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Modified Protrusion arch for Anterior Crossbite Correction - A Case Report

Article in International journal of orthodontics (Milwaukee, Wis.) · October 2021

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Abhishek Singha Roy

Mithila Minority Dental College and Hospital
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Modified Protrusion arch for Anterior Crossbite Correction - A Case

Report
By Abhishek Singha Roy, MDS; Gulshan Kr Singh, MDS; Pradeep Tandon, MDS; Ramsukh Chaudhary, MDS

Abstract: Borderline and mild skeletal Class III relationships in adult patients are usually treated by orthodontic camouflage. Reasonably
good results have been achieved with nonsurgical teatment of anterior crossbite. Class III malocclusion may be associated with mandibular
prognathism, maxillary retrognathism, or both. Class III maxillary retrognathism generally involves anterior crossbite, which must be
opened if upper labial brackets are to be bonded. If multiple teeth are in crossbite, after opening the bite usual step is to ligate forward or
advancement arch made of 0.018” or 0.020” stainless steel or NiTi wire main arch that must be kept separated 2 mm from the slot of upper
incisor [Link] stops or omegas are made 1 mm mesial to the tubes of the molar bands that will impede main arch from slipping,and in
this manner the arch will push the anterior teeth forward. Here we have fabricated a modified multiple loop protrusion arch to correct an
anterior crossbite with severe crowding that was not amenable to correct by advancement arches.
Keywords: Cross bite correction, Multiple loop, Protrusion arch.

ntroduction
Modified Protrusion-arch: The drawbacks with
the advancement arches (Figure 1A,B,C) are
they require a reasonably good alignment of the
upper anteriors, so it is difficult to ligate in severely crowded
situations. Secondly they have the potential to cause transverse 1A
expansion across the premolar, that might not be desirable if
the archform is already wide. The multiple loop protrusion
arch only engages the crowded upper anteriors bypassing the
premolars. A system made of .016 x .016 blue elgiloy (.018”
brackets) and .018 x .018 blue elgiloy (.022” brackets) has
been proven effective in achieving simultaneous extrusion and
protraction of incisors. This protrusion arch has a centered “T” 1B
loop and two helical “L” loops that were placed distal to the
central incisors on either side (Figure 2A,B). 1C
Construction: A small rounded bird beak plier is used
to bend the loop into a straight length Blue elgiloy archwire
(Figure 2A,2B). The vertical legs and horizontal part of the
centered “T” loop is 8 mm and 10 mm repectively with a loop
diameter of 2mm. Similarly, “L” loops were made with a mesial
and distal leg of 8 mm and 6 mm respectively along with a 8
Figure 1. Stops are made 1 mm posterior to the main
mm horizontal extension incorporating a 2 mm helix. Vestibular
slot on both side .Passive (1A), Activated(1B); thereby
segment extended up to the level of molar tube. To facilitate
separating the forward arch 2 mm from the slots of the
slight extrusion of the upper incisors and correct the smile arc, anterior braces (1C).
we added 30° reverse tipback bends on each side (Figure 2C).

Case Report mm and 3mm respectively. She had completed 95.8% of her
A 13-year-old female presented with the chief complaint skeletal growth. In the functional examination, she could move
of irregularly placed upper front teeth and protruding lower the mandible back to an edge-to-edge position . Pre-treatment
jaw (Figure 3). Initial evaluation revealed a normal profile with cephalogram showing a retrusive maxilla and retriclination of
tenderness in the right TMJ on palpation and bilateral clicking upper front teeth (Figure 4).
in opening and closing. The patient had a super-Class I molar Maxillary constriction in the sagittal plane had resulted in
relationship with an overjet of -2.5mm, overbite of 3mm, and maxillary retrusion relative to the cranial base, retroclination
maxillary and mandibular arch-length discrepancies of 10 of the upper incisors, and retrusion of the upper lip. The

IJO  VOL. 24  NO. 4  WINTER 2013 41

 main treatment objectives were elimination of the anterior
crossbite, correction of the upper arch-length discrepancy, and
improvement of the patient’s soft-tissue profile.
Non-extraction treatment approach was selected for this
patient with standard edgewise appliance (022 slot).To resolve
A B the arch-length discrepancy, flaring the anteriors in upper arch
and proximal stripping in the lower arch were considered .
C
Treatment Progress
Maxillary edgewise brackets were placed, and an .018” ×
.018” multiple loop protrusion arch was used to protrude the
upper incisors (Figure 5A-C). A customized .036” stainless
Figure 2. Multiple loop protrusion arch. Front (2A) & Side steel transpalatal arch was inserted between the first molars to
(2B) view. Figure 2C. Dimension of the loops showing 300 control molar width and axial inclination in the frontal plane.
reverse tip-back bend. To temporarily open the bite an interim bite raiser attached to
the occlusal surfaces mandibular posteriors was used.
To facilitate slight extrusion of the upper incisors and
correct the smile arc, we added 30° reverse tipback
bends on each side of the protrusion arch.
3A 3B
After four months of treatment with multiple
loop protrusion arch positive overjet had been
attained, maxillary crowding eliminated and the bite
3D 3E raisers were removed. The protrusion arch was left passively in
place for an additional two months for stabilization (Figure 6A,
6B).
Edgewise brackets were then bonded in the lower arch.
Proximal stripping were done in the lower anteriors to resolve
the crowding. 120g Class III elastics were used to achieve a
Figure 3: Pre-treatment photographs. Right buccal (3A),
Frontal (3B), Left buccal (3C), Upper occlusal (3D), Lower
Class I canine and molar relationship (Figure 7).
occlusal (3E). After an ideal buccal occlusion, overjet, and overbite had
been attained, the appliances were debonded (Figure 8A-8E).
A canine-guided occlusion with incisal guidance was achieved
.Functional efficiency during chewing was markedly improved,
Figure 4: and the TMJ pain was relieved with correction of the crossbite.
Pre-treatment
At the end of treatment, the patient showed no clicking on
Cephalogram.
opening and [Link] treatment cephalogram (Figure 9)
reveals flared upper anterior ,upright mandibular incisors
and forwardly placed soft tissue point “A”. Although anterior
crossbites typically do not require retention, the patient’s upper
anterior rotations and crowding and lower crowding indicated
the need for a removable Hawley retainer in the upper arch and
a bonded 4-4 lingual retainer in the lower.

Discussion
Malocclusions involving four or more teeth in
anterior crossbite occur mostly in Class III cases,
5A 5B 5C where the lower lip is often protruded relative
to the upper lip. Anterior crossbite should be
Figure 5: Multiple loop protrusion arch in place. Right corrected as early as possible, before eruption of the permanent
buccal (5A), Frontal (5B), Left buccal (5C). canines, given that delay can result in the development of a full
skeletal and dental Class III malocclusion1-5, requiring surgical
intervention at a later stage. While nonsurgical treatment of
adult patients with this type of malocclusion is challenging,
reasonably good results have been reported 6-7. This article
has discussed the principle of incisor extrusion and flaring in
6A 6B
correction of anterior crossbite with the help of a multiple-
Figure 6: Protrusion arch left passively. Front (6A) and loop protrusion arch that is capable of controlled flaring and
occlusal view (6B).
42 IJO  VOL. 24  NO. 4  WINTER 2013
 Dr. Abhishek Singha Roy is a Senior Lecturer,
Figure 7: Class III elastics Department of Orthodontics & Dentofacial
continued. Orthopedics. ITS Dental College Hospital and
Research Centre. Greater Noida,Uttar Pradesh, India.

Dr. Gulshan Kr. Singh is a Professor, Department of

Orthodontics & Dentofacial [Link] George
Medical University, Department of Orthodontics &
8A 8B 8C Dentofacial Orthopedics at King George Medical
University, Lucknow,Uttar Pradesh, India.
8D 8E

Dr. Pradeep Tandon is a Fellow W.F.O. USA. He is

Professor and Head of the Department of Orthodontics
Figure 8: Post treatment photographs. Right buccal (8A), & Dentofacial Orthopedics at King George Medical
Frontal (8B), Left buccal (8C), Upper occlusal(8D), Lower University, Lucknow, Uttar Pradesh, India.
occlusal (8E).

Figure 9:
Post-treatment Dr. Ramsukh Chaudhary is a Senior
Cephalogram. Resident, Department of Orthodontics &
Dentofacial Orthopedics. King George Medical
University,Lucknow,Uttar Pradesh, India.

extrusion of upper incisors with minimal side effects on the

posterior teeth.

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of age and treatment in preventable cases. J Am Dent Assoc. 1956;52:566-
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IJO  VOL. 24  NO. 4  WINTER 2013 43

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