Abstract
In the type III facial growth pattern, craniofacial disharmony is observed, which may be a maxillary retrusion or mandibular advancement as the most diagnosed postures. This case report aims to report the use of the technique (MAMP) in a patient, who is diagnosed with a growing type III facial and skeletal pattern, as well as its efficacy and adverse effect. For the treatment, the hybrid palatine circuit breaker with mini implants were used, associated with mini mandibular implants, joined by class III elastic. Obtaining satisfactory skeletal result for treatment of pattern III in patients in the final phase of growth.
1
Introduction
In the pattern of facial growth type III a craniofacial disharmony is observed, which one, may be by maxillary retrusion or mandibular advancement as the most diagnosed postures, considering the association of both as a cause also evidenced [ ]. Among possible causes, the genetic factor stands out as the most relevant. This pattern affects about 0.8–12% of the general population [ ] demonstrating the highest rate in the Asian population, reaching more than 50%, being one of the most challenging treatments of Orthodontics, especially in the final phase of growth [ ] (see Figs. 6–10 ).
The most commonly used treatment in children ‘’is maxillary protraction with face mask’’ (MF), combined with conventional Hyrax ( HC ) expander, supported on the molars, to perform rapid maxillary expansion (MRE), as it is believed that the opening of the palatine suture can help in the advancement of the maxilla, and this information is divergent in the literature [ ]. MF, on the other hand, seeks to stimulate the maxillary advancement down and forward, redirecting mandibular growth. However, some limitations accompanied in this technique, one of them is the ‘’reduced use’’, because it is an extraoral device. There are also some unwanted dental side effects due to the fact that it is a dento-supported appliance, which can vestibularize upper incisors and lingualize lower incisors [ ].
Over the years, new alternatives for the treatment of standard III in children have been sought in order to decrease dental effects, increasing real skeletal improvement. With this perspective [ ], launched the technique of maxillary protraction anchored purely in bone (BAMP), with two upper mini-plates (MP) inserted in the left and right infrazygomatic crest of the maxillary pillar and two mandibular MP between lateral and canine incisor, bilaterally, significantly improving the skeletal effects, minimizing the dental. However, this protocol does not incorporate MRS, where many are necessaries due to the presence of transverse maxillary deficiency.
As an alternative to the HC, Wilmes, al. [ ], introduced the Hybrid Hyrax (HH), which consists of a palatine expander with two mini-implants (MI) inserted parallel to the palatine suture, dissipating the force of disjunction and protraction of the maxilla in the IMs, decreasing the dental effect. In combination with the HH, mandibular MP was installed and class III elastic was applied, seeking the correction of pattern III.
Another study compared the use of HH-MF to the HH-MP protocol, where skeletal and dental behavior was evaluated, whose results found were similar to each other [ ].
Recently, (Manhães).”SOME Tricks” [ ] introduced another alternative for standard III treatment in growing patients. Using an HH, two mini implants (MIs) were installed in the palate after the third palatine wrinkle, associated with two mandibular IMs located between the lateral incisor and the canine, bilaterally. A horizontal bar with hooks at its ends was installed, this bar was named after the author (Manhães bar) BAR MORNINGS). Class III rubber bands were installed from the hook welded to the bands of the first molars upper than the hooks of the bar mornings, during the day; and another elastic band applied from the hook, at the height of the canines higher than the MF, during the night. Nullifying the surgical needs for installation and removal of PM, but still requiring MF, even if for a short time.
A new alternative was described by Miranda et al. [ ], for the treatment of pattern III in children in the final stage of growth, in late or young permanent mixed dentition. In the technique of maxillary protraction anchored in MI (MAMP), the HH was installed in the maxilla in the first third of the palatine inclination, with angulation of 45° in the anterior direction and two mandibular MIs installed between canine and premolar bilaterally, joined by class III elastics used continuously. Relevant results were evidenced with this protocol, having effective maxillary advancement, reducing dental effects, nullifying in need for MF and MP.
The present study aims to report the use of the technique (MAMP) in a patient diagnosed with a growing facial and skeletal pattern type III, as well as its efficacy and adverse effects.
2
Caso report
Patient A.G.L.S., 12 years and 8 months old, leukodermar or vitiligo, female, attended the dental clinic of the CECAPE College, in Juazeiro do Norte-CE, seeking orthodontic treatment, accompanied by his mother. Having as main complaint the “big chin”. Patient with upper fixed appliance already installed up to the premolars, without lower fixed appliance, history of diseases absent, good general health, good hygiene of the oral cavity, without the presence of caries or tartar.
When analyzing the patient’s face ( Fig. 1 A–C), both in the frontal view, but mainly laterally, the chin considerably advanced in relation to the upper lip, depression in the infrazygomatic region, chin line enlarged neck and upper lip behind the lower lip were visualized. In the intraoral analysis ( Fig. 1 D–F) it was observed anterior crossbite of 4–5 mm, molar and canine class III ratio, presence of deciduous tooth 53, absence of 23, absence of the 2nd upper and lower molars, lower soft crowding, absence of space for irruption of teeth 13 and 23.
In the cephalometric analysis, data were found that coincide with the facial and intraoral analysis, with the maxilla in a retruded position in relation with its normal pattern, as well as the mandible that was a little beyond the standard. Having the lower incisors protruded and with normal inclination and lingualized upper incisors.
In order to make use of rapid maxillary expansion and maxillary protraction, we could make use of the following device alternatives.
- 1.
Conventional Hyrax (HC) and Petit face mask;
- 2.
Hyrax hybrid (HH) associated with mini-plate (MP);
- 3.
Protocol Mornings: Hybrid Hyrax (HH), mandibular mini-implants (MIs) in the mesial region of the canines associated with Barra mornings, with Class III elastics (daytime use) and Petit face mask (night use);
- 4.
Hybrid hyrax (HH), mandibular mini-implants (MIs) in the distal region of the associated canines, with Class III elastics (full use – 14hs/day)
For the treatment of pattern III in which the patient presented, she could have made use of the first alternative. However, due to age and possible unwanted dental effects, this technique was not chosen. It could also have the second alternative, but due to the high cost and need for surgical procedures, this possibility was ruled out. The third alternative would also become viable, but due to the need for the use of MF, it was also excluded. Thus, the fourth option was chosen as an alternative possibility to MF, after reliable clarifications about the due characteristics of this technique.
With the MAMP technique, it is intended to achieve the maximum possible maxillary expansion, in the transverse direction, as well as its maximum advancement in the sagittal direction. Reducing side effects, also removing the need to use a face mask.
We did not choose to indicate orthognathic surgery, after growth, at this first moment, due to the absence of facial complaint, on the part of the patient and her family, due to lack of financial resources, and also, we chose to intervene at this age and choose this technique, because the patient is still growing, thus seeking to improve her occlusion and development as little as possible. Not ruling out the possibility of future orthognathic surgery, if the patient changes her opinion about her facial aesthetics.
After facial, dental and cephalometric diagnosis, the upper fixed apparatus was removed and the upper arch was molded for adaptation of the palatine expander. In the next session, the prefabricated 2S hybrid expander (PecLab Ltda, Belo Horizonte, MG, Brazil) with Orthobite resin (FGM Ltda, Joinville, SC , Brazil) was installed, supported by band in the first permanent maxillary molars, associated with the distal hooks welded in these bands for installation of Class III elastics ( Figure 3 A). Soon after, in the same session, the palatine mini-implants with 1.8 mm in diameter, 7 mm in length and 4 mm in transmucous profile (PecLab Ltda, Belo Horizonte, MG, Brazil) were installed in the expander guides in the 1st third of the palatine inclination, with an angulation of 45° in the anterior direction. Then, in the same session, mini-mandibular implants of 1.6 mm in diameter, 6 mm in length and 1 mm in transmucous profile (PecLab Ltda, Belo Horizonte, MG, Brazil) were installed in the vestibular border between permanent canines and the first premolars, at the level of the mucogingival junction ( Figure 2 B ).
