International Orthodontics 2022; 20: 100667

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Case report
Non-surgical adult orthodontic treatment of
a unilateral scissor bite

Yassir A. Yassir

Available online: 16 July 2022 Orthodontic Department, College of Dentistry, University of Baghdad, Baghdad, Iraq
yassirkyassir@gmail.com

Keywords Summary
Scissor bite
Unilateral scissors bite The following case report describes the non-surgical correction of a unilateral scissor bite using
Brodie bite orthodontic mini-implants and cross elastics. An adequate crossbite correction and occlusal setting
Non-growing patient was achieved.

Introduction occlusal dimension between the arches during treatment.

Crossbite is an abnormal transverse relationship between the
maxillary and mandibular teeth. It can be lingual or buccal. A
lingual crossbite occurs when the buccal cusps of the maxillary
teeth are in lingual contact with the buccal cusps of the man-
dibular teeth. A buccal crossbite is when the palatal cusps of the
maxillary teeth are in buccal position to the buccal cusps of the
mandibular antagonist teeth [1]. Bilateral buccal crossbite
(when the mandibular teeth completely telescoped within
the maxillary teeth) also referred as "bilateral buccal crossbite''
[2], "scissor bite'' [3], and "Brodie syndrome'' [4]. This could be
associated with skeletal discrepancy between the arches and
facial asymmetry. Therefore, such cases represent a challenge to
orthodontists [1–5]. The aetiology still unknown, but certain
factors could be attributed, such as inherited genes, bad oral
habits, and mouth breathing [6].
Scissor bite is conventionally treated surgically with fixed ortho-
dontic appliance [6]. However, this invasive approach may not
be welcomed by many patients [5]. Non-invasive alternative
approaches are also possible, but the biomechanical challenge
will be buccal tipping/extrusion of the maxillary buccal segment
and lingual tipping/extrusion of the mandibular buccal segment
in addition to the difficulty of achieving sufficient vertical
Therefore, non-surgical treatment in the adult patient is techni-
cally very difficult [7]; however, the use of temporary anchorage
devices (TADs) may help to resolve this limitation. This case
report presents a non-invasive treatment of unilateral scissor
bite with the use of TADs.
Case presentation
A 23-year-old female patient presented to the clinic for ortho-
dontic treatment of her deviated mandible with chewing diffi-
culties due to the presence of a scissor bite on the right buccal
segment resulting from a narrowed mandibular arch (lingual
invagination of the right buccal dentoalveolar region of the
mandible) (figure 1).
Diagnosis
Clinical and radiographic examination revealed the followings:
 scissor bite on the right side including first premolar, second
premolar, first, second, and third molars;
 class II left canine and class II molar end-to-end on this side;
 edge to edge incisal overbite;
 overjet: 2 mm;
 mandibular midline deviation to the left side about 4 mm due
to deviation during closure;

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https://doi.org/10.1016/j.ortho.2022.100667
© 2022 CEO. Published by Elsevier Masson SAS. All rights reserved.
Y.A. Yassir

Case report
Figure 1
Pre-treatment intra and extraoral photographs

 small diastemas in the maxillary region between the lateral
incisors and canines;

mesiocephalic facial form;

panoramic radiograph showed a small difference between the
right and left mandibular gonial angles without significant
morphological differences in the right and left condyles and
with no obvious temporomandibular disorder (figure 2);
 no serious medical history. Dental history included dental
restorations.
Treatment plan
The following sequence represented the treatment plan
required to achieve treatment objectives:
 levelling and alignment;
 correction of scissor bite using glass ionomer bite turbos,
buccal alveolar temporary anchorage devices (TADs), and cross
elastics;
 extraction of maxillary and mandibular third molars;
 midline correction;

 correction of buccal teeth relationship;

Treatment objectives
 settling and finishing.
The following objectives were determined to be achieved dur-
Due to a harmonious facial profile with no expected anteropos-
ing treatment:
terior movement of the maxillary and mandibular teeth, ceph-
 correction of unilateral posterior scissor bite;
alometric radiography was not performed to limit exposure to
 correction of lingually inclined mandibular buccal segment;
potentially harmful X-rays.
 achieving class I dental relationships with adequate overbite

and overjet;
 correction of midline discrepancy;
Archwire sequence
 settling a functional occlusal interdigitation.
The archwire sequence below was followed during treatment:

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International Orthodontics 2022; 20: 100667
Figure 2
Pre-treatment panoramic radiographic view
 0.014-inch thermally activated nickel-titanium;
 0.016-inch thermally activated nickel-titanium;
 0.016  0.022-inch thermally activated nickel-titanium;
 0.019  0.025-inch thermally activated nickel-titanium;
 0.019  0.025-inch stainless-steel;
 0.014-inch thermally activated nickel-titanium.
Maxillary archwires were used in the mandibular arch to aid in
expansion and vice versa.
Treatment progress
The appliance (0.022-inch MBT system, Pinnacles®, Ortho Tech-
nology, USA) was bonded using direct bonding technique with
Resilience® adhesive (Ortho Technology, USA). A large bite
Figure 3
Intraoral views in progress three months after levelling and alignment with the use of interdental TADs, cross elastics, and bite turbo
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Case report
opening was required to allow transverse movement of maxil-
lary and mandibular right buccal teeth during scissor bite cor-
rection. Since it was decided to extract the third molars, a large
bite raiser (Glass ionomer light-cure band cement; Resilience®,
Ortho Technology) was placed on the mandibular left third molar
(opposite side to permit movement on the right side). Three
months after levelling and alignment, the maxillary archwire
was changed to 0.016  0.022-inch thermally activated nickel-
titanium and the mandibular archwire remained 0.016-inch
thermally activated nickel-titanium. Two self-drilling TADs
1.6  8 mm (SPEED Dental, Korea) were inserted buccally in
the second premolar-first molar and first molar-second molar
interdental areas. On the other hand, two lingual buttons were
bonded on the mandibular right second premolar, first molar,
and second molar. Cross elastics (1=4 -inch 4.5 oz; Ortho Technol-
ogy, USA) were used in addition to three power chains extended
from the lingual buttons to each buccal TAD (figure 3).
At five months, some improvement was observed in the trans-
verse movement of mandibular buccal segment (figure 4).
After seven months, the scissor bite was almost corrected. The
maxillary archwire was changed to 0.019  0.025-inch ther-
mally-activated nickel titanium and the mandibular archwire
to 0.016  0.022-inch thermally activated nickel-titanium, and
the bite raiser was removed. However, a midline shift was still
observed with minor spacing in the mandibular anterior region.
At this time, the use of elastics was instructed to be part time
only (every other day for four weeks). Archwire sequence was
Y.A. Yassir

Case report
Figure 4
Intraoral views in progress at five months after bonding; some improvement in the scissor bite correction has been achieved

Figure 5
Intraoral views in progress: a: after seven months, the scissor bite was almost corrected but an open bite and midline shifting were
observed; b: after nine months, the open bite and midline shifting were almost corrected

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International Orthodontics 2022; 20: 100667

Case report
Nine months from bonding, TADs were inserted buccaly and
palatally in the maxillary arch to intrude first and second molars
using power chain extended over the occlusal surface. Simulta-
neously, two box elastics 1=4-inch 4.5 oz were used to correct the
midline; class II vector on the right side and class III vector on the
left side. The maxillary and mandibular archwire were 0.014-
inch thermally activated nickel-titanium. The occlusion was
settled with anterior box elastic 5/16-inch 4.5 oz and with fine
detailing of individual brackets (figures 5b and figure 6). Finish-
ing elastics (3/8-inch 2.5 oz) were used to settle the posterior
occlusion after sectioning the wire distal to the lateral incisor.
The third molars were then extracted.
Figure 6
Finally, the appliance was debonded after 18 months with minor
Panoramic view during the finishing process just before the third
space distal to the lateral incisors due to tooth size discrepancy
molar extractions
(figure 7). This was resolved with building-up the laterals with
composite restoration (figure 8).

then continued to reach 0.019  0.025-inch stainless-steel to Treatment results

achieve final root torque. Due to correction of scissor bite, the The case has ended with class I incisors, canines, and molars and
bite was opened anteriorly (figure 5a). coincident maxillary and mandibular midlines (figure 8).

Figure 7
At 18 months, the appliance was debonded with minor space distal to the lateral incisors due to tooth size discrepancy

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Y.A. Yassir
Figure 8
Post-treatment photographs with building-up of maxillary lateral incisors
Transverse buccal relationship with the unilateral scissor bite
was corrected. Overbite, and overjet were adequate. A vacuum
formed clear overlay retainer was delivered to the patient for
retention with full time wear for the first year and then night
wear only for at least another year. A follow-up visit after nine
months revealed stable results (figure 9).
Discussion
Unilateral scissor bite can be the cause or consequence of
interference with normal oral function. Thus, the growth of
the mandible may be disturbed, resulting in facial asymmetry.
The scissor bite can become progressively worse if left untreated
as it cannot be corrected spontaneously and the continued
growth of the maxillary teeth leads to overeruption and occlu-
sion on the buccal surfaces of the mandibular posterior teeth [8].
This results in buccal tipping of the maxillary posterior teeth and
lingual tipping of the opposing mandibular posterior teeth [9]. If
such condition persists, mandibular posterior teeth can become
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Case report
completely lingually tipped and the alveolar bone may be
severely affected as well [10]. The correction of the scissor bite
becomes more challenging as the patient ages and mandibular
growth decreases. More treatment options are available for
younger patients, including maxillary constriction and mandib-
ular expansion before growth is complete [11]. This early inter-
ceptive treatment can reduce the duration of treatment and
decrease the complexity of later orthodontic treatment stages
[8,9]. As such, early treatment of scissor bite is critical. In this
case, the patient complained of difficulty eating and discomfort
due to abnormal bite and mandibular deviation. This situation
can be complicated by temporomandibular disorder if left
untreated. The aetiology was confined to the right mandibular
dentoalveolar buccal segment which was lingually tipped. The
patient requested a non-invasive conservative approach of
treatment. Therefore, it was decided to use TADs with cross
elastics to upright the mandibular buccal teeth. As the occlusion
had to be elevated considerably and the wisdom teeth were to
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International Orthodontics 2022; 20: 100667
Figure 9
Nine-month follow-up photographs
be extracted later in the treatment, it was possible to use a large
glass ionomer bite turbo on the opposite side. It was therefore
expected after this approach to end up with anterior open bite
due to achieving the normal buccal bite with the extruded teeth.
However, the force vector with the use of interdental TADs and
power chains connected to lingual buttons limit the amount of
mandibular teeth extrusion. Scissor bite correction with unilat-
eral cross elastics produces an extrusive force that can result in
clockwise rotation of the mandible, anterior open bite, cant of
the occlusal plane, or occlusal prematurity. It was therefore
necessary to carefully monitor the amount of extrusion on
the affected side for later reversal [1]. Once adequate transverse
relationship was achieved, and since the mandibular molar
extrusion was limited, it was only required to intrude maxillary
molars to solve anterior open bite. Bilateral TADs buccally and
palatally were used to intrude molars (especially on the scissor
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Case report
bite side), to allow true intrusion without tipping. This was
preferred as it does not require patient cooperation compared
to other treatment modalities such as headgear and posterior
bite blocks [12,13]. Teeth intercuspation and the use of class II
and class III elastics to correct the midline yielded satisfactory
outcomes. This case presented a successful treatment of unilat-
eral scissor bite with the use of buccal TADs and cross elastics.
Conclusion
Using buccal interdental DATs with lingual buttons in addition to
cross elastics is an effective and minimally invasive approach to
correct scissor bite with a lingual mandibular buccal segment.
Disclosure of interest: the author declares that he has no competing
interest.
Y.A. Yassir
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Case report
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