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International Journal of Applied Dental Sciences 2020; 6(3): 146-154

ISSN Print: 2394-7489


ISSN Online: 2394-7497
IJADS 2020; 6(3): 146-154 Treatment of a growing male having a recessive
© 2020 IJADS
www.oraljournal.com
mandible with removable myofunctional appliance
Received: 01-05-2020
Accepted: 03-06-2020
therapy followed by fixed orthodontic treatment: A
case report
Dr. Bhushan Jawale
Professor, Dept of Orthodontics
and Dentofacial Orthopedics,
Sinhgad Dental College and
Dr. Bhushan Jawale, Dr. Lishoy Rodrigues, Dr. KM Keluskar, Dr. Roopa
Hospital, Sinhgad, Pune, Jatti, Dr. Anup Belludi and Dr Rohan Hattarki
Maharashtra, India
Abstract
Dr. Lishoy Rodrigues Class II malocclusion is one of the most common problems around the globe affecting around one-third
PG Student, Dept of
of the patients who come for orthodontic treatment Twin block appliance from its inception and
Orthodontics and Dentofacial
Orthopedics, Sinhgad Dental
evolution itself has been widely accepted as a more competent Class II corrector compared to earlier
College and Hospital, Sinhgad, bulky monoblock appliances. Functional appliances can be used successfully in growing patients with
Pune, Maharashtra, India certain skeletal Class II patients. Twin block appliance is very effective in a growing patient. The
successful use of this appliance in the treatment of skeletal Class II malocclusion is based upon factors
Dr. KM Keluskar such as; age of patient, compliance of the patient and other case selection criteria. This appliance is very
Dean, Professor and HOD, Dept successful in a patient with a retrognathic mandible and well aligned arches with a positive VTO. This
of Orthodontics and Dentofacial efficiently enables the mandibular forward positioning and improves the profile. This case report is of a
Orthopedics, KLE Dental 12-year-old growing male patient with a Skeletal Class II Pattern and a recessive lower jaw who was
College and Hospital, Belgaum, treated with Twin block appliance. The profile changes and treatment results were demonstrated. In
Karnataka, India permanent dentition, twin block appliance produces a similar effect as in mixed dentition phase. With
proper case selection and good patient cooperation, we can obtain a significant result with twin block
Dr. Roopa Jatti appliance.
Professor, Dept of Orthodontics
and Dentofacial Orthopedics,
KLE Dental College and Keywords: Removable myofunctional appliance, fixed appliance therapy, recessive mandible,
Hospital, Belgaum, Karnataka, Twinblock, Class II
India
Introduction
Dr. Anup Belludi Twin block appliance is very effective in a growing patient. The successful use of this
Professor and HOD, Dept of
appliance in the treatment of skeletal Class II malocclusion is based upon factors such as; age
Orthodontics and Dentofacial
Orthopedics, KLE Dental of patient, compliance of the patient and other case selection criteria Dentofacial orthopedic
College and Hospital, Bangalore, treatment can significantly alter and improve facial appearance in addition to correcting
Karnataka, India irregularity of the teeth. Functional appliance therapy can be used successfully in Class II
malocclusion, e.g., in a growing patient. Twin blocks are simple bite blocks that interlock at a
Dr Rohan Hattarki 70° angle and correct the maxillomandibular relationship through functional mandibular
Associate Professor, Dept of
Orthodontics and Dentofacial displacement. The twin block appliance was developed by Clark in 1980s. They modify the
Orthopedics, KLE Dental occlusal inclined plane, guiding the mandible forward into correct occlusion. The use of these
College and Hospital, Belgaum, appliances is greatly dependent on patient’s compliance and they simplify the fixed appliance
Karnataka, India phase. Functional appliances may be defined as orthodontic appliances that use the forces
generated by the muscles to achieve dental and skeletal changes [1, 2]. These appliances have
been used in clinical orthodontics for a long time and are extensively featured in the literature
[3, 4]
. Their effect is produced from the forces generated by the stretching of the muscles [5]. It is
a commonly used functional appliance partly due to its acceptability by patients (Chadwick et
Corresponding Author: al., 1998) [6]. The muscles and soft tissues are stretched with the generated pressure transmitted
Dr. Lishoy Rodrigues to the skeletal and dental structures potentially resulting in skeletal growth modification and
PG Student, Dept of
Orthodontics and Dentofacial tooth movement [6]
Orthopedics, Sinhgad Dental
College and Hospital, Sinhgad,
Pune, Maharashtra, India

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Case Report competent lips, deep mentolabial sulcus and an average


Extra-Oral Examination Nasolabial Angle, a Leptoprosopic facial form,
A 12year 8 month old male patient presented with the chief Dolicocephalic head form, Average width of nose and mouth,
complaint of forwardly placed and irregular upper and lower minimal buccal corridor space, a consonant smile arc and
front teeth and a backwardly placed lower jaw. On Extraoral posterior divergence of face . The patient had no relevant
examination, the patient had a convex profile, grossly prenatal, natal, postnatal history, history of habits or a family
symmetrical face on both sides with a retruded chin, history.

Pre Treatment Extraoral Photographs

Intra-Oral Examination 5mm. There is moderate crowding in upper and lower anterior
Intraoral examination on frontal view shows presence of a region. The upper and lower arch shows the presence of a V
deep overbite, on side views the patient shows the presence of shaped arch form. OPG of the patient shows presence of all
Class II div 1 incisor relationship, an End on canine four 3rd molars in a developing stage. Hand wrist radiograph
relationship on both sides and an end on molar relationship on shows SMI stage 3 and lateral cephalogram is clearly
both sides. Patient has an overjet of 7 mm and an overbite of indicative of a concex facial profile and a recessive lower jaw,

Pre-Treatment Intraoral Photographs

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Pre Treatment Radiographs

Pre Treatment Cephalometric Readings maxillary and mandibular anteriors, forwardly placed
Parameters Pre- Treatment
maxillary and mandibular anteriors and protrusive upper
SNA 83° and lower lips
SNB 76° 2. Tweeds analysis shows a Horizontal growth pattern and
ANB 7° proclined mandibular incisors
WITS 5mm 3. Wits appraisal shows AO ahead of BO by 4 mm
MAX. LENGTH 75mm indicating Skeletal Class II pattern
MAN. LENGTH 98mm 4. Ricketts analysis shows a retrognathic
IMPA 110° mandible,retropositioned condyles and proclined
NASOLABIAL ANGLE 88° mandibular anteriors
U1 TO NA DEGREES 39° 5. McNamara analysis shows a retrognathic maxilla,
U1 TO NA mm 8mm retrognathic mandible, a horizontal growth pattern,
L1 TO NB DEGREES 35° decreased lower anterior facial height and proclined
L1 TO NB mm 7mm mandibular incisors
U1/L1 ANGLE 103° 6. Rakosi Jaraback analysis shows a Horizontal growth
SADDLE ANGLE 130°
pattern and proclined maxillary and mandibular incisors
ARTICULAR ANGLE 154°
7. Holdaway soft tissue analysis shows increased maxillary
GONIAL ANGLE 143°
FMA 24°
and mandibular sulcus depth and increased strain of lips
Y AXIS 69° 8. Downs analysis shows a retropositioned chin, a Class II
Skeletal pattern, a horizontal growth pattern and
1. Steiners analysis shows an average maxilla and a proclined maxillary and mandibular anterior teeth
retrognathic mandible, Class II Skeletal pattern, an
Average to Horizontal growth pattern, proclined Model Analysis

Diagnosis 5. To correct a deep mentolabial sulcus


This 12 years 8 month old male patient was diagnosed with 6. To correct a deep curve of spee
Angle’s Class II div 1 malocclusion with a avrerage maxilla, 7. To achieve a pleasing smile and a pleasing profile
retrognathic mandible and a horizontal growth pattern,
increased overjet and overbite, proclined upper and lower Treatment Plan
incisors, deep mentolabial sulcus and protrusive upper and a) Myofuntional Therapy: Removable Twinblock appliance
lower lips b) Appliance design:

Treatment Objectives  Saggital advancement: 7 mm


1. To correct mandibular retrognathism  Vertical opening: 4 mm
2. To correct crowding in upper and lower anterior region c) Fixed Appliance Therapy
3. To correct proclination of upper and lower anteriors
4. To correct overjet and overbite

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Treatment Twinblock Design


The treatment plan followed 2 phases of orthopedic and The design of the upper component of the twin block involved
orthodontic correction. 1st phase involved correction of an acrylic base plate, which covers the palate and occlusal
Sagittal discrepancy using Twinblock functional appliance surfaces of the first molars and second premolars. There was
therapy. The appliance used was a standard Clarks original an inclined plane at the end of the mesial end of the acrylic
Twinblock with a sagittal advancement of 6 mm and a vertical block. A labial bow was used for anterior retention of the
opening of 4 mm. The 2nd phase of treatment involved fixed appliance. A midline screw was also included. The lower
orthodontic treatment with MBT 0.022 inch slot. component consisted of a lingual acrylic base plate covering
the edge of the lower incisors.

Twinblock Appliance Delivery Intraoral Photographs

Treatment Progress of the case. The overall treatment time was 24 months, i.e., 12
Construction bite of the patient was registered by training the months of functional appliance wear and 12 months of fixed
patient to bite in the desired anterior position which corrected appliance treatment. The molar relationship was
the profile and enabled a class I molar relation bilaterally. overcorrected to a super Class I on the right and left side.
Construction bite was taken with 6mm advancement and 4 Retention by means of both removable Hawleys retainer was
mm opening. Clarks Twinblock was fabricated and appliance given for 1 year and permmanent Lingual Bonded retainers in
was delivered to the patient and proper post appliance upper and lower arch were given.
delivery instructions were given. Follow ups were carried out
regularly. Pterygoid response was observed in the patient
within 28 days of delivery of the appliance. Trimming of the
appliance was done in an occlusogingival direction at an
interval of 3 weeks. Sagittal correction into a class I molar
relation was achieved in 8 months. Photograph of Profile
change after myofunctional therapy show the positive change
in patients profile.

Profile Changes after Myofunctional therapy

Fixed Appliance Therapy with Mbt0.022 Inch Slot


Treatment Rationale of Phase I of the treatment involved the
use of functional appliance to reduce the overjet, achieve class
I molar relationships, and gain anchorage at the start of the
treatment to simplify the fixed appliance stage and improve
the patient’s profile by causing a small skeletal change. This
phase was followed with upper and lower fixed appliances Mid Treatment Intraoral of Fixed Appliance Therapy
(0.022″ slot brackets) to close spaces, detailing, and finishing
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Mid Treatment Xrays

Discussion myofunctional therapy resulted in an improvement in the


Class II malocclusion might have any number of a patient's profile, which is largely attributed to the favorable
combination of the skeletal and dental component. Hence, growth and partly to the functional appliance. It has been
identifying and understanding the etiology and expression of proved in the literature that functional appliances do not
Class II malocclusion and identifying differential diagnosis is produce long-term skeletal changes and most of their effects
helpful for its correction Twin block functional appliance has are dentoalveloar. In a prospective controlled trial with twin
several well established advantages including the fact that it is blocks and controls to investigate the skeletal and dental
well tolerated by patients and it can be used in the mixed and effects showed that the ANB angle reduced by 2°, which was
permanent dentition. There are potential disadvantages such almost entirely due to mandibular length increase which was
as the proclination of the lower incisors and development of 2.4 mm compared to the controls as measured from Ar-Pog.
posterior open bites. In this case, the treatment objectives There was no evidence of a restriction in maxillary growth.
were achieved largely due to good patient compliance The Successful results were obtained after the myofunctional
patient's chief complaint was forwardly placed and irregular therapy within 12 months of time. The overall treatment time
upper and lower front teeth and a backwardly placed lower was 24 months, i.e., 12 months of functional appliance wear
jaw. The selection of functional appliances is dependent upon and 12 months of fixed appliance treatment. After this active
several factors which can be categorized into patient factors, treatment phase, the profile of this 12 year old growing male
such as age and compliance, and clinical factors, such as patient improved significantly as seen in the post treatment
preference/familiarity and laboratory facilities. The extra oral photographs

Pre Finishing Intraoral

Pre Finishing Xrays

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Post Treatment Cephalometric Readings


Parameters Post-Treatment
SNA 81°
SNB 80°
ANB 1°
WITS 1mm
Max. Length 76mm
Man. Length 104mm
Impa 97°
Nasolabial Angle 99°
U1 To Na Degrees 26°
U1 TO NA Mm 2mm
L1 To Nb Degrees 24°
L1 TO NB Mm 2mm
U1/L1 Angle 132°
Saddle Angle 123°
Articular Angle 145°
Gonial Angle 132°
Fma 25°
Y Axis 71°

Post Treatment Extraoral Photographs

Post Treatment Intraoral Photographs

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International Journal of Applied Dental Sciences http://www.oraljournal.com

Post Treatment Xrays

Comparison of Pre and Post Treatment Cephalometric Readings

Parameters Pre- Treatment Post-Treatment


SNA 83° 81°
SNB 76° 80°
ANB 7° 1°
WITS 5mm 1mm
MAX. LENGTH 75mm 76mm
MAN. LENGTH 98mm 104mm
IMPA 110° 97°
NASOLABIAL ANGLE 88° 99°
U1 TO NA DEGREES 39° 26°
U1 TO NA mm 8mm 2mm
L1 TO NB DEGREES 35° 24°
L1 TO NB mm 7mm 2mm
U1/L1 ANGLE 103° 132°
SADDLE ANGLE 130° 123°
ARTICULAR ANGLE 154° 145°
GONIAL ANGLE 143° 132°
FMA 24° 25°
Y AXIS 69° 71°

Removable Retention

Fixed Retention

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Profile Changes Pre-Treatment, After Twinblock Therapy and After Fixed Appliance Treatment

The Wonders of a Myofunctional Appliance

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