Facial asymmetry accounts for approximately two-thirds of orthognathic surgical patients and may involve discrepancies in any of the three spatial planes. Conventional bilateral sagittal split osteotomy (BSSO) has limitations in correcting patients with significant discrepancies in bilateral ramus angles. This paper proposes a novel surgical approach for the correction of facial asymmetry using BSSO combined with an anterior midline mandibular split osteotomy and genioplasty. A 30-year-old woman presented with a skeletal Class III pattern, occlusal canting, and a 3-mm deviation of the chin to the right. Intraoral examination revealed an anterior crossbite, dental midline deviation, and a left Angle’s Class III molar relationship. The additional anterior midline mandibular split osteotomy allowed expansion of the posterior transverse dimension and modification of the anterior transverse dimension. This innovative midline osteotomy enabled independent yaw rotation of the bilateral mandibular segments, resulting in improved correction of facial asymmetry compared with conventional BSSO
Background: Craniofacial microsomia (CFM) is the second most common craniofacial anomaly with asymmetrical, congenital malformation. Treatment is challenging and requires interdisciplinary cooperation to restore function and facial esthetics. Objective: A CFM patient suffered from facial asymmetry, occlusal plane cant, malocclusion and severe obstructive sleep apnea, and a 3D surgical orthodontic treatment was planned. Case report: A 37-year-old male patient complained of small chin with deviation. Craniofacial microsomia grade IIa by Pruzansky system and S2A1T1 by SAT system was diagnosed. Clinical examination showed severe facial asymmetry, right microtia, chin deviation to right side 7.0 mm, occlusal plane cant, right Class II and left Class III molar, anterior crowding with upper left lateral incisor missing and lower right first molar buccal crossbite. Cephalometric analysis revealed severe skeletal Class II (ANB 9.0) with hyperdivergent facial type (SN-MP 43.0). Sleep study showed severe obstructive sleep apnea (OSA) with apnea-hypopnea index (AHI) 43.3/h. After general dental care, seven-month pre-surgical orthodontic treatment included leveling and alignment, arch coordination, lower right first molar extraction and initiating second and third molar protraction. 3D surgical plan included Le-Fort I-2 pieces osteotomy, bilateral sagittal split osteotomy (BSSO) and genioplasty. Bimaxillary advancement with counterclockwise rotation along with advanced genioplasty were designed to correct OSA. Post-surgical treatment continued for dental midline correction, upper left lateral incisor space adjustment, lower right molars protraction, finishing and detailing. After total 27-month treatment, significant improved OSA (AHI 0.9), normal overbite and overjet, Class I molar and canine, solid interdigitation and balanced facial symmetry and profile were achieved. Conclusion: 3D surgical orthodontics improves accuracy and efficacy in the treatment of adult craniofacial microsomia patients
This article presents a camouflage orthodontic treatment utilizing the improved superelastic Ti-Ni alloy wire (ISW) to address a case of skeletal Class II malocclusion with two missing mandibular incisors. A 28-year-old female patient with a chief complaint of poor dental alignment sought orthodontic evaluation. Clinical examination revealed a Class III molar relationship, mild crowding, and lingually positioning of tooth 35. Radiographic analysis confirmed a skeletal Class II pattern. The treatment plan included the application of an ISW curve over the maxillary arch to control anterior tooth inclination. Canine distal drive and anterior retraction were performed following the extraction of bilateral upper first premolars. Additionally, the ISW inside-out technique was employed to expand the mandibular arch, facilitating the alignment of the lingually positioned tooth 35 into normal occlusion. By the end of the treatment, a pleasant improvement in the patient’s profile was observed, along with the establishment of a stable occlusion, preserving the two remaining mandibular incisors.
Purpose: This retrospective study aimed to evaluate the correlation between buccal and palatal alveolar bone thickness and the degree of maxillary incisor inclination. The objective was to derive clinically relevant insights for orthodontic treatment planning and controlled tooth movement. Materials and Methods: Sixty-one maxillary central incisors from cone-beam computed tomography (CBCT) scans of thirty-four subjects were retrospectively evaluated and grouped as proclined, upright, and retroclined incisors. Buccal and palatal thicknesses of cortical and cancellous alveolar bone were measured at various levels of the incisor root. The correlation between bone thickness and incisor angulation was investigated using Spearman’s correlation test. Results: There was no significant difference between the cortical and cancellous bone thickness at various levels on labial and palatal sides amongst three groups except for the labial cortical bone thickness at 6 mm from the CEJ (PConclusions: The inclination of maxillary incisors is significantly correlated with the thickness of apical cancellous bone. The findings of the study provide valuable information regarding alveolar bone morphology in the anterior maxillary region, supporting precise and biologically sound orthodontic tooth movement planning.
Purpose: This article introduces a digital workflow for creating a miniscrew-assisted rapid palatal expander (MARPE) guide, to virtually determine the proper MARPE position and to precisely transfer it into the reality. Materials and Methods: A digital workflow was established by the following steps: (1) generating a digital model with palatal soft tissue from the digital scan, (2) isolating teeth on the digital model from the CBCT file for band size try-in using AI software (DentalSegmentator), (3) constructing a model with four parallel cylinders simulating the MARPE screws’ pathways, (4) superimposing the three models to determine the proper MARPE position, (5) 3D printing the model with cylinders guide and separated teeth for band try-in, (6) fitting the band and MARPE on the digital model, and sending it to the dental laboratory for soldering the MARPE extension arm with band. Conclusion: The MARPE guide helps clinicians achieve three key objectives: (1) Precise MARPE and minisrew positioning, and screw length decision to reduce the MARPE failure rate; (2) Reduce clinical visit frequency of patient and reduce the try-in fitness problem of MARPE for saving chair time; (3) Achieve 3D communication between doctor and dental technician.
An adult female patient presented with a pronounced maxillary dental midline deviation and localized crowding in the upper right quadrant, particularly involving the canine and second molar. The maxillary right canine was buccally erupted and overlapped the lateral incisor and first premolar due to insufficient arch space and unfavorable root proximity. The mandibular arch exhibited mild anterior crowding with a flat curve of Spee. Orthodontic treatment was initiated using preadjusted fixed appliances. Extraction of the maxillary right third molar was performed to allow immediate sequential distalization of the maxillary right molars. A bypassed-canine main archwire in combination with a temporary anchorage device (TAD) placed distal to the apex of the maxillary right first molar facilitated efficient molar distalization and buccal expansion. Correction of the maxillary dental midline was achieved through total arch distalization using an additional TAD placed in the upper left posterior region. Guided eruption of the maxillary right canine was accomplished using an improved super-elastic nickel–titanium alloy wire (ISW), which delivered light, continuous forces conducive to physiological tooth movement and favorable periodontal adaptation. The treatment resulted in proper tooth alignment and inclination, stable intercuspation, optimal overjet and overbite, and bilateral Class I canine and molar relationships. A four-year post-treatment follow-up demonstrated stable occlusion and an improved facial soft tissue profile, confirming the long-term effectiveness of the treatment approach.
This case report presents the orthodontic management of a 23-year-old male with severe hypodontia, specifically the congenital absence of all premolars and bilateral peg laterals. The patient sought treatment due to dissatisfaction with previous orthodontic outcomes, characterized by noticeable spacing in the upper anterior region. Clinical evaluation revealed a skeletal Class II relationship and several dental anomalies, prompting the need for an interdisciplinary approach. The patient was treated using an improved super-elastic Ti-Ni alloy wire (ISW), which provided consistent light continuous forces, high elasticity, and super-elastic properties beneficial for controlling tooth movement in patients with missing teeth and anchorage limitations. The primary objectives were to improve occlusion, overbite, and overjet while preparing for future prosthodontic rehabilitation. The treatment plan included the extraction of non-restorable teeth, application of full-mouth brackets, and strategic orthodontic alignment. Resin restorations enhanced the aesthetics of the peg laterals, and space maintenance was carefully managed throughout the treatment. After 37 months of active treatment, significant improvements were observed, including the closure of anterior spaces and optimal alignment of the teeth. Radiographic assessments confirmed ideal root parallelism. This case highlights the complexities of managing severe hypodontia and underscores the importance of tailored orthodontic strategies and interdisciplinary collaboration in achieving functional and aesthetic outcomes.
A 20-year-old female presented with concerns about poor dental alignment and a tendency to bite on her lip easily. Clinical examination revealed a concave and brachy facial profile, accompanied by a deep overbite and a moderate overjet. Radiographic examination showed skeletal Class III with a low mandibular plane angle. Correction of the deep bite was achieved by using the Improved Super-elastic Ti-Ni alloy Wire (ISW) and Intermaxillary elastics (IMEs). To correct the moderate overjet, interproximal reduction (IPR), the Multi-bend Edgewise Archwire (MEAW) technique, and arch lengthening of the lower arch were applied. The active treatment duration took approximately 54 months, resulting in significant improvements in appearance and dentition alignment.
Introduction: Buccal shelf area (BSA) is a recommended anatomic site for mini-screw insertion. Stability of miniscrew is determined by quantity of bone available in the region. Objective: To determine bone thickness and height of BSA for optimum placement of miniscrew. Materials and Methods: This cross-sectional observational study included 40 cone-beam computed tomography (CBCT) scans (23 males, 17 females) of patients aged 19-38 years. Patients were further divided into two age groups 19-28 years and 29-38 years. Measurements were made at 4 different sites: mandibular first molar mesial root (M6) and distal root (D6), second molar mesial root (M7) and distal root (D7). Bone thicknesses were measured at 6 mm and 11 mm apical to the cementoenamel junction (CEJ), and bone heights at 4 mm and 5 mm buccal to the CEJ. Analysis of variance was used to compare bone thickness and height at different sites. Independent t-Test compared the difference in bone thickness and height between gender and age groups. Results: Bone thickness significantly increased from M6 to D7 at both 6 mm and 11 mm levels (PP Conclusion: The optimal sites for miniscrew placement in buccal shelf area are distal root of second molar at 6 mm, and mesial and distal roots of second molar at 11 mm apical to CEJ.
A 16-year-old adolescent female presented with the chief complaint of poor dental alignment and protrusion of the lower teeth. Clinical examination revealed Angle Class III malocclusion accompanied by lower anterior crowding and a protrusive lip profile involving both the upper and lower lips. Cephalometric analysis demonstrated a skeletal Class I relationship with a normal mandibular plane angle. To facilitate anterior retraction, four premolars (15, 24, 34, and 45) were extracted. Following extraction, Improved Super-elastic Ti-Ni alloy wire (ISW) was employed to relieve lower anterior crowding. Canine distalization and anterior retraction were subsequently performed. Elastic chains were used to assist midline correction and tooth derotation, while intermaxillary elastics were applied to achieve optimal interdigitation. The total treatment duration was 5 years and 3 months. At completion, favorable dental alignment and a stable occlusal relationship were obtained.
This case report describes the use of Improved Super-elastic Ti-Ni alloy wire (ISW), developed by Tokyo Medical and Dental University, in managing a skeletal Class III malocclusion with anterior crossbite and a missing lower molar. A 26-year-old female presented with a chief complaint of poor dental alignment. Clinical and radiographic evaluation revealed Angle Class III malocclusion, anterior crossbite, a missing mandibular first molar (36), and a centric occlusion–centric relation (CO–CR) functional shift, consistent with a skeletal Class III pattern. Treatment involved the use of ISW for leveling and alignment of both arches and correction of the anterior crossbite, while maintaining space in the lower left quadrant for future prosthetic rehabilitation. Intermaxillary elastics were applied to enhance occlusal interdigitation. Treatment was completed over 22 months, achieving a stable occlusion and improved facial and dental aesthetics.
Purpose: This study aimed to clarify the anatomical boundaries of mandibular molar distalization, emphasizing the risk of inferior alveolar nerve (IAN) contact. Patients and Methods: In total, 30 skeletal Class III patients undergoing orthognathic surgery (59 mandibular hemi-arches) were analyzed using pretreatment three-dimensional (3D) computed tomography scans. The shortest horizontal distance between the mandibular second molar and the inferior alveolar canal (M2-IAC) was measured at multiple depths below the cementoenamel junction, along with the distance to the lingual cortical plate (M2-MLC). Samples were categorized by vertical facial pattern (low-, normal-, and high-angle case). Simulated distalization cases predicting IAN contact were recorded. Results: Potential IAN contact after full distalization of the second molar was observed in 8 of 59 mandibular sides (13.6%). High-angle cases occurred most frequently (25%), followed by low-angle (16.7%) and normal-angle (3.7%) cases. In most cases, M2-MLC was shorter than M2-IAC, indicating that the lingual cortex would be reached before the nerve; however, in four cases M2-IAC was shorter, suggesting that the nerve would be contacted first. Typically, the distal root apex was the initial point of IAN contact. Conclusion: In Class III skeletal patients, due to the sufficient buffer zone between the mandibular second molar and the IAC, the nerve is seldom the limitation of molar distalization. However, if a larger-than-5 mm molar distalization is attempted, a careful evaluation should be made beforehand, especially those with hyperdivergent (high-angle) skeletal patterns, which showed minimal clearance between the molar root and the IAN. These results highlight the importance of 3D imaging and careful planning to prevent possible IAN impacts during mandibular molar distalization.
Background: Management of severe malocclusion in patients with chronic periodontitis poses significant challenges due to compromised periodontal support and alveolar bone loss. Periodontally accelerated osteogenic orthodontics (PAOO) may facilitate tooth movement while promoting bone regeneration in such cases. Case presentation: A 33-year-old male with chronic periodontitis and severe malocclusion presented for orthodontic correction. Initial treatment included comprehensive periodontal therapy—oral hygiene control, open-flap debridement, and bone grafting—prior to orthodontic intervention. Congenital absence of tooth 12 resulted in mesial drift, and teeth 17, 24, and 27 were extracted due to poor prognosis. Despite initial periodontal improvement, inflammation and labial plate collapse at the extraction site of tooth 24 hindered space closure. Localized PAOO with regenerative materials restored bone integrity, allowing efficient orthodontic tooth movement and achieving stable occlusion. Outcome and follow-up: Periodontal health and occlusion remained stable over a 13-year follow-up period. Conclusion: In patients with chronic periodontitis and severe malocclusion, localized PAOO combined with regenerative therapy can effectively address alveolar defects, enabling safe and stable orthodontic treatment. Long-term interdisciplinary management is critical to maintaining both periodontal and occlusal stability.
Objective: The development of newer archwires can be achieved either by discovering novel materials or by modifying existing ones. The objective of the present study was to coat beta-titanium (β-Ti) archwires with tetrahedral amorphous carbon (ta-C)/hard carbon and to evaluate selected physical and mechanical properties. Methods: Hard carbon–coated (n = 5) and uncoated (n = 5) β-Ti wires were assessed for surface roughness, wear resistance, load-deflection characteristics, and friction using appropriate testing apparatus under dry in vitro conditions. Results: Compared to uncoated β-Ti wires, ta-C–coated β-Ti wires demonstrated a statistically significant reduction in surface roughness, increased wear resistance, and lower coefficients of friction (p < 0.05). However, the ta-C coating did not significantly affect load-deflection properties. Conclusion: Hard carbon (ta-C) coating enhances the surface and tribological properties of beta-titanium archwires without altering their mechanical behavior. Within the limitations of this in vitro study, ta-C–coated β-Ti wires are superior to uncoated β-Ti wires.
Background: Orthodontic intrusion of maxillary incisors is commonly used to treat gummy smiles in deep bite patients. The effectiveness of using one versus two miniscrews for this purpose remains debated. This systematic review and meta-analysis aimed to compare the dental effects of one versus two miniscrews for maxillary incisor intrusion. Materials and Methods: A literature search was conducted across multiple databases for studies published up to December 31, 2024. Five studies (four randomized controlled trials and one non-randomized study) met the inclusion criteria. Risk of bias was assessed using the RoB 2 and ROBINS-I tools. Results: Intrusion was greater in the two-miniscrew group, while incisor proclination was higher in the one-miniscrew group. No significant difference was found between the groups in overbite correction. Root resorption was observed in both groups, with central incisor resorption more in the one-miniscrew group and lateral incisor resorption slightly more in the two-miniscrew group. Conclusion: Two miniscrews placed distal to lateral incisors offer greater incisor intrusion and less proclination than a single miniscrew between central incisors. Overbite reduction was comparable, and root resorption varied by location
Introduction: Severe midface hypoplasia is a common craniofacial deformity in patients with cleft lip and palate (CLP), often linked to functional impairment and esthetic concerns. Although surgical and orthodontic advances have improved outcomes, long-term stability remains challenging. This report presents the management of a bilateral CLP patient and evaluates stability after more than 12 years of follow-up. Diagnosis: A 31-year-old male with bilateral CLP showed a concave facial profile, widened lip scars, reverse overjet of –30 mm, complete crossbite, and missing teeth (12, 22, 36). Palatally displaced premolars (15, 25) produced an hourglass-shaped arch. The diagnosis was skeletal Class III malocclusion with midface hypoplasia and secondary lip and nasal deformities. Treatment Overview: One year of presurgical orthodontics with alignment, decompensation, and extractions (15, 25) preceded two-jaw orthognathic surgery: Le Fort I advancement, bilateral sagittal split osteotomy, mandibular anterior segmental osteotomy and extractions (34, 44). Postsurgical orthodontics continued for two years, followed by prosthetic rehabilitation. Secondary nasal and lip revisions enhanced esthetics. During retention, minor mandibular spacing was corrected with localized appliances. After more than 12 years of follow-up, skeletal correction and functional occlusion remained stable. Cephalometry showed mandibular clockwise rotation. Facial esthetics improved, with only minor residual prognathism and scar depression, both clinically acceptable. Conclusion: Comprehensive orthodontic and orthognathic treatment, supplemented with soft tissue revision, can provide predictable and stable long-term outcomes in cleft-related midface hypoplasia. Careful interdisciplinary planning and follow-up are essential to minimize relapse and manage residual soft tissue issues.
Treating skeletal Class II malocclusion in non-growing patients remains a significant challenge in contemporary orthodontics. Treatment options range from dental camouflage, often involving extractions, to combined orthodontic–surgical approaches. In this case, orthodontic camouflage with extractions was selected to manage a severe skeletal Class II discrepancy in a 28-year-old female patient. A modified intrusive arch was employed to achieve simultaneous retraction and intrusion of the maxillary anterior teeth, effectively reducing excessive overjet. The biomechanical system of the modified intrusive arch generates an anterior intrusive force, a posterior extrusive force, and a posterior tip-back moment. The combined use of Tip-Edge Plus brackets and the modified intrusive arch provided efficient control of tooth movement, enabling successful correction without surgical intervention. This case highlights the effectiveness and biomechanical advantages of the modified intrusive arch in managing severe skeletal Class II malocclusion in adult patients.
This case report describes the successful non-surgical orthodontic management of a complex Class I malocclusion characterized by unilateral posterior tooth loss and functionally induced facial asymmetry. A 28-year-old male patient presented with a non-restorable maxillary first molar (#26) and a missing mandibular second molar (#37). The resulting occlusal discrepancy contributed to a mandibular functional shift and facial asymmetry. The patient declined prosthetic and surgical options, prompting a conservative orthodontic approach. The treatment plan incorporated third molar protraction and upright to substitute for the missing second molar, combined with occlusal rehabilitation to correct the asymmetry. Space closure was achieved using elastic chains, and intermaxillary elastics (IME) were employed to improve intercuspation. The Low Hysteresis super-elastic Ti-Ni alloy wire developed by Tokyo Medical and Dental University played a key role in achieving controlled tooth movement and space closure. Upon completion, the patient exhibited well-aligned dental arches, optimal overbite and overjet, and a marked improvement in facial symmetry. This case highlights the effectiveness of a minimally invasive orthodontic approach for managing complex malocclusions involving unilateral molar loss—achieving functional and esthetic improvement without surgical intervention.
This article presents the orthodontic treatment of a non-surgical, non-growing skeletal Class III malocclusion using an Improved Super-elastic Ti-Ni Alloy Wire (ISW), developed by the Institute of Science Tokyo (formerly Tokyo Medical and Dental University). Teeth 28 and 48 were extracted, and ISW with long Class III intermaxillary elastics (L3–U6) was applied to eliminate anterior occlusal interference, retract the mandible, and induce a clockwise rotation of the mandibular plane. In addition to mandibular space closure, the deviated dental midline and chin asymmetry were corrected using elastic chains and intermaxillary elastics. Proper arch coordination, space management, and midline alignment were achieved, resulting in an improved facial profile after 24 months of treatment.
The decision to remove permanent teeth is often challenging for the orthodontist, and multiple factors should be considered. The primary reason for extracting teeth is crowding, followed by aesthetic concerns, particularly the risk of creating a flat facial profile from over-retracting the front teeth. Often, the facial growth patterns are overlooked in this decision-making process. This review will explore how facial morphology, growth patterns, and maturation stages influence the extraction decision. We shall address common concerns related to extractions, such as the impact on esthetics, airways, the effect of extractions on buccal corridors, their relationship to TMJ issues, and the potential link to sleep apnea. The review will outline the indications and contraindications for extracting four first premolars and discuss factors affecting post-treatment stability, particularly the importance of establishing a solid anterior occlusion. A clinical example will illustrate an unusual extraction protocol for correcting a midline deviation and asymmetric occlusion. The correct timing of extractions is crucial, as improper timing can lead to relapse. Extraction of certain teeth for the best treatment outcomes and long-term occlusal stability will be discussed.
