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Achieving Esthetics in Severe Crowding Without Extractions: A Modern Orthodontic Approach

Rajat Kanta Satapathy1 and Derine Rosalia Raj 2

1,2Post Graduate resident, Department of Orthodontics and Dentofacial Orthopaedics, Army College of Dental Sciences, Secunderabad, Telangana, India, 500087
1Orcid ID -https://orcid.org/0000-0002-6426-3876
2Orcid ID -https://orcid.org/0009-0004-2466-5813

*Corresponding author

*Rajat Kanta Satapathy, Post Graduate resident, Department of Orthodontics and Dentofacial Orthopaedics, Army College of Dental Sciences, Secunderabad, Telangana, India, 500087

Abstract

The smile arc, vertical incisal display, maxillary transverse dimension, upright upper incisors, and microesthetics are key components in evaluating smile esthetics. In cases of Class I malocclusion with upper anterior teeth proclination and severe crowding, tooth extraction is often necessary to achieve proper dental occlusion and function. However, extraction can sometimes lead to an unesthetic appearance as the patient grows, affecting the overall harmony of the smile.

This case report showcases an alternative treatment approach where one such severe malocclusion case was treated without tooth extraction. Instead, arch expansion supported by the advanced Pitts-21 bracket system was utilized, to create space and improve dental alignment. This method achieved an esthetically pleasing smile without extractions by maintaining a fuller dental arch and optimizing the smile arc, delivering both esthetic and functional results for similar cases.

Key words: Non extraction, smile arc protection, microesthetics, arch expansion

Introduction

Smile is not only a reflection of oral health, but also an emotion which is associated with well-being, social interaction, beauty and cultural values making it a significant focus in both orthodontics and cosmetic dentistry. People with crooked teeth may experience stigma or self-consciousness, as their smiles deviate from societal ideals. Cosmetic dental services, such as smile makeovers, are marketed as a means of achieving an ideal smile, which in turn boosts confidence and social acceptance amongst individuals [1]. Orthodontic treatments, especially amongst younger individuals, are often motivated by the desire to conform to societal standards of beauty and self-image [2].

Smile is the basic component of an individual’s esthetics and appearance, which further gravely contributes to their quality of life [3]. Esthetic concerns regarding dental malocclusions in the anterior region has popularized the need for a non-extraction orthodontic treatment to provide good smile esthetics in the least treatment span possible. The Pitts 21 self-ligating bracket system with its archwires enabled achieve such results successfully via arch expansion.

Case presentation

An 18-year-old female patient reported to the Department of Orthodontics in Army College of Dental Sciences, Secunderabad, India, complaining of protruded irregular front teeth and an unesthetic smile. She was diagnosed with skeletal Class II, with orthognathic maxilla, retrognathic mandible, vertical growth pattern, Angle’s Class I malocclusion, upper anterior proclination, severe upper and lower anterior crowding, decreased nasolabial angle and lip strain (Figure 1).

She was treated with Pitts-21 self-ligating brackets bonded in Smile Arc Protection (SAP) protocol with respect to upper and lower arches. In 4 months significantly expanded, levelled and well aligned dental arch could be seen (Figure 2). In a total time span of 6 months with a total of 4 wire changes a consonant smile arc with adequate vertical incisor display and upright incisors could be noted.  A reduction in buccal corridors could be appreciated further enhancing the smile esthetics (Figure 3).

Discussion

Patients desire for an attractive smile, makes esthetics a key objective. Smile analysis is an extensive subject encompassing various factors, such as incisal design, tooth symmetry, gingival design, and buccal corridors. Among these, the maxillary central incisors are the "esthetic zone's" most vital elements, serving as the focal point of the smile [4].

An ideal incisal design forms a gentle curve that follows the lower lip contour, enhancing both beauty and youthfulness. A straight or reverse curve can make the smile appear less attractive or older. Ideal proportion and symmetry of the maxillary central incisors focuses on maintaining proper width-to-length proportions of the central incisors, typically between 75% and 80%, and ensuring symmetry [5]. Bracket positioning at proper heights using SAP Protocol provides adequate vertical incisal display on smiling and the smile consonance [6].

Evrard et al, showcased the importance of soft tissue profile, crowding, incisor axes, tooth and arch shape, vertical dimension in smile esthetics and decision for extraction. However, patients increasingly prefer non extraction due to fear of pain and reluctance to lose a vital part of their body [7].

Moreover, tooth extraction can negatively impact smile aesthetics by reducing dental arch fullness and increasing buccal corridors, leading to less attractive smiles. It may decrease maxillary incisor visibility and alter the smile arc, resulting in a less favorable perception compared to non-extraction treatments. Cheng et al assessed the esthetic perceptions of smiles in extraction versus non-extraction orthodontic treatments across different malocclusion groups. The findings indicated that smiles characterized by greater maxillary incisor display, more visible teeth, and favorable buccal corridor ratios were deemed more attractive which was seen in non-extraction cases. Consequently, non-extraction treatments are often associated with better smile esthetics, emphasizing the importance of tooth retention in achieving desirable orthodontic results [8].

Escobar et al, in a photographic observational cross-sectional study evaluated the smile characteristics, focusing on the smile arc in extraction versus non-extraction cases where non-extraction patients exhibited a flatter smile arc compared to those who underwent extractions highlighting the necessity for development of a method to overcome this limitation [9]. Pitts 21 brackets positioned using SAP protocol, controlling the vertical incisal display help achieve the smile consonancy [6]. Furthermore, arch expansion via its broad archwires aids space gain to relieve crowding and reduce overjet by incisal inclination control [10].

Pitts 21 is a progressive slotted self-ligating bracket (SLB) system with a 2-4° play compared to ≥10-14° in other SLBs. Early engagement of square cross-sectional archwire in the square slot combined with the variable modulus concept by Charles Burstone regarding metallurgical variation in archwires used in this system gives early torque control over anterior teeth providing proper inclination of front teeth early in treatment [11].

Figure 1: A: Pretreatment Extraoral photographs; B: Pretreatment Intraoral photographs; C: Pretreatment Radiographs.

Figure 2: Treatment progress in 4 months.

Figure 3: Treatment results in 6 months.

Conclusion

Advancements in orthodontics now allow severe malocclusions, which previously required tooth extractions without guaranteed smile improvement, to be corrected using non-extraction methods. This shift has created new opportunities for non-invasive treatment methods aimed at enhancing smile esthetics, with high patient satisfaction.

Acknowledgements

None

REFERENCES

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  2. Saini R, Thakur N, Goyal RJ, Rai KS, Bagde H, Dhopte A. Analysis of Smile Aesthetic Changes With Fixed Orthodontic Treatment. Cureus. 2022 Dec;14(12).
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  9. Arrubla-Escobar D, Barbosa-Liz DM, Zapata-Noreña O, Carvajal-Flórez A, Correa-Mullet K, Gómez-Gómez SL, Ardila CM. Smile Aesthetics Assessment in Patients Undergoing the Finishing Phase of Orthodontic Treatment: An Observational Cross-Sectional Study. Cureus. 2023 Sep;15(9).
  10. Seixas MR, Câmara CA. The smile arc: review and synthesis. Dent Press J Orthod. 2021 Jun 30;26:e21spe3.
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ISSN: 3064-8025

Journal of Clinical & Medical Case Reports, Images (JCMCRI) ISSN: 3064-8025 is a peer-reviewed journal dedicated to publishing clinical images from all sectors of medicine. The goal of this magazine is to disseminate information about new discoveries and treatments in science and medicine.

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