Total arch maxillary distalization using infrazygomatic crest
miniscrews in the treatment of Class II malocclusion: a
prospective study
Wilson Guilherme Nunes Rosa ; Renata Rodrigues de Almeida-Pedrin ; Paula
Vanessa Pedron Oltramari ; Ana Cla´udia Ferreira de Castro Conti ; Thais Maria
Freire Fernandes Poleti ; Bhavna Shroff ; Marcio Rodrigues de Almeida
(Angle Orthod;sept 2022)
Presented by:
Farheen Arzoo
MDS III Year
INTRODUCTION
◉Class II malocclusion is one of the most prevalent types
of malocclusion in contemporary orthodontic practice,
being observed in 38% to 50% of patients.
◉ It has been related to less favorable perceptions of facial
and dental esthetics, contributing negatively to the quality
of life and self-esteem of patients.
2
◉Class II treatment in permanent dentition during the growth
period can help establish an ideal and stable occlusion.
◉Numerous therapeutic options are available for the treatment of
Class II malocclusion, such as headgear, functional orthopedic
appliances, mandibular protraction, conventional fixed
appliances with intermaxillary elastics, and a combination of
these mechanics with tooth extractions, which have proven to
be effective;
3
◉To overcome dependence on patient compliance, temporary
anchorage devices (TADs) were introduced by Kanomi, who
placed miniscrews (MS) between the roots of posterior teeth to
promote retraction of anterior teeth. These MS were classified
as interradicular (IR).
◉However, IR MS have some major problems such as a high
rate of failure, interference with the path of tooth movement,
and impingement on the roots of adjacent teeth.
4
◉On the other hand, MS installed in the region of the
infrazygomatic crest (IZC) of the maxilla have been
highlighted in the literature, allowing free dental movement
along the path of posterior teeth since the position of the MS is
outside the roots. They may be used for various orthodontic
mechanics, such as total arch maxillary distalization, severe
crowding correction, and correction of asymmetry.
5
◉There have been several methods advocated for total arch
maxillary distalization through buccal placement of TADs.
Additionally, a modified C-palatal plate (MCPP) for maxillary
distalization has also been suggested for Class II correction.
6
AIMS AND OBJECTIVES:
◉The objective of this study was to analyze the treatment effects
of IZC MS during distalization of the whole maxillary
dentition.
◉The hypothesis was that IZC TADs would be effective for total
arch distalization.
7
8
MATERIALS AND METHODS:
The inclusion criteria: Exclusion criteria:
bilateral Class II molar posterior crossbite,
relationship,
age between 11 and 17 years syndromes
no history of previous skeletal asymmetries,
orthodontic treatment
and presence of all permanent patients in need of extractions,
teeth fully erupted, except third agenesis (except for third
molars. molars), or dental anomalies
9
◉All patients had complete orthodontic records at the beginning
(T1) of treatment and after Class II molar correction (T2).
◉The sample of 25 patients (14 females and 11 males) with an
initial mean age of 13.6 ± 1.5 years were analyzed.
10
◉Total arch distalization mechanics took place after the insertion
of a 0.017 * 0.025-inch beta-titanium archwire with crimpable
hooks placed on the distal aspect of the lateral incisors and the
placement of IZC MS (diameter: 2 mm; length: 12 mm)between
the maxillary first and second molars.
11
Distalization was initiated by engaging chain elastics (TP
Orthodontics, La Porte, Indiana) between the MS and
archwire hooks applying 350 g of force.. 12
13
14
Results:
◉ There was a significant increase in the ANB angle
◉Wits measurement showed a significant decrease (1.6 ± 2.5
mm).
◉ No significant changes were found regarding vertical growth
of the mandible.
◉A clockwise rotation of the occlusal plane was seen (2.8 ± 3.9
mm).
15
◉ There were significant decreases in the overjet (3.6 ± 2 mm)
and overbite (2.4 ±1.7 mm). Significant retroclination (13.48 ±
10.28) and retrusion of the maxillary incisors (4.3 ± 2.6 mm)
were observed.
◉Upper lips were significantly retracted (1 ± 1.2 mm) and the
nasolabial angle showed a significant increase (5.1 ± 8.3 mm).
IZC MS achieved 4 mm of maxillary first-molar distalization,
1.2 mm of intrusion, with 11.28 tipping
16
◉Also, there was 4.7 mm of retraction of the incisors, lingual
tipping of 13.48, labial movement of the apex of 0.9 mm, and
1 mm of apex extrusion (Table 3 and Figure 6). The apex of
the mesiobuccal root of the first molar was significantly
distalized by 1.3 mm.
◉The maxillary intercanine measures did not show significant
changes (Table 4). However, interpremolar (first, 2.8 mm;
second, 3.1 mm) and intermolar distances (first, 2.3 mm;
second, 1.4 mm) showed a significant increase. No significant
changes were observed in arch perimeter and arch length. 17
18
19
20
21
DISCUSSION:
◉This prospective study evaluated the treatment effects of IZC
MS. All patients showed correction of the Class II molar
relationship in a mean period of 7 months.
◉ Molar distalization of 4 mm and intrusion of 1.2 mm were
observed.
◉The maxillary incisors were retracted 4.7 mm and extruded 1
mm, which helped reduce the overjet by 3.6 mm.
22
◉Similarly, Wu et al. found distalization (3.5 mm), intrusion of
the molars (2.1 mm), and also retraction (4.3 mm) and extrusion
(3.8 mm) of the maxillary incisors during a mean treatment time
of 8 months using IZC MS.
◉ A similar magnitude of dental changes was showed by
Bechtold et al., who achieved 4.2 mm of distalization and 3.4
mm of retraction of incisors using IR MS.
23
◉Although a similar amount of molar distalization was also
achieved with IR MS, buccally placed TADs must be relocated
to retract the whole dentition posteriorly due to the limited
amount of space between the roots and the screws.
◉The current study showed greater incisor retraction, apex
extrusion, and lingual tipping compared to Lee et al., who
obtained incisor retraction of 2.9 mm and lingual tipping of the
incisor of 4.48.
24
◉Greater distal tipping of the molars was seen in the current study
versus the study of Lee et al., who found 2º distal tipping. Since
the apex moved labially 0.9 mm and the incisal edge of the
incisors moved lingually 4.7 mm, the movement can be
considered uncontrolled tipping.
◉These differences may have occurred because, in this study,
0.017 * 0.025-inch TMA wires were used in 0.022-inch slot
brackets, while Lee et al used 0.017 * 0.025-inch stainless steel
wires in 0.018-inch slot brackets, thus allowing less play
between the bracket and wire. 25
◉Another factor that influenced the results was the relationship
between the line of action of the force from MS to the
crimpable hook and the position of the center of resistance
(CR).
◉ The IZC MS promoted a clockwise rotation of the maxillary
occlusal plane because the line of force passed below the CR.
◉Rotation of the maxillary occlusal plane was expected because
it can improve the overjet and protrusion of anterior teeth in
Class II patients.
26
27
◉The differences in the amount of tooth displacement seemed to
be due to the vertical position of the MS and the height of the
hooks and variations in the direction of the force vector.
◉The MS were implanted in the IZC approximately 11 mm
above the occlusal plane and the length of the hook was
approximately 4 mm. The height of the hook could also
influence torque of the incisors and the occlusal plane rotation
and, thus, care should be taken when choosing the appropriate
biomechanics for a given patient.
28
◉The upper lip was retracted 1 mm and the nasolabial angle
increased by 5.18. Similar results were attained previously
with 1.1 mm of upper lip retraction and 5.78 increase in the
nasolabial angle using MCPP.
◉ In the present study, there was an increase in the transverse
widths between first (2.8 mm) and second (3.1 mm) premolars.
A significant increase in the distances between first and second
molars of 2.3 and 1.4 mm was also seen.
29
◉The findings of this study supported the hypothesis that IZC
MS are effective for total arch distalization in Class II
correction. In addition, IZC MS are inexpensive and there is no
need to relocate them during treatment as would be required
for IR MS. They are also simpler for clinicians to use
compared to miniplates or the MCPP.
30
◉Considering that there was an increase in ANB and clockwise
rotation of the occlusal plane when achieving maxillary total
dentition distalization using IZC MS, appropriate selection
among Class II patients for application of this method is
required.
◉The present study also had some limitations, such as the lack
of a control group, a short-term evaluation period, and the
possible influence of growth that may take place during
treatment
31
CONCLUSION:
◉IZC MS provided 4 mm of molar distalization and
uncontrolled tipping to upright maxillary incisors.
◉The occlusal plane rotated clockwise 2.88.
◉The upper lip was retracted by 1 mm and the nasolabial angle
increased 5.18.
◉There was significant expansion of the maxillary dental arch..
32
Long-term stability of miniscrew
anchored maxillary molar distalization
in Class II treatment
Till Edward Bechtold ; Young-Chel Park ; Kyung-Ho Kim ; Heekyu
Jung ; Ju-Young Kang ; Yoon Jeong Choi
(Angle Orthod;Jan 2020)
33
OBJECTIVE
◉To investigate treatment stability of miniscrew-anchored
maxillary distalization in Class II malocclusion.
34
MATERIAL AND METHODS:
◉This retrospective study included a distalization (n=19) and a
control (n=19) group; a patient group with minor corrections
served the control.
◉ Lateral cephalograms of 38 adult patients were taken before
(T0), immediately after (T1), and 3–4 years after (T2)
treatment. Horizontal and vertical movement and tipping of the
maxillary first molars (U6) and central incisors (U1) were
measured along with skeletal craniofacial parameters at three
time points to compare the two groups regarding the achieved
treatment effects and their stability 35
MEASUREMENTS:
36
RESULTS:
37
38
39
40
DISCUSION:
◉In a sample of 38 adult patients, the present study revealed
stable anterior and posterior distalization caused by maxillary
total arch distalization compared with the control group over
an average retention period of 42 months (SD =19):
◉(1) maxillary total arch distalization resulted in distal
movement and intrusion of the maxillary first molars (without
tipping), retraction and palatal tipping of the incisors (without
significant vertical movement), and steepening of the occlusal
plane;
41
◉(2) there was significant relapse of the achieved maxillary first
molar intrusion. Although counterclockwise rotation of the
mandible (increase of PFH/AFH and decrease of SN-MP) was
found in the control group, compared with the distalization
group during retention, the average range of 1.0 % PFH/AFH
and 0.98º SN-MP can be considered clinically insignificant.
42
◉The two treatment groups of adult patients differed significantly
regarding duration of treatment (P <.05). Logically, because of
the need for greater orthodontic correction, the total arch
distalization group underwent a longer treatment time than the
control group with minor tooth movements.
◉ As for the duration of retention investigated, the distalization
group had an average of over 3 years of retention.
43
◉The control group with minor tooth movement had a slightly
longer retention period of nearly 4 years.
◉Significant differences were noted between the distalization and
control group at T0 in SNB and ANB angles as well as the
vertical values PFH/AFH and SNMP.
◉ The significant Class II relationship reflected by the SNB and
ANB angle in the distalization group compared with a Class I
relation in the control group, clearly indicated the treatment
need for maxillary distalization in order to correct the Class II
occlusion. 44
◉PFH/AFH and SN-MP values revealed a neutral facial pattern
in the distalization group, while patients in the control group
showed a growth pattern that was significantly more
horizontal.
◉Post treatment changes in both groups indicated minor, yet
significant, differences in skeletal vertical changes which, on
the one hand, could be attributed to ‘‘the normal maturational
process’’ of the respective growth pattern.
45
◉In the distalization group, significant horizontal distal
movement of the U6 crowns was achieved. This was also
shown by others using different appliances and mechanics.
◉Distalizing tooth movement at the crown level alone includes
distal tipping, which has been described as a major cause of
substantial relapse
46
◉Various skeletal anchorage mechanics have been shown to
minimize distal tipping through distalization and to even
entirely control root movement.
◉significant palatal tipping was observed along with significant
crown movement, but this remained stable during the retention
period and therefore remained clinically acceptable.
47
◉In the current study’s distalization group, the insignificant
intrusion of the maxillary molars (P > .05) in combination with
significant palatal tipping of the maxillary incisors (P < .05)
resulted in an even more significant steepening of the occlusal
plane (SN-OP, P <.01), as has been shown before.
◉ The significant alterations of horizontal incisor positions
helped to significantly correct overjet in the distalization group
48
◉After treatment, the U6 on average extruded an amount to
which it had been intruded during treatment. This could
partially be ascribed to vertical relapse of the previous
intrusion by total arch distalization mechanics. Occlusal
adjustment and minor facial changes, which have been
described to take place in humans in their third decade of life,
were probably responsible for part of these measurements as
well.
49
◉Over the posttreatment time investigated, the stability of the
sagittal, vertical, and axial treatment results achieved was
impeccable in miniscrew anchored total arch distalization.
Therefore, it can be stated that, within the scope of this study,
in Class II treatment, maxillary molar distalization by total
arch distalization resulted in treatment of the anterior and
posterior dentition, as stable as treatment with minimal
mesiodistal tooth movement.
50
CONCLUSIONS:
◉Total arch distalization against miniscrews between the first
molar and second premolar can achieve translational molar
distalization, resulting in minor steepening of the occlusal
plane.
◉ Total arch distalization can achieve stable results lasting years
after retention.
◉Long-term skeletal changes may not be expected as a result of
total arch distalization
51
52
