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CASE REPORT

CASE REPORT Application of palatal plate for nonextraction treatment in an adolescent boy with severe overjet
CASE REPORT Application of palatal plate for nonextraction treatment in an adolescent boy with severe overjet

Application of palatal plate for nonextraction treatment in an adolescent boy with severe overjet

Yoon-Ah Kook, a Jae Hyun Park, b Mohamed Bayome, c Chang Yoon Jung, a YoonJi Kim, a and Seong-Hun Kim d Seoul, Korea, Mesa, Ariz, and Asunci on, Paraguay

A modi ed C-palatal plate (MCPP) is introduced as a treatment option for adolescent patients with Class I maloc- clusion and severe overjet. A boy, 10 years 11 months old, was successfully treated without extractions in 22 months. Indications for clinical application of the MCPP as well as procedures and biomechanical analysis of the treatment effects are described in detail. The MCPP was used to distalize the maxillary dentition. The re- sults were stable 1 year after retention. Clinicians should consider the application of MCPP as a nonextraction treatment option for adolescents with Class I malocclusion and severe overjet when the patient or parent refuses extractions. (Am J Orthod Dentofacial Orthop 2017;152:859-69)

W ith life expectancy increasing, patients and parents are shying away from treatments that require tooth extractions. They want to

preserve what they have and are increasingly looking for nonextraction treatment options. 1-3 Distalization of the maxillary dentition is necessary for nonextraction Class II treatment, but it is challenging to achieve bodily movement without extrusion of the

molars. 4 In such cases, the palatal approach might be a key element in obtaining these results. Palatal bone thickness and density, and soft tissue thickness can usu- ally support temporary skeletal anchorage devices in adults and adolescents. 5,6 Studies have identi ed the

a Department of Orthodontics, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Korea. b Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health,

A. T. Still University, Mesa, Ariz; Graduate School of Dentistry, Kyung Hee

University, Seoul, Korea. c College of Medicine, Catholic University of Korea, Seoul, Korea; Department of Postgraduate Studies, Universidad Auton oma del Paraguay, Asunci on, Paraguay.

d Department of Orthodontics, School of Dentistry, Kyung Hee University, Seoul, Korea. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Con icts of Interest, and none were reported. Address correspondence to: Yoon-Ah Kook, Department of Orthodontics, Seoul

St. Mary's Hospital, Catholic University of Korea, 222 Banpo-daero, Seocho-Gu,

Seoul, 137-701, Korea; e-mail, kook190036@yahoo.com . Submitted, June 2016; revised and accepted, September 2016.

0889-5406/$36.00

2017 by the American Association of Orthodontists. All rights reserved.

most appropriate regions in the palate for their placement. Recently, Kook et al 7 reported on the treatment ef- fects of palatal plates in the distalization of maxillary dentitions in adults and adolescents. The modi ed C-palatal plate (MCPP) can be an important tool for correction of maxillary protrusion in patients who decline extraction treatment. However, the clinical pro- cedures and the biomechanics of this appliance have not been fully reported. We introduce the use of palatal plates in nonextrac- tion treatment of growing patients with Class I maloc- clusion and severe overjet. Indications, procedures, biomechanics, and stability of treatment with MCPPs are discussed. The indications for MCPPs are (1) Class I malocclu- sion with bimaxillary protrusion or severe overjet, (2) maxillary total distalization in patients with Class II dental relationship, (3) additional correction of severe lip protrusion after premolar extraction, (4) anterior open-bite tendency in dental Class II patients, and (5) distalization of the maxillary molars in Class III patients combined with mandibular setback to avoid extraction of the maxillary premolars. MCPPs come with 2 extended lever arms that have 3 notches on each of them. The notches are designed to provide a more secure engagement during intrusion me- chanics. The arms are connected through a body con- taining 3 miniscrew tubes (2.5 mm long) that accept

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860 Kook et al Fig 1. A, Silicon jig-MCPP complex; B, placement procedures of MCPP: a

Fig 1. A, Silicon jig-MCPP complex; B, placement procedures of MCPP: a, the palate after local anes- thesia; b , the jig-MCPP complex placed in mouth; c, miniscrews installed in the screw tubes with a contra-angle motor while the jig-MCPP complex is held in position; d , removal of the jig using a plier; e, the MCPP placed in the palate; f , the palatal bar placed on the maxillary rst molars, and power chains connected between its hooks and the MCPP hooks.

8-mm long, 2-mm diameter screws, 2 posterior and 1 anterior, located in the paramedian region to avoid the midpalatal suture. This should be considered especially important when treating adolescent patients. The 2 extended lever arms curve distally to increase the range of action of the distalizing springs or elastics and to avoid contact with the palatal archwire. MCPPs should be placed as posteriorly as possible to increase the range of action; however, bone thickness of the far posterior palate might not be suf cient to sup- port the appliances. Therefore, it is recommended to install the miniscrews for the MCPP in the region be- tween the second premolar and rst molar.

A tight adaptation between the tube and miniscrew reduces the potential for plate tipping. However, soft- tissue impingement can result when force is applied. Therefore, a silicone jig is placed on the maxillary pos- terior teeth to hold the palatal plate and to ensure the accuracy of the placement of the plate in its predeter- mined site where the arms are at a consistent distance from the palatal tissues. The plate is adapted to the selected placement site using the patient's dental casts, and the arms are adjusted to be 2 mm away from palatal soft tissues. This jig is made by applying a 3- mm thickness of silicone material on the palatal surface of the dental cast and extending it over the occlusal surfaces of the premolars (or deciduous molars) and

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Kook et al 861 Fig 2. Pretreatment intraoral and facial photographs. Fig 3. Pretreatment study models.

Fig 2. Pretreatment intraoral and facial photographs.

861 Fig 2. Pretreatment intraoral and facial photographs. Fig 3. Pretreatment study models. molars. Then, the

Fig 3. Pretreatment study models.

molars. Then, the plate is pressed gently into position,

and the jig-plate assembly is heat-cured. After

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862 Kook et al Fig 4. Pretreatment: A, panoramic radiograph; B, lateral cephalogram; and C, tracing.

Fig 4. Pretreatment: A, panoramic radiograph; B, lateral cephalogram; and C, tracing.

removing the assembly from the cast, the silicone should be removed from the screw tubes, and diagonal cuts should be made through the silicone to facilitate its removal after delivery of the plate. The assembly should be sterilized in ethylene oxide gas for 24 hours before placement ( Fig 1, A ). After administration of local anesthesia, the jig-plate assembly is placed in position. Self-drilling miniscrews are installed in the tubes using a rotary screwdriver at 30 rpm with 30 Ncm of force. The tubes are inserted into the palatal soft tissue, contacting or almost contact- ing the palatal bone. Then the jig is removed by pulling gently and rmly from each side with utility pliers, and the miniscrews are tightened manually, if necessary. The palatal bar is then placed. Distalization can be started immediately after placement by connecting the MCPP to the palatal bar with elastomeric chains or nickel-titanium closed-coil springs (Fig 1 , B ). An anal- gesic might be prescribed to alleviate the postoperative pain. See Supplemental Materials for a short video pre- sentation about this study.

DIAGNOSIS AND ETIOLOGY

A boy, aged 10 years 11 months, visited the Department of Orthodontics, Seoul St. Mary's Hospital in Korea, with chief complaints of protrusion and deepbite. He had no signicant medical and dental history. He had both protru- sive upper and lower lips with a convex prole. Due to his severe overjet and short upper lip, he showed severe lip incompetency (7-mm interlabial gap). There were no signs or symptoms of temporomandibular joint dysfunction. Intraorally, the patient had a 7-mm overjet and a 50% overbite. He had Class I molar relationships and end-on Class II canine relationships on both sides. There was mild crowding in his maxillary arch and moderate crowding in his mandibular arch with a moderate curve of Spee. His dental midlines were coincident with his facial midline ( Figs 2 and 3 ). His maxillary second molars had not erupted yet. A lateral cephalometric analysis indicated skeletal Class I (ANB, 3.5 ; Wits appraisal, 1.5 mm) with a hypodiver- gent growth pattern (FMA, 23.0 ). The maxillary and mandibular incisors were proclined (U1-FH, 121.0 ; IMPA, 96.0 ) ( Fig 4 , Table ).

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Table. Cephalometric measurements

Norm Pretreatment Posttreatment

Cephalometric analysis

SNA ( )

82.0

85.5

86.0

SNB ( )

80.0

81.5

82.0

ANB ( )

2.0

3.5

3.0

A-pointN Perp (mm)

1.1

3.0

3.5

Pog-N Perp (mm)

0.3

2.0

0.0

Wits (mm)

2.2

1.5

1.5

Harvold (mm)

35.8

27.5

33.0

Vertical skeletal pattern

Facial height ratio (P/A) (%) 66.4

66.5

70.0

FMA ( )

24.0

23.0

22.0

ODI ( )

73.3

72.0

71.5

Dental analysis

U1 to FH ( )

116.5

121.0

107.0

IMPA ( )

90.0

96.0

96.0

Interincisal angle

124.0

123.0

132.0

FH to occlusal plane ( )

10.5

5.0

7.0

Soft tissue analysis

TVL to UL (mm)

5.0

8.0

6.5

TVL to LL (mm)

2.5

5.0

4.0

TVL to Pog' (mm)

3.0

5.0

5.0

Nasolabial angle ( )

85.0

86.0

101.5

Interlabial gap (mm)

2.0

7.0

3.0

TVL, True vertical line; UL , upper lip; LL, lower lip; Pog', soft tissue pogonion.

TREATMENT OBJECTIVES

The treatment objectives were to (1) obtain normal overjet and overbite, (2) establish Class I canine relation- ships, (3) reduce lip protrusion and incompetency, and (4) improve the facial pro le and esthetics.

TREATMENT ALTERNATIVES

Considering the patient's prole and large overjet, the rst treatment option was extraction of the 4 rst premo- lars for correction of lip protrusion and incisor proclina- tion, but this method was refused by his parents. The second treatment option consisted of distalizing the whole maxillary dentition using skeletal anchorage devices. Total arch distalization would retract the incisors and reduce lip protrusion. This treatment option was chosen.

TREATMENT PROGRESS

The patient was bonded with 0.022-in Roth prescrip- tion brackets (Clippy-C; Tomy, Tokyo, Japan). A modi- ed palatal anchorage plate was placed in the palate with 3 miniscrews (2 3 8 mm; Jeil Medical, Seoul, Ko- rea). The maxillary rst molars were banded, and a palatal arch was fabricated with the arch running above the gingival margin. Approximately 250 g of distalizing force was engaged to the hooks of the palatal arch and the notches of the palatal plate by elastomeric chains.

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They were replaced once a month, and the length of the chain was updated at every visit.

TREATMENT RESULTS

The posttreatment records showed improved pro le esthetics including resolved lip incompetency and pro- trusion. The patient's overbite and overjet were also improved, and Class I canine and molar relationships were achieved with a canine-protected occlusion ( Figs 5 and 6 ). The posttreatment panoramic radiograph showed acceptable root parallelism with no signi cant sign of bone or root resorption (Fig 7 , A ). After distaliza- tion, the maxillary incisors were uprighted (U1 to FH, 121.0 to 107.0 ), and his nasolabial angle increased from 86.0 to 101.5 ( Fig 7 , B and C ; Table ). The mandibular growth that occurred during the patient's growth spurt resulted in a favorable mandibular position ( Fig 8 , A ). In the maxillary superimposition, the maxillary incisor and rst molar were retracted 2.5 mm and distal- ized 3.0 mm, respectively (Fig 8 , B). In the mandibular superimposition, vertical dentoalveolar growth was found, and the inclinations of the mandibular incisors were maintained. The mandibular plane angle was decreased by 1.0 , and the Frankfort horizontal to occlusal plane angle increased by 2.0 (Fig 8 , C ; Table ). The total treatment time was 22 months. The pa- tient maintained good occlusion and pro le for 10 months after the end of treatment ( Fig 9 ).

DISCUSSION

MCPPs have been successfully applied for distaliza- tion of the maxillary dentition to avoid 1 main disadvan- tage of headgear appliances patient compliance due at least in part to esthetics and social acceptance. 8 In this report, the growth and development of the maxillofacial structures resulted in masking of the intru- sion effect of the MCPP. In other words, this plate decreased the amount of molar extrusion that might have occurred without the treatment. Because of a hypo- divergent growth pattern, the mandibular growth was favorable; therefore, the patient had a pleasant pro le at the end of the treatment, thanks to the development of his chin. The skeletal relationship of our protrusive patient was improved ( Table ), supporting the results of a recent study that reported more signi cant skeletal ef- fects with palatal plates in adolescents than with head- gear appliances. 9 Yamada et al 10 reported 2.8 mm of distal movement of the maxillary rst molars with miniscrews in the buccal in- terradicular region. Other studies have shown about 5 mm of distal movement of the maxillary rst molars using

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864 Kook et al Fig 5. Posttreatment intraoral and facial photographs. Fig 6. Posttreatment study models.

Fig 5. Posttreatment intraoral and facial photographs.

al Fig 5. Posttreatment intraoral and facial photographs. Fig 6. Posttreatment study models. December 2017 Vol

Fig 6. Posttreatment study models.

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Kook et al 865 Fig 7. Posttreatment: A, panoramic radiograph; B, lateral cephalogram; and C, tracing.

Fig 7. Posttreatment: A, panoramic radiograph; B, lateral cephalogram; and C, tracing.

radiograph; B, lateral cephalogram; and C, tracing. Fig 8. Superimpositions: A, overall superimposition; B,

Fig 8. Superimpositions: A, overall superimposition; B, maxillary superimposition; C, mandibular su- perimposition.

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866 Kook et al Fig 9. Ten-month retention facial and intraoral photographs. conventional or bone-anchored pendulum

Fig 9. Ten-month retention facial and intraoral photographs.

conventional or bone-anchored pendulum and palatal implants. 11-13 However, these results included a

relatively large amount of distal tipping of the maxillary

rst molars. Also, the palatal implant option comes with

a high risk of damaging the incisive canal. The amount of distalization in our patient was more than 3 mm without distal tipping or the risk of nerve damage. Traditionally, clinicians have been concerned about the fate of the unerupted second molar after distaliza- tion. Several reports have shown greater distalization and distal tipping of the maxillary rst molars when the second molars were at the apical third of the rst mo- lars, acting as a fulcrum. 14,15 Kang et al 16 reported more

root movement than crown movement in the rst molars regardless of the eruption stage of the second molars when MCPPs were used. In our patient, the

second molar was still erupting at the beginning of treatment, but after distalization, it had fully erupted. The plate provides a more optimal anchorage support for total arch disalization than does a single miniscrew on each side. The amount of force required for total arch distalization using the MCPP is usually within the orthopedic range (300 g/side), similar to headgear. How- ever, miniscrews are usually functioning within the or- thodontic force levels. In a recent study of molar distalization, there were less distal tipping and extrusion with palatal plates than with buccal miniscrews. 17 Also, the MCPPs were more versatile because they had several notches that facilitated better control of the force vectors used for distalization (Fig 10 , A ). The amount of intrusion and

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Kook et al 867 Fig 10. A, Engagement of the elastomeric chains through different MCPP hooks

Fig 10. A, Engagement of the elastomeric chains through different MCPP hooks results in changing

the force vector; B, biomechanical analysis of the movement of the maxillary miniscrew distalization force ( a) and MCPP force ( b ). M, mesial; D , distal.

under buccal

rst

molar

tipping can be selected by engaging the elastics in the appropriate notch. The direction of force application and the location of the center of resistance determine the distalization pattern of the maxillary dentition. 18 With MCPPs, the force vector is occlusal to the center of resistance of the maxilla; therefore, it results in distalization and clockwise rotation of the maxillary dentition. The amount of each component depends on the distance be- tween the force vector and the center of resistance. This clockwise rotation results in intrusion of the posterior teeth, which may in turn result in a decrease of the mandibular angle and, therefore, forward positioning of the chin.

The relationship of the force vector to the center of resistance of the maxillary rst molar is essential for an understanding of the treatment effect. When the maxil- lary rst molar is distalized with a buccal miniscrew, the line of force is located coronal to the center of resistance which results in extrusion and distal tipping of the maxillary rst molar (Fig 10 , B, a ). If the most apical hook of the plate is engaged, the force vector passes close to the center of the resistance of the rst molar; therefore, it results in a minimal amount of distal tipping combined with a larger amount of distalization and intrusion of the molar ( Fig 10, B, b ). When the most cor- onal hook is engaged, there is more distal tipping and less bodily movement, and almost no intrusion would be expected.

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868 Fig 11. Biomechanical analysis of the effect of the MCPP when A, excluding the second

Fig 11. Biomechanical analysis of the effect of the MCPP when A, excluding the second molar from the archwire; B, including the second molar; and C, engaging Class III elastics.

Growth and development of the maxilla and mandible may mask the treatment effects of the MCPP. For example, maxillary growth has been reported to be forward and downward. When this growth pattern is combined with the treatment effects of a MCPP, the intrusion of the posterior teeth would be concealed by the downward growth of the maxilla. Also, the amount of distalization would be decreased due to the forward growth. 9

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If the second molar is not included in the archwire, it would tip distally, since its contact area with the rst molar is located occlusally to the line of force application. It may also show buccal tipping because of the lower resistance of that side of the bony housing. In addition, the MCPP results in more intrusion of the rst molars. The intrusion of the rst molars and distal tipping of the second molars result in the creation of an occlusal step between the rst and second molars ( Fig 11, A). Inclusion of the secpnd molar avoids these undesir- able effects and hence avoids interference between the maxillary and mandibular dentitions. It also decreases the amount of molar intrusion induced by the MCPP because the center of resistance of that system is more posterior to the center of the system when the second molar is not included ( Fig 11 , B). Intrusion of the maxillary molars induces counter- clockwise rotation of the mandible. However, in some patients, the mandibular se cond molars extrude pre- maturely and prevent the mand ibular rotation. There- fore, it might be recommend ed to place a miniscrew between the rst and second mandibular molars and intrude the second molar or hold it in its position. In patients with a protruding mandibular dentition, the application of Class III elastics results in distalization of the mandibular dentition. The reciprocal forces be- tween the mandibular and maxillary dentitions act on the mandibular side; on the maxillary dentition, it would be overcome or at least opposed by the distalization force of the MCPP ( Fig 11 , C ). The close contact between the plate and the palatal soft tissue made oral hygiene dif cult and interfered with the engagement of elastic chains, but the new version of the MCPP has reduced these problems. The shape and size of the palatal vault may play an important role in the de nition of the force vector and, conse- quently, the treatment effects. A future study is recom- mended to assess the effect of the palatal vault on the treatment effects of the MCPP.

CONCLUSIONS

The application of the MCPP was successful in distal- ization of the maxillary dentition and correction of the severe overjet without the need for extractions in this adolescent patient. Clinicians should consider the appli- cation of MCPPs in patients with Class I and severe over- jet as a nonextraction treatment option when the patient or parent denies extraction.

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SUPPLEMENTARY DATA

Supplementary data related to this article can be

033 .

REFERENCES

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