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Received: 17 February 2021    Revised: 26 May 2021    Accepted: 30 May 2021

DOI: 10.1111/ocr.12507

ORIGINAL ARTICLE

Comparison of treatment effects from total arch distalization

using modified C-­palatal plates versus maxillary premolar
extraction in Class II patients with severe overjet

Fawaz Alfawaz1 | Jae Hyun Park2,3  | Nam-­Ki Lee4  | Mohamed Bayome5,6  |

Kiyoshi Tai7,8 | Ja Hyeong Ku1 | Yoonji Kim1 | Yoon-­Ah Kook1

1
Department of Orthodontics, Seoul St.
Mary's Hospital, College of Medicine, The Abstract
Catholic University of Korea, Seoul, Korea Introduction: This study aimed to compare the skeletodental and soft tissue changes
2
Postgraduate Orthodontic Program,
with total arch distalization using a modified C-­palatal plate (MCPP) and maxillary first
Arizona School of Dentistry & Oral Health,
A.T. Still University, Mesa, AZ, US premolar extraction treatment in Class II malocclusion patients with severe overjet.
Setting and sample population: The sample consisted of 46 adult patients who
3
International Scholar, Graduate School of
Dentistry, Kyung Hee University, Seoul,
Korea
had Class II Division 1 malocclusion with severe overjet; 25 of them received non-­
4
Department of Orthodontics, Section extraction treatment with MCPPs (age, 22.5 ± 7.2 years), and 21 received maxillary
of Dentistry, Seoul National University first premolar extraction treatment (age 23.4 ± 6.5 years).
Bundang Hospital, Seongnam, Korea
5 Method: A total of 26 variables were measured on pre-­ and post-­treatment lat-
Department of Preventive Dentistry,
College of Dentistry, King Faisal University, eral cephalograms. To evaluate the differences between pretreatment and post-­
Alhufuf, Saudi Arabia
6
treatment in each group, t tests and Wilcoxon rank-­sum tests were used. To compare
Department of Postgraduate Studies,
Universidad Autonóma del Paraguay, the amount of change between the two groups, MANOVA test was used.
Asunción, Paraguay Results: The overjet was significantly reduced in the MCPP and extraction groups
7
Postgraduate Orthodontic Program,
by 4.8  mm and 5.4  mm, respectively. However, the two groups had no significant
Arizona School of Dentistry & Oral Health,
Mesa, AZ, US difference in the sagittal, vertical and angular changes of the maxillary incisors. In
8
Private practice of orthodontics, Okayama, addition, regarding soft tissue changes, the MCPP and extraction groups showed an
Japan
increased nasolabial angle of 7.5° and 9.4°, decreased upper lip to the true vertical
Correspondence line of 1.8 mm and 2.2 mm, respectively (P < .001).
Yoon-­Ah Kook, Department of
Orthodontics, Seoul St. Mary’s Hospital,
Conclusions: There was no significant difference in the skeletal changes between the
College of Medicine, The Catholic University MCPP and extraction groups, and the reduction in overjet was similar in the groups.
of Korea, 222 Banpo-­daero, Seocho-­Gu,
Seoul 06591, Korea.
These results suggest that MCPP might be a viable treatment option for total arch
Email: kook2002@catholic.ac.kr distalization in Class II malocclusion patients with severe overjet.

Funding information
KEYWORDS
This study was funded by The Catholic
University of Korea, Seoul St. Mary's Class II malocclusion, maxillary first premolar extraction, modified C-­palatal plate, severe
hospital (grant ZC20EISE0176) overjet

© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Orthod Craniofac Res. 2021;00:1–9.  |

wileyonlinelibrary.com/journal/ocr     1
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2       ALFAWAZ et al.

1 |  I NTRO D U C TI O N including 25 patients (average age, 22.3 ± 7.2 years) who had been
treated with MCPP at Seoul St. Mary's Hospital in Seoul, South
Non-­extraction treatment is one of the challenging modalities in Korea from January 2009 to December 2019, and 21 patients (aver-
Class II malocclusion adult patients with severe overjet. Traditionally, age age 23.4 ± 6.5 years) who had received orthodontic treatment
premolar extraction was performed to correct severe overjet and to with maxillary first premolar extraction at a private practice office in
improve facial profiles. However, extraction space tends to reopen in Okayama, Japan (Table 1).
the long run in extraction cases.1,2 In addition, in recent years, more For the distalization group (3/4 cusp Class II, 10; full cusp Class II,
patients are seeking non-­extraction treatment.3,4 15 patients), MCPPs were installed by a single operator (Y.-­AK) using
With the introduction of the temporary skeletal anchorage de- three 8  mm long, 2.0  mm diameter miniscrews (Jeil Medical Co.,)
vices (TSADs), buccal miniscrews have been used to correct Class II in the paramedian area of the midpalatal suture. A palatal bar with
malocclusion by distalizing maxillary molars.5-­7 When a large amount two hooks extending along the palatal gingival margins of the teeth
of total arch distalization is needed, interdental miniscrews need was banded to the maxillary first molars. Distalization was initiated
to be relocated because of the limited inter-­radicular distance.8 To by engaging elastomeric chains between the notches on the MCPP
overcome this drawback, palatal placement of TSADs has been pro- arm and the hooks on the palatal bar with a force of approximately
posed by some clinicians due to the broader range of tooth move- 300 g per side. During the same visit, fixed appliances with 0.022-­
ment possible and less tipping of the first molars.9-­12 inch slot brackets and bands (Tomy) were delivered on the maxillary
In addition, total arch distalization has been used to treat full-­step and mandibular arches, including the second molars. The patient ap-
Class II or severe overjet cases with palatal TSADs for total arch distal- pointment interval was maintained at 3 to 4 weeks.
ization in adolescents.13,1 Jung15 reported no significant different treat- In the extraction group (3/4 cusp Class II, 9; full cusp Class II, 12
ment outcome between total arch distalization using buccal miniscrews patients), the maxillary first premolars were extracted. In addition,
and second premolar extraction treatment. Meanwhile, Jo et al16 found 8.0  mm long, 1.6  mm in diameter miniscrews (OSAS; DEWIMED,
that the amount of incisor retraction was significantly greater in the Tuttlingen, Germany) were inserted mesial to the first molars as sup-
premolar extraction group compared to total arch distalization using plemental anchorage. The anterior teeth were retracted en masse
the palatal TSADs, in Class II malocclusion patients with 4 mm overjet. with sliding mechanics using elastomeric chains on 0.019 × 0.025-­
Previous studies have evaluated the treatment effect of dental arch inch stainless steel archwires.
and therapeutic changes and compared the aesthetic impact of pre-
molar extraction versus non-­extraction treatment.17-­19 Nevertheless,
no studies have assessed treatment outcomes after distalization with 2.1 | Cephalometric Measurements
modified C-­ palatal plates (MCPPs) versus upper first premolar ex-
tractions in adult Class II patients with more than 7 mm of overjet. The cephalograms of the MCPP group were taken with Dimax3
Therefore, this study aimed to investigate the skeletodental and (Promax, Planmeca) with 70  kVp and 11 mAs, whereas those of
soft tissue changes with total arch distalization using MCPPs com- the extraction group were taken with Veraviewepocs X700  + 2D
pared with those from the maxillary first premolar extraction treat-
ment in Class II malocclusion patients with severe overjet. The null
TA B L E 1   Demographic data
hypothesis was that there was no significant difference in treatment
outcome between total arch distalization using MCPPs and ortho- MCPP Extraction
group group P value
dontic treatment with maxillary first premolar extraction.
Gender
Male 10.0 2.0 0.019a 
2 |  M ATE R I A L S A N D M E TH O DS Female 15.0 19.0
Age (years) 22.3 ± 7.2 23.4 ± 6.5 0.435b 
This study was approved by the institutional review board of the Overjet (mm) 8.1 ± 0.9 8.4 ± 1.0 0.378b 
Catholic University of Korea (No. KC20RISI0720), and informed
Amounts of crowding (mm)
consents were obtained according to the declaration of Helsinki.
Maxilla 2.5 ± 1.3 2.0 ± 1.4 0.418b 
The inclusion criteria for this retrospective study were (1) older than
Mandible 1.5 ± 0.9 1.6 ± 1.2 0.739b 
16 years, (2) dental Class II molar relationship with overjet greater
Severity of Class II
than 7 mm (3) having had lateral cephalogram images taken immedi-
3/4 cusp 10.0 9.0 0.845a 
ately before and after distalization, and (4) exclusive use of an MCPP
appliance by the distalization group. The exclusion criteria were (1) Full cusp 15.0 12.0

unilateral distalization (2) previous orthodontic treatment (3) syn- Treatment Duration (months) 26.5 ± 6.0 27.2 ± 5.1 0.580 b 

dromes or congenital craniofacial anomalies. Abbreviation: MCPP, Modified C-­palatal plate

a
The sample consisted of 46 adult patients (12 males and 34 Chi-­square test
b
females) with Class II Division 1 malocclusion with severe overjet, Independent t-­test
ALFAWAZ et al. |
      3

(Morita). All pretreatment and post-­treatment cephalograms were
standardized to a 1:1 ratio, traced, and analysed via V-­Ceph software
(version 8.0; Cybermed, Seoul, Korea) by the same examiner (FSF).
The horizontal reference line (HRL) was the Frankfort horizontal
plane, and the vertical reference line (VRL) was a perpendicular line
passing through the pterygoid point. A total of 23 linear and angular
measurements were taken as illustrated in Figure 1).
Records of 10 randomly selected patients were retraced and an-
alysed two weeks after the initial analysis by the same examiner.
and post-­treatment within each group, paired t tests were used.
To compare the pretreatment measurements, the post-­treatment
measurements, and the amount of change between the two groups,
Multivariate analysis of variance (MANOVA) tests were used.
Statistical significance was set at P  <  .05. The Bonferroni correc-
tion was applied for multiple-­comparison corrections, therefore,
the significance level for single variable comparison was changed to
P < .002.

2.2 | Statistical analysis
The sample size calculation was performed via G*power ver.3.1.9.7
(Heinrich-­Heine-­Universität). It showed that at least 20 patients
were required in each group to identify an effect size of one unit,
with an alpha of 0.05 and a beta of 0.2.
All statistical analyses were performed by SAS software for
Windows V 9.4 (Cary). Intra-­examiner reliability was assessed for
all variables by the intraclass correlation coefficient (ICC), which
showed that the measurements were reliable (ICC >0.95). The
Shapiro-­Wilk test was used to confirm the normal distribution of the
measurements. To evaluate the differences between pretreatment
3 | R E S U LT S
The MCPP and extraction groups showed no significant differ-
ences in initial age, overjet and severity of Class II malocclusion.
However, the distribution of gender within each group was sig-
nificantly different (P  =  .019). There was no significant differ-
ence between thetwo groups regarding the treatment duration
(Table 1). Even though all pretreatment skeletal, dental, and soft-­
tissue measurements showed no significant differences between
the two groups, the main effect of the multivariate analysis was
significant (P = .011) (Table 2).
At post-­treatment measurements, there was a significant dif-
ference between the two groups in general (P  <  .001). The MCPP

F I G U R E 1   (A), Cephalometric linear measurements were used in this study. 1. Upper incisor (U1) crown to vertical reference line (VRL)*,
2. U1 root to VRL, 3. U1 crown to Frankfort horizontal plane (FH), 4. U1 root to FH, 5. Upper first molar (U6) crown to VRL, 6. U6 root to
VRL, 7. U6 crown to FH, 8. U6 root to FH, 9. Upper lip to true vertical line (TVL), 10. Lower lip to TVL, 11. Soft pogonion to TVL, 12. Overjet,
13. Overbite. * VRL : A perpendicular line to FH plane with passing through the pterygoid point. (B), Cephalometric angular measurements
were used in this study. 1. SNA, 2. SNB, 3. ANB, 4. Facial angle, 5. Occlusal plane angle, 6. Mandibular plane angle, 7. U1 to FH, 8. U6 axis-­
FH, 9. Nasolabial angle, 10. Mentolabial angle, 11. IMPA, 12. Lower first molar (L6) to mandibular plane(MP) angle, 13. Wits
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4       ALFAWAZ et al.

TA B L E 2   Comparison of pretreatment
MCPP Group (n = 25) Extraction Group (n = 21)
P variables between the MCPP and the
Measurement Mean SD Mean SD value maxillary first premolar extraction groups

Skeletal
SNA (°) 83.2 3.4 83.1 3.5 0.898
SNB (°) 76.5 3.5 76.7 3.6 0.837
ANB (°) 6.7 1.1 6.4 2.0 0.474
Facial angle (°) 86.5 4.0 87.6 3.1 0.292
Occlusal plane angle (°) 8.9 3.7 5.6 4.3 0.009
Mandibular plane angle (°) 28.0 6.5 26.8 6.5 0.528
Wits (mm) 2.8 1.3 3.6 2.0 0.121
Dental
Overjet mm) 8.1 0.9 8.4 1.0 0.348
Overbite (mm) 3.4 1.0 3.2 0.9 0.487
U1 crown to VRL (mm) 54.7 4.7 56.3 7.8 0.428
U1 root to VRL (mm) 45.8 3.9 45.7 6.2 0.983
U1 to FH (°) 117.3 8.5 120.8 5.7 0.107
U1 crown to FH (mm) 54.3 3.9 56.3 8.2 0.843
U1 root to FH (mm) 36.8 3.4 39.0 6.2 0.290
U6 crown to VRL (mm) 17.9 3.5 18.6 4.3 0.568
U6 root to VRL (mm) 22.0 3.1 23.2 3.7 0.255
U6 axis-­FH (°) 109.7 4.5 109.0 4.2 0.635
U6 crown to FH (mm) 44.1 2.7 45.5 6.5 0.869
U6 root to FH (mm) 31.8 2.6 33.5 5.4 0.414
IMPA (°) 94.9 6.7 99.5 8.3 0.058
L6 to MP angle (°) 72.4 6.8 72.8 4.9 0.290
Soft Tissue
Nasolabial angle (°) 96.9 11.0 96.2 11.4 0.836
Mentolabial fold (°) 124.1 8.8 131.1 16.2 0.086
Upper lip to TVL (mm) 4.4 1.2 5.4 2.0 0.049
Lower lip to TVL (mm) 2.6 1.9 2.2 1.6 0.460
Soft pog-­T VL (mm) -­9.1 5.3 −9.3 5.8 0.885

Abbreviations: (MANOVA), Multivariate analysis of variance; FH, Frankfort horizontal plane; L6,
Lower first molar; MCPP, Modified C-­palatal plate; MP, Mandibular plane; pog, Pogonion; TVL, True
vertical line; U1, Upper incisor; U6, Upper first molar; VRL Means a perpendicular line to FH plane
with passing through the pterygoid point.

group showed a 3.3 mm overjet while the extraction group showed
an overjet of 3.0 mm, with no significant differences between both
groups. Also, no significant differences between the two groups
were reported in skeletal variables, the position of the central in-
cisors, and soft tissue variables. However, the first molars showed
significant differences between both groups in their sagittal position
and inclination (P < .001) (Table 3).
When the treatment effects were compared, there was a sig-
nificant difference between the two groups in general (P  <  .001).
Both groups showed a significant decrease in overjet, however, the
amount of reduction was significantly greater in the extraction group
(5.4 mm) than in the MCPP group (4.8 mm) (P < .001). In the MCPP
and extraction groups, the central incisors showed retraction of 6.1
and 7.8 mm (P < .001), retroclination of 14.1° and 17.3° (P < .001),
and non-­significant amount of extrusion of 1.1 and 1.6 mm, respec-
tively. Also, the treatment effects on the skeletal and soft tissue
variables were not significantly different between both groups. The
MCPP and extraction groups showed an increased nasolabial angle
of 7.5° and 9.4°, decreased upper lip to TVL of 1.8 mm and 2.2 mm,
respectively (P < .001) (Table 4).
Meanwhile, the changes in position of the maxillary first molar
were significantly different (P  <  .001) between the two groups. In
the MCPP group, the maxillary first molars showed an average of
5.4 mm distal movement (P < .001), 1.3 mm of intrusion (P = .001)
and 3.3° of distal tipping (P < .001). However, in the extraction group,
the first molars showed an average of 1.2 mm of mesial movement
(P  <  .001), 3.5° of mesial tipping (P  <  .001), and a non-­significant
amount of extrusion (0.3 mm; P = .363) (Table 4 and Figure 2).
ALFAWAZ et al.       5|
TA B L E 3   Comparison of post-­
MCPP Group Extraction Group
treatment variables between the MCPP
(n = 25) (n = 21)
and the maxillary first premolar extraction P
groups Measurement Mean SD Mean SD value

Skeletal
SNA (°) 82.2 3.6 82.0 3.7 .810
SNB (°) 76.4 3.6 76.4 3.5 .990
ANB (°) 5.8 1.1 5.5 1.9 .617
Facial angle (°) 86.0 4.4 86.5 3.6 .656
Occlusal plane angle (°) 9.8 4.3 6.8 5.1 .036
Mandibular plane angle (°) 29.5 6.5 28.0 6.9 .451
Wits (mm) 1.1 0.8 1.7 1.4 .158
Dental
Overjet (mm) 3.3 0.5 3.0 0.5 .064
Overbite (mm) 3.1 0.7 2.8 0.5 .024
U1 crown to VRL (mm) 48.6 5.0 48.5 6.7 .916
U1 root to VRL (mm) 44.3 4.0 44.0 5.9 .834
U1 to FH (º) 103.2 7.4 103.5 8.9 .896
U1 crown to FH (mm) 55.4 3.3 56.7 7.9 .886
U1 root to FH (mm) 36.7 3.4 36.7 3.5 .725
U6 crown to VRL (mm) 12.5 3.6 19.7 4.4 <.001*
U6 root to VRL (mm) 17.1 3.2 24.8 4.8 <.001*
U6 axis-­FH (°) 113.0 4.1 105.5 4.0 <.001*
U6 crown to FH (mm) 42.8 1.8 45.7 6.2 .022
U6 root to FH (mm) 30.7 2.3 33.5 5.1 .017
IMPA (°) 97.1 6.3 98.1 7.4 .615
L6 to MP angle (°) 71.4 6.2 70.3 5.3 .543
Soft Tissue
Nasolabial angle (°) 104.4 11.7 96.2 13.1 .726
Mentolabial fold (°) 131.3 9.8 131.1 11.3 .060
Upper lip to TVL (mm) 2.6 1.6 5.4 2.1 .289
Lower lip to TVL (mm) 3.2 1.8 2.2 2.1 .485
Soft pog-­T VL (mm) −10.3 5.3 −10.2 6.2 .926

Abbreviations: (MANOVA), Multivariate analysis of variance; FH, Frankfort horizontal plane; L6,
Lower first molar; MCPP, Modified C-­palatal plate; MP, Mandibular plane; pog, Pogonion; TVL, True
vertical line; U1, Upper incisor; U6, Upper first molar; VRL means a perpendicular line to FH plane
with passing through the pterygoid point.
*P < .002

4 | D I S CU S S I O N
Extraction of maxillary premolars has been used for a long time in or-
thodontic treatment, but the extraction decision is still the most crit-
20,21
ical decision made by orthodontists when they plan treatment.
Meanwhile, the development of TSADs over the past decade has
6,22-­24
expanded the envelope of non-­extraction treatment. Although
some authors reported the treatment of full-­step Class II or severe
13,14
overjet cases with palatal TSADs for total arch distalization,
cohort studies have assessed the treatment outcomes after distali-
zation with TSADs in adult Class II patients with a large overjet.
In our study, the MCPP and extraction groups showed 6.1 and
7.8 mm of retraction, and 14.1° and 17.3° of lingual inclination of the
maxillary central incisors, respectively, with severe overjet cases. A
previous study16 with cases with 4 mm of overjet showed that the
MCPP and first premolar extraction groups had 3.4 mm and 5.3 mm
of retraction, respectively. In addition, Jung15 reported that the
miniscrew and second premolar extraction groups showed 3.8 mm
and 3.3  mm of retraction respectively. These differences may be
no the result of using samples with severe overjet in this study. This
suggests that MCPPs seem to be a preferred alternative treatment
modality to upper premolar extraction.
 |
6       ALFAWAZ et al.

TA B L E 4   Comparison of treatment effects between the MCPP and the maxillary first premolar extraction groups

MCPP Group Extraction Group

(n = 25) (n = 21)
P value within P value within P value between
Measurement Mean SD groupa  Mean SD groupa  groupsb 

Skeletal
SNA (°) −1.0 0.4 <.001* −1.1 0.8 <.001* .499
SNB (°) −0.1 0.4 .158 −0.3 1.0 .197 .317
ANB (°) −0.9 0.5 <.001* −0.8 0.8 <.001* .730
Facial angle (°) −0.4 1.1 .063 −1.1 1.7 .010 .153
Occlusal plane angle (°) 0.9 2.7 .111 1.3 2.7 .047 .840
Mandibular plane angle (°) 1.5 1.8 <.001* 1.3 2.1 .011 .567
* *
Wits (mm) −1.7 1.0 <.001 −1.9 2.1 <.001 .297
Dental
Overjet (mm) −4.8 0.9 <.001* −5.4 1.0 <.001* <.001*
Overbite (mm) −0.3 0.8 .097 −0.5 0.9 .028 009
* *
U1 crown to VRL (mm) −6.1 2.6 <.001 −7.8 3.3 <.001 .084
U1 root to VRL (mm) −1.5 2.1 .002 −1.8 2.5 .004 .682
U1 to FH (°) −14.1 6.3 <.001* −17.3 6.8 <.001* .264
U1 crown to FH (mm) 1.0 2.5 .045 0.3 1.6 .350 .457
U1 root to FH (mm) 0.1 1.6 .665 0.1 1.7 .702 .498
U6 crown to VRL (mm) −5.4 1.1 <.001* 1.2 2.2 .001 <.001*
U6 root to VRL (mm) −4.9 1.3 <.001* 1.6 2.9 <.001* <.001*
* *
U6 axis-­FH (°) 3.3 1.4 <.001 −3.5 0.9 <001 <.001*
U6 crown to FH (mm) −1.3 1.8 .001* 0.3 1.2 .363 <.001*
*
U6 root to FH (mm) −1.2 1.4 .001 0.1 0.7 .662 <.001*
IMPA (°) 2.2 5.5 .056 −1.1 6.4 .450 .161
L6 to MP angle (°) −1.0 5.3 .017 −2.5 4.9 .031 .894
Soft Tissue
Nasolabial angle (°) 7.5 4.0 <.001* 9.4 6.1 <.001* .223
*
Mentolabial fold (°) 7.2 6.5 <.001 6.2 11.9 .028 .421
Upper lip to TVL (mm) −1.8 1.2 <.001* −2.2 1.7 <.001* .682
Lower lip to TVL (mm) 0.6 1.8 .022 0.6 2.7 .283 .635
Soft pog-­T VL (mm) −1.2 1.5 <.001* −0.8 4.2 .148 .694

Abbreviations: FH, Frankfort horizontal plane; L6, Lower first molar; MCPP, Modified C-­palatal plate; MP, Mandibular plane; pog, Pogonion; TVL,
True vertical line; U1, Upper incisor; U6, Upper first molar; VRL means a perpendicular line to FH plane with passing through the pterygoid point.
a
paired t-­test
b
Multivariate analysis of variance (MANOVA)
*P < .002

Regarding the soft tissue changes, the MCPP and extraction
groups showed an increased nasolabial angle of 7.5° and 9.4°, re-
spectively, and there was no significant difference between the
16
two groups. However, Jo et al reported the extraction group had
a greater amount of nasolabial angle change; 9.6° compared to 5.5°
20
in the MCPP group. In addition, Lim et al concluded that extraction
patients showed more improvement in their facial profiles than did
non-­extraction patients. On the other hand, in our study, there was no
difference in the nasolabial angle changes between the two groups.
During molar distalization, distal tipping of molars is com-
mon. 25-­27 Our results showed the distal tipping of the maxillary first
molar was 3.3°. Shoaib et al22 demonstrated maxillary molar distal
tipping of 2.4° using molar distalization with MCPPs that was sta-
ble 3 years post-­treatment. However, there is a 30.2% chance that
the space will reopen at the extracted tooth site with premolar ex-
traction treatment.1 So, total arch distalization using TSADs might be
considered because there is less tipping and space reopening.
Some studies concluded that there was no difference in the ver-
tical dimensions of the face between extraction and non-­extraction
treatment. 28,29 In our study, mandibular plane angle was increased in
both groups but had no intergroup difference. In addition, the max-
illary first molars were intruded by 1.3  mm after treatment in the
ALFAWAZ et al.
(A) (B)
(D) (E)
F I G U R E 2   (A and B), Representative changes in pretreatment and post-­treatment lateral cephalograms, MCPP, (C) Treatment summary
of the mean treatment effect MCPP group (D and E), Representative changes in pretreatment and post-­treatment lateral cephalograms,
maxillary premolar extraction treatment. (F) Treatment summary of the mean treatment effect extraction group
MCPP group but extruded by 0.3 mm in the extraction group. This
might have been caused by mandibular molar eruption to compen-
sate for the maxillary molar intrusion since no TSADs were placed in
the mandibular dentition.
Regarding treatment duration, in our study, the treatment took
26.5 months in the MCPP group and 27.2 months in the extraction
group, not a significant difference. Janson et al30 showed that max-
illary premolar extraction took 7.4 months less treatment time than
non-­extraction treatment. On the other hand, Landin-­Ramos et al31
32
and Holman et al concluded that the overall extraction treatment
time takes significantly longer. Moreover, Jung15 showed the dis-
talization group took 3.5 months less time than that the extraction
group. All things considered, a shorter distalization treatment time
can be expected with MCPPs than with extraction therapy.
In our study, the amount of maxillary incisor angle change after
treatment was a reduction of 14° and 17° in the MCPP and extraction
groups, respectively (Figure 2). Clinically, considering lingual inclina-
tion of maxillary incisor position during total arch distalization, high
torque anterior brackets need to be bonded to the central and lateral
incisors in normal or retroinclined incisor cases or it is recommended
that torque springs be used during total arch distalization.8 In adults,
maxillary tuberosity might be the limit of total arch distalization, and
therefore the extraction of third molars was usually recommended
|
      7
(C)
(F)
before distalization. Meanwhile, in adolescents, Kang et al33 re-
ported no significant difference in the amount of third molar erup-
tion between patients who underwent maxillary total distalization
and a control group and suggested that it might not be necessary to
extract the developing third molar before molar distalization.
Although MCPP application was an efficient modality for molar
distalization, maxillary premolar extractions were recommended in
cases of pure distalization over 4.2 mm of the molars in Class II pa-
tients and the severe pneumatization with the maxillary sinus.9,34
One limitation of this study is that it was retrospective.
Randomized controlled trials are warranted to examine MCPP treat-
ment effects on patients with severe overjet. Also, long-­term stability
of these treatment effects should be assessed. It is recommended that
a future study compare the effect of extraction and non-­extraction
treatment on the changes in transverse dimensions and patient smiles
in patients with Class II malocclusion and severe overjet.
5 | CO N C LU S I O N S
This study compared treatment effects with total arch distalization
in patients with Class II malocclusion and severe overjet. MCPPs
were used for non-­extraction treatment in one group while the other
 |
8       ALFAWAZ et al.
group was treated with maxillary first premolar extraction. We con-
cluded as follows:
There were no significant differences in the skeletal and soft tis-
sue changes between the MCPP and extraction groups.
Amongst the dental variables, only the amount of reduction in
overjet and the positional changes of the maxillary first molar were
significantly different between the two groups.
There was no significant difference in the treatment duration be-
tween the two groups.
These results suggest that total arch distalization via MCPPs
might be an effective treatment option for total arch distalization in
adult patients with Class II malocclusion adult patients with severe
overjet.
AC K N OW L E D G E M E N T
This study was funded by the Catholic University of Korea, Seoul St.
Mary's hospital (grant ZC20EISE0176).
C O N FL I C T O F I N T E R E S T
The authors deny any conflicts of interest.
AU T H O R ' S C O N T R I B U T I O N
Fawaz Alfawaz: contributed to data collection and writing the ar-
ticle. Jae Hyun Park: contributed to critical revision of the article
and reviewing the literature. Nam-­K i Lee: contributed to critical
revision of the article and reviewing the literature. Mohamed
Bayome: contributed to the statistical analysis and critical revision
of the article. Kiyoshi Tai: contributed to data collection. Hyeong
Ku: contributed to data collection. Yoonji Kim: contributed to criti-
cal revision of the article and reviewing the literature. Yoon-­A h
Kook: contributed to supervising overall project and overall re-
sponsibility. All authors have completed and submitted the ICMJE
Form for Disclosure of Potential Conflicts of Interest, and none
were reported.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from
the corresponding author upon reasonable request.
ORCID
Jae Hyun Park  https://orcid.org/0000-0002-3134-6878
Nam-­Ki Lee  https://orcid.org/0000-0003-1505-2551
Mohamed Bayome  https://orcid.org/0000-0001-7314-1419
Yoon-­Ah Kook  https://orcid.org/0000-0001-9969-8645
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How to cite this article: Alfawaz F, Park JH, Lee N-­K , et al.
Comparison of treatment effects from total arch distalization
using modified C-­palatal plates versus maxillary premolar
extraction in Class II patients with severe overjet. Orthod
Craniofac Res. 2021;00:1–­9. https://doi.org/10.1111/
ocr.12507