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PSCO NewsWire Case Report

Cant Correction With TADs and Accelerated Orthodontics: A Case Report

Susan B. McBeth, DDS MS (Orthodontics), Charles A. White, DDS MS MSD (Periodontics)

 The patient, age 37, presented with existing lower braces. Two deliveries of upper veneers had been fabricated in order to correct the smile. The patient’s chief concern was “loose molar, spaces aren’t closing, I’d like to improve my smile.”

Significant findings were:

            Mobility LR7, due to traumatic occlusion

Lower spaces, which have been resistant to closure

Posterior left crossbite (narrow maxilla and wide mandible)

Lateral tongue position at rest and during function, with myofunctional in coordination

Upper left quadrant was vertically insufficient

Lower left quadrant was vertically over erupted

Pretreatment Photos

 
 


Treatment

The primary goals of treatment were

1)      Intrude the lower left quadrant

2)      Extrude the upper left quadrant

3)      Expand the upper left quadrant

4)      Constrict the lower left quadrant

The treatment recommended was upper and lower fixed appliances, TADS (Temporary Anchorage Devices), and PAOO (Periodontally Accelerated Osteogenic Orthodontics). Four TADs were placed facially in the lower left quadrant and 2 TADs were placed lingual to the lower left quadrant. Elastomeric thread was placed from the TADs to the braces in order to intrude the lower left quadrant. After this intrusion was complete, elastics were worn from the upper left teeth to the lower TADs in order to extrude the upper left quadrant, correcting the maxillary cant.  To address the posterior crossbite of the left side, a crossbite elastic was worn from the lingual of the upper left molars to the lower facial TADs. Also, to further expand the maxilla, an expander stainless steel overlay archwire was employed. To constrict the mandibular arch, a constricted lower lingual holding arch was used. This lower lingual holding arch was placed after PAOO surgery for ease of surgical instrumentation. 

 Photos taken 12 weeks after PAOO. Intrusion of the lower left quadrant has been significant.

 

 
PAOO was utilized in the upper left and lower left quadrants, and the benefits were several:

1) The magnitude of tooth movement that we needed did occur.

2) Additional bone facial to the upper left quadrant was helpful to provide additional support for the expansive movement of the maxillary molars.

3) Decreased treatment time (16 months)

 PAOO was completed after rigid archwires were in place, to fully utilize the first 12 weeks of rapid PAOO activity. The PAOO prescription written for the periodontist was “PAOO of teeth #’s 9-15 and 18-23, with anchor teeth #2-8 and 24-31.” In other words, no PAOO was performed around the anchor teeth, as we needed these teeth for anchorage. The TADs were placed at the same time as PAOO.

Myofunctional therapy (with a speech pathologist) was pursued to achieve better coordination.  Full transference of those skills proved to be a challenge for this patient. Other difficulties during the course of treatment included keeping the TADs in place, especially on the left lingual, as well as the patient’s resolve to keep elastic wear consistent and brackets intact.

 Retention

The upper retainer used was a vacuform Essix, and the lower retainer was a fixed lingual retainer from canine to canine, with each tooth bonded, as well as a lower vacuform Essix.

Discussion

14 months after debanding, the correction of the maxillary (and mandibular) cant appeared to be stable. The transverse correction and buccal/lingual positioning of the lower left premolars  proved to be slightly less stable, which is likely related to the myofunctional incoordination. According to the developers of PAOO, Drs. Thomas and William Wilcko, it works well to retain significant maxillary width change with a trans-palatal arch for approximately 18 months after removing braces, to allow the bone to fully mature. This has also been our experience in other cases.

The first months of treatment focused on working toward rigid archwires, so that the PAOO procedure could be completed. This 9 month period was longer than anticipated, due to numerous emergencies and repairs. This did delay our getting started on the accelerated part of treatment. So, effectively, the significant tooth movements occurred only in the last 7 months of treatment, indication that treatment time could have been much shorter than 16 months.

Summary

With the adjunct treatment of TADs and PAOO, a significant skeletal problem was treated conservatively. The patient experience was months, not years, and the patient was pleased with her smile and occlusion.

 Pre-treatment and Post-treatment photos







   


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