Global Academic Journal of Dentistry and Oral Health

Available online at https://www.gajrc.com

DOI: 10.36348/gajdoh.2021.v03i03.002

ISSN-2706-8994 (P)
ISSN-2707-8868 (O)

Case Report

“Fixed Orthodontic Mechanotherapy for Correction of Generalized

Spacing and Severe Proclination of Anterior Teeth” – A Case Report
Dr. Bhushan Jawale1, Dr. Lishoy Rodrigues2*, Dr. Anand Ambekar3, Dr. Anup Belludi4, Dr. Pushkar Gawande5, Dr.
Rohan Hattarki6
1Professor, Dept of Orthodontics and Dentofacial Orthopedics, Sinhgad Dental College and Hospital, Vadgaon Bk, Pune, Maharashtra, India
2Post Graduate Resident, Dept of Orthodontics and Dentofacial Orthopedics, Sinhgad Dental College and Hospital, Vadgaon Bk, Pune,
Maharashtra, India
3Professor, Dept of Orthodontics and Dentofacial Orthopedics, MIDSR Dental College and Hospital, Vadgaon Bk, Pune, Maharashtra, India
4 Professor and HOD, Dept of Orthodontics and Dentofacial Orthopedics, KLE Dental College and Hospital, Bangalore, Karnataka, India
5Reader, Dept of Oral and Maxillofacial Surgery, Sinhgad Dental College and Hospital, Vadgaon Bk, Pune, Maharashtra, India
6Associate Professor, Dept of Orthodontics and Dentofacial Orthopedics, KLE Dental College and Hospital, Belgaum, Karnataka, India

*Corresponding Author Abstract: Background: Maxillary midline diastema is one of the most frequently
Dr Lishoy Rodrigues encountered esthetic problems in mixed and permanent dentition. Several causes
have been attributed to the midline diastema, including developmental, pathologic
Article History or iatrogenic. It can also be seen as a transient malocclusion in which case any
Received: 26.03.2021 intervention is contraindicated. A wide range of possible treatments like
Accepted: 10.05.2021 restorative procedures, composite build up, surgeries (frenectomies) can be done,
Published: 16.05.2021 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 32 year old male patient with maxillary midline diastema and a
generalized spaced upper and lower dentition. The upper arch midline diastema
can be attributed to presence of a thick band of fibrous tissue between the upper
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. Conclusion: Maxillary
and mandibular arch spaces were closed down . The dental changes and treatment
results were demonstrated. This case report illustrates the interdisciplinary
collaboration of an Orthodontist and Periodontist for treatment of such a case.
With proper case selection, planning and good patient cooperation, we could
obtain significant results.
Keywords: Fixed orthodontic mechanotherapy, Midline diastema, Spaced
dentition, Generalized spacing, Severe proclination, MBT Mechanotherapy,
Unaesthetic smile, Class I malocclusion, Spaced dentition, Aesthetic improvement.
Copyright © 2021 The Author(s): This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0
International License (CC BY-NC 4.0) which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use
provided the original author and source are credited.

INTRODUCTION and increase in the size of premaxilla at the time of

A space between adjacent teeth is called a eruption of the maxillary permanent central incisors
“diastema”. Midline diastema (or diastemas) occur in [1, 19]. In Today’s times, Fixed Appliance treatment
approximately 98% of 6 year olds, 49% of 11 year can significantly alter and improve facial appearance
olds and 7% of 12–18 year olds.The midline is very in addition to correcting irregularity of the teeth.
often seen to be a routine part of the developing Class I malocclusion is the second most prevalent
occlusion, due to the natural position of teeth in occlusion after Class II malocclusion [2-3, 14-15].
their bony crypts, the eruption path of the cuspids, Over the last few decades, there has been an

Citation: Bhushan Jawale et al (2021). “Fixed Orthodontic Mechanotherapy for Correction of Generalized Spacing and Severe Proclination of
Anterior Teeth” – A Case Report. Glob Acad J Dent Oral Health; Vol-3, Iss- 3, pp-29-35.

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Bhushan Jawale et al; Glob Acad J Dent Oral Health; Vol-3, Iss- 3 (May-Jun, 2021): 29-35

increase in the awareness about orthodontic consonant reverse smile arc. The patient had no
treatment which has led to more and more adults relevant prenatal, natal, postnatal history, history of
demanding high quality treatment in the shortest habits or a family history. On Smiling, there was
possible time with increased efficiency and reduced excessive show of maxillary anterior teeth. The
costs [4, 16-18]. There are many ways to treat Class I patient had a toothy smile. On smiling he also
malocclusions, according to the characteristics showed the presence of spaced anterior dentition
associated with the problem, such as and an unaesthetic facial profile and smile. The
anteroposterior discrepancy, age, and patient patient was very dissatisfied with his smile.
compliance [5-6, 20]. The indications for extractions
in orthodontic practice have historically been Pretreatment extra oral photographs
controversial [7-9, 21]. On the other hand,
correction of Class I malocclusions in growing
patients, with subsequent dental camouflage to
mask the skeletal discrepancy, can involve either
retraction by non-extraction means simply by
utilizing the available spaces or by extractions of
premolars [10, 11]. Lack of crowding or
cephalometric discrepancy in the mandibular arch is
an indication of 2 premolar extraction [12, 13, 22-
25]. Fortunately, in some instances satisfactory
results with an exceptional degree of correction can
Intra-oral examination
be achieved without extraction of permanent
Intraoral examination on frontal view
premolars. This case presents the correction of a
shows presence of an increased overjet and an
Bimaxillary dentoalveolar protrusion with a Class I
average overbite with severe spacing in upper and
malocclusion in an adult male patient with
lower anterior region. On lateral view the patient
generalized spacing and severely proclined
shows the presence of Class II Division 1 incisor
maxillary and mandibular anterior teeth by
relationship and a Class I Canine and molar
executing a non-extraction protocol. The Non-
relationship bilaterally. There was proclined and
Extraction protocol shown in this case is indicative
forwardly placed upper and lower anterior teeth
of how an unesthetic smile can be converted into an
with presence of upper midline diastema and a
aesthetic and pleasant one by routine fixed
lower dental midline shift to the left by 2mm.
Orthodontic treatment without need for any
extractions simply by utilizing the existing availabe
Pretreatment intra oral photographs
spaces.

CASE REPORT
Extra-oral examination
A 32 year old adult male patient presented
with the chief complaint of forwardly placed upper
and lower front teeth with spacing and excessive
show of front teeth. On Extraoral examination, the
patient had an orthognathic facial profile, grossly
symmetrical face on both sides with competent lips
,moderately deep mentolabial sulcus and an acute
Nasolabial Angle, a Mesoprosopic facial form,
Dolicocephalic head form, average width of nose and
mouth, minimal buccal corridor space and a non-

Pretreatment cephalometric readings

PARAMETERS PRE- TREATMENT
SNA 84°
SNB 82°
ANB 2°
WITS -1mm
MAX. LENGTH 106mm
MAN. LENGTH 98mm
IMPA 112°
NASOLABIAL ANGLE 87°

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PARAMETERS PRE- TREATMENT

U1 TO NA DEGREES 38°
U1 TO NA mm 8mm
L1 TO NB DEGREES 35°
L1 TO NB mm 6mm
U1/L1 ANGLE 109°
SADDLE ANGLE 128°
ARTICULAR ANGLE 145°
GONIAL ANGLE 128°
FMA 24°
Y AXIS 64°

Cephalometric evaluation 8. Increased lip strain

1. Steiners analysis shows a slightly prognathic
maxilla and mandible, Class I Skeletal pattern, Treatment objectives
an average to horizontal growth pattern, 1. To correct proclined maxillary and mandibular
averagely inclined maxillary and mandibular anterior teeth
anterior teeth and proclined upper and lowers 2. To correct spacing in the maxillary and
lips mandibular anterior teeth
2. Tweeds analysis shows an average to 3. To correct maxillary and mandibular
horizontall growth pattern and averagely prognathism
inclined mandibular incisors 4. To correct the increased overjet
3. Wits appraisal shows BO ahead of AO by 1 mm 5. To correct the decreased Nasolabial angle
indicating Skeletal Class I pattern 6. To maintain Angles Class I Molar relationship
4. McNamara analysis shows a prognathic maxilla 7. To maintain Class I Canine relationship
and mandible, an average to horizontal growth 8. To achieve a Class I Incisor relationship
pattern and averagely inclined mandibular 9. To achieve congruent midlines
incisors 10. To decrease the lip strain
5. Rakosi Jaraback analysis shows a horizontal 11. To achieve a pleasing smile and a pleasing
growth pattern and average inclination of profile
maxillary and mandibular incisors
6. Holdaway soft tissue analysis shows average Treatment plan
maxillary and mandibular sulcus depth,  Non Extraction protocol was followed
protrusive upper and lower lips with increased  Fixed appliance therapy with MBT 0.022 inch
strain in lips. bracket slot
 Initial leveling and alignment with 0.012”,
Diagnosis 0.014”, 0.016”, 0.018”, 0.020” Niti archwires
This 32 year old male patient was diagnosed following sequence A of MBT
with a Class II malocclusion with a slightly  Retraction and closure of spaces by use of
prognathic maxilla and mandible and an average to 0.019” x 0.025” rectangular NiTi followed by
horizontal growth pattern, increased overjet and 0.019” x 0.025” rectangular stainless steel wires.
average overbite, proclined upper and lower  Group A anchorage in the upper and lower arch
incisors with lower midline shift to the left, spacing with the help of Nance palatal button
in the upper and lower anterior region with  Frenectomy in upper midline region for removal
presence of midline diastema in upper arch, of fibrous band of tissues resulting in the
protrusive upper and lower lips with increased lip midline diastema in the upper arch
strain, moderately deep mentolabial sulcus,  Final finishing and detailing with 0.014” round
competant lips and decreased Nasolabial angle. stainless steel wires
 Retention by means of Begg’s Wrap-around
List of problems retainers along with lingual bonded retainers in
1. Proclined maxillary and mandibular anterior the upper and lower arch.
teeth
2. Spacing in maxillary and mandibular anterior Treatment plan
region To correct the unaesthetic dentition, it was
3. Slightly prognathic maxilla and mandible decided to treat this patient with preadjusted
4. Increased overjet edgewise appliance and 0.022" slot MBT
5. Decreased Nasolabial angle prescription was used. Frenectomy was planned to
6. Incompetant lips excise the thick band of fibrous connective tissue
7. Non-congruent dental midlines
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between the maxillary central incisors causing the was addressed. Patient had a pleasant smile and a
diastema. The procedure was planned to be pleasant dentition at the end of the treatment which
executed just before the closure of spaces towards continued over 16 months.
the end of orthodontic treatment.
Post treatment cephalometric readings
Treatment progress Parameters Post-treatment
Complete bonding & banding in both SNA 83°
maxillary and mandibular arch was done, using SNB 82°
MBT-0.022X0.028”slot. Initially a 0.012” NiTi wire ANB 1°
was used which was followed by 0.014, 0.016”, WITS -1mm
0.018”, 0.020” Niti archwires following sequence A MAX. LENGTH 104mm
of MBT. After 6 months of alignment and leveling MAN. LENGTH 97mm
NiTi round wires were discontinued. Retraction and IMPA 96°
closure of existing spaces was then started by use of NASOLABIAL ANGLE 99°
0.019” x 0.025” rectangular NiTi followed by 0.019” U1 TO NA DEGREES 26°
x 0.025” rectangular stainless steel wires. Reverse
U1 TO NA mm 2mm
curve of spee in the lower arch and exaggerated
L1 TO NB DEGREES 24°
curve of spee in the upper arch was incorporated in
L1 TO NB mm 1mm
the heavy archwires to prevent the excessive bite
deepening during retraction process and also to U1/L1 ANGLE 132°
maintain the normal overjet and overbite. SADDLE ANGLE 126°
Anchorage was conserved in the upper and lower ARTICULAR ANGLE 145°
arch by using light retraction forces, thus constantly GONIAL ANGLE 130°
monitoring molar and canine relationship. Group A FMA 25°
anchorage was needed in the upper and lower arch Y AXIS 65°
to achieve a Class I incisor relationship and to
maintain the Class I canine and molar relationship Post treatment extra oral photographs
bilaterally. Retraction and closure of existing spaces
was done with the help of Elastomeric chains
delivering light continuous forces and replaced after
every 4 weeks due to force decay and reduction in
its activity. Frenectomy surgery was performed by
the periodontist in upper midline region for removal
of fibrous band of connective tissues resulting in the
midline diastema in the upper arch. Final spaces
were closed down after the frenectomy procedure.
Finally light settling elastics were given with
rectangular steel wires in lower arch and 0.012” Post treatment intra oral photographs
light NiTi wire in upper arch for settling , finishing,
detailing and proper intercuspation. The increased
overjet was corrected with an ideal occlusion at the
end of the fixed apppliance therapy. Patient had a
pleasant and consonant smile arc on smiling along
with significantly improved nasolabial angle. There
was improvement in occlusion, smile arc, profile and
position of chin at the end of the treatment.

Treatment results
All of the original treatment objectives were
achieved. Maxilary midline diastema was corrected.
Spacing in the upper and lower arch was closed. The
maxillary and mandibular arches were well aligned
and coordinated with corrections of the lower
midline deviation. Normal overbite was maintained
and normal overjet was achieved. Class I incisor
relationship was achieved, Class I canine and Class I
molar relationship was maintained. The chief
complaint of forwardly placed upper and lower front
teeth with spacing and excessive show of front teeth

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DISCUSSION clear bimaxillary dentoalveolar protrusion with

It is important for an Orthodontist to severely proclined upper and lower anterior
consider contributing factors before determining an dentition. The selection of orthodontic fixed
optimal treatment plan. These include normal appliances is dependent upon several factors which
growth and development, tooth size discrepancies, can be categorized into patient factors, such as age
excessive incisor vertical overlap of different causes, and compliance, and clinical factors, such as
mesiodistal and labiolingual incisor angulation, preference/familiarity and laboratory facilities. The
generalized spacing and pathological conditions. A execution of all 1st premolar extraction followed by
carefully developed differential diagnosis enables Fixed appliance therapy could be executed for
the practitioner to choose the most effective improvement in the patient's convex profile in this
orthodontic and/or restorative treatment. case. The most important point to be highlighted
Restorative and prosthetic treatment is usually here is the decision to not extract the premolars.
employed to treat Diastemas based on tooth-size After analysing the case thoroughly and reading all
discrepancies. The most appropriate treatment often pretreatment cephalometric parameters along with
requires orthodontically closing the midline evaluating the patients profile clinically, a decision
diastema. A well-chosen individualized treatment was made of proceeding with the treatment without
plan, undertaken with sound biomechanical extracting the 1st premolars as the patient presented
principles and appropriate control of orthodontic with severe spacing and the exising spaces would be
mechanics to execute the plan is the surest way to enough to correct the proclined anterior teeth. This
achieve predictable results with minimal side case could be managed by non-extraction and hence
effects. Treatment of a Spaced Class I malocclusion we proceeded with the same. The treatment and
without extraction of premolars is challenging. A closure of existing spaces very efficiently improved
well-chosen individualized treatment plan, the patients smile at the end of the treatment.
undertaken with sound biomechanical principles Successful results were obtained after the fixed Pre-
and appropriate control of orthodontic mechanics to adjusted Edgewise appliance therapy within a
execute the plan is the surest way to achieve stipulated period of time. The overall treatment time
predictable results with minimal side effects. Class I was 16 months. After this active treatment phase,
malocclusion with Bimaxillary Dentoalveolar the profile of this 32 year old adult male patient
protrusion might have any number of a combination improved significantly as seen in the post treatment
of the skeletal and dental components. Hence, extra oral photographs. Upper and lower Hawleys’s
identifying and understanding the etiology and retainers were then delivered to the patient along
expression of Class I malocclusion and identifying with fixed lingual bonded retainers in upper and
differential diagnosis is helpful for its correction. lower arch. One year follow up records were taken
The patient's chief complaint was forwardly placed and did not reveal any drastic untoward changes in
and spaced upper and lower front teeth with the patients smile and profile.
excessive show of front teeth . The case was of a

Comparison of pre and post treatment cephalometric readings

PARAMETERS PRE- TREATMENT POST-TREATMENT
SNA 84° 83°
SNB 82° 82°
ANB 2° 1°
WITS -1mm -1mm
MAX. LENGTH 106mm 104mm
MAN. LENGTH 98mm 97mm
IMPA 112° 96°
NASOLABIAL ANGLE 87° 99°
U1 TO NA DEGREES 38° 26°
U1 TO NA mm 8mm 2mm
L1 TO NB DEGREES 35° 24°
L1 TO NB mm 6mm 1mm
U1/L1 ANGLE 109° 132°
SADDLE ANGLE 128° 126°
ARTICULAR ANGLE 145° 145°
GONIAL ANGLE 128° 130°
FMA 24° 25°
Y AXIS 64° 65°

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Bhushan Jawale et al; Glob Acad J Dent Oral Health; Vol-3, Iss- 3 (May-Jun, 2021): 29-35

Retention photographs forwardly placed upper and lower anterior teeth

included the retraction and retroclination of
maxillary and mandibular incisors utilizing the
existing spaces with a resultant decrease in soft
tissue procumbency and facial convexity. The profile
changed from convex to orthognathic .The maxillary
and mandibular teeth were found to be esthetically
satisfactory in the line of occlusion. Patient had an
improved smile and profile. The correction of the
malocclusion was achieved, with a significant
improvement in the patient aesthetics and self-
esteem. The patient was very satisfied with the
result of the treatment.

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