A Case Report of Bilateral Brodie Bite in Early Title Mixed Dentition Using Bonded Constriction Quad- helix Appliance.

Nojima, K; Takaku, S; Murase, C; Nishi, Y; Sueishi Author(s) K.

Journal Bulletin of Tokyo Dental College, 52(1): 39-46

URL http://hdl.handle.net/10130/2330

Right

Posted at the Institutional Resources for Unique Collection and Academic Archives at Tokyo Dental College, Available from http://ir.tdc.ac.jp/ Bull Tokyo Dent Coll (2011) 52(1): 39–46 39

Case Report

A Case Report of Bilateral Brodie Bite in Early Mixed Dentition Using Bonded Constriction Quad-helix Appliance

Kunihiko Nojima, Sakiko Takaku*, Chiaki Murase, Yasushi Nishii and Kenji Sueishi Department of , Tokyo Dental College, 1-2-2 Masago, Mihama-ku, Chiba 261-8502, Japan * Division of Orthodontics, Department of Oral Health Clinical Science, Tokyo Dental College, 2-9-18 Misaki-cho, Chiyoda-ku, Tokyo 101-0061, Japan

Received 26 July, 2010/Accepted for publication 6 October, 2010

Abstract Brodie bite is a comparatively rare type of found in primary and mixed dentition. It not only adversely affects chewing and muscle functions, but also impairs normal growth and development of the mandible. This report describes the therapeutic results of a patient with bilateral Brodie bite in early mixed dentition after using a bonded constriction quad-helix appliance. The patient, a boy aged 9 years and 2 months, first visited our hospital after occlusal abnormality in the molar region was detected at a local dental clinic. Case analysis resulted in a diagnosis of bilateral Brodie bite with slight mandibular . Treatment objectives were to reduce the arch width of the maxillary dentition and expand the mandibular arch in order to establish and stabilize molar occlusion and to achieve a Class I molar relation and appropriate and overjet. Treatment comprised covering the occlusal surface of the maxillary molars with resin and attaching a bonded constriction quad-helix appliance joined with a 0.040-inch quad-helix wire. A bi-helix appliance was also fixed to the mandibular dentition. Brodie bite visibly improved after 5 months. Cervical headgear was then fitted and the patient observed until eruption of the permanent dentition was complete. Class I molar relation was achieved after 2 years and 6 months, although spacing remained in the maxillary and mandibular dentitions. Treatment of bilateral Brodie bite in mixed dentition by means of a bonded constriction quad-helix appliance attached to the maxillary dentition enabled effective bite opening and reduction in the width of maxillary arch independent of the patient’s cooperation, providing good therapeutic outcome in a short time period. Key words: Brodie bite—Early treatment—Angle Class II malocclusion— Bonded constriction quad-helix appliance—Bi-helix appliance

Introduction arch was telescoped within the maxillary den- tal arch, known as the Brodie syndrome13). In 1943, Brodie first described a type of This type of occlusion, also called “scissors occlusion in which the mandibular dental ” or “buccal crossbite”, refers to molar

39 40 Nojima K et al.

Fig. 1 Pre-treatment facial photographs at age 9y2m

Fig. 2 Pre-treatment intraoral photographs at age 9y2m

crossbite resulting from incorrect horizontal the prevalence of this syndrome is 1–2%, positioning of the maxillary and mandibular making it a comparatively rare form of mal- dental arches, in which all the mandibular occlusion5). As it does not affect aesthetics, molar buccal cusps are telescoped within the both patients and their parents or guardians lingual side of the maxillary molars, so that may be unaware of the malocclusion. There- there is no intercuspation of the maxillary fore, fewer patients present with Brodie bite as and mandibular molars. In mixed dentition, a primary complaint compared with patients A Case Report of Bilateral Brodie Bite 41

Table 1 Model analysis

Maxillary arch Mandibular arch Measurements S.D. Pre. treat Post. treatעS.D. Pre. treat Post. treat MeanעMean Coronal arch 30.0 28.2 1.21ע31.08 41.5 41.2 1.43עAnterior width 39.10 44.6 35.9 1.72ע44.65 53.2 57.2 1.86עPosterior width 50.98 11.0 9.1 1.28ע9.65 14.8 15.6 1.18עAnterior length 14.00 32.0 32.1 1.69ע28.63 37.4 37.5 2.08עPosterior length 32.18 Basal arch 34.2 33.7 1.41ע34.77 42.9 45.9 3.01עAnterior width 45.10 61.6 55.6 2.24ע62.01 68.1 71.0 2.39עPosterior width 65.72 8.5 8.8 1.42ע4.30 11.5 12.0 2.06עAnterior length 7.90 32.0 32.8 1.42ע23.13 33.0 33.5 2.25עPosterior length 25.35 (mm)

exhibiting other types of malocclusion. For this reason, there have been few case reports of the treatment of Brodie bite in primary or mixed dentition. Nevertheless, this occlusal abnormality is unlikely simply to resolve spontaneously. It not only adversely affects chewing function3) and muscle function10) but also impairs the normal growth and development of the mandible Fig. 3 Pre-treatment panoramic radiograph at age 9y2m if left untreated, with the possibility of jaw deformities such as facial asymmetry and mandibular retrognathism. Therefore, early correction of this occlusion is essential. oral examination revealed a dental age of IIIA ,mm overjet 8ם 5mm overbite andם We obtained good therapeutic results in a with patient with bilateral Brodie bite within a spacing in the maxillary anterior teeth, bilat- short time period by fitting a bonded con- eral Brodie bite, and Class II molar relation striction quad-helix appliance to reduce the (Fig. 2). Model analysis showed an exces- width of the maxillary arch and raise the bite, sive coronal arch width of 57.2 mm (Mean mm) and basal arch width of 1.86עas well as a bi-helix appliance to expand the 50.98 -mm) in the max 2.39עmandibular arch. 71.0 mm (Mean 65.72 illary molar region, with narrow mandibular dental arch width at the molars of 35.9 mm mm) and alveolar base 1.72עCase (Mean 44.65 (mm 2.24עwidth of 55.6 mm (Mean 62.01 A boy, aged 9 years and 2 months, first came (Table 1). A panoramic radiograph revealed to our hospital after occlusal abnormality that the entire permanent dentition was in the molar region had been identified at a present (Fig. 3). indi- local dental clinic. He was healthy with no cated slight skeletal mandibular retrogna- contributing medical history. The patient’s thism with SNA 79.0°, SNB 75.0°, and ANB family history did not reveal any relevant 4.0°, and labial inclination of the maxillary information. The facial features were symmet- and mandibular anterior teeth with U1 to FH ric from the frontal view, and the profile was 126.0°, L1 to FH 54°, and interincisal angle convex from the lateral view (Fig. 1). Intra- 108° (Fig. 4). From these findings, bilateral 42 Nojima K et al.

S.D. Pre. treat Post. treatעMeasurements Mean 86 84 3.3עFacial angle (deg.) 86.1 3 8 3.0עConvexity (deg.) 6.4 1.5מ 6מ 2.5ע5.2מ (.A-B plane (deg 34 35 5.9עMandibular plane (deg.) 24.8 63 64 3.1עY-axis (deg.) 64.0

10 12 4.2עOcclusal plane (deg.) 8.4 110 108 5.6עInterincisal angle (deg.) 131.6 24 24 5.3עL-1 to Occlusal (deg.) 21.3 90.5 91 4.9עL-1 to Mandibular (deg.) 97.1 13 18.5 2.5עU-1 to A-P plane (mm) 7.8 10 10 2.4עFH to SN plane (deg.) 5.4 77.5 79 2.6עSNA (deg.) 83.4 76 75 2.5עSNB (deg.) 80.0 1.5 4 1.7עSNA-SNB diff. (deg.) 3.4 127 126 5.6עU-1 to FH plane (deg.) 110.8 55.5 54 5.8עL-1 to FH plane (deg.) 61.6 138 134 8.1עGonial angle (deg.) 117.5 75 80 4.5עRamus angle (deg.) 88.5

Fig. 4 Tracing and measurements on pre-treatment cephalometric radiograph

Fig. 5 Intraoral occlusal view of constriction quad-helix appliance bonded on occlusal surface in maxillary arch (left) and bi-helix appliance in mandibular arch (right)

Fig. 6 Post-treatment facial photographs at age 11y8m

Brodie bite with slight mandibular retrogna- achieve a Class I molar relation, as well as thism was diagnosed. appropriate overbite and overjet until erup- Treatment objectives were to reduce the tion of the permanent dentition was complete. arch width of the maxillary dentition and The treatment plan consisted of reducing the expand the mandibular arch in order to width of the maxillary arch by covering the establish and stabilize molar occlusion and to occlusal surfaces of the maxillary first primary A Case Report of Bilateral Brodie Bite 43

Fig. 7 Post-treatment intraoral photographs at age 11y8m

molar, second primary molar, and first perma- nent molar on both sides with resin to raise the bite and support and activate a bonded constriction quad-helix appliance, which was joined by a 0.040-inch quad-helix wire in 5-mm sections on either side and attached with a light-cured adhesive (Fig. 5). In addi- tion, a bi-helix appliance was fitted to the mandibular first molars to expand the man- dibular arch. After 5 months, the Brodie bite showed improvement. Cervical headgear was Fig. 8 Post-treatment panoramic radiograph at age 11y8m then fitted in order to correct the Class II molar relation, and the patient was observed regularly until eruption of the permanent dentition was complete. A Class I molar rela- pattern, anterior growth of the maxilla had tion was achieved after 2 years and 6 months, been controlled, while the mandible had although spacing remained in the maxillary grown markedly in the anteroinferior direc- and mandibular dentition (Figs. 6–8). tion with no clockwise rotation (Fig. 9). As Cephalometric superimposition before and a result, major skeletal improvement was after treatment showed that in the skeletal achieved, with ANB decreasing from 4° to 1.5° 44 Nojima K et al.

Fig. 9 Superimposition of pre-treatment and post-treatment tracings on cephalometric radiographs Solid line: pre-treatment at age 9y2m. Dashed line: post-treatment at age 11y8m

(Fig. 4). In the denture pattern, no antero- tion was the result of multiple skeletal factors posterior or vertical movement occurred in caused by excessive growth of the maxilla and either the maxillary anterior teeth or molars. insufficient growth of the mandible. The mandibular anterior teeth and molars With respect to treatment planning, Brodie had shifted slightly in a mesial direction, bite frequently involves not only horizontal with almost no vertical change. Eruption of problems but also anteroposterior and vertical both upper and lower molars was controlled issues, as in the present case. The treatment (Fig. 9). In addition, a comparative model sequence basically comprises prioritizing analysis showed that the width of the dental horizontal improvement, after which vertical arch at the maxillary molars had decreased and anteroposterior problems should be by 4 mm to 53.2 mm and the alveolar base corrected. In cases of molar deep bite such width had decreased by 2.9 mm to 68.1 mm, as the present case, however, molar interfer- whereas the width of the dental arch at the ence while horizontal problems are being mandibular molars had expanded by 8.7 mm improved can result in clockwise rotation of to 44.6 mm and the alveolar base width had the mandible. As Class II molar relation may expanded by 6.0 mm to 61.6 mm (Table 1). deteriorate as a result, attention must be paid to the treatment mechanism. In adult patients, major skeletal abnormali- Discussion ties have been reported, and orthodontic treatment by means of complex treatment Possible causes of Brodie bite include mechanisms1,14), orthognathic surgery11,12), and microglossia and hypoglossia, the involve- mandibular widening by distraction osteo- ment of neurological and muscular mecha- genesis6) had to be performed for correction. nisms causing oral habits, skeletal Class II These treatment procedures require much factors, and abnormal tooth germ position or patient cooperation, and impose a major eruption direction11). In the present case, no physical and psychological burden on the functional or organic causes were observed, patient. Therefore, correction of Brodie bite and as the patient not only had an excessively at an early stage is recommended. wide maxillary arch and narrow mandibular In most reports of patients with primary arch but also a deep bite and mandibular and mixed dentition, treatment of unilateral retrognathism, it is probable that the condi- Brodie bite involved bite opening using a bite A Case Report of Bilateral Brodie Bite 45 plate combined with lateral expansion of the complain of any discomfort or problems with mandibular arch by means of a lingual arch or mastication or articulation during the treat- removable lower lateral expansion plate7,10). A ment period. Cephalometric superimposition bite plate is used to separate the molar occlu- in the present case showed that occlusion sion and eliminate occlusal interference in had been unlocked by improvement in the order to improve therapeutic results. How- Brodie bite and deep bite, with anterior ever, this method was not recommended in growth promoted by the catch-up growth of the present case, as the excessive width of the the mandible. In addition, the inhibition of maxillary arch meant that active constriction anterior growth of the maxilla as an effect of the maxillary dentition was necessary. This of the headgear was effective for skeletal Class would also cause molar extrusion in patients II treatment and achieving a Class I molar with mandibular retrognathism, potentially relation. Vertically, eruption of upper and worsening the mesiodistal occlusal relation. To lower molars was controlled by the bonded reduce maxillary arch width, some researchers constriction quad-helix appliance, and clock- have used modified removable-type appli- wise rotation of the mandible was inhibited, ances4,9) and modified fixed-type appliances despite the fact that the patient had long face- for constriction2,4,13). However, correction would type mandibular retrognathism. Model analy- take longer with this approach in patients sis showed that reduction of the arch width with molar deep bite, such as in the present in the molar region was achieved in both the case. As these methods can also cause molar coronal and basal arches of the maxilla, and interference, they were considered inappro- in the mandible both the coronal and basal priate for the reasons described above. We arches were expanded in the molar region as were unable to locate any case reports on the a result of the bi-helix appliance treatment. treatment of bilateral Brodie bite that actively Correction of bilateral Brodie bite was thought incorporated reduction of the maxillary arch to be achieved as a result of improvement in width in the treatment mechanism while tak- the buccolingual tooth axis of the molars and ing the vertical relationship into account. lateral skeletal improvement. Some reports To reduce maxillary arch width in this case, concerning treatment period have stated that the occlusal surfaces of the first and second around 5–8 months are required for primary primary molars and the permanent first dentition9,13), with several years required for molar were coated with resin, and a bonded correction of the first molar7). In the present constriction quad-helix appliance consisting case, despite the difficulty of correction, effec- of four constriction helices joined with 0.040 tive improvement was seen in a short period stainless steel wire was used. In recent years, of 5 months. Later, although labial inclination bonded-type orthodontic appliances such as of the maxillary and mandibular anterior the Herbst appliance have been used for teeth occurred after eruption of the man- rapid maxillary expansion. McNamara8) has dibular second molar, the patient had a reported the use of a bonded expansion spaced arch, and we intend to proceed with appliance that inhibited the eruption of pos- corrective orthodontic treatment without terior teeth in patients with increased facial tooth extraction to maintain the lateral molar height; slight tipping was observed during occlusal relation. expansion due to the rigid framework of the Treatment of bilateral Brodie bite in mixed appliance and bonding of the appliance to dentition by fitting a bonded constriction the posterior teeth. In this study, use of a quad-helix appliance achieved effective bite similar type of resin cover was intended to opening and reduction in the width of the improve the retention of the appliance and maxillary arch, providing good results in a maximize its effect on the skeleton, while short time period independent of the minimizing clockwise rotation of the man- patient’s cooperation. dible and raising the bite. The patient did not 46 Nojima K et al.

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