CASE REPORT

Class II malocclusion treated by combining a lingual retractor and a palatal plate

Kyu-Rhim Chung,a Yoon-Ah Kook,b Seong-Hun Kim,c Sung-Seo Mo,d and Jae-An Junge Gyeonggi-do, Korea In this article, we describe the treatment of a woman, aged 25 years 8 months, with a Class II malocclusion, severe anterior protrusion, and a high mandibular plane angle. The treatment plan consisted of extracting both maxillary rst premolars and mandibular second premolars. En-masse retraction of the 6 maxillary anterior teeth was performed with a lingual approach combining a C-lingual retractor and a C-palatal plate (C-plate). However, the mandibular dentition was treated with conventional labial xed appliances. After the maxillary anterior retraction, labial xed appliances were placed on the maxillary dentition only during the nishing stage. Correct overbite and overjet, facial balance, and improved lip protrusion were obtained. The active treatment period was 17 months, and the results were stable for 13 months after debonding. This C-lingual retractor and C-plate combined retraction method can be effective for intrusive retraction of the anterior teeth. (Am J Orthod Dentofacial Orthop 2008;133:112-23)

lthough lingual orthodontic treatment is more esthetically appealing to patients than labial approaches, the appliances can complicate torque control of the maxillary anterior teeth in patients with lip protrusion who need maximum anchorage.1-4 Sliding mechanics are preferred because of their simple design, but accurate retraction force calibration is made difcult by friction.5 The C-lingual retractor (C-retractor) was introduced as an alternative lingual method for obtaining a direct controlled retraction force on the maxillary anterior teeth.6,7 Consideration of the center of resistance (CRes) is essential for anterior retraction in maximum anchorage cases.3,8 The lingual force can be directed through the CRes, making it possible to precisely control tooth movement during en-masse retraction. CRes is determined by loop extension to the palatal side or complex
a

President, Korean Society of Speedy Orthodontics, Gyeonggi-do, Korea. Associate professor and chairman, Department of Orthodontics, Catholic University of Korea, Kangnam St Marys Hospital, Gyeonggi-do, Korea. c Assistant professor, Department of Orthodontics, Catholic University of Korea, Uijongbu St. Marys Hospital, Gyeonggi-do, Korea. d Assistant professor, Department of Orthodontics, Catholic University of Korea, Uoido St. Marys Hospital, Gyeonggi-do, Korea. e Former resident, Department of Orthodontics, Catholic University of Korea, Uoido St. Marys Hospital, Gyeonggi-do, Korea. Partly supported by the Korean Society of Speedy Orthodontics and the Alumni Fund of the Department of Dentistry and Graduate School of Clinical Dental Science, Catholic University of Korea. Reprint requests to: Seong-Hun Kim, Department of Orthodontics, Catholic University of Korea, Uijongbu St Marys Hospital, 65-1 Kumoh-dong, Uijeongbu, Gyeonggi-do, 480-130, South Korea; e-mail, bravortho@catholic. ac.kr. Submitted, January 2006; revised and accepted, April 2006. 0889-5406/$34.00 Copyright 2008 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2006.04.033
b

wire bending in conventional lingual therapy, but, if it is insufcient, uncontrolled tipping of anterior teeth and bowing can result (Fig 1). Solutions such as labial bracketing, complex archwire bending, or skeletal anchorage might need to be considered to correct it. Large-diameter osseointegrated implants have been used for palatal anchorage during anterior retraction. However, these systems require a waiting period of over 4 months, and immediate loading is impossible, and the surgery process is more invasive due to the large diameter.9,10 Currently, various types of orthodontic mini-implants are used for palatal anchorage.11,12 These mini-implants are placed with 2 or 3 miniscrews in the midpalatal suture area, and the head portions are bonded with resin for the retraction of the 6 maxillary anterior teeth. A cross-type titanium miniplate (C-plate) can stand immediate heavy force to minimize the disadvantages of palatal implants and maximize their advantages during C-retractor based en-masse retraction (Fig 2, A).13 Its main arm has 3 holes for inserting the miniscrews and 2 horizontal arms with holes for elastics or nickel-titanium (Ni-Ti) coil springs. Effective anterior retraction can be achieved by simple retraction in patients with severe protrusion (Fig 3). The C-retractor is fabricated based on a dental model in CRes position. If intrusion is needed during the retraction period, the length of the horizontal arms can be adjusted. For simultaneous intrusion and retraction of 6 anterior teeth, orthodontic force should be applied in the CRes area that is positioned 44.32% from the cervical area.14 If these combined mechanics are used during the en-masse retraction period, effective

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Fig 1. Schematic illustration of en-masse retraction with the conventional lingual approach.

Fig 3. Schematic illustration of C-plate and C-retractor combined retraction mechanics.

Fig 2. A, Schematic illustration of titanium C-plate and drill-free screws; B, frontal image of palatal computed tomography view. Median palatal suture area has thin mucosa and thick cortical bone.

closing of the jaw. The pretreatment photographs showed the facial characteristics typical of Class II anterior protrusion, with everted lips, convex prole, and hypermentalis activity. The dental casts demonstrated Class II molar and canine relationships except for the right molars, minor mandibular anterior crowding, and severely protruded incisors (Fig 5). The dental midlines coincided with the facial midline. A panoramic radiograph showed no missing teeth, and the periodontal condition was normal. Cephalometric analysis showed a skeletal Class II relationship (ANB angle, 7; maxillary incisor to NA angle, 26; maxillary incisor to NA, 5.5 mm) with a steep occlusal plane (SN-OP angle, 24), high mandibular plane angle (FMA, 33.5), and protrusive incisors (interincisal angle, 108; mandibular incisor to NA angle, 40; mandibular incisor to NB, 11.5 mm; IMPA, 101) (Fig 6, Table). The patient was diagnosed with skeletal Class II malocclusion and bidentoalveolar protrusion.
TREATMENT OBJECTIVES

retraction can be achieved. Because no friction is produced, accurate tooth movements are possible.17 Ni-Ti closed-coil springs (Jinsung, Seoul, Korea) are stretched from the retractor to the horizontal arm of the C-plate for retraction of the 6 maxillary anterior teeth. This case report describes the application of the lingual retractor and plate combinationa useful method for patients who need maximum anchorage, anterior torque control, and intrusion.
DIAGNOSIS

The treatment objectives based on the cephalometric and dental cast analyses were to extract 2 maxillary premolars and 2 mandibular premolars, retract and intrude the anterior teeth, improve the interincisal angle relationship, improve lip competence, achieve a wellintercuspated bilateral Class I canine and molar occlusion, and improve facial balance. Near the end of the en-masse retraction, conventional labial xed appliances would be used for nishing.
TREATMENT ALTERNATIVES

A woman, age 25 years 8 months, sought treatment for her protruded anterior teeth (Fig 4). She was healthy and had no signicant temporomandibular joint symptoms, except for a clicking sound during opening and

The patients chief concern was improvement of facial balance, and her goal was maximum retraction of the maxillary anterior teeth with the lingual appliance.

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Fig 4. Pretreatment intraoral and extraoral photographs.

The patient rejected a treatment plan involving headgear for maximum anchorage. Thus, 2 alternatives, both involving maxillary rst premolar extraction and en-masse retraction of the maxillary dentition with mini-implants, were presented: (1) a conventional lingual approach with bonded lingual brackets and miniimplants as anchorage to reinforce the posterior teeth during anterior retraction and (2) a C-retractor and C-plate combined approach for controlled anterior retraction without assistance of bonded or banded posterior anchorage, and nishing with labial orthodontic appliances for a short time. The treatment plan included mandibular second premolar extractions, because the mandibular anterior retraction needed moderate anchorage. Even though nishing would be done with labial xed appliances, the patient selected the second treatment plan for en-masse retraction. This plan allowed

maximum retraction of the maxillary anterior teeth without affecting the molar occlusal relationship and periodontal condition, and it required fewer appointments. During the en-masse retraction period, the patient would be checked only for deformation or removal of the appliances. After en-masse retraction of the maxillary anterior teeth, full xed labial appliances would be used for a short time to nish treatment.
TREATMENT PROGRESS

Treatment was started with the placement of a maxillary C-retractor and a C-plate in the maxilla and by leveling the mandibular anterior dentition. The C-retractor, made of 0.032-in stainless steel spring wire soldered to mesh brackets, consolidated the anterior teeth with stiff wires, and the resultant forces were applied directly to the C-retractor as suggested by

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Fig 5. Pretreatment dental casts.

Fig 6. Pretreatment lateral cephalogram.

Burstone.15 The fabrication and clinical application of the C-retractor were explained previously.6,7 A C-plate with a wide horizontal arm (Gebrder Martin GmbH, Tuttlingen, Germany) was placed on the cortical bone of the midpalatal suture area with the following sequence (Fig 7, A-C): (1) local anesthesia with lidocaine with 1:100,000 epinephrine on the midpalatal suture; (2) longitudinal incision by using a #15 blade from the rst premolar to the rst molar distal area; (3) positioning of the C-plate after ap elevation by using a periosteal elevator; (4) 2 or 3 drill-free miniscrews, 1.5 mm in diameter and 5 mm in length (Gebrder Martin GmbH), were xed by using a hand driver; and (5) suture. In case of a thin mucosal ap in the midpalatal suture area, the C-plate can be implanted without ap surgery (Fig 7, D-F). The sutures were removed, and the C-retractor was bonded on the lingual sides of the maxillary anterior teeth 1 week after placement of the C-plate. After extraction of both maxillary rst premolars and mandibular second premolars, the mandibular dentition was treated with conventional labial xed appliances, and maxillary anterior retraction was started with a Ni-Ti

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Table 1.

Cephalometric measurements before and after treatment

Average (female) Pretreatment 83 76 7 76/126 (60.3%) 24 118 33.5 101 45.5 1.5 2.5 108 5.5 26 11.5 40 14 Posttreatment 82.5 76 6.5 76/127 (59.8%) 25 105 34.5 86 59.5 0.5 0.0 135 0.0 13 6 28 14

SNA angle () SNB angle () ANB angle () PFH/AFH (%) SN-OP () FH-UI () FMA () IMPA () FMIA () UL-E plane (mm) LL-E plane (mm) Interincisal angle () Mx 1 to NA (mm) Mx 1 to NA () Mn 1 to NB (mm) Mn 1 to NB () SN to PP ()

81.6 79.2 2.4 85.1/127.4 (66.8%) 17.9 116.0 24.3 95.9 59.8 -0.9 0.6 123.8 7.3 25.3 7.9 28.4 10.2

Fig 7. Surgical procedure of C-plate application: A-C, open method for thick mucosa with longitudinal incision along the midpalatal suture; D-F, closed method for thin mucosa without incision.

coil spring between the C-plate and the C-retractor. A total of 400 g was initially loaded on the C-plate by the 2 sides of the lever arm (200 g each) (Fig 8). The mandibular rst molars were banded to withstand heavy loads for the molar protraction period. A .016 .022-in copper Ni-Ti archwire (Ormco, Glendora, Calif) with a gable bend was placed as the initial archwire for treatment of the mandibular denti-

tion. During retraction of the mandibular anterior teeth, moderate anchorage was used. A drill-free miniscrew, 1.5 mm in diameter and 7 mm in length, was placed between the mandibular left canine and the rst premolar for molar key correction. A Ni-Ti coil spring was immediately loaded, but conventional treatment was used when the screw became loose and fell out 2 months later.

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Fig 8. Progress intraoral photographs during en-masse retraction.

Fig 9. Intraoral photographs after en-masse retraction.

The retraction period for the maxillary anterior dentition was 7 months (Fig 9). Intrusion and retraction were performed with a force direction of 2 to the occlusal plane (Fig 10). The patient could return for appointments only every 6 to 8 weeks, for a total of 4 visits during the retraction period. Molar protraction of the mandibular dentition was achieved with a .018 .025-in stainless steel archwire with a shoehorn loop.

After en-masse retraction, the nishing phase was started by placing a .022 .028-in preadjusted xed appliance on the maxillary posterior teeth. Because the effect of the C-retractor on tooth movement is mainly focused on the controlled retraction of the maxillary anterior segment, it is important to control the axis of the canines individually after en-masse retraction. Using a .016 .022-in stainless steel archwire with a T loop, bilateral canine axis control and space closure

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The occlusal plane also increased slightly after treatment (SN to OP angle, from 24 to 25). The maxillary incisors were remarkably retracted and intruded by C-retractor and C-plate combined mechanics compared with normal measurements (FH-U1 angle, from 118 to 105; maxillary incisor to NA, from 5.5 to 0 mm; maxillary incisor to NA angle, from 26 to 13). The ANB angle decreased a little during treatment, from 7 to 6.5. The mandibular incisors were uprighted and retracted signicantly, even though moderate anchorage mechanics were used (IMPA, from 101 to 86; FMIA, from 45.5 to 59.5; mandibular incisor to NB, from 11.5 to 6 mm; mandibular incisor to NB angle, from 40 to 28). The lower lip was retracted more than the upper lip (upper lip to E-plane, from 1.5 to 0.5 mm; lower lip to E-plane, from 2.5 to 0 mm). The interincisal angle increased signicantly (from 108 to 135). The posteroanterior facial height ratio decreased a little after treatment (from 76/126 mm [60.3%] to 76/127 mm [59.8%]). In spite of the overretracted anterior dentition, the patient was pleased with the nal results, which were stable 13 months later (Fig 16).
Fig 10. Intrusive movement of maxillary anterior dentition during en-masse retraction. DISCUSSION

were performed (Fig 11). Detailing of the dentition took 10 months. Although there was some remaining space in the band area around the maxillary left posterior teeth and the mandibular left rst molar, the patient requested that the appliance be removed. The maxillary C-plate was removed under local anesthesia before debonding. The palatal soft tissue healed within a few days. The active treatment period with a xed appliance was 17 months. The retention was provided by a maxillary lingual xed retainer and a mandibular circumferential retainer.
TREATMENT RESULTS

Class I canine and molar relationships on the right side and improved overjet and overbite were obtained after treatment (Figs 12 and 13). Although the anchorage teeth were controlled, correction of the canine and molar relationship on the left side was insufcient because of the severe skeletal discrepancy and poor patient cooperation during the nishing stage. The posttreatment facial photographs showed a dramatic decrease of lip protrusion and improvement of facial esthetics (Fig 12). The facial midline coincided with the dental midline. The cephalometric analysis (Figs 14 and 15) showed a slight increase of FMA (from 33.5 to 34.5).

In lingual en-masse retraction of the 6 maxillary anterior teeth, torque and anchor control are the most important factors. Hong et al3 introduced a lever arm and mini-implant system for anterior torque control during retraction in lingual orthodontic treatment. They suggested that favorable torque control of the maxillary incisors can be obtained with this approach. In addition, other reports described an additional process that uses a guide bar to select the mini-implant placement site.11,16 However, after the leveling and alignment stages, an additional step of soldering the lever arm to the main archwire is required. These methods do not accurately control the 6 anterior teeth during retraction because the lever arm is connected to the main archwire, and they do not easily control the CRes because of play between the main archwire and the bracket slot. These lever-arm systems can cause vertical changes in the posterior teeth during retraction because a continuous wire is attached to the posterior bracket. Some authors showed lingual treatment of skeletal Class II malocclusion with palatally placed microimplants.17,18 However, several factors must be considered when 2 miniscrews are placed in the midpalatal area or force is applied directly to a mini-implant in the lateral side of palate. First, this complicated structure can be difcult to keep clean. Second, the resin on the head of the miniscrew can irritate the palatal tissue. The laboratory procedures require additional cost. Fi-

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Fig 11. Finishing stage: detailing with xed labial appliances.

Fig 12. Posttreatment intraoral and extraoral photographs.

nally, loosening or fracturing of the miniscrews can result from increased lateral force from the thick mucosa on the lateral sides. The C-plate is designed to be placed in the mid-

palatal area, because, in contrast to the lateral palate with its thick soft tissue, palatal nerves, and vessels that cannot stand force, the midpalatal suture area has thinner soft tissues and thicker cortical bone that could

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Fig 13. Posttreatment dental casts.

Fig 14. Posttreatment lateral cephalogram.

be ideal for skeletal anchorage (Fig 2, B).11,16 Miniplates, compared with mini-implants, have the disadvantage of requiring ap surgery. However, immediate loading with heavy force is possible. The C-plate has bendable horizontal arms that can be adjusted to allow 3-dimensional retraction of the anterior teeth. Various tooth movements eg, intrusion, rotation correction, and distalization of the posterior and anterior teeth can be achieved. Previous reports have described the retraction of the 6 anterior teeth with a C-retractor.6,7 The C-retractor is fabricated on the lingual side of the maxillary anterior teeth on a dental cast; therefore, the clinician can estimate the CRes direction of the 6 maxillary anterior teeth as 1 segment. This patient had a high mandibular plane angle and required full retraction of the anterior teeth. The 6 maxillary anterior teeth were treated by using a C-plate placed in the palatal area and without appliances on the maxillary posterior teeth. Backward and upward movement of the anterior teeth did not cause premature contact with the mandibular anterior teeth. However, a C-retractor and a palatal plate can be used for patients with protrusion and moderate anterior crowding.

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Fig 15. Superimposition of pretreatment and posttreatment lateral cephalograms.

Unlike conventional lingual treatment, the mechanics of the C-retractor combined with C-plate do not require banded or bonded brackets on the maxillary posterior teeth during en-masse retraction.13 We intended to use skeletal anchorage as the major appliance for the retraction period. The C-retractor fabricated on the initial model has an advantage in that it does not require special control during this period. Due to its simple design, periodontal damage and discomfort in the maxillary posterior dentition were minimized. An open surgical method was planned for this patient because of the thick mucosa. Loosening of miniscrews can easily occur when they directly penetrate a thick mucosa without ap surgery. There is a heavy load on the bone in this method because there is a large moment on the plate. To withstand this heavy load, it is recommended that 2 or 3 self-drilling miniscrews be placed, depending on bone quality, after the longitudinal incision. However, C-plate miniscrews can be placed directly and immediately without ap surgery in areas of thin mucosa in which the midpalatal suture is covered. The C-plate can withstand heavy orthodontic force (300-500 g) with 2 miniscrews in open-method cases. It is necessary to place miniscrews into all 3 holes in the C-plate for retention without irritating the soft tissue in the closed method. For successful placement of the C-plate, the bone thickness in the sagittal area of the palate must be considered before the miniscrews are placed.10 It was

suggested that vertical bone support should be at least 2 mm higher than apparent on the cephalogram.10,19 Crismani et al20 reported that 10% of palatal implants caused histologic fenestration of the nasal cavity, and 20% of implants projecting beyond the nasal oor were false-positive records on the lateral cephalograms in 20 studies. A C-plate used with a C-retractor is xed with multiple miniscrews that are 1.5 mm in diameter and 5 mm in length. Therefore, it is harder to perforate the nasal cavity than it is with conventional miniscrews or mini-implants, which have larger dimensions. If a slight bony perforation without penetration of the nasal mucosa occurs, the thick nasal mucosa will prevent an open connection to the nasal sinus.19 After removal of the C-plate in our patient, a slight perforation in the small bony structure healed uneventfully and did not cause any untoward postoperative sequelae, as happened in other studies.19,21,22 When 6 anterior teeth are retracted by a C-retractor, tipping and intrusion of the maxillary canine tend to occur. This phenomenon is caused by intrusion and retraction of the 6 maxillary anterior teeth responding as 1 segment. To resolve this problem for the patient, a beta-titanium alloy T loop was used to control the canine retraction, which was accomplished with the removal of the C-retractor in the canine area before completing the anterior segment retraction. Since the patient did not return for frequent visits, conventional treatment was used to resolve the tipped and intruded

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Fig 16. Extraoral and intraoral photographs after 13 months of retention.

maxillary canines after the anterior retraction (Fig 9), and detailing was needed for 10 months after retraction. Cephalometric analysis showed a slight clockwise rotation of the mandible (FMA, from 33.5 to 34.5). It was assumed that the mandibular posterior teeth were extruded slightly during leveling. The patient did not cooperate with intermaxillary elastic wear during the nishing stages. In spite of her poor compliance, the occlusal plane opened slightly (1).
CONCLUSIONS

method can be effective for intrusive retraction of anterior teeth. We thank Hyung-Keun Kook for his help with the illustrations.

REFERENCES 1. Fulmer DT, Kuftinec MM. Cephalometric appraisal of patients treated with xed lingual orthodontic appliances: historic review and analysis of cases. Am J Orthod Dentofacial Orthop 1989;95: 514-20. 2. Miyawaki S, Yasuhara M, Koh Y. Discomfort caused by bonded lingual orthodontic appliances in adult patients as examined by retrospective questionnaire. Am J Orthod Dentofacial Orthop 1999;115:83-8. 3. Hong RK, Heo JM, Ha YK. Lever-arm and mini-implant system for anterior torque control during retraction in lingual orthodontic treatment. Angle Orthod 2004;75:129-41.

The C-plate and C-retractor combined approach can correct a Class II malocclusion that requires maximum anchorage. The placement of the C-plate on the midpalatal cortical bone can offer sufcient anchorage for a heavy retraction force immediately without damaging vital anatomic structures. This combined retraction

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4. Caniklioglu C, ztrk Y. Patient discomfort: a comparison between lingual and labial xed appliances. Angle Orthod 2004;75:86-91. 5. Kurz C. The use of lingual appliances for correction of bimaxillary protrusion (four premolars extraction). Am J Orthod Dentofacial Orthop 1997;112:357-63. 6. Kim SH, Park YG, Chung KR. Severe Class II anterior deep bite malocclusion treated with a C-lingual retractor. Angle Orthod 2004;74: 280-5. 7. Kim SH, Park YG, Chung KR. Severe anterior open bite malocclusion with multiple odontoma treated by C-lingual retractor and horseshoe mechanics. Angle Orthod 2003;73: 206-12. 8. Vanden Bulcke MM, Burstone CJ, Sachdeva RCL, Dermaut LR. Location of the centers of resistance for anterior teeth during retraction using the laser reection technique. Am J Orthod Dentofacial Orthop 1987;91:375-84. 9. Block MS, Hoffman DR. A new device for absolute anchorage for orthodontics. Am J Orthod Dentofacial Orthop 1995;107: 251-8. 10. Favero L, Brollo P, Bressan E. Orthodontic anchorage with specic xture: related study analysis. Am J Orthod Dentofacial Orthop 2002;122:84-94. 11. Lee JS, Kim DH, Park YC, Kyung SH, Kim TK. The efcient use of midpalatal miniscrew implants. Angle Orthod 2004;74:711-4. 12. Kyung SH, Choi HW, Kim KH, Park YC. Bonding orthodontic attachments to miniscrew heads. J Clin Orthod 2005;39:348-53. 13. Chung KR, Kim SH, Kook YA. C-palatal plate. In: Cope JB, editor. Orthotads: The clinical guide and atlas. Dallas: Texas Under Dog Media; 2007.

14. Lee HK, Chung KR. The vertical location of the center of resistance for maxillary six anterior teeth during retraction using three dimensional nite element analysis. Korean J Orthod 2001;31:425-38. 15. Burstone CJ. The segmental arch approach to space closure. Am J Orthod 1982;82:361-78. 16. Wehrbein H, Merz BR, Diedrich P, Glatzmaier J. The use of palatal implants for orthodontic anchorage. Design and clinical application of the orthosystem. Clin Oral Implants Res 1996;7: 410-6. 17. Lee JS, Park HS, Kyung HM. Micro-implant anchorage for lingual treatment of a skeletal Class II malocclusion. J Clin Orthod 2001;35:643-7. 18. Kyung HM, Park HS, Bae SM, Sung JH, Kim IB. The lingual plain-wire system with micro-implant anchorage. J Clin Orthod 2004;38:388-95. 19. Wehrbein H, Merz BR, Diedrich P. Palatal bone support for orthodontic implant anchoragea clinical and radiological study. Eur J Orthod 1999;21:65-70. 20. Crismani AG, Bernhart T, Tangl S, Bantleon HP, Watzek G. Nasal cavity perforation by palatal implants: false-positive records on the lateral cephalogram. Int J Oral Maxillofac Implants 2005;20:267-73. 21. Meechan JG. Oro-nasal stula occurring after a simple dental extraction. Br J Oral Surg 1983;21:229-32. 22. Tataryn RW, Torabinejad M, Boyne PJ. Healing potential of osteotomies of the nasal sinus in the dog. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:196-202.