A comparison of treatment effects of total arch distalization using modified C-palatal plate vs buccal miniscrews

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1 Originl Article A comprison of tretment effects of totl rch distliztion using modified C-pltl plte vs uccl miniscrews Sng Kyu Lee ; Noh H. As ; Mohmed Byome c,d ; Un-Bong Bik ; Yoon-Ah Kook e ; Mihee Hong f ; Je Hyun Prk g,h ABSTRACT Ojective: The purpose of this study ws to compre the tretment effects of pltlly vs ucclly plced temporry nchorge devices. Mterils nd Methods: Of 40 Clss II division 1 mlocclusion ptients, 22 were treted with modified C-pltl plte (MCPP) pplinces (ge yers), nd 18 (ge yers) were treted with ucclly plced miniscrews etween the mxillry first molr nd second premolr. A totl of 26 liner nd ngulr mesurements were nlyzed on pre- nd posttretment lterl cephlogrms. Multivrite nlysis of vrince ws performed to evlute the tretment effects within ech group nd to compre the effects etween groups. Results: Overll, the MCPP pplinces showed 4.2 mm of distliztion, 1.6 mm of intrusion of the first molr with 28 tipping, nd 0.8 mm extrusion of incisors. The miniscrew group resulted in 2.0 mm of distliztion, 0.1 mm intrusion of the first molr with 7.28 tipping, nd 0.3 mm of incisor extrusion. Regrding soft tissue chnge, in the MCPP group, the upper lip ws significntly retrcted (P,.001). Conclusions: Compring the tretment effects etween MCPP pplinces nd uccl miniscrews, the MCPP pplinces showed greter distliztion nd intrusion with less distl tipping of the first molr nd less extrusion of the incisor compred to the uccl miniscrews. (Angle Orthod. 2018;88:45 51.) KEY WORDS: Totl rch distliztion; Modified C-pltl plte (MCPP) pplinces; Buccl miniscrews; Temporry nchorge devices (TADs) Privte Prctice, Seoul, Kore. Assistnt Professor, Deprtment of Orthodontics, Fculty of Dentistry, Ain Shms University, Ciro, Egypt. c Reserch Assistnt Professor, Deprtment of Dentistry, College of Medicine, The Ctholic University of Kore, Seoul, Kore. d Visiting Professor, Deprtment of Postgrdute Studies, the Universidd Autonóm del Prguy, Asunción, Prguy. e Professor, Deprtment of Orthodontics, Seoul St. Mry s Hospitl, College of Medicine, The Ctholic University of Kore, Seoul, Kore. f Assistnt Professor, Deprtment of Orthodontics, School of Dentistry, Kyungpook Ntionl University, Degu, Kore. g Professor nd Chir, Postgrdute Orthodontic Progrm, Arizon School of Dentistry & Orl Helth, A.T. Still University, Mes, AZ, USA. h Interntionl Scholr, Grdute School of Dentistry, Kyung Hee University, Seoul, Kore. Corresponding Author: Dr. Je Hyun Prk, Postgrdute Orthodontic Progrm, Arizon School of Dentistry & Orl Helth, A.T. Still University, 5835 Est Still Circle, Mes, AZ (e-mil: JPrk@tsu.edu) Accepted: August Sumitted: June Pulished Online: Octoer 5, 2017 Ó 2018 y The EH Angle Eduction nd Reserch Foundtion, Inc. INTRODUCTION Temporry nchorge devices (TADs) hve ecome n essentil prt of orthodontic tretment, especilly in nonextrction cses. TADs hve overcome the disdvntges of erlier extr- nd introrl pplinces, such s dependence on ptient complince, nchorge loss, incresed distl tipping, nd the extrusion of first molrs. 1 4 TADs hve een used indirectly for molr distliztion through one-nchored pplinces such s the pendulum nd distl jet. However, some disdvntges remin with these pplinces, such s the lrge mount of distl tipping creted y the force delivery system. 5,6 Severl methods hve een pplied for the distliztion of the mxillry dentition through uccl plcement of TADs Minipltes hve een plced in the infrzygomtic region, 12 ut this pproch requires the surgicl plcement nd removl of one plte on ech side. Alterntively, miniscrews cn e instlled ucclly into interrdiculr spces. 10,11 This DOI: /

2 46 LEE, ABBAS, BAYOME, BAIK, KOOK, HONG, PARK Figure 1. (A) The MCPP pplince ws plced on the plte nd connected to the pltl r instlled on the mxillry first molrs for totl rch distliztion. (B) A miniscrew ws plced ucclly etween the mxillry first molr nd second premolr. An elstic chin ws connected etween the miniscrew nd hook welded to the distl wing of the cnine rcket. procedure is less invsive thn the infrzygomtic pltes, ut it comes with higher risk of injury to the roots of the djcent teeth. The pltl pproch of TAD plcement hs een suggested y some clinicins Recently, the use of the modified C-pltl plte (MCPP) for mxillry rch distliztion ws reported for Clss II corrections in oth dolescents nd dults. 1,16 21 The MCPP is distliztion pplince with lrge rnge of ction tht cn e esily plced without rising flp. It lso hs een shown to hve the cpility of verticl control during distliztion. Using finite element nlysis, distliztion with pltl plte rther thn mini-implnts on the uccl side provided odily molr movement without tipping or extrusion 22 ; ut no clinicl comprison hs een mde etween the two pproches. Therefore, the purpose of this study ws to compre the tretment effects of pltlly vs ucclly plced temporry nchorge devices. MATERIALS AND METHODS The smple for this retrospective study consisted of pre- (T1) nd posttretment (T2) lterl cephlogrms of 40 ptients: 22 were treted with MCPP pplinces (ge yers) t the Deprtment of Orthodontics, Seoul St. Mry s Hospitl, The Ctholic University of Kore, nd 18 were treted with distliztion vi miniscrews plced ucclly in the interrdiculr spce (ge yers) in privte prctice office. Smple size clcultion showed tht t lest 16 cses were required in ech group to identify n effect size of 1 unit, provided tht lph is.05 nd et is.2 ( Approvl ws grnted y the institutionl review ord of the Ctholic University of Kore (KC11RA- SI0790), nd informed consent ws otined ccording to the Declrtion of Helsinki. The inclusion criteri were the following: (1) dult ptients, (2) skeletl clss I reltionship with dentl Clss II division 1 mlocclusion nd normovergent growth pttern, (3) moderte mxillry rch crowding (less thn 5 mm) with mxillry protrusion, (4) nonextrction tretment, (5) mxillry molr distliztion tht ws chieved y either MCPPs or ucclly plced miniscrews exclusively, (6) sence of crniofcil syndromes, nd (7) the vilility of good-qulity lterl cephlogrms nd tretment records. The MCPPs were plced y single opertor using three 8-mm length nd 2.0-mm dimeter miniscrews (Jeil Corportion, Seoul, Kore). A pltl r with 2 hooks extending long the gingivl mrgins of the teeth ws connected to the mxillry first molrs. Immeditely fter plcement, distliztion ws initited y engging elstics (Ormco, Glendor, Clif) etween the MCPP rm notches nd hooks on the pltl r, pplying pproximtely 300 g of force per side (Figure 1A). 1 The ucclly plced miniscrews (6.0-mm length nd 1.5-mm dimeter; Biomterils Kore, Seoul, Kore) were instlled y single opertor etween the mxillry first molr nd second premolr pproximtely 5-mm picl to the cementoenmel junction. A closed coil spring (or chin elstic) ws connected etween the miniscrew nd 7-mm hook welded to the distl wing of the cnine rcket (Figure 1B). Distliztion ws performed on inch stinless steel rchwire on full-fixed inch predjusted orthodontic rckets. Cephlometric Mesurements The lterl cephlogrms of the MCPP group were tken y Dimx3 (Promx, Plnmec, Helsinki, Finlnd) with 70 kvp nd 11 mas, wheres those of the miniscrew group were tken y DCTP-90-P (Vtech, Hwseong, Kore). All imges were in nturl hed position, centric reltion, nd reposed lips. The mgnifiction errors were corrected vi digitizing scle incorported with ech imge to chieve the 1:1 rtio. Lterl cephlogrms were digitized using V-Ceph 5.5 softwre (Cyermed, Seoul, South Kore). The horizontl reference line (HRL) represented the Frnkfort horizontl (FH) plne nd the verticl reference line (VRL) ws perpendiculr to the FH plne, pssing through the pterygoid point. A totl of 26 liner nd ngulr mesurements were mde y one exminer s shown in Figures 2 nd 3. The differences etween T1 nd T2 were clculted (T1 T2). To identify mesurement reliility, 10 rndomly selected cses from ech group were redigitized nd nlyzed 2 weeks prt y the sme exminer.

3 DISTALIZATION BY PALATAL VS BUCCAL TADS 47 Figure 2. Liner cephlometric vriles. P indictes porion; Pt, pterygoid; Or, oritle; Sn, sunsle; UL, upper lip; LL, lower lip; N, nsion; FH, Frnkfort horizontl plne; HRL, horizontl reference line; VRL, verticl reference line; TVL, true verticl line; N Perp., N perpendiculr to FH; 1, A point to N Perp; 2, centrl incisor pex to HRL; 3, centrl incisor pex to VRL; 4, centrl incisor crown to HRL; 5, centrl incisor crown to VRL; 6, first molr pex to HRL; 7, first molr pex to VRL; 8, first molr crown to HRL; 9, first molr crown to VRL; 10, overjet; 11, overite; 12, UL to TVL; 13, LL to TVL. Intrexminer reliility ws evluted using the intrclss correltion coefficient, which ws Sttisticl Anlysis Sttisticl evlution ws performed using SPSS 16.0 (SPSS Inc., Chicgo, Ill). Pired t-tests were used to evlute the skeletl, dentl, nd soft tissue chnges tht occurred from T1 to T2 for vriles following the norml distriution within ech group. The vriles tht were significntly different from the norml distriution were compred etween T1 nd T2 within ech group using the Wilcoxon rnk sum test. Multivrite nlysis of vrince ws performed to evlute the differences in pre- nd posttretment nd the tretment effects etween the groups for vriles following the norml distriution. Mnn-Whitney U-test ws used to compre these differences in vriles tht did not follow the norml distriution. Sttisticl significnce ws set t.05. Bonferroni correction ws pplied for multiple comprisons. RESULTS Compring the tretment effects etween the MCPP pplinces nd uccl miniscrews, the MCPP pplince showed greter distliztion nd intrusion of the mxillry first molr with less distl tipping nd less extrusion of the incisor compred to the uccl miniscrews. Multivrite nlysis resulted in no significnt min effect in the comprison of pretretment vriles for the groups; however, there ws significnt min effect etween the groups in the comprison of posttretment vriles (Tles 1 nd 2). In the MCPP group, the men vlue of A point decresed y 1.9 mm (P,.001). However, in the miniscrew group, there were no significnt differences etween pre- nd posttretment vlues. Overll, the MCPP pplinces showed 4.2 mm of distliztion, 1.6 mm of intrusion with 28 tipping, nd 0.8 mm extrusion of the incisors. The miniscrew group showed 2.0 mm of distliztion nd 0.1 mm intrusion of the first molr with 7.28 tipping nd 0.3 mm of incisor extrusion (Figure 4). The pex of the pltl root of the first molr ws significntly distlized in the MCPP group y 3.8 mm (P,.001), ut it showed nonsignificnt chnge of 0.3 mm in the miniscrew group. Therefore, the miniscrew group showed significnt distl tipping of the mxillry first molrs. Regrding soft tissue chnges in the MCPP group, the upper lips were significntly retrcted (P,.001). All soft tissue vriles demonstrted no significnt differences etween the groups (Tle 3). DISCUSSION In the tretment of Clss II cses, pltl pltes nd uccl miniscrews re highly effective pplinces tht cn e esily plced nd mnged y clinicins. However, n nlysis of the tretment effects etween pltl pltes nd uccl miniscrews in lterl cephlogrms hs not een studied previously. Distliztion of the mxillry dentition hs een pplied s one of the tretment pproches for the correction of Clss II mlocclusions. Trditionl pproches such s hedger nd noncomplince devices such s the pendulum nd distl jet were designed for molr distliztion. 3,4,23,24 They hve een mrked y untowrd side effects including extrusion, distl tipping, nd the distl rottion of the mxillry first molrs Previously, the tretment effects of single ucclly plced miniscrew on ech side resulted in 1.4 to 2.0 mm of molr distliztion nd 1 mm intrusion with pproximtely 3.58 of distl tipping. 10 In the current study, the miniscrew group showed 2.0 mm of

4 48 LEE, ABBAS, BAYOME, BAIK, KOOK, HONG, PARK Figure 3. Angulr cephlometric vriles. S indictes sell; N, nsion; Po, porion; Or, oritle; FH, Frnkfort horizontl plne; PNS, posterior nsl spine; ANS, nterior nsl spine; Col, columell; A, A point; U, upper; Occ, occlusl plne point; L, lower; Go, gonion; B, B point; Pog, pogonion; Me, menton; 1, SNA, sell, nsion, A point; 2, ANB, A point, nsion, B point; 3, occlusl plne ngle; 4, fcil ngle; 5, mndiulr plne ngle; 6, IMPA, incisor mdiulr plne ngle; 7, centrl incisor inclintion; 8, first molr ngultion; 9, nsolil ngle. distliztion nd 0.1 mm of intrusion of the first molr with 7.28 of tipping nd 0.3 mm of incisor extrusion. Recently, Bechtold et l. 11 demonstrted difference in the distliztion pttern depending on the numer of miniscrews. A single miniscrew produced 1.8-mm distliztion, 0.8-mm intrusion, nd 3.28 distl tipping of the first molr with 0.5-mm extrusion of the incisors, wheres two miniscrews on ech side resulted in 2.9- mm distliztion, 1.4-mm intrusion, nd 1.68 distl tipping of the molr, with 1.6-mm intrusion of the incisors. 11 However, the plcement of four miniscrews, reloction of miniscrews s result of root proximity, nd technique sensitivity within nrrow interrdiculr spces were limittions of this pproch. Becuse the pltl re provides esy ccess, mple kertinized tissue, nd the necessry one thickness nd density, 29,30 it might e superior option for the plcement of miniscrews. In the current study, MCPP pplinces showed 4.2-mm distliztion nd 1.6 mm of intrusion with 28 tipping nd 0.8-mm extrusion of the incisors: greter distliztion nd intrusion with less distl tipping nd less extrusion of the incisor compred to the outcomes of the uccl miniscrews. A previous finite element study compred distliztion of the mxillry dentition using ucclly plced miniscrews nd MCPP pplinces. It reported tht distliztion with pltl plte would result in odily molr movement nd insignificnt displcement of the incisors, wheres distliztion with mini-implnts on the uccl side would cuse the first molr to e distlly tipped nd extruded while the incisors were flred lilly nd intruded. 22 In greement, the current results showed tht distliztion with MCPP pplinces provided much less distl tipping when moving molrs thn with the uccl miniscrew group. The tretment outcome with MCPP pplinces might chieve etter stility for long-term retention s result of the greter root movement. Regrding stility, longitudinl study with pendulum pplinces for distliztion reported tht 43% of the distliztion relpsed during fixed pplince therpy. 31 A recent cse reported using uccl miniscrews

5 DISTALIZATION BY PALATAL VS BUCCAL TADS 49 Tle 1. Comprison of Pretretment Cephlometric Vriles Between the MCPP nd Buccl Miniscrew Groups Mesurement MCPP Buccl Miniscrew Men SD Men SD P Vlue Skeletl A point - N perp. (mm) SNA (8) ANB (8) Fcil ngle (8) Occ. plne ngle (8) FMA (8) Dentl U1 crown to VRL (mm) U1 root to VRL (mm) U1 crown to FH (mm) U1 root to FH (mm) U1 to FH (8) U6 crown to VRL (mm) U6 root to VRL (mm) U6 crown to FH (mm) U6 root to FH (mm) U6 to FH (8) U7 crown to VRL (mm) U7 crown to FH (mm) U7 root to FH (mm) U7 to FH (8) IMPA (8) Overjet (mm) Overite (mm) Soft tissue U lip to TVL (mm) L lip to TVL (mm) Nsolil ngle (8) Multivrite nlysis of vrince. MCPP indictes modified C- pltl plte; SD, stndrd devition; perp., perpendiculr; Occ., occlusl; FMA, Frnkfort mndiulr plne ngle; VRL, verticl reference line; FH, Frnkfort horizontl plne; TVL, true verticl line; U, upper; nd L, lower. Significnce level t P,.002 with Bonferroni correction. for distliztion nd showed tht the resultnt occlusion ws stle throughout 5-yer retention period. 32 However, long-term tretment stility should e evluted in future studies in lrge smples. Krisson nd Bondemrk 33 suggested tht it is more effective to distlize the mxillry first molrs efore eruption of the second molrs. However, Flores-Mir et l. 34 showed miniml effect of the mxillry second nd third molr eruption stges on molr distliztion, demonstrted y oth liner nd ngulr mesurements. In the current study, the second molr ws distlized 3.6 mm in the MCPP group nd 2.2 mm in the miniscrew group. However, the effect of the third molr on distliztion ws not evluted. The current study ws conducted on two-dimensionl lterl cephlogrms. It ws ffected y their inherent shortcomings nd the difficulty in identifying lndmrks ecuse of the superimposition of ntomicl structures. 35 In future studies, the evlution of the Tle 2. Comprison of Posttretment Cephlometric Vriles Between the MCPP nd Buccl Miniscrew Groups Mesurement MCPP Buccl Miniscrew Men SD Men SD P Vlue Skeletl A point - N perp. (mm) SNA (8) ANB (8) Fcil ngle (8) Occ. plne ngle (8) FMA (8) Dentl U1 crown to VRL (mm) U1 root to VRL (mm) U1 crown to FH (mm) U1 root to FH (mm) U1 to FH (8) U6 crown to VRL (mm) U6 root to VRL (mm) U6 crown to FH (mm) U6 root to FH (mm) U6 to FH (8) U7 crown to VRL (mm) U7 crown to FH (mm) U7 root to FH (mm) U7 to FH (8) IMPA (8) Overjet (mm) Overite (mm) ,.001 Soft tissue U lip to TVL (mm) L lip to TVL (mm) Nsolil ngle (8) Multivrite nlysis of vrince. MCPP indictes modified C- pltl plte; SD, stndrd devition; Perp., perpendiculr; Occ., occlusl; VRL, verticl reference line; FH, Frnkfort horizontl plne; TVL, true verticl line; U, upper; nd L, lower. Significnce level t P,.002 with Bonferroni correction. distliztion of the mxillry rch using cone-em computed tomogrphy would e recommended for more ccurte ssessments of the tretment outcome. In ddition, study on the long-term stility of totl rch distliztion might e wrrnted. CONCLUSIONS There ws significntly greter distliztion nd intrusion with smller mount of distl tipping of the mxillry first molrs ssocited with the MCPP s compred to the uccl miniscrews. Only the MCPP group showed significnt retrction of the upper lip. However, there were no significnt differences etween the groups in their soft tissue tretment effect. The ppliction of the MCPP pplince my e recommended s one of the tretment modlities for mxillry molr or totl upper rch distliztion with etter root control.

6 50 LEE, ABBAS, BAYOME, BAIK, KOOK, HONG, PARK Figure 4. (A) Men tretment chnges of the mxillry first molr nd centrl incisor in the MCPP group (pltl view) nd (B) the ucclly plced miniscrews group (uccl view). Tle 3. Comprison of Tretment Effects Between the MCPP nd Buccl Miniscew Groups Mesurement MCPP Buccl Miniscrew Within-Group Test, Men SD P Vlue * Men SD Within-Group Test, P Vlue * Between-Group Test, P Vlue Skeletl A point - N perp. (mm) , ,.001 SNA (8) ANB (8) Fcil ngle (8) Occ. plne ngle (8) , FMA (8) Dentl U1 crown to VRL (mm) U1 root to VRL (mm) U1 crown to FH (mm) U1 root to FH (mm) U1 to FH (8) U6 crown to VRL (mm) , ,.001,.001 U6 root to VRL (mm) , ,.001 U6 crown to FH (mm) , U6 root to FH (mm) U6 to FH (8) , U7 crown to VRL (mm) , , U7 crown to FH (mm) U7 root to FH (mm) U7 to FH (8) IMPA (8) Overjet (mm) Overite (mm) Soft tissue U lip to TVL (mm) , L lip to TVL (mm) Nsolil ngle (8) MCPP indictes modified C-pltl plte; SD, stndrd devition; Perp., perpendiculr; Occ., occlusl; VRL, verticl reference line; FH, Frnkfort horizontl plne; TVL, true verticl line; U, upper; nd L, lower. Significnce level t P,.002 with Bonferroni correction. * Pired t-test. Multivrite nlysis of vrince.

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Long-term stility of mxillry group distliztion with interrdiculr miniscrews in ptient with clss ii division 2 mlocclusion. Am J Orthod Dentofcil Orthop. 2016:149: Krisson I, Bondemrk L. Introrl mxillry molr distliztion. Angle Orthod. 2006;76: Flores-Mir C, McGrth L, Heo G, Mjor PW. Efficiency of molr distliztion ssocited with second nd third molr eruption stge. Angle Orthod. 2013;83: Olmez H, Gorgulu S, Akin E, Bengi AO, Tekdemir I, Ors F. Mesurement ccurcy of computer-ssisted threedimensionl nlysis nd conventionl two-dimensionl method. Angle Orthod. 2011;81:

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