CASE REPORT

Treatment of an adult with several missing teeth and atrophic old mandibular rst molar extraction sites
Armando Yukio Saga,a Ivan Toshio Maruo,a Hiroshi Maruo,b Odilon Guariza Filho,c Elisa Souza Camargo,c and Orlando Motohiro Tanakab Curitiba, Paran a, Brazil This report describes the orthodontic treatment of a woman, aged 34 years 2 months, with several missing teeth and atrophic mandibular rst molar extraction sites. We had planned to close the spaces from the missing maxillary canines with mesial movement of the premolars and molars. In the mandibular arch, protraction of the second molars into rst molar extraction sites and reduction of the mandibular incisor protrusion were performed. No miniscrews or bone plates were used. A modied helical loop was used, and it can be considered a simple and an efcient orthodontic method of closing the spaces without mesial or lingual tipping and rotation. Pleasing esthetic and functional results were achieved. (Am J Orthod Dentofacial Orthop 2011;140:869-78)

rthodontic treatment for patients with several missing teeth is challenging. Orthodontists are often confronted with adults who have large edentulous spaces in the molar areas or need molar extractions. Adults needing comprehensive orthodontic therapy often have dental and periodontal problems that require multidisciplinary treatment approaches. Such problems include periodontal defects, missing teeth, and atrophic extraction sites. Proft et al1 described several common sequelae of missing mandibular rst molars, such as tipping and drifting of adjacent teeth, poor interproximal contacts, poor gingival contour, reduced interradicular bone, and supereruption of unopposed teeth. Since the bone contour follows the cementoenamel junction, pseudopockets form adjacent to the tipped teeth. In adults, closing an extraction site with bone defects is a challenge for orthodontists. Typically, several years after the

extractions, bone remodeling results in narrowing of the alveolar ridge; therefore, closure of the extraction spaces requires remodeling of cortical bone. Additionally, malocclusions in adults can be complicated by the migration of adjacent teeth into the extraction sites. Under these circumstances, functional and esthetic results might only be achieved with the combination of surgery, orthodontic treatment, and prosthodontic rehabilitation. The aim of this case report was to present the interdisciplinary treatment of an adult patient with several missing teeth, preexisting extraction spaces, and some periodontal and esthetic problems that required applied orthodontic mechanics.
ETIOLOGY AND DIAGNOSIS

From the Graduate Dentistry Program, Orthodontics, Pontical Catholic University of Paran a, Curitiba, Paran a, Brazil. a Postgraduate student. b Professor. c Associate professor. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Reprint requests to: Orlando Motohiro Tanaka, Pontical Catholic University of Paran a-PUCPR, Graduate Dentistry Program, Orthodontics, R. Imaculada Conceic ao, 1155, CEP: 80215-901, Curitiba, Paran a, Brazil; e-mail, tanakaom@ ~ gmail.com. Submitted, December 2009; revised and accepted, June 2010. 0889-5406/$36.00 Copyright 2011 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2010.06.027

The patient, a woman, aged 34 years 2 months, was referred for orthodontic evaluation by her general dentist. Her chief complaints were her dissatisfaction with her smile and the spaces in the maxillary and mandibular dental arches. Her medical history showed no contraindication for orthodontic therapy. Extraoral examination showed symmetric facial structures, and lip competence could be achieved at rest with no strain. She had a slightly concave prole, and the upper lip was retruded relative to the lower lip. Her nasolabial angle was normal (Fig 1). There were no signs or symptoms of temporomandibular joint dysfunction. Mandibular movements, such as maximal opening and lateral and anterior displacement, were within normal limits. Intraoral analysis showed coincidence of the maxillary and mandibular dental midlines relative to the facial midline. Overjet
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Fig 1. Pretreatment facial photographs.

Fig 2. Pretreatment intraoral photographs.

was 3 mm, and overbite was 2.5 mm. A negative space discrepancy (2 mm) was present in the mandibular incisor region. The mesiodistal width of the maxillary lateral incisors was narrowed, and the maxillary canines were not visible intraorally. Surgical extraction of the maxillary left canine was reported by the patient. The mandibular rst molars and maxillary left rst molar had been extracted because of extensive caries when she was an adolescent, and the alveolar ridges were atrophic and narrowed. The edentulous spaces mesial to the mandibular second molars measured 8 mm on the right side and 7 mm on the left side. The buccolingual widths of atrophic

bone were 5 mm on the right side and 4 mm on the left side. The mandibular second and third molars and the maxillary left second and third molars had tipped and drifted mesially. The mandibular third molars were present and anatomically normal (Fig 2). She had a maxillary removable partial denture, but she was displeased with the esthetic appearance, and it was uncomfortable. Although the rst molars and maxillary canines were missing, the premolars had a Class II relationship. The intercanine width was 24 mm, and the intermolar width was 47 mm. The curve of Spee was moderate (Fig 3). The panoramic radiographs showed no caries or pathology. The maxillary right canine was dilacerated and

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Fig 3. Pretreatment dental casts.

Fig 4. Pretreatment panoramic radiograph.

impacted in an oblique position. The maxillary right rst molar, second premolar, and lateral incisor, as well as the left central and lateral incisors, had been treated endodontically. The mesial region of the maxillary second molar had a signicant periodontal bone defect (Fig 4). The cephalometric radiograph and analysis conrmed the maxillary protrusion and a well-positioned mandible (SNA, 85 ; SNB, 80 ). Although the ANB of 5 suggested a skeletal Class II pattern, prole variables showed that the upper lip was retruded relative to the lower lip (upper lip to S line, 4 mm; lower lip to S

Fig 5. Pretreatment cephalometric radiograph.

line, 3.5 mm). Her facial form was considered mesocephalic (GoGn to SN, 39.5 ; FMA, 26.5 ). Dentally, the maxillary incisors were well positioned (U1 to NA, 5 mm; U1 to NA, 23 ). The mandibular incisors were

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protrusive (L1 to NB, 8 mm) and also proclined relative to the cranial base (L1 to NB, 29 ) with a closed interincisal angle (123 ) (Fig 5, Table).
TREATMENT OBJECTIVES

Table. Cephalometric measurements

Variable Norm 82 SNA ( ) 80 SNB ( ) 2 ANB ( ) 32 GoGn to SN ( ) 25 FMA ( ) 67 FMIA ( ) 88 IMPA ( ) 22 U1 to NA ( ) U1 to NA (mm) 4 25 L1 to NB ( ) L1 to NB (mm) 4 131 Interincisal angle ( ) Pog to NB (mm) Upper lip to 0 S line (mm) Lower lip to 0 S line (mm) Pretreatment Posttreatment (T1) (T2) (T2-T1) 85 85.5 0.5 80 80 0 5 5.5 0.5 39.5 38 1.5 26 26.5 0.5 65.5 69 3.5 88.5 84.5 4 23 9 14 5 0 5 29 24 5 8 5.5 2.5 123 141 18 0 1.5 0.5 0.5 1 0 0.5 0.5 0.5

1.

2.

3. 4. 5. 6. 7.

Extract the impacted maxillary right canine and obtain a Class I relationship between the maxillary premolars and the mandibular canines. Improve smile esthetics by aligning and leveling both dental arches, closing the space of the maxillary canines with mesial movement of the premolars and molars, and increasing the mesiodistal width of the maxillary lateral incisors. Prepare space for dental implants in the maxillary left rst molar area. Protract the mandibular second molars into the rst molar extraction sites. Improve the facial prole. Obtain normal overjet and interincisal guidance. Reduce the mandibular incisor protrusion.

TREATMENT ALTERNATIVES

Surgical exposure and orthodontic traction could be a possible approach for management of the impacted maxillary right canine. However, there was not adequate space to move the canine into correct alignment and to increase the mesiodistal width of the lateral incisor. So, since the maxillary right rst premolar was in a Class I relationship with the mandibular right canine, it would be necessary to distalize the maxillary posterior teeth or extract a tooth (premolar or molar). The maxillary right canine was dilacerated and impacted in an oblique position, and it would also be difcult to retract without root resorption. We could visualize closure of the maxillary left rst molar space. But it was not the choice of treatment because of the vertical and buccolingual bone defect. Thus, a dental implant was indicated. A practical way to solve the problem of the missing mandibular teeth would be to open space to insert dental implants in the mandibular rst molar areas. Nevertheless, the patient preferred to reduce the surgical procedures, the number of dental restorations, and costs. Hence, the closure of those spaces with protraction of the mandibular second molars and retraction of anterior teeth into the maxillary left rst molar area was the choice of treatment.
TREATMENT PROGRESS

At the start of the treatment, the patient was referred to a surgeon to extract the maxillary right canine. After

the appropriate healing time, all maxillary and mandibular teeth were bonded with 0.022-in nontorqued, nonangulated edgewise brackets, except for the mandibular second and third molars. The archwires progressed from 0.016-in nickel-titanium, 0.016-in stainless steel, 0.018-in stainless steel, to 0.020-in stainless steel archwires to align and level all teeth. After alignment, a nickel-titanium compressed coil spring on a 0.020-in stainless steel archwire was used to open the space between the maxillary central and lateral incisors. Then, the patient was referred to her dentist to restore the mesiodistal width of the maxillary lateral incisors. The remaining spaces between the maxillary teeth were closed with an 0.018 3 .025-in stainless steel wire with an 8 3 4-cm helical loop distal to the lateral incisors. The mandibular second molars were bonded and an 0.018 3 0.025-in stainless steel wire with a modied helical loop inserted to retract the anterior teeth and protract the mandibular molars. Initially, the second molars were uprighted by using the helical loop opened passively without any protraction force (Fig 6), and the molars were tied to the distal small loop to shift the center of rotation of the second molars coronally. Therefore, the helical loop worked passively as an aligning and leveling loop. After second molar uprighting, the helical loops were activated to protract the molars and retract the incisors at the rate of 1 mm at each appointment. Effective tipbacks of 20 to 30 were applied to correct the mesial molar tipping. A slight toein bend was necessary to prevent mesiolingual rotation of the molars. Some labial crown torque of the mandibular incisors and anterior vertical and Class II elastics

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Fig 6. Progress applied mechanics diagram: mandibular second molar uprighting.

Fig 8. Progress applied mechanics diagram: mandibular third molar bonding and nishing.

Fig 7. Progress applied mechanics diagram: mandibular second molar protraction and incisor retraction.

were required as auxiliary mechanics to prevent excessive retraction of the incisors (Fig 7). No miniscrews or bone plates were used. After all spaces were closed, the mandibular third molars were bonded. Further nishing and detailing were performed with 0.019 3 0.025-in stainless steel wires in both arches (Fig 8). Then the appliances were removed, a maxillary Hawley retainer was placed, and a mandibular lingual wire retainer was bonded from canine to canine.
TREATMENT RESULTS

At the end of the treatment, space closure was obtained with moderate improvement in the facial prole (Fig 9). The dental examination showed satisfactory posterior occlusion, good interdigitation of the teeth, and

an acceptable overjet and overbite relationship. Good tooth alignment with a Class I relationship between the maxillary rst premolars and the mandibular canines was obtained (Fig 10). Because of the shortened height of the premolars when compared with the canines, a group functional occlusion was created. But the main result was closure of the atrophic ridges without great periodontal complications. Bodily movement of the molars was noted, with the roots moving much more than the crowns bilaterally. The intercanine width was maintained at 24 mm, and the intermolar width was reduced from 47 to 44 mm (Fig 11). The panoramic radiograph shows uprighting of the mandibular second molars. The mandibular third molars were also somewhat uprighted (Fig 12). As seen in the cephalometric superimposition, the maxillary anterior teeth were bodily retracted with intrusion, and the maxillary and mandibular posterior teeth were uprighted and moved mesially. The mandibular anterior teeth were retracted with uprighting (Fig 13). Since the mandibular incisors were retracted by 2.5 mm (L1 to NB), the mandibular molars were protracted by approximately 5.5 mm on the right side and 4.5 mm on the left side. Root resorption was minimal for both molars, even though they had translated through the atrophic bone. The anteroposterior relationship (ANB) was maintained, and the vertical pattern (GoGn to SN line) was diminished, probably because of mesialization of the mandibular molars. The mandibular incisors were uprighted from 88.5 to 84.5 , the upper lip to S line was improved from 1.5 to 1 mm, the lower lip to S line was improved from 0.5 to 0 mm (Fig 14, Table). All these changes contributed to improving the facial prole. Some recession of the gingival margin was observed

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Fig 9. Posttreatment facial photographs.

Fig 10. Posttreatment intraoral photographs.

on the mandibular molars, but no mobility or discomfort was evident, and periodontal maintenance was recommended. Treatment lasted for 3 years 9 months, the objectives were accomplished, and the patient was pleased with the nal results.
DISCUSSION

Precise control of tooth movement during closure of extraction spaces in 3 dimensions is of paramount importance in meeting treatment goals.2 The large root surfaces of the mandibular molars make their movement uncertain and simultaneously cause unwanted tooth

movements such as lingual tipping of the incisors. So, differential moments are used for obtaining differential anchorage, intrusive or extrusive forces, and root movement. Anchorage control is important in the treatment of these patients, because excessive lingual tipping of the mandibular incisors must be prevented while protracting the second molars.3 To obtain the desired force system while edentulous spaces are being closed, the clinician should consider various situations such as the presence or the absence of other permanent teeth, the relationship with opposing teeth, the amount and site of the crowding, the amount of mesial or lingual tipping of the molars, and the need for anchorage.4

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Fig 11. Posttreatment dental casts.

Fig 12. Posttreatment panoramic radiograph.

Tweed tip-back bends, Begg or tip-edge mechanics, intermaxillary elastics, and headgear can produce different moment-to-force ratios between the anterior and posterior teeth. This difference in the momentto-force ratio acting on the anterior vs the posterior teeth is produced by applying either unequal moments (a moment differential) or unequal forces.2 Kulhberg

and Burstone2 demonstrated that a centered T-loop produces equal and opposite moments with negligible vertical forces, and off-center positioning of a T-loop produces differential moments. More posterior positioning produced an increased beta moment, and more anterior positioning produces an increased alpha moment. So, following this reasoning, in our case, the helical loop was placed distally to the mandibular second premolars. Space closure after extraction of the rst permanent molars has been studied in some detail and has led to conclusions about the results achieved in children and young adults.5 Adults showed less bone apposition when moving second molars into the narrowed space, poor maintenance of the closed space, and, in some cases, resorption of the second molar roots. Other authors concluded that complete closure could be achieved with the roots of the second molars moving almost twice as far as the crowns.6 They agreed that most patients showed crestal bone loss mesially to the second molars after treatment, but suggested that root resorption of the second molars was only minimal. This light force

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Fig 13. Superimposition of cephalometric tracings: black, Pretreatment; red, posttreatment.

delivered from the helical loop seemed to be suitable to close the atrophic bone spaces. In our patient, the side effects observed during the closure of the missing mandibular molar spaces were acceptable. Although some vertical bone loss and gingival recession occurred, the second molars were not mobile or painful. If mandibular rst molar implants had been chosen, augmentation of the buccolingual bone thickness with autogenous or allogenic bone grafts would have been necessary. It was assumed that, if the buccolingual width of the alveolar crest were constricted, the second molar should not be moved mesially, because this would result in loss of bone support.7 According to Zachrisson,8 orthodontic tooth movement is an excellent way (maybe the best and most predictable method) to regenerate new alveolar bone and soft tissue. It was speculated that bone defects resulting in atrophy of the alveolar ridge could be repaired by guided bone regeneration and decalcied freeze-dried bone allografts before orthodontic tooth movement. However, the type and magnitude of the lesion as well as clinical variability will highly inuence the success rate of regenerative procedures.9 Other research has demonstrated successful long-term follow-ups when a premolar is moved orthodontically into an edentulous space.10,11 In our patient, the implant was placed in the position occupied previously by the premolar and was restored with an implant-supported crown. We decided to close the remaining mandibular extraction sites to eliminate the need for additional surgical procedures or implants, and also to decrease the treatment expenses.

Fig 14. Posttreatment cephalometric radiograph.

Ideal dimensions for successful mandibular rst molar space closure are reported to be 6 mm or less of mesiodistal space and 7 mm of buccolingual width.6 Although in this patient the mesiodistal dimension of the extraction spaces (8 mm on the right side, 7 mm on the left side) were greater and the buccolingual widths were narrower, complete closure of the extraction sites without molar tipping was successfully achieved with orthodontic tooth movement. Because of the

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posterior divergence of the mandible, the mesial movement of the molars reduced the intermolar width from 47 to 44 mm, placing the molars in a narrower area of the mandible. The patient had good plaque control throughout the orthodontic treatment. So, vertical bone loss around the mandibular second molars probably occurred because of the mesial molar movement. If rst molar implants had been chosen, some peri-implant bone loss would have been expected.12 Although the maxillary third molars had been bonded, the nal occlusion was obtained with an active Hawley retainer that improved the lingual crown torque. Some root proximity between adjacent roots was observed on the posttreatment panoramic radiograph. The periapical radiographs did not show such a hopeless situation. The proximity between the maxillary left central and lateral incisors occurred because of the altered crown morphology of the lateral incisor. After the alignment and leveling phase, a black space was noted. Shorter and more incisally positioned interproximal contacts and divergent or triangular-shaped crown forms are associated with posttreatment open gingival embrasures.13 Grinding the mesial surface could be an option to correct this unesthetic problem, but the patient refused, since the mesiodistal width of the maxillary lateral incisors had been narrowed already. So, the general dentist, who restored the lateral incisor, preferred inclination of the left lateral incisor toward the distal aspect to improve the prole of the restoration. The proximity between the maxillary rst and second premolars occurred because of the necessity for a slight mesial rotation of the rst premolars to prevent eccentric contact during lateral excursive mandibular movements. Since the buccolingual width of the premolar root is greater than the mesiodistal dimension, some root proximity can occur. The surgeon inserted a premolar implant into the rst molar site, because of the bone defect. To obtain good intercuspation, it was necessary to tip the mandibular left second premolar, which caused the proximity between the mandibular left rst and second premolar roots. These root proximities were not irrelevant. Root proximity can affect the risk for periodontitis, as manifested by progressive alveolar bone loss, by limiting access for personal oral hygiene or professional cleaning.14 Kim et al15 observed that there was no clinically relevant association between the interradicular distance of more than 0.8 to 1.0 mm and alveolar bone loss. However, if the interradicular distance is less than 0.8 mm, there is a moderately increased risk for loss of alveolar bone. In periodontal patients, root proximity was most

often encountered in the coronal portion of the root, whereas subjects without periodontal disease had more root proximity in the apical part where it is less critical.16 So, in these areas of root proximities, special plaque and calculus control care was recommended to prevent progressive alveolar bone loss. The extraction of canines has long been regarded as a compromise. In unusual circumstances, however, canine extraction is a viable option that satises the major treatment goals of esthetics, health, function, and stability.17 The attempt to move a dilacerated and obliquely positioned maxillary right canine could produce disastrous side effects such as lateral incisor root resorption. The replacement of the maxillary canines with premolars to establish group functional occlusion was already described.17 In a review article, Rinchuse et al18 concluded that a single type of functional occlusion was not prevalent in nature. The belief that canine-protected occlusion is the optimal type of functional occlusion for orthodontic patients is unsupported by evidence-based literature. Moreover, canine-protected occlusion might be merely one of several possible optimal functional occlusion types for orthodontic patients. Group functional occlusion (with no interferences) appears to be acceptable, depending on the patients characteristics. The stability and longevity of canine-protected occlusion were considered questionable. Consideration of the patients chewing pattern, craniofacial morphology, static occlusion, current oral health status, and parafunctional habits might provide important and relevant information about the most suitable functional occlusion type. But there is a lack of information from long-term studies considering the premolar periodontal status with this type of occlusion. A potential side effect after space closure of an atrophic mandibular rst molar extraction site is space reopening. After appliance removal, a stainless steel 0.016-in wire was bonded as a retainer from the mandibular right and left second molars to the second premolars for about 3 months to prevent space reopening. After that, the general dentist requested that the retainer be removed to restore the second premolars. The interproximal contact points were not tight, but the patient had no discomfort; after 8 months, the space closure seemed to be stable. Continuous clinical and periapical radiographic monitoring was recommended.
CONCLUSIONS

This case report shows that space closure of missing molars with atrophic interradicular bone should be considered as a potential solution. However, precise control of tooth movement during closure of extraction spaces

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in 3 dimensions is important in meeting treatment goals. The modied helical loop is a simple and efcient orthodontic technique of closing the space without mesial or lingual tipping, and rotation of molars by using the same arch.
REFERENCES 1. Proft WR, Fields HW Jr, Sarver DM. Contemporary orthodontics. St Louis: Mosby; 2007. 2. Kuhlberg AJ, Burstone CJ. T-loop position and anchorage control. Am J Orthod Dentofacial Orthop 1997;112:12-8. 3. Nagaraj K, Upadhyay M, Yadav S. Titanium screw anchorage for protraction of mandibular second molars into rst molar extraction sites. Am J Orthod Dentofacial Orthop 2008;134:583-91. 4. Chae J, Kim S. Running loop in unusual molar extraction treatment. Am J Orthod Dentofacial Orthop 2007;132:528-39. 5. Stepovich ML. A clinical study on closing edentulous spaces in the mandible. Angle Orthod 1979;49:227-33. 6. Hom BM, Turley PK. The effects of space closure of the mandibular rst molar area in adults. Am J Orthod 1984;85:457-69. 7. Kessler M. Interrelationships between orthodontics and periodontics. Am J Orthod 1976;70:154-72. 8. Zachrisson BU. Implant site development by horizontal tooth movement. World J Orthod 2001;4:266-72. 9. Carvalho RS, Nelson D, Kelderman H, Wise R. Guided bone regeneration to repair an osseous defect. Am J Orthod Dentofacial Orthop 2003;123:455-67.

10. Spear FM, Mathews DM, Kokich VG. Interdisciplinary management of single-tooth implants. Semin Orthod 1997;3: 45-72. 11. Thilander B, Odman J, Lekholm U. Orthodontic aspects of the use of oral implants in adolescents: a 10-year follow-up study. Eur J Orthod 2001;23:715-31. 12. Branemark PI, Hansson BO, Adell R, Breine U, Lindstrom J, Hallen O, et al. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl 1977;16:1-132. 13. Kokich VG. Esthetics: the orthodontic-periodontic restorative connection. Semin Orthod 1996;2:21-30. 14. Smukler H, Nager MC, Tolmie PC. Interproximal tooth morphology and its effect on plaque removal. Quintessence Int 1989;20: 249-55. 15. Kim T, Miyamoto T, Nunn ME, Garcia RI, Dietrich T. Root proximity as a risk factor for progression of alveolar bone loss: the Veterans Affairs Dental Longitudinal Study. J Periodontol 2008;79: 654-9. 16. Vermylen K, De Quincey GN, Wolffe GN, van t Hof MA, Renggli HH. Root proximity as a risk marker for periodontal disease: a case-control study. J Clin Periodontol 2005;32: 260-5. 17. Schach RT. Treatment of a Class II, Division 1, malocclusion with the extraction of maxillary canines and mandibular rst premolars. Am J Orthod Dentofacial Orthop 2000;117:459-64. 18. Rinchuse DJ, Kandasamy S, Sciote J. A contemporary and evidence-based view of canine protected occlusion. Am J Orthod Dentofacial Orthop 2007;132:90-102.

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