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Mini-Implant-Assisted En Masse Protraction of Maxillary Posterior Segment

Article in Turkish Journal of Orthodontics · September 2019

DOI: 10.5152/TurkJOrthod.2019.18058

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CASE REPORT

En-masse protraction of mandibular

posterior teeth into missing mandibular
lateral incisor spaces using a fixed
functional appliance
Aditya Chhibbera and Madhur Upadhyayb
Norwalk, OH, and Farmington, Conn

Protraction of mandibular posterior teeth requiring absolute anchorage has always been a challenge, especially
when the space is located in the anterior region, since more teeth must be protracted. Traditionally, skeletal
anchorage devices have been used for anchorage reinforcement during protraction. However, drawbacks
such as requirement of a surgical step, inability to tolerate heavy forces, and patient willingness to undergo
such surgical procedures can be limiting factors. Additionally, the mechanics involved can sometimes create un-
desirable side effects, thereby limiting their application in such situations. This report describes the use of a fixed
functional appliance as an anchorage-reinforcement device for en-masse protraction of mandibular posterior
teeth into a missing lateral incisor space. (Am J Orthod Dentofacial Orthop 2016;150:864-75)

O
rthodontic mechanotherapy often entails treat-
ment of patients with missing teeth. Treatment
options for missing teeth commonly require
either closing spaces or maintaining them for future
restorative work. With endosseous implants generally
the preferred method for restoring a missing tooth
over fixed partial dentures,1,2 it is common for
adolescents to have an extended retention or space
maintenance phase for subsequent implant placement
until facial growth and eruption of teeth have
ceased.3,4 Often during the long retention phase, teeth
may drift into the edentulous spaces, thereby
increasing the risk for orthodontic retreatment for
future implant placement.5,6
Orthodontic space closure, although a viable alterna-
tive treatment option, is even more challenging than
space maintenance because it commonly involves pro-
traction of posterior teeth to close spaces. Anchorage
control is often critical, and various forms of skeletal
anchorage devices have been used for bearing the
a
Private practice, Norwalk, OH.
b
Assistant professor, Division of Orthodontics, Department of Craniofacial Sci-
ences, Health Center, University of Connecticut, Farmington, Conn.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Aditya Chhibber, 137 Benedict Avenue, Norwalk, OH
44857; e-mail, adityachhibber14@gmail.com.
Submitted, June 2015; revised and accepted, October 2015.
0889-5406/$36.00
Ó 2016 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2015.10.034
864
anchorage load; however, their usefulness for en-
masse protraction of a segment of posterior teeth
can be questioned.7-9 Failure of implants is not
uncommon. Also, placement of such devices is
technique sensitive: location, surgical skills, and the
patient's oral hygiene are critical factors for their
successful placement.10-13 In addition, all patients may
not necessarily be willing to have invasive procedures
during orthodontic treatment.14,15 Therefore, it is
desirable to develop alternative noninvasive methods
that can provide absolute anchorage for en-masse pro-
traction of posterior teeth.
Fixed functional appliances have traditionally been
used for skeletal Class II correction. The effect of these
appliances is reported to be primarily dentoalveolar,
causing retroclination of maxillary incisors, proclination
of mandibular incisors, distalization of maxillary teeth,
and mesial movement of mandibular molars.16,17 The
use of a fixed functional appliance and its effects on
the dentoalveolar process are fully highlighted in this
report. See Supplemental Materials for a short video pre-
sentation about this case report.
DIAGNOSIS AND ETIOLOGY
A boy, aged 13 years 8 months, came with a chief
complaint of a missing tooth in the mandibular arch.
He had a Class II subdivision (right) malocclusion on
an underlying mild Class II skeletal base (Table) with a
Chhibber and Upadhyay 865

to adverse effects on the patient's facial profile, which

Table. Cephalometric skeletal analysis
had to be maintained through treatment. Therefore, a
Pretreatment Posttreatment Retention nonextraction treatment plan involving protraction of
SNA (
) 87 87 88 the posterior teeth into the missing lateral incisor space
SNB (
) 83 85 86 was adopted.
ANB (
) 5 2 2
SN-GoGn (
) 27 25 25
FMA (
) 23 20 20
TREATMENT PROGRESS
U1-SN (
) 118 110 105
U1-NA (
) 18 23 17 Treatment was initiated by bonding all teeth using a
U1-NA (mm) 3 3 1 0.022-in preadjusted edgewise appliance, with 6
of
IMPA (
) 94 92 92
lingual crown torque on the mandibular anterior
L1- NB (
) 21 19 19
U1-NB (mm) 5 2 2 brackets. In the maxillary arch, initial leveling and
E-line–upper 4 6 6 alignment were done with 0.16-in nickel-titanium arch-
lip (mm) wires. The archwire was gradually built up to a
E-line–lower 3 5 5 0.021 3 0.0250-in stainless steel wire. In the mandib-
lip (mm)
ular arch, the initial leveling and alignment were done
with 0.16-in nickel-titanium archwires. The archwire
was gradually built up to a 0.019 3 0.0250-in stainless
slightly forwardly placed maxilla and a normally placed steel wire without engaging the severely rotated
mandible, an average growth pattern, and reduced lower mandibular right canine. Elastic chains were applied
facial height. In the mandibular arch, the patient had a from the buccal and lingual surfaces of the mandibular
congenitally missing right lateral incisor, severely right canine to create a moment due to a couple to der-
rotated right canine, crossbite in relation to the right first otate the tooth (Fig 5).
premolars, spacing, a 2-mm overjet, and a 3-mm curve Once the canine was derotated and aligned, a crimp-
of Spee creating a 50% overbite. able hook was spot welded onto the 0.019 3 0.0250-in
Extraorally, the patient had a mesoprosopic facial stainless steel archwire distal to the mandibular canine
type with a convex soft tissue profile, right-angled naso- on the right side (Fig 6). A passive Forsus Fatigue Resis-
labial angle with 100% maxillary incisor display on tant appliance (3M Unitek, Monrovia, Calif) (right side,
smile. The upper midline was coincident with the facial 29; left side, 25) was placed bilaterally from the headgear
midline, and no interlabial gap at rest was noted tube in the maxillary arch to the mandibular archwire
(Figs 1-3). (Fig 7). An elastomeric chain was placed from the molar
tube on the mandibular arch to the crimpable hook
TREATMENT OBJECTIVES delivering approximately 300 cN of force for en-masse
protraction of the premolars and the first molar on the
The treatment objectives were to close the space right side. The patient was recalled every 6 weeks, and
created by the missing lateral incisor by protraction of the elastomeric chain was replaced to complete the space
the posterior teeth so that the patient's soft tissue profile closure. The protraction phase lasted 10 months. During
could be maintained. Our goal was to create bilateral the space-closure phase, bracket breakages were found
Class I molar and canine relationships. A diagnostic on 2 visits; this is a common side effect with a fixed
setup using emodel (GeoDigm Corporation, Falcon functional appliance.18,19 However, instead of
Heights, MN) was created to simulate the final outcome realigning the teeth, the brackets were bonded
by protraction of the mandibular right posterior segment passively to continue with the space closure. The teeth
into the missing lateral incisor region (Fig 4). were realigned during the finishing stages.
A progress panoramic radiograph was taken to eval-
TREATMENT ALTERNATIVES uate the root positions of the protracted teeth. No
The alternative treatment plan that was considered tipping was observed (Fig 8). Finishing and detailing of
entailed maintaining the space for the missing lateral the occlusion were performed, and the patient was de-
incisor and subsequent implant placement after the pa- bonded after 30 months of active treatment (Figs 9-11).
tient's facial growth was completed. However, this A Hawley removable retainer was provided for the
required space maintenance for a long time. The pa- maxillary teeth, and a fixed lingual retainer was placed
tient's parent did not agree to this treatment. Extractions on the mandibular teeth. The patient was evaluated
of the maxillary first premolars and the mandibular left 2 years after treatment, and stable results were
first premolar were also considered, but this could lead observed (Figs 12-14).

American Journal of Orthodontics and Dentofacial Orthopedics November 2016  Vol 150  Issue 5
866 Chhibber and Upadhyay

Fig 1. Pretreatment photographs.

Fig 2. Pretreatment models.

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Chhibber and Upadhyay 867

Fig 3. Pretreatment radiographs and tracing.

Fig 4. Diagnostic setup using digital models to simulate protraction of the mandibular right posterior
segment. Blue, Pretreatment; white, simulation.

American Journal of Orthodontics and Dentofacial Orthopedics November 2016  Vol 150  Issue 5
868 Chhibber and Upadhyay

Fig 5. Derotation of the mandibular right canine.

Fig 6. Placement of a 0.021 3 0.0250-in stainless steel archwire in the maxilla and a 0.019 3 0.0250-in
stainless steel archwire in the mandible.

Fig 7. Placement of a passive fixed functional appliance for anchorage reinforcement during en-masse
protraction of the mandibular right posterior segment.

TREATMENT RESULTS superimpositions were done on the cranial base using

All treatment objectives were achieved. Lateral cepha- the best-fit method. For regional superimposition, the
lograms were taken before and after treatment. Overall ork and Skieller20 was used.
structural method of Bj€

November 2016  Vol 150  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Chhibber and Upadhyay
Fig 8. Progress panoramic radiograph after en-masse protraction of the mandibular right segment.
Superimpositions (Fig 15) showed that the maxillary
molar did not move, whereas the mandibular posterior
segment underwent mesial movement with no distal
movement of the mandibular anterior segment. However,
there was a slight extrusion of the molar during protrac-
tion, and this may have led to the minimal increase in the
mandibular plane angle at the end of treatment. During
retention, evaluation of the results was maintained.
DISCUSSION
Although endosseous implants are generally the
treatment of choice for edentulous spaces, they increase
the overall financial burden to patients as opposed to
space closure in patients seeking orthodontic treatment.
In addition to placement of implants, vertical facial
growth should have ceased, thereby prolonging the
retention time in growing patients with missing teeth.3
Furthermore, Olsen and Kokich5 reported that 17% of
patients whose treatment was aimed at space mainte-
nance for future implant placement had space inade-
quacy in the long term. They also reported that
younger patients were more susceptible to space inade-
quacy issues, indicating that perhaps an increased reten-
tion time may be a risk factor associated with increasing
relapse tendencies. Therefore, orthodontic mechano-
therapy to reduce the need for subsequent implant
placement should be advocated when feasible in
growing patients.
This report demonstrates the clinical usefulness of
a fixed functional appliance for en-masse protraction
of mandibular posterior teeth into the space created
by a missing lateral incisor with no significant side ef-
fects. Davoody et al21 reported using a fixed func-
tional appliance for simultaneous Class II correction
and molar protraction, but they had minimal residual
space because of drift of the second molar into the
American Journal of Orthodontics and Dentofacial Orthopedics
869
first molar site. Moreover, there have been no reports
in the literature about fixed functional appliances for
en-masse protraction of an entire segment of teeth.
The larger number of teeth that were protracted, the
larger the roots and the thicker the cortical bone sur-
rounding them, thus making their movement chal-
lenging and often resulting in unwanted side effects
such as lingual tipping of the incisors.
A fixed functional appliance is commonly used for
Class II correction with predominantly dental effects.
In the maxillary arch, the appliance causes distalization
and intrusion of the maxillary molars and incisors; in
the mandibular arch, it results in mesial and intrusive
movement of the anterior teeth.16,17 It has been
reported that the distalization and intrusion of the
maxillary molars with a fixed functional appliance is a
transient effect of the appliance and not observed
during overall treatment of Class II correction using
fixed functional appliances.22 On the contrary, mesial
movement and extrusion of the mandibular molars
have been reported to be stable outcomes of fixed func-
tional appliances.22 The mesial movement of the
mandibular anterior teeth with fixed functional appli-
ances can be used for anchorage reinforcement during
protraction of the posterior dentition. In our patient,
the Forsus appliance was placed in a nonrigid manner,
since no skeletal Class II correction was being attempted.
Placement of an elastic chain between the between
the molar and the archwire hook created a mesial force
on the mandibular posterior segment leading to en-
masse protraction of the posterior teeth. However, at
the same time, it also resulted in a distal force on the
mandibular anterior teeth. This force was effectively
negated by the fixed functional appliance, which exerted
a mesially directed force on the mandibular anterior
teeth, thereby preventing lingual tipping of the
November 2016  Vol 150  Issue 5
870 Chhibber and Upadhyay

Fig 9. Posttreatment photographs.

Fig 10. Posttreatment models.

incisors—ie, anchorage loss (Fig 16). This was verified
from the superimpositions (Fig 15). Another key aspect
of the mechanics involved was to ensure a translation-
like movement of the posterior segment into the extrac-
tion space. This was critical to ensure that the spaces do
not open in the long term.
The mesially directed force on the molar via the
elastic chain created a moment, tending to tip the pos-
terior segment. Counteracting this moment was critical
to achieve bodily tooth movement. This was generated
by the main archwire. The archwire should have suffi-
cient flexural rigidity to generate the desired moment

November 2016  Vol 150  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Chhibber and Upadhyay
Fig 11. Posttreatment radiographs and tracing.
and not to undergo flexion or elastic deformation
beyond a certain limit. Flexural rigidity is defined as
the wire's ability to resist deformation under load and
is denoted by EI, where E is Young's modulus of the
archwire material, and I is the moment of inertia of the
cross-sectional area. It is well known that the elastic
deformation of archwires is influenced by the flexural ri-
gidity of the wire and the net force acting on it.23,24
Archwires with less flexural rigidity tend to deflect
more (Fig 17, A) and can impede sliding mechanics.
Therefore, we used a 0.019 3 0.025-in stainless steel
archwire for protraction to minimize its elastic deforma-
tion. In addition, the push rods of the fixed functional
appliance have a downward component of the total
force on the archwire in the mandibular anterior region;
this could minimize wire deformation, permitting easier
sliding of the teeth over the wire (Fig 17, B). The defor-
mation can be appreciated in a finite element simulation
American Journal of Orthodontics and Dentofacial Orthopedics
871
that was performed to mimic the clinical setup. Figure 18
shows that because of tipping of the posterior teeth dur-
ing mesial movement, the archwire tends to deflect in
the anterior region and could impede tooth movement
during sliding mechanics. However, further research is
required to validate this concept. It could be argued
that use of a stiff archwire could increase the frictional
resistance to tooth movement.25 However, it has been
suggested that during tooth movement, classical fric-
tional resistance is typically not the rate-limiting step
for tooth movement. Resistance to sliding in the active
configuration is reported to be a combination of bind-
ing, notching, and critical contact angle.26 Although
the use of large archwires may reduce the critical contact
angle, for generating the counterbalancing moment, the
contact angle must be greater than the critical contact
angle; thus, larger archwires may be more beneficial in
this aspect.27
November 2016  Vol 150  Issue 5
872 Chhibber and Upadhyay

Fig 12. Two-years retention photographs.

Fig 13. Retention models.

November 2016  Vol 150  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Chhibber and Upadhyay 873

Fig 14. Retention radiographs and tracing.

Fig 15. Overall and regional superimpositions: black, pretreatment; red, posttreatment; green, reten-
tion.

American Journal of Orthodontics and Dentofacial Orthopedics November 2016  Vol 150  Issue 5
874 Chhibber and Upadhyay

Fig 16. Biomechanics during use of the fixed functional appliance for posterior tooth protraction. A,
Green dot, Center of resistance of the molar; d, vertical distance between the molar tube and the center
of resistance of the molar; F, force applied by the elastomeric chain on the molar; Fr, reciprocal force
acting on the mandibular anterior segment; Fr0 , force applied by the fixed functional appliance on the
mandibular anterior segment; a, length of the molar tube; Mc, moment of the couple; Mf, moment of
the force. B, The inside of a molar tube with a 0.019 3 0.025-in stainless steel archwire; a, length of
the molar tube; f, vertical forces generated due to tipping of the molar tube during protraction; Mc,
moment of the couple.

Fig 17. A, Deflection of the archwire with the retraction force, Fr. Black archwire is the original position,
and orange archwire is the new position of the wire. B, Introduction of the fixed functional appliance
leads to intrusive force, Fi, on the mandibular archwire. Black archwire is the position of the archwire
from the retractive force, and orange archwire is the final position of the wire after insertion of the fixed
functional appliance.

It could be argued that the patient has a compro-
mised occlusion on the right side. However, he was
informed of the possibility of not finishing to ideal oc-
clusion standards on the right side because of a Bolton
discrepancy; thus, he was finished in super Class I molar
and Class I canine relationships with optimal overjet.
White spot lesions were observed at the end of treat-
ment, and the patient was prescribed MI Paste (GC
America, Alsip, Ill) during and after appliance removal;
it has been shown to promote remineralization of the
enamel surfaces.28
CONCLUSIONS
This report demonstrates the effectiveness of a fixed
functional appliance for absolute anchorage reinforce-
ment during en-masse protraction of a mandibular pos-
terior segment into an anterior edentulous space.

November 2016  Vol 150  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
 Chhibber and Upadhyay
Fig 18. Finite element simulation to mimic the clinical setup. F, Force applied on the molar.
SUPPLEMENTARY DATA
Supplementary data related to this article can be
found online at http://dx.doi.org/10.1016/j.ajodo.2015.
10.034.
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