Beruflich Dokumente
Kultur Dokumente
Department of
was improved. Orthodontics (Chic) 2013;14:e140–e149. doi: 10.11607/ortho.604
Orthodontics, University
Center of Maranhão
(UNICEUMA), São Key words: orthodontic mini-implant, Class II malocclusion correction,
Luís, Maranhão, Brazil; molar distalization appliance
Professor, Program of
T
Orthodontics, Pontifical
Catholic University Madre he distalization of maxillary molars is commonly used for correcting mo-
y Maestra, Santiago de lar relationships, especially in Class II malocclusions, providing intra-arch
los Caballeros, Dominican
Republic.
space to correct the dental occlusion. During many years, the main ap-
3Assistant Professor, pliance indicated for molar distalization was facebow headgear (HG), which re-
Department of quires good patient cooperation. As a result of the unesthetic appearance of
Orthodontics, University
Center of Maranhão
HG, the orthodontic literature has presented different maxillary molar distaliz-
(UNICEUMA), São ing orthodontic appliance alternatives that use other force systems to induce
Luís, Maranhão, Brazil. orthodontic movement.1–8 The molar distalization appliances more commonly
Professor and Program
Director, Program of
used to replace HG are pendulum, nickel titanium (NiTi) coils, transpalatal
Orthodontics, Pontifical arches (TPAs), and distal jets.5–8 These appliances exert a distalization force
Catholic University Madre on maxillary molars, causing distal tipping of the molars, anchorage loss ex-
y Maestra, Santiago de
los Caballeros, Dominican
pressed as mesial movement and tipping of the canines and the first or sec-
Republic. ond premolars, and proclination of the incisors. The presence of these side
4Graduate Student,
effects creates an undesirable increase in treatment time.9–11
Program of Orthodontics,
Pontifical Catholic
Temporary anchorage devices (TADs) provide skeletal anchorage, which has
University Madre y shown superior stability when compared with other dental anchorage modalities.
Maestra, Santiago de los Among the types of TADs, mini-implants represent the simplest way to obtain an-
Caballeros, Dominican
Republic.
chorage for different types of tooth movement, including molar distalization.1,2,4
Mini-implants require placement in a position that favors orthodontic mechanics
CORRESPONDENCE while preserving anatomical and dental structures. For this purpose, the associa-
Dr Júlio de Araújo Gurgel
R. Cel José Braz, 480 Centro tion or modification of orthodontic appliances is necessary in some situations to
17501-570 Marília - SP - achieve desirable dental movement. This case report presents a maxillary molar
Brazil distalization method that combines the use of a mini-implant placed in the pala-
©2013 by Quintessence tal posterior area and the TPA joined through an elastomeric chain to produce a
Publishing Co Inc. system of forces to distalize the molars, avoiding possible side effects.
a b c
d e f
g h
CASE REPORT
Case summary
The patient, aged 17 years and 2 months, presented for orthodontic treat-
ment. Her major reason for seeking treatment was lip incompetence. Facial
analysis showed a convex profile, proportional facial thirds, obtuse nasolabial
angle, protrusion of the lips, and a normal menton-cervical line. Frontal facial
analysis demonstrated facial symmetry, a consonant smile, filled buccal cor-
ridors, coincident midlines, and lip incompetence (Fig 1).
Analysis of the dental casts showed half-cusp Class II molar and canine re-
lationships. Overjet and overbite measured 5 and 4 mm, respectively. Mild ir-
regularity of the maxillary and mandibular teeth was observed without tooth
loss or significant rotations (Fig 2).
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Case Report Distalization of maxillary molars using a lever arm and mini-implant
a b c
d e
a b
Treatment objectives
Based on the initial diagnosis, the following treatment objectives were devel-
oped: (1) correction of molar relationship; (2) correction of canine relationship;
(3) dental alignment; (4) reduction of maxillomandibular prognathism; and
(5) improvement in soft tissue, mainly eliminating the lip incompetence.
Treatment alternatives
To achieve the objectives proposed, three treatment options were suggested
to the patient.
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Case Report Distalization of maxillary molars using a lever arm and mini-implant
Fig 4 (above left) Mini-implant in the center of the palate between the maxillary first permanent
molars and modified TPA, assembled with 1.2-mm SS wire welded onto the maxillary first molar
bands and with a hook at the omega loop to attach a power chain.
Fig 5 (above) Progress panoramic radiograph of maxillary first molars distalized with distal root
inclination.
Treatment progress
A 1.6 × 1 × 6–mm mini-implant (Dewimed) was placed in the middle of the
median palatine suture. In order to increase the distance between the TPA and
the mini-implant, a modification was done in the TPA design, including an an-
terior extension to work like a lever arm. To build the TPA, a 1.2-mm stainless
steel (SS) wire was used, reaching from the maxillary first molar bands to the
mesial surface of the first premolars. A 0.020-inch SS wire hook was welded
onto the anterior portion of the TPA loop (Fig 4). Extraction of the two maxil-
lary third molars was indicated.
A 0.022-inch-slot preadjusted edgewise appliance was placed to initi-
ate leveling and alignment, starting with 0.014-inch NiTi wire, followed by
0.016 × 0.021–inch NiTi thermal activated wire, 0.019 × 0.025–inch NiTi wire,
and 0.019 × 0.025–inch SS wire.
One month after the 0.019 × 0.025–inch SS wire was inserted, the distaliza-
tion system was activated. Medium elastic chains were used, reaching from
the mini-implant to the hook of the TPA, creating a monthly average force of
485 g, measured at each visit with a calibrated tension gauge.
Three months after the start of the distalization phase, a control panoramic
radiograph was taken, which revealed significant distal inclination of the roots
of the maxillary first molars (Fig 5). In order to obtain the distalization of the
crowns, two sliding jigs were adapted at the accessory rectangular tubes of the
maxillary first molars; both were made using 0.019 × 0.025–inch SS wire. The
Class II intermaxillary elastic (3/16-inch) with medium force was used from the
sliding jig to the mandibular first molar and replaced every 48 hours (Fig 6).
a b c
d e f
g h
After 5 months of use, the sliding jigs were removed and replaced by Class II
elastics with the same size/force to correct sagittal and occlusal positioning of
the canines. Stripping of the mandibular incisors was performed to eliminate
the tooth size discrepancy and to improve the inclination of the mandibular
incisors.
The total treatment time was 19 months. The fixed appliances were re-
moved at the same time as the mini-implant and TPA. For retention, maxillary
and mandibular bonded canine-to-canine retainers (0.0195-inch coaxial wire)
were used.13,14 The patient was instructed to continue with this retainer for at
least a year, after which the quality of oral hygiene in the area of the retainer
would be reevaluated, and a decision would be made regarding the mainte-
nance or replacement of the retainer.
© 2013 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Case Report Distalization of maxillary molars using a lever arm and mini-implant
a b c
d e
Results
The posttreatment photographs demonstrate a good facial profile with com-
petent lips (Fig 7). The final occlusion showed a Class I molar relationship on
the right and left sides as well as normal overjet and overbite (Fig 8). The ceph-
alometric superimposition demonstrated reduction of the maxillomandibular
prognathism and improvement of the lip relationship (Fig 9). The panoramic
radiograph showed satisfactory root parallelism (Fig 10).
a b
DISCUSSION
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Case Report Distalization of maxillary molars using a lever arm and mini-implant
CONCLUSIONS
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© 2013 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.