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Distalization of the Mandibular Dentition with Mini-Implants to Correct a Class III Malocclusion with a Midline Deviation

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Distalization of the Mandibular Dentition with Mini-Implants to Correct a Class III Malocclusion with a Midline Deviation CASE REPORT Distalization of the mandibular dentition with mini-implants to correct a Class III malocclusion with a midline deviation Kyu-Rhim Chung,a Seong-Hun Kim,b HyeRan Choo,c Yoon-Ah Kook,d and Jason B. Copee Uijongbu and Seoul, Korea, Philadelphia, Pa, and Dallas, Tex This article describes the orthodontic treatment for a young woman, aged 23 years 5 months, with a Class III malocclusion and a deviated midline. Two orthodontic mini-implants (C-implants, CIMPLANT Company, Seoul, Korea) were placed in the interdental spaces between the mandibular second premolars and first mo- lars. The treatment plan consisted of distalizing the mandibular dentition asymmetrically and creating space for en-masse retraction of the mandibular anterior teeth. C-implants were placed to provide anchorage for Class I intra-arch elastics. The head design of the C-implant minimizes gingival irritation during orthodontic treatment. Sliding jigs were applied buccally for distalization of the mandibular posterior teeth. The active treatment period was 18 months. Normal overbite and overjet were obtained, and facial balance was improved. (Am J Orthod Dentofacial Orthop 2010;137:135-46) very orthodontic tooth movement is accompa- patients. Therefore, several authors have attempted to nied by a reaction. This can make it difficult to treat this type of malocclusion by distal tooth movement Ecorrect a malocclusion by using intraoral appli- alone. For example, animal studies and clinical investi- ances alone, especially when complete distal movement gations have used conventional implants as absolute of the mandibular dentition is planned in nonsurgical anchorage2-4 and miniplates for intrusion or distalization Class III malocclusion treatment. Traditionally, fixed ap- of the mandibular posterior teeth.5,6 Because all portions pliances and intermaxillary elastics have been used to of the anchor plates and screws were placed outside the move mandibular molars distally, often resulting in un- dentition in these studies, it was possible to move the desirable proclination of the maxillary incisors and ex- mandibular molars without disturbing tooth movement. trusion of the maxillary molars as reciprocal side Recently, the mechanics of group distal movement effects.1 This can cause an esthetic problem and instabil- of teeth with microscrew implant anchorage was intro- ity, especially in long-faced adults. Also, because inter- duced.7 A distalizing force is applied to the canines maxillary elastic wear requires patient compliance, it is through a nickel-titanium (NiTi) coil spring connecting difficult to predict the final result in uncooperative the miniscrew to hooks on the archwire. The primary treatment effect in the mandible is distal tipping move- a President, Korean Society of Speedy Orthodontics, Seoul, Korea. ment of the posterior teeth concurrent with uprighting b Assistant professor, Department of Orthodontics, Catholic University of and distal movement of the anterior teeth. Because there Korea, Uijongbu St. Mary’s Hospital, Uijongbu, Korea. is no force to move the maxillary anterior teeth forward c Attending orthodontist, The Children’s Hospital of Philadelphia; clinical asso- ciate, University of Pennsylvania School of Dental Medicine, Philadelphia, Pa. (via Class III elastics), there are no side effects on the d Professor and chairman, Department of Orthodontics, Catholic University of maxillary anterior teeth in microscrew implant-aided Korea, Seoul St. Mary’s Hospital, Seoul, Korea. mechanics. Therefore, distal movement assisted by e Adjunct clinical assistant professor, Department of Orthodontics; adjunct assistant professor, Department of Oral and Maxillofacial Surgery, Baylor a rigid orthodontic implant can be a good alternative College of Dentistry, Dallas, Tex. for treatment when intermaxillary elastics are not indi- Partly supported by the Korean Society of Speedy Orthodontics, the alumni fund cated or the patient is uncooperative. of the Department of Dentistry, and the Graduate School of Clinical Dental Sci- ence, Catholic University of Korea. The stability of temporary skeletal anchorage The authors report no commercial, proprietary, or financial interest in the prod- devices is achieved from primary mechanical retention ucts or companies described in this article. between the implant surface and the cortical bone, and Reprint requests to: Seong-Hun Kim, Catholic University of Korea, Uijongbu St. Mary’s Hospital, 65-1 Geumo-dong, Uijeongbu, Gyeonggi-do, 480-717, secondary stability is provided by the healing process South Korea; e-mail, [email protected] or [email protected]. of the surrounding tissue. Primary stability is important Submitted, April 2007; revised and accepted, June 2007. to minimize the potential for failure from micromotion. 0889-5406/$36.00 Copyright Ó 2010 by the American Association of Orthodontists. Secondary stability is related to the microstructure of 8-11 doi:10.1016/j.ajodo.2007.06.023 the implant surface. In conventional dental 135 136 Chung et al American Journal of Orthodontics and Dentofacial Orthopedics January 2010 Fig 1. Two-part design of the C-implant. Fig 2. Schematic illustration of the C-implant depen- dent on mandibular distalization mechanics. prosthetic implants, implants with a rough surface velop between the anterior teeth. To retract the anterior showed better stability and tissue reactions than did teeth with en-masse retraction, closing loops are placed those with a smooth surface. In orthodontic implants, between the lateral incisors and canines, and connected porous-surfaced implants show higher marginal bone to the C-implants by elastics. Because intermaxillary levels and less relative implant displacement than elastics are not applied to the maxillary dentition, threaded implants.12,13 mesial movement of the maxillary arch and extrusion The C-implant (CIMPLANT Company, Seoul, Ko- of the maxillary molars are avoided, and the incisors rea) was developed to use osseointegration as the are not flared. This case report describes the distaliza- main stabilizing mechanism.14-17 This mini-implant tion of the mandibular dentition to treat a dental has an upper abutment head component and a lower Class III malocclusion with a deviated midline by using threaded body or screw-type component (Fig 1). The C-implants. unique head design makes it possible to apply multiple elastics while simultaneously preventing the elastics from slipping off.15,16 The body or retentive component DIAGNOSIS of the C-implant is better able to resist the rotational ten- The patient was a woman, aged 23 years 5 months, dency of heavy dynamic loads and control 3-dimen- whose chief concern was protruding mandibular teeth. sional tooth movement as a result of its higher Her medical history was noncontributory, and occa- osseointegration potential. sional clicking of her temporomandibular joints (TMJ) When distalizing the mandibular dentition with was noted in her dental history. a mandibular C-implant, the most important consider- The pretreatment facial photographs (Fig 3) show an ation is its position. The placement site should be as acceptable facial profile, despite mild midface defi- close as possible to the mesial surface of the mandibular ciency and slight mandibular prognathism. No facial first molar because this will help achieve optimal distal- asymmetry was noticeable in the frontal view. The clin- ization of the mandibular dentition. The initial tooth ical examination (Figs 3 and 4) showed a Class III molar movement in distalization is posterior movement of and canine relationship that was more significant on the the second molar by using a sliding jig that is connected right side. Other findings included an anterior edge- to the main archwire, followed by moving the other to-edge relationship, a midline discrepancy, mild man- teeth posteriorly (Fig 2). While the second molar is dis- dibular anterior crowding, and mesial angulation of talizing, the first molar also moves distally as a result of the mandibular posterior teeth. The lower midline was drifting. When molar distalization is complete, the pre- not coincident with the facial midline and was shifted molars will also begin to move with the sliding jig. to the left by 2.5 mm. The maxillary third molars and While the premolars are distalizing, spaces might de- the mandibular right third molar were missing American Journal of Orthodontics and Dentofacial Orthopedics Chung et al 137 Volume 137, Number 1 Fig 3. Pretreatment extraoral and intraoral photographs. (Fig 5A). There was only slight contact between the patient did not want extractions (except for the third maxillary right second molar and the opposing tooth be- molars) or changes to her facial appearance; she wanted cause of the Class III molar relationship. only to correct the incisor relationship. Although the The cephalometric analysis (Fig 5B; Table) showed maxillary incisors were slightly upright, the patient re- a skeletal Class III relationship with a high mandibular quested that they not be allowed to move forward. plane angle and a slightly retrognathic maxilla. The an- Therefore, we rejected the premolar-extraction treat- terior facial height was slightly long relative to the pos- ment option. terior facial height. The incisor position and interincisal Based on the initial records and the patient’s desires, relationship were within normal limits except for the the treatment objectives were to distalize all mandibular retroclined maxillary incisor. The patient was diagnosed teeth, improve
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