Download maxillary first molar distalization with the frog appliance

Romanian Journal of Oral Rehabilitation
Vol. 6, No. 4, October - December 2014
MAXILLARY FIRST MOLAR DISTALIZATION WITH THE FROG
APPLIANCE: A CASE REPORT
Eduard Radu Cernei*, Laura Gavrila, Dana Cristiana Maxim, Veronica PintiliucSerban, Irina Nicoleta Zetu
“Grigore T. Popa" University of Medicine and Pharmacy - Iași, Romania, Faculty of Dentistry,
Department of Dentoalveolar and Oro-Maxillofacial Surgery
*Corresponding author:
Eduard Radu Cernei, DMD, PhD student
“Grigore T. Popa" University of Medicine and Pharmacy
- Iași, Romania;
e-mail: [email protected]
ABSTRACT
Traditional upper molar distalization techniques require patient co-operation with the headgear or elastics.
Recently, several different intraoral procedures have been introduced to minimize the need for patient cooperation. Distalizing maxillary first molars is often an objectiv in treatment plans inolving Class II
malocclusions and is sometimes indicate for non-extraction treatments with maxillary crowding. Pacient
compliance has become a factor in choosing effective orthodontic appliances. In recent years various appliances
that do not require patient compliance have been developed to drive maxillary molars distally. Some of these
appliances produce unwanted tipping of the maxillary molars and a tendency to create crossbites if not properly
adjusted. Therefore we want to present a case that presented in the clinic of Orthodontics and dento-facial
orthopedics in the Ambulatory Pediatric Dentistry in Iasi. L.S. patient aged 12 years presenting for aesthetic
and functional disorders. On examination extraoral facial changes occur hyperdivergent profile. Clinical
examination reveals intraoral Angle Class I molar malocclusion, anterior deep bite, mesial inclination of the
lower left permanent molar. Upper canines teeth are erupting bucally, due to lack of space. OPT examination
and anamnesis reveled reduction the space for the lower left second premolar and for the lower right canin
probabily due to premature loss of second primary molar and primary canine. Indicate a slight lateral
cephalometric skeletal Class II (∠ ANB inv. = 5.040) with a hyperdivergent profile ∠GoGn/SN=360 .We
wanted a non extraction treatment except the 3rd molars.. The treatment plan included distalization of the upper
first molars bilaterally followed by a palatal expander and a full fixed appliance therapy. For the lower arch we
applied a lip-bumper for moderate arch expansion and for lower molars distalization. For the upper molar
distalization, a new system, the Frog Appliance, was constructed and applied. Lateral cephalometric radiographs
were used to evaluate the treatment results. It was obtained an over distalization of the first molars after 10
mouths of treament because the patient missed the subsequent checks. The lower lip-bumper was not carried.
According to the results of the cephalometric evaluation, a nearly bodily distal molar movement was attained.
It was reapplied lip bumper and a palatal expander. The patient is still in treatment. In conclusion, the Frog
Appliance was found to be effective, non-invasiv appliance for achieving bilateral molar distalization, but the
patients should be more motivated to come to check up.
Keywords: Frog appliance, molar distaliyation
INTRODUCTION
Traditional upper
molar
techniques require patient co-operation with
the headgear or elastics. Recently, several
distalization
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Romanian Journal of Oral Rehabilitation
Vol. 6, No. 4, October - December 2014
different intraoral procedures have been
introduced to minimize the need for patient
co-operation [1].
Distalizing maxillary first molars is often
an objective in treatment plans involving
Class II malocclusions and is sometimes
indicate for non-extraction treatments with
maxillary crowding [2]. Patient compliance
has become a factor in choosing effective
orthodontic appliances. In recent years
various appliances that do not require patient
compliance have been developed to drive
maxillary molars distally. Some of these
appliances produce unwanted tipping of the
maxillary molars and a tendency to create
crossbites if not properly adjusted [3].
Intra-oral distalization techniques such as
pendulum appliance, Jones Jig, and distal jet
are frequently used in this fashion. Many
clinical studies substantiated the effectiveness
of these appliances [4-14]. A new system Frog Appliance, Forestadent, Pforzheim,
Germany- for upper molar distalization has
been developed. The purpose of this article is
is to present a clinical situation of this system
in the treatment of maxillary crowding.
CLINICAL CASE
Therefore we want to present a case that
presented in the clinic of Orthodontics and
dento-facial orthopedics in the Ambulatory
Pediatric Dentistry in Iasi. L.S. patient aged
12 years presenting for aesthetic and
functional disorders.
The extra-oral examination (fig. 1)
revealed an oval shape of the face, a
mesocephalic head shape, a mesoprosopic
face, a mild convex profile. Facial changes
occur hyperdivergent profile and an acute
naso-labial angle. The smile was unaesthetic.
The patient showed a good range of
mandibular
movements
and
no
temporomandibular-joint symptoms.
Figure 1. Extraoral aspect - before treatment
Clinical examination (fig. 2) reveals
intraoral Angle Class I molar malocclusion,
anterior deep bite, mesial inclination of the
lower left permanent molar. Upper canines
teeth are erupting bucally, due to lack of
space.
The space for the canine alignment was
decreased. Both upper and lower arches were
asymmetric. The discrepancy in the upper
arch was 9 mm and in the lower arch was 11
mm.
OPG examination and anamnesis
revealed reduction the space for the lower left
second premolar and for the lower right
canin probabily due to premature loss of
second primary molar and primary canine.
Also, are seen only wisdom tooth in quadrant
IV (fig. 3).
Cephalometric measurements of the
patient indicate a slight skeletal Class II (∠
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Romanian Journal of Oral Rehabilitation
Vol. 6, No. 4, October - December 2014
profile ∠GoGn/SN=360 (Fig. 3).
ANB inv. = 5.040) with a hyperdivergent
Figure 2. Intraoral aspect- before treatment
Figure 3. OPG and Cephalometry- before treatment
appliance: (1) distalization of upper and lower
molars using an intraoral appliance [15] or (2)
extraction of four first premolars, and fixed
orthodontic treatment [16].
TREATMENT ALTERNATIVES
The patient’s chief concern was the upper
and the lower arch crowding. There were two
treatment alternatives for this case because
the patient did not want to wear an extraoral
Figure 4. Intraoral aspect- after application of orthodontic appliances
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Romanian Journal of Oral Rehabilitation
Vol. 6, No. 4, October - December 2014
The patient accepted a non extraction
treatment except the 3rd molars. The
treatment plan included distalization of the
upper first molars bilaterally followed by a
palatal expander and a full fixed appliance
therapy. For the lower arch we applied a lipbumper for moderate arch expansion and for
lower molars distalization. For the upper
molar distalization, a new system, the Frog
Appliance (fig. 4) was constructed and
applied.
RESULTS
After 10 months of treatment it was
obtained an over distalization of the first
molars because the patient missed the
subsequent checks. Lip bumper was not worn
enough as it was lost.
Basically the patient returned to the clinic
because of the 25 composite fell. In the upper
arch has been obtained as a surplus of +2.2
mm. In the lower arch space deficiency
reached at -9.1 mm (fig. 5).
Figure 5. Intraoral aspect- after 10 months of treatment
Figure 6. OPG and Cephalometry - 10 months of treatment
Figure 7. Intraoral aspect - after 10 months of treatment
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Romanian Journal of Oral Rehabilitation
Vol. 6, No. 4, October - December 2014
Table 1. Cephalometric measurements of the patient
Results
Unit
Minimum
Maximum
Initial value
After distalization value
SNA
°
80.00
89.00
82.75
84.24
SNB
°
75.00
82.00
77.48
78.93
ANB
°
2.00
4.00
5.27
5.31
SND
°
76.00
77.00
74.75
76.06
II
°
130.00
150.00
148.56
141.96
SN-OcP
°
14.00
14.00
22.77
22.47
SN-GoGn
°
30.00
30.00
35.27
35.42
Max1-NA
°
22.00
22.00
11.70
16.98
Max1-SN
°
108.00
108.00
94.45
101.21
Mand1-NB
°
25.00
25.00
14.47
15.76
1u-NA
mm
4.00
4.00
0.34
2.12
1l-NB
mm
4.00
4.00
3.04
3.84
Pog-NB
mm
1.02
0.63
Holdaway ratio
mm
0.00
2.00
2.02
3.21
S-L
mm
51.00
51.00
38.92
41.92
S-E
mm
22.00
22.00
14.61
14.44
6u-PTV
mm
14.00
20.00
11.20
8.11
1l-APog
mm
-1.30
3.30
-1.36
-0.29
1u-APog
mm
1.20
5.80
1.61
4.10
Lateral cephalometric radiographs were
used to evaluate the treatment results. After
distalization, cephalometric analysis using
Onyx CephR software revealed that the
maxillary first molars were moved 3.09 mm
(according to PTV) and tipped 30 (according
to ANS/ PNS) distally. As for anchorage loss,
the upper central incisors exhibited a mesial
movement of 2 mm, associated with a
proclination of 5° (Table 1, fig. 6).
It was reapplied lip bumper and a palatal
expander. A segmentar fix orthodontic was
applied. The patient is still in treatment (fig.
7).
degree of acceptance by the patient.compliance or noncompliance aplliances-.
Compliance-dependent appliances such as
headgear or removable plate appliance were
traditionally used for upper molar
distalization in treatment of Class II
malocclusions [17].
For over a decade, various innovative
noncompliance intraoral molar distalization
appliances have been described. These
appliances derive their anchorage in an
intramaxillary manner and act only in the
maxillary arch to move molars distally: eg,
the pendulum appliance, the sectional jig
assembly, the distal jet, the Keles slider[414].
One of the important goals of molar
distalizing therapy is to obtain bodily tooth
movement of the molars with minimal
rotation and distal inclination [18]. The Frog
DISCUSSIONS
Several methods exist for the correction
Class I with crowding or Class II
malocclusion. It was therefore made a
classification appliances according to the
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Romanian Journal of Oral Rehabilitation
Vol. 6, No. 4, October - December 2014
appliance was positioned approximately 10 to
12 mm apically to the occlusal surface of the
maxillary molar with parallel orientation to
the occlusal plane in our case. In this manner,
a vector of effective force passing through the
centre of resistance of the first molar was
obtained [19].
In the current case, the correction of the
Class I molar with crowding originally
wanted the permanent molars distalization
thus obtaining the necessary space arch
alignment of ectopic canines. In the lower
arch still opted for molars distalization using
lip-bumper. However, the patient presented
proved noncompliant, missing the routine
checks-up. It obtained a distalization 3 mm
and 3 degrees of distal tip of upper first
molars [20].
Previous studies have indicated that the
pendulum appliance produces a molar
distalization between 3.14 and 6.1 mm and
the distal jet appliance a molar distalization
of 2.1 - 3.2 mm. The distal jet produces a
molar distal tip of 1.8 – 5 degrees far away
from pendulum whose distal tip varies from
8.4 to 15.7 degrees [3,4,11,13].
And in terms of loss of anchorage results
are similar. In the case presented was
obtained a loss of anchorage translated by
mezialization of the upper incisors by 2 mmand a tip forward of 5 degrees. Mehmet
Bayram in his previous article obtained
similar results - an incisors mesial movement
of 2 mm, associated with a proclination of 4
degrees [21].
CONCLUSION
In conclusion, the Frog Appliance was
found to be effective, non-invasiv appliance
for achieving bilateral molar distalization, but
the patients should be more motivated to
come to check up, not transforming thus a
non compliance-dependent appliances in an
ineffective one.
REFERENCES
1 Keles A, Erverdi N, Sezen S. Bodily distalization of molars with absolute anchorage. Angle Orthod
2003;73:471-82.
2 Ghosh J, Nanda RS. Evaluation of an intraoral maxillary molar distalization technique. Am J Orthod
Dentofacial Orthop 1996;110:639-46.
3 Bolla E , Muratore F , Carano A , Bowman S J. Evaluation of maxillary molar distalisation with the
distal jet: a comparison with other contemporary methods Angle Orthod 2002, 72 : 481 – 494
4 Byloff FK, Darendeliler MA. Distal molar movement using the pendulum appliance. Part 1: clinical
and radiological evaluation. Angle Orthod 1997;67:249-60.
5 Bussick TJ, McNamara JA Jr. Dentoalveolar and skeletal changes associated with the pendulum
appliance. Am J Orthod Dentofacial Orthop 2000;117:333-43.
6 Haydar S, Uner O. Comparison of Jones jig molar distalization appliance with extraoral traction. Am
J Orthod Dentofacial Orthop 2000;117:49-53.
7 Brickman CD, Sinha PK, Nanda RS. Evaluation of the Jones jig appliance for distal molar
movement. Am J Orthod Dentofacial Orthop 2000;118:526-34.
8 Carano A, Testa M. The distal jet for upper molar distalization. J Clin Orthod 1996;30:374-80.
9 Ngantung V, Nanda RS, Bowman SJ. Posttreatment evaluation of the distal jet appliance. Am J
Orthod Dentofacial Orthop 2001;120:178-85.
10 Bolla E, Muratore F, Carano A, Bowman SJ. Evaluation of maxillary molar distalization with the
distal jet: a comparison with other contemporary methods. Angle Orthod 2002;72: 481-94.
11 Keles A, Pamukcu B, Tokmak EC. Bilateral maxillary molar distalization with sliding mechanics:
keles Slider. World J Orthod 2002;3:57-66.
12 Kinzinger GS, Fritz UB, Sander FG, Diedrich PR. Efficiency of a pendulum appliance for molar
distalization related to second and third molar eruption stage. Am J Orthod Dentofacial Orthop
2004;125:8-23.
13 Gulati S, Kharbanda OP, Parkash H. Dental and skeletal changes after intraoral molar distalization
36
Romanian Journal of Oral Rehabilitation
Vol. 6, No. 4, October - December 2014
with sectional jig assembly. Am J Orthod Dentofacial Orthop 1998;114:319-27.
14 Cetlin NM, Ten Hoeve A. Nonextraction treatment. J Clin Orthod 1983;17:396-413.
15 Janson G, Brambilla AC, Henriques JFC. Class II treatment success rate in 2- and 4-premolar
extraction protocols, Am. J. Orthod 2004; 125(4):472 479.
16 Cangialosi TJ, Meistrell ME Jr, Leung MA, Ko JY. A cephalometric appraisal of edgewise Class II
nonextraction treatment with extraoral force. Am J Orthod Dentofacial Orthop 1988; 93:315-24.
17 Kim SJ, Chun YS, Jung SH, Park SH. Three dimensional analysis of tooth movement using different
types of maxillary molar distalization appliances. Korean J Orthod 2008;38:376-87.
18 Worms F W , Isaacson R J , Speidel T M 1973 A concept and classifi cation of centers of rotation
and extraoral force systems . Angle Orthodontist 43 : 384 – 401
19 Papadopoulos M A , Mavropoulos A , Karamouzos A 2004 Cephalometric changes following
simultaneous first and second maxillary molar distalization using a non-compliance intraoral
appliance . Journal of Orofacial Orthopedics 65 : 123 – 136
20 Bayram M, Nur M, Kilkis D. The frog appliance for upper molar distalization: a case report. Korean
J Orthod 2010;40(1):50-60.
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