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Received: 15 Nov. 2014 Accepted: 6 Apr. 2015
1- Assistant Professor, Oral and Dental Diseases Research Center AND Kerman Social Determinants on Oral Health
Research Center AND Department of Pediatric Dentistry, School of Dentistry, Kerman University of Medical Sciences, Kerman, Iran
2- Professor, Department of Orthodontics, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran
3- Assistant Professor, Endodontology Research Center AND Department of Orthodontics, School of Dentistry, Kerman University of
Medical Sciences, Kerman, Iran
Correspondence to: Fatemeh Jahanimoghadam, DDS, MSc
Email: fatemehjahani4@gmail.com
http://johoe.kmu.ac.ir, 4 April
46 J Oral Health Oral Epidemiol / Winter & Spring 2016; Vol. 5, No. 1
Correction of severe tooth rotation by using two different orthodontic
appliances: Report of two cases
Fatemeh Jahanimoghadam DDS, MSc1, Shahla Momenidanayee DMD, MS2,
Marziyeh Karimiafshar DDS, MS3
Abstract
BACKGROUND AND AIM: Severe rotation of tooth is one of the most common problems in orthodontics and considered
as a developmental phenomenon. These rotations can cause cosmetic problems, gingival recession, and traumatic
occlusion. By using removable appliances, severe rotations can be treated. Furthermore, gingival damage, tooth
attrition, and transposition of other teeth could be prevented. Early treatment of these rotated teeth could improve dental
aesthetic affecting on child’s behavior and enhanced self-confidence. This case report presents two treated cases using
the removable appliance in severe tooth rotations.
CASE REPORT: Case 1: The severe rotation of right upper central incisor in a 9-year-old girl is corrected with removable
orthodontic appliance and whip spring. Case 2: The severe rotation of left lower lateral incisor in an 8-year-old girl is
corrected with a force couple and elastic anchored on the removable orthodontic appliance.
CONCLUSION: In this paper, it was revealed that to correction the problem, in the first case a removable appliance with a
whip spring was used and in the second case, a removable appliance in combination with bracket and elastic was
efficient to prevent from a complicated orthodontic treatment in the future.
KEYWORDS: Rotation; Removable Orthodontic Appliance; Correction
Citation: Jahanimoghadam F, Momenidanayee Sh, Karimiafshar M. Correction of severe tooth rotation
by using two different orthodontic appliances: Report of two cases. J Oral Health Oral Epidemiol 2016;
5(1): 46-51.
rowding is the most common dental
malocclusion and associated with a
reduction in the size of the jaws. The
role of crowding in the development
of dental caries and periodontal disease has
been confirmed.1 A rotated central incisor
creates numerous aesthetic and psychological
problems for a patient. Tooth rotation is
considered as observable mesiolingual or
distolingual intra-alveolar displacement of
the tooth around its longitudinal axis.2 The
exact etiology of tooth rotation is unknown,
but it seems to be a developmental
phenomenon. Displacement of dental follicle
and path of tooth eruption can create tooth
rotations.1,3 If there are multiple rotations of
teeth, comprehensive orthodontic treatment
with fixed appliances are used. But in cases
with a single severe tooth rotation, it can be
used removable appliances, for correction of
rotated teeth.4,5
When a fixed orthodontic appliance is used
to correct only some of the teeth in the mixed
dentition, arch wire spans are longer, the wire
is springier and large movements are easily
possible. However, it may be difficult to use
fixed appliances correctly during the mixed
dentition period since the available permanent
C
Case Report
http://johoe.kmu.ac.ir, 4 April
Jahanimoghadam et al.
Correction of severe tooth rotation
J Oral Health Oral Epidemiol/ Winter & Spring 2016; Vol. 5, No. 1
47
teeth are grouped into anterior (incisor) and
posterior (molar) segments. In addition,
anchorage control becomes difficult as only the
first permanent molars serve as an anchorage
in the posterior segment of the arch.
The whip appliance was introduced by
Houston and Isaacson in 1980. The original
appliance has been mildly modified to better
satisfy the therapeutic needs. This appliance
consists of a removable orthodontic plate, a
cantilever spring and a bracket or bonded
tube that enables effective correction of
severely rotated anterior teeth in a short
period of time. Better anchorage control,
relatively simple force system, easier oral
hygiene management, and less critical patient
cooperation are the advantages of the
appliance.
6
Correction of the rotated teeth in
early ages also prevents from irreparable
injuries to the supporting tissues, and dental
follicle transposition.
7
Canine-lateral
transposition can be problematic in laterally
mandibular movements.
8
In addition,
avoiding of tooth eruption in a rotated
position can reduce the relapse of treatment.
9
The early treatment of these rotated teeth
could improve dental aesthetic affecting on
child’s behavior and enhanced self-
confidence. Researchers have also found that
an attractive appearance and social
acceptance can assist the individual in
achieving social success.
10
In this report, two
different methods for correction of severe
tooth rotation by means of removable
orthodontic appliances offered.
In the first case, severe rotation of right
maxillary central incisor in a 9-year-old girl
corrected by whip spring and removable
orthodontic appliance and in the latter one,
severe rotation of lower left lateral incisor in
an 8-year-old girl corrected by a force couple
and elastic anchored on the removable
orthodontic appliance.
Case Report
Case 1
The 9-year-old girl was referred to the private
practice with the chief complain of severe
rotation of the upper anterior tooth
(Figure 1). Her medical history revealed no
problems. Clinical examination showed a
slightly convex facial profile and symmetric
face. The soft tissue of the lips, chin, and nose
were evaluated. Intraoral examination
revealed class I malocclusion, but over jet and
overbite was reduced. In panoramic
radiography, severe rotation of the upper
right central incisor was observed. The device
included a removable orthodontic appliance,
a whip spring and a bonded tube (Figure 2).
Figure 1. Central incisor with 90° rotation
Figure 2. Removable appliance, whip spring and
bonded tube
The removable appliance consists of
acrylic base plate, circumferential clasps on
the maxillary first permanent molars and a
labial arch on the upper primary canines.
http://johoe.kmu.ac.ir, 4 April
Jahanimoghadam et al.
Correction of severe tooth rotation
48 J Oral Health Oral Epidemiol / Winter & Spring 2016; Vol. 5, No. 1
Molar Adams clasps and labial arch were
made of 28 mil (0.7 mm) stainless steel wire
(Dentarum, Germany). A bonded tube
(Dentarum, Germany) was bonded on the
1/3 incisal area of the labial surface of central
incisor with light-cured composite resin
(Trans Bond XT, 3M Unitek, USA). To
increase flexibility, the range of motion and
easier insertion of coil springs, whip spring
was made with a segment of 0.4 mm stainless
steel orthodontic wire (Dentarum GmbH &
Co. KG TurnstraBe 31, 75228 Inspringen-
Germany) and a length of 20 mm. The mesial
end of the spring was inserted into the tube
slot and bent toward the gingiva, and the
hook located in the distal end of the wire was
engaged to the labial arch. The patient was
monitored monthly and during 4 months the
upper right central incisor was repositioned to
its normal position (Figure 3). The induction
force of flexibility of the wire corrected the
rotated tooth. After over correcting the tooth
rotation, the appliance was removed, and
retention begins using a modified Hawley
retainer. Circumferential supra crestal
fiberotomy surgery was not performed
because no satisfaction of her parents.
Figure 3. Correction of the rotated tooth
Case 2
The 8-year-old girl was referred to the School of
Dentistry of Shiraz University of Medical
Sciences, Iran, with chief complain of severe
rotation of the lower left lateral incisor. The
medical history of the child revealed no
problems. In the clinical examination, normal
growth pattern was seen. In the extra oral
examination, the patient’s profile was slightly
convex and in front view was normal. Intraoral
examination showed class II malocclusion with
the severe rotation of the lower left lateral
incisor and over jet was increased (Figures 4
and 5). Upper mid-line was deviated to right
(1 mm) and lower midline was deviated to left
(2 mm). Space analysis by using radiography
revealed lack of space for the eruption of
permanent teeth in the mandible and maxilla
(7 and 4 mm, respectively).
Figure 4. Intra oral view of the patient
Figure 5. Lateral incisor with 90° rotation
In the panoramic radiograph, lateral
incisor had a severe rotation, and the risk of
impaction or incomplete transposition of
canine-lateral in the same side due to
superimposition of the canine crown on the
http://johoe.kmu.ac.ir, 4 April
Jahanimoghadam et al.
Correction of severe tooth rotation
J Oral Health Oral Epidemiol/ Winter & Spring 2016; Vol. 5, No. 1
49
lateral incisor root was observed. The device
included a removable orthodontic appliance,
two brackets (Dentarum, Germany) on
lingual and labial surfaces of the rotated
tooth and elastic 3/16 Median pull (American
Orthodontics EC Certification Service GmbH
Sandgasse7, A-9300 St. Veit/glan, Austria).
The removable appliance consists of an
acrylic base plate, circumferential clasps on
the mandibular first permanent molar, first
and second primary molars and a labial arch
on the lower incisors. Labial arch included a
double loop at equal distances from the
brackets (Figure 6). Molar Adams clasps and
labial arch were made of 28 mil (0.7 mm)
stainless steel wire (Dentarum, Germany).
Two brackets were bonded on the lingual
and labial surfaces of the left lower lateral
incisor with light cure composite resin (Trans
Bond XT, 3M Unitek, USA). Using two equal
forces (a force couple) and elastic 3/16 by the
medium pull from opposite sides of the
tooth, lateral incisor was derotated well
during 2 months (Figure 7).
Figure 6. Appliance design
Figure 7. Removable appliance, two brackets
and elastic in oral cavity
Discussion
Severe tooth rotation can cause dental and
gingival problems. It is also can create the
inappropriate appearance and adverse
psychological effects on the child’s life.
Although the etiology is clearly unknown,
dental follicle displacement and path of tooth
eruption can be the possible causes.
1
In two
present cases, it seems to be the same causes.
If these rotations cannot be modified, they
cause a traumatic occlusion that it can cause
gingival recession, root resorption in
involved teeth. Since fixed orthodontic
treatment in childhood and adolescence is
not recommended, early correction of severe
tooth rotations using removable devices or a
combination of fixed and removable devices
to reduce the injuries mentioned above could
be very useful. Whip spring is an auxiliary
spring and is usually placed in the molar
band.
4
Jalali and Bagherian
11
used whip spring
joined to Adams clasp for correction of sever
rotation of maxillary central incisor. They
didn’t observe any harmful side-effects on
root development. They also mentioned,
mobility and sensitivity to pain until 1 month
after the active phase of treatment was
normal. Mavragani et al.
12
mentioned that
since root shortening due to apical resorption
is one of the most serious side-effects of
orthodontic treatment, it seems advisable to
initiate orthodontic correction of the incisors
at a young age during mixed dentition.
Complications involving delayed treatment
of a rotated permanent incisor include:
Dilacerations of the developing roots, root
resorption, loss of tooth vitality and
compromised oral hygiene.
2
Whip appliance
has many advantages for use in the mixed
dentition as follows:
1. Offering a solution in the mixed
dentition period, relatively in a short time
2. Providing increased vertical and
horizontal anchorage due to palatal coverage
3. Anchorage control is less critical
4. Force system is relatively simple when
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Jahanimoghadam et al.
Correction of severe tooth rotation
50 J Oral Health Oral Epidemiol / Winter & Spring 2016; Vol. 5, No. 1
this appliance is used
5. Management of oral hygiene is easier
6. Patient compliance is less critical,
because when removing the appliance, the
damage of mucosa by wire leads to patient
discomfort
7. Whip appliance can be used in
emergency situations in the mixed dentition,
such as traumatic occlusion of central
incisors.
13
In the first case, the spring was placed on
the labial arch and the patient didn’t have
any limitation in wearing the removable
appliance. After derotation of the tooth, the
other appliance was used for retention.
Mobility and mild pain were the natural
complications of rotation correction, and
these complications were observed in both
patients. In treatment planning of the latter
case, using the removable appliance and
whip spring wasn’t possible. Therefore, we
used the combination of removable and fixed
appliances to derotate the tooth. Rotation
correction by using a light force in early
stages of root development can lead to a
stable outcome.
One of the problems with the use of whip
appliance is that much attention should be
considered not to activate it in the vertical
plane, otherwise unwanted mesiodistal
crown and root movement may be occurred.
4
Furthermore, this appliance can hurt the
mucosa if not adjusted carefully.
It is mentioned that rotations are easy to
treat but very difficult to retain. There is a
high risk of relapse due to stretching of the
supra-alveolar and transseptal gingival
fibers, which slowly reposition. Therefore, it
should be overcorrected and long-term
retention period is needed to achieve the
stability of treatment. Correction of single
tooth severe rotation using orthodontic
appliances or a combination of fixed and
removable orthodontic appliances is
affordable and secure way, and the possible
need for future orthodontic complex
treatment reduce. Timely correction of these
rotations reduces the risk of damage to
gingiva and teeth and also traumatic
occlusion decrease. The early treatment of
these rotated teeth could improve dental
aesthetic affecting on child’s behavior and
enhanced self-confidence.
Conflict of Interests
Authors have no conflict of interest.
Acknowledgments
The authors wish to thank the patients for
their assistance in all periods of study.
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