Introduction: Severe dental crowding in Class I malocclusion presents significant aesthetic and functional challenges. This case report demonstrates the non-extraction management of severe maxillary anterior crowding with tooth rotations.
Case Description: A 13-year-old female presented with chief complaints of irregular upper and lower anterior teeth. Clinical examination revealed Class I molar relationship, severe maxillary crowding, distopalatal rotation of 21, mesiobuccal rotations of 11, anterior crossbite 11,12 and 21 were present and mandibular anterior crowding. Cephalometric analysis indicated skeletal Class I with proclined incisors. Space analysis showed no arch length deficiency.
Management: Treatment involved maxillary fixed appliances (0.022" MBT) with a modified transpalatal arch (TPA) and E-chain for derotation of 21. A removable bite plane resolved the anterior crossbite. Non-extraction alignment progressed through NiTi to stainless steel archwires (0.012"–0.019×0.025"). Mandibular crowding was corrected with fixed appliances
Results: After 17 months, severe crowding and rotations were fully resolved, achieving ideal occlusion, facial balance, and smile aesthetics. A 6-month follow-up confirmed stable results with no relapse.
Key words: Crowding,Non extraction,Rotation,Transpalatal arch
Introducción: El apiñamiento dental severo en la maloclusión de clase I presenta importantes desafíos estéticos y funcionales. Este reporte de caso demuestra el manejo sin extracción del apiñamiento maxilar anterior severo con rotaciones dentales.
Descripción del caso: Niña de 13 años de edad que se presentó con quejas principales de dientes anteriores superiores e inferiores irregulares. El examen clínico reveló relación molar clase I, apiñamiento maxilar severo, rotación distopalatina de 21, rotaciones mesiobucales de 11, mordida cruzada anterior 11,12 y 21 y apiñamiento mandibular anterior. El análisis cefalométrico indicó clase I esquelética con incisivos proclinados. El análisis del espacio no mostró ninguna deficiencia en la longitud del arco.
Manejo: El tratamiento consistió en aparatos fijos maxilares (0,022" MBT) con un arco transpalatino modificado (TPA) y cadena E para la desrotación de 21. Un plano de mordida removible resolvió la mordida cruzada anterior. La alineación sin extracción progresó a través de NiTi a arcos de acero inoxidable (0.012"–0.019×0.025"). El apiñamiento mandibular se corrigió con aparatos fijos Resultados: Después de 17 meses, el apiñamiento severo y las rotaciones se resolvieron por completo, logrando una oclusión, un equilibrio facial y una estética de la sonrisa ideales. Un seguimiento de 6 meses confirmó resultados estables sin recaídas.
Palabras clave: Apiñamiento,No extracción,Rotación,Arco transpalatal
Malocclusion, particularly when associated with crowding, can negatively impact an individual's social interactions, as facial aesthetics play a crucial role in how society perceives attractiveness, as well as in shaping one’s self-image. Dental crowding typically arises when there is a descrepancy between tooth size and the available arch space1. Treatment decisions for crowding are influenced by several factors, including the severity of the crowding, the patient’s age, facial structure, and the specific type of malocclusion present2.
Studies have shown that crowding is most prevalent in the anterior region and decreases progressively towards the posterior region3. Since the anterior teeth are the most visible during smiling, their proper alignment is essential for achieving desirable aesthetics in orthodontic treatment4. The main goal in managing severe crowding is to restore facial balance with a harmonious soft tissue profile, ensure proper occlusal function, and achieve an attractive smile5.
Among dental anomalies, rotation is notably common, accounting for 10.24% of cases in the Indian population. The most commonly affected teeth are the mandibular second premolars (2.14%), followed by the mandibular first premolars (1.69%) and the maxillary central incisors (1.60%).Rotations were found to be more prevalent in females, particularly in the mandibular second premolars and maxillary central incisors6. Typically, these rotations range between 45° to 90°, occurring mesiolingually along the tooth's long axis7.
In untreated individuals, the prevalence of rotated teeth is estimated between 2.1% and 5.1%.Class I malocclusion can be managed through comprehensive orthodontic treatment using one of two primary approaches: extraction or non-extraction8. The present case illustrates the successful management of severe maxillary crowding in a Class I malocclusion through a non-extraction treatment strategy.
A 13-year-old female student was referred to the Department of Orthodontics and Dentofacial Orthopedics,MINDS,with the chief complaint of irregularly placed upper and lower front teeth.The patient had no relevant medical history. Temporomandibular joint (TMJ) examination showed no history of pain and clicking while engaged in various jaw movements.In the extraoral examination, frontal and profile soft tissue revealed a symmetrical and balanced facial pattern with a convex profile and competent lip at rest (Figure 1).
Intraoral examination revealed a Class I molar relation on both sides with maxillary and mandibular crowding.Upper arch was U shaped with anterior spacing,Distopalatally rotated 21,Mesiobuccally rotated 11 and 25,Erupting 12,13,14 and 15.Lower arch was U shaped with lower anterior crowding and lingually placed 42.Anterior crossbite in relation to 11,12 and 21 were present.(Figure 2)
Radiographic examination confirmed severe rotation of left maxillary central incisor and revealed that 3/4 root of all teeth was completed.Deciduous tooth 62 which was extracted prior to the orthodontic treatment.Tooth buds of 18,28,38 and 48 was present. The lateral cephalometric analysis revealed a skeletal Class I with orthognathic maxilla and mandible and horizontal growth pattern and mandibular plane were normal.(Figure 3)
Cephalometric values show that upper and lower incisors were proclined (Table 1).After taking an alginate impression to fabricate study model,space analysis on study models did not show any space deficiency.
Based on the information gathered from the clinical examination and the diagnostic records, the treatment plan included relieving the maxillary and mandibular crowding using a maxillary and mandibular fixed appliance with non-extraction pattern. After appropriately prophylactically cleaning the labial and lingual surfaces of all teeth bonding was done in the upper arch using 0.022 slot Preadjusted edgewise brackets,MBT prescription.Banding was done on upper first permanent molars and lingual tube were soldered on the palatal side of bands. A removable posterior bite plane was given in the lower arch to relieve anterior crossbite.Modified Transpalatal arch with a hook on the left side extending to the palatal surface of left maxillary permanent second premolar was fabricated and attached to the lingual tube of maxillary permanent first molars.Lingual button was bonded to the labial surface of left maxillary central incisor and an e-chain was placed from modified transpalatal hook to lingual button to correct overlapping of 21 .0.012 NiTi archwire was placed on all upper teeth except 21(Figure 4).
After 6 weeks,overlap correction was achieved ,21 was bonded and continuous archwire is engaged on all teeth.Lower teeth also bonded using 0.022 slot preadjusted edgewise brackets,MBT prescription and lower molars were banded (Figure 5).Alignment and leveling procedures were followed by installing 0.14,0.016,0.018,0.017x0.025,0.019x0.025 NiTi archwires and were completed using 0.019x0.025 SS archwire.
Finishing was done using 0.14 SS archwire. At the end of treatment removable retainer appliance was fabricated and given to the patient for one year to maintain the corrected tooth position.Six months of follow up showed no signs of relapse.(Figure 6,7)
Orthodontists must evaluate different treatment options based on the patient’s skeletal and dental characteristics. Tooth rotation refers to the visible mesiolingual or distolingual displacement of a tooth within its alveolar socket along its long axis. Crowding can arise from genetic predisposition, environmental influences, or more frequently, a combination of both. Clinical assessment and patient history often reveal that malocclusion stems from dental factors 8. While genetic factors primarily determine tooth size, both hereditary and environmental influences affect dental arch shape and width9.
For Class I malocclusion with crowding, orthodontic treatment may involve extraction or non-extraction methods such as interproximal reduction, dental arch expansion or molar distalization. The treatment choice typically depends on the severity of crowding and the patient’s facial profile10. Cobourne et al. suggested that moderate crowding (5–8 mm) may require first or second premolar extractions, whereas severe crowding (>8 mm) often necessitates first premolar extraction11.
In the presented case, space analysis indicated no significant arch length deficiency, leading to a non-extraction approach for crowding correction. Traditional treatment for rotated teeth involves fixed appliances, which anchor to select teeth rather than the entire permanent dentition. Although archwire elongation allows for greater torque with lighter forces, it also increases the risk of wire breakage, distortion, or displacement. A drawback of fixed appliances is compromised oral hygiene, which may cause decalcification around banded or bonded teeth12.
For mixed dentition, a whip appliance can address rotations13. Alternatively, a removable appliance with a labial bow and palatal spring (e.g.-Z-spring) can generate the necessary force to derotate teeth14. However, this method is limited to maxillary central incisors and cannot correct severe or multiple rotations15. While rotations are relatively straight forward to correct, retention remains challenging due to the slow adaptation of supra-alveolar and transseptal gingival fibers. Overcorrection and prolonged retention are often necessary to ensure long-term stability and prevent relapse16.
Following active treatment, an optimal facial profile and functional occlusion were attained. The treatment duration of 17 months effectively resolved maxillary and mandibular crowding while significantly enhancing occlusal alignment, dental aesthetics, and facial harmony. All of the patient’s initial concerns were addressed, resulting in a more balanced smile and improved facial profile.