CASE REPORT

Correction of a dental arch-width asymmetric discrepancy with a slow maxillary contraction appliance
Xianming Hua,a Hui Xiong,b Guangli Han,c and Xiangrong Chengd Wuhan, China A boy, aged 12 years 3 months, sought treatment for a complete unilateral Brodie bite. His maxillary dental arch was asymmetric, and his dentition was 10 mm wider than normal values for his age. The transverse discrepancy was his chief complaint because it caused a chewing dysfunction. We used a special slow maxillary contraction appliance, which contains a screw, connectors, and retainers, to contract the maxillary transverse asymmetric dental arch. This was followed by preadjusted xed appliances to level the teeth and adjust the occlusion. A symmetric and functional Class I occlusion was achieved. (Am J Orthod Dentofacial Orthop 2012;142:842-53)

Brodie bite is a type of posterior crossbite that causes interocclusal contact between the outer oblique surfaces of the maxillary lingual cusp and the mandibular buccal cusp.1 With a Brodie bite discrepancy, the maxillary dentition is wider or the mandibular dentition is narrower than normal, or both dentitions can be abnormal. A Brodie bite can be unilateral or bilateral and occurs in 1.0% to 1.5% of the population.2 The techniques for treating a complete unilateral or bilateral Brodie bite with transverse mandibular deciency have been reported and include mandibular widening by distraction osteogenesis,3-6 mandibular transverse expansion by using cross-arch elastics,2-7 and expansion of the mandibular dental arch with a Schwarz appliance.8 A transverse skeletal deciency (or narrow dentition) can be treated with mandibular widening (or dental arch expansion). However, can we treat a complete unilateral Brodie bite by constricting the maxillary dental arch if the maxillary asymmetric dentition is wider than normal?
From the Department of Orthodontics, School & Hospital of Stomatology, Wuhan University, Wuhan, P. R. China. a PhD student, Orthodontic graduate program. b Associate professor. c Associate professor. d Professor and chair. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Reprint requests to: Guangli Han, Department of Orthodontics, School & Hospital of Stomatology, Wuhan University, 237 Luoyu Rd, Wuhan P. R. China; e-mail, hgl8855@gmail.com. Submitted, February 2011; revised and accepted, March 2011. 0889-5406/$36.00 Copyright 2012 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2011.03.029

In this case report, we address this question in our treatment of a teenaged patient with a complete unilateral Brodie bite on the right side. His maxillary asymmetric dentition was 10 mm wider than normal for children of his age. We successfully corrected his malocclusion with a slow maxillary contraction appliance followed by xed appliance treatment.
DIAGNOSIS AND ETIOLOGY

The patient was a boy, aged 12 years 3 months, with a complete unilateral Brodie bite. His chief complaint was chewing dysfunction. His soft-tissue prole was convex, with an open lip closure in resting status. His upper and lower lips were slightly thicker than normal (Fig 1). His face was asymmetric. He had no signs or symptoms of a temporomandibular disorder. Intraorally, he had a dental Class III molar relationship and a Class I canine relationship on both sides (Fig 1). His oral hygiene was excellent, and his periodontium was in good condition. The mesial margin of the maxillary left central incisor was coincident with the facial midline, but the right one deviated by 1.8 mm (a space between the maxillary incisors) to the right. The mandibular dental midline was the same as the facial midline in centric occlusion. His right lateral occlusion was a complete unilateral Brodie bite with an asymmetric maxillary dentition. Analysis of the dental casts showed a dental Class III relationship (Fig 2). The spaces between the maxillary right rst molar and left rst premolar were 15 mm. A wide, severe maxillary transverse process was a problem. The maxillary rst molar's cross-arch width (44.40 mm)

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Fig 1. A-G, Pretreatment photographs (age, 12 y 3 mo): arrows, unilateral Brodie bite; vertical lines, maxillary right central incisor deviated 1.8 mm (space between the central incisors) to the right of the facial midline. The maxillary occlusal view shows the asymmetric dental arch and interdental spaces (15 mm); the mandibular occlusal view shows the right second premolars slightly inclined lingually.

was greater than normal (34.69 mm) in children of his age.9 The maxillary dental arch was asymmetric, with the right side larger than the left. The mandibular rst molar's cross-arch width (33.91 mm) was nearly normal (32.50 mm). The mandibular right second premolars were slightly inclined lingually. Transverse and sagittal measurements are shown in Figure 3 and Table I. The cephalometric analysis showed a skeletal Class I relationship, with a slight downward and backward rotation of the mandible (Fig 4; Table II). The maxillary incisors appeared to be severely tipped labially. A pretreatment panoramic radiograph showed a healthy periodontium, with endodontic treatment of the mandibular right rst molar. The primary problem was the serious maxillary and mandibular transverse discrepancy. The maxillary dental arch was asymmetric and 10 mm wider than normal for his age. His parents did not have a similar malocclusion.
TREATMENT OBJECTIVES

dental arch width, and maintain the mandibular intermolar width; (3) close the maxillary dental arch space and correct the maxillary and mandibular dental midlines; and (4) improve the patient's prole.
TREATMENT ALTERNATIVES

The treatment objectives were to (1) maintain the skeletal Class I relationship of the maxilla and the mandible; (2) establish a dental Class I relationship, correct the asymmetric maxillary dentition, reduce the maxillary

Among the above treatment objectives, it was important to constrict the asymmetric maxillary dentition on the side of the Brodie bite. To achieve the main objective, 4 possibilities were considered. The rst treatment option was to use intermaxillary crossbite elastics to tip the maxillary right posterior teeth lingually and the mandibular right posterior teeth labially. This would effectively correct the posterior buccal crossbite.5 This would also constrict the asymmetric maxillary dental arch width. However, for this patient, the inclination of the teeth on the Brodie bite side was normal with the exception of the mandibular second premolar. So, the effects might have increased the mandibular dental arch width and tip the maxillary and mandibular posterior teeth on the right side. Meanwhile, intermaxillary crossbite elastics might promote posterior tooth extrusion, which would not improve the patient's prole. After

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Fig 2. A-E, Pretreatment dental casts.

Fig 3. Landmarks and measurements on the cast models. A, Transverse measurements. Tooth crossarch widths (dashed lines): the distance between the bilateral points located at the gingival margin on the lingual contour of the maxillary permanent tooth's long axis; intertooth widths (solid lines): the width from a tooth's tip (or ssure) to the tooth on the other side, and left or right width: the distance from tooth tip (or ssure) to the midpalatine raphe. B, Sagittal measurements. The distances (red lines) from the tip (or ssure) of a maxillary tooth to the line that crosses the incisive papilla, vertically to the midpalatine raphe.

we considered the long-term stability and the prole, we did not select intermaxillary crossbite elastics. The second option was to use implants. Implants as anchorage devices on the palate could make the maxillary posterior teeth move lingually. However, this would increase the risks and the costs. In addition, it is difcult to move a complete unilateral dentition in a parallel fashion. Implants require more skill and a special design when used for anchorage. The third option was to place a hyrax expander in an open position to produce palatal constriction and narrow the maxilla bilaterally.5 This technique would

correct the right unilateral Brodie bite but might also create a left posterior crossbite, because of the asymmetry in the maxillary left and right dentitions. The fourth option was an adjustable slow maxillary contraction appliance. Anchorage control was critical for this patient. The optimal treatment should reduce the maxillary right posterior dental arch width more than the left one and move the teeth in parallel fashion. A specially designed slow maxillary contraction appliance could achieve this goal of treatment of this malocclusion. The slow maxillary contraction appliance has a screw, connectors, and retainers and was modied from

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Table I. Transverse and sagittal measurements

Pretreatment Transverse measurements (mm) Maxillary canine cross-arch width Maxillary intercanine width Left Right Maxillary rst premolar cross-arch width Maxillary interrst premolar width Left Right Maxillary rst molar cross-arch width Maxillary interrst molar width Left Right Maxillary cross-arch alveolar process width Mandibular interrst molar width Sagittal measurements (mm) Canine distance Left Right First premolar distance Left Right First molar distance Left Right SMC, Slow maxillary contraction. After SMC Posttreatment Retention

T0 (12 y 3 mo) T1 (12 y 10 mo) T2 (14 y 8 mo) T3 (17 y 9 mo) T1-T0 T2-T1 T3-T0 T3-T2 30.36 39.35 19.15 20.20 36.15 45.06 21.78 23.28 44.40 56.09 27.34 28.75 60.17 33.91 26.08 34.14 17.51 16.63 30.40 38.90 20.06 18.84 39.13 50.33 25.43 24.90 56.86 35.42 28.35 37.23 18.61 18.62 32.21 40.75 20.37 20.38 39.62 50.86 25.56 25.30 60.32 35.48 27.86 37.20 18.60 18.60 32.32 41.94 20.96 20.98 39.94 51.78 25.95 25.83 63.18 36.55 4.28 5.21 1.64 3.57 5.75 6.16 1.72 4.44 5.27 5.76 1.91 3.85 3.31 1.51 2.27 3.09 1.10 1.99 1.81 1.85 0.31 1.54 0.49 0.53 0.13 0.40 3.46 0.06 2.50 2.15 0.55 1.60 3.83 3.12 0.82 2.30 4.46 4.31 1.39 2.92 3.01 2.64 0.49 0.03 0.01 0.02 0.11 1.19 0.59 0.60 0.32 0.92 0.39 0.53 2.86 1.07

2.87 2.86 12.34 11.44 27.31 30.22

2.58 2.13 12.05 10.55 27.01 27.95

1.28 1.10 7.39 7.61 22.38 23.3

0.77 0.69 8.02 8.16 23.01 23.98

0.29 3.86 3.64 0.73 3.23 3.55 0.29 4.65 4.32 0.89 2.94 3.28 0.30 4.63 4.30 2.27 4.65 6.24

0.51 0.41 0.63 0.55 0.63 0.68

Fig 4. A, Pretreatment cephalometric radiograph, and B, tracing (age, 12 y 3 mo).

a conventional rapid maxillary expansion appliance (Fig 5). Briey, the screw was put on a t point according to the Brodie bite. To leave the tube for constriction, the 2 ends of the screw were embedded with plastic in advance and then rotated to an almost fully open position

before putting the screw on the dental cast model for manufacturing. Retainers were made with articial plastic and covered the entire clinical crowns of the posterior teeth. We usually expect to have a larger area of connectors and retainers to achieve maximum anchorage. The

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Table II. Cephalometric summary

Pretreatment Measurement Skeletal ( ) SNA SNB ANB SN-MeGo SN-Gn Dental ( ) U1 to SN L1 to MeGo U1 to L1 Mean 80.8 80.1 2.7 32.5 65.8 105.7 96.9 124.2 SD 4.0 3.9 2.0 5.2 4.2 6.3 6.0 8.2 T0 (12 y 3 mo) 81.2 79.4 1.8 35.5 67.0 119.3 94.3 110.0 Posttreatment T1 (14 y 8 mo) 82.0 78.8 3.4 34.1 66.4 109.5 91.1 124.0 Retention T2 (17 y 9 mo) 81.3 79.2 2.1 34.6 66.9 113.6 91.7 120.1 T1-T0 0.8 0.6 1.6 1.4 0.6 9.8 3.2 14 T2-T1 0.7 0.4 1.3 0.5 0.5 4.1 0.6 3.9 T2-T0 0.1 0.2 0.3 0.9 0.1 5.7 2.6 10.1

S, Midpoint of sella; N, nasion; Me, menton; Go, gonion; Gn, gnathion; U1, maxillary central incisor; L1, mandibular central incisor; SN, sellanasion line; MeGo, menton-gonion line.

Fig 5. Slow maxillary contraction appliance: A, upper occlusal view: the space between the 2 sides of the slow maxillary contraction appliance was great (arrows); B, the structure of the slow maxillary contraction: a screw, connectors, and retainers; the left side area (anchorage) was larger than the right one; C-E, the slow maxillary contraction appliance was placed intraorally.

width of the maxillary dental arch would constrict when the screw was turned. To improve the patient's prole, we also proposed to extract 4 rst premolars. However, the patient and his parents refused any surgical treatment.
TREATMENT PROGRESS

Orthodontic treatment started by placement of the slow maxillary contraction appliance. During the treatment period, the patient was told to keep this appliance on every day and to turn the screw to keep 90 around the axis once every 2 days. After 7 months, the unilateral Brodie

bite was corrected (Figs 6 and 7). The slow maxillary contraction appliance was then used as a retainer for another 5 months by placing articial plastic on the screw. The main objective of this period was to constrict the asymmetric maxillary dentition, especially the right side, by using the slow maxillary contraction appliance. After 12 months of treatment with the slow maxillary contraction appliance, preadjusted xed appliances (0.022 3 0.028 in) were placed (Fig 8), with a maxillary rst molar palatal bar for leveling and alignment. A stepwise treatment through the various round wire sizes from 0.014 to 0.018 in was used until the rotations were corrected and full leveling was achieved. Then

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Fig 6. Intraoral photographs after slow maxillary contraction treatment (age, 12 y 10 mo): A, the upper sides of the slow maxillary contraction appliance were closed (arrows); B, the spaces between the canines were closed, and the maxillary dental arch width was contracted greatly; C-E, the unilateral Brodie bite was corrected (arrows), and no space remained between the maxillary central incisors.

Fig 7. A-E, Dental casts after the slow maxillary contraction treatment (age, 12 y 10 mo).

0.215 3 0.275-in rectangular wires were used to achieve the optimum axial inclinations of the roots of all teeth. During this treatment period, the dental Class III relationship was corrected by Class III elastics, and the maxillary and mandibular dental midlines were adjusted by anterior intermaxillary elastics. The space between the

maxillary right rst molar and the left rst premolar was closed with an elastomeric chain. Finally, vertical elastics were used to nish the occlusion. The active treatment lasted for 17 months. The maxillary and mandibular removable Hawley retainers were constructed for the patient.

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Fig 8. A-E, Intraoral photographs during initial xed appliance therapy.

Fig 9. A-H, Photographs after xed appliance treatment (age, 14 y 8 mo).

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Fig 10. A-E, Dental casts after xed appliance treatment (age, 14 y 8 mo).

Fig 11. A, Cephalometric radiograph, and B, tracing after xed appliance treatment (age, 14 y 8 mo).

TREATMENT RESULTS

At the end of active orthodontic treatment, a wellaligned dentition was obtained. Lateral excursions demonstrated group function-guided occlusion, with no working or balancing interferences. Due to the patient's cooperation with turning the screw and oral hygiene, the treatment results were excellent. Optimal overbite and overjet relationships were achieved, and the patient was satised with his teeth and prole after treatment (Figs 9 and 10). His oral function was improved greatly.

The cephalometric analysis showed that the SNA angle increased by 0.8 and the SNB decreased by 0.6 after treatment (Fig 11; Table II). The maxilla moved forward slightly from the slow maxillary contraction and the Class III elastic treatment. The mandible moved back slightly because of the Class III mechanics. Anteroposteriorly, the skeletal Class I relationship was maintained. Vertically, the mandible rotated counterclockwise, since the mandibular plane angle (SN-MeGo) changed from 35.5 to 34.1 (Table II). These changes were thought to result from

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Fig 12. Panoramic radiographs and cephalometric tracing: A, pretreatment (age, 12 y 3 mo); B, after slow maxillary contraction treatment (age, 12 y 10 mo); C, after xed appliance treatment (age, 14 y 8 mo); D, retention (age, 17 y 9 mo); E, pretreatment (black lines; age, 12 y 3 mo) and posttreatment (red lines; age, 14 y 8 mo) cephalometric tracings superimposed on SN at sella.

Fig 13. Tooth position tracing superimposition on midpalatine raphe at the incisive papilla before (age, 12 y 3 mo) and after (age, 12 y 10 mo) slow maxillary contraction (SMC) treatment.

the combined use of the slow maxillary contraction appliance and the Class III elastics. The slow maxillary contraction moved the maxillary teeth mesially, and the Class III elastics extruded the maxillary molar. The nal panoramic radiograph showed good root parallelism and minimal loss of the bony crest in the mandibular anterior region (Fig 12, C). Analysis of the dental casts showed that the maxillary dentition changed dramatically transversely and anteroposteriorly (Table I). Transverse constriction of the maxillary dentition was 5.21 mm in the canine area, 6.16 mm in the rst premolar area, and 5.76 mm in the rst molar area. Furthermore, the posterior teeth were almost displaced parallel to the palatal suture by the plastic retainer of the slow maxillary contraction appliance. The

maxillary rst molar cross-arch width and the interrst molar width were almost parallel at 5.27 and 5.76 mm, respectively. Similar results were seen for the maxillary rst premolars (5.75 and 6.16 mm, respectively). As expected, the maxillary right posterior teeth (Brodie bite) moved to the palatine raphe more than the left ones, because of the anchorage. Surprisingly, the maxillary cross-arch alveolar process width was transversely reduced by 3.31 mm after the slow maxillary contraction treatment and relapsed a little after the preadjusted xed appliance treatment (Table I). The spaces between the maxillary right rst molar and the left rst premolar were closed. However, the changes in the anteroposterior area were unexpected. The maxillary left and right posterior teeth moved mesially, and the right side (Brodie bite) moved more than the left. The reason might have been the anchorage on the left side. The distances of mesial movement were the following: canines, 0.29 mm (left) and 0.73 mm (right); rst premolars, 0.29 mm (left) and 0.89 mm (right); and rst molars, 0.30 mm (left) and 2.27 mm (right). In addition, the maxillary incisors inclined labially. Transverse and sagittal superimpositions were drawn (Fig 13) on the time points before and after the slow maxillary contraction treatment according to the dental cast analysis. During treatment with the preadjusted xed appliance, transversely, the maxillary left and right dental arch widths changed, as shown in Table I. The mandibular rst molar cross-arch width increased by 1.51 mm. Anteroposteriorly, in the maxilla, both sides moved mesially. The maxillary and mandibular incisors were retracted and uprighted (Fig 12, E).

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Fig 14. A-G, Follow-up photographs at 37 months (age, 17 y 9 mo) after xed appliance therapy. A metal crown had been placed on the right rst molar.

At the 37-month follow-up, the patient had a stable transverse occlusion (Figs 14 and 15; Table I). This stability contributed to the good occlusion after orthodontic treatment, based on his prepubertal age and 2 years of retention. Anteroposteriorly, the SNA and SNB angles relapsed to their pretreatment values (Table II) because of his growth. The maxillary incisors tipped labially a little more after retention.
DISCUSSION

It has been proposed that correction and adjustment of asymmetric malocclusions are complicated and challenging.10 If the malocclusion is moderately severe, treatment should be considered to control and modify asymmetric growth, because of the patient's active growth.11 A true unilateral Brodie bite is relatively rare.2 Previous reports have presented serious mandibular asymmetric transverse deciencies, treated with mandibular widening by distraction osteogenesis.5,12 However, treatment of a wider asymmetric maxillary dentition in a Brodie bite has not been published. Skeletal asymmetries are usually treated with a combination of orthodontics and orthognathic

surgery.13 For this patient, the maxillary dental arch was asymmetric and 10 mm wider than the normal value for his age. Meanwhile, the maxillary arch's asymmetry primarily resulted from alveolar bone (or had a dental origin). Therefore, we developed a special slow maxillary contraction appliance to constrict the asymmetric maxillary dentition, especially on the right side (Brodie bite). Maxillary dental arch constriction can be corrected by several techniques.14-16 For example, maxillary dental arch broadness can be treated by contracting the maxillary arch to some extent with a removable appliance.17 For this patient, to reduce the maxillary right posterior dental arch width more than the left one and to move teeth in a parallel manner, it was important to strengthen the maxillary left anchorage and move the teeth on the right. Therefore, the slow maxillary contraction device was specially designed for correcting the unilateral Brodie bite. We used various dental measurements on the dental casts to demonstrate a nearly parallel constriction of the alveolar bone (dental arch width) (Table I). The optimal treatment outcomes of maxillary expansion are that the posterior teeth are

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Fig 15. A-E, Follow-up dental casts at 37 months (age, 17 y 9 mo) after xed appliance therapy.

displaced bodily, with minor or no buccal tipping of the anchorage teeth, and no root and bone resorption.18 Thus, we concluded that satisfactory results were obtained to meet these requirements. Placing constricting screws at different locations resulted in different effects. Force is characterized by magnitude and vector, which are determined by location and orientation. Similar to the transpalatal distractor on the transverse maxillary deciency, the placement point and the angulations of the screw were vital.19 In this case, the screw was placed at the level of the second premolar, and the right teeth (Brodie bite) were moved more forward to the midpalatine raphe rather than to the left side (anchorage) after the slow maxillary contraction treatment. Greater constriction occurred in the anterior part of the maxilla than in the posterior part, with minor or no lingual tilting of teeth. In this slow maxillary contraction appliance, the left plastic part, which extended to the right canine, was larger than the right one. Thus, the forces on the 2 sides were different, and this was the rationale that the right posterior teeth move more to the midpalatal raphe than to the left. Valuable experience gained from this case raises several questions. (1) Can an asymmetric maxillary dentition be constricted by slow maxillary contraction unilaterally? (2) If yes, how and where is the screw placed? (3) Is the alveolar process or the basal bone constricted? (4) Is the maxillary dental arch stable after slow maxillary contraction treatment? We demonstrated that

an asymmetric maxillary dental arch can be adjusted and corrected unilaterally by designing sufcient anchorage. This supports the concept of segmental unilateral transpalatal distractor.20 The maxillary alveolar process could be constricted during slow maxillary contraction treatment with minor relapse after the xed appliance was placed and remained stable after active treatment. On 1 hand, the maxillary bone was compacted, and resorption occurred during slow maxillary contraction treatment. On the other hand, the period of treatment was longer (7 months with the slow maxillary contraction appliance), so the stability of the slow maxillary contraction treatment was different from rapid maxillary expansion treatment. At the 37-month follow-up, the patient had a stable transverse occlusion. However, we could not verify whether the basal bone was constricted, although the maxillary cross-arch alveolar process width was reduced by 3.31 mm. To further explore this issue, additional research is needed.
CONCLUSIONS

A specially designed slow maxillary contraction appliance can provide powerful anchorage for treating a unilateral Brodie bite with signicant maxillary and mandibular transverse discrepancies. In this unique case, the maxillary dentition was constricted, particularly on the side of Brodie bite. The posterior teeth on both sides moved mesially, and the maxillary alveolar process was compacted during treatment with the slow maxillary contraction appliance. The transverse occlusion was

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stable after retention. Slow maxillary contraction is an inexpensive and effective way to treat a transverse maxillary asymmetry. We thank Peng Liu for improving the language of the manuscript and Medjaden Bioscience Limited for editing and proofreading.
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