Download Treatment of Class II Malocclusion by Nonextraction Therapy using

10.5005/jp-journals-10021-1119
CASE REPORT
Rajkumar S Alle et al
Treatment of Class II Malocclusion by
Nonextraction Therapy using Microimplants
and Pendex Appliance
1
Rajkumar S Alle, 2T Suma, 3BK Sharmada
ABSTRACT
The treatment of Class II cases is always challenging. Treatment modalities involve growth modulation, expansion of the maxillary arch or
extraction of premolars and retraction. The patient compliance is key factor in success of the treatment. In the present article a male patient
with Class II malocclusion was treated using a Pendex appliance to simultaneously expand the upper arch and distalize the molars. The
maxillary anteriors were retracted using microimplants. The results were satisfactory. This approach can be used in patients with mild
skeletal discrepancy and with slight increase in the gingival display.
Keywords: Class II malocclusion, Pendex appliance, Microimplants.
How to cite this article: Alle RS, Suma T, Sharmada BK. Treatment of Class II Malocclusion by Nonextraction Therapy using Microimplants
and Pendex Appliance. J Ind Orthod Soc 2012;46(4):352-356.
INTRODUCTION
Class II malocclusion is one of the most common problems
in orthodontics, with an estimated one-third of all orthodontic
patients treated for this condition. Many treatment options are
available for the correction of Class II malocclusion, depending
on which part of craniofacial skeleton is affected. In general,
treatment of Class II malocclusion can include growth
modification in terms of mandibular advancement (to treat
patients with mandibular skeletal retrusion), maxillary retraction
(to treat patients maxillary skeletal protrusion), maxillary molar
distalization (to treat patients with maxillary dentoalveolar
protrusion)2 treatment approaches include the use of functional
or removable appliance, extraoral traction by means of
headgears, and fixed appliances combined with Class II elastics.1
Unfortunately, successful orthodontic treatment using these
modalities often relies heavily on the patients willingness to
wear the suggested appliance. For example, regarding the
wearing of headgear, apart from the discomfort and extraoral
1
Professor, 2Reader, 3Senior Lecturer
1,2
Department of Orthodontics, Rajarajeshwari Dental College
Bengaluru, Karnataka, India
3
Department of Orthodontics, Vydehi Institute of Dental Sciences
Bengaluru, Karnataka, India
Corresponding Author: Rajkumar S Alle, Professor, Department
of Orthodontics, Rajarajeshwari Dental College, Bengaluru
Karnataka, India, e-mail: [email protected]
Received on: 27/1/12
Accepted after Revision: 23/6/12
352
appearance of the patient (factors that can reduce their
cooperation), there is also a risk of headgear causing
accidental injuries on eye and other facial tissue damage. In
addition, the elastic cervical strap puts a nonphysiologic strain
on the cervical spine and on the neck muscles and in some
patients it causes irritation of the skin, 3,4 furthermore,
cephalometric evaluation has revealed that extraoral
appliances can produce skeletal effects in addition to
maxillary molar distalization5-8 which could be a drawback
when there is no need for growth guidance.
For all the above reasons, nonextraction treatment as well
as noncompliance approaches have become very popular for
the correction of Class II malocclusions. Many treatment
modalities, known as ‘noncompliance appliance’ have been
introduced which minimize or eliminate the need for patient
compliance in order to activate the relevant force system. A
major category is the ‘noncompliance distalization appliance’
which is used for the treatment of patients with maxillary
dentoalveolar protrusion. These appliances derive their
anchorage in an intramaxillary manner and act only in the
maxillary arch in order to move the molars distally, e.g.
pendulum appliance,9 the distaljet,10 repelling magnets,11,12
the Jones jig,13 the new distalizer,14 etc. The force systems of
these appliances can be flexible or rigid and can be positioned
bucally or palatally.
Nickel-titanium coil springs have been used in conjunction
with various noncompliance appliances to produce rapid
maxillary molar movement,10,13,15,16 because it was found that
they have greater spring back and superelastic properties than
stainless steel coils. Furthermore, the most important reason
for their implementation in noncompliance distalization
devices is their ability to exert a very long range of constant,
light and continuous force.17
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Treatment of Class II Malocclusion by Nonextraction Therapy using Microimplants and Pendex Appliance
Among the distalization appliances that use nickel-titanium
coil spring as a buccally positioned flexible force system, the
Jones jig is one of the most commonly used in noncompliance
Class II orthodontic treatment.13
CASE REPORT
A 13-year-old male patient reported with the chief complaint
of protruding anterior teeth. The pretreatment facial photographs
showed a symmetric face and a convex facial pattern with a
deep mentolabial sulcus and a retruded mandible constricted
maxillary arch (Figs 1 and 2). Clinical examination showed
complete permanent dentition without dental caries, intraoral
photograph shown increase overjet of 5 mm and overbite of
6 mm and Class II molar and canine relationship.
Cephalometric analysis showed Class II skeletal base:
ANB: 8 mm, SNA: 89°, SNB: 81°, U1 TONA: 30, 6 mm,
L1 to NB: 32, 6 mm, L1 TOMP: 102°.
TREATMENT OBJECTIVES
1.
2.
3.
4.
5.
Expansion of upper arch
Correction of the profile
Correction of proclination
Establishing Class I molar and canine relationship
Retention of correction
two distalizing screw springs made up of 0.30 TMA wire,
appliance was stabilized with extensions bonded on the occlusal
surface of premolars (Fig. 3).
The expansion was achieved in about 3 months and molar
distalization was accomplished simultaneously followed by
bonding of upper and lower arch with 0.022" slot MBT
appliance, after leveling and aligning the upper anterior was
retracted using microimplants placed between premolars
(Fig. 4). Implants provided stable anchorage for retraction of
anteriors. The molars were not taxed during this phase.
After 18 months of treatment, there was a good
improvement in the profile esthetics. The upper and lower
arches were well aligned, Class I molar and Class I canine
relationship was achieved. There was a good intercuspation
established between upper and lower arches (Figs 5 and 6).
PENDEX APPLIANCE
Intial wire 0.014" u/l NiTi placed
0.016" u/l NiTi wire placed
0.017" × 0.025" NiTi wire placed
0.019" × 0.025" NiTi wire placed
0.019" × 0.025" stainless steel with soldered hooks placed
along with miniscrew implants for retraction of anterior teeth.
DISCUSSION
TREATMENT PLAN
Maxillary arch was expanded using Pendex appliance. The
appliance consisted of an expanision screw in the center, and
Recently, many noncompliance appliances and approaches
have been presented to overcome the problem of compliance
and correct Class II malocclusion efficiently. However, when
Fig. 1: Pretreatment extraoral photographs
Fig. 2: Pretreatment intraoral photographs
The Journal of Indian Orthodontic Society, October-December 2012;46(4):352-356
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Rajkumar S Alle et al
Fig. 3: Pendex appliance occlusal view
Fig. 4: Midtreatment photographs
Fig. 5: Post-treatment extraoral photographs
Fig. 6: Post-treatment intraoral photographs
354
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Treatment of Class II Malocclusion by Nonextraction Therapy using Microimplants and Pendex Appliance
noncompliance distalization appliances are used to correct
Class II malocclusion, three other problems are usually
evident:
1. Anchorage loss of the anterior dental unit expressed as
forward movement and proclination of the anterior teeth.
2. Distal tipping of the molars during active maxillary molar
distalization.
3. Anchorage loss of the posterior dental unit also in the
forward direction that takes place after distalization during
the subsequent stage of anterior tooth retraction and final
alignment of the dental arches.18
Lately, conventional implants have been used as stationary
anchorage for maxillary molar distalization and other
orthodontic purposes. These are complicated and invasive
placement and removal surgical procedures must be done by
an experienced oral and maxillofacial surgeon. They also need
complex laboratory procedures, to facilitate safe and precise
implant placement and to connect implant with the dentition.
In addition, placement locations are limited, they are more
expensive than other anchorage modalities, and a waiting period
for osseointegration before loading the implants with
orthodontic forces is necessary, increasing total treatment
time.19 In contrast to conventional orthodontic implants,
miniscrew implants as temporary anchorage devices are now
in widespread use by orthodontists, because they are not
associated with the above-mentioned problems of orthodontic
implants. Miniscrew has the following advantages as temporary
anchorage devices for orthodontic purposes:19
1. Their placement and removal do not require a particular
surgical procedure, in contrast to orthodontic implants,
miniplates and onplants that require flap surgery.
2. Miniscrew implants can be easily placed at chairside in a
single appointment by the orthodontist.
3. There is no need for complicated clinical and laboratory
procedures to facilitate safe and precise implant placement
or to connect it with the teeth.
4. Miniscrew implants can be immediately loaded, reducing
total treatment time.
5. Miniscrew implants, unlike conventional orthodontic
implants, can be placed in a great variety of locations of
the maxilla and the mandible.
6. The absolute anchorage they provide eliminates
undesirable effects on the teeth that otherwise would have
been used as anchorage.
7. Patient cooperation is limited to maintaining oral hygiene.
8. Miniscrew implants can be easily removed.
9. Cost is relative compared with other conventional methods
used for anchorage, and much lower than orthodontic
implants. Noncompliance maxillary molar distalization
with miniscrew implants used as temporary stationary
anchorage could be an efficient treatment option for
correcting Class II malocclusion.
Our treatment results support this new type of treatment
biomechanics, since our patient, with a Class II malocclusion
and large overjet and overbite, was successfully and efficiently
treated to a well-functioning Class I occlusion after 18 months
without extractions and without a need for patient cooperation,
except for maintaining, as much as possible, optimal oral
hygiene. By using this, initially to distalize the maxillary molars
and later with conventional full-fixed orthodontic appliances
to retract and intrude the anterior teeth, after the total
orthodontic treatment, a stable, functional occlusion with good
posterior intercuspation and bilateral Class I molar and canine
relationship were achieved, and lip competence and facial
balance were improved.
As is obvious from the superimpositions of the tracings
of the lateral cephalometric radiographs of the patient after
maxillary molar distalization, there were no side effects of
conventional noncompliance distalization appliances in terms
of forward movement and proclination of the anterior teeth
or distal molar crown tipping. The corresponding
superimpositions after treatment showed that after active
distalization and during anterior tooth retraction and final
alignment of the dental arches, there was no anchorage loss
of the posterior teeth in the forward direction.
Nevertheless, a unique advantage of this appliance is that
it uses miniscrew implants for temporary and stationary
anchorage to support both molar distalization and anterior
tooth retraction, after a slight chairside modification. Thus,
the side effects of anchorage loss of the anterior dental unit
during molar distalization and the posterior anchorage loss in
terms of mesial molar movement during anterior tooth
retraction are eliminated (Figs 7A and B).
Figs 7A and B: Superimposition areas: Basion nasion plane at Ptm
point, ANS-PNS at ANS
The Journal of Indian Orthodontic Society, October-December 2012;46(4):352-356
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Rajkumar S Alle et al
CONCLUSION
Expansion of maxillary arch along with distalization of molars
provides an efficient way to handle the Class II dentoalveolar
problems. The Pendex appliance along with microimplants can
be used successfully for this purpose.
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