International Journal of Oral Health Dentistry 2023;9(4):310–314

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International Journal of Oral Health Dentistry

Journal homepage: www.ijohd.org

Case Report
TADS assisted camouflage orthodontic treatment of class II malocclusion in a
non-growing patient- A case report
Yenika Manchanda 1 *, Merry Goyal 1, Sanjay Mittal 1, Isha Aggarwal 1,
Abida Parveen 1
1 Dept. of Orthodontics, Bhojia Dental College & Hospital, Baddi, Himachal Pradesh, India

ARTICLE INFO ABSTRACT

Article history: Background: In individuals with Class II malocclusions, there is an anteroposterior discrepancy
Received 11-08-2023 between the maxillary and mandibular dentitions, which may or may not be accompanied with a skeletal
Accepted 12-12-2023 discrepancy, the most effective treatment option to eliminate is by modified three-piece base arch combined
Available online 16-01-2024 with TADS for simultaneous deep bite correction and en masse retraction.
Aim: The present case report showcases the treatment results and biomechanics involved for en masse
retraction and intrusion of anterior teeth using three-piece intrusion arch and temporary anchorage device.
Keywords:
Conclusion: The modified three-piece base arch combined with TADS is effective in controlled translation
Class II malocclusion and intrusion of anteriors and would be a preferable mechanotherapy in low angle case with deep bite,
Three- piece intrusion arch proclined anteriors and Class II malocclusion.
TADS
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1. Introduction 2 malocclusions are defined as excessive tilting of the

maxillary central incisors with overlapping labial maxillary
Class II malocclusions are generally defined as having lateral incisors. Sometimes both the middle and posterior
dental, skeletal and/or functional components or features. incisors descend lingually, and the canines overlap the labial
It should be noted that most often they show features lateral incisors.
simultaneously and to different degrees.
Angle (1907) proposed a classification system based on Angular class II malocclusion in adults with skeletal
the relationship of mandibular first molars to maxillary class II contours and maxillary vertical excess is a difficult
first molars. Class II defines malocclusion as a relationship problem for the dentist to treat. This is because clockwise
between the mandibular teeth and the maxillary teeth rotation of the mandible to correct molar relationship
more than half the width of the tubercle. Angle (1907) after the removal of the upper molars confuses skeletal
described two types of malocclusion in class II based on the differences and sometimes worsens facial features. In
impression of the maxillary central incisors. addition, in patients with severe gingival trauma due to
Class II division 1 malocclusions, is defined as labial vertical enlargement of the maxilla, incursion of only
inclination of the maxillary incisors, increased coating, the maxillary anterior teeth is aesthetically inappropriate
narrow or absent maxillary arch. Vertical incisor overlap because the procedure worsens smile arch. Therefore, the
can range from overbite to open bite. Class II and Class best treatment option for patients who want to remove their
gingival smile is the orthognathic (surgical) method. Due
* Corresponding author. to the reluctance of some patients to undergo surgery, a
E-mail address: [email protected] (Y. Manchanda). new dental treatment is required in patients with deep bite

https://doi.org/10.18231/j.ijohd.2023.058
2395-4914/© 2023 Author(s), Published by Innovative Publication. 310
 Manchanda et al. / International Journal of Oral Health Dentistry 2023;9(4):310–314 311

and vertical gingival smile. This treatment is necessary to

effectively treat maxillary teeth and eliminate gingival smile
without invasive surgery.
The skeletal anchor was recently developed to treat
severe malocclusions. Using this technique allows the
maxillary molars to move without side effects. In addition,
several reports describe the use of temporary bearing
devices to support the posterior teeth of the two arches
and to reduce the facial height of adults with osteoporosis. Figure 1: Pre-treatment extraoral photographs
In class II malocclusionin the 1970s Burstone A partial
segment invaded the mandibular incisors and thus flattened
the Spee curve applied for. The wire used in this treatment
does not extend from the right molar to the left molar.
The Burstone (1970) invasive mechanism has three parts:
(1) posterior fixation using buccal stabilization based on
placement of posterior brackets or tubes from either side;
(2) anterior portion of fourth incisors; (3) There are inlet
springs on both sides.
The present case report showcases the treatment results
and biomechanics involved for en masse retraction and
intrusion of anterior teeth using three-piece intrusion arch
and temporary anchorage device. Figure 2: Pre-treatment Intraoral photographs

2. Case Report
A female patient of age 20 years visited the department
of Orthodontics and dentofacial orthopaedics at Bhojia
dental College, Budh Baddi with the chief complaint of
forwardly placed upper and lower front teeth. Extra oral
examination (Figure 1) showed that she had a leptoprosopic
facial form with good facial symmetry, convex profile with
posterior divergence, increased facial height, incompetent
lips, acute nasolabial angle, deep mentolabial sulcus, high
mandibular plane angle, and a non-consonant smile arc. No
signs/ symptoms of temporomandibular joint dysfunction.
Intraoral examination (Figure 2) revealed as Class II molar Figure 3: Pre-treatment radiographs
relation on right side and Class I on left side. The vertical
relation showed deep bite (6 mm, 80%), overjet of 8 mm,
mandibular midline was coincident. Orthopantomogram
(Figure 3) showed full complements of teeth were present. Table 1: Pre-treatment cephalometric values
The maxillary and mandibular anterior teeth presented with Measurements Pre-treatment
extrusion and the deep curve of spee (3 mm). Lateral SNA 90º
cephalograms showed (Figure 3) she had prognathic maxilla SNB 82º
(90) and orthognathic mandible (80) with ANB (8), Wits ANB 8º
(7 mm) depicting a skeletal Class II jaw bases. Patient had Beta Angle 22º
a hyperdivergent growth pattern on account of Sn-Go-Gn SN-GoGn 38º
(39), FMA (33) and Jaraback ratio of 66% (Table 1). FMA 33º
Jarabak ratio 66%
1 to NA 8 mm
2.1. Treatment objectives 1 to SN 110º
To correct the inclination of upper and lower anterior IMPA 99º
Nasolabial Angle 106º
teeth, obtain optimum overjet and overbite, to correct deep
Upper lip to E-Line 2.5mm
curve of spee, establish Class I molar and canine relation,
Lower lip to E-Line 3.5mm
improve the facial features by obtaining a straight profile
with straight divergence, a pleasing smile arc and soft tissue
312 Manchanda et al. / International Journal of Oral Health Dentistry 2023;9(4):310–314

aesthetics. backs with a force of 200 gm was given, Finishing and

detailing were carried out and the appliance was debonded.
2.1.1. Treatment The total treatment time was 19 months.
After analysing all diagnostic records, the patient was
treated with extractions. The maxillary and mandibular teeth
were bonded and banded with pre-adjusted 0.022” slot
MBT prescription brackets. A 0.9 mm nance palatal arch
(Figure 4) was placed to preserve the anchorage and to
prevent buccal flaring of molars. The arches were aligned
using the following sequence of arch wires; 0.016 Niti, 17
× 25 Niti, and 19 × 25 Nickel Titanium arch wires. Later
19 × 25 stainless steel archwire. After both the arches were
levelled and aligned they were followed by extraction of all
first premolars.

Figure 6: TAD in the region distal to lateral incisor 16 mm away

on right side and 17.5 mm away on left side

Figure 4: Mid treatment photographs 3. Treatment Results

There was remarkable improvement in the patient’s
This was followed by placement of three-piece intrusion profile and facial aesthetics as seen in the post-treatment
arch (0.017” X 0.025” TMA with 2 mm helix was engaged facial photographs. Facial balance, smile aesthetics, and
in auxiliary tube and placed in extracted space of 1st lip positions were improved. (Figure 7). There was
premolar in anterior piece of intrusion arch) (Figure 5) in intrusion and retroclination of the upper and lower
the upper arch to intrude and retract the upper incisors incisors. Class I molar and canine relationships were
which help to attain a proper incisor inclination, overjet and established. Overjet and overbite were improved to 0.5
overbite. Retraction force of 150 gm was given and intrusion and 2mm respectively (Figure 8). Cephalometrically the
force of 60 gm was given This phase was continued for 1 upper incisors were retroclined from 8 mm to 1 mm
year. in relation to NA perpendicular to point A line and
lower incisors were retroclined from 99 to 92 (IMPA)
(Table 2). Superimposition demonstrated the treatment
changes (Figure 9). There was a significant intrusion and
retraction of maxillary incisors. At the end of treatment, the
patient had reduced Interlabial gap with reduced convexity
of face. Intraorally, 2 mm overjet, and 2 mm overbite with
Figure 5: Three-piece intrusion arch (0.017” X 0.025” TMA with stable functional occlusion were achieved. Posttreatment
2mm [internal diameter] helix was engaged in auxiliary tube and orthopantogram (OPG) and lateral cephalograms were taken
placed in extracted space of 1 st premolar in anterior piece of at the end of orthodontic treatment.
intrusion arch)

After achieving desirable intrusion and retraction three-

piece intrusion arch was removed and placement of
temporary anchorage device in the region distal to lateral
incisor 16 mm away on right side and 17.5 mm away on left
side was done (Figure 6). 50 gm intrusive force was added
via hooks made between 11, 12 and 21, 22 to prevent buccal
flaring with intrusion of incisors. This resulted in intrusion
of incisors and for canine retraction continuous active tie Figure 7: Posttreatment extraoral photographs
 Manchanda et al. / International Journal of Oral Health Dentistry 2023;9(4):310–314 313

but relative invasiveness in the growth stage and absolute

invasiveness in the nongrowth stage is allowed. For
patients with anterior incisors, our central arch suppression
mechanism can perform overbite correction and gap closure
at the same time. The force system applied to the front
depends on the point and direction of application of the
input force.
This segmented approach to intrusion and retraction was
developed because it allows simultaneous control of tooth
Figure 8: Post-treatment intraoral photographs movement in the vertical and anteroposterior planes. 2 The
equipment has low load bias to ensure stable input power
and low power consumption. The design of the device
allows the therapist to provide static control with minimal
chair adjustments. Article (2008) evaluated the effect of
Spee mechanics’ augmentation and inversion curves on root
resorption of incisors and found that the invasive approach
caused more root resorption than the control group.
In contrast, Costopoulos and Nanda (1996) found that
infestation was only negligible due to root resorption. The
main difference between these studies is the amount of
force used to grip the incisor. Spee Mechanics’ reverse
projection curve provides an interference force of 100 to
150 g, while Burstone’s interference arc is only 15 g per
maxillary incisor. 3–5
El Aouame, et al. (2023) present clinical data of 3
Figure 9: Post treatment lateral cephalogram and superimposition young patients treated and followedup for Class II Class
1 malocclusion. Early treatment phase was applied to the
first and second patients. The third patient was treated in
Table 2: Post-treatment cephalometric values two stages when his teeth were mixed. They concluded that
Measurements Pre- Mid Post there was no significant difference between the two methods
treatment treatment treatment (one-stage or two-stage). Early treatment of malocclusion is
SNA 90º 89º 89º important because it normalizes the structure and growth of
82º 80º 80º bones and shortens the duration of subsequent treatment. 6
ANB 8º 9º 9º
Review process overview to better understand what
Beta Angle 22º 26º 27º
is important or new 4 Draws conclusions from different
SN-GoGn 38º 38.5º 38.5º
FMA 33º 30º 38º
studies; this is particularly important in TAD because a
Jarabak ratio 66% 62% 60.6% large database of simulations is available to describe clinical
1 to NA 8mm 7 mm 1mm outcomes and inform clinical decisions. There are, but
1 to SN 110º 107º 98º not included in the review of more familiar interventions
IMPA 99º 101º 92º focused on randomized clinical trials. It is clear from this
Nasolabial Angle 106º 98º 97º study that the use of TAD can be effective and efficient,
Upper lip to E-Line 2.55mm 4 mm 4 mm but the data support the advantages of TAD over non-TAD
Lower lip to E-Line 3.5 mm 5.5 mm 5mm anchors. 7
Mahmood (2023) conducted a retrospective study of
40 cephalometric interpretations of patients scheduled for
fourunit extraction. All patients received the McLaughlin
4. Discussion
Bennett Trevis (MBT) treatment, a temporary anchor device
Absolute incursion, relative incursion and posterior (TAD) with the same protocol, in the same orthodontic
extrusion are the three overbite treatments. Relative clinic, including 22 holes and onestep retraction after
intrusion is achieved by preventing eruption of the lower four units of extraction. While the inclination of the
incisors where posterior growth provides vertical space occlusal plane does not change significantly, all tissues
for posterior eruption, and during posterior extrusion related to cephalometric values are reduced according to
the mandible rotates downward and backward without the relationship of the upper and lower lip part for the
eruption. 1 As a general rule, extrusion is undesirable, Ricketts aesthetic line (ELine), except for the nasolabial
314 Manchanda et al. / International Journal of Oral Health Dentistry 2023;9(4):310–314

angle is reduced. For both the Frankfurt mandibular 6. Source of Funding

angle and the Frankfurt level, the upper incisor was not
None.
significantly associated with the change in posttreatment
contour. Therefore, the use of MBT therapy in combination
with TAD-based reversal is a good method in the treatment 7. Conflict of Interest
of complications. None.
A recurring theme in the results is the relationship
between the position of the dental guard and the References
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and therefore it should be checked periodically during
treatment. This study explores the use of force for TAD-
based orthodontic intervention to better understand how to Author biography
provide the necessary force to achieve effective orthodontic
tooth movement while remaining within the confines of the Yenika Manchanda, PG Student https://orcid.org/0000-0002-1275-
bones. Global retraction of anterior teeth and use of TAD 4630
intrusion are currently the two most studied topics. 3–5,11,12
Merry Goyal, Reader https://orcid.org/0000-0002-7098-5496

5. Conclusion Sanjay Mittal, Professor & Head https://orcid.org/0000-0002-7125-

0424
The three-piece intrusion arch combined with TADS
improves Class II malocclusion in different stages of
Isha Aggarwal, Professor https://orcid.org/0000-0002-7030-2579
dentofacial development. This study provided a better
understanding of the complex interactions and has provided Abida Parveen, Senior Lecturer https://orcid.org/0000-0003-2964-2894
a guide to the level and direction of forces in each type
of intervention to aid clinicians in achieving high quality
outcomes. 13 Cite this article: Manchanda Y, Goyal M, Mittal S, Aggarwal I,
Parveen A. TADS assisted camouflage orthodontic treatment of class II
malocclusion in a non-growing patient- A case report. Int J Oral Health
Dent 2023;9(4):310-314.