Treatment of Proclined Upper Incisors with Reverse Bracket Placement: A Case Report

Transposition of a maxillary canine and a lateral incisor and use of cone-beam computed tomography for treatment planning

Maxillary midline diastema is one of the most frequently encountered esthetic problems in mixed and permanent dentition. Several causes have been attributed to the midline diastema, including developmental, pathologic or iatrogenic. It can also be seen as a transient malocclusion in which case any intervention is contraindicated. A wide range of possible treatments like restorative procedures, composite build up, surgeries (frenectomies) can be done, based on etiology. Thus, correct diagnosis of etiology and specific early intervention plays a major role in deciding the treatment plan.Class I malocclusion is one of the most common problems around the globe affecting around one-third of the patients who come for orthodontic treatment. This case report evaluates the management of Class I malocclusion with spaced dentition and a tongue thrusting habit in a male patient with the help of a single phase appliance therapy without the need for 2 phase correction, i.e, 1st the correction of tongue thrusting with the help of a habit breaking appliance followed by Fixed appliance therapy with braces. This modality not only saves time, but also promotes faster habit breaking as intervention is done in the earlier stages of life when the patient is still growing. Severe maxillar incisor proclination with a convex Orthognthic facial profile, increased mandibular plane angle, incompetent lips and increased overjet was observed on clinical and cephalometric analysis. Orthodontic treatment resulted in a marked improvement of the patient’s smile and a remarkable increase in self-confidence and quality of life. The profile changes and treatment results were demonstrated with proper case selection and good patient cooperation with fixed appliance therapy.

This article examines the prevalence, mechanism and risk factors associated with orthodontically induced root resorption. The long term prognosis for those who suffer severe root resorption is also discussed. CPD/Clinical Relevance: Root resorption is an inevitable consequence of treatment with fixed appliances. This article indicates risk factors which may be identified prior to treatment, and measures which may be taken to minimize shortening during treatment.

The aim of orthodontic treatment in a bimaxillary protrusion case is to obtain an esthetically pleasing face with harmonious soft tissue profile, stable occlusion and pleasant smile. The etiology of bimaxillary protrusion is multifactorial involving both genetic and environmental causes like mouth breathing, tongue and lip habits and tongue volume. The following case report shows management of class I bimaxillary protrusion malocclusion in a hypodivergent case with extraction of all first premolars. The effective management of space without losing anchorage is itself a big challenge. The results produced a pleasant facial profile with attainment of good occlusion. The case required extraction of 1st premolars for correction of the proclined, forwardly placed and crowded upper and lower anterior teeth. Clinical and cephalometric evaluation revealed a Class I skeletal pattern and clinical examination revealed presence of an orthognathic facial profile, a horizontal growth pattern, increased overjet and average overbite, crowding in maxillary and mandibular anterior region, potentially incompetent lips, increased lip fullness and lip strain with an unaesthetic smile arc and a decreased nasolabial angle. Following fixed orthodontic treatment by removal of all 1st premolars and with retraction of anterior segment, a marked improvement in patient's smile, facial profile and occlusion was achieved and there was a remarkable increase in the patient's confidence and quality of life. The profile changes and treatment results were demonstrated with proper case selection and good patient cooperation with fixed appliance therapy.

A midline diastema is a part of normal dental development, which, in the mixed dentition, is termed the ‘ugly duckling’ stage. Supernumerary teeth, however, can also be a cause, with the most common type being a mesiodens. Supernumeraries can cause other complications including delayed or failure of eruption of a permanent tooth, displacement of crowns, crowding, root resorption and cyst formation. Treatment options for supernumeraries include immediate or delayed removal or active monitoring. This article advocates for early diagnosis and treatment to reduce the need for future complex treatment. CPD/Clinical Relevance: This case emphasizes the importance for clinicians to accurately and carefully diagnose the cause of a midline diastema and the presence of supernumerary teeth early in development. Prompt orthodontic referral can reduce the need for later complex surgical and orthodontic treatment.

Moving an incisor across the midline: A treatment alternative in an adolescent patient

Background: Maxillary midline diastema is one of the most frequently encountered esthetic problems in mixed and permanent dentition. Several causes have been attributed to the midline diastema, including developmental, pathologic or iatrogenic. It can also be seen as a transient malocclusion in which case any intervention is contraindicated. A wide range of possible treatments like restorative procedures, composite build up, surgeries (frenectomies) can be done,based on etiology. Thus, correct diagnosis of etiology and specific early intervention plays a major role in deciding the treatment plan. Case report: This case report evaluates the management of Class I malocclusion with spaced anterior dentition in a 26 year old male patient with presence of peg shaped lateral incisors and maxillary and mandibular midline diastema. The upper and lower arch midline diastema can be attributed to presence of a thick band of fibrous tissue between the upper and lower central incisors. The case was treated with routine fixed orthodontic therapy and frenectomy was performed at the end of the treatment just before closure of midline diastema space to prevent scar tissue formation. After orthodontic treatment, the patient was referred to an aesthetic dentist for maxillary lateral incisors build-up with composite. Conclusion: Maxillary and mandibular anterior arch spaces were closed down . The dental changes and treatment results were demonstrated. This case report illustrates the interdisciplinary collaboration of an Orthodontist, Periodontist and Endodontist for treatment of such a case. With proper case selection, planning and good patient cooperation, we could obtain significant results.

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This study aims to assess morphological changes, the spatial relationship between the maxillary central incisor (U1) and the incisive canal (IC), and root resorption in non-extraction cases treated with either clear aligners or fixed appliances using 3D-CBCT. Two hundred eight maxillary central incisors from 104 patients underwent maxillary incisors retraction without extraction using clear aligners (n = 60) or fixed appliances (n = 44). Measurements, including IC width, root-IC distance, cortical bone width, IC height, and root resorption, were taken before (T1) and after (T2) treatment at specified heights (H1, H2, and H3; 2, 4, and 6 mm above the labial cementoenamel junction of U1). IC width increased with aligners but decreased with fixed appliances, particularly at H1. IC cortical bone width decreased at various levels, with more pronounced reductions at H1 and H3 in the fixed group. The U1 root-IC distance also decreased significantly in both groups, especially in the fixed group at H1 (0.73 ± 0.86mm vs 0.40 ± 58mm, P = 0.042), H2 (0.88 ± 0.94mm vs 0.47 ± 0.78mm, P = 0.024), and H3 (0.73 ± 0.92mm vs 0.30 ± 0.98mm, P = 0.008). Root-IC proximity patterns varied notably, with higher separation rates in the aligner group and greater approximation, contact, and invasion rates in the fixed group. Root resorption was more significant in the fixed group than in the aligner group (1.01 ± 0.74mm vs 0.32 ± 0.56mm, P < 0.001). Factors such as treatment duration, U1 movement, and U1-IC distance were identified as primary predictors of root-IC proximity changes. These results highlight the need for careful treatment planning to preserve root health and prevent IC-related risks. Clear aligners may be preferable in non-extraction cases, particularly when the upper incisor is near the IC or requires more retraction, as they could reduce root resorption while maintaining IC dimensions better than fixed appliances.

Supernumerary teeth are relatively rare anomalies, with mesiodens being the most common type. They are often detected in childhood, but when left undiagnosed, can persist into adulthood and interfere with occlusion and aesthetics. Timely identification and management are therefore essential to prevent long-term complications. The presence of a mesiodens in adult patients, although rare, often leads to complications including midline deviation, localised spacing, and aesthetic concerns. This case report presents the comprehensive orthodontic management of a 25-year-old male with an erupted mesiodens positioned between the maxillary central incisors. The patient exhibited localised spacing in both arches with a skeletal and dentoalveolar Class I malocclusion. Following the extraction of the mesiodens under local anaesthesia, fixed appliance therapy with pre-adjusted MBT 0.022″ brackets was initiated. Alignment and levelling were achieved with 0.016″ NiTi wires progressing to 0.019×0.025″ stainless steel wires. Space closure was accomplished using continuous light forces through elastomeric chains, with careful anchorage management to achieve midline correction and preserve molar and canine relationships. The total treatment duration was 12 months. Post-treatment assessment revealed successful space closure, corrected midline, and improved smile aesthetics. Bonded lingual retainers were placed to ensure long-term stability. This case highlights the importance of early identification and management of mesiodens to achieve optimal orthodontic and aesthetic outcomes. Detection of mesiodens in adulthood can still be regarded as early because it precedes the onset of secondary complications such as cyst formation, root resorption, or complex malocclusion. Additionally, orthodontic correction is more efficient and stable at this stage when compared to later decades of life. Controlled biomechanics and diligent retention protocols are crucial in achieving predictable and stable results in adult patients. The novelty of this case lies in managing space closure and midline correction following the extraction of an erupted mesiodens in an adult patient, which is rare compared to routine cases.

This case report intended to evaluate the clinical outcome of the esthetic buttons for midline diastema space closure rather than full conventional fixed appliance therapy followed by conventional frenectomy. Four esthetic buttons were placed on the central incisors (2 on each tooth) for complete bodily movement of the teeth followed by traction. Space closure was achieved by a 1-month time interval followed by a build-up of lateral incisors and followed by frenectomy. This approach can be followed in patients with compromised financial support who are seeking orthodontic treatment for minor correction and with compromised periodontal support as this delivers less force with great comfort. Patients who are hesitant to begin treatment due to financial obstacles with fixed appliance therapy may find this helpful.

Autogenous mandibular canine transplantation

This study was conducted to systematically evaluate the biomechanical impact of varying degrees of root and bone resorption resulting from periodontitis and orthodontic tooth movement (OTM) on the mandibular anterior teeth. The objective was to determine whether these distinct resorption patterns exert a specific influence on tooth displacement and strain patterns. A finite element (FE) model of an idealized anterior mandible from the first premolar in the third to the fourth quadrant was developed without bone or root resorption and a constant periodontal ligament (PDL) thickness of 0.2 mm. Variations included three root resorption levels (0%, 20%, 50%) and three bone resorption types (circular 50%, circular 80%, vestibular 80%). Models ranged from 200,000 to 440,000 elements and 55,000 to 130,000 nodes. Orthodontic forces, namely root torque (5 Nmm), intrusion (0.2 N), and distalization (0.5 N) were applied for subsequent crown displacement and PDL strain analysis. A total of 180 simulations were performed. Simulations showed that displacement was similar across different bone resorption conditions, irrespective of modeled root resorptions. Circumferential bone resorption increased tooth displacement, regardless of root resorption status. Vestibular bone resorption exhibited less increase in tooth displacement. However, when accompanied by root resorption, the combination exacerbated tooth displacement. Strains in the PDL clearly increased with a circumferential bone resorption of 80%. This study highlights the critical role of bone resorption in tooth displacement during OTM, particularly the challenges associated with circumferential resorption. Clinicians must consider both bone and root resorption for personalized medicine treatment of patients with severe periodontitis, in favor of low-force application strategies to optimize outcomes and minimize complications linked to excessive tooth displacement.

Maintaining the achieved occlusion following the orthodontic treatment is the most difficult task of the entire treatment process. Relapses are common in noncompliant patients and in some cases despite the patient following the protocol. There are various factors for the relapse after the orthodontic treatment. The relapsed malocclusions can be corrected by simple procedures such as composite buttons. They are economical and esthetic considering the relapsed space. A 27-year-old female patient presented to our orthodontic department with the chief complaint of mild anterior spacing with midline diastema and anterior crossbite in relation to 21, after treatment with fixed appliance therapy. The patient was treated with composite buttons, and satisfactory results were obtained. Composite buttons are an alternate treatment line for mild relapsed cases in patients who are not willing to undergo the fixed appliance therapy again.

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