-
CASE REPORT
Distalization of the mandmini-implants to correct awith a
midline deviation
Kyu-Rhim Chung,a Seong-Hun Kim,b HyeRan Choo,c Yoo
Uijongbu and Seoul, Korea, Philadelphia, Pa, and Dallas, Tex
This article describes the orthodontic treatment for a young
wmalocclusion and a deviated midline. Two orthodontic minSeoul,
Korea) were placed in the interdental spaces betweenlars. The
treatment plan consisted of distalizing the mandibulfor en-masse
retraction of the mandibular anterior teeth. C-im
lantationd ov5-46
Recently, the mechanics of group distal movementof teeth with
microscrew implant anchorage was intro-
caninesnectingprimarymove-
rightingse thereforwards on the
maxillary anterior teeth in microscrew implant-aided
for treatment when intermaxillary elastics are not indi-
Secondary stability is related to the microstructure ofthe
implant surface.8-11 In conventional dental
Professor and chairman, Department of Orthodontics, Catholic
University of
College of Dentistry, Dallas, Tex.
0889-5406/$36.00
Copyright 2010 by the American Association of
Orthodontists.doi:10.1016/j.ajodo.2007.06.023135cated or the
patient is uncooperative.The stability of temporary skeletal
anchorage
devices is achieved from primary mechanical retentionbetween the
implant surface and the cortical bone, andsecondary stability is
provided by the healing processof the surrounding tissue. Primary
stability is importantto minimize the potential for failure from
micromotion.
Partly supported by the Korean Society of Speedy Orthodontics,
the alumni fund
of the Department of Dentistry, and the Graduate School of
Clinical Dental Sci-
ence, Catholic University of Korea.
The authors report no commercial, proprietary, or financial
interest in the prod-
ucts or companies described in this article.
Reprint requests to: Seong-Hun Kim, Catholic University of
Korea, Uijongbu
St. Marys Hospital, 65-1 Geumo-dong, Uijeongbu, Gyeonggi-do,
480-717,
South Korea; e-mail, [email protected] or
[email protected].
Submitted, April 2007; revised and accepted, June
2007.mechanics. Therefore, distal movement assisted bya rigid
orthodontic implant can be a good alternative
Korea, Seoul St. Marys Hospital, Seoul, Korea.eAdjunct clinical
assistant professor, Department of Orthodontics; adjunct
assistant professor, Department of Oral and Maxillofacial
Surgery, Baylority, especially in long-faced adults. Also, because
inter-maxillary elastic wear requires patient compliance, it
isdifficult to predict the final result in uncooperative
duced.7 A distalizing force is applied to thethrough a
nickel-titanium (NiTi) coil spring conthe miniscrew to hooks on the
archwire. Thetreatment effect in the mandible is distal tippingment
of the posterior teeth concurrent with upand distal movement of the
anterior teeth. Becauis no force to move the maxillary anterior
teeth(via Class III elastics), there are no side effect
aPresident, Korean Society of Speedy Orthodontics, Seoul,
Korea.bAssistant professor, Department of Orthodontics, Catholic
University of
Korea, Uijongbu St. Marys Hospital, Uijongbu, Korea.cAttending
orthodontist, The Childrens Hospital of Philadelphia; clinical
asso-
ciate, University of Pennsylvania School of Dental Medicine,
Philadelphia, Pa.dClass I intra-arch elastics. The head design of
the C-imptreatment. Sliding jigs were applied buccally for
distaliztreatment period was 18 months. Normal overbite animproved.
(Am J Orthod Dentofacial Orthop 2010;137:13
Every orthodontic tooth movement is accompa-nied by a reaction.
This can make it difficult tocorrect a malocclusion by using
intraoral appli-
ances alone, especially when complete distal movementof the
mandibular dentition is planned in nonsurgicalClass IIImalocclusion
treatment. Traditionally, fixed ap-pliances and intermaxillary
elastics have been used tomove mandibular molars distally, often
resulting in un-desirable proclination of the maxillary incisors
and ex-trusion of the maxillary molars as reciprocal sideeffects.1
This can cause an esthetic problem and instabil-ibular dentition
withClass III malocclusion
n-Ah Kook,d and Jason B. Copee
oman, aged 23 years 5 months, with a Class IIIi-implants
(C-implants, CIMPLANT Company,the mandibular second premolars and
first mo-ar dentition asymmetrically and creating spaceplants were
placed to provide anchorage for
minimizes gingival irritation during orthodonticof the
mandibular posterior teeth. The activeerjet were obtained, and
facial balance was)
patients. Therefore, several authors have attempted totreat this
type of malocclusion by distal tooth movementalone. For example,
animal studies and clinical investi-gations have used conventional
implants as absoluteanchorage2-4 andminiplates for intrusion or
distalizationof themandibular posterior teeth.5,6 Because all
portionsof the anchor plates and screws were placed outside
thedentition in these studies, it was possible to move
themandibular molars without disturbing tooth movement.
-
136 Chung et al American Journal of Orthodontics and Dentofacial
Orthopedicsprosthetic implants, implants with a rough surfaceshowed
better stability and tissue reactions than didthose with a smooth
surface. In orthodontic implants,porous-surfaced implants show
higher marginal bonelevels and less relative implant displacement
thanthreaded implants.12,13
The C-implant (CIMPLANT Company, Seoul, Ko-rea) was developed to
use osseointegration as themain stabilizing mechanism.14-17 This
mini-implant
Fig 1. Two-part design of the C-implant.has an upper abutment
head component and a lowerthreaded body or screw-type component
(Fig 1). Theunique head design makes it possible to apply
multipleelastics while simultaneously preventing the elasticsfrom
slipping off.15,16 The body or retentive componentof the C-implant
is better able to resist the rotational ten-dency of heavy dynamic
loads and control 3-dimen-sional tooth movement as a result of its
higherosseointegration potential.
When distalizing the mandibular dentition witha mandibular
C-implant, the most important consider-ation is its position. The
placement site should be asclose as possible to the mesial surface
of the mandibularfirst molar because this will help achieve optimal
distal-ization of the mandibular dentition. The initial
toothmovement in distalization is posterior movement ofthe second
molar by using a sliding jig that is connectedto the main archwire,
followed by moving the otherteeth posteriorly (Fig 2). While the
second molar is dis-talizing, the first molar also moves distally
as a result ofdrifting. When molar distalization is complete, the
pre-molars will also begin to move with the sliding jig.While the
premolars are distalizing, spaces might de-velop between the
anterior teeth. To retract the anteriorteeth with en-masse
retraction, closing loops are placedbetween the lateral incisors
and canines, and connectedto the C-implants by elastics. Because
intermaxillaryelastics are not applied to the maxillary
dentition,mesial movement of the maxillary arch and extrusionof the
maxillary molars are avoided, and the incisorsare not flared. This
case report describes the distaliza-tion of the mandibular
dentition to treat a dental
Fig 2. Schematic illustration of the C-implant depen-dent on
mandibular distalization mechanics.January 2010Class III
malocclusion with a deviated midline by usingC-implants.
DIAGNOSIS
The patient was a woman, aged 23 years 5 months,whose chief
concern was protruding mandibular teeth.Her medical history was
noncontributory, and occa-sional clicking of her temporomandibular
joints (TMJ)was noted in her dental history.
The pretreatment facial photographs (Fig 3) show anacceptable
facial profile, despite mild midface defi-ciency and slight
mandibular prognathism. No facialasymmetry was noticeable in the
frontal view. The clin-ical examination (Figs 3 and 4) showed a
Class III molarand canine relationship that was more significant on
theright side. Other findings included an anterior edge-to-edge
relationship, a midline discrepancy, mild man-dibular anterior
crowding, and mesial angulation ofthe mandibular posterior teeth.
The lower midline wasnot coincident with the facial midline and was
shiftedto the left by 2.5 mm. The maxillary third molars andthe
mandibular right third molar were missing
-
American Journal of Orthodontics and Dentofacial Orthopedics
Chung et al 137
Volume 137, Number 1(Fig 5A). There was only slight contact
between themaxillary right second molar and the opposing tooth
be-cause of the Class III molar relationship.
The cephalometric analysis (Fig 5B; Table) showeda skeletal
Class III relationship with a high mandibularplane angle and a
slightly retrognathic maxilla. The an-terior facial height was
slightly long relative to the pos-terior facial height. The incisor
position and interincisalrelationship were within normal limits
except for theretroclined maxillary incisor. The patient was
diagnosedwith a skeletal Class I malocclusion with mild
maxillarydeficiency and a dental Class III relationship.
TREATMENT OBJECTIVES
A mandibular premolar extraction plan would bea relatively
simple and stable way to resolve the anteriorcrossbite. Complex
treatment mechanics and manytooth movements would not be needed.
However, the
Fig 3. Pretreatment extraoral apatient did not want extractions
(except for the thirdmolars) or changes to her facial appearance;
she wantedonly to correct the incisor relationship. Although
themaxillary incisors were slightly upright, the patient re-quested
that they not be allowed to move forward.Therefore, we rejected the
premolar-extraction treat-ment option.
Based on the initial records and the patients desires,the
treatment objectives were to distalize all mandibularteeth, improve
the interincisal relationship to have nor-mal overjet and overbite,
shift the mandibular midline tocoincide with the facial and
maxillary midlines, andachieve Class I canine and molar intercuspal
relation-ships. A conventional fixed appliance was prescribed.
TREATMENT ALTERNATIVES
Maxillary advancement surgery was not a viabletreatment option
because the skeletal deficiency was
nd intraoral photographs.
-
Fig 4. Pretreatmen
Fig 5. Pretreatment radiographs: A, panoramic;
B,cephalometric.
138 Chung et al American Journal of Orthodontics and Dentofacial
Orthopedicst dental casts.January 2010not significant, and the
patient was pleased with herfacial appearance. Maximum anchorage
and interarchelastics were discussed for en-masse movement ofthe
mandibular dentition. She refused the interarchelastics because of
their visibility. Her occasionalclicking was also a matter of
concern because it mightlead to TMJ dysfunction symptoms during
orthodontictreatment. Therefore, mandibular distalization witha
C-implant in the posterior dentition and intra-archelastics was the
treatment of choice. After distalmovement of the mandibular
dentition, a full fixedappliance would be used in the maxillary
dentitionfor finishing.
TREATMENT PROGRESS
Two C-implants, 1.8 mm in diameter and 8.5 mmlong, were placed
in the interdental spaces betweenthe mandibular second premolars
and first molars.Bone quality in the mandible was good, and the
im-plants were loaded immediately. A 0.016-in NiTi initialarchwire
was used for leveling and distalization of themandibular posterior
dentition. Intra-arch elastics(1/4-in, 3.5 oz) were applied from
the 0.7-mm-diameterstainless steel sliding jig to the neck of the
C-implant fordistalization of the mandibular second molar and
ante-rior decrowding (Fig 6A).
-
American Journal of Orthodontics and Dentofacial Orthopedics
Chung et al 139Table. Cephalometric measurements
Measurement Average (women)*
SNA () 81.6SNB () 79.2ANB difference () 2.4
Volume 137, Number 1The maxillary dentition was not bonded
initially be-cause the dental and facial midlines were
coincident,and no forward movement of the anterior teeth was
de-sired. While the mandibular dentition was distalizing,drifting
occurred. Therefore, a power chain was appliedto correct the
midline (Fig 6B). This applied an intrusivemovement to the
mandibular incisors because the NiTiarchwire was not stiff, and
elastics were applied from
PFH/AFH (%) 85.1/127.4 (66.8)
SN-OP () 17.9FH-U1 () 116.0FMA () 24.3IMPA () 95.9FMIA ()
59.8UL-E plane (mm) 0.9LL-E plane (mm) 0.6
Interincisal angle 123.8
Mx 1-NA (mm) 7.3
Mx 1-NA () 25.3Mn 1-NB (mm) 7.9
Mn 1-NB () 28.4SN-PP () 10.2
*For Korean women, data from, Korean Association of
Orthodontists.31
Fig 6. Progress photographs: A,mandibular secondless steel
sliding jig; B, power chain between C-implaand midline
correction.Pretreatment Posttreatment
77 76.5
76.5 76
0.5 0.5the incisors to the apically placed C-implant. To
correctthe anterior open-bite tendency from the force directionof
the elastics, the mandibular archwire was changed toa 0.016 3
0.022-in NiTi archwire and then a 0.016 30.022-in stainless steel
archwire with closing loops(Fig 7).
As the mandibular molars moved distally, the max-illary molars
were extruded. To correct the extrusion,
88.5/137 (64.6) 91/140.5 (64.8)
20.6 18
109.5 110
33 33.5
91 80
56 66.5
1.5 11 0.5
127.5 136.5
7 7.5
24 26
8 4.5
27.3 17
9.5 9.5
molar distalization with 0.7-mm diameter stain-nts and
mandibular anterior teeth for retraction
-
140 Chung et al American Journal of Orthodontics and Dentofacial
Orthopedicsthe maxillary dentition was bonded for intrusion
andleveling of the maxillary molars. A Class I molar rela-tionship
of the mandibular left dentition was achievedby using a sliding
jig. The mandibular right dentitionwas distalized 6 mm but still
required further move-ment. The sliding jig was continuously
applied to themandibular first molar. The mandibular premolars
Fig 7. Progress photographs of 0.016 3 0.022-in stto the
mandibular dentition with a sliding jig to the mrelationship
improvement.
Fig 8. Progress photographs of themandibular rightmandibular
en-masse retraction with C-implants.January 2010continued to move
separately (Fig 8). The closingloop of the 0.016 3 0.022-in
stainless steel archwirewas used as a hook for mandibular en-masse
retraction.Distalization of the mandibular dentition and
midlinecorrection took 18 months. The fixed appliances wereremoved,
and retention was provided by maxillary andmandibular fixed
retainers.
ainless steel archwire with closing loop appliedandibular right
first molar activated for molar
second premolar distalized by the sliding jig and
-
American Journal of Orthodontics and Dentofacial Orthopedics
Chung et al 141
Volume 137, Number 1TREATMENT RESULTS
The active treatment period was 18 months. Thepatients facial
profile was mostly unchanged (Fig 9).A Class I canine and molar
relationship and normaltooth alignment with better midline
coincidence,and normal overjet and overbite were achieved(Figs 9
and 10). The maxillary incisors moved for-ward slightly. The
mandibular incisors were retractedconsiderably and extruded. The
upper and lower lipsmoved very little. The interincisal angle
increased asthe mandibular incisors uprighted and the ANB
angleremained unchanged. The posterior facial height-anterior
facial height ratio and the FMA were onlyslightly changed in spite
of the significant mandibu-lar molar distalization as seen in the
superimposition(Fig 11).
Fig 9. Posttreatment extraoral aThe patient was pleased with the
treatment results.An ideal incisor relationship and Class I canine
andmolar relationship were obtained. All radiographic(Fig 12) and
clinical measurements were within accept-able limits. Lingual
bonded retainers and wrap-aroundretainers were placed. Intraoral
photographs after 8months of retention (Fig 13) showed substantial
relapseon the right side back to Class III molar and
caninerelationships and a shallow overbite. We asked the pa-tient
to wear the wraparound retainer more, and after26 months of
retention, the occlusal relationship wasstable (Fig 14).
DISCUSSION
The entire mandibular dentition was distalized withintra-arch
elastics and a supporting C-implant between
nd intraoral photographs.
-
142 Chung et al American Journal of Orthodontics and Dentofacial
Orthopedicsthe second premolars and first molars bilaterally
andwithout extrusion or forward movement of the maxil-lary
dentition. Mandibular posterior distalization beganwith a NiTi wire
for anterior decrowding and midlinecorrection. After distalization
and decrowding, anterior
Fig 10. Posttreatme
Fig 11. Cephalometric superimposition. BlaJanuary 2010spacing
was closed rapidly by using elastomeric chainfrom the C-implant.
The implant site was based on cor-tical bone thickness, anatomic
structures, and soft-tissuefunctional movements. Most reports
suggest that thepreferred site for arch distalization with
skeletal
nt dental casts.
ck, pretreatment; gray, posttreatment.
-
American Journal of Orthodontics and Dentofacial Orthopedics
Chung et al 143
Volume 137, Number 1anchorage is the terminal molar.18,19 The
retromolararea has been reported as an optimal placement site,
of-fering a relatively thick cortical bone layer in the
man-dible.18,19 However, soft-tissue problems can occuraround the
screw implants because the soft tissue is usu-ally thicker and more
movable in the retromolar areathan in other areas.7 This can result
in inflammation,patient discomfort, and difficulty applying
elastics orNiTi coil springs.
Alternative sites for posterior anchorage are theedentulous
areas of the alveolar process and posterioralveolar bone.19,20
Therefore, the alveolar bone aroundthe posterior teeth can be the
site of choice in patientswithout edentulous areas. Miniscrews can
be placedbetween the roots of the posterior teeth without damag-ing
the roots, because the cortical bone in these areas isnot very
thin.20
Orthodontic mini-implants can be placed eitherbetween the first
and second molars or between the sec-ond premolar and the first
molar in the mandibular arch.The thickness of the cortical bone
between the firstand second molars is enough to provide primary
Fig 12. Posttreatment radiographs: A, panoramic;
B,cephalometric.stability,19,20 but this site is not recommended
becauseof tissue irritation during mastication.21 Thus, thealveolar
bone between the second premolar and the firstmolar might be a good
choice for minimum discomfortand maximum stability. The mental
foramen and man-dibular canal can be avoided if the implant is
placednot too far from the apex of the adjacent teeth.21
We reviewed computed-tomography studies ofinterradicular space
to prevent root damage.20,22
Park20 evaluated the computed tomography imagesand reported bone
thicknesses and distances betweenroots 5 to 7 mm apical to the
alveolar crest. The averagedistance between the roots of the
mandibular secondpremolar and first molar was 3.47 mm (range,
2.0-4.8mm). The distance between the roots of the mandibularfirst
and second molars was 4.57 mm (range, 2.7-6.5mm). Park et al21
found smaller distances of 2.4 to3.3 mm between the second premolar
and the first mo-lar, and 2.8 to 3.7 mm between the first and
second mo-lars. The distances from the cortical bone surface to
theinterradicular space however, were relatively larger(3.7-4.2 and
5.3-7.0 mm, respectively). It follows thatorthodontic implants 1.8
mm in diameter can be placedat a slight angle of inclination
relative to the buccal cor-tical bone to overcome the limitation of
minimum inter-radicular space.
The amounts of distal tooth movement have beenreported
previously. Saito et al23 reported 1.8 to10.7 mm of tooth movement
in a dog study. In anotherreport, the average amounts of
distalization of the man-dibular first molars were 3.5 mm at the
crown level and1.8 mm at the root level. The average amount of
relapsewas 0.3 mm at both the crown and root apex levels.6 Ina
recent case report, the mandibular dentition was distal-ized 5 and
2 mm on the left and right sides, respec-tively.16 In another case
report, the mandibularposterior teeth were distalized 6 and 4 mm on
the rightand left sides, respectively.24
As seen in the treatment results reported here, distal-ization
of the entire mandibular dentition was accompa-nied by a slight
mandibular posterior extrusion, which isnot problematic in
brachyfacial patients. However, insevere dolichofacial patients,
intrusion of posterior teethwould be desirable, since
counterclockwise mandibularrotation leads to more esthetic results.
Maxillary poste-rior C-implants and interarch elastics might be
goodchoices in such cases.16 Interarch elastics induce man-dibular
posterior intrusion by tip-back mechanics,instead of extrusion.
Maxillary C-implants can also beused as anchorage for additional
maxillary posteriorintrusion. This allows selection of specific
treatment
mechanics for distalization based on the skeletal andfacial
pattern of patients.
-
144 Chung et al American Journal of Orthodontics and Dentofacial
OrthopedicsAnother issue of concern is the relationship
betweeninterarch elastics and temporomandibular disorders(TMD).
According to a previous report, Class IIinterarch elastics were not
related to TMD.25 However,Class III elastic usage in patients with
subclinical TMDproblems needs more careful consideration.
Someauthors suggested that a posteriorly positioned condyleis a
common predisposing factor in anterior TMJdisc displacement.26,27
It has also been reported thatinterarch force might be an etiologic
factor of TMD in
Fig 13. Retention intraoral ph
Fig 14. Retention intraoral phJanuary 2010animals.28 Although
the exact cause of TMD is notcompletely understood, loading is at
least considereda possible etiologic causes. Therefore, it might be
pru-dent to create a treatment plan that minimizes condylarloading
in patients with potential TMD problems.
A final issue of concern is the relationship betweenthe
long-term retention results and the entire dentitiondistalization
method. We recommended the fixedretainer and wraparound retainer
combined retentionmethod to the patient and also encouraged her to
chew
otographs at 8 months.
otographs at 26 months.
-
retention and habitual mastication on left side. Merri-29
Orthod 2005;75:119-28.
17. Jeon MS, Kang YG, Mo SS, Lee KH, Kook YA, Kim SH.
Effects
American Journal of Orthodontics and Dentofacial Orthopedics
Chung et al 145field defined directional forces as those that use
direc-tional control to precisely position the teeth, and Limaand
Lima30 showed 4 years of stable retention aftermandibular dentition
distalization treatment in a casereport.
If the mandibular molars in our patient werecontrolled bodily by
additional loop mechanics aftertip-back movement, a more stable
result was possible.The sliding jig application on a stiffer
archwire wouldbe better than only tip-back treatment methods
forbodily distalization of molars. On the contrary, thedistalized
mandibular left dentition showed more stableretention compared with
the right dentition. It wasassumed that second molar distalizing
began a weekafter the mandibular left third molar extraction,
andthe bodily tooth movement was possible because of rel-atively
low cortical resistance on that side. Maxillaryand mandibular
wraparound retainers were used inthis patient in that period, and
she had a recall check 3months later. After 26 months of retention,
the patientdid not show a significant relapse tendency as she
hadafter 8 months of retention (Fig 14).
Mandibular premolar extraction without movingmolars distally
would perhaps have led to a more stableresult. Despite the patients
request, we should havepersuaded her to select this simpler
treatment option.However, the tip-back tooth movement and
long-termretention results of this patient will be helpful for
clini-cians who consider similar treatment mechanics forpatients
with Class III anterior crossbite.
In cases of whole-dentition distalization, we recom-mend both a
wraparound removable retainer and a fixedretainer, and that chewing
be done on both sides. ClassIII intermaxillary elastics applied to
a splint-typeretainer with hooks for night wear can be a good
alter-native to conventional retention methods.
CONCLUSIONS
The C-implant can withstand heavier loads thanother skeletal
anchorage systems. It also has the advan-tage that its abutment
head design can be used for elasticapplications. In this case, the
C-implant and multipleintra-arch elastics distalized the entire
mandibularon both sides after treatment. However, she acceptedonly
the fixed retainers. Eight months after debonding,significant
relapse on the right side was observed. Therelapse tendency was
assumed to be due to severe tip-ping of the mandibular molar
distally, as can be seenin the cephalometric radiograph, and also
to insufficient
Volume 137, Number 1dentition independently, without extrusion
or flaringof the maxillary dentition.of surface treatment on the
osseointegration potential of orthodon-
tic mini-implant. Korean J Orthod 2008;38:328-36.We thank
Jae-Hee Cho for assisting with manuscriptpreparation.
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146 Chung et al American Journal of Orthodontics and Dentofacial
OrthopedicsJanuary 2010
Distalization of the mandibular dentition with mini-implants to
correct a Class III malocclusion with a midline
deviationDiagnosisTreatment objectivesTreatment
alternativesTreatment progressTreatment
resultsDiscussionConclusionsReferences