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CLINICAL CASE
Dent. Med. Probl. 2009, 46, 3, 365–370
ISSN 1644−387X
© Copyright by Wroclaw Medical University
and Polish Stomatological Association
KATARZYNA RAFTOWICZ−WÓJCIK, JOANNA ANTOSZEWSKA, BEATA KAWALA
Non−Extraction Therapy of Class II/1 Malocclusion
Using Quick Self−Ligating Brackets
and Orthodontic Miniimplants – Case Report
Leczenie nieekstrakcyjne klasy II/1 z zastosowaniem zamków
samoligaturujących Quick oraz miniimplantów ortodontycznych
– opis przypadku
Department of Dentofacial Orthopedics and Orthodontics, Wroclaw Medical University, Poland
Abstract
The paper presents a case of Class II/ division 1 malocclusion, treated without extraction. Quick self−ligating brac−
kets and miniimplants were used to shorten the treatment time and provide absolute anchorage for the en masse di−
stal movement of teeth. Miniscrews were maintained firmly throughout the therapy. Self−ligating brackets seem to
be a promising solution, reducing a frictional resistance and shortening treatment and chairside time. Orthodontic
miniimplants provide an absolute anchorage – their ability to distalize the teeth without adverse reciprocal move−
ment is especially important in non−extraction treatment of Class II malocclusion. Such therapy requires posterior
movement of the upper teeth, anterior movement of the lower ones or a combination of both. Described approach
involving self−ligating brackets and miniimplants seems a promising, effective and well−tolerated solution in non−
extraction treatment (Dent. Med. Probl. 2009, 46, 3, 365–370).
Key words: class II/1 malocclusion, self−ligating brackets, orthodontic miniimplants.
Streszczenie
W pracy przedstawiono opis przypadku wady dotylnej z protruzją (klasa II/1), leczonej bez ekstrakcji. Zastosowa−
no zamki samoligaturujące Quick oraz miniimplanty, aby skrócić czas leczenia oraz zapewnić absolutne zakotwie−
nie do dystalizacji zębów en masse. Miniśruby zachowały stabilność podczas wszystkich faz terapii. Systemy za−
mków samoligaturujących wydają się obiecującym rozwiązaniem, zmniejszającym opór tarcia i skracającym czas
leczenia oraz czas pracy przy fotelu. Miniimplanty ortodontyczne zapewniają absolutne zakotwienie – ich zdolność
dystalizowania zębów bez niepożądanych działań ubocznych jest istotna zwłaszcza w leczeniu nieekstrakcyjnym
wad dotylnych. Taka terapia wymaga dystalnego przesunięcia zębów górnych, doprzedniego ruchu zębów dolnych
lub kombinacji obu tych przemieszczeń. Opisana metoda z wykorzystaniem zamków samoligaturujących oraz mi−
niimplantów wydaje się obiecującym, skutecznym i dobrze tolerowanym rozwiązaniem w leczeniu nieekstrakcyj−
nym (Dent. Med. Probl. 2009, 46, 3, 365–370).
Słowa kluczowe: klasa II/1, zamki samoligaturujące, miniimplanty ortodontyczne.
The prototype of self−ligating brackets was
Russell Lock, described for the first time in 1935,
however the low−friction systems were subjected
to many modifications in contemporary orthodon−
tic treatment. Currently self−ligating brackets can
be divided into active – with a spring clip, that
presses actively against the archwire, and passive
ones with a slide [1, 2]. In some clinical studies
shorter treatment time was reported: decreased
number of follow up visits and reduced chair−side
time when comparing with conventional treatment
involving standard brackets [3–5]. On the other
hand, similar efficiency in providing torque for
upper incisors was noticed in both systems [6].
Nonetheless, most studies emphasized in vitro re−
duction of friction force in self−ligating systems if
366
K. RAFTOWICZ−WÓJCIK, J. ANTOSZEWSKA, B. KAWALA
comparing with conventional ones, which is very
important feature especially during levelling phase
and in sliding mechanics with extraction approach
[7–12].
Method for obtaining maximum anchorage has
been searched in orthodontics for many years. In
1997 Kanomi published a case report with ortho−
dontic miniiplants – titanic screws [13] and since
that time many new anchorage systems were laun−
ched on the market. They can enable correction of
anterior−posterior dimension (anterior teeth retrac−
tion, posterior teeth protraction, molar distalization
in distal occlusion) or vertical one (molar−intrusion
in open bite malocclusion, incisor−intrusion in deep
bite). Miniscrews may be also applied whenever
dental displacements are essential, as well as in
pre−prosthetic therapy. Miniiplants can be divided
into two types: self−tapping and self−drilling ones
[14]. In Titan® system, 1.7 mm diameter conical
self−tapping miniscrews of two lengths: 6 mm in
mandible and 8 mm in maxilla are the most com−
mon. Insertion procedures include local anesthesia,
3–4 mm vertical incision of mucosal membrane
and preparation of the locus for miniscrew, with
a pilot drill directed at 90º towards alveolar process, spinning at 500 rounds per minute, with massive cooling using 0.9% NaCl. The best area to insert miniimplants is located vestibularly, between
the roots of second bicuspid and first molar in maxilla and between the roots of first and second molars in mandible. Evaluation of inserted miniscrews
may be obtained via periapical radiograms taken in
different projections. Miniiplants may be loaded
immediately after insertion, however two-week
postponement is suggested due to healing of soft
tissues. Removing of screws succeeds debonding:
elements of temporary anchorage devices may be
removed in local anesthesia [15].
In the presented case, two modern techniques
were applied: both self−ligating brackets and mini−
iplants, enabled en masse distalization achieved
faster with no adverse side−effects.
Fig. 1. Intraoral photo en face – before treatment
Ryc. 1. Zdjęcie wewnątrzustne en face – przed lecze−
niem
Fig. 2. Intraoral photo – left side – before treatment
Ryc. 2. Zdjęcie wewnątrzustne – strona lewa – przed
leczeniem
Fig. 3. Intraoral photo – right side – before treatment
Ryc. 3. Zdjęcie wewnątrzustne – strona prawa – przed
leczeniem
Case Report
Patient S. K. was a 15−year−old adolescent in−
dividual referred to the Department of Orthodon−
tics and Dentofacial Orthopedics with the diagno−
sis of Class II division 1 malocclusion. The analy−
sis of photographs (transfrontal and retrognathic
profile), diagnostic models (overjet – 9.2 mm;
overbite – 3.9 mm) and cephalometric variables
(<1+:NA = 34.0º; <1+:NB = 31.2º; <1+:1– = 108.4 º;
1+:NA mm = 7.8 mm; 1–:NB = 8.8 mm; 1+: NPg
= 14.4 mm) showed the need for extraction treatment, subsequently negated by the parents. Func-
tional test: forced advancement of the mandible
was positive. Non-extraction treatment was planned, utilizing Quick self-ligating brackets and 4
miniimplants. The appliances were bonded in both
dental arches, in November 2007. The archwire
sequence was following: .012 NiTi, .016 × .022
NiTi, .016 × 022 S.S. (Posted). Stripping of lower
incisors was also performed. In June 2008, two
8 mm miniplants Titan® were implanted in maxilla between teeth 15, 16 and 25, 26. Subsequently,
two miniscrews (6 mm long) were inserted in the
mandible between the second premolar and the
Non−Extraction Therapy of Class II/1 Malocclusion
367
Fig. 4. En face – before treatment
Ryc. 4. Widok en face – przed leczeniem
Fig. 6. Cephalometric radiogram – before treatment
Ryc. 6. Zdjęcie cefalometryczne – przed leczeniem
Fig. 7. Intraoral photo en face – after 10 months of
treatment
Ryc. 7. Zdjęcie wewnątrzustne en face – po 10 miesią−
cach leczenia
Fig. 5. Profile – before treatment
Ryc. 5. Profil – przed leczeniem
first molar in both quadrants. Indirect anchorage in
the lower arch was obtained due to the stiff connection – via. 016 × .016 S.S wire – of miniscrews
and bands on the lower first molars serving as the
attachments for Class II elastics. After 2 weeks
and, once the soft tissues healing process was over,
the miniimplants were loaded with NiTi coil
springs, expanded between miniimplants and posted .016 × .022 S.S. basic archwire in the upper
arch (force 150 G) and Class II 3/16” elastics were used from the hooks of posted archwire to the
hooks on the bands on lower first molars. After 10
months of treatment Class I relationships on molars and canines were regained. In October 2008
.016 × .022 anty-Spee archwires were used in
upper and lower arch with vertical 5/16” medium
Fig. 8. Intraoral photo – left side – after 10 months of
treatment
Ryc. 8. Zdjęcie wewnątrzustne – strona lewa – po 10
miesiącach leczenia
elastics in anterior segment to deepen the overbite.
Transitional open bite in this case was the side effect of torque play; even the largest diameter of archwire (21 × 25) engaged in .022 slot of self−liga−
ting brackets with an active clip still allows slight
368
Fig. 9. Intraoral photo – right side – after 10 months
of treatment
Ryc. 9. Zdjęcie wewnątrzustne – strona prawa – po 10
miesiącach leczenia
K. RAFTOWICZ−WÓJCIK, J. ANTOSZEWSKA, B. KAWALA
Fig. 12. Orthopantomogram – a finishing phase
Ryc. 12. Zdjęcie pantomograficzne – faza końcowa
torque−loss. This effect may by avoided if TAD−
s are in high position, however this is not always
achievable due to anatomical limitations; further−
more – as proved by the evidence – TAD−s placed
high in maxilla in Caucasians are more susceptible
to instability. The miniiplants were maintained
firmly during the treatment. The case is currently
in finishing phase.
Discussion
Fig. 10. En face – after 10 months of treatment
Ryc. 10. Widok en face – po 10 miesiącach leczenia
Fig. 11. Profile – after 10 months of treatment
Ryc. 11. Profil – po 10 miesiącach leczenia
Class II can be corrected with 4 methods:
1) growth modification, 2) teeth movement, camo−
uflaging maxilla disproportion (orthodontic camo−
uflage), 3) combination of both methods, 4) ortho−
gnathic surgery in conjunctive orthodontic−surgi−
cal treatment [16].
Treatment of the presented case started after
pubertal spurt; furthermore, parameters of cepha−
lometric radiogram and the positive result of func−
tional test called for orthodontic camouflage. Co−
nventionally, treatment of Class II with co−exciting
crowding requires evaluation of incisor placement
in their basal bones, as well the assessment of the
profile−type, prior to choice of either extraction or
non−extraction approach. The treatment of Class II
division 1 malocclusion usually involves extrac−
tions: removal of two upper premolars followed by
canine distalization and en masse retraction which
requires maximum anchorage [17]. However, firm
refusal of either the patient or his parents to be
subjected to extraction approach, forced the clini−
cians to choose non−extraction protocol. As repor−
ted in the literature [18], treatment of Class II ma−
locclusion without planned removing of teeth re−
quires distal movement of the upper teeth, mesial
movement of the lower ones or combination of
both displacements what was reached in the pre−
sented case. Typically, distalization of molars pro−
Non−Extraction Therapy of Class II/1 Malocclusion
ceeds further distal displacements of adjacent
upper teeth. Distal movement of terminal molars
can be achieved applying extraoral appliance, such
as headgear [19] or with intraoral appliances; the
latter ones require intra− and intermaxillary or ab−
solute anchorage. Management of different co−
nventional devices serving as intramaxillary an−
chorage reinforcement is widely known: remova−
ble upper plate with distalizing spring/screw or
permanent appliance with magnets, superelastic
Niti wires, NiTi or TMA springs, Keles Slider, Jo−
nes Jig, Distal Jet, Pendulum should be listed as
the efficient tools for anchorage reinforcement
[20–23]. Intermaxillary, mutual anchorage is best
exemplified in MALU [24] and Herbst appliances
[25] or Carriere Distalizer [17], however their ba−
sic disadvantage – requirement of periodontal sup−
369
port for settlement overloads ones teeth and they
are exposed to undesirable displacements called
jiggling. Elimination of the described iatrogenic
adverse side−effects can be achieved only with pa−
latal implants and miniscrews, which play the role
of resistant units for orthodontic force [26]. Mini−
implants provide skeletal anchorage and they are
used in 28,5% cases to correct Class II malocclu−
sion, of all cases treated with miniscrews [27].
The authors concluded that non−extraction
therapy of Class II/1 malocclusion using self−liga−
ting brackets and orthodontic miniscrews seems
a promising, effective and well−tolerated modern
treatment modality. Distalization en masse and
low−friction system shorten the active treatment ti−
me. Excluding of ligatures also facilitates proper
oral hygiene.
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Address for correspondence:
Katarzyna Raftowicz−Wójcik
Department of Dentofacial Orthopedics and Orthodontics
Wroclaw Medical University
Krakowska 26
50−425 Wrocław
Poland
Tel./fax: +48 71 784−02−99
E−mail: [email protected]
Received: 19.05.2009
Revised: 15.06.2009
Accepted: 2.07.2009
Praca wpłynęła do Redakcji: 19.05.2009 r.
Po recenzji: 15.06.2009 r.
Zaakceptowano do druku: 2.07.2009 r.