Original Article. Shushu He a ; Jinhui Gao b ; Peter Wamalwa c ; Yunji Wang d ; Shujuan Zou e ; Song Chen f

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1 Originl Article Cmouflge tretment of skeletl Clss III mlocclusion with multiloop edgewise rch wire nd modified Clss III elstics by mxillry mini-implnt nchorge Shushu He ; Jinhui Go b ; Peter Wmlw c ; Yunji Wng d ; Shujun Zou e ; Song Chen f ABSTRACT Objective: To evlute the effect of the multiloop edgewise rch wire (MEAW) technique with mxillry mini-implnts in the cmouflge tretment of skeletl Clss III mlocclusion. Mterils nd Methods: Twenty ptients were treted with the MEAW technique nd modified Clss III elstics from the mxillry mini-implnts. Twenty-four ptients were treted with MEAW nd long Clss III elstics from the upper second molrs s control. Lterl cephlometric rdiogrphs were obtined nd nlyzed before nd fter tretment, nd 1 yer fter retention. Results: Stisfctory occlusion ws estblished in both groups. Through principl component nlysis, it could be concluded the nterior-posterior dentl position, skeletl sgittl nd verticl position, nd upper molr verticl position chnged within groups nd between groups; verticl lower teeth position nd Wits distnce chnged in the experimentl group nd between groups. In the experimentl group, the lower incisors tipped lingully 2.7 mm nd extruded 2.4 mm. The lingul inclintion of the lower incisors incresed 3.5u. The mndibulr first molrs tipped distlly 9.1u nd intruded 0.4 mm. Their cusps moved 3.4 mm distlly. In the control group, the upper incisors proclined 3u, nd the upper first molr extruded 2 mm. SN-MP incresed 1.6u nd S-Go/N- ME decresed 1. Conclusions: The MEAW technique combined with modified Clss III elstics by mxillry miniimplnts cn effectively tip the mndibulr molrs distlly without ny extrusion nd tip the lower incisors lingully with extrusion to cmouflge skeletl Clss III mlocclusions. Clockwise rottion of the mndible nd further proclintion of upper incisors cn be voided. The MEAW technique nd modified Clss III elstics provided n pproprite tretment strtegy especilly for ptients with high ngle nd open bite tendency. (Angle Orthod. 2013;83: ) KEY WORDS: Cmouflge; Skeletl Clss III; MEAW; Mxillry mini-implnts PhD student, Stte Key Lbortory of Orl Disese, Deprtment of Orthodontics, West Chin School of Stomtology, Sichun University, Chengdu, Chin. b Clinicin, Deprtment of Stomtology, Shunyi Hospitl, Beijing, Chin. c Clinicl Supervisor, Primry Helth Deprtment, Ltrobe Community Helth Service, Victori, Austrli. d Postgrdute student, Deprtment of Orthodontics, Chongqing Stomtology Hospitl, Chongqing Medicl University, Chongqing, Chin. e Professor, Stte Key Lbortory of Orl Disese, Deprtment of Orthodontics, West Chin School of Stomtology, Sichun University, Chengdu, Chin. f Associte Professor, Stte Key Lbortory of Orl Disese, Deprtment of Orthodontics, West Chin School of Stomtology, Sichun University, Chengdu, Chin. Corresponding uthor: Dr Song Chen, Associte Professor, Stte Key Lbortory of Orl Disese, Deprtment of Orthodontics, West Chin School of Stomtology, Sichun University, Section 3, No. 14, Renmin South Rod, Chengdu, Sichun, Chin (e-mil: songchen882002@hotmil.com) INTRODUCTION The prevlence of skeletl Clss III mlocclusion vries mong rces. In the white popultion the incidence hs been reported to be 1% to 5%, nd in the Asin popultions it is up to 14%. 1 5 This mlocclusion is considered one of the most difficult to tret. 5,6 Nongrowing ptients with skeletl Clss III mlocclusion could be treted by orthognthic surgery or orthodontic cmouflge tretment. In severe cses, surgicl procedures should be performed to correct the skeletl nd dentl discrepncies, s well s to improve fcil esthetics nd hrmonize the profile. 7 In borderline cses where cmouflge is possible nd Accepted: November Submitted: September Published Online: Jnury 11, 2013 G 2013 by The EH Angle Eduction nd Reserch Foundtion, Inc. 630 DOI: /

2 SKELETAL CLASS III CAMOUFLAGE TREATMENT 631 is vlid option, the tretment should cmouflge the dentl nd skeletl discrepncies to n extent tht could stisfy fcil esthetic nd functionl concerns of the ptient s much s possible. 8 This is sometimes difficult to chieve due to lck of dequte nchorge since dequte nd proper nchorge control is fundmentl to the success of orthodontic tretment. 9 A common form of cmouflge tretment strtegy for skeletl Clss III mlocclusion is the use of multiloop edgewise rch wire (MEAW) technique nd Clss III elstics, which could upright the inclintion of the lower teeth, reconstruct the occlusl plne, coordinte the width of both rches nd torque of posterior teeth, 10 nd decrese the Clss III discrepncy. 11,12 Long Clss III elstics hve been reported, however, to extrude the upper molrs nd proclined the upper incisors when upper dentition is used s the nchor unit to move the lower dentition distlly. 8,12,13 The resultnt extrusion of the upper molrs cn led to clockwise rottion of the mndible, which increses the lower nterior fcil height nd decreses the overbite. 14 This effect would be beneficil in tretment of ptients with low mndibulr plne ngle nd deep bite becuse it helps correct the mlocclusion nd lso reduces the chin prominence. Unfortuntely, high mndibulr plne ngle nd n incresed lower nterior fce height re often two clssic ntomic fetures of skeletl Clss III mlocclusion. 15 Extrusion of upper molrs with the resultnt clockwise mndibulr rottion nd increse in lower nterior fce height would be, therefore, n undesirble outcome. Long Clss III elstics my lso further procline the upper nterior teeth which re lredy proclined s prt of the dentolveolr compenstions in most skeletl Clss III ptients, compromising the profile esthetic outcome nd stbility of the tretment. 15 To provide more pproprite nchorge nd eliminte intermxillry Clss III elstics, extrorl pplinces such s mndibulr cervicl hedger, high-pull hedger, nd hedger with J-hook hve been trditionlly employed for distl movement of the lower rch in the tretment of skeletl Clss III mlocclusion. 11,12 Mjor disdvntges of extrorl nchorge re its generl inconvenience, limited wering time, nd high dependence on ptient coopertion. The im of this study ws to evlute the effects of the MEAW technique with mxillry mini-implnt nchorge for modified Clss III elstics in the tretment of ptients with skeletl Clss III mlocclusion. MATERIALS AND METHODS The study ws pproved by the ethicl bord of Sichun University. Prticiption ws voluntry, nd informed consent documents were signed by ll Figure 1. Cephlometric ngulr mesurements. (1) SNA. (2) SNB. (3) ANB. (4) SN-OP. (5) SN-MP. (6) U1-L1. (7) L1-MP. (8) L6-MP. (9) U1-SN. prticipnts before they entered this retrospective study. Forty-four nongrowing ptients with skeletl Clss III mlocclusions t the Deprtment of Orthodontics, West Chin Hospitl of Stomtology, Chengdu, Chin, were included in this study. Inclusion criteri were: (1) mild to moderte skeletl Clss III reltionship (24u # ANBu # 0u); (2) Angle Clss III molr reltionship bilterlly; (3) no or mild crowding (,4 mm); (4) lck of functionl mndibulr shift nd inbility of the mndible to move bck spontneously; nd (5) lck of temporomndibulr disorder symptoms. The experimentl group consisted of 20 ptients (10 mle nd 10 femle) who were treted with MEAW nd modified Clss III elstics from the mxillry mini-implnts. The control group consisted of 24 ptients (10 mle nd 14 femle) who were treted with MEAW nd long Clss III elstics from the upper second molrs. All of the ptients were treted with inch predjusted edgewise pplinces. Mndibulr third molrs were extrcted before tretment, if presented. All of the teeth were bnded or bonded, including the second molrs in both rches. After initil lignment nd leveling hd been chieved by sequentil use of round to rectngulr Ni-Ti wires, MEAW inch stinless steel wire ws plced on

3 632 HE, GAO, WAMALWA, WANG, ZOU, CHEN Figure 2. Cephlometric liner mesurements: FHV (McNmr line) ws drwn perpendiculr to FH plne from the nsion. : (1) A-McNmr line. (2) Pog-McNmr line. (3) U1-FHV, perpendiculr distnce from the edge of upper incisors to FHV. (4) L1-FHV, perpendiculr distnce from the edge of lower incisors to FHV. (5) U6-FHV, perpendiculr distnce from the mesil cusp of upper first molr to FHV. (6) L6-FHV, perpendiculr distnce from the mesil cusp of lower first molr to FHV. (7) U1-PP, perpendiculr distnce from the edge of upper incisors to pltl plne. (8) L1-MP, perpendiculr distnce from the edge of lower incisors to mndibulr plne. (9) U6-PP, perpendiculr distnce from the mesil cusp of upper first molr to pltl plne. (10) L6-MP, perpendiculr distnce from the mesil cusp of lower first molr to mndibulr plne. b: (11) S-Go. (12) N-Me. (13) Wits pprisl. (14) E line to upper lip. (15) E line to lower lip. the lower rch nd stright stinless steel wire, size inch, ws plced on the upper. The multiloop edgewise rch wire (MEAW) hd reverse curve of Spee incorported into it through series of 3u to 5u tip-bck bends on ech tooth beginning with the first premolr nd progressing posteriorly to the second molr. Mini-implnts 1.6 mm in dimeter nd 9 mm in length were plced in the buccl interrdiculr spces between the upper second premolrs nd the first molrs in the experimentl group. Symmetric or symmetric light Clss III elstics, size 5/16 inch nd weight 3.5 ounces, were used from the implnts in the experimentl group nd from the upper second molrs in the control group to the first loops on the MEAW (mesil to the cnines) to resolve the Clss III mlocclusion nd/or to correct ny lower midline shift. The Clss III elstics were used until Clss I molr nd cnine reltionship ws chieved nd for 2 more months fter this to improve the stbility of the result. Detiling nd setting of the occlusion were done on the sme rch wires with djustments in the MEAW rch wires s necessry. Hwley retiners were plced on both rches immeditely fter the removl of the fixed pplinces. Digitl lterl cephlometric rdiogrphs nd pnormic rdiogrphs were tken by the sme X-ry mchine before tretment (T1, T19), immeditely fter the ctive tretment (T2, T29), nd 1 yer fter retention (T3, T39). T1, T2, nd T3 represent the experimentl group, nd T19, T29, nd T39 the control group. All of the lterl cephlometric rdiogrphs were rndomly numbered nd ptients identities were conceled during cephlometric nlysis. The rdiogrphs were digitlly nlyzed using WinCeph softwre version 7.0 for Windows (Rise Corportion, Sendi, Jpn). The lndmrks identified, the cephlometric plnes, nd the prmeters used in the cephlometric nlysis re shown in Figures 1 nd 2. Ech rdiogrph ws nlyzed three times by one experienced investigtor, nd the men vlue of ech prmeter ws used for further nlysis. Twenty rndomly selected rdiogrphs were mesured 1 month prt to test the relibility of the mesurements. A pired smple t-test showed high introbserver relibility of the mesurements (P..05). Principl component nlysis ws employed to groupcorrelted vribles into sets of uncorrelted vribles clled principl components. Comprison of the extrcted principl components nd originl mesurements within group ws done by pired-smple t-test or by Wilcoxon signed rnk test. Comprison of chnges between groups ws done by independent-smples

4 SKELETAL CLASS III CAMOUFLAGE TREATMENT 633 Figure 3. Photogrphs of one ptient in the experimentl group. (A) Profiles pretretment nd posttretment, nd 1 yer fter retention. (B) Introrl photogrphs pretretment. (C) Introrl photogrphs during tretment. (D) Introrl photogrphs posttretment. (E) Introrl photogrphs 1 yer fter retention. t-test or by Mnn-Whitney U-test. All sttisticl nlysis ws done using SPSS softwre for Windows (relese 16.0, stndrd version, SPSS, Chicgo, Ill). The level of sttisticlly significnt differences ws P,.05. RESULTS Stisfctory occlusion ws estblished for ll ptients. No one exhibited ny temporomndibulr problems. One mini-implnt loosened nd ws replced Tble 1. Summry of Principl Component Anlysis Principl Component Vrince Explined, % Cumultive Vrince, % Vribles Representtion U1-FHV (mm), U1-SN (u), L1-FHV (mm), Anterior-posterior dentl position L1-MP (u), U1-LI (u), L6-FHV (mm) A-Mc line (mm), Pog-McN line (mm), SNA (u), Skeletl sgittl nd verticl position SNB (u), S-Go/N-ME, SN-MP (u), ODI U6-PP (mm) Upper molr verticl position ANB (u), APDI, Wits distnce (mm), overjet (mm) Sgittl skeletl nd dentl discrepncy SN-MP (u), S-Go/N-ME, SNA (u), SNB (u) Sgittl nd verticl skeletl position Overbite (mm), U6-PP (mm), U1-PP (mm) Overbite, verticl upper teeth position L6-MP (mm), L1-MP (mm) Verticl lower teeth position Wits distnce Wits discrepncy

5 634 HE, GAO, WAMALWA, WANG, ZOU, CHEN Tble 2. Comprison of Six Principl Components Within Groups nd Between Groups During Observtion Principl T2-T1 T3-T2 T29-T19 T39-T29 TC vs TC9 RC vs RC9 Component P Sig P Sig P Sig P Sig P Sig P Sig ***.012 *.001 ***.000 ***.000 ***.000 *** NS.218 NS.290 NS.440 NS.109 NS.125 NS NS.709 NS.689 NS.162 NS.509 NS.229 NS NS.737 NS.346 NS.424 NS.229 NS.423 NS ***.455 NS.130 NS.775 NS.005 ***.465 NS ***.911 NS.037 *.841 NS.003 ***.888 NS T1 indictes experimentl group before tretment; T2, experimentl group post tretment; T3, experimentl group 1 yer fter retention; TC, tretment chnges of experimentl group; RC, retention chnges of experimentl group; T19, control group before tretment; T29, control group post tretment; T39, control group 1 yer fter retention; TC9: tretment chnges of control group; nd RC9, retention chnges of control group. * P,.05; ** P,.01; *** P,.001. NS indictes not significnt. in the experimentl group. The totl tretment times of the experiment group nd the control group were 14 months nd 18.5 months, respectively. Figure 3 shows one ptient in the experimentl group. Principl Component Anlysis Six principl components were extrcted nd compred in Tbles 1 nd 2. Further sttistics were done to get more detiled informtion. Tble 3. Comprison of Ptients in Experimentl Group nd Control Group t T1 T1 T19 T1 vs T19 Men SD Men SD P Significnce Age, y NS SNA, degrees NS SNB, degrees NS ANB, degrees NS OP-SN, degrees NS SN-MP, degrees NS S-Go/N-ME NS A-McN line, mm *** Pog-McN line, mm *** APDI NS ODI NS U1-L1, degrees * U1-SN, degrees ** L1-MP, degrees NS L6-MP, degrees NS U1-PP, mm ** U6-PP, mm ** L1-MP, mm NS L6-MP, mm NS U1-FHV, mm ** U6-FHV, mm NS L1-FHV, mm ** L6-FHV, mm NS Wits pprisl NS Overjet, mm NS Overbite, mm NS UL-EP, mm NS LL-EP, mm NS T1 indictes experimentl group before tretment; T19, control group before tretment. McN line indictes McNmr line, line perpendiculr to FH plne from the nsion; PTV, line perpendiculr to FH plne from the nsion; U1-FHV, perpendiculr distnce from the edge of upper incisors to FHV; L1-FHV, perpendiculr distnce from the edge of lower incisors to FHV; U6-FHV, perpendiculr distnce from the mesil cusp of upper first molr to FHV; L6-FHV, perpendiculr distnce from the mesil cusp of lower first molr to FHV; the vlue ws defined s negtive (2) when the point ws behind the line. L1-MP, the posterior ngle between the xis of lower incisors nd mndibulr plne; L6- MP, the posterior ngle between the xis of lower first molr nd mndibulr plne. * P,.05; ** P,.01; *** P,.001. NS indictes not significnt.

6 SKELETAL CLASS III CAMOUFLAGE TREATMENT 635 Tble 4. Cephlometric Anlysis of Ptients in Experimentl Group After Tretment nd Retention T2 T3 TC (T2-T1) RC (T3-T2) Men SD Men SD Men SD P Sig Men SD P Sig SNA, degrees NS NS SNB, degrees NS NS ANB, degrees NS NS OP-SN, degrees *** * SN-MP, degrees NS NS S-Go/N-ME NS NS A-McN line, mm NS NS Pog-McN line, mm ** NS APDI *** * ODI ** *** U1-L1, degrees *** NS U1-SN, degrees ** NS L1-MP, degrees *** NS L6-MP, degrees *** ** U1-PP, mm NS NS U6-PP, mm NS NS L1-MP, mm *** NS L6-MP, mm ** NS U1-FHV, mm NS NS U6-FHV, mm *** ** L1-FHV, mm *** * L6-FHV, mm *** *** Wits pprisl *** NS Overjet, mm *** NS Overbite, mm *** ** UL-EP, mm NS NS LL-EP, mm ** NS T1 indictes experimentl group before tretment; T2, experimentl group post tretment; T3, experimentl group 1 yer fter retention; TC, tretment chnges of experimentl group; nd RC, retention chnges of experimentl group. McN line indictes McNmr line, line perpendiculr to FH plne from the nsion; PTV, line perpendiculr to FH plne from the nsion; U1-FHV, perpendiculr distnce from the edge of upper incisors to FHV; L1-FHV, perpendiculr distnce from the edge of lower incisors to FHV; U6-FHV, perpendiculr distnce from the mesil cusp of upper first molr to FHV; L6-FHV, perpendiculr distnce from the mesil cusp of lower first molr to FHV; the vlue ws defined s negtive (2) when the point ws behind the line. L1-MP, the posterior ngle between the xis of lower incisors nd mndibulr plne; L6- MP, the posterior ngle between the xis of lower first molr nd mndibulr plne. * P,.05; ** P,.01; *** P,.001. NS indictes not significnt. Within-group Comprisons After Active Tretment Tble 3 shows ges nd cephlometric nlysis of the two groups before tretment. Descriptive sttistics nd comprisons fter tretment re shown in Tbles 4 nd 5. Posttretment mesurements show OP-SN, Pog-McN, APDI, L1-MP (u), L6-MP (u), L1-FHV, nd L6-FHV decresed significntly, nd L1-MP (mm), Wits distnce, overjet, overbite, nd ODI incresed significntly in both groups. For the experimentl group, U1-SN nd U1-L1 incresed significntly, nd U6-FHV, L6-MP (mm), nd LL-EP decresed significntly. The lower incisors tipped lingully 2.7 mm nd extruded 2.4 mm. The lingul inclintion of the lower incisors incresed 3.5u. The mndibulr first molrs tipped distlly 9.1u nd intruded 0.4 mm. Their cusps moved 3.4 mm distlly. The occlusl plne showed counterclockwise rottion of 2.5u. The distnce of lower lip to E line decresed 0.8 mm. In the control group, U1-SN nd S-Go/N-Me decresed significntly nd SN-MP, U6-PP, U1-PP, U1-FHV, UL-EP, L6-MP, nd LL-EP incresed significntly. The upper incisors proclined 3u nd the upper first molr extruded 2 mm. SN-MP incresed 1.6u nd S-Go/N-ME decresed 1u. Superimpositions of cephlometric trcings of smples in two groups t pretretment nd posttretment re presented in Figure 4. Within-group Comprisons During Retention During the retention time, severl mesurements chnged significntly in the experimentl group nd even more chnged in the control group, but the chnges were very smll. From clinicl observtion, the occlusion ws well mintined. Between-group Comprisons of Chnges During Tretment nd Retention During tretment, the chnges of severl mesurements such s S-Go/N-ME, U1-SN, nd U6-PP were

7 636 HE, GAO, WAMALWA, WANG, ZOU, CHEN Tble 5. Cephlometric Anlysis of Ptients in Control Group After Tretment nd Retention T29 T39 TC9 (T29-T19) RC9 (T39-T29) Men SD Men SD Men SD P Sig Men SD P Sig SNA, degrees NS NS SNB, degrees NS NS ANB, degrees NS NS OP-SN, degrees *** *** SN-MP, degrees *** ** S-Go/N-ME *** ** A-McN line, mm NS NS Pog-McN line, mm * ** APDI ** *** ODI ** *** U1-L1, degrees NS NS U1-SN, degrees *** ** L1-MP, degrees ** * L6-MP, degrees *** NS U1-PP, mm *** ** U6-PP, mm *** * L1-MP, mm *** *** L6-MP, mm ** NS U1-FHV, mm *** ** U6-FHV, mm NS NS L1-FHV, mm ** NS L6-FHV, mm *** * Wits pprisl *** *** Overjet, mm *** ** Overbite, mm *** ** UL-EP, mm *** * LL-EP, mm ** NS T19 indictes control group before tretment; T29, control group post tretment; T39, control group 1 yer fter retention; TC9: tretment chnges of control group; nd RC9, retention chnges of control group. McN indictes McNmr line, line perpendiculr to FH plne from the nsion; PTV, line perpendiculr to FH plne from the nsion; U1-FHV, perpendiculr distnce from the edge of upper incisors to FHV; L1-FHV, perpendiculr distnce from the edge of lower incisors to FHV; U6-FHV, perpendiculr distnce from the mesil cusp of upper first molr to FHV; L6-FHV, perpendiculr distnce from the mesil cusp of lower first molr to FHV; the vlue ws defined s negtive (2) when the point ws behind the line. L1-MP, the posterior ngle between the xis of lower incisors nd mndibulr plne; L6-MP, the posterior ngle between the xis of lower first molr nd mndibulr plne. * P,.05; ** P,.01; *** P,.001. NS indictes not significnt. significntly different (Figure 5; Tble 6). During retention, the chnges of ODI, U1-SN, for exmple, were significntly different. DISCUSSION Orthodontists re still striving to develop biomechnicl systems tht cn overcome the undesired side effects of extrusion of nchorge teeth, mndibulr rottion, nd increse in lower nterior fce height when treting skeletl Clss III mlocclusions. 11,12,16,17 In the tretment of Clss III ptients using protrction hedger or during mxillry expnsion, for instnce, prevention of dverse verticl tooth movements nd mndibulr counterclockwise rottion re desirble, prticulrly in ptients with n open bite tendency. 16,17 Cmouflge tretment does not exclude orthodontists from better controlling tooth movements. On the contrry, tretment with more rtionl mechnicl systems should be developed to improve tretment results. Successful cmouflge tretment should cmouflge both the skeletl nd soft tissue discrepncies, chieve good nd cceptble fcil esthetic result, nd estblish stble occlusion. Both kinds of orthodontic tretments to cmouflge the skeletl Clss III mlocclusion in this study chieved good occlusion nd were stble fter 1 yer, though observtion in the long term is still needed. Chnges of principl component 1 indicted tht the nterior-posterior dentl position, skeletl sgittl nd verticl position, nd upper molr verticl position chnged during tretment within groups nd between groups; chnges of components 5 nd 6 in the experimentl group nd between-group comprisons demonstrted tht verticl lower teeth position nd Wits vlues chnged in experimentl group, nd the mount of chnges vried between the two groups. More specificlly, both groups exhibited decrese of pogonion to McNmr line (Pog-McN line), APDI, L1-MP (u), L6-MP (u), L1-FHV, L6-FHV, OP-SN, nd

8 SKELETAL CLASS III CAMOUFLAGE TREATMENT 637 Figure 4. Superimpositions of cephlometric trcings on sell-nsion plne t sell t pretretment (blck line) nd posttretment (dotted line). (A) One smple in the experimentl group. (B) One smple in the control group. n increse regrding L1-MP (mm), Wits pprisl, overjet, overbite, nd ODI, which contribute to the correction of occlusl reltionship. The Pog to McNmr line liner distnce decresed, indicting reduction in the chin prominence. The significnt decrese in the APDI nd Wits distnce indicted reduction in the nterior-posterior discrepncy. The reduction in ODI demonstrted decrese in the tendency to hve n open bite. Some tretment effects, however, were quite different between the two groups. In the experimentl group, there ws no extrusion of upper molrs or ny clockwise rottion of the mndible. Norml overjet nd overbite were chieved minly through distl movement of lower dentition nd extrusion of the lower incisors. The upper incisors were not further proclined, nd were, in fct, retrcted little becuse of brodening of the upper rch. The upper incisors were just little extruded nd this helped estblish n dequte overbite with the lower incisors, while the ptients hd no gummy smile fter the tretment. The mndibulr first molrs were tipped distlly, effectively without ny extrusion. In the control group, however, the upper incisors were proclined, the upper molrs were extruded, nd the nterior fce height nd the mndibulr ngle were incresed. These chnges resulting from intermxillry Clss III elstics would be n undesirble outcome in ptients with open bite, long fce, or high mndibulr plne ngle nd should be voided for fcil blnce nd esthetics. 16,18,19 The lower lip is often protruded in reltion to the upper in skeletl Clss III ptients. 20 The reduction of lower lip protrusion in the experimentl group improved fcil esthetics, while the upper nd lower lips becme more protrusive in the control group. The successful cmouflge tretment of ptients in the experimentl group depended on the proper selection of ptients, effective nd efficient mechnics of the system, nd stisfctory nchorge control. All ptients in this study hd mild to moderte skeletl Clss III reltionship, cceptble profiles, nd slight crowding on both dentitions, nd this mde nonsurgicl tretment possible. Verticl discrepncies such s high mndibulr plne ngle nd horizontl discrepncies such s crossbite nd mndibulr devition in some ptients, however, my complicte the cmouflge tretment. All pretretment pnormic rdiogrphs showed lower posterior teeth to be mesilly tipped, mking the MEAW technique suitble for cmouflge tretment of these ptients. Mini-implnts in the upper lveolr bone were used to provide nchorge needed to correct the Clss III mlocclusion. Ptients hve been reportedly treted by mini-implnts in the mndible to move lower molrs distlly without the MEAW technique with good results. 21,22 In order to distlly upright the lower teeth

9 638 HE, GAO, WAMALWA, WANG, ZOU, CHEN Figure 5. Significntly different tretment effects between groups. without hindering tooth movement, the mini-implnt in the mndible sometimes hs to be plced in the retromolr region, the rmus, or the mndibulr externl oblique line. It is more difficult nd flp surgery my be needed, sometimes cusing greter tissue dmge. Insertion of mini-implnts in the upper jw is esier in prctice, is ssocited with less pin nd discomfort, nd shows higher success rte. Severl clinicins hve observed tht the corticl bone of the mndible is thick reltive to the mxill, which cuses insertion torque to be higher, nd so filure rte of insertion in the mndible is firly high. 23,24 The buccl interrdiculr spce between the upper second premolr nd the first molr, the inserting position in this

10 SKELETAL CLASS III CAMOUFLAGE TREATMENT 639 Tble 6. Comprison of Tretment nd Retention Chnges of Ptients Between Experimentl Group nd Control Group TC vs TC9 RC vs RC9 P Significnce P Significnce SNA, degrees.425 NS.362 NS SNB, degrees.131 NS.800 NS ANB, degrees.859 NS.795 NS OP-SN, degrees.114 NS.329 NS SN-MP, degrees.002 **.748 NS S-Go/N-ME.000 ***.106 NS A-McN line, mm.615 NS.145 NS Pog-McN line, mm.903 NS.640 NS APDI.009 **.981 NS ODI.304 NS.001 ** U1-L1, degrees.003 **.066 NS U1-SN, degrees.000 ***.001 ** L1-MP, degrees.168 NS.605 NS L6-MP, degrees.037 *.133 NS U1-PP, mm.023 *.031 * U6-PP, mm.000 ***.133 NS L1-MP, mm.085 NS.908 NS L6-MP, mm.017 *.028 * U1-FHV, mm.000 ***.207 NS U6-FHV, mm.001 **.004 ** L1-FHV, mm.013 *.327 NS L6-FHV, mm.020 *.387 NS Wits pprisl.005 **.248 NS Overjet, mm.207 NS.053 NS Overbite, mm.095 NS.527 NS UL-EP, mm.000 ***.117 NS LL-EP, mm.000 ***.025 * TC indictes tretment chnges of experimentl group; RC, retention chnges of experimentl group; TC9, tretment chnges of control group; nd RC9, retention chnges of control group. McN indictes McNmr line, line perpendiculr to FH plne from the nsion; PTV, line perpendiculr to FH plne from the nsion; U1-FHV, perpendiculr distnce from the edge of upper incisors to FHV; L1- FHV, perpendiculr distnce from the edge of lower incisors to FHV; U6-FHV, perpendiculr distnce from the mesil cusp of upper first molr to FHV; L6-FHV, perpendiculr distnce from the mesil cusp of lower first molr to FHV; the vlue ws defined s negtive (2) when the point ws behind the line. L1-MP, the posterior ngle between the xis of lower incisors nd mndibulr plne; L6-MP, the posterior ngle between the xis of lower first molr nd mndibulr plne. * P,.05; ** P,.01; *** P,.001. NS indictes not significnt. study, is the most populr loction for insertion of miniimplnt for ntomic considertions since this re is usully firly wide. 23 Also, the force direction of Clss III elstics from the first lower loop to the mxillry mini-implnt is suitble for the extrusion of lower nterior teeth nd, therefore, cn benefit the open bite nd occlusl plne correction. Plcing the mini-implnt in the mxill, therefore, is n lterntive, especilly when it is difficult to insert in the mndible for some ptients. Ptients esily wore nd replced the elstics with little discomfort, nd complince ws high. The Clss III elstics were used for less thn 6 months in the experimentl group. CONCLUSIONS N The MEAW technique with modified Clss III elstics by mxillry mini-implnts cn effectively tip the mndibulr molrs distlly without ny extrusion nd tip the lower incisors lingully with extrusion to cmouflge skeletl Clss III mlocclusions. N Clockwise rottion of the mndible nd further proclintion of upper incisors cn be voided. The MEAW technique nd modified Clss III elstics provides n pproprite tretment strtegy especilly for ptients with high ngle nd open bite tendency. REFERENCES 1. Mssler M, Frnkel JM. Prevlence of mlocclusion in children ged 14 to 18 yers. Am J Orthod. 1951;37: Thilnder B, Myrberg N. The prevlence of mlocclusion in Swedish schoolchildren. Scnd J Dent Res. 1973;81: Irie M, Nkmur S. Orthopedic pproch to severe skeletl Clss III mlocclusion. Am J Orthod. 1975;67: Bccetti T, Reyes BC, McNmr JA Jr. Gender differences in Clss III mlocclusion. Angle Orthod. 2005;75: Cozz P, Mrino A, Mucedero M. An orthopedic pproch to the tretment of Clss III mlocclusions in the erly mixed dentition. Eur J Orthod. 2004;26: Km JD, Ozer T, Brn S. Orthodontic nd orthopedic chnges ssocited with tretment in subjects with Clss III mlocclusions. Eur J Orthod. 2006;28: Chew MT. Soft nd hrd tissue chnges fter bimxillry surgery in Chinese Clss III ptients. Angle Orthod. 2005; 75: Hiller ME. Nonsurgicl correction of Clss III open bite mlocclusion in n dult ptient. Am J Orthod Dentofcil Orthop. 2002;122: Deguchi T, Tkno-Ymmoto T, Knomi R, Hrtsfield JK Jr, Roberts WE, Gretto LP. The use of smll titnium screws for orthodontic nchorge. J Dent Res. 2003;82: Kim YH. Anterior openbite nd its tretment with multiloop edgewise rchwire. Angle Orthod. 1987;57: Mor DR, Oberti G, Elo M, Bccetti T. Cmouflge of moderte Clss III mlocclusions with extrction of lower second molrs nd mndibulr cervicl hedger. Prog Orthod. 2007;8: Kurod Y, Kurod S, Alexnder RG, Tnk E. Adult Clss III tretment using J-hook hedger to the mndibulr rch. Angle Orthod. 2010;80: Bek SH, Shin SJ, Ahn SJ, Chng YI. Initil effect of multiloop edgewise rchwire on the mndibulr dentition in Clss III mlocclusion subjects. A three-dimensionl finite element study. Eur J Orthod. 2008;30: Sto S. Cse report: developmentl chrcteriztion of skeletl Clss III mlocclusion. Angle Orthod. 1994;64: ; discussion Mcey-Dre LV. The erly mngement of Clss III mlocclusions using protrction hedger. Dent Updte. 2000;27: Dos Sntos BM, Stuni AS, Fri G, Quinto CC, Ssso Stuni MB. Soft tissue profile chnges fter rpid mxillry expnsion with bonded expnder. Eur J Orthod. 2012;34:

11 640 HE, GAO, WAMALWA, WANG, ZOU, CHEN 17. Goyenc Y, Ersoy S. The effect of modified reverse hedger force pplied with fcebow on the dentofcil structures. Eur J Orthod. 2004;26: Bene RA, Reimnn G, Phillips C, Tulloch C. A cephlometric comprison of blck open-bite subjects nd blck normls. Angle Orthod. 2003;73: Profitt WR. Interrch elstics: their plce in modern orthodontics. In: Hösl E, Blduf A, eds. Mechnicl nd Biologicl Bsics in Orthodontic Therpy. Heidelberg, Germny: Huthig Buchverlg GmbH; 1991: Gelgor IE, Krmn AI. Non-surgicl tretment of Clss III mlocclusion in dults: two cse reports. J Orthod. 2005;32: Chung KR, Kim SH, Choo H, Kook YA, Cope JB. Distliztion of the mndibulr dentition with mini-implnts to correct Clss III mlocclusion with midline devition. Am J Orthod Dentofcil Orthop. 2010;137: Chung K. C-orthodontic microimplnt for distliztion of mndibulr dentition in Clss III correction. Angle Orthod. 2005;75: Te-Woo, Kim., Kim H. Clinic Appliction of Orthodontic Mini-Implnt. Seoul, South Kore: Myung Mun Publishing; Crno A, Velo S, Leone P, Sicilini G. Clinicl pplictions of the Miniscrew Anchorge System. J Clin Orthod. 2005; 39:9 24; quiz

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