CLINICIAN’S CORNER

Brodie bite with an extracted mandibular firstmolar in a young adult: A case report

Vinay K. Chugh,a Vijay P. Sharma,b Pradeep Tandon,c and Gyan P. Singhd

Jaipur and Lucknow, India

Total buccal crossbites are rare, but, when they occur, they can be extremely difficult to correct, even withsurgery and orthodontics. In most patients with in-locking crossbites, the maxillary teeth erupt past theirmandibular antagonists, creating severe occlusal difficulties. This article presents an adult patient withscissors-bite or partial telescoping bite bilaterally in the posterior region and an extracted mandibular firstmolar on the right side. She was treated with expansion of the mandibular arch, and the subsequent openbite was closed with the help of masticatory muscle exercises and high-pull headgear. The second and thirdmolars were uprighted and moved mesially to close the extraction spaces. (Am J Orthod Dentofacial Orthop2010;137:694-700)

Total buccal crossbite problems—ie, in-locking,Brodie bite,1 buccal nonocclusion, or telescop-ing bite—are rare, but, when they occur, they

can be extremely difficult to correct, even with surgeryand orthodontic treatment. In most patients with in-locking crossbites, the maxillary teeth erupt past theirmandibular antagonists, creating severe occlusal diffi-culties and all but eliminating lateral excursions. Inter-estingly, a tendency toward maxillary buccal crossbiteis found in Australian aborigines, who otherwise haveideal dentitions and perfect occlusions. Barrett2 calledthis ‘‘X’’ occlusion. Although it might initially bea transverse discrepancy with fault in the maxilla orthe mandible, or in both jaws, it becomes a problem be-cause the unopposed teeth in each arch supraerupt, cre-ating a situation in which the elongated posterior teethneed to be intruded by several millimeters and reposi-tioned laterally.

This rare situation of total buccal crossbite or totalin-locking is due to a combination of excessive maxil-

aAssistant professor, Department of Orthodontics and Dentofacial Orthopedics,

MG Dental College and Hospital, Jaipur, Rajasthan, India.bProfessor and head, Department of Orthodontics and Dentofacial Orthopedics,

Faculty of Dental Sciences, CSM Medical University Lucknow, Uttar Pradesh,

India.cProfessor, Department of Orthodontics and Dentofacial Orthopedics, Faculty

of Dental Sciences, CSM Medical University, Lucknow, Uttar Pradesh, India.dAssistant professor, Department of Orthodontics and Dentofacial Orthopedics,

Faculty of Dental Sciences, CSM Medical University, Lucknow, Uttar Pradesh,

India.

The authors report no commerical, proprietary, or financial interest in the

products or companies described in this article.

Reprint requests to: Vinay K. Chugh, c/o Sanjay Medicos, Chugh Nursing

Home, Bikaner Rd, Suratgarh, 335804, Rajasthan, India; e-mail, drvinaychd@

yahoo.com.

Submitted, February 2008; revised and accepted, April 2008.

0889-5406/$36.00

Copyright � 2010 by the American Association of Orthodontists.

doi:10.1016/j.ajodo.2008.04.033

694

lary width and mandibular deficiency. The mandibularalveolar process might be narrow, but the width of themandibular base is usually normal. Many clinicianshave reported the potential effects on the health of thetemporomandibular joints. Although the crossbite itselfmight not cause pathosis, compromised masticationcould eventually lead to temporomandibular dysfunc-tion.3 The extreme vertical overlap on the affectedside makes it impossible to place orthodontic attach-ments on the facial surfaces of the mandibular teeth.

Loss of 1 tooth can have significant effects on thestability of both arches. With loss of a mandibular firstmolar, the mandibular second and third molars tip mesi-ally, the mandibular second premolars move distally,and the opposing maxillary first molar is supraerupted.Mesial tipping of the mandibular second molar resultsin redundant edematous gingivae accumulating at themesial surface, creating a defect that cannot be cleanedwith routine home-care procedures. Mesial tipping pla-ces the distal cusps of the second molar into occlusalprominence, creating excursive deflective occlusal con-tacts that generate horizontal forces on the ipsilateralmolars.

CASE REPORT

A 17-year-old girl came for treatment at the Depart-ment of Orthodontics and Dentofacial Orthopedics,King George’s University of Dental Sciences (now,CSM Medical University), Lucknow, Uttar Pradesh, In-dia. Her chief complaint was inability to chew with herback teeth. The intraoral examination showed that hermandibular posterior teeth telescoped partially insidethe maxillary teeth. She had a bilateral scissors-bite inthe posterior region. Her mandibular right first molar

Fig 1. Pretreatment intraoral photographs.

Fig 2. Pretreatment models.

American Journal of Orthodontics and Dentofacial Orthopedics Chugh et al 695Volume 137, Number 5

had been extracted 4 years earlier because of a poor end-odontic prognosis, resulting in mesial tipping and drift-ing of the second molar. This malocclusion developedpartially because of lingual tipping of the mandibularbuccal segments and partially because of loss of the firstmolar (Figs 1 and 2). The maxillary right and leftposterior teeth were extruded, and the labial surface ofthe first molar was worn, with the underlying dentin

exposed. She had a Class I molar relationship on theleft side and a Class II relationship on right side,because of mesial migration of the mandibular rightsecond molar. The dental midline was deviated 1.5mm toward the right side. Other than the Brodie biteand the mesial tipping and drifting of the mandibularsecond molar, almost everything else about herocclusion was within acceptable limits. Cephalometric

Table. Cephalometric analysis

Variable Pretreatment Normal Posttreatment Change

SNA (�) 82 82 6 3 82 0

SNB (�) 79 79 6 3 79 0

ANB (�) 3 3 6 1 3 0

Wits appraisal (mm) –1 0 –2.5 –1.5

Maxillary incisor

to maxillary

plane angle (�)

118 108 6 5 118 0

Mandibular incisor

to mandibular

plane angle (�)

95 92 6 5 97 2

Interincisal angle (�) 124 133 6 10 123 –1

Maxillomandibular

plane angle (�)24 27 6 5 24 0

Upper anterior

face height (mm)

56 56 0

Lower anterior

face height (mm)

66 66 0

Face height

ratio (%)

54 55 54 0

Mandibular incisor

to APo line (mm)

3 0-2 3.5 0.5

Lower lip to Ricketts

E-plane (mm)

3 –2 3 0

Upper lip to E-line

(mm)

0 –2- –3 0 0

Fig 3. Pretreatment radiographs.

696 Chugh et al American Journal of Orthodontics and Dentofacial Orthopedics

May 2010

analysis (Table) indicated that she was an averagegrower with a skeletal Class I pattern. The soft-tissueprofile was convex with good frontal symmetry andfacial proportions. The panoramic radiograph (Fig 3)showed complete permanent dentition, except for theextracted mandibular right first molar, and the severetipping and mesial drifting of the second molar intothe extraction space.

Treatment options were limited for this patient. Sherefused to consider surgery, but, because the problemwas caused mainly by buccolingual tipping of the den-tition rather than an underlying skeletal problem, a non-surgical approach was feasible. Therefore, the treatmentplan called for dental correction with standard edgewiseappliances, 0.022 3 0.028 in. The mandibular archwould be expanded, the maxillary arch constricted,and the mandibular molars uprighted. High-pull head-gear with a force of 500 g per side would be usedthroughout the expansion period when cross elasticswere used to aid in minimizing molar extrusion and topromote intrusion. Third molar extraction (except themandibular right) would provide space for alignment.

TREATMENT PROGRESS

A maxillary removable plate (Fig 4) was deliveredto open the bite in the posterior region so that the man-dibular posterior teeth could be banded. After 3 months

of initial alignment and leveling, a 0.019 3 0.025-instainless steel archwire was placed in the mandibulararch, and a 0.040-in stainless steel jockey arch4 (Fig5) expanded up to 1 cm was placed into the headgeartubes of the last banded molars. The jockey archwirewas also tied to the stainless steel archwire at variousregions to maintain the vertical level and stability ofthe jockey arch. Along with the jockey archwire, crosselastics (3/16-in, 4 oz, TP Orthodontics, LaPorte, Ind)or ‘‘through the bite elastics’’ were worn.1 Transverseexpansion of the mandibular arch was continued alongwith cross elastics for 2.5 months, until the buccal seg-ments began to upright to oppose the maxillary arch.High-pull headgear with a force of 500 g per sideworn a minimum of 12 to 14 hours per day was usedduring the expansion period with the cross elastics.However, bite opening in the anterior region was inevi-table, as vertical control of the mandibular molars couldnot be done while simultaneously uprighting them. Asa consequence, 9 mm of bite opening was recorded atthe incisor region (Fig 6).

Fig 4. Maxillary removable plate (different views).

American Journal of Orthodontics and Dentofacial Orthopedics Chugh et al 697Volume 137, Number 5

To control the open-bite problem, we used a combi-nation of masticatory muscle exercises and high-pullheadgear.5 Appointments were scheduled every 3weeks to make certain that the patient was wearingthe headgear and doing the exercises. She cooperatedwith both; at each visit, the open bite was reduced by2 mm.

When sufficient uprighting of the right second molarwas achieved, we decided to close the extraction spacewith loop mechanics. A new 0.019 3 0.025-in stainlesssteel stabilizing archwire was fabricated that bypassedthe first molars and was placed into the tube of the thirdmolar on the right side. A tissue guard was placed in thebypassed region to prevent gingival trauma. A verticaltube, 0.018 3 0.025 in, was soldered to the stainlesssteel wire between the lateral incisor and canine region(Fig 7). A 0.017 3 0.025-in TMA (Ormco/‘‘A’’ Com-pany, Orange, Calif) T-loop was fabricated with all pre-activation bends, placed in the soldered vertical tube,ligated into the second molar bracket (Fig 7), and acti-vated 3.5 mm by cinching back.6 The T-loop was reac-tivated as needed, and the mechanics were continueduntil the roots of the second molar were parallel to thoseof the second premolar (Fig 8).

Nine months into treatment, the overbite was cor-rected to pretreatment levels. To move the mandibularright third molar mesially, the same archwire was mod-ified and placed on the second molar, with the third mo-lar set free. A new T-loop was fabricated and placed inthe auxillary tube of the third molar on 1 side and thevertical tube on the other side. This was also augmentedwith Class II elastics (1/4-in, 3.3 oz, TP Orthodontics).

Near the end of treatment, a unilateral Forsus fixedfunctional appliance (3M Unitek, Monrovia, Calif)was used on the right side for midline correction andto establish a Class I molar and canine relationship. Ac-tive treatment time was 18 months. A maxillary Hawleyretainer with a wraparound labial bow and a mandibularbonded lingual retainer from canine to canine were pro-vided. A mandibular bonded labial retainer was alsoplaced in the buccal segment.

TREATMENT RESULTS

In general, the patient’s treatment outcome wasexcellent, and her cooperation with the extraoral appli-ances, clenching exercises, and oral hygiene was good.Posttreatment records (Figs 9 and 10) showed a well-aligned and interdigitated dentition with the occlusionfinished in a Class I molar and canine relationship.The bilateral scissors-bite and anterior open bite werecorrected, and the resulting profile was satisfactory.The final panoramic and intraoral periapical radio-graphs show acceptable root parallelism. The patientwas satisfied with her teeth and profile and reportedno discomfort near the temporomandibular joints.

Cephalometric analysis (Table) showed no skeletalchanges in the maxilla or the mandible, as expected inan adult. Nearly all cephalometric measurements weremaintained at the pretreatment levels except that themandibular incisors proclined slightly. Superimpositionof pretreatment and posttreatment cephalograms dem-onstrated intrusion of the maxillary molars and a slightextrusion of the mandibular molars. The maxillary mo-lar was intruded approximately 2 mm. Superimpositionalso showed mesial movement of the mandibular rightmolars and slight proclination of mandibular incisors.Overall, the superimposition showed that facial heightwas the same as before treatment (Fig 11).

DISCUSSION

When correcting a telescoping bite, vertical space isneeded for easy tooth movement. Temporary and instantraising of the bite during fixed orthodontic treatment iscommonly obtained with removable occlusal plates.However, complete patient cooperation is needed.

Various treatment procedures have been developed tocorrect scissors-bite and establish proper molar interdigi-tation. The critical procedures for scissors-bite correctionare intruding and palatal or buccal tipping of the involvedteeth when they are both extruded and buccally orlingually tilted. With a surgical-orthodontic approach,the buccolingual tipping and vertical repositioning could

Fig 5. The 0.040-in stainless steel jockey wire in themandibular arch.

Fig 6. Inevitable open bite.

Fig 7. Second molar mesialization with T-loop mechanics.

Fig 8. Periapical radiographs.

698 Chugh et al American Journal of Orthodontics and Dentofacial Orthopedics

May 2010

have been handled in 1 step, but we had to rely on a com-bination of high-pull headgear and masticatory muscleexercises. The treatment progressed well, although thesupraeruption of the posterior teeth as a result of upright-ing led to the inevitable opening of the bite in the anteriorregion.

In a prospective study of early open-bite treatment,English7 demonstrated that light masticatory exercisescombined with high-pull headgear produced significantreductions in the ANB and gonial angles, and reducedmandibular autorotation by 2.2�. We used the same mo-dality, in which the patient was asked to clench on a softbite wafer (GAC International, Bohemia, NY) for 1minute, 5 times per day. Each 1-minute session included5 seconds of isometric clenching (80% of maximum),followed by 5 seconds of rest. English and Olfert5 rec-ommended this regimen for growing patients; adultpatients can also use it but with greater intensity andlonger duration, at least 5 minutes per hour for 6 hoursminimum. Chewing sugarless gum as much as possiblewas also advised. The patient showed excellent cooper-ation with the high-pull headgear and followed the in-structions for the masticatory muscle exercises; thus,the positive overbite was reestablished to the pretreat-ment level. Open-bite closure was accomplished solelyby intrusion of the posterior teeth; mechanics to extrudethe anterior teeth were not used.

The third molars were extracted, except on the man-dibular right side. Extraction space closure was favoredover uprighting followed by prostheses to achieve betterprognosis and long-lasting functional results. Moreover,restorations would most likely need to be replacedseveral times during the patient’s lifetime.8,9

Considerable time was spent in bodily mesializationof the mandibular right second and third molars. Somedifficulty in mesialization was encountered initiallywith sliding mechanics; therefore, we switched tosectional mechanics, using a T-loop to generate the nec-essary moments for root movement. The entire mandib-ular arch and the labial crown torque in the mandibularanterior teeth were used to reinforce anchorage whilemaintaining the integrity of the arch. The patient hadexcellent oral health throughout treatment. Plaque-harboring pseudopockets associated with tipped anddrifted molars were completely eliminated, and thebone defect just mesial to the severely tipped mandibu-lar right second molar was resolved.

Labial bonded retainers were used in the buccal seg-ments to retain the results. Clenching exercises were

Fig 9. Posttreatment intraoral photographs.

Fig 10. Posttreatment radiographs.

American Journal of Orthodontics and Dentofacial Orthopedics Chugh et al 699Volume 137, Number 5

continued. Good Class I molar and canine relationshipswere established to ensure long-term stability. The endresult of the treatment was good, and the goals wereachieved.

CONCLUSIONS

Tooth migration after extraction of the first perma-nent molar results in periodontal deformities and ‘‘col-lapse’’ of the occlusion. Deviations from normal toothalignment bring changes in gingival and bony architec-

ture. Irregular soft-tissue architecture prevents completeplaque removal and complicates oral hygiene, leadingto progressive disease in the form of inflammation,loss of attachment, and caries. It becomes apparentthat the proximal and occlusal contacts are importantin maintaining tooth alignment and arch integrity.Treatment can improve masticatory function, esthetics,occlusion, and periodontal condition.

Masticatory exercise is an important adjunctivetreatment in correcting an open-bite malocclusion.

Fig 11. Cephalometric superimpositions at ages 17 (black) and 18 years 6 months (red): A, overallsuperimposition registered on SN line at S; B, maxillary superimposition registered on the palatalplane at ANS; C, mandibular superimposition registered on the corpus axis at suprapogonion.

700 Chugh et al American Journal of Orthodontics and Dentofacial Orthopedics

May 2010

Although surgery or miniscrews mean that virtually anymalocclusion is correctable, proper understanding andapplication of the fundamental principles of biome-chanics can still make a tremendous difference. If thepatient is reasonably motivated, adult orthodontic ther-apy can provide complete rehabilitation in both functionand appearance with a satisfactory long-term prognosis.

REFERENCES

1. Harper DL. A case report of a Brodie bite. Am J Orthod Dentofacial

Orthop 1995;108:201-6.

2. Seward FS. Tooth attrition and temporomandibular joint. Angle

Orthod 1976;46:162-70.

3. Okeson JP. Management of temporomandibular disorders and

occlusion. 6th ed. St Louis: Mosby; 2008.

4. McLaughlin RP, Bennett JC, Trevisi HJ. Systemized orthodontic

treatment mechanics. 1st ed. St Louis: Mosby; 2001. p. 92 and 290.

5. English J, Olfert K. Masticatory muscle exercise as an adjunctive

treatment for open bite malocclusions. Semin Orthod 2005;11:

164-9.

6. Burstone CJ. The segmented arch approach to space closure.

Am J Orthod 1982;82:361-78.

7. English J. Early treatment of skeletal open bite malocclusion.

Am J Orthod Dentofacial Orthop 2002;121:563-5.

8. Creugers NHJ, Kayser AF, Van’t Hof MA. A meta-analysis of

durability data on conventional fixed bridges. Community Dent

Oral Epidemiol 1994;22:448-52.

9. Kennedy DB. Orthodontic management of missing teeth. J Can

Dent Assoc 1999;65:548-50.