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Copyright: © 2016 Deshmukh SV, et al.
Case Report
http://dx.doi.org/10.19104/jdos.2016.110
Journal of Dentistry and Orofacial Surgery
Open Access
Temporary Anchorage Devices in Bimaxillary Protrusion
Shailesh V. Deshmukh and Amol S. Patil*
Department of Orthodontics and Dentofacial Orthopedics, Bharati Vidyapeeth Dental College and Hospital, Bharati Vidyapeeth Deemed University, Pune
410043, Maharashtra, India
Received Date: January 15, 2016, Accepted Date: March 14, 2016, Published Date: March 24, 2016.
*Corresponding author: Amol S. Patil, Department of Orthodontics and Dentofacial Orthopedics, Bharati Vidyapeeth Dental College and Hospital, Bharati
Vidyapeeth Deemed University, Pune 410043, Maharashtra, India, Tel: 910-777-404-8166; E-mail: [email protected]
Case Report
Abstract
Introduction of mini implants in orthodontic treatment mechanics
has caused a paradigm shift in the treatment modalities. Mini-screw
type of temporary anchorage devices (TADs) are small, placed with a
minor surgical procedure and have helped treat complicated as well as
borderline surgical cases with relative ease. This case report highlights
the use of TADs for the treatment of a 19-year-old female with severe
bimaxillary dento-alveolar proclination, protrusive lips and divergent
face type. Clinical examination and cephalometric parameters indicated
that the case was a critical anchorage case which required extraction of
all first premolars. The TADs were placed in all four quadrants between
the roots of the second premolar and first molar with the aim of providing
absolute anchorage. After retraction of the anterior teeth, fullness of the
upper and lower lip has reduced, lip incompetency is eliminated and
the severe dentoalveolar proclination is corrected providing absolute
anchorage.
Clinical Relevance: The treatment of severe bimaxillary dentoalveolar proclination cases with conventional orthodontics has
always remained as a challenge; with a greater chance of anchorage
loss and inadequate retraction of anteriors into the extraction space
resulting in an unsatisfactory treatment result. Use of TADs helps us in
implementation of absolute anchorage into the treatment mechanics.
Keywords:
Temporary
Anchorage
Dentoalveolar Protrusion; Niti Wires
Devices;
Premolars;
A 19 year old female patient reported to the clinic with forwardly
placed upper anterior teeth. Extraoral examination revealed a
convex profile, incompetent lips at rest, protrusive upper as well as
lower lips, and an acute nasolabial angle. Due to protrusive lower
lip the mento-labial sulcus appeared deep. Intra-oral examination
revealed Angle’s Class I molar and canine relationship with mild
crowding in upper as well as lower incisors and normal overjet/
overbite (Figure 1).
Radiographic examination confirmed the presence of
permanent set of teeth with normal mandibular condyle. The
cephalometric analysis showed a boderline Class I skeletal pattern
(ANB 1°) with proclined upper and lower anteriors (U1 to NA 46°/
15mm; L1 to Md 34° / 10.5 mm; IMPA was 115°). Upper and lower
lips were protruded when compared to the E-line, 3.5 mm and 5.5
mm, respectively and compared to S line lower lip was protrusive
by 4 mm. Nasolabial angle was very acute (83°).
The treatment objectives were (i) to decrease the bimaxillary
proclination, (ii) correct crowding in upper and lower anteriors,
(iii) maintain class I molars, (iv) improve the facial esthetics with
retraction of upper as well as lower lip, and (v) treat it as a critical
anchorage case.
Treatment Progress
Introduction
The ultimate goal of orthodontic treatment has always been
to improve the patient’s aesthetic harmony, achieve a structural
balance and functional efficiency. Anchorage i.e. resistance to
unwanted tooth movement [1], is an integral part of orthodontic
treatment to achieve an ideal result [2,3].
After the extraction of all first bicuspids, fixed pre-adjusted
Edgewise appliances (Clarity SL 022 MBT) were used (0.022 ×
0.028 slot). Alignment and levelling was peformed with 0.014”
Niti wires followed by 19 x 25 Niti wires. Four orthodontic mini-
Absolute anchorage means no movement of the anchorage unit
as a consequence to the reactionary forces applied to move teeth
which are impossible if the force applied is from the anchorage unit
since it defies Newton’s Third law of Motion i.e. Every action has an
equal and opposite reaction. Thus, it is essential to have absolute
anchorage, a term which was never a reality before the introduction
of TADs in orthodontic treatment mechanics [4-6]. Introduction of
TADs have changed the orthodontic scenario and expanded the
boundaries of tooth movement [7-10].
Treatment of bimaxillary dentoalveolar protrusion cases
involves alignment and leveling of teeth, complete retraction of
maxillary as well as mandibular incisors resulting in a decrease in
soft tissue procumbency and convexity. Usually treatment plan will
include extraction of all first premolars and complete retraction
of the anterior teeth into the extraction space with minimal or no
movement of the posteriors into the extraction space i.e. absolute
anchorage. Therefore, this case report demonstrates the orthodontic
treatment of a severe bimaxillary dentoalveolar protrusion with
incompetent lips with the use of TADs to achieve absolute anchorage.
J Dent Oro Surg
Figure 1: Extra oral and intra oral Picture With proclined upper and
lower anteriors, protrusive upper and lower lips.
ISSN: 2470-9735
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J Dent Oro Surg
Vol. 1. Issue. 2. 32000110
ISSN: 2470-9735
implants (Dentos, Korea) of conical shape, 6 mm length and 1.3 mm
diameter were placed inter-radically between the maxillary and
mandibular second bicuspids and first molars during the alignment
stage itself (Figure 2).
A 0.019 × 0.025-inch Stainless steel arch-wire with anterior
hooks was placed in upper and lower arches with a Ni–Ti coil
spring applied from the maxillary and mandibular mini-implants
to the anterior hook on the arch wire to retract the anterior teeth
(Figure 3). After retraction, the treatment was completed with
ideal arch-wires sequencing and use of settling elastics. Angles
Class I molar and canine relationship was preserved bilaterally
with well coordinated upper and lower arches. The dentoalveolar
protrusion was significantly reduced due to retraction of upper and
lower anteriors completely into the extraction spaces without any
anchorage loss (Figure 4).
After superimposition of the before and after treatment
cephalometric tracing, the maxillary and mandibular incisors were
bodily retracted (U1 to NA 25°/ 6mm; L1 to Md 29° / 5.5 mm).
There were no significant change in the position of both maxillary
and mandibular first molars nor was there any significant change in
ANB angle. The upper and lower lip were retracted with an increase
in nasolabial angle to 102° from 83° pretreatment resulting in
significant profile changes in the patient’s lower facial third (Figure
4). The entire treatment duration was 18 months. The results of
treatment were shown in table 1.
Figure 4: Extraoral and intra oral Picture after orthodontic treatment
(Note: The reduced lip protrusion and improved facial profile).
Discussion
Esthetics is one of the main reasons patients opt for orthodontic
treatment especially in bimaxillary protrusion cases, which is
characterized by flaring of the maxillary and mandibular anteriors
and concomitant procumbancy of the upper as well as lower lips
[11]. Depending on the severity of malocclusion the case is treated
as non extraction, second premolar extraction or first premolar
extraction case depending on the anchorage requirements.
Figure 5: Superimposition of pre and post treatment of maxilla
and mandible showing maximum incisor retraction and absolute
anchorage.
Figure 2: 022 MBT appliance in place with implants between second
premolar and first molars.
Parameter
Angle ANB
U1 to NA
L1 to Md
Nasolabial angle
Upper lip to E line
Lower lip to E line
Lower lip to S line
Pre treatment
1°
46°/ 15mm
34° / 10.5 mm
83°
3.5mm
5.5 mm
4 mm
Post Treatment
1°
25°/ 6mm
29° / 5.5 mm
102°
0 mm
1.5 mm
0.5 mm
Table 1: Cephalometric parameters of patient before and after treatment.
Figure 3: Schematic representation of force application from the TADs
to arch wire.
Temporary skeletal anchorage such as retromolar implant
[12], onplants [1,3], palatal implants [13,14], mini-plates [15],
mini-screws [7] and mini-implants [16] have overcome previous
limitation of orthodontic tooth movement of anchorage loss and
helped make absolute anchorage a reality by causing en masse
movement in the desired direction without anchorage loss. As
shown in the above case report, the use of TADs have provided
absolute anchorage in the posterior segment and facilitated
complete retraction of the anteriors into the extraction space with
no forward movement of the posteriors as shown in figure 5.
Citation: Deshmukh SV, Patil AS (2016) Temporary Anchorage Devices in Bimaxillary Protrusion. J Dent Oro Surg 1(2): 110
http://dx.doi.org/10.19104/jdos.2016.110.
Page 2 of 3
J Dent Oro Surg
ISSN: 2470-9735
Various authors [8,16-18] have discussed the stability and
efficacy of TADs in maximum en masse retraction of the maxillary
and mandibular anteriors into the extraction space with absolute
anchorage control preventing adverse effect of conventional
mechanics like molar slippage which has resulted in the desirable
outcome.
Conclusions
In Class I bimaxillary dentoalveolar protrusion cases, TADs
provide absolute anchorage for en masse retraction of the anterior
teeth into the extraction space.
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*Corresponding Author: Amol S. Patil, Department of Orthodontics and Dentofacial Orthopedics, Bharati Vidyapeeth Dental College and Hospital,
Bharati Vidyapeeth Deemed University, Pune 410043, Maharashtra, India, Tel: 910-777-404-8166; E-mail: [email protected]
Received Date: January 15, 2016, Accepted Date: March 14, 2016, Published Date: March 24, 2016.
Copyright: © 2016 Deshmukh SV, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation: Deshmukh SV, Patil AS (2016) Temporary Anchorage Devices in Bimaxillary Protrusion. J Dent Oro Surg 1(2): 110 http://dx.doi.org/10.19104/jdos.2016.110.
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Citation: Deshmukh SV, Patil AS (2016) Temporary Anchorage Devices in Bimaxillary Protrusion. J Dent Oro Surg 1(2): 110
http://dx.doi.org/10.19104/jdos.2016.110.
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