ORIGINAL ARTICLE

Treatment effects of microimplant-aided sliding mechanics on distal retraction of posterior teeth

Young-Hee Oh,a Hyo-Sang Park,b and Tae-Geon Kwonc Daegu, Korea

Introduction: Our objective was to quantify the treatment effects of microimplant-aided mechanics on group distal retraction of the posterior teeth. Methods: The pretreatment and posttreatment cephalometric radiographs and dental casts of 23 patients (mean age, 22.1 6 5.17 years), treated with distalization of the posterior teeth against microimplant anchorage and without extraction of the premolars or other teeth except the third molars, were used. The soft-tissue, skeletal, and dental measurements in the vertical and anteroposterior dimensions were analyzed. The changes in interpremolar and intermolar widths and rotations of the molars were analyzed with dental casts. Results: The upper and lower lips were repositioned distally. The Frankfort horizontal to mandibular plane angle was decreased in the adult group. The maxillary posterior teeth were distalized by 1.4 to 2.0 mm with approximately 3.5 of distal tipping, and the mandibular posterior teeth were also distalized by 1.6 to 2.5 mm with approximately 6.6 to 8.3 of distal tipping. The maxillary posterior teeth showed intrusion by 1 mm. There were increases in arch widths at the premolars and molars. The overall success of microimplants was 89.7%; a well-experienced clinician had a higher success rate (98%) than did novices in this sample. The mean treatment time was 20 6 4.9 months. Conclusions: With microimplant-aided sliding mechanics, clinicians can distalize all posterior teeth together with less distal tipping. The technique seems effective and efcient to treat patients who have mild arch length discrepancy without extractions. (Am J Orthod Dentofacial Orthop 2011;139:470-81)

here have been many attempts to distalize molars with intraoral distalizing appliances.1-5 The side effects of these appliances are anchorage loss at the reactive part, aring of the incisors, distal tipping, and rotation of the distalized molars. To reduce these consequences, dental implants,6 miniscrews,7-9 and microscrews10,11 were tried. All of these skeletal devices can provide suitable anchorage. Miniscrews and microimplants, which have many advantages such as easy surgical placement and removal, low costs, and a small enough size to be placed into the interradicular bone between the roots of adjacent teeth, have achieved popularity over other skeletal anchorage devices. Dental implants6 and miniscrew implants7,8 are placed in the anterior or
From the School of Dentistry, Kyungpook National University, Daegu, Korea. a Research fellow, Department of Orthodontics. b Professor and clinical director, Department of Orthodontics. c Associate professor, Department of Oral and Maxillofacial Surgery. Supported by the Korea Science and Engineering Foundation grant funded by the Korea government (R13-2008-009-01003-0). The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Reprint requests to: Hyo-Sang Park, Department of Orthodontics, School of Dentistry, Kyungpook National University, 188-2, Samduk 2-Ga, Jung-Gu, Daegu, Korea 700-412; e-mail, parkhs@knu.ac.kr. Submitted, February 2009; revised and accepted, May 2009. 0889-5406/$36.00 Copyright 2011 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2009.05.037

midpalate and connected to the premolars for applying distal force to the molars. Alternatively, the distalizing force is applied to the molars from skeletal anchorage devices. With skeletal anchorage, the side effects on the reactive part were alleviated, but distal tipping and rotation of distalizing molars are still issues.7,8 The 1-by1 tooth movement is effective, but it tends to produce side effects of rotation and tipping movement when the force does not pass the center of resistance of a tooth. Group distal retraction of the whole dentition with microimplants was introduced and showed several good treatment results.12,13 The distal force was applied to the canines or anterior hooks attached on the main archwire from microimplants placed between the roots of the posterior teeth. By moving teeth together, individual tooth movements, rotation, and tipping were prevented. Several clinical case reports showed the efcacy of microimplants and the efciency of the treatment mechanics in distalization of the whole dentition.12,13 However, only 1 pilot study evaluated the treatment effects of these mechanics with cephalometric analysis.14 Therefore, the purpose of this study was to quantify the treatment effects of en-masse retraction of the posterior teeth against microimplants by analyzing cephalometric radiographs and dental casts, and with clinical examinations.

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MATERIAL AND METHODS

The cephalometric radiographs and dental casts of 23 patients who had been treated with 0.022-in straightwire brackets at the orthodontic department of Kyungpook National University Hospital in Korea were collected. Consecutively treated patients who received the microimplants for distal movement of the posterior teeth without extraction of the premolars or other teeth except the third molars and had a complete set of records were selected. The rst step of treatment planning for all patients was setting the goal for the soft-tissue prole. The position of the anterior teeth was determined according to the ratio of soft-tissue change to the amount of anterior teeth retraction. After transferring the anteroposterior position of the anterior teeth to the occlusogram, all teeth were aligned from anterior to posterior. All patients required distal movement of the posterior teeth. The maxillary and mandibular posterior teeth with or without the anterior teeth were distalized to resolve crowding or improve the facial prole. The microimplants were placed between the roots of the posterior teeth. Microimplants were used for distalization of the maxillary or mandibular dentitions. Eighteen of the 23 patients had microimplants in both jaws. One patient had microimplants only in the maxilla, and 4 patients had microimplants only in the mandible. All patients were between the ages of 12 years 9 months and 31 years 7 months (mean, 22.1 6 5.17 years). The descriptive data of the patients are given in Table I. Most patients had a moderate amount of arch length discrepancy, except 2 patients with anterior spacing and 2 with no arch length discrepancy. Four patients also required distal movement of the posterior teeth to improve their facial prole. All patients had erupted second molars in both arches at the beginning of treatment. We used 70 microimplants (Absoancho, Dentos, Daegu, Korea) and 12 surgical microscrews (Osteomed, Dallas, Tex). In the maxilla, 32 microimplants were placed in the buccal alveolar bone between the second premolars and the rst molars. Six microimplants were placed in the palatal slope between the rst and second molars in 3 patients who were treated with lingual brackets. In the mandible, 14 microimplants were placed into the bone distobuccally to the mandibular second molars, 26 into the alveolar bone between the mandibular rst and second molars, and 4 into the alveolar bone between the mandibular second premolar and the rst molar. Detailed surgical procedures have already been discussed.15 We used 0.022-in slot straight-wire brackets in all patients, and distalizing forces of approximately 200 g were applied from the maxillary and mandibular microimplants to the canines or premolars with nickel-

titanium closing-coil springs or elastomeric threads (Super thread, Rocky Mountain Orthodontics, Denver, Colo) in the maxillary and mandibular arches (Fig 1). After making space mesial to the canines by distalizing the buccal teeth, the anterior teeth were aligned. During the initial alignment, the anterior teeth were ligated loosely to prevent forward movement. The archwires used during distalization were initially rectangular beta-titanium alloy and were switched to 0.016 3 0.022-in stainless steel in the maxilla and 0.017 3 0.025-in stainless steel in the mandible. After anterior teeth alignment, the 6 anterior teeth were tied together, and the distalizing force was applied to the canines or to the short anterior hooks attached between the lateral incisors and the canines.12-14 The directions of the applied forces were backward and upward in the maxillary arch, and backward and downward in the mandibular arch.13 All cephalograms were taken with the CX-90SP (Asahi, Kyoto, Japan) with 10% magnication. All pretreatment and posttreatment cephalograms were traced by 1 examiner (Y.-H.O.). The soft-tissue and skeletal measurements, dental angular measurements, and dental linear measurements are illustrated in Figures 2 through 4. When there was a double image, the midpoint between the 2 points was traced. The measurement points for the soft-tissue, skeletal, and maxillary dental linear and angular measurements were the same as used by Ghosh and Nanda.1 The centroid point, the midpoint on a horizontal line between the greatest mesial and distal convexity of the crowns, was used for dental linear measurements. To determine the amount of horizontal movement of maxillary teeth, the pterygoid vertical (PTV) plane was used.16 The vertical movement of the maxillary teeth was determined from superimposition on the palatal plane (PP). The horizontal movement of the mandibular teeth was determined by measuring and comparing the distance from the centroid point of the teeth to the mandibular lingual cortex (MLC), whereas the vertical measurements were determined from superimposition on the mandibular plane (MP). Angular changes of tooth positions were determined by the inclination of the long axes of the teeth to the sella-nasion plane (SN) in the maxillary arch and to the MP in the mandibular arch. Arch length discrepancies and intermolar widths of the maxillary and mandibular arches that were distalized were measured before and after treatment on dental casts by using a digital caliper. The 3 lingual patients were removed from the sample when evaluating arch widths and rotation of the molars. To evaluate the rotation of the distalized molars, the transverse measurements were recorded between the buccal cusp tips of the maxillary and mandibular second premolars

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Table I. Descriptive distribution of the patients

Patient (sex) 1. (F) 2. (M) 3. (F) 4. (F) 5. (F) 6. (F) 7. (M) 8. (F) 9. (F) 10. (F) 11. (M) 12. (F) 13. (M) 14. (M) 15. (M) Brand and type of microimplant H ( , diameter) Dentos AX 1311-107, -106 Dentos AN 12-106 Dentos SH 1312-106 H Osteomed (1.2 ,10 H mm) Osteomed (1.2 ,6 mm) Dentos AX 13-1065 Dentos AX 1311-107 Dentos SH 1312-107, -110 Dentos SH 1312-106 H Osteomed (1.2 ,6 mm) Dentos SH 1312-107 Dentos SH 1312-107 Dentos AX 1311-108 Dentos ATX 1311-105 Dentos ATX 1311-108 Dentos AX 12-106 H Osteomed (1.2 ,6 mm) Dentos SH 1312-107 Dentos SH 1312-106 Dentos ATX 1311-108 Dentos AN 13-105 H Osteomed (1.2 H ,6 mm) Osteomed (1.2 ,6 mm) Dentos AN 12-204 Dentos SH 1312-107 Dentos SH 1311-106, Dentos SH 1412-105 Dentos SH 1312-107 Dentos SH 1312-106 Dentos ATX 1311-107 Dentos AX 12-107 Dentos SH 1312-107 Dentos AX 1311-107 Dentos AX 1311-107 Dentos SH 1311-107 Dentos AX 12-106 Dentos SH 1312-107 Dentos SH 1312-106 Dentos ATX 1311-107 Dentos AX 12-106 Dentos ATX 1412-07 Dentos ATN 1312-05 Location of microimplant placement #15-16 B, #25-26 B #36-37 B, #46-47 B #37 DB, #47 DB #37 DB, #47 DB #16-17 P, #26-27 P #15-16 B, #25-26 B #36-37 B, #46-47 B #16-17 P, #26-27 P #36-37 B, #46-47 B #37 DB, #47 DB #15-16 B, #25-26 B #36-37 B, #46-47 B #15-16 B, #25-26 B #36-37 B, #46-47 B #15-16 B, #25-26 B #37 DB, #47 DB #37 DB, #47 DB #15-16 B, #25-26 B #36-37 B, #46-47 B #15-16 B, #25-26 B #35-36 B, #45-46 B #37 DB, #47 DB #15-16 B, #25-26 B #37 DB, #47 DB #15-16 B, #25-26 B #36-37 B, #46-47 B #15-16 B, #25-26 B #36-37 B, #46-47 B #15-16 B, #25-26 B #36-37 B, #46-47 B #15-16 B, #25-26 B #15-16 B, #25-26 B #36-37 B, #46-47 B #15-16 B, #25-26 B #35-36 B, #45-46 B #15-16 B, #25-26 B #36-37 B, #46-47 B #16-17 P, #26-27 P #36-37 B, #46-47 B #15-16 B, #25-26 B #36-37 B, #46-47 B Duration of force application 17 mo, 17 mo 10 mo, 10 mo 19 mo, 19 mo 9.2 mo, 9.2 mo 9.2 mo, 9.2 mo 14 mo, 14 mo 14 mo, 14 mo 11 mo, 11 mo 14 mo, 14 mo 16 mo, 16 mo 11 mo, 11 mo 11 mo, 11 mo 21 mo, 21 mo 15 mo, 15 mo 20 mo, 22 mo 19 mo, 19 mo 13 mo, 13 mo 17 mo, 17 mo 17 mo, 17 mo 19 mo, 19 mo 19 mo, 19 mo 21 mo, 21 mo 17 mo, 17 mo 17 mo, 17 mo 13 mo, 13 mo 7 mo, 7 mo 18 mo, 21 mo 11 mo, 11 mo 15 mo, 15 mo 14 mo, 14 mo 8 mo, 8 mo 22 mo, 22 mo 15 mo, 19 mo 8 mo, 8 mo 23 mo, 23 mo 10 mo, 20 mo 13 mo, 13 mo 12 mo, 12 mo 13 mo, 13 mo 25 mo, 25 mo 21 mo, 21 mo

Age 22 y 11 mo 24 y 4 mo 28 y 3 mo 24 y 2 mo 26 y 9 mo 15 y 3 mo 23 y 1 mo 29 y 3 mo 18 y 11mo 22 y 5 mo 31 y 7 mo 21 y 1 mo 23 y 3 mo 13 y 9 mo 16 y

16. (F) 17. (F) 18. (F) 19. (F) 20. (M) 21. (M) 22. (F) 23. (M)

12 y 9 mo 20 y 9 mo 21 y 1 mo 26 y 3 mo 16 y 11 mo 13 y 3 mo 26 y 11 mo 30 y 2 mo

ALD, arch length discrepancy; B, buccal; DB, distobuccal; P, palatal; Y, yes; N, no; Mx, maxillary; Mn, mandibular.

along with the mesiobuccal and distobuccal cusp tips of the rst and second molars.1,5
Statistical analysis

of the paired t test were illustrated, unless the P values of the Wilcoxon signed rank test were illustrated.
RESULTS

The statistical analyses were performed with SPSS software (version 14.0, SPSS, Chicago, Ill). A paired t test and a Wilcoxon signed rank test were used. When the sample showed normal distribution as evaluated by the Kolmogorov-Smirnov test, the P values

To calculate the error of measurements, 20 cephalometric lms and models from 10 patients were retraced, redigitized, and remeasured 1 month later. Measurement errors were calculated based on the differences between the rst and second values with a paired

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Table I. Continued
Failure (month after placement) N Y (17 mo) N N N N Y (1 mo) N N N Replacement (location, period of use) Pericoronitis on mandibular second molar Operculum Operculum Duration of treatment 17 mo 20 mo 10 mo 15 mo 14 mo 16 mo 21 mo 23 mo 22 mo 13 mo 20 mo 19 mo 21 mo 17 mo Y (27 mo) 28 mo Microimplant treatment Mx/Mn Mn Mx/Mn Mx/Mn Mx/Mn Mn Mx/Mn Mx/Mn Mx/Mn Mn Mx/Mn Mx/Mn Mn Mx/Mn Mx/Mn ALD Mx/Mn (mm) 5.43/4.45 10.73/6.31 4.21/4.74 3.50/1.10 0.75/3.97 10.16/5.66 5.49/1.78 4.46/0.44 3.13/0 3.23/0 0/1.57 1.23/1.23 0/1.49 5.36/1.49 7.19/9.50 1.43/2.06 1.11/1.41 4.02/0 1.46/6.60 0.81/0.70 3.0/4.0 4.45/2.3 3.06/0

Y (2 mo)

Y (8 mo)

N N N Y (1 mo)

N Y (2 mo) N N N N Y (1, 7 mo) Y (2 mo) Y (9, 6 mo) Y (19 mo) Mild Mild Y (12 mo)

30 mo 15 mo 27 mo 22 mo 23 mo 34 mo (2 phase) 21 mo (xed) 22 mo 25 mo

Mx/Mn Mx/Mn Mx Mx/Mn Mx/Mn Mx/Mn Mx/Mn Mx/Mn

Operculum

t test. There was no signicant difference between the 2 measurements. To measure the range of methodologic errors, Dahlbergs formula17 was used, and the results were 0.3 for angular measurements and 0.1 mm for linear measurements. The mean distal repositionings of the upper and lower lips relative to the E-line were 0.72 and 1.18 mm, respectively. The lower lip moved distally more than the upper lip (Table II). The skeletal changes during treatment (before distalization to posttreatment) are summarized in Table II and showed that the Frankfort horizontal-mandibular plane

angle (FMA) decreased with statistical signicance. The other measurements were not statistically different. The distance of ANS-Me increased (0.66 mm), but it was not statistically signicant. To preclude the effect of growth and to quantify the treatment effect only, the sample was divided into adult and growing groups. In the adults, the FMA decreased with statistical significance, and the distance of ANS-Me also decreased by 0.32 mm, although it was not statistically signicant (Table III). In the growing patients, however, ANS-Me increased by 2.07 mm with statistical signicance. In the adults, after the maxillary and mandibular

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Fig 1. A, Initial leveling stage: to gain space for alignment of anterior teeth, distalizing force was applied to the canines from microimplants; B, en-masse retraction, with the 6 anterior teeth tied together; C, en-masse retraction (lateral view), with the retraction force applied to the canines; D, schematic drawing of the whole dentition retraction.

Fig 2. Cephalometric measurements used in this study: 1, upper lip to E-line; 2, lower lip to E-line; 3,\SN-PP (SN-palatal plane angle); 4,\SN-OP (SN-bisected occlusal plane angle); 5,\FMA (Frankfort-mandibular plane angle); 6, PTV to Point A; 7, PTV to Point B; 8, ANS to Me.

dentitions were distalized, Points A and B moved posteriorly with statistical signicance only for Point B (Table III).

The movement of the maxillary and mandibular teeth was evaluated in the patient groups in which the maxillary and mandibular teeth were distalized against

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Fig 3. Cephalometric dental angular measurements (maxilla): 1, SN-incisor; 2, SN-rst premolar; 3, SN-rst molar; 4, SN-second molar; (mandible) 5, MP-incisor; 6, MP-rst premolar; 7, MP-rst molar; 8, MP-second molar.

the microimplants, respectively. The long axes of the maxillary central incisors, maxillary rst premolars, and maxillary rst molars to the SN plane decreased by 3.68 , 3.43 , and 3.47 , respectively, on average, meaning that the teeth were tipped distally (Table IV). There were mean decreases of 2.62, 1.42, 1.51, and 1.95 mm, respectively, in the horizontal distances from the maxillary central incisors, rst premolars, and rst and second molars to the PTV plane, and all measurements were statistically signicant (Table IV). This means that all maxillary teeth were distalized. There were decreases in the vertical distances from the centroid points of the maxillary central incisors, rst premolars, rst molars, and second molars to the PP, with mean decreases of 0.36, 0.55, 1.00, and 1.12 mm, respectively (Table IV). Among these, there was statistical signicance for the maxillary rst and second molars. All mandibular teeth were tipped distally. The mean decreases in the angle of the long axes of mandibular central incisors, rst premolars, and rst and second molars to the mandibular plane were 2.45 , 6.64 , 7.62 , and 8.25 , respectively (Table IV). Statistically signicant values were found for the rst premolars, and the rst and second molars. The horizontal distances from the centroid points of the mandibular rst premolars, and the rst and second molars to the MLC, increased by 1.60, 2.45, and 2.08 mm, respectively (Table IV), meaning that all mandibular teeth were moved distally. The vertical distance from the centroid point of the

Fig 4. Cephalometric dental linear measurements. Horizontal measurements in the maxilla: 1, PTV-incisor tip; 2, PTV-rst premolar centroid; 3, PTV-rst molar centroid; 4, PTV-second molar centroid. Vertical measurements in the maxilla: 5, PP-incisor; 6, PP-rst premolar centroid; 7, PP-rst molar centroid; 8, PP-second molar centroid. Horizontal measurements in the mandible: 9, MLC-rst premolar centroid; 10, MLC-rst molar centroid; 11, MLC-second molar centroid. Vertical measurements in the mandible: 12, MP-incisor; 13, MP-rst premolar centroid; 14, MP-rst molar centroid; 15, MP-second molar centroid.

mandibular second molars to the mandibular plane was decreased by 1.07 mm with statistical signicance (Table IV). There were signicant differences in maxillary and mandibular intermolar widths before and after distalization. There were mean expansions of 1.25 mm in the maxilla and 0.98 mm in the mandible (Table V). The maxillary rst and second molars and the mandibular rst molar were rotated distally by minimal amounts, whereas signicant mesial rotation was evident on the mandibular second molars. The distance between the mesiobuccal cusps of the maxillary rst molars on both sides increased by 1.41 mm, and the distobuccal cusp distance increased by 0.5 mm. Therefore, the difference in expansion between the mesiobuccal and distobuccal cusps was 0.91 mm. The differences in expansion between the mesiobuccal and distobuccal cusps of the maxillary second molars, and the mandibular rst and second molars, were 0.61, 0.30, and 0.14 mm, respectively. Seventy microimplants and 12 microscrews were used in the 23 patients. Among the 82 microimplants, 4 microimplants (in 1 patient) were excluded because a student removed the microimplants intentionally to

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Table II. Descriptive statistics of cephalometric measurements at pretreatment, posttreatment, and pretreatment to

posttreatment (n 5 23)
Pretreatment Measurement Soft tissue Upper lip to E-line (mm) Lower lip to E-line (mm) Skeletal SN-PP ( ) SN-OP ( ) FMA ( ) PTV-A (mm) PTV-B (mm) ANS-Me (mm) Dental-angular ( ) SN-U1 SN-U4 SN-U6 SN-U7 MP-L1 MP-L4 MP-L6 MP-L7 Dental-linear (mm) PTV-U1 PTV-U4 PTV-U6 PTV-U7 PP-U1 PP-U4 PP-U6 PP-U7 MLC-L4 MLC-L6 MLC-L7 MP-L1 MP-L4 MP-L6 MP-L7 Mean 1.22 1.17 9.26 17.32 26.00 48.99 50.30 75.03 108.75 85.91 75.12 65.17 93.62 82.61 80.53 81.71 59.96 40.30 23.33 12.58 31.76 25.43 21.99 19.67 5.00 21.60 33.94 45.56 37.59 33.01 30.35 SD 2.19 2.78 3.68 5.36 5.23 2.59 4.83 7.29 6.90 6.52 5.53 11.93 6.85 5.42 4.78 8.49 3.91 2.90 3.12 2.85 3.72 3.06 5.19 3.28 3.13 2.64 3.18 3.74 4.07 3.58 3.26 Posttreatment Mean 1.94 0.01 9.50 17.78 25.30 48.93 49.77 75.69 106.48 81.72 72.84 65.97 92.83 77.52 73.35 72.93 58.18 38.75 21.59 10.93 31.30 25.07 22.31 19.46 6.80 24.19 35.78 45.93 38.35 33.11 29.61 SD 1.91 1.93 3.82 4.92 5.05 2.74 4.45 7.27 9.84 6.18 4.89 9.32 7.72 7.65 9.44 10.10 3.37 3.10 3.36 3.83 3.83 2.88 2.50 2.65 3.88 3.32 3.47 4.07 4.22 3.52 3.61 Change Mean 0.72 1.18 0.24 0.03 0.70 0.07 0.53 0.66 2.28 4.19 2.28 0.80 0.79 5.09 7.18 8.78 1.79 1.55 1.75 1.75 0.45 0.36 0.32 0.22 1.80 2.58 1.84 0.37 0.76 0.10 0.74 SD 1.29 1.42 1.31 3.29 1.25 1.43 2.01 2.02 8.08 7.18 6.09 7.04 6.75 9.40 8.12 7.27 3.08 2.11 2.01 2.12 1.41 1.18 4.14 2.54 1.89 2.10 1.99 1.82 1.89 1.31 1.29 t 0.014* 0.001y 0.391 0.970 0.014* 0.829 0.223 0.130 0.212 0.015* 0.102 0.617 0.579 0.015* 0.003y 0.001y 0.002y 0.157 0.174 0.0002y \0.0001y 0.336 0.066 0.735 0.013* Signicance W 0.004y \0.0001y \0.0001y 0.121 0.111 \0.0001y -

t, t test; W, Wilcoxon signed rank test. *P \0.05; yP \0.01.

change the position during the treatment period. The success rate was calculated for 78 microimplants. Seventy of 78 microimplants were maintained during force application, and the success rate was 89.7%. There was a difference in the success rates between the professor (H.-S.P.) and the postgraduate students. The success rate for the professor was 98.1% (53 of 54 microimplants); the students had a lower success rate of 70.8% (17 of 24 microimplants). The mean treatment time was 20 6 4.9 months (range, 13-30 months). When the full mandibular dentition was distalized, opercula were noted in 3 patients, distal to the second molars, and mild pericoronitis was seen in 2 patients.

DISCUSSION

Ngantung et al4 reported that, when distalization appliances such as the distal jet or the pendulum are used, the anterior teeth tend to move forward during distalization of the molars. Then the anterior teeth need to be retracted against the distalized molars. Accordingly, the anterior teeth suffered round-trip movement and were exposed to jiggling forces. To prevent this side effect, a dental implant or miniscrew implants have been used with the distalization appliance for anchorage reinforcement.6-8 However, the mechanics of retraction of the whole dentition with microimplants prevent the round tripping movement of the anterior

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Table III. Skeletal changes in adults vs growing patients

Pretreatment Measurement Adult patients (n 5 16) SN-PP ( ) SN-OP ( ) FMA ( ) PTV-A (mm) PTV-B (mm) ANS-Me (mm) Growing patients (n 5 7) SN-PP ( ) SN-OP ( ) FMA ( ) PTV-A (mm) PTV-B (mm) ANS-Me (mm) Mean 9.99 17.42 26.22 49.02 50.93 75.51 7.57 18.21 25.51 48.93 48.86 75.03 SD 3.74 5.58 5.90 2.64 4.67 8.45 3.16 5.15 3.61 2.66 5.24 6.57 Posttreatment Mean 9.93 17.37 25.31 48.63 49.84 75.20 8.50 18.71 25.30 49.61 49.61 77.10 SD 4.10 5.03 5.72 2.77 4.59 8.00 3.13 4.91 3.41 2.75 4.45 7.16 Mean 0.06 0.05 0.91 0.39 1.09 0.32 0.93 0.20 0.21 0.69 0.76 2.07 Change SD 1.32 3.30 1.13 1.15 1.52 1.91 1.07 3.53 1.48 1.80 2.50 1.40 t 0.867 0.952 0.006y 0.193 0.0497* 0.061 0.886 0.716 0.352 0.454 0.008y Signicance W 0.222 -

t, t test; W, Wilcoxon signed rank test. *P \0.05; yP \0.01.

Table IV. Dental changes of cephalometric measurements at pretreatment, posttreatment, and pretreatment to posttreatment in patients with molars distalized
Pretreatment Measurement Mean Maxillary dental change (n 5 19) Dental-angular ( ) SN-U1 109.43 SN-U4 84.28 SN-U6 75.61 SN-U7 64.93 Dental-linear (mm) PTV-U1 60.96 PTV-U4 40.60 PTV-U6 23.88 PTV-U7 13.08 PP-U1 31.68 PP-U4 25.52 PP-U6 23.23 PP-U7 20.31 Mandibular dental change (n 5 22) Dental-angular ( ) MP-L1 93.76 MP-L4 82.77 MP-L6 79.77 MP-L7 79.89 Dental-linear (mm) MLC-L4 5.19 MLC-L6 21.38 MLC-L7 33.45 MP-L1 46.18 MP-L4 38.23 MP-L6 33.77 MP-L7 30.78 t, t test; W, Wilcoxon signed rank test. *P \0.05; yP \0.01. SD Posttreatment Mean SD Mean Change SD t Signicance W

8.11 5.61 6.79 10.37 4.27 2.83 2.65 2.62 3.77 2.81 2.45 2.39

105.75 80.85 72.14 65.89 58.34 39.18 22.37 11.14 31.32 24.97 22.23 19.19

10.87 5.24 4.32 6.53 3.84 3.53 3.45 3.53 3.92 2.57 2.26 2.31

3.68 3.43 3.47 0.96 2.62 1.42 1.51 1.95 0.36 0.55 1.00 1.12 2.45 6.64 7.62 8.25 1.60 2.45 2.08 0.02 0.21 0.43 1.07

6.92 4.94 5.92 7.11 3.16 1.87 1.59 1.48 1.42 1.04 1.15 1.16

0.080 0.056 0.634 0.011* 0.018* 0.005y 0.0005y 0.375 0.084 0.009y 0.005y

0.023* -

7.30 6.21 4.75 8.16 2.97 2.50 2.91 3.85 4.33 3.78 3.68

91.31 76.13 72.15 71.65 6.79 23.83 35.53 46.20 38.43 33.35 29.71

7.58 8.97 10.85 11.84 3.67 3.21 3.22 4.15 4.47 3.96 4.24

5.29 10.85 9.63 6.80 1.59 2.18 1.06 1.87 1.93 1.07 1.32

0.095 0.0003y 0.002y \0.0001y 0.968 0.685 0.145 0.008y

0.010* 0.001y 0.0001y -

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Table V. Changes in intermolar width and arch length discrepancy

Pretreatment Measurement (mm) Maxillary arch Intersecond premolar width Intermolar width Arch length discrepancy Mandibular arch Intersecond premolar width Intermolar width Arch length discrepancy Mean 50.09 41.49 2.06 42.34 41.96 2.98 SD 2.69 2.24 3.14 2.80 2.28 2.67 Posttreatment Mean 52.23 42.74 0 43.91 42.94 0 SD 1.87 2.41 0 1.88 2.21 0 Change Mean 2.14 1.25 2.06 1.57 0.98 2.98 SD 1.68 0.83 3.14 1.92 1.47 2.67 t 0.0002y \0.0001y 0.016* 0.005y 0.008* Signicance W \0.0001y

t, t test; W, Wilcoxon signed rank test. *P \0.05; yP \0.01.

Fig 5. Summary of cephalometric changes after distalization of the posterior and anterior teeth with microimplants.

teeth. The distalization of the canines with the posterior teeth by applying distal force to the canines from microimplants could make spaces to align the anterior teeth. After alignment of the anterior teeth, the full dentition was retracted.12,13 Because the rotated anterior teeth were not ligated tightly during the initial alignment, there was no force to move the anterior teeth forward, and the resulting round tripping movement could be avoided.14

The upper and lower lips relative to the E-line moved distally after distal retraction of the anterior teeth by 0.72 and 1.18 mm, respectively (Table V). The initial mean arch length discrepancies of 2.06 mm in the maxilla and 2.98 mm in the mandible were resolved (Table V). This means that the posterior teeth were distalized sufciently to resolve crowding as well as to obtain a better prole after distal movement of the anterior teeth. Figure 5 is a summary of the cephalometric changes. Although the FMA was decreased, the distance of ANS-Me was increased slightly (Table III). However, in the adult group, with no effect of growth, the distance of ANS-Me did not change (Table III). The force from the microimplants to the canine brackets is backward and in an apical direction. With these forces, the teeth might experience distal movement and intrusion. When distal force is applied to the canines, they might tip distally, and this would exert an intrusion force on the posterior teeth. The maxillary and mandibular second molars were intruded by 1.12 and 1.07 mm, respectively (Table IV). This result suggests that, although the full dentitions of the maxilla and the mandible were distalized, the intrusion of the second molar prevents the wedging effect and the increases of the FMA. The intrusion of the molars during distal movement could keep the anterior facial height. The intrusion of the posterior teeth might produce a lateral open bite, which can be minimized by bonding a posterior bracket or buccal tube gingivally. On the other hand, in growing patients, the distance of ANS-Me was increased signicantly (Table III). This might reect the growth pattern of the mandible that lower facial height is increased as the mandible grows. Ghosh and Nanda1 and Chiu et al3 reported that the FMA was increased when molars were distalized with intraoral distalizing appliances. In this study, however, the FMA was decreased in the adult group with statistical

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Fig 6. Maxillary and mandibular superimpositions of pretreatment and posttreatment (yellow) digital dental models of a patient showing expansion of the dental arch.

Table VI. Means, standard deviations, and minimum and maximum values for changes in the transverse measurements from dental casts
Measurement (mm) Maxillary transverse Between rst molars Mesiobuccal cusp Distobuccal cusp Between second molars Mesiobuccal cusp Distobuccal cusp Mandibular transverse Between rst molars Mesiobuccal cusp Distobuccal cusp Between second molars Mesiobuccal cusp Distobuccal cusp t, t test. *P \0.01. Mean SD Minimum Maximum t

1.41 0.50 0.75 0.14

0.90 0.93 1.73 1.40

0.2 -1.7 -1.6 -1.7

2.8 2.0 4.0 2.3

.0002* .056 .184 .754

1.74 1.44 1.67 1.81

1.80 2.06 1.85 2.06

-1.0 -1.5 -1.0 -2.0

4.8 5.7 5.5 6.5

.001* .011* .005* .006*

signicance and also decreased in the growing patients, although it was not statistically signicant. This suggests that we could distalize the full dentition of the maxilla and the mandible, and the FMA can be maintained or decreased, if necessary. Therefore, these mechanics seem a better treatment in high-angle patients than in low-angle patients. When treating low-angle patients with these mechanics, other deviceseg, a bonded anterior bite planeshould be placed to maintain or increase the vertical dimension. With the distal jet appliance, Ghosh and Nanda1 had distal tipping of the maxillary rst and second molars of 8.36 and 11.99 , respectively, during distalization. It was stated that the molar key could be corrected by a tipping movement of the molar, but the retention would be doubtful during distal retraction of the incisors. The

molar distalizing appliances anchored by screws also showed distal tipping of the distalized maxillary rst molars by 8.8 8 and 10.9 .7 In our study, the maxillary rst molar tipped distally by 3.47 ; this was far smaller than in previous reports.1,7,8 Moreover, the maxillary second molar tipped mesially by 0.96 . This might be explained because the treatment mechanics used in this study were sliding mechanics with a rigid main archwire without loops, and tipping of the teeth could be alleviated. By distalizing the posterior teeth with bodily movement, the stability of the treatment would be good. The distal movement of the maxillary molars was evident, but the amount of distal movement was approximately 1.4 to 1.5 mm (Table IV). This was less movement than other molar distalizing appliances in which the maxillary rst molars moved distally by 3.8

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mm7 and 3.9 mm.8 However, because of less distal tipping of the distalized molars and the measurements made on the centroid point of the crown, not on the tip of the crown as in the previous studies, the amount of real tooth movement might be similar.7,8 The amounts of distal movement of the mandibular rst and second molars were 2.45 and 2.08 mm, respectively; these were greater than movements of the maxillary molars (Table IV). It might be because several patients had an anterior crossbite or an edge-to-edge bite initially, and we needed to retract the teeth to a greater extent to obtain proper incisal relationships. This produced greater distal repositioning of the lower lip than of the upper lip. The mandibular molars showed more distal tipping than did the maxillary molars. This was because the mandibular posterior teeth needed to be tipped distally to level the curve of Spee and to upright to the occlusal plane. There were increases in maxillary interpremolar and intermolar widths by 2.14 and 1.25 mm, respectively. These amounts were greater than in the mandible in which interpremolar width was increased by 1.57 mm, and a 0.98-mm increase was evident at the intermolar width (Table V). Because the distal force was applied to the canines, there might be a tendency of arch expansion in the canine and premolar areas. This can be prevented by using a rigid archwire with a slight constriction around the canines. Figure 6 gives superimpositions of the digital images of the initial and nal casts. It shows the increases in intermolar width at posttreatment. When a distal force is applied to the canines, they tip distally. The distal tipping of the canines produces an intrusion force on the molars. The intrusion force on buccal brackets can bring about buccal uprighting of molars and result in expansion of intermolar width. One drawback of pendulum appliances might be the rotation of distalized molars. Ghosh and Nanda1 showed that the width between the mesiobuccal cusps of the right and left maxillary rst molars increased by 1.4 mm, whereas that between the distobuccal cusps showed only 0.04 mm of increase. The difference in width increases between the mesiobuccal and distobuccal cusps was about 1.36 mm. For the maxillary second molars, the width difference between the mesiobuccal (2.33 mm) and the distobuccal cusps (1.59 mm) was 0.74 mm. This implies mesiobuccal rotation of the molars. This rotation might improve the dental relationships and gain additional space in a Class II malocclusion. With the distal jet appliance, the difference in width between the mesiobuccal and distobuccal cusps of the rst molars was 0.2 mm (2.9-2.7 mm), and that of the second molars was 0.3 mm (1.1-0.8 mm).5

Therefore, the pendulum appliance produced more rotation of the distalized molars than did the distal jet appliance. In this study, the difference in width increases between the mesiobuccal and distobuccal cusps of the maxillary rst molars was 0.91 mm (1.41-0.5 mm). That for the second molars was 0.61 mm (0.75-0.14 mm) (Table VI). The rotation of the distalized molars with these mechanics lies between the pendulum and the distal jet appliances. For the mandible, the difference in width increases between the mesiobuccal and distobuccal cusps of the rst molars was 0.30 mm (1.741.44 mm), and that for the second molars was 0.14 mm (1.67-1.81 mm). The distalized molars in the mandibular arch experienced less rotation than those in the maxillary arch, and the mandibular second molars showed distobuccal rotation, whereas the other molars rotated mesiobuccally. In the treatment of Class II malocclusion, mesiobuccal rotation of the maxillary molars improves dental relationships and yields additional space. However, in the treatment of distal retraction of both maxillary and mandidular dentitions, this rotation might not be a favorable movement. To minimize rotation of the molars, it is better to bond molar brackets or buccal tubes slightly distal to the middle of the crown or to use buccal tubes with no offset. The overall success rate of the microimplants was 89.7%. The success rates were 98.1% for a wellexperienced clinician and 70.8% for postgraduate students. Many factors affect the success of microimplants. The success seems to be inuenced by the operators skill. The success rate follows the learning curve. The success rate of the microimplants in this sample was similar to or higher than in previous reports.18-21 The success rates in previous studies ranged from 93.3%18 to 81%.20 Regarding treatment time, Ngantung et al4 reported that mean treatment time was 25.7 6 3.9 months to complete treatment with the distal jet appliance with full bracket appliance therapy. Chiu et al3 reported that the treatment time for the distal jet appliance was 28 months, consisting of 10 months for distalization of the molars and 18 months for the second phase of xed appliance treatment. The treatment time for the pendulum appliance was 31 months, consisting of 7 months for distalization of the molars and another 24 months for xed appliance therapy. The mean treatment time in this study was 20 6 4.9 months. It was much shorter than that with intraoral distalizing appliances. This might be because, in molar distalizing appliance treatment, treatment starts at an early age, and it is a step-by-step treatment consisting of molar distalization and incisor retraction. However, with microimplant sliding mechanics, treatment was started after the eruption of the second

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molars or started in adult patients, and all teeth in the arch were distalized at the same time. For individual teeth, the movement was slow because the molars were distalized by 1.5 to 2 mm during a year of treatment. However, by moving all teeth together, treatment time can be shortened. Alveolar surgery could accelerate the rate of tooth movement.22 To enhance distal movement of the molars, the third molars can be extracted just before applying the distal force. Distal movement of the mandibular posterior teeth can produce pericoronitis by the accumulation of soft tissue over the crown of the second molar. In 3 patients, opercula were observed; these patients might need an operculectomy.23 Mild pericoronitis distal to the mandibular second molar was observed in 2 patients. Therefore, to prevent this, the available space distal to the molar should be checked when determining the treatment plan.
CONCLUSIONS

With microimplant-aided sliding mechanics, clinicians can distalize all teeth together with less distal tipping and rotation of distalized molars, and retract the upper and lower lips to improve facial esthetics. The technique seems effective and efcient to treat patients who have a mild arch length discrepancy without extractions.
REFERENCES 1. Ghosh J, Nanda RS. Evaluation of an intraoral maxillary molar distalization technique. Am J Orthod Dentofacial Orthop 1996;110: 639-46. 2. Bussick TJ, McNamara JA Jr. Dentoalveolar and skeletal changes associated with the pendulum appliance. Am J Orthod Dentofacial Orthop 2000;117:333-43. 3. Chiu PP, McNamara JA Jr, Franchi L. A comparison of two intraoral molar distalization appliances: distal jet versus pendulum. Am J Orthod Dentofacial Orthop 2005;128:353-65. 4. Ngantung V, Nanda RS, Bowman SJ. Posttreatment evaluation of the distal jet appliance. Am J Orthod Dentofacial Orthop 2001; 120:178-85. 5. Bolla E, Muratore F, Carano A, Bowman SJ. Evaluation of maxillary distalization with the distal jet: a comparison with other contemporary methods. Angle Orthod 2002;72:481-94.

 G, Akyalc 6. Oncag in S, Arikan F. The effectiveness of a single osteointegrated implant combined with pendulum springs for molar distalization. Am J Orthod Dentofacial Orthop 2007; 131:277-84. 7. Kircelli BH, Pektas ZO, Kircelli C. Maxillary molar distalization with a bone-anchored pendulum appliance. Angle Orthod 2006;76: 650-9. r IE, Bu yu kyilmaz T, Karaman AI, Dolanmaz D, Kalayci A. 8. Gelgo Intraosseous screw-supported upper molar distalization. Angle Orthod 2004;74:838-50. 9. Creekmore TD, Eklund MK. The possibility of skeletal anchorage. J Clin Orthod 1983;17:266-9. 10. Park HS. The skeletal cortical anchorage using titanium microscrew implants. Korean J Orthod 1999;29:699-706. 11. Park HS, Bae SM, Kyung HM, Sung JH. Micro-implant anchorage for treatment of skeletal Class I bialveolar protrusion. J Clin Orthod 2001;35:417-22. 12. Park HS. The use of micro-implant as orthodontic anchorage. 2nd ed. Seoul, Korea: Nare Publishing; 2001:257288. 13. Park HS, Kwon TG, Sung JH. Nonextraction treatment with microscrew implants. Angle Orthod 2004;74:539-49. 14. Park HS, Lee SK, Kwon OW. Group distal movement of teeth using microscrew implant anchorage. Angle Orthod 2005;75:602-9. 15. Park HS, Bae SM, Kyung HM, Sung JH. Simultaneous incisor retraction and distal molar movement with microimplant anchorage. World J Orthod 2004;5:164-71. 16. Enlow DH, Kuroda T, Lewis AB. The morphological and morphogenetic basis for craniofacial form and pattern. Angle Orthod 1971;41:161-88. 17. Houston WJ. The analysis of errors in orthodontic measurements. Am J Orthod 1983;83:382-90. 18. Park HS. Clinical study on success rate of microscrew implants for orthodontic anchorage. Korean J Orthod 2003;33:151-6. 19. Park HS, Jeong SH, Kwon OW. Factors affecting the clinical success of screw implants used as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2006;130:18-25. 20. Miyawaki S, Koyama I, Inoue M, Mishima K, Sugahara T, Takano-Yamamoto T. Factors associated with the stability of titanium screws placed in the posterior region for orthodontic anchorage. Am J Orthod Dentofacial Orthop 2003;124:373-8. 21. Kuroda S, Sugawara Y, Deguchi T, Kyung HM, Takano-Yamamoto T. Clinical use of miniscrew implants as orthodontic anchorage: success rates and postoperative discomfort. Am J Orthod Dentofacial Orthop 2007;131:9-15. 22. Ren A, Lv T, Kang N, Zhao B, Chen Y, Bai D. Rapid orthodontic tooth movement aided by alveolar surgery in beagles. Am J Orthod Dentofacial Orthop 2007;131:160.e1-10. 23. Kravitz ND, Kusnoto B. Soft-tissue lasers in orthodontics: an overview. Am J Orthod Dentofacial Orthop 2008;133(Suppl):S110-4.

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