Combining different treatment philosophies and techniques to reach the desired treatment goal using butterfly system: Customizing orthodontic treatment

This case report describes the orthodontic treatment of an 18-year-old male patient who presented with straight profile, tongue thrust habit, proclined upper incisors, generalized spacing in the upper and lower arches, Katz Class II premolar relation unilaterally, and Class II canine relation unilaterally with increased overjet and overbite. A butterfly system was used for the treatment combined with frictionless biomechanics in the initial stage of the treatment followed by continuous arch mechanics in the later part of the treatment. A tongued crib was used to stop the tongue thrust habit along with one elastic swallow exercise. Micro-implant anchorage was used unilaterally in the upper arch for retraction of the entire segment and correction of the unilateral Class II canine and premolar relationship. To avoid a dished-in profile, a nonextraction treatment was executed. Final correction of distally tipped canines was achieved using conventional Begg's uprighting auxiliaries in the vertical slots of the butterfly system in the finishing stage. The case was finished using bite-settling elastics. The total treatment time was 1 year and 2 months. Esthetic and functional goals were achieved satisfactorily with proper selection of biomechanics.


INTRODUCTION
Orthodontic practitioners and beginners in orthodontics often have many questions in mind: which philosophy to use? What bracket prescription is appropriate for a particular case? When to use a straight archwire and segmented mechanics? Is it appropriate to combine the various treatment philosophies and techniques to reach the final treatment outcome?
Making an accurate diagnosis of the changes observed in patients is of utmost importance. It is essential that an effective treatment plan is executed in order to treat the malocclusion within a shorter period of time, with as little injuries to protective and supporting tissues as possible. Thus, recommending the most appropriate treatment for a particular malocclusion, regardless of the type of bracket prescription, technique, or slot, is what really matters. For this reason, knowing the principles on which each technique is based on, as well as its limitations, is essential. [1] The preadjusted edge-wise straight wire appliance was introduced in the 1970s. [2] Since then, there have been many suggested modifications to the bracket prescriptions in terms of torque and tiP values, often differing by only a few degrees. Over the years, clinicians have considered how bracket design can help achieve these objectives. [3] Andrews made extensive measurements on untreated excellent occlusions. [4] Molar anchorage loss has been shown to occur during the early stages of alignment with preadjusted appliances. [5,6] Low friction is most advantageous during initial alignment, whereas friction is needed for control in finishing and torque Combining different treatment philosophies and techniques to reach the desired treatment goal using butterfly system: Customizing orthodontic treatment Access this article online Website: www.orthodrehab.org Quick Response Code DOI:

10.4103/ijor.ijor_14_17
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How to cite this article: Lekhadia DR, Hegde G. Combining different treatment philosophies and techniques to reach the desired treatment goal using butterfly system: Customizing orthodontic treatment. Int J Orthod Rehabil 2019;10:31-41. expression. If the friction level of a bracket could be adjusted for different treatment stages, orthodontic tooth movement would be more efficient. [7] In a conventional preadjusted appliance, with the buccal tube positioned parallel to the line of buccal cusps, the passive archwire will lie below the anterior brackets because of the curve of Spee. When the anterior teeth are engaged with a continuous archwire, a counterclockwise tip forward moment will be created on the molar resulting in anchor loss while the anterior teeth are extruded. [4] This bite-deepening effect can be avoided by using a sectional archwire in the initial stage of treatment, [8] and micro-implants can be used to reinforce the anchorage as they can be more efficient than traditional anchorage methods besides making treatments more predictable. [9] Therefore, combining different treatment techniques and philosophies with a desired bracket system can bring about superior treatment results.

CASE REPORT
The present case report showcases the treatment results achieved by combining the different treatment philosophies and techniques using butterfly system. [10] Diagnosis and treatment plan An 18-year-old male patient in the permanent dentition presented with the chief complaint of forwardly placed anterior teeth with spacing in between them. Upon extraoral examination, the patient had a straight profile, horizontal growth pattern, reduced nasolabial angle, upper midline shifted to the right by 1 mm, competent lips, and nonconsonant smile [ . He was also diagnosed with tongue thrust habit. Upon intraoral examination, he had proclined anteriors, generalized spacing in the upper and lower arches, distally tipped canines in the upper and lower arches, increased curve of Spee, Class I molar relation bilaterally, Katz Class II premolar relation and Class II canine relation on the left side, and crossbite in relation to 15; the overjet was 7 mm and overbite was 40% [ . The findings were confirmed with study models  and pretreatment radiographs [ Figures 17 and 18]. Cephalometric analysis indicated a Class I skeletal pattern, horizontal growth pattern, reduced lower anterior facial height, and proclined upper and lower incisors [ Table 1].
Following a comprehensive clinical and database analysis, we devised a treatment plan involving nonextraction approach leaving the incisors mildly proclined to prevent a dished-in profile and to have an adequate lip support.  Treatment progress A butterfly system with 0.022" slot was used. Initial leveling and alignment was carried out in the upper and lower arches using sectional 0.016" nickel titanium (NiTi) wire from the second molar to canine as posterior section and incisors in the anterior section [ Figures 19-23]. This was done to prevent the bite-deepening effect of continuous archwire and prevent strain on the anchorage. Myofunctional exercise was advised for the correction of tongue thrust habit. After the correction of distal crown tip of canines, a continuous 0.016" heat-activated NiTi wire was placed in the upper and lower arches. This was followed by 0.019 × 0.025" heat-activated NiTi wire.
A miniscrew was placed in the apical portion, between the 2 nd premolar and 1 st molar, near the Cres of posterior segment on Class II side [ Figure 24]. This assisted us in achieving a Katz Class I premolar and a Class I canine relation without disturbing the molars.
Space closure was done on 0.019 × 0.025" stainless steel wires in the upper and lower arches using NiTi closed coil springs. Direct anchorage from the implants was used on the Class II side. A fixed tongue crib was placed because of  Figure 25]. An openbite was observed at the end of space closure which was because of the tongue thrust habit. This was corrected using box elastics in the anteriors [ Figure 26] and tongue crib. Since the patient did not have enough incisor exposure upon social smile, extrusion of anteriors by box elastics helped achieve a favorable incisor exposure.
At the end of space closure, conventional Begg's uprighting springs were used on the upper and lower canines to achieve final correction of the canine tip [ Figures 27-29]. This ensures stability of the treated case. Finishing was done using triangular elastics with hooks in vertical slots on a light 0.016" NiTi wire in the upper and lower arches.

DISCUSSION
Making an accurate diagnosis of the changes observed in patients and formulating an appropriate treatment plan is the key to successful orthodontic treatment. A preference to butterfly system [10] was given to treat the present case because it has versatile vertical slots which could be used to upright the canines in the finishing stage of treatment; +3° mesial crown tip which helps to reduce marginal ridge discrepancy, especially on the Class II side; progressive mandibular anterior tip which in this case would help tent posting of the lower incisors which in turn would increase the stability of the end results; and preventive mandibular anterior torque of −5° which helps prevent lower anterior flaring and finishing with an adequate overjet without having Bolton's discrepancy. An initial continuous archwire was not used because, unlike sectional mechanics, continuous archwires with distally tipped canine crowns tend to deepen the bite and put more strain on the anchorage. [4] Training of correct swallow and posture of the tongue was done by myofunctional exercise [11] where the patient was guided regarding the correct posture of the tongue during swallowing by various exercises. The patient was asked to place the tip of the tongue in the rugae areas for 5 min and is asked to swallow and repeat the same with an increased frequency. An micro-implant was placed on the Class II side because there was spacing mesial to the molar, leaving a weak anchorage value. Maximum anchorage was required on the left side as the entire segment had to be retracted in a functional Class I occlusion. The position of miniscrew was preferred in the apical portion, between the 2 nd premolar and 1 st molar, near the Cres of posterior segment [ Figure 24]. Use of miniscrew for the reinforcement of orthodontic anchorage has become increasingly popular in recent years, especially for the space closure in maximum anchorage cases. [12] At the end of space closure, traditional Begg's uprighting springs were used in the vertical slots of canine brackets as described by Bowman and Carano. [10] A Class I molar relationship was maintained throughout the treatment, and Katz Class II premolar relation was achieved bilaterally along with bilateral Class I canine relation. Overjet was 2 mm and overbite was 2 mm, and the midlines were coincident at the end of the treatment [ Figures 30-34]. An Superimposition of pre-and post-lateral cephalogram reveals that the maxillary incisors were left with enough proclination to provide lip support. The mandibular incisors were finished with adequate tip and torque and mild proclination [ Figure 41]. Postoperative orthopantomogram revealed parallel roots without any significant root resorption [ Figure 42], and postoperative lateral cephalogram revealed adequate lip support and pleasing profile at the end of the treatment [ Figure 43]. The findings were confirmed from posttreatment study models [ Figures 44-48].