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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Transdisciplinary treatment of Class III malocclusion using conventional
implant-supported anchorage: 10-year posttreatment follow-up</title><author><name sortKey="Rinaldi, Mariana Roennau Lemos" sort="Rinaldi, Mariana Roennau Lemos" uniqKey="Rinaldi M" first="Mariana Roennau Lemos" last="Rinaldi">Mariana Roennau Lemos Rinaldi</name><affiliation><nlm:aff id="aff1">PhD resident in Orthodontics, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</nlm:aff></affiliation></author><author><name sortKey="Rizzatto, Susana Maria Deon" sort="Rizzatto, Susana Maria Deon" uniqKey="Rizzatto S" first="Susana Maria Deon" last="Rizzatto">Susana Maria Deon Rizzatto</name><affiliation><nlm:aff id="aff2">Professor of Orthodontics, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</nlm:aff></affiliation></author><author><name sortKey="De Menezes, Luciane Macedo" sort="De Menezes, Luciane Macedo" uniqKey="De Menezes L" first="Luciane Macedo" last="De Menezes">Luciane Macedo De Menezes</name><affiliation><nlm:aff id="aff3">PhD in Oral and Maxillofacial Surgery, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</nlm:aff></affiliation></author><author><name sortKey="Polido, Waldemar Daudt" sort="Polido, Waldemar Daudt" uniqKey="Polido W" first="Waldemar Daudt" last="Polido">Waldemar Daudt Polido</name><affiliation><nlm:aff id="aff3">PhD in Oral and Maxillofacial Surgery, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</nlm:aff></affiliation></author><author><name sortKey="De Lima, Eduardo Martinelli Santayanna" sort="De Lima, Eduardo Martinelli Santayanna" uniqKey="De Lima E" first="Eduardo Martinelli Santayanna" last="De Lima">Eduardo Martinelli Santayanna De Lima</name><affiliation><nlm:aff id="aff4">Adjunct professor of Orthodontics, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">26154459</idno><idno type="pmc">4520141</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4520141</idno><idno type="RBID">PMC:4520141</idno><idno type="doi">10.1590/2176-9451.20.3.069-079.oar</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000280</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000280</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Transdisciplinary treatment of Class III malocclusion using conventional
implant-supported anchorage: 10-year posttreatment follow-up</title><author><name sortKey="Rinaldi, Mariana Roennau Lemos" sort="Rinaldi, Mariana Roennau Lemos" uniqKey="Rinaldi M" first="Mariana Roennau Lemos" last="Rinaldi">Mariana Roennau Lemos Rinaldi</name><affiliation><nlm:aff id="aff1">PhD resident in Orthodontics, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</nlm:aff></affiliation></author><author><name sortKey="Rizzatto, Susana Maria Deon" sort="Rizzatto, Susana Maria Deon" uniqKey="Rizzatto S" first="Susana Maria Deon" last="Rizzatto">Susana Maria Deon Rizzatto</name><affiliation><nlm:aff id="aff2">Professor of Orthodontics, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</nlm:aff></affiliation></author><author><name sortKey="De Menezes, Luciane Macedo" sort="De Menezes, Luciane Macedo" uniqKey="De Menezes L" first="Luciane Macedo" last="De Menezes">Luciane Macedo De Menezes</name><affiliation><nlm:aff id="aff3">PhD in Oral and Maxillofacial Surgery, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</nlm:aff></affiliation></author><author><name sortKey="Polido, Waldemar Daudt" sort="Polido, Waldemar Daudt" uniqKey="Polido W" first="Waldemar Daudt" last="Polido">Waldemar Daudt Polido</name><affiliation><nlm:aff id="aff3">PhD in Oral and Maxillofacial Surgery, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</nlm:aff></affiliation></author><author><name sortKey="De Lima, Eduardo Martinelli Santayanna" sort="De Lima, Eduardo Martinelli Santayanna" uniqKey="De Lima E" first="Eduardo Martinelli Santayanna" last="De Lima">Eduardo Martinelli Santayanna De Lima</name><affiliation><nlm:aff id="aff4">Adjunct professor of Orthodontics, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</nlm:aff></affiliation></author></analytic><series><title level="j">Dental Press Journal of Orthodontics</title><idno type="ISSN">2176-9451</idno><idno type="eISSN">2177-6709</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>INTRODUCTION:</title><p> Combined treatment offers advantages for partially edentulous patients.
Conventional implants, used as orthodontic anchorage, enable previous orthodontic
movement, which provides appropriate space gain for crown insertion. </p></sec><sec><title>OBJECTIVE:</title><p> This case report describes the treatment of a 61-year and 10-month-old patient
with negative overjet which made ideal prosthetic rehabilitation impossible,
thereby hindering dental and facial esthetics.</p></sec><sec><title> CASE REPORT: </title><p>After a diagnostic setup, conventional implants were placed in the upper arch to
anchor intrusion and retract anterior teeth. Space gain for lateral incisors was
achieved in the lower arch by means of an orthodontic appliance. </p></sec><sec><title>CONCLUSIONS:</title><p> Integrated planning combining Orthodontics and Implantology provided successful
treatment by means of conventional implant-supported anchorage. The resulting
occlusal relationship proved stable after 10 years.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Agarwal, S" uniqKey="Agarwal S">S Agarwal</name></author><author><name sortKey="Gupta, S" uniqKey="Gupta S">S Gupta</name></author><author><name sortKey="Chugh, Vk" uniqKey="Chugh V">VK Chugh</name></author><author><name sortKey="Jain, E" uniqKey="Jain E">E Jain</name></author><author><name sortKey="Valiathan, A" uniqKey="Valiathan A">A Valiathan</name></author><author><name sortKey="Nanda, R" uniqKey="Nanda R">R Nanda</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pinho, T" uniqKey="Pinho T">T Pinho</name></author><author><name sortKey="Neves, M" uniqKey="Neves M">M Neves</name></author><author><name sortKey="Alves, C" uniqKey="Alves C">C Alves</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Uribe, F" uniqKey="Uribe F">F 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Araújo</name></author><author><name sortKey="Riera, R" uniqKey="Riera R">R Riera</name></author><author><name sortKey="Atallah, A" uniqKey="Atallah A">A Atallah</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Southard, Te" uniqKey="Southard T">TE Southard</name></author><author><name sortKey="Buckley, Mj" uniqKey="Buckley M">MJ Buckley</name></author><author><name sortKey="Spivey, Jd" uniqKey="Spivey J">JD Spivey</name></author><author><name sortKey="Krizan, Ke" uniqKey="Krizan K">KE Krizan</name></author><author><name sortKey="Casko, Js" uniqKey="Casko J">JS Casko</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Dental Press J Orthod</journal-id><journal-id journal-id-type="iso-abbrev">Dental Press J Orthod</journal-id><journal-title-group><journal-title>Dental Press Journal of Orthodontics</journal-title></journal-title-group><issn pub-type="ppub">2176-9451</issn><issn pub-type="epub">2177-6709</issn><publisher><publisher-name>Dental Press International</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">26154459</article-id><article-id pub-id-type="pmc">4520141</article-id><article-id pub-id-type="doi">10.1590/2176-9451.20.3.069-079.oar</article-id><article-categories><subj-group subj-group-type="heading"><subject>Articles</subject></subj-group></article-categories><title-group><article-title>Transdisciplinary treatment of Class III malocclusion using conventional
implant-supported anchorage: 10-year posttreatment follow-up</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Rinaldi</surname><given-names>Mariana Roennau Lemos</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Rizzatto</surname><given-names>Susana Maria Deon</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>de Menezes</surname><given-names>Luciane Macedo</given-names></name><xref ref-type="aff" rid="aff3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Polido</surname><given-names>Waldemar Daudt</given-names></name><xref ref-type="aff" rid="aff3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>de Lima</surname><given-names>Eduardo Martinelli Santayanna</given-names></name><xref ref-type="aff" rid="aff4"><sup>4</sup></xref></contrib></contrib-group><aff id="aff1"><label>1</label>PhD resident in Orthodontics, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</aff><aff id="aff2"><label>2</label>Professor of Orthodontics, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</aff><aff id="aff3"><label>3</label>PhD in Oral and Maxillofacial Surgery, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</aff><aff id="aff4"><label>4</label>Adjunct professor of Orthodontics, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil</aff><author-notes><corresp id="c01"><bold>Contact address:</bold> Eduardo Martinelli S. de Lima Av. Ipiranga, 6681 -
Prédio 6 (Faculdade de Odontologia), Porto Alegre - RS, CEP 91530-000 - Brazil.
E-mail: <email>elima@pucrs.br</email></corresp></author-notes><pub-date pub-type="epub-ppub"><season>May-Jun</season><year>2015</year></pub-date><pmc-comment>Fake ppub date generated by PMC from publisher
pub-date/@pub-type='epub-ppub' </pmc-comment>
<pub-date pub-type="ppub"><season>May-Jun</season><year>2015</year></pub-date><volume>20</volume><issue>3</issue><fpage>69</fpage><lpage>79</lpage><history><date date-type="received"><day>02</day><month>7</month><year>2014</year></date><date date-type="accepted"><day>25</day><month>11</month><year>2014</year></date></history><permissions><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an Open Access article distributed under the terms of the Creative
Commons Attribution Non-Commercial License, which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the
original work is properly cited.</license-p></license></permissions><abstract><sec><title>INTRODUCTION:</title><p> Combined treatment offers advantages for partially edentulous patients.
Conventional implants, used as orthodontic anchorage, enable previous orthodontic
movement, which provides appropriate space gain for crown insertion. </p></sec><sec><title>OBJECTIVE:</title><p> This case report describes the treatment of a 61-year and 10-month-old patient
with negative overjet which made ideal prosthetic rehabilitation impossible,
thereby hindering dental and facial esthetics.</p></sec><sec><title> CASE REPORT: </title><p>After a diagnostic setup, conventional implants were placed in the upper arch to
anchor intrusion and retract anterior teeth. Space gain for lateral incisors was
achieved in the lower arch by means of an orthodontic appliance. </p></sec><sec><title>CONCLUSIONS:</title><p> Integrated planning combining Orthodontics and Implantology provided successful
treatment by means of conventional implant-supported anchorage. The resulting
occlusal relationship proved stable after 10 years.</p></sec></abstract><trans-abstract xml:lang="pt"><sec><title>INTRODUÇÃO:</title><p> tratamentos combinados podem oferecer vantagens em casos de edentulismo parcial.
O uso de implantes convencionais como ancoragem ortodôntica permite a movimentação
ortodôntica prévia, fornecendo os espaços apropriados para inserção das coroas.
</p></sec><sec><title>OBJETIVO:</title><p> este relato de caso descreve o tratamento de uma paciente, com 61 anos e 10 meses
de idade, que possuía um <italic>overjet</italic> negativo que tornava impossível
uma reabilitação protética ideal, comprometendo a estética dentária e facial. </p></sec><sec><title>RELATO DO CASO: </title><p>após um <italic>setup</italic> diagnóstico, os implantes convencionais foram
colocados na mandíbula para ancorar a intrusão e retração dos dentes anteriores.
Espaços para os incisivos laterais foram abertos na maxila, usando-se aparelho
ortodôntico. </p></sec><sec><title>CONCLUSÕES:</title><p> o planejamento integrado entre Ortodontia e Implantodontia propiciou um
tratamento bem-sucedido, usando implantes convencionais como ancoragem. A relação
oclusal obtida apresenta estabilidade 10 anos pós-tratamento.</p></sec></trans-abstract><kwd-group><kwd>Orthodontic anchorage procedures</kwd><kwd>Dental implants</kwd><kwd>Angle Class III malocclusion</kwd><kwd>Tooth loss</kwd></kwd-group><counts><fig-count count="12"></fig-count><table-count count="1"></table-count><equation-count count="0"></equation-count><ref-count count="28"></ref-count><page-count count="11"></page-count></counts></article-meta></front><body><sec sec-type="intro"><title>INTRODUCTION</title><p>Transdisciplinarity is a trend in Dentistry as well as in other areas of the health
sciences. This is because the interaction established among different specialties
provides patients with a comprehensive treatment plan.<xref rid="B01" ref-type="bibr">1</xref><sup>,</sup><xref rid="B02" ref-type="bibr">2</xref><sup>,</sup><xref rid="B03" ref-type="bibr">3</xref> Osseointegration has opened up new
possibilities not only for Prosthodontics, but also for Orthodontics. Proper anchorage
has always been fundamental for orthodontic treatment efficiency, as it allows the
desired orthodontic movements to be performed and reduces potential adverse effects. The
use of conventional implants and temporary anchorage devices (TAD) has improved
anchorage control and provided absolute resistance units against movement. Absolute
anchorage allows space closure, intrusion, extrusion, protraction, retraction of teeth
and stabilization of periodontally compromised teeth.<xref rid="B04" ref-type="bibr">4</xref><sup>-</sup><xref rid="B08" ref-type="bibr">8</xref></p><p>Conventional implants for prosthetic restoration can also be used for orthodontic
anchorage.<xref rid="B09" ref-type="bibr">9</xref> Implant selection and insertion
site should be appropriate for the dual function of implants: rehabilitation and
anchorage. The anatomical aspects of the case, the intended orthodontic movement and the
ideal position for final rehabilitation should be planned ahead of time.<xref rid="B05" ref-type="bibr">5</xref><sup>,</sup><xref rid="B10" ref-type="bibr">10</xref><sup>,</sup><xref rid="B11" ref-type="bibr">11</xref> Combined treatment offers advantages for
partially edentulous patients, and so does previous orthodontic movement, as it provides
appropriate space gain for implant insertion.<xref rid="B12" ref-type="bibr">12</xref><sup>-</sup><xref rid="B15" ref-type="bibr">15</xref></p><p>The aim of this case report is to demonstrate the transdisciplinary treatment of a Class
III malocclusion patient with multiple missing teeth. Conventional implants were used as
anchorage to retract lower teeth. This combined transdisciplinary plan intended to
maximize patient's benefits, enhance dental esthetics and establish a balanced occlusion
associated with healthy tissues. This report illustrates a case of successful 10-year
posttreatment stability.</p></sec><sec><title>CASE REPORT</title><p>In 1998, a healthy female patient, aged 61 years and 10 months old, presented at the
orthodontic service of the Brazilian Dental Association with anterior crossbite and
multiple missing teeth. Her chief complaint was related to poor dental esthetics.
Prosthetic rehabilitation was thought to be determined by the conditions of dental
occlusion. There was premature contact between lower central incisors, and anterior
crossbite was mostly caused by functional sliding resulting from contact. In occlusion,
the patient had Class I canine relationship on both sides (<xref ref-type="fig" rid="f01">Figs 1</xref> and <xref ref-type="fig" rid="f02">2</xref>).</p><p><fig id="f01" orientation="portrait" position="float"><label>Figure 1.</label><caption><title>Pre-treatment facial and intraoral photographs.</title></caption><graphic xlink:href="dpjo-20-03-00069-gf01"></graphic></fig></p><p><fig id="f02" orientation="portrait" position="float"><label>Figure 2.</label><caption><title>Initial dental casts.</title></caption><graphic xlink:href="dpjo-20-03-00069-gf02"></graphic></fig></p><p>Patient's face was symmetrical in frontal view, with a marked nasolabial fold. Facial
profile was unbalanced, with mild maxillary deficiency and protrusion of the lower lip
which was positioned ahead of the upper lip. The nasolabial angle denoted the incorrect
anterior-posterior position of the maxilla, which was confirmed by cephalometric
findings. The mentolabial sulcus was flat, most likely due to muscle adaptation to
anterior crossbite.</p><p>Lower dentition was mutilated: molars and second premolars were absent on both sides. On
the right side, there was a single-unit ceramic crown over the lower first premolar. In
the upper arch, posterior teeth were extruded, left first molar was absent and right
first premolar had a ceramic crown. A midline diastema of 5 mm was found in the upper
arch and associated to the migration of central incisors and to the space of missing
lateral incisors (<xref ref-type="fig" rid="f03">Fig 3</xref>).</p><p><fig id="f03" orientation="portrait" position="float"><label>Figure 3.</label><caption><title>Initial lateral cephalometric radiograph, panoramic and periapical
radiographs.</title></caption><graphic xlink:href="dpjo-20-03-00069-gf03"></graphic></fig></p><p>Periapical radiographs revealed generalized mild attachment loss, which suggested
judicious periodontal control during orthodontic treatment. In spite of the edentulous
regions, bone height was enough for conventional implant placement. Cephalometric
evaluation revealed skeletal Class III malocclusion associated with retrusion of upper
incisors and protrusion of lower incisors (<xref ref-type="fig" rid="f04">Fig
4</xref>and <xref ref-type="table" rid="t01">Table 1</xref>).</p><p><fig id="f04" orientation="portrait" position="float"><label>Figure 4.</label><caption><title>Initial cephalometric tracing.</title></caption><graphic xlink:href="dpjo-20-03-00069-gf04"></graphic></fig></p><p><table-wrap id="t01" orientation="portrait" position="float"><label>Table 1.</label><caption><title>Cephalometric data.</title></caption><table frame="hsides" rules="groups" style="border-top: 1px solid black; border-bottom: 1px solid black; width: 100%"><thead><tr><th rowspan="1" colspan="1"></th><th rowspan="1" colspan="1">Pre-treatment</th><th rowspan="1" colspan="1">Post-treatment</th><th rowspan="1" colspan="1">10-year follow-up</th></tr></thead><tbody><tr><td rowspan="1" colspan="1"> SNA (degrees)</td><td rowspan="1" colspan="1"> 82</td><td rowspan="1" colspan="1"> 81</td><td rowspan="1" colspan="1"> 81</td></tr><tr><td rowspan="1" colspan="1"> SNB (degrees)</td><td rowspan="1" colspan="1"> 83</td><td rowspan="1" colspan="1"> 81</td><td rowspan="1" colspan="1"> 81.5</td></tr><tr><td rowspan="1" colspan="1"> ANB (degrees)</td><td rowspan="1" colspan="1"> -1</td><td rowspan="1" colspan="1"> 0</td><td rowspan="1" colspan="1"> -0.5</td></tr><tr><td rowspan="1" colspan="1"> 1.NA (degrees)</td><td rowspan="1" colspan="1"> 14</td><td rowspan="1" colspan="1"> 25</td><td rowspan="1" colspan="1"> 25.5</td></tr><tr><td rowspan="1" colspan="1"> 1-NA (mm)</td><td rowspan="1" colspan="1"> 4.0</td><td rowspan="1" colspan="1"> 9</td><td rowspan="1" colspan="1"> 9</td></tr><tr><td rowspan="1" colspan="1"> 1.NB (degrees)</td><td rowspan="1" colspan="1"> 24.5</td><td rowspan="1" colspan="1"> 23</td><td rowspan="1" colspan="1"> 23</td></tr><tr><td rowspan="1" colspan="1"> 1-NB (mm)</td><td rowspan="1" colspan="1"> 8.0</td><td rowspan="1" colspan="1"> 5.5</td><td rowspan="1" colspan="1"> 5.5</td></tr><tr><td rowspan="1" colspan="1"> Pog-NB (mm)</td><td rowspan="1" colspan="1"> 1.5</td><td rowspan="1" colspan="1"> 0.5</td><td rowspan="1" colspan="1"> 0.6</td></tr><tr><td rowspan="1" colspan="1"> 1:1 (degrees)</td><td rowspan="1" colspan="1"> 142</td><td rowspan="1" colspan="1"> 132</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> SN:OP (degrees)</td><td rowspan="1" colspan="1"> 9</td><td rowspan="1" colspan="1"> 12</td><td rowspan="1" colspan="1"> 12.5</td></tr><tr><td rowspan="1" colspan="1"> SN:GoGn (degrees)</td><td rowspan="1" colspan="1"> 31</td><td rowspan="1" colspan="1"> 32</td><td rowspan="1" colspan="1"> 32</td></tr><tr><td rowspan="1" colspan="1"> S to upper lip (mm)</td><td rowspan="1" colspan="1"> -1</td><td rowspan="1" colspan="1"> 1</td><td rowspan="1" colspan="1"> 1</td></tr><tr><td rowspan="1" colspan="1"> S to lower lip (mm)</td><td rowspan="1" colspan="1"> 2</td><td rowspan="1" colspan="1"> 1</td><td rowspan="1" colspan="1"> 3</td></tr><tr><td rowspan="1" colspan="1"> FMA (degrees)</td><td rowspan="1" colspan="1"> 28</td><td rowspan="1" colspan="1"> 29.5</td><td rowspan="1" colspan="1"> 29.5</td></tr><tr><td rowspan="1" colspan="1"> FMIA (degrees)</td><td rowspan="1" colspan="1"> 61</td><td rowspan="1" colspan="1"> 62.5</td><td rowspan="1" colspan="1"> 61.5</td></tr><tr><td rowspan="1" colspan="1"> IMPA (degrees)</td><td rowspan="1" colspan="1"> 91</td><td rowspan="1" colspan="1"> 88</td><td rowspan="1" colspan="1"> 89</td></tr><tr><td rowspan="1" colspan="1"> Angle of convexity (degrees)</td><td rowspan="1" colspan="1"> -4</td><td rowspan="1" colspan="1"> -2</td><td rowspan="1" colspan="1"> -2.5</td></tr></tbody></table></table-wrap></p><p>The objectives of treatment were: (1) correct anterior crossbite; (2) reestablish
vertical dimensions in the posterior region, which would provide space gain for
implant-retained prosthetic restorations in the region of lower premolars and molars;
(3) close interincisal diastema; (4) gain space for implants and prosthetic crowns in
the region of upper lateral incisors; and (5) improve the relationship established
between upper and lower lips.</p><p>Delay in rehabilitation treatment after extraction of posterior teeth is expected to
provoke alveolar bone atrophy; therefore, only basal bones of the maxilla and mandible
remain intact. Lack of dental occlusion in the posterior region leads to a reduction in
lower facial height and changes in the position of remaining teeth. The mandible rotates
anticlockwise, remodeling the condyle process and the glenoid fossa.<xref rid="B16" ref-type="bibr">16</xref><sup>,</sup><xref rid="B17" ref-type="bibr">17</xref> Orthognathic surgery may be the first choice
to correct anterior crossbite and provide the height necessary for prosthetic
rehabilitation in the posterior region. Presurgical Orthodontics may create space for
implants to replace missing lateral incisors.</p><p>Surgery was considered a risky procedure for a 61-year-old patient. She presented
favorable conditions for camouflage, since adequate anchorage could be provided.
Conventional dental implants can also be used for orthodontic anchorage. Upper incisors
should be proclined so as to increase arch perimeter, which would help space gain for
upper lateral incisors. Treatment plan was designed according to patient's needs and
expectations.</p><p>A diagnostic setup was performed according to cephalometric findings. Lower central
incisors underwent retrusion of 4 mm and intrusion of 1.5 mm (<xref ref-type="fig" rid="f05">Fig 5</xref>). Upper central incisors were subsequently positioned in
contact, with an increase in buccal inclination so as to achieve a 2-mm overjet.
Bilateral spaces of 6 mm were created to replace missing upper lateral incisors.</p><p><fig id="f05" orientation="portrait" position="float"><label>Figure 5.</label><caption><title>Setup records.</title></caption><graphic xlink:href="dpjo-20-03-00069-gf05"></graphic></fig></p><p>Implants should be inserted 2 mm distal to the lower right first premolar and 3 mm
distal to the lower left first premolar. Temporary acrylic crowns were adapted over
conventional dental implants (Brånemark System, Nobel Biocare, Kloten, Switzerland: 11.5
x 5 mm in the region of molars and 4 x 11.5 mm in the region of premolars) on both sides
of the lower arch. Orthodontic brackets were bonded after six months. Absolute anchorage
unit allowed distal movement of lower right canine and left premolar; in addition, it
provided retraction and intrusion of lower incisors.</p><p>Upper molars were banded and a full fixed orthodontic appliance was placed (Standard
Edgewise 0.022 x 0.028-in, 3M-Unitek, Monrovia, USA). Leveling and alignment followed
the sequence of stainless steel archwires in increasing stiffness (3M-Unitek, Monrovia,
USA). Upper diastema closure and distal movement of lower teeth were performed by
sliding mechanics with elastomeric chains.</p><p>Retraction of lower incisors and proclination of upper incisors occurred simultaneously.
Tear drop loops were bent in 0.018 x 0.025-in stainless steel archwires halfway between
lateral incisors and canines. Ideal 0.019 x 0.026-in stainless steel archwires allowed
detailed angulation to be performed. Total treatment lasted 36 months.</p><p>Maxillary implants were inserted after orthodontic space opening (Brånemark System,
Nobel Biocare, Kloten, Switerland: 3.3 x 13 mm on the right side and 3.3 x 15 mm on the
left side).</p></sec><sec sec-type="results"><title>RESULTS</title><p>By the end of orthodontic treatment, ideal overjet and overbite were achieved. In
addition, the necessary space gain for implant-supported definite crowns, placed in the
posterior region of the lower arch, was achieved (<xref ref-type="fig" rid="f06">Figs
6</xref> and <xref ref-type="fig" rid="f07">7</xref>). Midline upper diastema was
closed, which favored prosthetic rehabilitation of lateral incisors. After bracket
debonding, definite crowns were placed over implants, central incisors were restored
with resin veneers and other damaged restorations were replaced (<xref ref-type="fig" rid="f08">Fig 8</xref>).</p><p><fig id="f06" orientation="portrait" position="float"><label>Figure 6.</label><caption><title>Post-treatment facial and intraoral photographs.</title></caption><graphic xlink:href="dpjo-20-03-00069-gf06"></graphic></fig></p><p><fig id="f07" orientation="portrait" position="float"><label>Figure 7.</label><caption><title>Final dental casts.</title></caption><graphic xlink:href="dpjo-20-03-00069-gf07"></graphic></fig></p><p><fig id="f08" orientation="portrait" position="float"><label>Figure 8.</label><caption><title>Rehabilitation of the upper incisor region.</title></caption><graphic xlink:href="dpjo-20-03-00069-gf08"></graphic></fig></p><p>Superimposition of cephalometric tracings revealed that the mandible rotated clockwise
(FMA from 28° to 29.5°). There was an increase in the occlusal plane angle (SN-OP from
9° to 12°) and a decrease in the incisor-mandible plane angle (IMPA from 91° to 88°),
which reflects intrusion and retrusion, respectively, of lower incisors. Proclination of
upper incisors was highlighted by an increase in the 1.NA angle (14° to 25°) (<xref ref-type="fig" rid="f09">Figs 9</xref> and <xref ref-type="fig" rid="f10">10</xref>,
<xref ref-type="table" rid="t01">Table 1</xref>).</p><p><fig id="f09" orientation="portrait" position="float"><label>Figure 9.</label><caption><title>Final lateral cephalometric radiograph, panoramic and periapical
radiographs, and cephalometric tracing at treatment completion</title></caption><graphic xlink:href="dpjo-20-03-00069-gf09"></graphic></fig></p><p><fig id="f10" orientation="portrait" position="float"><label>Figure 10.</label><caption><title>Superimposition of cephalometric tracings at treatment onset (black) and
after treatment completion (red): A) Sella-nasion plane at sella; B) Best-fit
of the maxilla; C) Mandibular plane at the internal symphysis cortical plate to
assess tooth movement, intrusion and incisor repositioning.</title></caption><graphic xlink:href="dpjo-20-03-00069-gf10"></graphic></fig></p><p>Regarding the facial profile, maxillary deficiency was camouflaged. Upper and lower lips
were improved (upper lip to S-line, from -1 to 1 mm; lower lip to S-line, from 2 to 1
mm) with upper incisors support.</p><p>Ten years after the completion of the case, the patient showed occlusal stability, as
well as integrity of dentition and prostheses. Resin veneers showed pigmentation and
discoloration, as expected. Periodontal structures remained healthy (<xref ref-type="fig" rid="f11">Figs 11</xref> and <xref ref-type="fig" rid="f12">12</xref>).</p><p><fig id="f11" orientation="portrait" position="float"><label>Figure 11.</label><caption><title>Facial and intraoral photographs 10 years after treatment
completion.</title></caption><graphic xlink:href="dpjo-20-03-00069-gf11"></graphic></fig></p><p><fig id="f12" orientation="portrait" position="float"><label>Figure 12.</label><caption><title>Radiograph 10 years after treatment completion. Superimposition of
cephalometric tracings at treatment completion (red) and 10 years after
treatment (brown). Sella-nasion plane at sella.</title></caption><graphic xlink:href="dpjo-20-03-00069-gf12"></graphic></fig></p></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>Anterior-posterior and transversal Class III malocclusion relationships tend to worsen
with aging.<xref rid="B18" ref-type="bibr">18</xref><sup>,</sup><xref rid="B19" ref-type="bibr">19</xref> Patient's Class III skeletal pattern
associated with loss of lower posterior teeth were limiting factors in the planning of
this case. Without orthognathic surgery, conventional mechanics would not solve the
patient's problem. However, there are increased risks associated with surgery and, for
this reason, the patient ultimately elected not to undergo surgery.</p><p>In this case, prognosis for camouflage was very favorable, considering mild maxillary
deficiency and the possibility to procline upper central incisors. The need for oral
rehabilitation led this case to be planned based on the use of implants and prostheses.
Dentistry restored key features of patient's quality of life: proper mastication as well
as smile and facial esthetics. In 1998, the life expectancy for women in Brazil was 72
years.<xref rid="B20" ref-type="bibr">20</xref> Thus, we offered a reliable treatment
which promotes long-term oral health to our patient. Additionally, transdisciplinary
treatment plan fulfilled patient's needs and expectations.</p><p>In the late 1990s, skeletal anchorage in Orthodontics was not as usual as it is today.
Therefore, we considered the possibility of losing implants with the application of
orthodontic movement and occlusal forces, leading to decreased alveolar width and
height.</p><p>Orthodontic forces are small when compared to the complex system of intermittent and
multidirectional forces acting on implants during mastication. Thus, biomechanical
responses are within biological limits; for instance, an elastic chain used for canine
retraction leads to a force of 1 N or less. The association between orthodontic forces
and function stimulates responses of bone modeling and remodeling, which may lead to a
new balance of forces.<xref rid="B10" ref-type="bibr">10</xref><sup>,</sup><xref rid="B16" ref-type="bibr">16</xref></p><p>The approach presented herein took advantage of conventional implants which functioned
as orthodontic anchorage before prosthetic procedures.<xref rid="B08" ref-type="bibr">8</xref><sup>,</sup><xref rid="B21" ref-type="bibr">21</xref> Therefore, implants placed in the region of
lower molars provided anchorage necessary for intrusion and retraction of anterior lower
teeth. This was considered a worthwhile strategy: previous orthodontic treatment
improved occlusion and created space necessary for crown placement (<xref ref-type="fig" rid="f06">Fig 6</xref>).<xref rid="B08" ref-type="bibr">8</xref><sup>,</sup><xref rid="B10" ref-type="bibr">10</xref><sup>,</sup><xref rid="B14" ref-type="bibr">14</xref><sup>,</sup><xref rid="B22" ref-type="bibr">22</xref> Implant selection and insertion site must
consider patient's anatomical features, quality and quantity of bone available (alveolar
width and height), gingival conditions, ideal position for teeth replacement and
orthodontic movement.<xref rid="B04" ref-type="bibr">4</xref><sup>,</sup><xref rid="B14" ref-type="bibr">14</xref><sup>,</sup><xref rid="B23" ref-type="bibr">23</xref><sup>,</sup><xref rid="B24" ref-type="bibr">24</xref></p><p>Whenever anterior teeth are missing, it is challenging to obtain a natural smile and
achieve correct occlusion. Before implants were developed, alternative therapies for
these cases included the use of adhesive crowns and preparation of healthy teeth to
function as pillars. Both treatment options have esthetics limitations.<xref rid="B25" ref-type="bibr">25</xref><sup>,</sup><xref rid="B26" ref-type="bibr">26</xref></p><p>The esthetic objectives of implant therapy include creating adequate gingival margins
without abrupt changes in tissue height, maintaining the papilla intact and preserving
alveolar crest convex contour. To this end, 1-mm space or more, between the implant and
the adjacent tooth root, is required in addition to adequate space for crown
placement.<xref rid="B14" ref-type="bibr">14</xref> Whenever it is impossible to gain
the space required, space closure with mesial movement of posterior teeth is a
reasonable option, especially if only one or two teeth are missing in the anterior
region.<xref rid="B13" ref-type="bibr">13</xref></p><p>No consensus has been reached regarding the best treatment option to replace missing
lateral upper incisors.<xref rid="B27" ref-type="bibr">27</xref> It is important to
consider various aspects of treatment, namely: patient's age, alveolar ridge and
gingiva, type of malocclusion, other missing teeth and the possibility to restore space.
Implant placement is the best choice for cases similar to that demonstrated in the
present report: multiple missing teeth, interincisal diastema and mild Class III
malocclusion. Space closure would have caused the collapse of the upper arch, thereby
reducing arch perimeter. Mesial movement of central incisors produced the necessary
space for implant placement. This was based on the margin of space required to the roots
of adjacent natural teeth.<xref rid="B02" ref-type="bibr">2</xref><sup>,</sup><xref rid="B03" ref-type="bibr">3</xref><sup>,</sup><xref rid="B07" ref-type="bibr">7</xref></p><p>In addition to absolute anchorage provided by implants, biomechanics was similar to the
conventional technique. This treatment option requires the understanding of forces
involved in the system and the ability to control the magnitude of forces on implants.
Implants are structures fixed to bone and which transfer the load to the teeth which, in
turn, are connected by the appliance. It is important to consider the functional
characteristics of occlusion with implants, which assures stability and success (<xref ref-type="fig" rid="f11">Figs 11</xref> and <xref ref-type="fig" rid="f12">12</xref>).<xref rid="B17" ref-type="bibr">17</xref><sup>,</sup><xref rid="B28" ref-type="bibr">28</xref></p></sec><sec sec-type="conclusions"><title>CONCLUSION</title><p>The goals of this transdisciplinary treatment were to create adequate space in vertical,
transversal and horizontal planes for dental implant and prosthesis placement, with a
view to establishing functional occlusion and attractive dentition. Treatment plan
combining Implantology, Orthodontics and Prosthodontics proved to be effective in
overcoming the challenges. Tissue stability and healthy conditions remain after a
10-year posttreatment follow-up, which confirms the usefulness of this approach.</p></sec></body><back><fn-group><fn fn-type="supported-by"><p>» The authors report no commercial, proprietary or financial interest in the products
or companies described in this article.</p></fn><fn fn-type="other"><p>» Patients displayed in this article previously approved the use of their facial and
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