Orthodontic treatment combined with temporary anchorage device for a case of Class II with osteoarthrosis of the temporomandibular joint

orthodontic waves 71 (2012) 99–104

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Case report

Orthodontic treatment combined with temporary anchorage device for a case of Class II with osteoarthrosis of the temporomandibular joint Naoko Watanabe *, Tadao Fukui, Isao Saito Division of Orthodontics, Department of Oral Biological Science, Niigata University Graduate school Medical and Dental Sciences, 2-5274 Gakkocho-dori, Chuo- ku, Niigata 951-8514, Japan

article info

abstract

Article history:

An adult female patient presented with open bite at Orthodontic Clinic, Niigata University

Received 3 April 2012

Medical and Dental Hospital. The patient was diagnosed as skeletal Class II open bite with

Received in revised form

Class III molar relationship, because of temporomandibular joint-osteoarthrosis (TMJ-OA)

18 April 2012

and the congenital absence of the mandibular lateral incisors. To correct anterior open bite,

Accepted 19 April 2012

surgical orthodontic treatment was considered, but post treatment stability was unpredict-

Published on line 20 May 2012

able and doubtful due to condylar erosion on the CT. We therefore determined that

Keywords:

anchorage device (TAD) placement bilaterally for intruding the maxillary molars would be

TMJ-osteoarthrosis

indicated. At the completion of the active treatment, ideal occlusion was achieved without

nonsurgical treatment with maxillary first premolars extraction and plate type temporary

TAD

further resorption of the condyles. Even two years after the treatment, the stable occlusion

Nonsurgical orthodontic treatment

has been maintained. In conclusion, the orthodontic treatment with TAD is one of the potent devices to provide the ideal occlusion for the patient with TMJ-OA. # 2012 Elsevier Ltd and the Japanese Orthodontic Society. All rights reserved.

1.

Introduction

Temporomandibular joint-osteoarthrosis (TMJ-OA) is sometimes concomitant with Class II mandibular retrusion [1,2]. A previous report has suggested that the patients who develop the skeletal relapse after surgical mandibular advancement have erosions or deformities of the condyle before treatment [2]. Although orthognathic surgery has been usually recommended for Class II dentofacial deformity with receding mandible, surgical mandibular advancement might be contraindicated method for the Class II patients with TMJ-OA. Recently, TAD has been developed and indicated to various types of orthodontic patients. The major applications for TAD in orthodontic treatment are intrusion or distal movement of molars [3–5].

To correct Class II with TMJ-OA, we have applied this method for controlling the maxillary molars and gradual change of mandibular position. This case report illustrates the treatment of the Class II jaw relationship with TMJ-OA combined with TAD, and posttreatment stability.

2.

Case report

2.1.

History and diagnosis

The patient was 22-year ten-month-old Japanese female with chief complaint of open bite. She presented with an anterior open bite of 3.0 mm. The patient was referred to Orthodontic Clinic of Niigata University Medical and Dental Hospital for

* Corresponding author. Tel.: +81 25 227 2904; fax: +81 25 223 5230. E-mail address: [email protected] (N. Watanabe). 1344-0241/$ – see front matter # 2012 Elsevier Ltd and the Japanese Orthodontic Society. All rights reserved. http://dx.doi.org/10.1016/j.odw.2012.04.002

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orthodontic waves 71 (2012) 99–104

Fig. 1 – Facial photographs: (A) pretreatment; (B) posttreatment; (C) postretention.

recommendation of surgical orthodontic treatment by general practitioner. She was in good health and possessed no contraindications to dental treatment. No facial asymmetry was evident in the frontal view of the face. She had slight convex facial profile (Fig. 1A). The intraoral pictures showed overjet of 5.5 mm, open bite and Angle Class III molar relation because of congenital absence of the mandibular lateral incisors. The maxillary dental midline almost coincided with the mandibular one (Fig. 2A). The maxillary right third molar and the mandibular third molars fully erupted. The impacted left maxillary third molar resulted in root resorption of the second molar (Fig. 3A). CT image showed condylar erosion on the surface of both TMJ (Fig. 4). Lateral cephalometric analysis revealed a Class II skeletal relationship (ANB = 6.58), a high mandibular plane

angle (FMA = 42.08) and a steep mandibular occlusal plane (21.08) (Table 1). For TMJ signs and symptoms, a clinical examination was performed. The patient had neither TMJ pain during mastication and at maximum mouth opening, nor muscle tenderness on palpation. Maximum mouth opening without pain was 50.0 mm, no click and clepitus was detected on both sides. She had habitual gum chewing and resting chin in hand. No psychological problems were found. As for the past history of TMJ symptoms, she had pain and click on both TMJ and felt difficulty of mouth opening during her high school days. She had neither experience of trauma nor anamnestic history of rheumatoid disease. The diagnosis for this patient was skeletal Class II open bite with Class III molar relationship, because of TMJ-OA and the congenital absence of the mandibular lateral incisors.

orthodontic waves 71 (2012) 99–104

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Fig. 2 – Intraoral photographs: (A) pretreatment; (B) posttreatment; (C) postretention.

2.2.

Treatment plan and progress

The treatment objectives were as follows: (1) assessment of inactive progressive condylar resorption (PCR), (2) correction of the anterior open bite and establishment of ideal overbite and overjet by intruding upper molars, uprighting lower molars, retracting and tipping the maxillary and mandibular incisors lingually, (3) establishment of Class I occlusal relationship by upright of the mandibular occlusal plane and mesial movement of the maxillary molars. Six months observation period was taken for this patient with advice of eliminating para-functional habits (resting chin in hand, cyclic chewing etc.). Six months later, the patient was reevaluated by CT and cephalometric analysis. CT images still showed condylar surface erosion, but condylar shape was not changed and cephaometric superimposition revealed no

change of mandibular position. Based on the reevaluation, we estimated that PCR by TMJ-OA was inactive at this stage and it would be possible to start the active orthodontic treatment. To retract maxillary incisors, the maxillary first premolars were extracted. Since the root of maxillary left second molar was resorpted by impacted third molar, the left second molar along with the maxillary right third molar were extracted. The .018  .025 standard edgewise appliance was placed on both dental arches. After one month of treatment, plate type TADs were placed bilaterally at the base of the zygomatic arch to provide anchorage for intruding the maxillary molars. After 2 months of the TADs placement, power chains attached between TADs and the maxillary first molars for their intrusion. In order to move the canines distally and the second premolars mesially, power chains were activated

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between the maxillary canine and the second premolar with stainless steel rectangular wires (.017  .022-in.). After three months of treatment, Class III intermaxillary elastics were worn for efficient upright of the mandibular molars for three months (Fig. 5). After establishment of a Class I molar relation, ideal arch wires with .018 .025 for maxillary and .017 .025 for mandibular dental arches were set with vertical elastics. Anterior open bite was completely corrected and suitable occlusion was achieved with Class I molar relationship (Fig. 2B). An active treatment time was two years and three months. After removal of the edgewise appliance, circumferential-type retainer for the maxilla and flexible spiral wires bonded retainer for the mandible were placed. In the cephalometric superimposition from pretreatment to posttreatment, the maxillary and mandibular incisors showed lingual inclination with a decrease in 13.58 of the U1 to SN angle and a decrease in 8.08 of the IMPA, and slight elongation of mandibular incisors was also recognized. The maxillary molars were intruded and moved mesially and the mandibular molars took upright position. According to the cephalometric superimposition, no forward rotation of the mandible occurred, suggested that PCR was not yielded with orthodontic treatment (Fig. 6 and Table 1). Posttreatment panoramic radiograph showed no remarkable root resorption in any teeth (Fig. 3B). The stable occlusion has been maintained even after two years of retention (Figs. 2C and 7).

3. Fig. 3 – Panoramic radiographs: (A) pretreatment; (B) posttreatment; (C) postretention.

Discussion

The etiology of TMJ-OA is still unclear. TMJ-OA is more common among young women, it has been thought that

Fig. 4 – CT images for TMJs at the initial stage: right; left.

Fig. 5 – Intaroral photographs at 3 months of active treatment. Power chains attached between TADs and maxillary first molars for intrusion. Power chains were activated between the maxillar canine and the second premolar. Class III intermaxillary elastics were used for efficient upright of the mandibular molars.

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Table 1 – Cephalometric measurements at pretreatment, posttreatment and postretention.

Angular (8) SNA SNB ANB Facial angle Convexity FMA Y-axis Gonial angle Mand occlusal plane U1-SN IMPA FMIA II Linear (mm) Overjet Overbite

Pretreatment

Posttreatment

Postretention

79.0 72.5 6.5 80.0 14.0 42.0 71.0 128.0 21.0 106.5 93.0 45.0 110.0

79.0 72.0 7.0 80.0 14.0 41.0 70.5 127.0 14.0 93.0 85.0 54.0 132.5

79.0 72.0 7.0 80.0 14.0 41.0 70.5 127.0 14.0 92.0 85.0 54.0 133.0

5.5 3.0

2.0 1.0

2.0 1.0

prominent factors might be sex hormones and age [6]. Since any definitive factor was not showed on the past history of TMJ symptoms, the etiology of PCR of this patient might be sex hormones and age. Furthermore, the para-functional habits, such as resting chin in hand and cyclic chewing, may facilitate TMJ-OA. Orthognathic surgery including mandibular advancement has been usually recommended for Class II dentofacial deformity with receding mandible. However, some patients who develop skeletal relapse after surgery have been reported to suffer from erosions or deformities of the condyle before treatment [2]. Surgical mandibular advancement therefore might be contraindicated method for the Class II patients with TMJ-OA. In this case, the patient underwent orthodontic treatment alone to avoid mandibular advancement and/or

rapid change of condylar position by orthognathic surgery. We were concerned about the possibility that a drastic change by orthognathic surgery might induce PCR. It is difficult to ascertain the condylar shape after the treatment, because CT was not taken after the treatment to avoid the risk of radiation dosage. However, PCR appears not to have exacerbated based on the superimposition of the lateral cephalograms and panoramic findings. Several reports have showed that condylar position change in the glenoid fossa is one of the risk factors for the severe skeletal relapse after surgical advancement of the mandibule [2,7]. In the present case, the condylar position was almost maintained during the treatment and pronounced condylar bony change was avoided. The determination of the onset time of active orthodontic treatment for the patients with TMJ-OA is still controversial.

Fig. 6 – Superimposed cephalometric tracings: (A) Sella – Nasion at Sella for overall change with treatment; (B) palatal plane at ANS for maxillary change; (C) mandibular plane at menton for mandibular change. —: Pretreatment and - - - -: posttreatment.

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Generally, the mechanics of high-pull headgear with Class III elastics is useful to correct some skeletal open bite cases. Even if headgear was carefully adjusted, slight extrusion of the maxillary molars will easily occur and come into clockwise rotation of mandible [12]. TAD is therefore considered useful for the treatment of the present case rather than headgear.

4.

Conclusions

In this case report, the orthodontic treatment with TAD is effective for the patients with TMJ-OA. Proper control of the maxillary molars and avoidance of the surgical mandibular advancement obtained by treatment with TAD seems to have probably contributed to successful stability of the final occlusion. Thus, this method is one of the potent devices to provide the ideal occlusion for the patient with TMJ-OA.

references

Fig. 7 – Superimposed cephalometric tracings: Sella – Nasion at Sella for overall change with treatment; —: Posttreatment and - - - -: postretention.

Michida et al. reported that orthodontic treatment for the adolescent patient with TMJ-OA was postponed until the TMD symptoms subsided and the patient’s growth completed [8]. The present patient did not show any TMD symptoms and the growth was completed at the first visit. However, since the CT image showed the erosion on both condylar surfaces, the treatment was postponed for six months. Then, TMJ condition and mandibular position were reevaluated by CT and lateral cephalogram, respectively. Since no change was detected by reevaluation of the condyle, we considered that PCR was inactive and decided to start the active orthodontic treatment. Root resorption is an iritative iatrogenic problem pertaining to orthodontic tooth movement. A photoelastic model showed that the predominant stress was concentrated at the apices of the upper first molar intruded with TAD [9]. Bondevik found a large amount of root resorption in the bifurcation area in rats when the molars were intruded [10]. The present case showed no severe root resorption after the treatment (Fig. 3 B) suggested that adequate amount of force was applied to the molars. The amount of intrusion of the maxillary first molars was only 1 mm by cephalometric superimposition. The mean amount of intrusion at the maxillary first molars with TAD was reported 3–4 mm [11]. Compared with the previous report, the intrusion amount of the maxillary first molars was considered small. 1 mm intrusion, however, was adequate for this case to establish suitable ideal occlusion without excessive extrusion of the mandibular incisors. Proper control of the maxillary molars for achievement of suitable occlusion was seen in the case treated with TAD.

[1] Yamada K, Satou Y, Hanada K, Hayashi T, Ito J. A case of anterior open bite developing during adolescence. J Orthod 2001;28:19–24. [2] Kobayashi T, Izumi N, Kojima T, Sakagami N, Saito I, Saito C. Progressive condylar resorption after mandibular advancement. Br J Oral Maxillofac Surg 2012;50:176–80. [3] Kravitz ND, Kusnoto B, Tsay TP, Hohlt WF. The use of temporary anchorage devices for molar intrusion. J Am Dent Assoc 2007;138:56–64. [4] Sugawara J, Kanzaki R, Takahashi I, Nagasaka H, Nanda R. Distal movement of maxillary molars in nongrowing patients with the skeletal anchorage system. Am J Orthod Dentofacial Orthop 2006;129:723–33. [5] Sugawara J, Baik UB, Umemori M, Takahashi I, Nagasaka H, Kawamura H, et al. Treatment and posttreatment dentoalveolar changes following intrusion of mandibular molars with application of a skeletal anchorage system (SAS) for open bite correction. Int J Adult Orthod Orthognath Surg 2002;17:243–53. [6] Arnett GW, Milam SB, Gottesman LL. Progressive mandibular retrusion—idiopathic condylar resorption. Part I. Am J Orthod Dentofacial Orthop 1996;110:8–15. [7] Arnett GW, Milam SB, Gottesman LL. Progressive mandibular retrusion—idiopathic condylar resorption. Part II. Am J Orthod Dentofacial Orthop 1996;110:117–27. [8] Michida M, Tanaka N, Tanimoto K, Tanne K. An adolescent case of skeletal maxillary protrusion with osteoarthritis of the temporomandibular joint. Orthodontic Waves 2010;69:23–32. [9] Otsuka Y, Momoi T, Oi M, Sakurai Y, Matsui S, Kanegae H. Photoelastic stress analysis of upper molars intrusion using temporary anchorage device (TAD). J Meikai Dent Med 2010;39:53–8. [10] Bondevik O. Tissue changes in the rat molar periodontium following application of intrusive forces. Eur J Orthod 1980;2:41–9. [11] Yao CJ, Lee J, Chen H, Chang ZJ, Chang H, Chen Y. Maxillary molar intrusion with fixed appliances and mini-implant anchorage studied in three dimensions. Angle Orthod 2005;75:754–60. [12] Saito I, Yamaki M, Hanada K. Nonsurgical treatment of adult open bite using edgewise appliance combined with high-pull headgear and Class III elastics. Angle Orthod 2005;75:277–83.