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Case report
Correction of Unilateral Scissor Bite using Periodontally 10.5005/jp-journals-10021-1272
Accelerated Osteogenic Orthodontics.
Correction of Unilateral Scissor Bite using Periodontally
Accelerated Osteogenic Orthodontics
1
Priyanka Marla, 2Ratna Parameswaran
ABSTRACT
This article is regarding a case report presenting a true unilateral
posterior crossbite in an adolescent patient, a challenging mal­
occlu­sion to treat. Conventional expansion methods are expec­ted
to have some of its shortcomings.
The aim of this paper is to introduce a technique for treating
unilateral posterior crossbite in an adolescent or adult patient,
advocating Periodontally Accelerated Osteogenic Orthodontics
(PAOO)TM as a part of adjunctive protocol in the orthodontic
realm. The procedure promises to radically shorten the treat­
ment time.
Methods: PAOO as an adjunctive procedure in orthodontics
for treatment of unilateral posterior scissor bite.
Results: Effective unilateral expansion was achieved using
PAOO, and functional occlusion was established as well.
Conclusion: Unilateral PAOO presents an effective and reliable
technique to treat true unilateral crossbite.
Keywords: Mandibular expansion, Unilateral scissor bite,
PAOO.
How to cite this article: Marla P, Parameswaran R. Correction
of Unilateral Scissor Bite using Periodontally Accelerated
Osteogenic Orthodontics. J Ind Orthod Soc 2014;48(4):343-348.
Source of support: Nil
Conflict of interest: None
Received on: 30/1/14
It is a rare type of malocclusion found in primary and
mixed dentition. It not only affects chewing and muscle
functions, but also impairs normal growth and development
of the mandible.2 Early treatment with expansion appliance
can be used to treat this anomaly in younger patients,
whereas in adults, the conventional nonsurgical method of
slow expansion or a segmental surgical intervention proves
to be a problematic, limited and inefficient method, which
takes a long time and might compromise periodontal health
if done beyond a few millimetres.3
Suya (1991) reported corticotomy-assisted orthodontic
treatment of 395 adult Japanese patients. Suya contrasted
his technique with conventional orthodontics in being less
painful, producing less root resorption, and exhibiting less
relapse. He believed that the tooth movements were made
by moving blocks of bone using the crowns of the teeth as
handles. Completing tooth movement in 3 to 4 months was
recommended, after which time the edges of the blocks of
bone would begin to fuse together (Suya 1991).4
The development of corticotomy-assisted orthodontics
has provided new solutions to many limitations in the
orthodontic treatment of adolescents and adults.3
Accepted after Revision: 24/2/14
DIAGNOSIS
INTRODUCTION
A 14-year-old male patient presented with the chief com­
plaint of proclination in the upper anterior teeth, unable to
approximate lips on closure and unesthetic smile.
On clinical examination, the frontal view of the patient
revealed a mild asymmetry with chin deviated to the right
side. The profile view revealed convexity with a retrusive
chin and low mandibular plane angle. Observation showed
the presence of incompetent lips and an everted lower lip
along with an average mentolabial sulcus (Figs 1A to C).
On functional examination, TMJ was asymptomatic. On
smile, he revealed 8 mm of incisor exposure. The severity of
the scissor bite also caused an occlusal prematurity, owing
to which the patient had a deflection on complete closure.
On intraoral examination, the upper arch was wide ‘Ushaped’ and the lower revealed a square-shaped arch form
presenting a dentoalveolar deformity on the right lower
posterior segment with teeth lingually tipped. The interarch
relationship showed a Class I canine relationship and Class I
molar relationship on the left side and on the right side
A scissor bite is defined as buccal displacement of a maxil­
lary posterior tooth, with or without contact between
the lingual surface of the maxillary lingual cusp and the
buccal surface of the mandibular antagonist’s buccal cusp.
A complete buccal crossbite, known as a Brodie bite, is
caused by a combination of excessive maxillary width and
a narrow mandibular alveolar process, although the width of
the mandibular base is usually normal or it can be limited to
one quadrant which is seen in this present case.1
1
Clinical Practitioner, 2Professor
1,2
Department of Orthodontics, Meenakshi Ammal Dental
College, Chennai, Tamil Nadu, India
Corresponding Author: Priyanka Marla, Clinical Practitioner
Department of Orthodontics, Meenakshi Ammal Dental College
Chennai, Tamil Nadu, India, Phone: 9176002321, e-mail:
[email protected]
The Journal of Indian Orthodontic Society, October-December 2014;48(4):343-348
343
Priyanka Marla, Ratna Parameswaran
A
B
C
Figs 1A to C: Pretreatment extraoral view
A
C
B
D
E
Figs 2A to E: (A to C) Pretreatment intraoral view, (D and E) pretreatment occlusal view
showed a unilateral scissor bite distal to the canine extending
to the second molar. Proclination of the maxillary anterior
teeth with deviation of the upper midline to the right side
and mild to moderate crowding in the mandibular anterior
teeth was observed (Figs 2A to E).
Casts analysis revealed a tooth-size arch length discrep­
ancy which indicated extraction treatment protocol.
Cephalometric analysis verified a Class II skeletal base
with proclination of the maxillary and mandibular teeth on
a low mandibular plane angle. On examination of OPG,
the posterior teeth exhibited mesial inclination and all the
third molars were present and were in favorable positions
(Figs 3 and 4).
The treatment objectives were to:
• Address the scissor bite initially
• Correct the vertical relationship
• Correct proclination and crowding
• Correct the midline
• Provide good functional occlusion
• Improve esthetics
344
Fig. 3: Preoperative lateral cephalogram
Extraction of all four first premolars was planned to
correct the midline deviation and proclination of upper and
lower anteriors.
TREATMENT PROGRESS
Planning was critical in correcting the scissor bite in the
right posterior quadrant, as the lower buccal teeth showed
severe lingual tipping along with an alveolar deformity.
JIOS
Correction of Unilateral Scissor Bite using Periodontally Accelerated Osteogenic Orthodontics.
Fig. 5: Periodontally accelerated osteogenic orthodontics
Fig. 4: Preoperative orthopantomogram
A surgical intervention with periodontally accelerated
osteogenic orthodontics was planned to aid in the process
of correction as the mandibular cortical bone is resistant
to conventional orthodontic forces (Fig. 5). Corticotomyassisted expansion is an optimal way to treat mild to
moderate maxillary or mandibular transverse deficiency in
adults with greater stability without compromising perio­
dontal health.3 Although corticotomy is an old technique
dating back to the early 1900s, it was not properly
introduced until Wilcko developed the patented technique
named Accelerated Osteogenic Orthodontics (AOO), also
called Periodontally Accelerated Osteogenic Orthodontics
(PAOO)™.5-9 This technique was originally designed to
enhance tooth movement, subsequently reducing treatment
time via inducing cortical bone injury through linear cutting
(corticotomy) and then performing orthodontic treatment.3
Following the surgical procedure, the orthodontic
treatment commenced after 10 days. 0.022" MBT preadjusted
appliance was bonded in the upper arch with double tubes
banded on the upper molar and single tube banded on the
lower left molar and bands were cemented, which were
welded with lingual attachments for elastic engagement.
Bilateral posterior bite plate with left bite block,
sufficiently increased to relieve the right lower segment
completely, was cemented to the upper arch so that it served
A
as an anchor segment while engaging cross elastics to the
lower segment. This prevented untoward extrusive and
buccal movement of the upper posterior teeth (Figs 6A to C).
The scissor bite correction was carried on for a period of
7 months.
Extraction of lower first premolars was performed to
aid in optimum aligning, leveling and correction of the arch
form under the influence of the bite plate. This prevented
any occlusal interference in the transverse correction. After
a reasonable arch form was achieved in lower, extraction of
upper first premolars was carried out.
It was observed that upper right second molar continued to
be in scissor bite and the mandibular shift persisted owing to
its interference. Hence, after assessing the status of the right
upper third molar, the right upper second molar was extracted.
0.018" SS wire followed by 0.016" × 0.022" SS with an
offset bend distal to the canine was placed in the right lower
segment to aid in maintaining the expansion achieved (Figs
6A to C and 7A to C).
Space closure was done with the help of a tear drop loop
in both the upper and lower arches. Cross elastics was given
throughout the treatment. Banding of right upper third molar
was done to align it in the position of the second molar.
TREATMENT RESULTS
The posterior scissor bite was corrected and the ideal
occlusal and esthetic goals were met. Contact between the
B
C
Figs 6A to C: Bilateral posterior bite blocks with elastics The Journal of Indian Orthodontic Society, October-December 2014;48(4):343-348
345
Priyanka Marla, Ratna Parameswaran
A
B
C
Figs 7A to C: Before retraction
A
B
C
Figs 8A to C: Postoperative extraoral view
A
B
D
C
E
Figs 9A to E: (A to C) Post-treatment intraoral view, (D and E) post-treatment occlusal view
16 and 18 could not be established due to the position of
the antrum preventing the mesial movement of the third
molar completely, thereby maintained it as self-cleansing.
The upper incisor proclination and the lower crowding
were corrected. Class I canine and molar relationships were
achieved, along with ideal overjet and overbite. A more
favorable incisor to lip position was established at rest and
during smile. Functional efficiency was markedly improved
[(Figs 8A to C) and (Figs 9 to 11). One year review showed
good stability of all the corrections achieved (Figs 12A to C)
and (Figs 13A to E)].
346
DISCUSSION
Unilateral scissor bite in the posterior segments often leads
to a deviated path of closure owing to the premature contacts.
If these go undetected in early stages of development it
can result in unfavorable teeth positions and change in
the alveolar bone contour. Correcting such problems may
require bite plates to dissocclude the occlusion which cause
transient limitation in a function like chewing. Hence,
duration becomes the most important factor to be considered
in treating scissor bite malocclusions.
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Correction of Unilateral Scissor Bite using Periodontally Accelerated Osteogenic Orthodontics.
Fig. 11: Post-treatment orthopantomogram
Fig. 10: Post-treatment cephalogram
A
B
C
Figs 12A to C: One year follow-up
A
B
D
C
E
Figs 13A to E: (A to C) One year follow-up intraoral view, (D and E) One year follow-up occlusal view
Periodontally Accelerated Osteogenic Orthodontics as an
ajunct was a viable option for this patient to reduce the duration
of the treatment in addition to which reduces the time availa­
ble for the bacterial biofilms to cause any tissue breakdown
(periodontopathic) and manifest the ability of enhanced ortho­
dontic tooth movement.10 Sebaoun et al reported that in selective
alveolar decortication, the calcified spongiosa adjacent to the
decortication reduced in volume momentarily and PDL activity
was observed to be enhanced there by increasing the tissue
turnover. This provides the basis for recon­touring the alveolar
bone altering the shape and volume, thus accommodating the
uprighted teeth augmenting the stability factor.11
The Journal of Indian Orthodontic Society, October-December 2014;48(4):343-348
347
Priyanka Marla, Ratna Parameswaran
Ferguson et al have suggested that the increased stability
provided by PAOO may be due to loss of tissue memory from
high tissue turnover of the periodontium, as well as increased
thickness of the alveolar cortices from the augmentation
grafting.12
CONCLUSION
Though treatment associated with periodontally assisted
osteogenesis involved a mild invasive procedure with
extra surgical cost, it had its following advantages, such as
reduced treatment time, less root resorption due to decreased
resistance of cortical bone and low relapse rate.
Hence, periodontally assisted osteogenic orthodontics
combined with orthodontic procedure proved to be an
efficient and rapid method in correcting scissor bite with
dentoalveolar deformity.
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