IP Indian Journal of Orthodontics and Dentofacial Research 2020;6(3):163–169

Content available at: https://www.ipinnovative.com/open-access-journals

IP Indian Journal of Orthodontics and Dentofacial Research

Journal homepage: www.ipinnovative.com

Case Report
Single phase correction of tongue thrust habit alongside fixed orthodontic
treatment for closure of spaced dentition and midline diastema in a male patient
with class I malocclusion without need for a two phase appliance therapy - A case
report
Lishoy Rodrigues1, *, Bhushan Jawale1 , Aljeeta Kadam2 , Priyal Rajani1
1 Dept. of Orthodontics and Dentofacial Orthopedics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
2 Huntly Dental Pratice, Scotland, United Kingdom

ARTICLE INFO ABSTRACT

Article history: Maxillary midline diastema is one of the most frequently encountered esthetic problems in mixed and
Received 23-06-2020 permanent dentition. Several causes have been attributed to the midline diastema, including developmental,
Accepted 08-07-2020 pathologic or iatrogenic. It can also be seen as a transient malocclusion in which case any intervention
Available online 04-09-2020 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
Keywords: common problems around the globe affecting around one-third of the patients who come for orthodontic
Tongue thrust correction treatment. This case report evaluates the management of Class I malocclusion with spaced dentition and
Midline Diastema
a tongue thrusting habit in a male patient with the help of a single phase appliance therapy without the
Fixed Appliance Therapy
need for 2 phase correction, i.e, 1st the correction of tongue thrusting with the help of a habit breaking
Class I malocclusion appliance followed by Fixed appliance therapy with braces. This modality not only saves time, but also
Spaced dentition promotes faster habit breaking as intervention is done in the earlier stages of life when the patient is
Aesthetic Improvement
still growing. Severe maxillar incisor proclination with a convex Orthognthic facial profile, increased
Habit breaking 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.

© 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license
(https://creativecommons.org/licenses/by-nc/4.0/)

1. Introduction significantly alter and improve facial appearance in addition

to correcting irregularity of the teeth. Class I malocclusion
A space between adjacent teeth is called a “diastema”.
is the second most prevalent occlusion after Class II
Midline diastema (or diastemas) occur in approximately
malocclusion. 1,2 Over the last few decades, there has been
98% of 6 year olds, 49% of 11 year olds and 7% of
an increase in the awareness about orthodontic treatment
12–18 year olds. 1 The midline is very often seen to be a
which has led to more and more adults demanding high
routine part of the developing occlusion, due to the natural
quality treatment in the shortest possible time with increased
position of teeth in their bony crypts, the eruption path
efficiency and reduced costs. 3 There are many ways to
of the cuspids, and increase in the size of premaxilla at
treat Class I malocclusions, according to the characteristics
the time of eruption of the maxillary permanent central
associated with the problem, such as anteroposterior
incisors. In Today’s times, Fixed Appliance treatment can
discrepancy, age, and patient compliance. 4,5 The indications
* Corresponding author. for extractions in orthodontic practice have historically been
E-mail address: [email protected] (L. Rodrigues).

https://doi.org/10.18231/j.ijodr.2020.032
2581-9356/© 2020 Innovative Publication, All rights reserved. 163
164 Rodrigues et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2020;6(3):163–169

controversial. 6–8 . On the other hand, correction of Class 2.2. Intra-oral examination
I malocclusions in growing patients, with subsequent dental
camouflage to mask the skeletal discrepancy, can involve Intraoral examination on frontal view shows presence of a
either retraction by non extraction means simply by utilizing large midline diastema of 3mm. On lateral view the patient
the available spaces or by extractions of premolars. 9,10 Lack shows the presence of Class II div 1 incisor relationship,
of crowding or cephalometric discrepancy in the mandibular a Class I Canine relationship on both sides and a Class
arch is an indication of 2 premolar extraction. 11,12 I molar relationship Bilaterally. Patient has an overjet of 6
Fortunately, in some instances satisfactory results with an mm and an overbite of 2 mm. There is spacing in upper
exceptional degree of correction can be achieved without anterior region with flared out anterior teeth, however the
extraction of permanent premolars. This case presents the lower arch is moderately well aligned. The upper and lower
correction of a Class I Spaced malocclusion in a male arch shows the presence of a U shaped arch form and both
patient with a midline diastema, a tongue thrusting habit, upper and lower anterior region show flared out anterior
increased overjet and a bimaxillary protrusion simply by teeth indicative of a bimaxillary dentoalveolar protrusion.
executing a non extraction protocol by breaking the tongue OPG of the patient shows presence of 3rd molars in a
thrusting habit alongside the progress of Fixed appliance developing stage and a spaced anterior dentition with a
therapy for retraction and closure of existing spaces. The midline diastema.
Non Extraction protocol shown in this case is indicative of
how a borderline extraction case can be converted into a non
extraction case by routine Fixed Orthodontic treatment

2. Case Report
2.1. Extra-oral examination
A 19 year old male patient presented with the chief
complaint of forwardly placed, spaced upper front
teeth and excessive show of upper front teeth. On
Extraoral examination, the patient had a convex profile,
grossly symmetrical face on both sides, incompetent lips
,moderately deep mentolabial sulcus and an average
Nasolabial Angle , a Leptoprosopic facial form,
Dolicocephalic head form, Average width of nose and
mouth, minimal buccal corridor space, a consonant smile
arc and slightly posterior divergence of face. The patient
had no relevant prenatal, natal, postnatal history or a
family history. However the patient had a tongue thrusting Fig. 2: Pre treatment intraoral photographs
habit, which was diagnosed when the patient was asked to
swallow on occlusion. The tongue protruded against the
spaced dentition. On Smiling, there was a complete show Photographic Analysis
of maxillary anterior teeth. However, mandibular teeth were
not visible on smiling. The patient had a toothy smile.
The patient had an unaesthetic flat smile arc and was very
dissatisfied with his smile.

Fig. 3: Photographic Analysis

Fig. 1: Pre treatment extraoral photographs
Rodrigues et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2020;6(3):163–169 165

Fig. 5: Pre treatment cephalometric readings

Fig. 4: Pre Treatment X-Rays

166 Rodrigues et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2020;6(3):163–169

Fig. 6:

Table 1: Pre treatment cephalometric summary

Parameters Pre- treatment
SNA 84◦
SNB 82◦
ANB 2◦
WITS 1mm(BO ahead of AO)
MAX. LENGTH 104mm
MAN. LENGTH 140mm
IMPA 98◦
NASOLABIAL ANGLE 102◦
U1 TO NA DEGREES 38◦
U1 TO NA mm 11mm
L1 TO NB DEGREES 32◦
L1 TO NB mm 7mm
U1/L1 ANGLE 106◦
SADDLE ANGLE 118◦
ARTICULAR ANGLE 148◦
GONIAL ANGLE 126◦
FMA 32◦
Y AXIS 62◦

3. Diagnosis
This 19 years old male patient is diagnosed with Angle’s
Class I malocclusion with an average to vertical growth
pattern, proclined upper and lower incisors, spacing in the
upper and mild crowding in the lower anterior region,
protrusive upper and lower lips, incompetent lips, an
unaesthetic flat smile arc, an increased overjet and decreased
overbite, tongue thrusting habit and presence of a midline
diastema.
 Rodrigues et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2020;6(3):163–169 167

Nance Palatal Button Appliance was given for correction

of tongue thrusting habit alongside fixed orthodontic braces
treatment. Retraction and closure of spaces was then started
by use of 0.019” x 0.025” rectangular NiTi with accentuated
Anchor sweeps in the upper and lower stiff archwires
for opening of bite to prevent the bite deepening during
retraction followed by 0.019” x 0.025” rectangular stainless
steel wires. Anchorage was conserved by light retraction
forces constantly monitoring the already well settled molar
relation. This is the most important step in a borderline
extraction case wherein anchorage conservation is of utmost
importance. Finally light settling elastics were given with
rectangular steel wires in lower arch and 0.012” light
NiTi wire in upper arch for settling , finishing, detailing
and proper intercuspation. Midline Diastema closure was
achieved. The smile of the patient changed from being flat
and unaesthetic to a more pleasing and consonant.

Fig. 8: Treatment extraoral photographs

Fig. 9: Treatment intraoral photographs with nance palatal arch for

habit breaking

Fig. 7: Model Analysis

3.1. Treatment Progress

Complete bonding & banding in both maxillary and
mandibular arch done, using MBT-0.022X0.028”slot.
Initially a 0.012” NiTi wire was used which was followed
by 0.014, 0.016”, 0.018”, 0.020” NiTi archwires following
sequence A of MBT. After 6 months of alignment and Fig. 10: PRE debonding x-rays
leveling NiTi round wires were discontinued. A Fixed
168 Rodrigues et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2020;6(3):163–169

Table 2: Pre Debonding Cephalometric Readings effects. Class I malocclusion with spacing might have
Parameters Post-treatment any number of a combination of the skeletal and dental
SNA 82◦ component. Hence, identifying and understanding the
SNB 80◦ etiology and expression of Class I spaced malocclusion
ANB 2◦ and identifying differential diagnosis is helpful for its
WITS 1mm correction. The patient’s chief complaint was forwardly
MAX. LENGTH 99mm placed, spaced and excessive show of upper front teeth
MAN. LENGTH 138mm
.The selection of orthodontic fixed appliances is dependent
IMPA 92◦
upon several factors which can be categorized into patient
NASOLABIAL ANGLE 106◦
factors, such as age and compliance, and clinical factors,
U1 TO NA DEGREES 30◦
U1 TO NA mm 3mm such as preference/familiarity and laboratory facilities.The
L1 TO NB DEGREES 27◦ execution of only Fixed appliance therapy appropriately
L1 TO NB mm 2mm resulted in an improvement in the patient’s profile in
U1/L1 ANGLE 130◦ this case. Alongside fixed orthodontic treatment, a habit
SADDLE ANGLE 119◦ breaking Fixed Nance Palatal Button appliance was given
ARTICULAR ANGLE 144◦ to the patient for correction of his severe tongue thrusting
GONIAL ANGLE 125◦ habit. The SNA value showed a significant decrease from
FMA 28◦ 84 to 82 degrees, the SNB value changed from 82 to 80
Y AXIS 64◦ degrees thus addressing the major problem of maxillary
and mandibular bidental protrusion. The mandibular
incisor proclination reduced from 98 to 92 degrees, the
nasolabial angle changed from 102degrees to 106degrees
thus moderately improving the patient’s profile and the
Frankfurts mandibular plane angle showed changes from
being vertical to more towards average growth pattern
of patient due to the counterclockwise rotation of the
mandibular plane. Successful results were obtained after
the fixed MBT appliance therapy within a stipulated period
of time. The overall treatment time was 12 months. After
this active treatment phase, the profile of this 19 year old
male patient improved significantly as seen in the post
treatment Extra oral photographs. Removable Vacuum
formed clear retainers were then delivered to the patient.
Fig. 11: Pre debonding extraoral photographs
Midline Diastema was corrected, spacing was corrected and
the smile arc of the patient improved drastically to being
4. Discussion consonant and pleasant. The patient was very happy and
satisfied with the results at the end of the treatment.
It is important for an Orthodontist to consider contributing
factors before determining an optimal treatment plan. 5. Conclusion
These include normal growth and development, tooth size
discrepancies, excessive incisor vertical overlap of different This case report shows how a Tongue thrusting habit
causes, mesiodistal and labiolingual incisor angulation, in a patient whose growth has nearly completed can be
generalized spacing and pathological conditions. A managed alongside fixed orthodontic treatment, thus saving
carefully developed differential diagnosis enables the time that is spend during a 2 phase appliance therapy
practitioner to choose the most effective orthodontic and/or with 1st correcting the inborn habit and then proceeding
restorative treatment. Restorative and prosthetic treatment towards fixed braces treatment. The planned goals set in
is usually employed to treat Diastemas based on tooth- the pretreatment plan were successfully attained. Good
size discrepancies. The most appropriate treatment often intercuspation of the teeth was maintained with class I molar
requires orthodontically closing the midline diastema. It is relationship by carefully conserving anchorage. Treatment
challenging to treat Class I malocclusion and bimaxillary of bimaxillary protrusion and localized spacing with
protrusion without extraction of premolars. A well chosen midline diastema included the retraction and retroclination
individualized treatment plan, undertaken with sound of maxillary and mandibular incisors with a resultant
biomechanical principles and appropriate control of decrease in soft tissue procumbency and convexity. The
orthodontic mechanics to execute the plan is the surest maxillary and mandibular teeth were found to be esthetically
way to achieve predictable results with minimal side satisfactory in the line of occlusion with a pleasing
 Rodrigues et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2020;6(3):163–169 169

Table 3: Comparison of pre treatment and pre debonding References

cephalometric readings
1. Hossain MZ. Prevalence of malocclusion and treatment facilities at
Parameters Pre- treatment Post- Dhaka Dental College and Hospital. J Oral Health. 1994;1(1).
treatment 2. Ahmed N. Prevalence of malocclusion and its aetiological factors. J
SNA 84◦ 82◦ Oral Health. 1996;2(2).
SNB 82◦ 80◦ 3. Khan RS, Horrocks EN. A Study of Adult Orthodontic Patients and
ANB 2◦ 2◦ their Treatment. Br J Orthod. 1991;18(3):183–94.
4. Salzmann JA. Practice of orthodontics. Philadelphia: J. B. Lippincott
WITS 1mm(BO ahead of AO) 1mm Company; 1966. p. 701–725.
MAX. LENGTH 104mm 99mm 5. Mcnamara JA. Components of Class II malocclusion in children 8 10
MAN. LENGTH 140mm 138mm years of age. Angle Orthod. 1981;51:177–202.
IMPA 98◦ 92◦ 6. Case C. The question of extraction in orthodontia. Am J Orthod.
NASOLABIAL 102◦ 106◦ 1964;50:660–91.
ANGLE 7. Case CS, Dewey C. Discussion of Case: the question of extraction in
orthodontia. Am J Orthod. 1964;50:900–12.
U1 TO NA 38◦ 30◦ 8. Tweed CH. Indications for the extraction of teeth in orthodontic
DEGREES procedure. Am J Orthod Oral Surg. 1944;30(8):405–28.
U1 TO NA mm 11mm 3mm 9. Cleall JF, Begole EA. Diagnosis and treatment of Class II Division 2
L1 TO NB 32◦ 27◦ malocclusion. Angle Orthod. 1982;52:38–60.
DEGREES 10. Strang RHW. Tratado de ortodoncia. In: Editorial Bibliogra´fica
L1 TO NB mm 7mm 2mm Argentina. Buenos Aires; 1957. p. 657–71.
11. Bishara SE, Cummins DM, Jakobsen JR, Zaher AR. Dentofacial
U1/L1 ANGLE 106◦ 130◦ and soft tissue changes in Class II, Division 1 cases treated
SADDLE 118◦ 119◦ with and without extractions. Am J Orthod Dentofacial Orthop.
ANGLE 1995;107(1):28–37.
ARTICULAR 148◦ 144◦ 12. Rock WP. Treatment of Class II malocclusions with removable
ANGLE appliances. Part 4. Class II Division 2 treatment. Br Dent J.
GONIAL 126◦ 125◦ 1990;168:298–302.
ANGLE
FMA 32◦ 28◦
Y AXIS 62◦ 64◦
Author biography

Lishoy Rodrigues Post Graduate Student

consonant smile arc. The overjet become near ideal Bhushan Jawale Professor
and normal overbite was found. The correction of the
malocclusion was achieved, with a significant improvement Aljeeta Kadam General Practitioner
in the patient aesthetics and self-esteem. The patient was
very satisfied with the result of the treatment. Priyal Rajani Intern

6. Source of Funding
Cite this article: Rodrigues L, Jawale B, Kadam A, Rajani P. Single
None. phase correction of tongue thrust habit alongside fixed orthodontic
treatment for closure of spaced dentition and midline diastema in a
male patient with class I malocclusion without need for a two phase
7. Conflict of Interest appliance therapy - A case report. IP Indian J Orthod Dentofacial
None. Res 2020;6(3):163-169.