Lingual extraction and non-extraction

case reports
D1X XChristopher RioloD1,2
2X X

This paper presents two case reports illustrating extraction and non-extraction
treatment using a custom lingual orthodontic appliance system (Incognito). The
initial pretreatment records and treatment setups are presented. Treatment
mechanics are described and illustrated. Pre-treatment and post-treatment ceph-
alometric superimpositions are presented. (Semin Orthod 2018; 24:325–338) ©
2018 Published by Elsevier Inc.

Introduction to paper Case 1: Diagnosis

here is an increasing demand for esthetic
T orthodontic treatment by our adolescent
and adult patients. Unfortunately, many
patients are forced to make a choice between a
buccal appliance or no treatment at all. This
false choice imposed by orthodontic providers
results in thousands of patients not benefiting
from the treatment they desire. For many
patients there is a difference between “excel-
lent treatment” and “excellent treatment out-
come”; for these patients an excellent
treatment outcome is necessary but not suffi-
cient to achieve an “excellent treatment”; these
patients also require an aesthetic treatment
experience that fits their lifestyle.
Case 1
The first case presentation illustrates a situation
where only a fixed appliance can fully correct
the Cl III relationship. While it is true that per-
haps Clear Aligner therapy in conjunction with
heavy IPR could improve this patient occlusal
relationship, clear aligners are unlikely to
achieve the Cl III correction shown here. This
case shows how a lingual appliance system can
provide not only an “excellent treatment results”
but the truly esthetic treatment that for this
patient constituted “excellent treatment”.
1
Affiiate Associate Profesor University of Washington, Depart-
ment of Orthodontics, Seattle, WA United States.
2 illa we wanted to expand the intercanine
Private Practice in Seattle Washington.
E-mail: criolo@umich.edu
© 2018 Published by Elsevier Inc.
1073-8746/12/1801-$30.00/0
https://doi.org/10.1053/j.sodo.2018.08.002
Patient was a 28 year old Caucasian male with no
significant medical or dental history. He had a
history of orthodontic treatment as an adoles-
cent. The chief complaint was, “I did not wear
my retainer and I want to fixed my teeth” .
The patient presented with a Cl III Skeletal
dysplasia, characterized by slightly retrognathic
maxilla and prognathic mandible. Dentally the
patient had a Cl III molar and canine (sub div)
relationship, upper and lower crowding and a
partial anterior crossbite Figs. 1 and 2 involving
the UR3-UL2 with LR3-LL2 (see Figs. 3 and 4).
The anterior crossbite has resulted in moderate
attrition of UR1 and L/10 s. The periodontal
charting revealed probing depths within normal
limits although he had gingival recession on
UR4,5, UL1,2,3, LL3, LR3,4. The functional anal-
ysis revealed no anterior guidance with signifi-
cant anterior traumatic occlusion. The etiology
of the Cl III relationship is likely genetic and the
anterior crossbite is likely a result of late mandib-
ular growth after the completion of his initial
orthodontic treatment.
Case 1: Objectives of treatment
Level and align the dentition, correct anterior
crossbite, establish proper anterior guidance
with a Cl I canine relationship, improve peri-
odontal stability and smile esthetics. In the Max-
distance and maintain the intermolar distance.
In the mandible our goal was to maintain or con-
strict the intercanine distance and maintain the
intermolar distance

Seminars in Orthodontics, Vol 24, No 3, 2018: pp 325 338 325

326
Figure 1. Pre treatment cephalometric image.
Figure 2. Pre treatment panoramic image.
Case 1: Treatment plan
Upper and lower lingual fixed appliances, non
extraction, lower anterior IPR (1.8 mm per
setup), Cl III elastics, finish Cl I canine and
deliver upper and lower Essix type retainers.
Case 1: Treatment discussion
The Incognito appliance design and wire pro-
gression can be seen in Fig. 6 a c; bands with
half occlusal coverage were employed to initially
Riolo
open the anterior bite. Fig. 5 also shows that the
upper first molar bands were designed with buc-
cal buttons in anticipation of using Cl II elastics.
Fig. 5a on the left shows 0.014 Niti wires engaged
into the upper and lower arches. The lower wire
is engaged into the self-ligating slot; in the upper
the wire is fully engaged using double overties.
Fig. 5b in the middle depict progress photos with
the upper and lower aligned with 0.016 £ 0.022
niti wires fully engaged. On the right in Fig. 5c
the arches are shown with upper and lower
0.016 £ 0.024 SS wires. The upper wire had 13°
 Lingual extraction and non-extraction case reports 327

Figure 3. The initial photo layout show a Cl III sub div molar relationship, anterior crossbite, upper and lower
crowding.

of extra torque in the anterior and lower clear
buttons have been placed on the lower canines
for the Cl III elastics. An upper 0.0182 £ 0.0182
TMA wire was used with the lower stainless steel
wire and vertical elastics to detail and finish the
treatment. During the finishing phase of treat-
ment, I added some composite to the incisal
edge of the upper left central incisor to provi-
sionally restore the incisal edge wear that was
present due to the original anterior crossbite.
The final treatment result is shown in Fig. 7.
Cl III elastics were planned and used during the
treatment to accomplish A-P Cl I correction of
the molars and canine; 1.8 mm of lower anterior
IPR planned in the treatment setup and was this
was accomplished during treatment (see
Fig. 4b). The amount of intercanine expansion
planned in the setup was fully expressed to the
tenth of a mm (see Table 1). Before analyzing
the superimpositions, I believed the I achieved
the correction from Cl III molar to Cl I molar
through A-P changes related to Cl III elastics; the
superimposition (see Fig. 11) reveals that the
molar Cl I correction was largely due to extrusion
328 Riolo

Figure 4. The malocclusion models are shown here: note the anterior crossbite and the Cl III molar relationship
on the left side.

Figure 5. The treatment setup and planned IPR are shown; the IPR was completed as planned.
 Lingual extraction and non-extraction case reports 329

Figure 6. abc: Column a, b and c show the treatment progression. In the first column “a” the initial leveling and
aligning wires are shown at the time of bonding. The lower wire was initially inserted into the self ligating slot
behind the wings the lower arch. This self ligating slot is only present on the lower anterior brackets and can
accommodate round wires up to 0.014. In the second Column labeled “b” upper and lower 16 £ 22 N wires are
shown, the initial alignment is now complete. In the third column labeled “c”, the 17 £ 25TMA finishing wires are
shown. The upper brackets were designed with buccal buttons in anticipation of using Cl III elastics; clear buttons
for Cl III elastics can be seen in the lower anterior.

Table 1. Best case theoretical engagement angle

with 5% and 15% oversized slots (assuming ideal achieve these results the way that we thought we
geometry) did. This fact reinforces the idea that self-evalua-
Wire Slot size 5% 10% tion through careful analysis of one own finished
cases is a critical to monitoring the quality of our
16 £ 22 0.018 8° 13°
17 £ 25 0.018 4° 9° treatment outcomes as well as understanding
19 £ 25 0.022 10° 16° exactly how we achieve these outcomes Figs.
7 10.

of the posterior teeth and down and backward
rotation of the mandible rather than strictly ante-
rior posterior movement of the upper and lower
dentition. This type of correction is very unlikely
with clear aligner therapy. This these treatment
results also demonstrate that while we as clini-
cians achieve the result that were planned in the
majority of our treatments, we do not always
Case 2
In the second case I will present illustrates an
extraction treatment to address the patient chief
complaint of bimaxillary protrusion. Clearly
clear aligners would not be a reasonable treat-
ment option in this circumstance; only a lingual
fixed appliance system can esthetically and pre-
dictably complete a four bicuspid extraction
treatment plan to an ABO quality finish. This
case shows how a lingual appliance system can
330
Figure 7. The final photo layout.
provide not only an “excellent treatment results”
but the truly esthetic treatment that for this
patient constituted “excellent treatment”.
Case 2: Diagnosis
This patient presented as a healthy 26 year old
male with the chief complaint “I think my teeth
are too far forward”. He has a history of caries
and regular dental care. The etiology of his
bimaxillary protrusion is likely genetics and it
is possible that early childhood caries may have
contributed to his upper and lower crowding.
The patient presented with a slightly dolicho-
cephalic Cl I skeletal pattern characterized by
excess LAFH. He presented with Cl I molar and
buccal segments, 3 mm maxillary crowding and
Riolo
6 mm of lower crowding with a bimaxillary pro-
trusion. He also presented with a partial anterior
crossbite involving the upper and lower left can-
ines. He has fair oral hygiene with localized slight
gingival recession on #4, 5, 10, 12, 13 and 22. He
has a convex facial profile, slight Mentalis muscle
strain on lip closure and excessive LAFH.
Case 2: Objectives of treatment
Level and align the dentition, correct anterior
crossbite, retract the upper and lower incisors
(decrease the dentoalveolar protrusion and lip
support, do not increase the LAFH, avoid expan-
sion of the buccal segments and aggravation of
the gingival recession.
 Lingual extraction and non-extraction case reports 331

Figure 8. The final models revealed an easily passing ABO CRE score of 15.

Figure 9. Post treatment cephalometric image.

Case 2: Treatment plan elastomeric chain and Cl I and Cl II elastics, fin-

ish Cl I molar/canine. Retain indefinitely with
Upper and lower fixed lingual appliances with
Essix type retainers. The initial records and treat-
the extraction of the upper and lower second
ment setup with the planned IPR are shown in
premolars, reciprocal space closure using
Figs. 12 16.
332 Riolo

Figure 10. Post treatment panoramic image.

Figure 11. The pre and post treatment superimpositions show extrusion as well as anterior movement of the max-
illary posterior molars. This dental movement resulted in rotation of the mandible, an increase in the LAFH and
correction of the Cl III molar relationship. The anterior crossbite was corrected through dental compensation.

Case 2: Treatment discussion enamalplasty to achieve Cl I canine and buc-

cal segments due to the lingual anatomy of
I considered extracting the first premolars but
the upper anterior teeth. In Fig. 17 you can
decided on second premolars due to 1) initial
see the attachment for Cl I elastics, these elas-
IMPA, 2) lack of severe crowding and the fact
tics are used to aid in space closure and elimi-
that we only needed moderate incisor retrac-
nate arch bowing. In extraction treatment
tion, and 3) improved esthetics during treat-
such as this with design is important. The ini-
ment (no need to manage pontics in the first
tial and space closure wires should be
premolar location). There was a clinically sig-
designed with straight buccal segments to
nificant Bolton discrepancy of 0.5 mm of man-
allow sliding mechanics. I also like to design
dibular excess. I did perform less than the
my initial leveling and alignment wires (the
1.0 mm of IPR that was originally planned in
round and 16 £ 22Niti wires) with extra space
the treatment setup (see Fig. 16). The treat-
between the canine offset bends in order to
ment setup was finished with interferences on
allow full engagement of these wires in the
the lingual marginal ridges of the upper inci-
presence of malalignment and slight spacing.
sors anticipating needing to do some
The stainless steel space closure wire should
 Lingual extraction and non-extraction case reports 333

Figure 12. The initial photographic survey can be seen in this figure.

Figure 13. The initial cephalometric image shows an orthognathic skeletal relationship and a bimaxillary protru-
sion.
334 Riolo

Figure 14. The Initial panoramic image is shown above.

Figure 15. The initial malocclusion models are displayed above; they show Cl I molar relationship with mild to
moderate crowding.

Figure 16. The treatment setup and planned IPR are shown above.
 Lingual extraction and non-extraction case reports 335

Figure 17. A progress photographic survey is shown. Note the attachments for Cl I elastics to aid space closure
and eliminate arch bowing.
336 Riolo

Figure 18. The final photographic survey is displayed in the figure above.

Figure 19. The final Cephalometric Image is shown here.

 Lingual extraction and non-extraction case reports 337

Figure 20. The final Panoramic image is shown here.

Figure 21. The initial and final superimpositions are shown in this figure. Uprighting and retraction of the ante-
rior teeth can be seen in this figure.

be designed with the canine offset bends tight
against the distal of the canine brackets so that
no lacing is required to keep the space closed
in the anterior due retraction of the anterior
teeth. This also allows the use of short elastics
chain segments from the molars to the canines
to minimize arch bowing effects. The patient
finished treatment Cl I molar and Canine with
ideal overjet and overbite and scored 18 on the
ABO CRE evaluation (see Figs. 18 20). The pre
and post treatment superimpositions show recip-
rocal space closure (see Fig. 21).
The need for extra anterior torque in the
anterior segment of the space close wire should
be anticipated due to the increased tendency for
“incisor dumping” and extrusion of the anterior
teeth during space closure with lingual mechan-
ics. This extra anterior torque can be incorpo-
rated in the setup or added to the wires. In this
case I added 10° of extra facial crown torque to
the maxillary space closing wire (16 £ 24SS).
In extraction treatment at least one finishing
wire with individual bends between each tooth
in the buccal segment will be require to
achieve the final posterior occlusion. If the fin-
ishing wire is a heavier gauge TMA or SS wire,
an additional individualized wire in Niti may
be required to transition to the heavier finish-
ing wire; depending on the degree of buccal
lingual offsets between the straight buccal seg-
ment space closing wire and the individual fin-
ishing wire.
338 Riolo

Conclusions outcome or the treatment time when using a lingual

appliance system compared to a traditional buccal
Lingual orthodontic mechanics allows the orthodon-
fixed appliance therapy. Our adult patients deserve
tist to achieve ABO quality treatment results using a
to have treatment options that not only deliver an
completely esthetic fixed appliance. Contrary to
excellent treatment outcome but also allow them to
myth, in the hands of an experienced lingual clini-
experience excellent esthetic treatment.
cian, there is no difference in quality of the treatment