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Occlusal Plane Changes After Molar Distalization with a Pendulum Appliance in Growing Patients with Class II Malocclusion: a Retrospective Cephalometric Study

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Occlusal Plane Changes After Molar Distalization with a Pendulum Appliance in Growing Patients with Class II Malocclusion: a Retrospective Cephalometric Study TURKISH JOURNAL of DOI: 10.5152/TurkJOrthod.2021.20050 Original Article Occlusal Plane Changes After Molar Distalization With a Pendulum Appliance in Growing Patients with Class II Malocclusion: A Retrospective Cephalometric Study Marco Serafin1 , Rosamaria Fastuca2 , Elisabetta Castellani3 , Alberto Caprioglio1 1Division of Orthodontics, Department of Medicine and Surgery, University of Insubria, Varese, Italy 2I.T.E.B. Research Center, University of Insubria, Varese, Italy 3Private Practice, Forlì, Italy Cite this article as: Serafin M, Fastuca R, Castellani E, Caprioglio A. Occlusal Plane Changes After Molar Distalization With a Pendulum Appliance in 10 Growing Patients with Class II Malocclusion: A Retrospective Cephalometric Study. Turk J Orthod 2021; 34(1): 10-7. Main points: • This study aimed to demonstrate the efficacy of pendulum appliance in distalizing the maxillary molars to correct a Class II malocclusion and pro- vide a propaedeutic molar relationship before the final correction of the occlusion with fixed orthodontic treatment. • A noteworthy result was the concordance of the data of this study with those of the previous ones; this emphasizes the environmental protocol and provides a further starting point for future investigations for the use of the pendulum appliance. • Of particular interest was the maintenance of the occlusal plane inclination in the distalizing phase that could be achieved by the pendulum appli- ance compared with other distalizing techniques that do not allow a vertical control of the maxillary molars with consequent change in the occlusal plane and bite opening. • The absence of changes in the inclination of the occlusal plane seems to not interfere with the normal maxillary and mandibular growth, which could be a strategy to achieve an improved Class II correction. ABSTRACT Objective: This study aimed to evaluate the skeletal and dental changes after distalization with a pendulum appliance in growing patients with Class II malocclusion, focusing on the occlusal plane (OP). Methods: The sample included 24 patients with Class II malocclusion (10 boys, 14 girls); their mean age was 12.1 years. All patients under- went molar distalization and had 2 serial cephalograms traced at baseline (T1) and after distalization (T2). Angular and linear dental changes were calculated by taking the sella-nasion (SN), palatal plane (PP), and pterygoid vertical as reference. OP inclination was compared with SN, PP, and mandibular plane. The collected data were computed for all the tested variables, and one-way paired t-test was used to assess the significance of the differences between the time points. α was set at 0.05. Multiple linear regressions were used to predict the OP changes. Results: The mean total treatment time was 8±2 months to obtain a super Class I molar relationship. In T1-T2 interval, statistically significant incisor buccal tipping of 5°±3.6° (p<0.05), first molar distal tipping of 8.9°±8.3° (p<0.001), and second molar tipping of 8.2°±8.1° (p<0.001) were observed. The maxillary first and second molars moved significantly backward by 2.8±3.2 mm (p<0.05) and 3.7±2.7 mm (p<0.001), respectively. Only the premolars showed a statistically significant anchorage loss of 2.7±3.3 mm (p<0.05); over- jet increased significantly at 1.3±1.2 mm (p<0.05). Regarding the OP, none of the tested variables showed any statistically significant changes between T1-T2. Conclusion: The pendulum appliance showed efficacy in distalizing the maxillary first and second molars at the expense of anterior anchorage loss. The OP did not show statistically significant changes after molar distalization. Keywords: Cephalometry, Class II Angle malocclusion, molar distalization, occlusal plane, pendulum appliance INTRODUCTION Class II malocclusion is one of the most frequent orthodontic problems, which dentists diagnose and treat, with a mean worldwide distribution of 19.56% in permanent dentition and 23.11% in mixed dentition (1). Depending on the diag- Address for Correspondence: Marco Serafin, Division of Orthodontics, Department of Medicine and Surgery, Received: April 28, 2020 University of Insubria, Varese, Italy Accepted: October 12, 2020 E-mail: [email protected] Available Online Date: ©Copyright 2020 by Turkish Orthodontic Society - Available online at turkjorthod.org February 23, 2021 Turk J Orthod 2021; 34(1): 10-7 Serafin et al. Occlusal plane changes produced by Pendulum appliance nosis, Class II malocclusions can be treated by several methods, for to the World Medical Association Declaration of Helsinki. Before example, functional orthopedic appliances, extraoral and intraoral starting treatment, an informed consent for releasing radiolog- devices for tooth distalization, camouflage treatment, or orthognath- ical diagnostic records for scientific research was obtained. Be- ic surgery. If there are no significant skeletal discrepancies and tooth cause the primary purpose of this study was to evaluate the ef- crowding, maxillary prognathism that involves Class II molar relation- fectiveness of molar distalization and its correlation with possible ship can be completely corrected by maxillary molar distalization. changes of the OP variables, the sample size was calculated on the cephalometric values of 5 patients, selecting the distance be- Molar distalization is a generally used non-extraction treatment tween the upper first molar centroid and the pterygoid vertical to establish a Class I molar and canine relationship, especially (PtV-Ctr1M) changes before and after distalization (mean=−2.7; using non-compliance devices (2). In fact, although the major- standard deviation [SD]=3.2) as the main outcome. A sample size ity of intraoral and extraoral devices are effective for achieving of at least 23 subjects was necessary to retrieve a power of 0.8 molar distalization, they are often highly dependent on patient (β=0.20) with α set at 0.05. An initial sample of 30 patients was compliance. Among several intraoral distalizing devices, since its selected according to the following inclusion criteria: development in 1992, the pendulum appliance might be consid- ered among one of the most investigated non-compliance and 1) Skeletal Class I or mild Class II malocclusion (ANB≤6°) efficient tools in compensating a Class II molar relationship, -es 2) Bilateral Class II molar relationship pecially those related with maxillary prognathism (3, 4). 3) Sella-nasion (SN)-mandibular plane (MP) <37° 4) Unerupted or incompletely erupted second maxillary molars The occlusal plane (OP) is a cephalometric line connecting the point 5) No previous orthodontic treatment and non-extraction treat- bisecting the first molar cusp height and the point bisecting the ment overbite (5). Many factors change this plane inclination during cra- 6) Use of the pendulum appliance niofacial growth to achieve a harmonic function of the masticatory 7) High-quality radiographs with clear landmark visualization 11 system. The OP reduces its inclination with respect to the maxilla and anterior cranial bases owing to an anterior rotation taking place Table 1. Sample selection and exclusion criteria during growth; this phenomenon is caused by a larger eruption Initial sample 30 of the upper molars than upper incisors (6). The cant of the OP is Primary exclusion criteria usually related to a malocclusion describing a vertical morphologic 1) Poor film quality 2 feature, which then affects the sagittal-mandibular position. Class III shows a flat OP, whereas Class II shows a steep one. Furthermore, 2) Incomplete records 1 orthodontic treatment changes the position and angulation of the Secondary exclusion criteria involved teeth, and it is acknowledged that slight dental angular 1) Treatment time >12 months 3 variations can result in significant alteration of the occlusion (7). Final sample 24 From a clinical perspective, treatment of the sagittal component of malocclusions, that is, distalizing techniques, could aim at changing the vertical position of the posterior teeth and subsequently the OP inclination and potentially advance the mandible toward a corrective position (8). OP is often strictly related to treatment, and a great part of the treatment effort is involved with its correction. A correct plane of occlusion allows protrusion without posterior interferences, enabling good function between the maxilla and mandible, whereas uncon- trolled changes in the OP might lead to worsening of the malocclu- sion in some cases or difficulties in performing desired movements. Several studies have evaluated the cephalometric changes af- ter distalization with a pendulum from different perspectives (9). Nevertheless, the OP changes after distalization in Class II malocclusion are still not completely clarified, and this aspect is relevant. This study aimed to evaluate the skeletal and dental changes after upper molar distalization with a pendulum device in terms of potential changes in OP inclination in growing pa- tients with a Class II malocclusion. Figure 1. Pendulum appliance design and activation. Occlusal and METHODS lateral views of the appliance showing activation of the wire on the right upper molar (arrow) and the wire already inserted in the slot Sample Selection and Exclusion Criteria band on the left upper molar (circle). Once inserted, the wire has a Ethical approval was obtained from the ethics committee of the wire/slot play (circle) that allows to apply tip bend to correct tipping of the molar during its distalization University of Insubria
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