By Failing to Plan, Are We Planning to Fail? Drs. Adith Venugopal and Can-Florian Keles

by Drs. Adith Venugopal and Can-Florian Keles

Orthodontic treatment aims to correct dental and skeletal issues while enhancing facial aesthetics. Through clinical examination, radiological analysis, and expertise, practitioners diagnose and plan treatment. Satisfaction is achieved when treatment objectives are successfully met, although treatment often entails challenges despite appearing straightforward. Treatment procedures involve a large number of relevant variables determined by patient characteristics, such as the dynamics of facial development and growth; the biomechanical interactions among appliances, dentition, and bone physiology; dentist-patient-family dynamics; the wide variety of treatment approaches; and the continuity of follow-up during the retention phase.^1,2

Difficulties in treatment may arise from various factors, such as improper selection of dental procedures, incorrect treatment indications, adoption of risky strategies, inadequate execution of treatment, misjudgment of treatment duration, failure to adjust the treatment plan as needed, incomplete resolution of malocclusion, insufficient follow-up during retention, and poor communication with the patient. These failures can significantly affect the effectiveness, quality, and stability of correction, highlighting the intricate nature of orthodontics and the potential for adverse outcomes resulting from neglecting key variables.^3–6

In this case report, I will first outline a transfer case that I treated during the initial stages of my orthodontic career without sufficient awareness or consideration of the existing periodontal conditions. This approach ultimately resulted in a satisfactory aesthetic outcome but an increased risk of future periodontal complications. I will then discuss a subsequent case treated after I had accumulated substantial experience, in which I analyzed every aspect to ensure a comprehensive understanding of the diagnosis. With sound knowledge of the individual patient’s periodontal status, a carefully planned treatment strategy was devised to achieve both pleasing aesthetic and functional outcomes.

Case 1
A 17-year-old male presented to our office with his mother. He had undergone orthodontic treatment for the previous 4.5 years and had recently had his braces debonded because of a lack of confidence in that treatment. On clinical and radiological examination, he presented with excessively proclined incisors, mildly proclined lower incisors, an anterior open bite, Class III molar and canine relationships, four missing first premolars because of previous extractions, a temporary anchorage device (TAD) in the right posterior maxillary region, and an excessively steep mandibular plane, all on a Class III skeletal base (Figs. 1 and 2).

Fig. 1: Pretreatment intraoral photos

Fig. 2: Pretreatment radiographs

The patient brought his pretreatment records from 4.5 years earlier for evaluation. The initial pretreatment extraoral records showed a convex and hyperdivergent profile with incompetent lips. The pretreatment intraoral records revealed severe crowding in the maxillary arch, moderate crowding in the lower arch, buccally and highly positioned ectopic maxillary canines, and a Class III molar relationship on both sides. Clinical and radiographic evaluation of the initial pretreatment records confirmed a very steep mandibular plane (Fig. 3).

Fig. 3: Records from the initial presentation, before the previous orthodontic treatment, 4.5 years earlier

In this skeletal Class III hyperdivergent case, in which four premolars had already been extracted and there was significant loss of anchorage in the maxilla and mandible, along with excessive buccal flaring of the maxillary anterior teeth, two treatment options were suggested to normalize the occlusion. The first was a combined orthodontic and orthognathic surgical approach.

The second treatment plan included orthodontic treatment alone, assisted by TADs in the mandible. Following extraction of the mandibular third molars, the mandibular teeth were to be distalized using two buccal shelf TADs. In the maxillary arch, the anterior teeth were then to be palatally tipped to achieve satisfactory overjet and overbite. It was made clear that this option would not treat or correct the high-angle mandible that contributed to the long facial appearance.

Because the patient had already been undergoing orthodontic treatment for 4.5 years before presenting to our practice, he and his mother expressed frustration with the existing treatment because of its long duration and unsatisfactory outcome. Wishing to avoid the financial burden of orthognathic surgery, they preferred a conservative solution and opted for the second option. An informed consent form was reviewed and signed to this effect.

This case was treated using .022” × .028” slot preadjusted edgewise appliances with an MBT prescription.

Step 1: Gaining a positive overjet by distalizing the lower arch
Initially, following extraction of the mandibular third molars, brackets were placed only on the lower arch to level and align the lower dentition. Leveling was performed using a .016” NiTi archwire, followed by .017” × .025” NiTi and .019” × .025” NiTi archwires.

Once the arch was completely leveled, two TADs (1.8 × 12 mm) were placed extra-radicularly on the buccal shelves in the mandible to distalize the entire lower arch. Two crimpable hooks, one between the lower premolars and canines and the other between the canines and lateral incisors, were crimped onto a .019” × .025” SS archwire. Elastic chains were first activated from the heads of the buccal shelf TADs to the distal hooks, with a force of 250 g on each side. After four months of active distalization, a positive overjet was achieved through a combination of lower incisor tipping and mandibular distalization. The elastic chains were then engaged from the TAD heads to the mesial hooks on the archwire for further activation (Fig. 4).

Fig. 4: Mid-treatment photos

Step 2: Palatal tipping of the upper incisors
Brackets were then placed on the upper arch. The four maxillary incisor brackets were flipped to generate greater palatal crown torque when a rectangular wire was inserted. A .014” NiTi archwire was placed to level the dentition. An intermaxillary elastic (5/16, 2 oz) was placed from the upper canine bracket to the lower TAD head to begin tipping the upper incisors. A Kobayashi hook was fabricated on the head of the extra-radicular TAD to prevent elastic slippage during placement. The upper leveling archwires then progressed from a .016” × .025” thermal NiTi to a .017” × .025” NiTi. The thickness of the intermaxillary elastics was also increased as the wire dimensions increased.

Lower distalization was continued simultaneously with upper incisor palatal tipping for the next seven months, until a satisfactory upper incisor inclination and Class I molar and canine relationships were achieved (Fig. 5).

Fig. 5: Mid-treatment photos

Step 3: Finishing and retention
A .016” NiTi archwire was reinserted into the upper and lower arches, and 1/8, 4.5 oz settling elastics were used for minor occlusal detailing to develop better interdigitation. The case was retained with an upper fixed lingual retainer in conjunction with upper and lower Essix clear retainers (Figs. 6 and 7).

Fig. 6: Posttreatment intraoral photos

Fig. 7: Posttreatment radiographs

One of the main reasons for the pretreatment anterior open bite and severely proclined incisors following the first orthodontic treatment was the premature engagement of the buccally and highly positioned canines after extraction of all bicuspids. Highly positioned ectopic canines tend to pull the anchorage unit away from the occlusal plane and usually cause an open bite.⁷

It is important to avoid early archwire engagement of highly positioned labial canines so that unwanted vertical movement of the lateral incisors and premolars does not occur. A piggyback archwire with a heavier base archwire or cantilever mechanics may be preferable for bringing such ectopic canines into occlusion.^8,9

Studies have shown that the extent of distalization of the lower dentition following extraction of the third molars is about 2–3 mm before the second molars begin to tip distally. The most common reason for this limited bodily movement is premature contact of the distolingual root of the second molar with the mylohyoid ridge. In cases with adequate clearance between the mylohyoid ridge and the roots of the second molars, a greater amount of distalization is possible (Fig. 8).^10,11

Fig. 8: Cephalometric superimpositions

Fig. 9: Bone levels in the lower anterior region

Root exposure of the lower anterior teeth
Comparison of the pretreatment and posttreatment cephalograms shows that the lower incisors have very little bone coverage on the labial aspect posttreatment. CBCT confirms a very thin plate of bone labial to the lower incisors (Fig. 9).

A study by Jing et al.¹² reported fenestration and dehiscence rates of 16.1% and 20.7%, respectively, at the tooth level in skeletal Class III subjects. They also reported that male patients with a history of orthodontic treatment were more likely to exhibit alveolar dehiscence.

Moreover, Class III patients are known to have a thinner mandibular symphysis than Class I and Class II patients. Sagittal or labiolingual movements must be performed very carefully, because dehiscence and fenestration are positively correlated with thin alveolar bone.^10,13,14

Case 2
A 17-year-old female patient presented with a skeletal Class III malocclusion attributed to an orthognathic maxilla and a prognathic mandible with upright incisors. She also presented with a high clinical FMA, increased lower anterior facial height, an anterior crossbite, and an anterior open bite. Dental findings included rotated lower molars, an ectopically positioned #23, and a palatally displaced #15. Extraction spaces were present in the mandibular #36 and #46 regions. The lower second molars had drifted mesially into the extraction spaces and caused steepening of the occlusal plane by prematurely contacting the maxillary first molars. The radiographic findings corresponded with the clinical findings (Figs. 10 and 11).

Fig. 10: Pretreatment extraoral and intraoral photos

Fig. 11: Pretreatment radiographs

The treatment objectives were to level and align the upper and lower arches, close the residual spaces, attain a positive overjet and overbite, and improve the patient’s overall facial aesthetics. The proposed treatment plan was to extract two premolars in the upper arch (#15 and #24) with moderate-to-minimal anchorage, retract the lower anterior segment, correct the open bite by intruding the upper molars, and protract the lower molars to close all residual spaces (Fig. 12).

Fig. 12: Planned orthodontic movements

The alternative treatment option would have been a surgical approach combined with orthodontic treatment. However, this option was ruled out because the patient declined surgery.

Full-arch fixed appliances were bonded, and extractions of #15 and #24 were performed at the same appointment to align the maxillary canine and begin relieving the crowding using the space created by the extractions. Following leveling and alignment, a .019” × .025” SS archwire was left in place until it was passively engaged in all bracket slots. IZC implants were then placed to intrude the upper molars. Class III elastics were initially used from the IZC implants to the lower canines to retract and tip them into the extraction spaces while the upper molars were being intruded. Another advantage of this strategy was the avoidance of counterclockwise rotation of the mandible that would otherwise result from intrusion of the maxillary molars. Counterclockwise rotation of the mandible would be detrimental to this patient’s profile because it would further increase chin prominence (Fig. 13).


Protraction of the lower molars was performed using a .019” × .025” SS archwire with a gable bend placed distal to the second premolar to increase the moment on the alpha segment. A power chain extending from the second molar in the third quadrant to the second molar in the fourth quadrant was used for space closure. Anchorage was further reinforced with Class II elastics (Fig. 14). Power chains were also run lingually from buttons placed on the lingual surfaces of the first molars and first premolars to avoid rotation of the molars during protraction. This strategy helped us achieve bodily movement of the second molars.

Fig. 13: Mid-treatment photos

Fig. 14: Molar protraction mechanics

The archwire in the lower anterior segment was torqued (lingual root torque) to correct the inclination of the lower incisors following molar protraction. The midlines were corrected using Class III elastics on the right side and Class II elastics on the left side. The occlusion was settled using settling elastics (3/16, 2.5 oz) (Fig. 15).

Fig. 15: Mid-treatment photos

Active treatment lasted 26 months. The case was finished with a Class II molar relationship, a Class I canine relationship, and coincident dental midlines. The soft-tissue profile improved greatly, with adequate lip competence and balanced vertical proportions (Figs. 16 and 17). The superimposition revealed intrusion of the upper molars and protraction of the lower molars, with marked improvement in the open bite and occlusal planes (Fig. 18).

Fig. 16: Posttreatment extraoral and intraoral photos

Fig. 17: Posttreatment radiographs

Fig. 18: Cephalometric superimposition

Orthodontists are still striving to develop biomechanical systems that can overcome the undesirable side effects of anchorage-tooth extrusion, mandibular rotation, and increased lower anterior facial height when treating skeletal Class III malocclusions.¹³ A successful camouflage treatment should mask both the skeletal and soft-tissue discrepancies, achieve an acceptable facial aesthetic result, and establish a stable occlusion. In this case, significant changes were observed in the anteroposterior dental position, the sagittal and vertical skeletal positions, the vertical position of the upper molars, and the position of the lower lip.

Patients with Class III malocclusion can benefit from the use of Class III elastics extending from TADs placed in the posterior maxilla to the anterior mandibular dentition, typically the canines. Maxillary TADs can prevent undesirable proclination of the maxillary incisors and extrusion of the maxillary posterior teeth, which are common side effects of conventional Class III elastic use. This approach may also help reduce counterclockwise rotation of the maxillary occlusal plane, which may reduce upper incisor display in Class III patients. Specifically, this mechanical approach is suitable for Class III patients with a high mandibular plane angle, a long-face tendency, or both.

Conclusion
Strategic utilization of TADs, coupled with a thorough grasp of the biomechanical principles at play, has the potential to broaden treatment options for severe Class III malocclusions. A meticulous initial case analysis is paramount; it allows clinicians to ascertain treatment limitations, communicate these boundaries effectively to the patient to obtain informed consent, and anticipate potential side effects. By doing so, the correction strategy can be streamlined and reversible measures readily implemented as necessary. 

References

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Dr. Adith Venugopal is a senior lecturer in the discipline of orthodontics, Department of Oral Sciences, faculty of dentistry at the University of Otago in Dunedin, New Zealand. He has published numerous scientific studies and clinical reports in international peer-reviewed journals and has served as a keynote speaker at orthodontic congresses around the world.

Dr. Can-Florian Keles earned his dental license at JMU in Wurzburg, Germany, where he also completed his first doctoral degree focusing on genetic variations. Keles obtained a master’s degree in orthodontics from DBU in Krems, Austria, with a special interest in enhancing patient compliance in orthodontic treatments. He is pursuing a second PhD in medical science at Paracelsus Medical University in Salzburg, Austria.