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  • 8/9/2019 All About the E's

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    T r e a t m e n t P l a n

    T he correction of Class IImalocclusion remainsone of the central issuesthat orthodontists face every dayin their busy practices. Withchapters in orthodontic textbooksdevoted to explaining the etiol-ogy and treatment options usedto correct these malocclusions,orthodontists are continuallyrequired to sift through a never-

    ending and always-expandingarray of new approaches andappliances to determine whatmay work best for each individualpatient to achieve the desiredtreatment goals.

    After 10 years in the UnitedStates market, the Carriere

    Motion Appliance has become astaple for Class II correction inmany orthodontic offices. Thereason for this can be explained

    by looking closely at what I callThe Five Es . Lets take look ateach one of these for furtherexplanation.

    Effectiveness T he Car r ie r e Mot i on

    Appliance has proven to be veryeffective in establishing a ClassI platform early in treatment ona broad range of malocclusionsrequiring Class II correction,from minor rotation all the waythrough full step Class II molarcorrection. The ability to treat a

    broad range of Class II cases hasmade this the go-to appliance forClass II correction in our office.

    The ball and socket featureis a key component (Figure 1).

    This feature allows a freedomof movement that is centeredon the buccal surface of the firstmolar. When Class II elasticsare applied to the cuspid, theforce is indirectly translated

    to the molar at the ball andsocket junction. This causes themolar to initially rotate to thedistal much the same as simpletip back and rotation bend ina round stainless steel wire abasic movement in Class II cor-rection (Figure 2).

    Heavy Class II elastics are worn to move the entire buccalsegment from the cuspid to thefirst molar in a distal direction.

    The recommended force levelsare -inch, 6.5 oz elastics. Ihave modified the elastic forceto be a little gentler at the startof treatment by starting with a5/16-inch, 4.0 oz elastic. After6 weeks we progress to a -inch,6.0 oz elastic for the remainder ofthe treatment.

    While the desired result isdistal movement of the buccalsegment, secondary effects arealso noted with heavy Class IIelastic use. An evaluation of theforce vectors would lead one to

    conclude that there should bea resultant vertical componenton the maxillary cuspid and themandibular molar. In addition,there should be an effect on theposition of the lower incisor. Thiscan vary depending upon the typeof mandibular anchorage.

    Using a temporary anchor-age device in the lower arch todirectly apply elastics will elimi-

    nate any dental changes in thelower archmaximum anchor-age. A full-coverage Essix-typeappliance in the lower arch willminimize the movement of thelower incisors. I have utilized afixed lower lingual arch, incor-porating additional anchoragefrom either the first bicuspids orthe second molars as the primaryanchorage device in the lowerarch (Figure 3).

    A complete evaluation of theeffects of the Carriere Motion Ap pl ia nc e woul d re qu ir e a

    three-dimensional analysisusing a combination of CBCTand intraoral scanning becausedental changes are noted inthree planes of space. To date,only limited information hasbeen available, mostly individualcase treatment reports.

    Sagittal measurements fromlateral cephalometric x-rays wereexamined in an unpublished

    study at the University of IllinoisChicago to determine some ofthe effects of the Carriere Motion

    Appliance. A paired t-test wasperformed to compare pretreat-ment cephalometric x-rays andsimilar x-rays taken at the timethe appliance was removedanaverage treatment time of 4.5months. Significant values werereported for the upper incisors,lower incisors, and the upper

    cuspid. More importantly, there were no skeletal changes notedin either the mandibular plane

    CLARK D. COLVILLE, DDS, MS, is a graduate of theUniversity of Texas Health Science Center at Houstonand maintains private orthodontic practices inSeguin and San Marcos, Tex. Colville is a Diplomateof the American Board of Orthodontics and isthe President-Elect of the Southwestern Societyof Orthodontists. In addition, he is an assistantclinical professor in the graduate orthodonticdepartment at UT Houston and lectures frequentlythroughout the United States on Invisalign and theCarriere Motion Appliance.

    Effectiveness, efciency, esthetics,and ease of use with the CarriereMotion Appliance

    BY CLARK D. COLVILLE, DDS, MS

    All About the Es

    Figure 1:Close-up ofthe ball andsocket.

    ELECTRONICALLY REPRINTED FROM OCTOBER 2

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    T r e a t m e n t P l a n

    angle, or the sagittal position ofthe maxilla, or the mandible inrelation to the cranial base.

    Distal movement of the upper

    incisors and cuspids is beneficialfor Class II correction and overjetreduction. Mandibular incisorproclination and protrusion isgenerally not favorable. However,this lower incisor position is aninterim position. The final posi-tion of the lower incisor willultimately be determined by theappliances placed following theremoval of the lower lingual arch.

    When using fixed appliances,I utilize a -6 torque .018 sloton the lower incisors and com-plete treatment using a full-size

    stainless steel archwire .018 x.025 to correct and upright thelower incisors from this interimposition when the distalizer is

    removed. The positive result ofincisor proclination when thedistalizer is removed is the reduc-tion in overbite on deep bite cases

    which allows placement of appli-ances without occlusal interfer-ences (Figure 4).

    The most relevant findingon panoramic x-rays reveals a

    widened periodontal ligamentextending the entire length ofthe mesial surface of the maxil-lary cuspid root (Figure 5). Thissuggests the movement of thecuspid is a combination of bodily

    movement with minimal distalcrown tip. The significance of thisis the stability following applianceremoval. Was the movement ofthe cuspid a clockwise rotation,

    where the crown moves distal with the root apex moving mesial,the anchorage loss when correct-ing the cuspid angulation wouldbe detrimental to the molar cor-rection that was achieved. In myopinion, this is what ultimatelymakes this appliance superior toother Class II appliancesthestability of the correction oncethe Class I platform has beenachieved.

    Given that there were no

    skeletal changes noted in thepreviously mentioned study, theideal indication for this appliance

    would be growing patients withonly minor discrepancy in therelationship between the maxillaand the mandible, a low ANBangle. Adolescent patients withmoderate to high mandibularplane angles have been success-fully treated, but the ideal patient

    would present with a low to

    normal mandibular plane angle with positive overbite of 1 mmor greater. Patients who present

    with open bite and/or tonguethrust should not be consideredfor treatment using the Carrieremotion appliance due to the likelyexacerbation of the open bite.

    Efficiency While there are a number

    of orthodontic appliances thatcan distalize molars, for me,the Carriere Motion Appliancetrumps them all because the

    entire buccal segment is correctedas a unit. This translates to feweroverall appointments and lesstotal treatment time comparedto appliances where only themaxillary molars are distalized,

    followed by stabilization of themolars and subsequent retractionof bicuspids, then cuspids, andfinally the anterior segment.

    With the Motion Appliance,complete correction to Class Imolar or better is achieved in 4.5months or less. Patients are seenin 6-week appointment intervalsfollowing appliance delivery.

    At the conclusion of the firs t6 weeks, there should be a breakin the contact between the cuspidand the lateral incisors. Thesize of the elastic is increasedas described above and at theconclusion of the second 6-week

    visit; there should be a noticeablespace between the cuspid and thelateral incisor, as well as visibleimprovement in the molar andcuspid relationship.

    At 18 weeks post insertion,the appliance is removed andthe transition to the next phase

    of treatment is ready to proceed(Figure 6). Correcting the mostdifficult problem in a relativelyshort period of time, at the start oftreatment, with only a few office

    visits makes this very efficient forthe doctor and the patient.

    Esthetics Another advantage of this

    appliance is its small size andlow profile. The appliance is

    smooth to the cheek, and mostpatients find the appearance ofthe elastics to be of little concern.For those patients who preferto show even less, the distalizercomes in smaller sizes that can befitted to the first bicuspid (Figure7). When this shorter bicuspiddistalizer is used, the elasticsshould be changed to 3/16-inch,4.5 oz or 6.0 oz intraoral elastics.

    The bicuspid distalizer is ideallysuited for patients with uneruptedor partially erupted cuspids inthe late mixed dentition. The

    E

    Figure 2: Occlusal view of the animation of the molar movement.

    Figure 3: Lower lingual arch.

    Figure 4: Front view showing before and after distalizer.

    A B

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    T r e a t m e n t P l a n

    distalization of the bicuspids

    and molars creates space for thecuspids to passively erupt into anideal position while alleviatinganterior crowding without pro-clining the maxillary incisors.

    Ease of Use An added benefi t of the

    Carriere Motion Appliancecomes from the ease of place-ment. While many appliancesrequire fabrication involvingmultiple parts requiring mul-tiple adjustments, the Motion

    Appliance is easily adapted to fit

    using study models or directly in

    the mouth. Sizes are spaced in2 mm increments, so a good fitcan be achieved with very littlemodification, generally limited tomaking the pad seat fully againstthe facial surface of the cuspid.

    In our office, orthodontictechnicians prepare the applianceprior to the patient arrival usingthe pretreatment study models.

    The correct length is determined,and minor adjustments are made

    with a three-prong plier. Toenhance the bond strength, ahybrid restorative composite

    material is used instead of stan-

    dard orthodontic adhesives. This requires bonding using asandwich technique, where thepads on the distalizer are lightlycoated with the unfilled resin/ adhesive first; followed by thecomposite material.

    The distalizer, with compositeapplied to the pads, is placed in adark drawer prior to the appoint-ment. When the patient is seated,the appliance is ready to bebonded by etching, drying, apply-ing the same unfilled resin/sealantto the tooth, and then positioning

    the distalizer and light curing forthe appropriate time.

    The advantage of using thehybrid composite is not onlyadded strength, but increased

    working time during positioning.

    Ambient light does not start thecuring process as quickly as seenin the less highly filled orthodon-tic adhesives, so there is no rushto seat and adjust the appliance.In our case, the mandibularlingual arch is cemented andthe Motion Distalizer is bondedin 20 minutes or less when theappliance is selected and adjustedprior to the patients scheduledappointment time.

    Evaluate Compliance This final benefit impac ts

    overa l l t r ea tment t ime .Compliance is an importantpart of orthodontic treatment.

    Many Class II correction devicesrequire some patient coop-erationwearing elastics andavoiding breaking appliances arethe most common requirements.

    By starting treatment withthe Carriere Motion Appliance,

    we are able to gauge the level ofcooperation at the start of treat-ment. We also benefit by treat-ing the most difficult problem atthe start of treatment when thepatient excitement and anticipa-tion is at the highest level. Thisis the reason I use the distalizer

    when only a small correction isrequired, because I dont want to

    wait to the end of treatment andhope the patient is still motivated

    to wear elastics after an extendedperiod of wearing fixed appliances.In growing patients, many

    times we will not need anyfurther elastic wear once theClass I platform has beenachieved. In those rare instances

    where patients fail to use theelastics at the start of treatment,

    we can change the treatmentplan to a noncompliance modeearly, before the fixed applianceshave been placed. This saves a lotof time and keeps overall treat-ment time to a minimum. OP

    Figure 5: Panoramic x-ray showing the mesial of the cuspid root.

    Figure 6: Side-by-side view before and after distalizer.

    Figure 7: Bicuspid distalizer.

    A B

    A B

    Posted with permission from October 2014 . Orthodontic Products , C opyright 2014. All rights reserved.

    http://www.orthodonticproductsonline.com/http://www.orthodonticproductsonline.com/http://www.orthodonticproductsonline.com/http://www.orthodonticproductsonline.com/
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    Fixed Cuspid Padwith Hook

    Molar Ball & Socket

    Sleek and Non-Invasive

    G A M E C H A N G E RTURN CLASS II INTO SIMPLE CLASS I PATIENTS

    Class II corrected in3 months, 1 week

    Total treatment time13 months

    CARRIERE MOTION CLASS II APPLIANCE

    Simplicity, ease of use and patient compliance add up to fast,more predictable results. With its sleek, aesthetic and non-invasivedesign, the Carriere Motion Appliance shortens treatment timeby up to four months.

    Faster than elastics alone, simpler than Forsus , and easier thanHerbst , the Carriere Motion Appliance can be a real game

    changer for you, your patients, and your practice.

    Learn more about the Carriere Motion Applianceat 888.851.0533 or HenryScheinOrtho.com .

    2014 Ortho Organizers, Inc. All rights reserved. 999-303 10/14All other trademarks or registered trademarks belong to their respective companies.