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Conservative Correction by Dr. Bilal Koleilat

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Conservative Correction 

A case study of intervention and strategic biomechanics that reshaped a 13-year-old patient’s smile.

by Dr. Bilal Koleilat

Introduction
Occlusal canting occurs in approximately 21 percent of the population. The etiology may be attributed to one or a combination of the following factors: skeletal disturbances in the growth of facial structures, vertical dental eruption disorders, or neuromuscular lip asymmetry. This case report presents the conservative treatment of a maxillary occlusal plane cant in a 13-year-old female patient utilizing a simplified biomechanical protocol.

Case History
A 13-year-old female presented for orthodontic consultation with the primary concern of dental crowding. The clinical extra-oral examination revealed well-balanced vertical and transverse proportions, a minor horizontal pupillary cant, and a more pronounced lip line cant with slight chin deviation. Soft tissue profile analysis demonstrated a harmonious relationship between the maxilla and mandible, with well-positioned upper and lower lips relative to the A-B line but retrusive in relation to Ricketts E-line, potentially because of slightly above-average nasal prominence (Fig. 1).
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Fig. 1: Initial intra- and extra- oral photographs.

Diagnosis
Skeletal
The patient showed mild skeletal class II (SNA 85, SNB 80, ANB 5) with a slightly protrusive maxilla, a normal mandible and a norm divergent vertical pattern (FMA 26) (Fig. 2).
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Fig. 2: Pre-treatment panoramic and lateral X-ray.
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Dental
On the right side, a moderate Class II Angle classification was observed for both molar and canine relationships, while the left side exhibited a Class I molar and canine relationship. The upper midline was aligned with the face’s center; however, both maxillary central incisors displayed an axial inclination angled to the right. The maxillary incisors were retroclined (U1/SN 100), and the mandibular incisors were slightly proclined (IMPA 95). The lower midline was shifted 2 mm to the right. The maxillary and mandibular arches were constricted in the transverse dimension, with lingual inclination of the lateral segment extending from the canines to the molars. Mild crowding was observed in both arches.

Smile
Upon smiling, the patient exhibited significant inclination of the maxillary occlusal plane, with greater eruption on the left side than on the right, resulting in increased gingival display on the left. The maxillary central incisor display was inadequate, and no smile arc was evident.

Treatment options
Two options were proposed to address the maxillary occlusal plane cant:

Utilize temporary anchorage devices (TADs) to intrude the maxillary left quadrant, level the occlusal plane and correct the right-side class II malocclusion.

Extrude and distalize the maxillary right quadrant without TADs by employing early light elastics.

Treatment plan
Option two was selected to extrude the maxillary right quadrant, equalize gingival display, enhance maxillary incisor display, and facilitate mandibular midline self-correction by repositioning the mandible to the left.

Treatment progress
 A full fixed Genius R passive self-ligating system (Mem & Orthopartner, Taiwan-Sweden) with a reduced slot of 0.0215 x 0.0275 inch was used on both maxillary and mandibular dentition. The orthodontic wire sequence was as follows:
  • 0.014 Thermal Ultra NiTi wire for the initial five months
  • 0.018 x 0.018 Thermal Ultra NiTi wire for six months
  • 0.018 x 0.018 Thermal Ultra NiTi wire with an overlay of 0.012 Thermal Ultra NiTi wire to align maxillary second molars for three months
  • 0.018 x 0.025 Thermal Ultra NiTi wire in the maxilla and 0.016 x 0.25 Stainless Steel wire in the mandible for three months until debonding.
On the day of bonding, bite ramps were placed on the occlusal surface of the maxillary first molars to disocclude both arches for the following purposes:
  • Prevent bracket breakage
  • Eliminate occlusal contacts and facilitate transverse arch expansion
  • Stabilize the vertical position of the maxillary first molars
  • Create a posterior open bite at the premolars level to allow vertical eruption.

Immediately post-bonding, the patient was instructed to wear short light elastics (2.5 oz, 3/16 in.) continuously, except during meals, extending from the maxillary right canine and first premolar to the mandibular first and second right premolars in a Class II diagonal inclination. This regimen was maintained until occlusal cant correction, achieved in nine months. Subsequently, nighttime wear of triangular-shaped elastics was prescribed for an additional three months, extending from the maxillary right canine to the mandibular first and second premolars, to stabilize and maintain the correction. Figure 3a was taken at six months into treatment; Figure 3b was taken at nine months into treatment.
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Fig. 3a
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Fig. 3b


After one year of active treatment, the occlusal cant was fully corrected, Class I molar and canine Angle classification was achieved, and occlusal ramps were removed. A delay in the full eruption of the maxillary right second molar was observed. To expedite eruption, a mini edgewise tube was bonded on the buccal surface of the maxillary right second molar, and a segment of 0.012 Thermal Ultra NiTi wire was overlaid in the posterior area (Fig. 4a). Full alignment of the second molar was successfully achieved. A step-down bend was placed on the maxillary central incisors to create a harmonious smile arc, and all appliances were removed after 17 months and 12 visits of active treatment (Figs. 4b, 5 and 6).
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Fig.4a
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Fig.4b
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Fig. 5: Final extra- and intra-oral photos.
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Fig. 6: Post-treatment panoramic, lateral X-rays.
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Discussion
Asymmetrical smiles result from structural or functional asymmetries. Correction may include differential Le Fort I osteotomy, orthodontic treatment using TADs for intrusion or vertical elastics for extrusion. The case presented here illustrates an asymmetrical smile with a right-to-left maxillary occlusal cant complicated by angulated and deviated maxillary and mandibular midlines. Frontal view images confirm the treatment approach, aiming to lower the maxillary occlusal plane on the right side and intrude it on the left using elastics, bite ramps and differential bonding.

Brackets on the maxillary and mandibular right side (from canine to second premolars) were bonded more gingivally, while on the left side, they were bonded more incisally. During alignment, light thermal NiTi wires, short light elastics, ramps and differential bonding facilitated the expeditious correction of the occlusal cant. The succession of light thermal NiTi wires on the maxillary left lateral segment facilitated controlled relative intrusion and uprighting of the posterior teeth. In addition to correcting the cant, aesthetic goals included creating a full maxillary incisor display and a consonant smile arc. As the patient continues to grow, a 2 mm gingival display upon smiling was deemed harmonious.

Bite ramps can be used in various configurations. They may serve as inclined planes for sagittal discrepancy correction (placed on upper first premolars), flat planes to decrease anterior bite depth (on maxillary central incisors’ cingulum), or to maintain or intrude a specific tooth’s vertical position (on molars’ occlusal surfaces). In this case, ramps on the maxillary first molars’ occlusal surfaces provided clearance for the eruption of right premolars, initiating occlusal cant correction and achieving stable interdigitation.

The combination of broad, light thermal Ultra NiTi wires with differential bonding facilitated maxillary transverse constriction correction, which subsequently reduced gingival exposure on the maxillary left side without TADs. TADs may have been required to further intrude the maxillary left posterior segment if necessary.

Conclusion
A conservative orthodontic treatment protocol was developed for the correction of occlusal cant in a 13-year-old female patient, utilizing simplified mechanics. Treatment comprised early light vertical elastics, strategic placement of bite ramps, differential bonding levels and low-force broad thermal Ultra NiTi wires in conjunction with a reduced slot passive self-ligation system.

References
1. Uydas Senisik, Neslihan Ebru & Hasipek, Selcan. (2015). Occlusal Cant: Etiology, Evaluation, and Management. Turkish Journal of Orthodontics, 27, 174-180.
2. Dym, Harry, et al. Diagnosis and Treatment Approaches to a “Gummy Smile.” Dental Clinics, 64(2), 341–349.
3. Hong RK, Lim SM, Heo JM, Baek SH. Orthodontic treatment of gummy smile by maxillary total intrusion with a midpalatal absolute anchorage system. Korean J Orthod, 43(3), 147-58.
4. Shu, Rui, et al. Adult Class II Division 1 patient with severe gummy smile treated with temporary anchorage devices. Am J Orthod Dentofacial Orthop, 140(1), 97-105.
5. Miller, Charles Jay. The Smile Line as a Guide to Anterior Esthetics. Dental Clinics of North America, 33(2), 157-164.
6. Sarver, David, & Jacobson, Ronald S. The Aesthetic Dentofacial Analysis. Clinics in Plastic Surgery, 34(3), 369-394.
7. Parks LR, Buschang PH, Alexander RA, Dechow P, Rossouw PE. Masticatory exercise as adjunctive treatment for hyperdivergent patients. Angle Orthod, 77(3), 457-62.
Author Bio
Dr. Bilal Koleilat Dr. Bilal Koleilat is a DHA-licensed orthodontist with more than 20 years of experience in Lebanon and Dubai, United Arab Emirates. He earned his dental degree from the Faculty of Dental Medicine at Saint Joseph University in Lebanon, completed a Master of Science in Orthodontics at the University of Kuopio in Finland, and earned a certificate in lingual orthodontics from Indiana University in the United States. Currently, Koleilat serves as an assistant professor in the Department of Orthodontics and Dentofacial Orthopedics at Lebanese University and is a former director of its postgraduate program. He maintains private orthodontic practices in Beirut, Lebanon and Dubai.


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