZA, a 41 year old female, was referred for orthodontic care as part of a preparation for prosthetic rehabilitation of her dentition.
She presented with characteristics of an Angle’s Classification II division 1 malocclusion, asymmetric and uncoordinated arches, a significant diastema, and cross bites in the right premolar region.  Her malocclusion was further complicated by a poor periodontal condition, several missing teeth, and poor partial prosthetic restorations.
Orthodontic treatment was to be delivered using fixed lingual brackets, and was to be accompanied by periodontal care and prosthetic treatment in order to improve oral health, function and esthetics.

Diagnosis and etiology
A 41 year old female was referred by her prosthodontist for orthodontic treatment in order to facilitate her prosthetic rehabilitation.  Orthodontics was considered in order to improve facial esthetics, reposition teeth so that bulky restorations could be replaced by ideal ones, and elimination of her diastema.  The objectives of orthodontic therapy was to redistribute the spaces, upright the posterior teeth and prepare the patient for prosthetic restorations.

Pre-treatment, the patient had an asymmetric face with incompetent lips and a convex retrognathic profile (Fig 1).   The intra-oral examination revealed that the maxillary midline (center of the diastema), was shifted 2mm to the left of her facial midline and the lower midline 8 mm to the left of the upper (Fig 2).  In addition, multiple teeth were missing (numbers: 13, 16, 22, 28, 38, 47, 48) due to extractions, etc, and poorly contoured and unesthetic restorations were present.

Space analysis of the upper arch shows an excess of  10mm, including the space of the extracted #13,#22 and the diastema between #11,#21.  In the lower arch there was an excess of space of 16mm including the space of #46. The upper and lower arches were ovoid in shape and #14,#15,#17,#33 were rotated. Tooth number 17 was mesially inclined.

Although her right side molar and canine occlusions were indeterminate, these were Class II and Class III, respectively on her left side.  Her interincisal relationships were 5% in the vertical (over bite), and 0.5mm in the sagittal (overjet).  There were crossbites of teeth numbered 14 and 15 –to- 43, 44, and 45.

Fig. 1: Pretreatment facila photographs

Fig. 2: Pretreatment intraoral phtographs

Furthermore, there was generalized severe bone loss and her oral hygiene was fair.  Her facial asymmetry was investigated radiographically (the condyles were scanned using computerized tomography), and ultimately she was diagnosed as having hemifacial maxillary hypoplasia.  Cephallometrically, the patient has a skeletal Class II relationship due to protrusive maxilla and slightly retrusive mandible, and long lower face height (Fig 3).

Fig. 3: Pretreatment cephalometric and panoramic photographs

Treatment objectives
The objectives of orthodontic treatment were to improve the periodontal condition of the posterior dentition by uprighting the mesially inclined teeth (1), and create spaces in the posterior areas for future implant or fixed partial restorations. In addition, it was planned to level and align the arches, close the anterior diastema, improve upper and lower midlines, close the spaces in the lower anterior region to improve (increase) the overjet and overbite. The maxillary midline was to be corrected by pulling the 3-unit bridge (no. 21-23) into a the right, thus closing the diastema between 11-21.  Because of the patients compromised periodontal status, it was determined orthodontic therapy would have to be minimized to avoid any further deterioration.

Treatment progress
The patient was referred to the periodontal department at the Tel-Aviv University School of Dental Medicine for initial periodontal preparation.

Lingual brackets (Ormco) with 0.018 inch slot were bonded on the maxillary incisors (11,21,12) and left canine (23) and 0.022 inch slot brackets were bonded to the premolars and molars.  This was done using the indirect Lingual Bracket Jig technique (SILAM) (2,3).

Initial leveling and alignment was accomplished in the lower arch using 0.0175 inch Respond (Ormco) wire and 0.016 inch nitinol wire for the upper arch. This wire was followed by .016 SS on which the spaces were closed with very light forces. Additionally, segmental labial mechanics was used together with the lingual appliance in the upper and lower posterior segments to improve control during de-rotation and uprighting of the teeth which presented with reduced bone level (Fig 4).

Fig. 4: Alignment stage with lingual and labial appliance

Coil springs between #15-17, # 35-37 and # 44-47 labial brackets were used to upright these teeth and create space for future prosthetic restorations. De-rotation was performed by elastic chains tied from the lingual arch to a labial bracket..

At the finishing stage a lower 0.016TMA and upper 0.016 SS wires were used. Clear plastic buttons were bonded on the labial surfaces of 23,43 so that the patient could wear intermaxillary elastics in order to correct the midlines and close the diastema.
The periodontal status of the patient was closely monitored during treatment, with the patient going for regular debridment with the oral hyginist every 3 months, and radiographic evaluation every 4 months.

At the time of fixed appliance removal, fixed (permanent) “splint” retainers were bonded in their stead (Fig 5).

Fig. 5: Posttreatment intraoral photographs

Retention
The patient was referred to the prosthodontic clinic for temporary restorations in the upper arch (Fig 6), immediately following the debonding.  Temporary fixed partial dentures were prepared prior to debonding, and were delivered immediately after removal of the orthodontic brackets. The temporary, and hence final restorations, served as permanant retention in the upper arch.

The mandibular dentition was retained by the placement of a fixed lingual “splint” retainer as well.  This placed from canine to canine and was in tandem with a Hawley retainer with acrylic filling in the edentulous areas until the implant restorations are completed.

Fig. 6: Interoral photographs with temporary restorations

Treatment results
Extra-orally, significant improvement in patient's smile and facial esthetics was noted (Fig 7).  Intraorally, her occlusion was remarkably improved. The upper and lower midline discrepancy was almost entirely corrected, the posterior teeth were uprighted and enough space for restoration insertion was achieved (Fig 8). A solid well-intercuspated occlusion with proper overjet and overbite was achieved.
A comparison of the pretreatment and the posttreatment cephalogrms showed that the upper and lower incisors were slightly retroclined during treatment (Fig 9).

Overall the prognosis of the posterior dentition was improved and no additional bone loss occurred during treatment.
 

Fig. 7: Pottreatment facial photographs

 Fig. 9: Superimposition of the pre- and post-treatment cephalograpms

  Fig. 8: Posttreatment cephalometric and panoramic photographs

References
1. Diedrich PR : Orthodontic procedures improving periodontal prognosis. Dental Clinics of North America I Vol 40,:No 4: 875-887 October 1996
2.Geron S. The lingual bracket jig. J Clin Orthod 1999;33:457-63
3. Gianelly AA, Bednar JR, Dietz VS. A bidimensional edgewise technique. J Clin Orthod 1985;19:418-21

 www.lingualnews.com 
Adult and Lingual Orthodontics
EDITORS:
Dr. Silvia Geron D.M.D., M.Sc
Dr. Rafi Romano D.M.D., M.Sc
Dr. Pablo Echarri D.M.D., M.Sc