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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 31-41

Combining different treatment philosophies and techniques to reach the desired treatment goal using butterfly system: Customizing orthodontic treatment


1 Department of Orthodontics, Tristar Hospital, Surat, Gujarat, India
2 Department of Orthodontics, A. J. Institute of Dental Sciences, Mangalore, Karnataka, India

Date of Web Publication28-Feb-2019

Correspondence Address:
Dhaval Ranjitbhai Lekhadia
20, Prajeet Row House, Umra, Surat - 395 007, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijor.ijor_14_17

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  Abstract 

This case report describes the orthodontic treatment of an 18-year-old male patient who presented with straight profile, tongue thrust habit, proclined upper incisors, generalized spacing in the upper and lower arches, Katz Class II premolar relation unilaterally, and Class II canine relation unilaterally with increased overjet and overbite. A butterfly system was used for the treatment combined with frictionless biomechanics in the initial stage of the treatment followed by continuous arch mechanics in the later part of the treatment. A tongued crib was used to stop the tongue thrust habit along with one elastic swallow exercise. Micro-implant anchorage was used unilaterally in the upper arch for retraction of the entire segment and correction of the unilateral Class II canine and premolar relationship. To avoid a dished-in profile, a nonextraction treatment was executed. Final correction of distally tipped canines was achieved using conventional Begg's uprighting auxiliaries in the vertical slots of the butterfly system in the finishing stage. The case was finished using bite-settling elastics. The total treatment time was 1 year and 2 months. Esthetic and functional goals were achieved satisfactorily with proper selection of biomechanics.

Keywords: Butterfly system, micro-implant, sectional mechanics, tongue crib, vertical slots


How to cite this article:
Lekhadia DR, Hegde G. Combining different treatment philosophies and techniques to reach the desired treatment goal using butterfly system: Customizing orthodontic treatment. Int J Orthod Rehabil 2019;10:31-41

How to cite this URL:
Lekhadia DR, Hegde G. Combining different treatment philosophies and techniques to reach the desired treatment goal using butterfly system: Customizing orthodontic treatment. Int J Orthod Rehabil [serial online] 2019 [cited 2019 May 19];10:31-41. Available from: http://www.orthodrehab.org/text.asp?2019/10/1/31/253269


  Introduction Top


Orthodontic practitioners and beginners in orthodontics often have many questions in mind: which philosophy to use? What bracket prescription is appropriate for a particular case? When to use a straight archwire and segmented mechanics? Is it appropriate to combine the various treatment philosophies and techniques to reach the final treatment outcome?

Making an accurate diagnosis of the changes observed in patients is of utmost importance. It is essential that an effective treatment plan is executed in order to treat the malocclusion within a shorter period of time, with as little injuries to protective and supporting tissues as possible. Thus, recommending the most appropriate treatment for a particular malocclusion, regardless of the type of bracket prescription, technique, or slot, is what really matters. For this reason, knowing the principles on which each technique is based on, as well as its limitations, is essential.[1]

The preadjusted edge-wise straight wire appliance was introduced in the 1970s.[2] Since then, there have been many suggested modifications to the bracket prescriptions in terms of torque and ti P values, often differing by only a few degrees. Over the years, clinicians have considered how bracket design can help achieve these objectives.[3] Andrews made extensive measurements on untreated excellent occlusions.[4] Molar anchorage loss has been shown to occur during the early stages of alignment with preadjusted appliances.[5],[6] Low friction is most advantageous during initial alignment, whereas friction is needed for control in finishing and torque expression. If the friction level of a bracket could be adjusted for different treatment stages, orthodontic tooth movement would be more efficient.[7] In a conventional preadjusted appliance, with the buccal tube positioned parallel to the line of buccal cusps, the passive archwire will lie below the anterior brackets because of the curve of Spee. When the anterior teeth are engaged with a continuous archwire, a counterclockwise tip forward moment will be created on the molar resulting in anchor loss while the anterior teeth are extruded.[4] This bite-deepening effect can be avoided by using a sectional archwire in the initial stage of treatment,[8] and micro-implants can be used to reinforce the anchorage as they can be more efficient than traditional anchorage methods besides making treatments more predictable.[9] Therefore, combining different treatment techniques and philosophies with a desired bracket system can bring about superior treatment results.


  Case Report Top


The present case report showcases the treatment results achieved by combining the different treatment philosophies and techniques using butterfly system.[10]

Diagnosis and treatment plan

An 18-year-old male patient in the permanent dentition presented with the chief complaint of forwardly placed anterior teeth with spacing in between them. Upon extraoral examination, the patient had a straight profile, horizontal growth pattern, reduced nasolabial angle, upper midline shifted to the right by 1 mm, competent lips, and nonconsonant smile [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]. He was also diagnosed with tongue thrust habit. Upon intraoral examination, he had proclined anteriors, generalized spacing in the upper and lower arches, distally tipped canines in the upper and lower arches, increased curve of Spee, Class I molar relation bilaterally, Katz Class II premolar relation and Class II canine relation on the left side, and crossbite in relation to 15; the overjet was 7 mm and overbite was 40% [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]. The findings were confirmed with study models [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16] and pretreatment radiographs [Figure 17] and [Figure 18]. Cephalometric analysis indicated a Class I skeletal pattern, horizontal growth pattern, reduced lower anterior facial height, and proclined upper and lower incisors [Table 1].
Figure 1: Pretreatment extraoral frontal view

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Figure 2: Pretreatment extraoral frontal smile view

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Figure 3: Pretreatment extraoral oblique view

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Figure 4: Pretreatment extraoral oblique smile view

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Figure 5: Pretreatment extraoral right lateral profile view

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Figure 6: Pretreatment extraoral left lateral profile view

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Figure 7: Pretreatment intraoral right lateral view

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Figure 8: Pretreatment intraoral frontal view

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Figure 9: Pretreatment intraoral left lateral view

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Figure 10: Pretreatment intraoral maxillary occlusal view

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Figure 11: Pretreatment intraoral mandibular occlusal view

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Figure 12: Pretreatment study model right lateral view

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Figure 13: Pretreatment study model frontal view

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Figure 14: Pretreatment study model left lateral view

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Figure 15: Pretreatment study model maxillary occlusal view

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Figure 16: Pretreatment study model mandibular occlusal view

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Figure 17: Pretreatment lateral cephalogram

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Figure 18: Pretreatment orthopantomogram

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Table 1: Cephalometric values

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Following a comprehensive clinical and database analysis, we devised a treatment plan involving nonextraction approach leaving the incisors mildly proclined to prevent a dished-in profile and to have an adequate lip support.

Treatment progress

A butterfly system with 0.022” slot was used. Initial leveling and alignment was carried out in the upper and lower arches using sectional 0.016” nickel titanium (NiTi) wire from the second molar to canine as posterior section and incisors in the anterior section [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23]. This was done to prevent the bite-deepening effect of continuous archwire and prevent strain on the anchorage. Myofunctional exercise was advised for the correction of tongue thrust habit. After the correction of distal crown tip of canines, a continuous 0.016” heat-activated NiTi wire was placed in the upper and lower arches. This was followed by 0.019 × 0.025” heat-activated NiTi wire.
Figure 19: Initial leveling and alignment with sectional archwire right lateral view

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Figure 20: Initial leveling and alignment with sectional archwire frontal view

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Figure 21: Initial leveling and alignment with sectional archwire left lateral view

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Figure 22: Initial leveling and alignment with sectional archwire maxillary occlusal view

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Figure 23: Initial leveling and alignment with sectional archwire mandibular occlusal view

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A miniscrew was placed in the apical portion, between the 2nd premolar and 1st molar, near the Cres of posterior segment on Class II side [Figure 24]. This assisted us in achieving a Katz Class I premolar and a Class I canine relation without disturbing the molars.
Figure 24: Micro-implant on Class II side in maxilla

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Space closure was done on 0.019 × 0.025” stainless steel wires in the upper and lower arches using NiTi closed coil springs. Direct anchorage from the implants was used on the Class II side. A fixed tongue crib was placed because of the persistence of the tongue thrust habit [Figure 25]. An openbite was observed at the end of space closure which was because of the tongue thrust habit. This was corrected using box elastics in the anteriors [Figure 26] and tongue crib. Since the patient did not have enough incisor exposure upon social smile, extrusion of anteriors by box elastics helped achieve a favorable incisor exposure.
Figure 25: Fixed tongue crib

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Figure 26: Box elastics

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At the end of space closure, conventional Begg's uprighting springs were used on the upper and lower canines to achieve final correction of the canine tip [Figure 27], [Figure 28], [Figure 29]. This ensures stability of the treated case. Finishing was done using triangular elastics with hooks in vertical slots on a light 0.016” NiTi wire in the upper and lower arches.
Figure 27: Traditional Begg's uprighting springs – right lateral view

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Figure 28: Traditional Begg's uprighting springs – left lateral view

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Figure 29: Traditional Begg's uprighting springs – frontal view

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  Discussion Top


Making an accurate diagnosis of the changes observed in patients and formulating an appropriate treatment plan is the key to successful orthodontic treatment. A preference to butterfly system[10] was given to treat the present case because it has versatile vertical slots which could be used to upright the canines in the finishing stage of treatment; +3° mesial crown tip which helps to reduce marginal ridge discrepancy, especially on the Class II side; progressive mandibular anterior tip which in this case would help tent posting of the lower incisors which in turn would increase the stability of the end results; and preventive mandibular anterior torque of −5° which helps prevent lower anterior flaring and finishing with an adequate overjet without having Bolton's discrepancy. An initial continuous archwire was not used because, unlike sectional mechanics, continuous archwires with distally tipped canine crowns tend to deepen the bite and put more strain on the anchorage.[4] Training of correct swallow and posture of the tongue was done by myofunctional exercise[11] where the patient was guided regarding the correct posture of the tongue during swallowing by various exercises. The patient was asked to place the tip of the tongue in the rugae areas for 5 min and is asked to swallow and repeat the same with an increased frequency. An micro-implant was placed on the Class II side because there was spacing mesial to the molar, leaving a weak anchorage value. Maximum anchorage was required on the left side as the entire segment had to be retracted in a functional Class I occlusion. The position of miniscrew was preferred in the apical portion, between the 2nd premolar and 1st molar, near the Cres of posterior segment [Figure 24]. Use of miniscrew for the reinforcement of orthodontic anchorage has become increasingly popular in recent years, especially for the space closure in maximum anchorage cases.[12] At the end of space closure, traditional Begg's uprighting springs were used in the vertical slots of canine brackets as described by Bowman and Carano.[10]

A Class I molar relationship was maintained throughout the treatment, and Katz Class II premolar relation was achieved bilaterally along with bilateral Class I canine relation. Overjet was 2 mm and overbite was 2 mm, and the midlines were coincident at the end of the treatment [Figure 30], [Figure 31], [Figure 32], [Figure 33], [Figure 34]. An esthetic, stable, and functional occlusion was achieved at the end of the treatment. Furthermore, a consonant smile arc and pleasing soft-tissue profile were achieved at the end of the treatment [Figure 35], [Figure 36], [Figure 37], [Figure 38], [Figure 39], [Figure 40].
Figure 30: Posttreatment intraoral right lateral view

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Figure 31: Posttreatment intraoral frontal view

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Figure 32: Posttreatment intraoral left lateral view

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Figure 33: Posttreatment intraoral maxillary occlusal view

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Figure 34: Posttreatment intraoral mandibular occlusal view

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Figure 35: Posttreatment extraoral frontal view

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Figure 36: Posttreatment extraoral frontal smile view

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Figure 37: Posttreatment extraoral oblique view

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Figure 38: Posttreatment extraoral oblique smile view

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Figure 39: Posttreatment extraoral right lateral profile view

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Figure 40: Posttreatment extraoral left lateral profile view

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Superimposition of pre- and post-lateral cephalogram reveals that the maxillary incisors were left with enough proclination to provide lip support. The mandibular incisors were finished with adequate tip and torque and mild proclination [Figure 41]. Postoperative orthopantomogram revealed parallel roots without any significant root resorption [Figure 42], and postoperative lateral cephalogram revealed adequate lip support and pleasing profile at the end of the treatment [Figure 43]. The findings were confirmed from posttreatment study models [Figure 44], [Figure 45], [Figure 46], [Figure 47], [Figure 48].
Figure 41: Pre- and post-lateral cephalogram superimposition

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Figure 42: Posttreatment orthopantomogram

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Figure 43: Posttreatment lateral cephalogram

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Figure 44: Posttreatment study model right lateral view

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Figure 45: Posttreatment study model frontal view

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Figure 46: Posttreatment study model left lateral view

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Figure 47: Posttreatment study model maxillary occlusal view

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Figure 48: Posttreatment study model mandibular occlusal view

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Clinical significance

Use of different techniques in a single case after reaching a proper diagnosis proves to be an efficient treatment mechanism. Unlike the traditional approach of treating all the cases with an MBT or Roth prescription and a continuous archwire mechanism, using a different system and combining and customizing the treatment methods is the need of the hour. The present case report is an evidence of such a method of treating each case differently based on its diagnosis and combining different techniques to suit the demands of a particular malocclusion.


  Conclusion Top


A careful combination of philosophy, bracket prescription, biomechanics, anchorage reinforcements, and finishing auxiliaries can help us to reach the desired treatment outcome. Each malocclusion type requires customizing of treatment method and selection of an appropriate bracket prescription from the pool of bracket systems available. A combination of butterfly system with sectional mechanics in the initial stage and continuous wire in the later stage, use of micro-implant where necessary, and use of traditional Begg's uprighting auxiliaries in the vertical slot of a preadjusted edgewise appliance have proved to be effective in the present case report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Caldas SG, Ribeiro AA, Simplício H, Machado AW. Segmented arch or continuous arch technique? A rational approach. Dental Press J Orthod 2014;19:126-41.  Back to cited text no. 1
    
2.
Thickett E, Taylor NG, Hodge T. Choosing a pre-adjusted orthodontic appliance prescription for anterior teeth. J Orthod 2007;34:95-100.  Back to cited text no. 2
    
3.
Andrews LF. Straight Wire, the Concept and Appliance. San Diego: L. A. Wells; 1989.  Back to cited text no. 3
    
4.
McLaughlin RP, Bennet JC, Trevisi HJ. Systemized Orthodontic Treatment Mechanics. Wolfe, London: Mosby; 2001.  Back to cited text no. 4
    
5.
Rajesh M, Kishore M, Shetty KS. Comparison of anchorage loss following initial leveling and aligning using ROTH and MBT prescription – A clinical prospective study. J Int Oral Health 2014;6:16-21.  Back to cited text no. 5
    
6.
Su H, Han B, Li S, Na B, Ma W, Xu TM, et al. Factors predisposing to maxillary anchorage loss: A retrospective study of 1403 cases. PLoS One 2014;9:e109561.  Back to cited text no. 6
    
7.
Chen S, Chen G, Xu T. Clinical application of the PASS technique. J Clin Orthod 2015;49:508-15.  Back to cited text no. 7
    
8.
Orton HS, McDonald F. A simple sectional canine retraction technique using the properties of nickel titanium rectangular wire. Eur J Orthod 1985;7:120-6.  Back to cited text no. 8
    
9.
Marassi C, Marassi: Mini-implant assisted anterior retraction. Dent Press J Orthod 2008;13:57-74.  Back to cited text no. 9
    
10.
Bowman SJ, Carano A. The butterfly system. J Clin Orthod 2004;38:274-87.  Back to cited text no. 10
    
11.
Speidel TM, Isaacson RJ, Worms FW. Tongue-thrust therapy and anterior dental open-bite. A review of new facial growth data. Am J Orthod 1972;62:287-95.  Back to cited text no. 11
    
12.
Park HS, Bae SM, Kyung HM, Sung JH. Micro-implant anchorage for treatment of skeletal class I bialveolar protrusion. J Clin Orthod 2001;35:417-22.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28], [Figure 29], [Figure 30], [Figure 31], [Figure 32], [Figure 33], [Figure 34], [Figure 35], [Figure 36], [Figure 37], [Figure 38], [Figure 39], [Figure 40], [Figure 41], [Figure 42], [Figure 43], [Figure 44], [Figure 45], [Figure 46], [Figure 47], [Figure 48]
 
 
    Tables

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