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the beginning, with special attention to dentofacial
orthopedics, will place teeth and jaws in a position that
ensures the improved relationships inside TMJ and the
successful completion of the subsequent prosthetic phase
of the patient’s full mouth rehabilitation and greatly
improve the overall esthetic result.
Case 1
Patient O., 40 years old presented with several concerns
about her smile (figs. 1, 2): her front teeth are too
vertical, gummy smile, cosmetically unpleasant prosthetic
restorations (fig. 3).
She also had numerous TMJ symptoms such as: “tension”
headaches, headaches in right and left temple areas and
back of her head. She had frequent neck aches, difficulty
of opening her mouth wide, clicking sounds in her joints
and ringing sounds in her ears. She was grinding her
teeth at night and had pain in her TM joints.
Clinical and X ray evaluations showed, that patient had
Class II malocclusion, with her front maxillary teeth in
vertical, almost retrusive position, trapping her mandible
distally (fig. 4).
Distally displaced position of the mandible pushed
patient’s condyles into posterior/ superior position, thus
causing abovementioned TMJ symptoms.
(Figs. 1 & 2) Facial view & Natural smile of the patient O.
before treatment
(Fig. 3) Retracted view of the patient smile before treatment
The objective of the treatment plan for this patient
was to advance her mandible down and forward,
thus improving her appearance and eliminating TMJ
problems. Expansion of Maxilla along with protrusion
of maxillary incisors forward was necessary in order to
achieve required advancement of mandible.
These objectives were accomplished in 4 months of
treatment by using 3-Way Sagittal Removable Appliance
(fig. 5).
Upper and lower braces were placed in order to move teeth
into best possible positions for future restorative treatment.
At the end of this stage of the treatment skeletal changes
in patient’s face and jaws were obvious (fig. 6).
Positions of the condyles inside TMJ also changed,
helping alleviate and eliminate most of her TMJ
symptoms (figs. 7, 8).
(Fig. 4) Cephalometric X ray before treatment
Restorative part of the treatment was performed after
completion of orthodontic phase. Zirconia crowns were
placed on teeth #7, #10, #12, #13, #14, #19, #20,
#21, #28 and #29. Porcelain veneers were place on
teeth #4, #5, #6, #8, #9 and #11. (figs 9-11)
The final results of the treatment may be described as
a triple effect:
First: Patient’s TMJ symptoms have completely disappeared,
allowing her pain free and symptoms free existence.
(Fig. 5) Retracted view after treatment with removable appliance
Smile Dental Journal | Volume 6, Issue 4 - 2011| 27 |