Transposition tooth corrected by orthodontic

TRANSPOSITION TOOTH CORRECTED BY ORTHODONTIC

Supervised : prof Maher Fouda Prepared by : Hawwa shoaib

DEFINITION

Tooth transposition is defined as the positional interchange of two adjacent teeth within the same quadrant. [1,5] It is identified as complete transposition when the crowns and the roots of the involved teeth exchange places in the dental arch and as incomplete transposition when the crowns are transposed but the roots remain in

their normal positions .]1[

.1Shapira Y, Kuftinec MM. Tooth transpositions—a review of the literature and treatment considerations. Angle Orthod. 1989;59:271–276.

.25 .Talbot TQ, Hill AJ. Transposed and impacted maxillary canine with ipsilateral congenitally missing lateral incisor. Am J Orthod Dentofacial Orthop.

2002;121:316– 323.

American Journal of Orthodontics and Dentofacial OrthopedicsFebruary 2001…

TRANSPOSED CANINE

The incidence has been reported as about 0.4%. [6] Tooth transpositions occur more commonly in the maxilla than the mandible, [6,7] and the maxillary permanent canine has been

reported as the tooth most frequently involved in transposition .]6,8[

6 .Chattopadhyay A, Srinivas K. Transposition of teeth and genetic etiology. Angle Orthod. 1996;66:147–152.

7 .Plunkett DJ, Dysart PS, Kardos TB, Herbison GP. A study of transposed canines in a sample of orthodontic patients. Br J Orthod. 1998;25:203–208.

8 .Shapira Y, Kuftinec MM. Maxillary tooth transpositions: characteristic features and accompanying dental anomalies. Am J Orthod Dentofacial Orthop. 2001;119:127–134.

(1 )TRUE TRANSPOSITION

In true transposition the both involved teeth e.g central incisor and canine do occupy each others respective positions.

This subdivided into : Unilateral Or bilateral

FALSE TRANSPOSITION

In this the involved teeth do not occupy each others normal respective positions.…

For example in case of canine and central incisors transpositions; the canine has taken the position of central incisor by migrating mesially and central incisor and lateral incisor which are in normal sequence have simply migrated or been forced distally

ETIOLOGIC FACTORS

genetics, [2,4,6,11,12] interchange in the position of the developing tooth

buds, [14]

2. Peck L, Peck S, Attia Y. Maxillary canine-first premolar transposition, associated dental anomalies and genetic basis. Angle Orthod. 1993;63:99–1104. Peck S, Peck L, Kataja M. Mandibular lateral incisor-canine transposition, concomitant dental anomalies, and genetic control. Angle Orthod. 1998;68:455–466.. 6. Chattopadhyay A, Srinivas K. Transposition of teeth and genetic etiology. Angle Orthod. 1996;66:147–152.

11 .Allen WA. Bilateral transposition of teeth in two brothers. Br Dent J. 1967;123:439–440.12 .Feichtinger CH, Rossiwall B, Wunderer H. Canine transposition as autosomal recessive trait in an inbred. J Dent Res. 1977;56:

1449–1452.14. Dayal PK, Shodhan KH, Dave CJ. Transposition of canine with traumatic etiology. J Ind Dent Assoc. 1983;55:283–285.

trauma, [3,10,14] mechanical interferences, [2,8,9]  early loss of incisors3 have been associated with

tooth transposition.

2 .Peck L, Peck S, Attia Y. Maxillary canine-first premolar transposition, associated dental anomalies and genetic basis. Angle Orthod. 1993;63:99–110.

3 .Peck S, Peck L. Classification of maxillary tooth transpositions. Am J Orthod Dentofacial Orthop. 1995;107:505–517.8 .Shapira Y, Kuftinec MM. Maxillary tooth transpositions: characteristic features and accompanying dental anomalies. Am J

Orthod Dentofacial Orthop. 2001;119:127–134.9 .Shapira Y. Transposition of canines. J Am Dent Assoc. 1980;100:710–712.

10 .Weeks EC, Power SM. The presentations and management of transposed teeth. Br Dent J. 1996;181:421–424.14. Dayal PK, Shodhan KH, Dave CJ. Transposition of canine with traumatic etiology. J Ind Dent Assoc. 1983;55:283–285.

SIX TYPES OF TRANSPOSITIONS  Maxillary canine-first premolar Maxillary canine-lateral incisor Maxillary canine to first molar site  Maxillary lateral incisor-central incisor Maxillary canine to central incisor site Mandibular lateral incisor-canine transpositions

3 .Peck S, Peck L. Classification of maxillary tooth transpositions. Am J Orthod Dentofacial Orthop. 1995;107:505–517.4 .Peck S, Peck L, Kataja M. Mandibular lateral incisor-canine transposition, concomitant dental anomalies, and genetic control. Angle

Orthod. 19915. 15 .Shapira Y, Kuftinec MM. Orthodontic management of mandibular canine-incisor transposition. Am J Orthod. 1983;83:271–276.8;68:455–466.

Unilateral transpositions have been reported more often than bilateral transpositions, and the left side has been more frequently involved than the right.3-5

3 .Shapira Y, Kuftinec MM. Tooth transpositions—a review of the literature

and treatment considerations. Angle Orthod 1989;59:271-6.

4 .Peck S, Peck L. Classification of maxillary tooth transpositions. AmJ Orthod Dentofacial Orthop 1995;107:505-17.

5 .Peck L, Peck S. Maxillary canine-first premolar transposition, associateddental anomalies and genetic basis. Angle Orthod 1993;63:

99-109.

Transposition can be complete or incomplete. In a complete transposition, both the crowns

structures of the involved teeth are found in their transposed positions and the entire root.

In an incomplete transposition, the crowns might be transposed, but the root apices still remain in their normal positions.

Several factors should be considered when making an orthodontic treatment plan for transposed teeth. In extraction treatment, many patients are treated by extraction of either tooth.

Non extraction treatment, patients undergo alignment of teeth in their normal positions or in their transposed positions. Whichever treatment is selected, several factors(positions of the crowns and roots, gingiva of the transposed teeth, caries risk, and duration of treatment) should be considered when making an orthodontic treatment plan for transposed teeth..

in the mandible, only canine-lateral incisor transpositions occur, with a majority being unilateral (3). There is a high incidence of congenitally absent teeth, peg-shaped lateral incisors, and/or supernumerary teeth associated with transposition, suggesting a genetic influence( 1,3,4).

Plunkett DJ, Dysart PS, Kardos TB, Hebison GP. A study of transposed canines in a sample of orthodontic patients. British Dental Journal 1998; 25(3): 203-

.3 .Peck S, Peck L, Kataja M. Mandibular lateral incisor-canine transposition, concomitant dental anomalies, and genetic control. Angle Orthodontist 1998; 68(5): 455-66.

4 .Newman GV. Transposition: orthodontic treatment. Journal of the American Dental Association 1977; 94(3): 544-7.

CLINICAL CASES

CASE ( 1 ) A female patient, aged 26 years, presented withtransposition of the maxillary left canine and firstpremolar. The patient had a Class I skeletal pattern with

good facial relationships and a slightly convex profile..

A mild Class II dental malocclusion inthe transposition side and Class I dental relationship inthe right side were recorded. We also noted a 2-mmdeviation of the maxillary midline towards the affectedside. The arch length discrepancy was 4 mm in the

maxillary and 6 mm in the mandibular dental arch.

PRE TREATMENT INTRAORAL PHOTOGRAPHS

Radiographs of patient before treatment. Pretreatmentpanoramic radiograph (A), lateral cephalometric

radiograph (B), and periapical radiograph (C).

Radiographic examination reveledcomplete transposition

TREATMENT OBJECTIVES

We aimed to establish functional Class I molar-caninerelationships and a satisfactory esthetic smile withoutextractions and without any reshaping procedures,

including enamel reduction or restoration, in order tocorrect the transposition with the help of palatal miniscrew anchorage. Further, we aimed to create an idealoverbite and over jet relationship while correcting and

midlines root inclination .

TREATMENT ALTERNATIVESTreatment plans were based on the results of cephalometricand study model analyses. Facial appearancewas satisfactory; therefore, extraction treatment was contraindicated.

When deciding on a treatment plan of]Maxilla 4-3 [transposition, the clinician should consider

at least 2 options: aligning the involved teeth intheir transposed positions or moving them to their correctanatomic position in the dental arch. Dental andfacial esthetics of the maxillary anterior teeth shouldbe carefully evaluated and considered when decidingwhich treatment option is suitable .

A treatment plan involvingthe alignment of the teeth in their transposed

positions and composite crown restoration for canine and premolars was offered but was declined

by the patient.

PRE-TREATMENT STUDY MODELS

This case of complete transposition of the maxillarycanine and premolar was treated with palatally locatedmini-implant anchorage and fixed orthodontic treatment mechanics. Esthetic and occlusal consideration suggested the alignment of the transposed teeth to their correct anatomic positions in the dental arch.

.

TREATMENT PROGRESS

The bucco palatal width of the bone is not sufficient to support 2 adjacent teeth that are moving in opposite directions.

For this reason, mini-implant anchorage was usedmove the transposed premolar in the palatal direction.

.

Treatment was initiated with leveling of the maxillary arch. After using super elastic leveling arches, a0.016 × 0.022 inch rectangular stainless steel arch wire was placed. Then, the first premolar was moved palatally with the help of a palatal implant.

(Necessary)space for canine placement was provided by mini implantanchorage, and root interferences were preventedwith a 0.016 × 0.022 inch stainless steel wirewith an offset bend at the transposition region, maintainingthe buccal position of the canine. Simultaneously,the maxillary canine was mesialized along a buccalpath over the maxillary first premolar, directed byan active open coil spring between canine and second premolar over the 0.016 × 0.022 inch continuous stainlesssteel arch wire. After 14 months, following repositioningof the canine.

a removable 0.032-inchTMA trans palatal arch with premolar extensions was inserted in the palatal sheath of the first molars..

A unilaterally activated trans palatal arch was used to movethe premolar labially, back to its normal position

Simultaneously, the mandibular arch was bonded..An open coil was placed between the maxillary rightcanine and second premolar to gain enough space forthe first premolar and for midline correction.

ACTIVATION OF TRANS PALATAL ARCH.

Bite raising was achieved by bonding composite onthe occlusal surfaces of both mandibular first molars.

By 18 months, the maxillary left first premolar was includedin the fixed mechanics. Special effort was madeto achieve optimal torque of the teeth with a rectangularstainless steel arch wire. A second lower premolarbracket of 0.22 inches with － 22torque degrees was placed upside down to achieve optimal torque control of the palatally

displaced transposed premolar For the transposed canine ..

another second lower premolar bracket of 0.22 incheswith － 22 torque degrees was placed in order to achievethe necessary palatal root movement.

PROGRESS INTRAORAL PHOTOGRAPHS

The total treatment time was 24 months, which relatively long in general is yet acceptable consideringthe absolute correction achieved. The clinical

result at the end of the treatment was satisfactory.. The maxillary canine and first premolar weresuccessfully positioned. Alignment was obtained, andInter cuspation was adequate. Ideal over jet and overbite were

also achieved .Class I dental relationships were established.

Root parallelism was achieved.

RESULTS

Nevertheless, the maxillary canine exhibited facialrecession, probably because it was initially positionedbuccally. To maintain the level of the attached gingivaof the canine with the adjacent teeth, intrusion of thecanine was avoided.

Using palatal mini-implantanchorage involves less treatment time when compared to orthodontic procedures alone. At the 2-year follow-

up, the patient had a stable occlusion, and the resultsof the orthodontic treatment were maintained. Thegingival height of the maxillary left canine was stable,and this tooth showed no mobility.

POST-TREATMENT EXTRA ORAL PHOTOGRAPHES

INTRAORAL PHOTOGRAPHS

POST-TREATMENT STUDY MODELS

RADIOGRAPHS OF PATIENT AFTER TREATMENT. POST-TREATMENTPANORAMIC RADIOGRAPH (A), LATERAL CEPHALOMETRIC

RADIOGRAPH(B), AND PERIAPICAL RADIOGRAPH (C).

24-MONTH POST-RETENTION INTRAORAL PHOTOGRAPHS AND PERIAPICAL RADIOGRAPH

DISCUSSION

The main difficulties faced when correcting the altered tooth position with maxillary premolar canine transposition are root interference and resorption and difficulties in controlling root inclination of the transposed teeth. There are many other aspects that have to be considered such as prolonged treatment time, esthetics, function, stability, biological damage, mechanical device, and professional preference and experience.

Additionally patient cooperation is an important factor that affects the treatment results. Since extraction was contraindicated after overall consideration of the cephalometric and dental cast analyses there were 2 treatment options remaining for [Maxilla4-3] transposition: (1) aligning the involved teeth in their transposed positions. (2) moving them to their correct anatomic position in the dental arch. Had the transposition not been corrected, reshaping of the incisal occlusal surfaces should have been performed to fulfill esthetic and restorative requirements. Furthermore, for ideal function, canine guidance during lateral movement of the mandible would be needed.

To avoid root interference or resorption during treatment and to prevent bone loss at the cortical plate of the labially positioned canine, the transposed premolar was first moved palatally, enough to allow for free movement of the canine to its normal place. Then, the canine could be moved mesially to its original position in the arch.

One advantage of aligning the teeth in their correct anatomic positions with the help of palatal mini implant anchorage is that the treatment time was shortened. There fore, root resorption as well as supporting tissue loss especially of the buccal bone plate were decreased and controlled in critical limits..

The patient was a 16-year-old Japanese girl. Herchief complaints were crowding and transposition ofthe maxillary right canine and first premolar. She hadno orthodontic history.

CASE ( 2 )

The intraoral examination showed an AngleClass III molar relationship bilaterally. All permanent teeth were erupted, and the maxillary right deciduous canine was retained. The maxillary right permanent canine had erupted in an ectopic position between the premolars. The maxillary right first premolar was in scissors bite

The arch length discrepancies were –4.3 mm inthe maxillary arch and –1.9 mm in the mandibular arch.She had 3.0 mm of over jet and 2.0 mm of overbite.Both maxillary and mandibular dental midlines nearlycoincided with the facial midline.

radiographic examination, the root of the maxillary rightdeciduous canine was mostly resorbed, and both thecrowns and the roots were transposed (Fig1). Dentalcomputed tomography scans showed that the root ofthe right canine was between the premolars, and theroot of the first premolar was close to the crown of thecanine but not resorbed (Fig 2).

(Fig1 .)

(Fig 2).

Several etiologies of transpositionhave been proposed: genetic origin, trauma, interchangeof the position of the developing tooth buds, lack ofdeciduous canine root resorption, early loss of deciduousteeth, and prolonged retention of deciduous teeth.

Because of the high incidence of retained deciduouscanines associated with tooth transpositions, some authorshave reported that deciduous teeth are the primaryetiologic factor of this anomaly.

In this patient, a possible etiology of transposition included. the retained deciduous canine

LATERAL CEPHALOMETRIC RADIOGRAPH

The maxilla was positioned posteriorly, and the mandiblewas positioned normally relative to Japanese standards

)SNA, 78.2; SNB, 76.7; ANB, 1.5 .(The patient hada skeletal Class III relationship.

Pretreatment cephalometric radiograph.

The inclination of the maxillary incisors was normal, but the mandibular incisors showed a lingual inclination ..

these findings, the patient was diagnosed with an AngleClass III malocclusion with crowding and transpositionof the maxillary right canine and first premolar.

TREATMENT OBJECTIVES

The treatment objectives were to correct the transposition,establish the natural tooth order by extraction ofthe maxillary right deciduous canine without extractionof the transposed tooth, establish a functional Class Imolar and canine relationship with coincident dentalmidlines, create ideal overbite and over jet, and correctthe lingual inclination of the incisor.

Pretreatment dental casts.

TREATMENT ALTERNATIVES

The following alternatives were considered for thetransposed teeth:)1( extraction of all first premolars, )2( extraction of the maxillary right canine or first premolar,

(3) Non extraction treatment and alignment ofthe teeth in the transposed order, and )4( non extractiontreatment and correction of the transposition.

In considering these treatment alternatives, the followingfactors were taken into account. Because the facialappearance was satisfactory for a Japanese girl, shedid not need retraction of the lips.

Treatment with extraction of the 4 first premolars would have required extensive linguoclination of the maxillary and mandibular incisors, or it would have required extensive mesial movement of the molars.

In addition, if either the maxillary right first premolaror the canine had been extracted, that dental arch wouldhave become asymmetric, and the treatment mechanicswould have become difficult. Therefore, we evaluatedhow the transposed teeth could be aligned without toothextractions.

Because both the crown and the root weretransposed in the maxillary right first premolar and canine,

aligning the teeth in the transposed order wouldprobably have required a shorter treatment time thancorrecting the transposition.

Correction of a transposition poses a high risk of damaging the teeth or the supporting structures.

Thus, alignment of the involved teeth in their transposed positions seemed to be the best alternative but the patient strongly desired alignment of the teeth in their correct

positions…

We decided to attempt treatment without extraction of the transposed tooth and with correction of the transposition to achieve a functional Class I canine and molar relationship.

TREATMENT PROGRESSAfter the maxillary right deciduous canine was extracted, a trans palatal arch and a lingual arch were placed on the maxillary arch as anchorageright first premolar was protracted with an elastic chainin a palatal direction with an intentional mesial rotation

The mesio distal root width of the maxillary firstpremolar was narrower than its bucco lingual diameter.

Therefore, we mesially rotated the first premolar to preventits contact with the canine root. In addition, thecanine was mesially protracted with an elastic chainfrom a buccally extended hook off the lingual arch.

The positional relationship between the canine and firstpremolar improved after 3 months of treatment. Thus,

edgewise appliances (0.018 *0.025 in) were placedon the maxillary teeth. Mesial movement of the maxillaryright canine began with the placement of an open-coilspring between the canine and the second premolar.

The first premolar was aligned in the dentalarch, while improving its rotation ..At 16 months,

edgewise appliances were placed on the mandibularteeth. Attainment of correct inter cuspation, and idealtorque and root parallelism were considered. Forty eightmonths later, all edgewise appliances were removed,

and bonded retainers and wraparound retainerswere fabricated to maintain the alignment.

POST TREATMENT FACIAL PHOTOGRAPHS

INTRAORAL PHOTOGRAPHS

POST TREATMENT DENTAL CASTS

CONCLUSIONS

Dental transpositions can be corrected orthodontically However, the mechanics are complex, treatment time is long, and dental tissues can be damaged. The patient's compliance, esthetics, function, caries risk, and age should all be considered when deciding whether treatment of a transposition should involve tooth extractions tooth alignment in the transposed order, or orthodontic correction of the transposition. A diagnostic setup model and computed tomography were effective and important in determining the appropriate treatment plan for our patient's transposed teeth.

DIAGNOSTIC SETUP MODEL

TWO-YEAR POST TREATMENT COMPUTED TOMOGRAPHY

TWO-YEAR POST TREATMENT INTRAORAL PHOTOGRAPHS

POST TREATMENT RADIOGRAPHS

A New Spring for Correction of

Maxillary Canine-PremolarTransposition

CASE ( 3 )

15-year-old female patient with peg-shaped lateral incisors, transposed maxillary right canine and first premolar, and missing mandibular left second premolar

.

chief complaint of crooked teeth ..Clinicalexamination revealed peg-shaped maxillary lateralincisors and partial transposition of the maxillaryright canine and first premolar. Agenesis ofthe mandibular left second premolar was alsonoted. The patient had a Class I molar relationshipand a Class I canine relationship on the left side,but a canine malocclusion on the right side.

Although she had a convex profile resulting frombimaxillary protrusion, cephalometric evaluationshowed a good maxillomandibular relationship..

The treatment plan for the maxillary archwas to extract both lateral incisors and move thecanines into the lateral incisor positions, using aJOB Spring on the right side, while moving thefirst premolars into the canine positions. The planfor the mandibular arch was to extract the rightsecond premolar to improve dental alignment. Theextractions were also needed to correct the bimaxillaryprotrusion.

After edgewise brackets were bonded, theJOB Spring was inserted and activated to move themaxillary right first premolar palatally.

The adjacent canine was moved mesially withelastic chain. When adequate space was availablefor the premolar, it was moved into its new positionusing elastics.

After 10 months of treatment, the transpositionhad been corrected. The maxillary canineswere then re contoured over a period of two monthsto resemble lateral incisors .An adequateocclusal relationship was achieved after 36 monthsof active treatment. A maxillarywraparound retainer was delivered, and an .028"

stainless steel 3-3 lingual retainer was bonded inthe mandibular arch. Follow-up records taken fouryears after the end of treatment showed good long termstability.

FOLLOW-UP RECORDS TAKEN FOUR YEARS AFTER END OF TREATMENT

CONCLUSION

The JOB Spring is a simple and effectivedevice that can allow correction of canine-firstpremolar transposition in the maxillary arch. Theresults obtained in this case show the potentialbenefits of treating this challenging malocclusion

Orthodontic treatment of transposition is complex Orthodontists should consider factors that could affect treatment results, such as function, occlusion, periodontal support, patient cooperation, and esthetic demands. In our case, moving transposed teeth to their correct anatomic positions in the dental arch with the help of palatal mini-implant anchorage provided excellent results in an acceptable treatment time. Post-retention records revealed the formerly transposed teeth in normal condition and the periodontal and surrounding tissues to be normal 2 years after the conclusion of treatment…

TRANSPOSITION VS TRANSMIGRATION

Transposition : interchange in the position of tow adjacent permanent teeth within the same quadrant of the dental arch.

Transmigration : it is referred as displacement of teeth from one quadrant across the midline to the other quadrant .

transmigration

 reverse obliquely transmigrated lower right canine with its crown piercing the lower border of mandible at the level of opposite canine .

WHY GREATEST INCIDENCE OF MAXILLARY CANINE

TRANSPOSITION

The max canine are important key stone in the dental arch both for good esthetics and normal

masticatory function .The max canine is the most common tooth to get transposed . In case of canines , the pre eruptive position of permanent max canine increases its

potential for ectopic eruption .

Orthodontic treatment of the transposition of a maxillary canine and a first premolar: a case

report

J Med Case Rep. 2015; 9: 48.

A 12-year-old Caucasian boy presented with transposition of his upper right canine and upper right first premolar. He had combined surgical-orthodontic treatment to correct the transposition and to obtain a Class I relationship between the molar and canine. This treatment resolved the dental crowding and achieved good functional and aesthetic results.

An intraoral examination revealed the presence of his deciduous upper right canine in the arch, the absence of the corresponding canine, and microdontia of his upper lateral incisors. His left lateral incisor showed a cross bite relationship with his lower left canine. A class I molar inter occlusal relationship was present on his right and left sides, with minimal crowding in the front section of his lower arch

To determine an adequate treatment plan, our patient underwent orthopantomography of his arches and latero-lateral cranium teleradiography for cephalometric evaluation. The orthopantomography highlighted the retention of his right upper canine and its transposition with his first premolar

One possible treatment approach for this patient was to align his teeth into the transposed position. Although this approach would probably have required less time overall, it had some disadvantages in terms of aesthetics and occlusion. Therefore, a combined surgical-orthodontic treatment was selected, with the aim of correcting the transposition and aligning the teeth into their correct positions. The selected approach involved a surgical incision in the mucosa proximal to the retained and transposed canine, traction of the tooth in the dental arch into its physiological position using an anchorage device, and banding of the dental arches to obtain alignment and leveling. The proposed treatment was interceptive and was chosen to prevent further impaction of the canine into the first molar.

Surgical operation

one week later, surgery was performed. The oral surgeon made an incision in the mucosa to expose the crown and created a trapezoidal paramarginal flap

Splint with eyelet positioned and cemented.

 button was placed at the crown level and tied with an elastic wire to the more distal eyelet of the splint to start the traction. The deciduous canine was preserved to maintain the necessary space for repositioning the permanent tooth. The elastic wire was replaced approximately every 15 days to ensure a slow and constant traction, in such a way as to avoid damage to the periodontal tissue and the canine.

About two months after surgery, his tooth was visible in the arch 

Intraoral photo two months after the start of traction

Traction was continued by tying an elastic wire to the mesial eyelet of the splint in zone 13. The more distal eyelet was removed. Four months after surgery, the tooth was sufficiently visible to allow for removal of the splint, extraction of the deciduous canine, replacement of the button with an orthodontic brace, and banding of the arches.

Intraoral photo four months after the start of traction.

Bonding was performed with pre-torqued and pre-angled brackets with a 0.022-inch slot. The first arch used was a 0.014-inch nickel-titanium round arch, to which the canine was directly tied

Banding and bonding of upper arch.

About two months after the start of treatment, a 0.018-inch nickel-titanium arch was applied. Once the crowding was resolved, the intermediate stage was begun, and a 0.016×0.022-inch nickel-titanium arch was applied. For the final stage, a 0.019×0.025-inch steel arch was used.

As soon as the canine reached its correct position in the arch, the lower arch was banded. The same procedure used for the upper arch was applied, using the same braces and the same sequence of wires 

Banding and bonding of lower arch.

Banding was removed after the established objectives were met, that is, the transposition was corrected and his arches

were aligned and leveled.…

Post treatment intraoral photograph

Our patient’s treatment lasted for two years. At the end of the treatment, he had a good aesthetic outcome. The median lines of occlusion were centered, his molars were in a class I relationship, and his right upper canine showed a slight gingival recession. The microdontic lateral incisors will be aesthetically reconstructed at a later stage, and a decision will be made then as to whether the reconstruction will be direct or indirect.

 Our patient is satisfied with the aesthetic results obtained.