Management of Mandibular Incisors Crowding by Using Passive Lower Lingual Arch PDF

Submitted: 05 August, 2022 Accepted: 09 November, 2022 Published: 03 March, 2023 DOI:10.22514/jocpd.2023.003 CASE REPORT Management of mandibular incisors crowding by using passive lower lingual holding arch: a case series and literature review Ahlam Habib1 , Ahmed Ghoneima1 , Samira Diar-Bakirly1, * 1 Department of Orthodontics and Abstract pediatric Dentistry, Hamdan Bin Mohammed College of Dental Medicine, Mandibular incisor crowding is a frequently encountered problem in daily orthodontic Mohammed Bin Rashid University of treatment. Success of the treatment greatly depends on the orthodontist’s ability to Medicine and Health Science (MBRU), manage the factors contributing to the existing crowding and implementing the proper 505055 Dubai, UAE interceptive means. The passive lower lingual holding arch (LLHA) helps maintain *Correspondence the position of the permanent first molars after the exfoliation of primary molars and [email protected] canines. Thus, relieving the mandibular incisor crowding during transitional dentition. (Samira Diar-Bakirly) Four case reports age ranged from 11–13.5 years old were used to report the effect of using LLHA on mandibular incisor crowding. Little’s Irregularity Index (LII) was used to assess the severity of mandibular incisors crowding as well as to compare the severity of the crowding before and after the use of LLHA. Passive LLHA could be considered the appliance of choice for space maintenance during the mixed dentition. Mandibular incisor crowding was reduced as measured by LII after the use of the passive LLHA over a duration of twenty months. Keywords Mandibular incisors crowding; Mixed dentition; Lower lingual arch; Little’s index 1. Introduction because of incompatibility between the primary teeth dimen- sion and the permanent successor and it is considered genetic. Mixed dentition stage starts from the first permanent tooth Secondary crowding occurs in the posterior dentition due to eruption at around six years of age until the last deciduous tooth early extraction of the primary molars with consequent arch exfoliation at around thirteen years of age. Several changes length loss. Tertiary crowding, which is evident at the end play a part to accommodate the transition from primary to of the growth spurt of the mandible and coincides with the permanent dentition. Arch length increase which occurs only eruption of the third molars. Primary crowding is additionally until the eruption of permanent canines is one of these changes. subdivided into two groups: definitive and temporary. It It is caused partially by the proclination of the permanent has been reported that 89%–94.7% of patients who had crowd- incisors and increase of the inter-canine width and inter-molar ing in the mixed dentition stage and/or early loss of primary width [1–4]. Another factor that contributes to permanent canine also showed crowding in the permanent dentition stage teeth accommodation into the arch is the mesiodistal width [2, 7, 13, 14]. Several methods have been used to assess the change between the deciduous molars and canines with their mandibular incisor crowding. Little’s Irregularity Index (LII) successors represented in Leeway space and E-space [3–9]. It being one of the methods, was developed in 1975 by Robert is crucial to note that as patients grow into their adolescent Little and is a diagnostic index that is used to assess relapse, years, subsequent arch length reduction takes place. Late irregularity, and alignment of mandibular incisors. mesial shift into the E-space to adjust the molar relation and Baume in 1950 and McDonald in 1987 have shown that the further uprighting of the permanent incisors to adjust the without space maintenance, the arch perimeter is reduced after overjet and overbite explains this arch length reduction and deciduous tooth loss during transition from mixed to perma- thus potential mandibular incisor crowding [1–9]. nent dentition [15, 16]. Although plaque accumulation is one According to the National Health and Nutrition Examination of the disadvantages of space maintainers, yet patients should Survey (NHANES III, 1998), dental crowding can be consid- be encouraged to maintain adequate oral hygiene while having ered the most common form of malocclusion among children in the device. Once the space maintainer is fitted, it must be the United States. The prevalence of dental crowding has been followed up by regular checks to guarantee that the appliance reported to be nearly 50% with varying degrees of severity is intact and to monitor the permanent dentition’s development of overlap between the anterior teeth. Dental crowding and eruption. It is imperative to note that the lack of space for is categorized into three types ; primary crowding occurs permanent teeth is an indication of space regaining rather than This is an open access article under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/). J Clin Pediatr Dent. 2023 vol.47(2), 101-107 ©2023 The Author(s). Published by MRE Press. https://www.jocpd.com 102 maintenance. Adequate assessment of space analysis is thus 2.4 Diagnostic assessment required to determine the right interceptive means and decide Each patient’s dental cast models (pre-treatment and post- if the patient needs a specialist. treatment) were scanned using Ortho Insight IT 3D Laser Various types of space maintainers, either fixed or remov- Scanner (Motionview Software, LLC, Hixson, TN, USA) with able [6, 17], each with various indications, have been used the cast positioned in a coronal position and calibrated to zero and reported in the literature. Appliances such as the Mayes rotation. STL files of the scanned models were then uploaded Fixed Crozat (Frozat) , the Crozat appliance (Bihelix and to 2010 Dolphin Imaging & Management Solutions (@petter- Quadhelix), the Wilson lingual arch [19, 20], the lip bumper son technology) and crowding was then assessed using Little’s [20, 21] have been used in the mandibular arch as variations irregularity index method. The horizontal distance between the of space maintainer devices. Appliances in the maxillary incisor edges was measured in mm using the software’s digital arch such as the cervical headgear have been used and led to ruler. The measured values were added, and LII was calculated spontaneous expansion and increase in the mandibular arch for every patient, pre-treatment and post-treatment values were length, thus, possibly relieving crowding. The passive then compared. Intraoral photos were taken as well at the pre- LLHA has been long used as a space maintainer to preserve treatment and post-treatment stages. arch length [4, 23–25]. LLHA is made either of 1.25 mm or 0.9 mm stainless steel wire and can be inserted into the 2.5 Therapeutic intervention sheaths of the molars (removable), or either welded/soldered to molar bands or bonded directly to the lingual surface of A passive LLHA was constructed for every patient using 0.036 mandibular molars [26, 27]. Using a 1.25 mm wire compared inch stainless steel wire (0.9 Chromium, Scheu Dental Anchor. to a 0.9 mm wire will increase wire stiffness which will result Iserlon city, Germany, 2020) to preserve the leeway space. The in increased forces on the mandibular incisors and first molars space maintainer was soldered to the mandibular first molar [26, 28]. Earlier in the 20th century, Mershon explained that an bands (Maximum Retention™ Bands, American Orthodontics active form of LLHA could be used, stabilized on the molars Inc. Sheboygan, WI, USA, 2022). The molar bands of the by attaching a small spring to the main arch to allow tooth LLHA were then cemented over the first permanent molars. movement when activated and produce transversal widening. 2.6 Follow-up and outcomes In this article, four cases are presented to show the effective- The patients were followed up during the treatment period of ness of the lower lingual holding arch in minimizing/resolving over twenty months. The appliance was regularly checked mandibular anterior crowding. every three months to ensure there is no damage to the ap- pliance and to enhance the patients’ oral hygiene regime. 2. Case reports Exfoliation pattern of primary teeth and the permanent den- tition’s development and eruption was observed at each visit 2.1 Patient information as well. Improvement or resolution of mandibular incisors crowding after cementation of passive LLHA was noted in all Accompanied by their parents/guardians, four adolescent Cau- four cases. The difference between pre-treatment and post- casian patients age ranged from 11–13.5 years old (1 boy and treatment values of LII for all patients ranged between 4.9 mm 3 girls) were examined with no specific concerns about their to 7.7 mm. (Table 1) family’s medical and dental histories. The patients’ medical history was negative for systemic conditions or allergies with 2.6.1 Case 1 no history of previous orthodontic treatment. An 11-year-old girl with skeletal class I relation and dental class I molar malocclusion/severe maxillary crowding and 2.2 Clinical findings impacted maxillary canines. Intraoral examination revealed For all the four patients, comprehensive orthodontic screening retained mandibular primary canines, primary first molars, and has been conducted including extraoral and intraoral exami- primary second molars. The mandibular incisor crowding was nation reported in each case. Intraoral examination revealed assessed, and her pre-treatment LII was 9.5 mm. After the use mixed dentition stage with mandibular incisor crowding and of the passive LLHA, post-treatment LII was 1.8 mm, the pre- healthy periodontium with minor plaque accumulation. All treatment mandibular incisor crowding was almost resolved permanent mandibular incisors were present as well as at least (Fig. 1A–D), (Table 1). retained bilateral primary second molars. 2.6.2 Case 2 2.3 Timeline A 12-years boy with skeletal class I relation and dental class I malocclusion. Intraoral examination revealed retained The treatment duration for all patients was twenty months mandibular primary canines, primary first molars, and primary after cementing the passive LLHA. Patients were kept under second molars. The mandibular incisor crowding was assessed observation until complete permanent dentition erupted, with- and her pre-treatment LII was 9 mm. After the use of the out any further active orthodontic treatment. Deciduous teeth passive LLHA, post-treatment LII was 3.2 mm, the initial exfoliated in a normal sequential manner. mandibular incisor crowding was dramatically improved. (Fig. 2A–D), (Table 1). 103 TA B L E 1. Descriptive data showing LII pre and post treatment values after twenty months of use of passive LLHA. Case No. Patient Age/Sex Retained Primary Tooth Pre-ttt LII Post-ttt LII Difference pre-ttt/post-ttt LII Case 1 11 Years/Female Canines, 1st molars, and 2nd molars 9.5 mm 1.8 mm 7.7 mm Case 2 12 Years/Male Canines, 1st molars, and 2nd molars 9.0 mm 3.2 mm 5.8 mm Case 3 13.5 Years/Female 2nd molars 8.0 mm 1.0 mm 7.0 mm Case 4 11 Years/Female 2nd molars 9.9 mm 5.0 mm 4.9 mm LII: Little’s Irregularity Index. F I G U R E 1. Case 1. (A) Intraoral pre-treatment photograph of mandibular arch. (B) Pre-treatment digital study cast displaying the mandibular incisor crowding. (C) Intraoral post-treatment photograph of mandibular arch. (D) Post-treatment digital study cast with LLHA. F I G U R E 2. Case 2. (A) Intraoral pre-treatment photograph of mandibular arch. (B) Pre-treatment digital study cast displaying the mandibular incisor crowding. (C) Intraoral post-treatment photograph of mandibular arch. (D) Post-treatment digital study cast with LLHA. 104 2.6.3 Case 3 the crowding by the space they provide after placement of A 13 years and 5 months girl with skeletal class I relation and LLHA before their exfoliation. In the present cases in this dental class I malocclusion. Intraoral examination revealed study, the average resolution of mandibular incisor crowding retained mandibular primary second molars. The mandibular after placement of LLHA ranged from 4.9–7.7 mm. Mandibu- incisor crowding was assessed, and her pre-treatment LII was lar incisor crowding resolution after placement of LLHA was 8 mm. After the use of the passive LLHA, post-treatment reported in the literature to range between 5–10 mm. LII was 1 mm, the considerable change in LLI can be noted Reduction in the mesial migration of the permanent (Fig. 3A–D), (Table 1). mandibular first molars into the E space has been deemed one of the reasons behind the effects of the LLHA [6, 25, 31]. In 2.6.4 Case 4 1995, Gianelly demonstrated that a lingual arch can be used to An 11-year girl with skeletal class I relation and dental class maintain arch length by preventing the mesial movement of I malocclusion. Her intra-oral examination revealed retained the molars and the lingual collapse of the mandibular incisors mandibular primary second molars. The mandibular incisor. In addition, preserving the leeway space of canine crowding was assessed, and her pretreatment LII was 9.9 mm. and primary molars allows the distal drifting of mandibular After the use of the passive LLHA, post-treatment LII was canines and first premolars into the available leeway space 5 mm with residual minor crowding of mandibular incisors [24–26, 31]. It is imperative to note that this distal shift of remaining as shown (Fig. 4A–D), (Table 1). the canines can lead to a greater inter-canine distance rather than a true arch expansion. Gianelly and Brennan et al. 3. Discussion (2000) noted an increase of the intercanine width when using LLHA by 1.5 mm. In 1995, Chiarini and DeBaets noted In this study, passive LLHA was used to relieve crowding in the that an increase of the intercanine width by 1.1 mm because mandibular incisors. The crowding was measured before and of the lateral drifting of canines was due to their migration to after the use of LLHA using the digital models of four patients the leeway space. In an observational cohort study an increase and LII. The reliability/accuracy of LII using digital models in intercanine and intermolar width was reported to be 0.72 to report different degrees of mandibular dental crowding has mm and 2.41 mm respectively. Nevertheless, an Increase been investigated and validated by Palazzo et al. (2019). in arch length could vary from as little as 0.2 mm due to Accordingly, each patient’s pre-treatment and post-treatment distal movement of the molars after 0.9 mm SS lingual arch dental casts were scanned and used to report the cases. insertion to as much as 4.8 mm. All the patients included in this study presented with class It is not prudent to claim that resolving mandibular incisor I skeletal relation and did not need any orthopaedic treatment crowding could be achieved by holding the mandibular perma- intervention. All the patients had at least one retained primary nent molars from drifting mesially and allowing the distal drift canines, primary first molars, and/or primary second molars. of permanent canines, only. Proclination of the mandibular The treatment duration lasted twenty months, which is close to incisors was reported as another possible reason behind the what has been reported in previous studies to resolve mandibu- relief of crowding as well [26, 33]. Rebellato et al. (1997) lar incisor crowding using a passive fixed lower lingual holding confirmed that the lingual arch reduced arch perimeter loss arch [23, 31]. at the expense of mandibular incisor proclination. Forward Upon dealing with mandibular incisor crowding, the clini- movement and proclination of the mandibular incisors relative cian needs to differentiate between temporary primary crowd- to the A-Pog line (Li-A-Pog) was increased along the use of ing that might be resolved spontaneously due to the dimen- LLHA. Yet, mandibular permanent incisors didn’t always sional changes that take place during mixed dentition and the procline along the use of the LLHA. Lingual inclination of definitive primary crowding that is related to the dental arch the mandibular permanent incisors rather than proclination has morphology and needs early intervention. Mandibular been reported in several studies [34–36]. incisors crowding is typical in mixed dentition as the width of Regardless of the different reasons behind the relief of the permanent incisors is 5 mm more than the primary incisors mandibular incisor crowding, the agreed notion is that in the mandibular arch. Identifying potential mandibular whenever the LLHA is used, it proves to be an effective incisor crowding in permanent dentition can be observed by appliance for preserving arch length. LLHA simplicity in the lack of interdental space in primary dentition and premature intervention is considered one of the main strengths of its use. loss of one of the primary canines. Whether it was after the The simplicity that resides in the design and fabrication of loss of primary canines and/or primary first or second molars, LLHA turns it to serve other goals beside space maintenance. the use of passive LLHA as a simple interceptive treatment dur- Pontics added to lingual arches can serve in cases of missing ing the mixed dentition phase could lead to relief of mandibular teeth. Moreover, incorporating an anterior biteplate in incisor crowding in 15% of cases and an improvement in 49% the appliance serve as anterior bite planes in deep bite cases. when used in the upper arch. In cases 1 and 2, the LLHA was placed when the bilateral Several limitations in this case series study such as the lack primary canines, primary first molars, and primary second of classification of molar occlusion and incisor relation could molars were not exfoliated yet. In cases 3 and 4, the LLHA was be addressed in a future randomized clinical trial. Moreover, placed when the mandibular primary second molars bilaterally measuring the incisal inclination as well as the mesial move- were the only retained primary teeth. Even preserving the ment of the permanent molars will reinforce the interpretation second primary molars alone could contribute to the relief of of the reasons behind the contributing factors that led to the 105 F I G U R E 3. Case 3. (A) Intraoral pre-treatment photograph of mandibular arch. (B) Pre-treatment digital study cast displaying the mandibular incisor crowding. (C) Intraoral post-treatment photograph of mandibular arch. (D) Post-treatment digital study cast immediately after removal of the LLHA. F I G U R E 4. Case 4. (A) Intraoral pre-treatment photograph of mandibular arch. (B) Pre-treatment digital study cast displaying the mandibular incisor crowding. (C) Intraoral post-treatment photograph of mandibular arch. (D) Post-treatment digital study cast with LLHA. 106 relief of crowding. 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Management of mandibular incisors crowd- subjects with a different degree of crowding: a reproducibility study. ing by using passive lower lingual holding arch: a case series and Applied Sciences. 2020; 10: 7108. literature review. Journal of Clinical Pediatric Dentistry. 2023; Chen CY, Hsu KLC, Marghalani AA, Dhar V, Coll JA. Systematic review 47(2): 101-107. doi: 10.22514/jocpd.2023.003. and meta-analysis of passive lower lingual arch for resolving mandibular Copyright of Journal of Clinical Pediatric Dentistry is the property of MRE Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

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