carriere distalizer workbook
TRANSCRIPT
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The Carriere
disTalizer workbooksftng t y yu tn ut tntc.
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The CarriereDistalizer Appliance is a biominimalist appliance o
unqualifed simplicity.
It operates on the premise that achieving a Class I relationship beore
correcting individual tooth positions is o strategic importance in
simpliying Class II cases being treated nonextraction. This protocol
eliminates competing orce vectors inherent in traditional Class II
correction when traction is combined with fxed appliance treatment.
In developing the Carriere DistalizerAppliance, I was intent on creating
a device that mimics the bodys natural processes using a noninvasive
technique to stimulate distalization o the entire buccal segment as a unit. This biomimetic approach
is the result o research that takes advantage o the most advanced 3D computer technologies. It
represents an evolution o Dr. Jos Carrires protocol, which is based on the principle o dental
movement using available space. It consists o creating space by a distomesial sequence, transverse
arch development, or a combination o both, according to the diagnostic needs prior to movement o
the anterior segment in Class II nonextraction cases.
Clinical experience indicates that compared with Class II elastics traction used on ully bonded arch,
the Carriere DistalizerAppliance can resolve the posterior segments o Class II malocclusions in three
to fve months, reducing the total treatment time by 35% to 40%. It has also opened new vistas or
a more conservative and simplifed approach to Class II cases that would have previously required
extractions. My hope is that clinicians around the world will fnd it an invaluable adjunct to their clinical
armamentarium.
Luis Carrire, D.D.S., M.D.S., Ph.D.
Clinical Orthodontist and ResearcherBarcelona, Spain
1 Carriere, J.: The Inverse Anchorage Technique in Fixed Orthodontic Treatment, Quintessence Publishing Co., Chicago, 1991.
A Message rom Dr. Carrire
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Rigid, Hal-Round Armconnects the anterior and posterior
pads and curves over the two maxillary
bicuspids, providing stability to the
cuspid while directing movement
longitudinally.
Posterior Paddirect bonds to the maxillary
1
st
molar and houses anarticulating ball in a socket
to foster free yet controlled
movement that allows the
molar to travel directly to
the desired position after
derotating and uprighting it.
Cuspid Movement
The maxillary cuspid requires a bodily movement along the corner o the alveolar ridge with inclination control o its
longitudinal axis. The portion o the distalizer attached to it has to be a fxed element that provides stability to the tooth itsel
while simultaneously directing movement longitudinally and distally. The anterior pad o the Carriere DistalizerAppliance that
attaches to the maxillary cuspid (or frst bicuspid i the cuspid is inaccessible) is a rigid hal-round arm that aords this stability(Figure 3). The arm then curves posteriorally over the bicuspids, ending as an articulation ball within a socket on the posterior
pad, which direct-bonds to the maxillary frst molar.
Metal Injection Molded (MIM)Stainless steel affords proven strength,
performance and patient safety.
Fixed Anterior Paddirect bonds to the maxillary cuspid
(or 1st bicuspid), fostering bodily
distal movement of the cuspid along
the alveolar ridge. Its hook offers an
attachment point for Class II traction.
Smooth, Rounded Design
and Low Pofleoffers maximum patient comfort.
Free Yet Controlled Movement.The ball and socket joint offers maximum freedom of movement that allows
molars to travel directly to the desired position. It has built-in stops that prevent
unwanted molar overrotation, tipping and torquing.
Figure 3. The Carriere DistalizerAppliance
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To prevent the tendency or relapse, it is important to surpass the neutroclusion o the cuspids to a Super Class I by continuing
the distalization process until the distal incline plane o the maxillary cuspid establishes a contact against the mesial incline
plane o the mandibular rst bicuspid (Figure 4a). Once accomplished, and the clinician has removed the distalizer and bonded
the arches with the xed appliance o choice to nish treatment, it is necessary to ligate the distalized teeth under the archwire
using a .012" stainless steel ligature wire tied in a gure-8 rom the maxillary cuspids to the maxillary rst molars, maintaining
the consolidation throughout the remainder o treatment (Figure 4b). I you are using aligners to nish treatment, you will
ollow the protocol outlined in Full Esthetic Treatment on page 17.
Figure 4a-bTo prevent relapse, it is important to continue distalization until the cuspids are in Super Class I (a), then, after bonding the case, consolidate the
distalized teeth for the remainder of treatment (b).
a
a
b
b
First Molar Movement
The maxillary rst molar requires a triple movement: distal rotation around its palatal root and controlled distal displacement
while preventing the distal tipping o its crown and even uprighting i need be. Obviously, the Carriere DistalizerAppliance
must rst derotate and upright the molar so that the distalizing movement can proceed unettered. Once the molar uprights,
the articulation o the ball within the socket prevents unwanted distal tipping (Figure 2).
In true biomimetic design, the ball and socket imitates the bodys hip joint. This joint provides maximum reedom o movement
with minimal riction while causing the molar to travel directly to the desired position ater derotating and uprighting it. There
are several predened points that stop movement or controlling undesired consequences. Polar cuts on the ball articulate
with fat suraces in the socket at a maximum orientation o -15 to the longitudinal axis o the arm, which act as a stop, limiting
undesirable movements and providing torque control over the cuspid and molar (Figure 5a-b). When the molar has derotated,
the mesial shoulder o the posterior base contacts an eminence in the distal end o the arm that runs between the anterior and
posterior pads, preventing overrotation. While the movement o the molar is independent and qualitatively dierent rom the
movement o the cuspid, it must also be coordinated with it in order to express a simultaneous response as a unit.
Figure 5a-bThis image (a) depicts the
posterior pad of the Carriere
DistalizerAppliance in a position
that fosters molar derotation.
When the molar has derotated,
the shoulder of the posterior base
contacts the mesial arm to prevent
overrotation and unwanted
tipping and torquing (b).
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Primary IndicationsThe Carriere DistalizerAppliance is ideal or treating growing patients and eective or treating adults. Clinicians can usually
expect the same amount o distalization and molar rotation in adults as children although, as one would expect, treatment
time or adults will be longer. On average, adult distalization takes fve months; growing children, three months.
Brachyacial patterns respond best to this treatment ollowed by mesoacial patterns; dolichoacial types are less responsive.
The Carriere DistalizerAppliance is indicated in the ollowing types o cases i deemed to warrant nonextraction therapy:
ClassIImalocclusions,bothdivision1anddivision2,symmetricalorasymmetrical.
ClassIandpseudoClassIcaseswithmesiallypositionedmaxillarymolars.
ClassIImixeddentitionandadultcaseswithmaxillarydentoalveolarprotrusion.
PhaseItreatmentofmixeddentitionClassIIcaseswithfullyeruptedmaxillaryrstmolars.Inthesecases,thedeciduouscuspids must be in good position to hold the anterior segment o the appliance.
Secondary Indications
The Carriere DistalizerAppliance can be used creatively in the treatment o:
ClassIandClassIIcasesinwhichfourextractionswouldseemnecessary.Insuchcases,thenumberofextractionscan
oten be minimized and a more esthetic acial result achieved.
UnilateralClassIIcases.
SpacerecoveryforretainedmaxillarycuspidsinClassIIcases,unilaterallyandbilaterally.
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Forming the Passive Lingual Arch
A mandibular lingual arch to sustain Class II elastics traction is one means o preparing anchorage or the Carriere Distalizer
Appliance and is particularly suited to patients with strong musculature. A .036" lingual arch adapted to the mandibular dental
anatomy must run passively rom frst molar to frst molar (second molars i they have erupted.) When second molars are ully
erupted, it is advisable to band them (with buccal tubes) in order to obtain the maximum amount o orce rom elastics and
create better anchorage resistance.
The clinician must remain vigilant that the lingual arch does not create protrusion o mandibular anteriors. The archwire must
remain completely passive in order to disallow reciprocal movement o the mandibular dentition. It must also ft the length
o the arch exactly and be perectly adapted anatomically; otherwise, spaces will emerge between the mandibular incisors,
an indication o anchorage loss. Clinicians must monitor and control against rotations and torque changes in the mandibular
molars at every appointment. Patient acceptance o the lingual arch is excellent: it is invisible, comortable, requires minimal
patient care and is hygienic.
Materials to Fabricate (Figure 7)
.036"lingualarchwire
.036"lingualarchpliers
Edgewisepliers
Waxpencil
Patientsmodel
Figure 7
Possible Sources of AnchorageTo avoid protrusion o the mandibular incisors during activation o the
Carriere DistalizerAppliance, clinicians must determine an adequate source
ofanchoragebasedoneachpatientsskeletalandneuromuscularpattern
(Figure 6). A sound diagnosis or the proper selection o anchorage is a
undamental requirement to prevent anchorage loss. There are our primary
sources or establishing anchorage that will each be discussed:
Apassivemandibularlingualarchwithmolartubesweldedbuccallyand
lingually on mandibular molar bands;
AmandibularEssixappliancewithdirect-bondedbuccaltubesonthe
mandibular molars (the preerred method); Fullmandibularxedapplianceswithdirect-bondedbuccal
tubes on the mandibular molars;
Temporaryanchoragedevices(TADs).
Figure 6Once the distalizer is bonded, a Class II elastic
attaches rom the 1st mandibular molar or TADto the hook o the anterior segment o the
appliance bonded to the maxillary cuspid or
frst bicuspid i the cuspid is inaccessible.
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Procedure to Fabricate
1. Shape the archwire rom cuspid to cuspid to lie at above the
cingulum o the incisors.
2. At the juncture between the cuspids and bicuspids, make a45 bayonet bend slanting downward and inward so that the wire
runs along the middle third o the bicuspids (Figure 8).
3. Just mesial to the frst molar, make another 45 inward bayonet
bend in the wire and shape it to insert in the lingual molar tube
bonded to the frst molar (Figure 9).
4. With a wax pencil, mark the model at the distal end o where
the lingual tube will ft. Note: The other white wax pencil marks
demonstrate the points where a compensating bend is made
(Figure 10).
5. Recurve and compress the distal end o the lingual arch into a bend
or insertion into the lingual molar tube (Figure 11).
6. Apply pressure to this distal bend using the tips o the lingual arch
pliers. There are two channels at the end o the lingual pliers that ft
over the recurved bend. Recurve the distal bend over itsel again to
make a second bend (Figure 12).
7. Compress the bends again to retain the lingual arch (Figure 13).
8. Closeup o the distal end o the lingual arch that is inserted into the
lingual molar tube (Figure 14).
9. Occlusal view o an ideal lingual archwire shaped and placed
passively over a dental model (Figure 15).
Note: Ortho Organizers also sells a pre-abricated kit (PN 032-060).
Figure 8
Figure 11
Figure 10
Figure 9
Figure 14
Figure 15
Figure 13
Figure 12
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Essix Fabrication
1. Bond buccal tubes with hooks onto the buccal surace o the mandibular frst or second molar.
2. Cut a window in the thermoormed Essix appliance to allow the buccal tubes to protrude.
3. To provide maximum traction and maintain the appliance in position:
a. Ensure it fts properly to the dental arch orb. Fabricate the appliance with small composite wedges bonded to the buccal suraces
that ft over the mandibular bicuspids.
Fixed Appliances Bonded on the Mandibular Arch
For patients who present with a severe curve o spee or mild crowding in the mandibular arch, it is advisable to bond
brackets to the mandibular dentition to prepare anchorage or supporting Class II traction. Ater leveling the case with
round wires, advance to a .016" x .025" dimension archwire and then to a .019" x .025" Bio-Kinetix Archwire beore
attaching the Class II elastics.
Mandibular Essix Appliance
The Essix appliance (Dentsply Raintree Essix, Sarasota, FL, USA) provides a very good source o anchorage or Class II elastics
traction. It unlocks the occlusion, is highly efcient and has become the anchorage method o choice or most clinicians
(Figure 16a-b). It must be worn ull time except during meals and is particularly applicable to patients with weak musculature.
The recommended material is A+ with .040" (1 mm) thickness.
Figure 16a-bThe Essix appliance (a-before and b-after distalizing treatment) has become the most popular choice for anchorage
with the Carriere DistalizerAppliance.
a b
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Temporary Skeletal Anchorage (Temporary Anchorage Devices or TADs)
A variety o temporary anchorage devices (TADs), such as miniimplants, miniplates and miniscrews, are designed with
heads that oer mechanisms to receive the insertion o elastics or anchorage maintenance (Figure 17). Examples include
Infnitas (DB Orthodontics, West Yorkshire, UK) and ST Bone Anchor (Surgi-Tec, Ghent, Belgium) and, as shown in the
case below, VectorTAS (Ormco, Orange, CA, USA).
In the maxilla. For noncompliant patients, the suggested TAD placement is in the maxillary arch using NiTi coil springs or
permanent elastics or traction. It is best positioned between the frst and second molar at the mid to apical height o the
buccal side o the bone, ollowing the direction o the axis o these teeth. In this position, the TAD is actually placed in
the prominent arched border o the zygomatic process in which the cortical bone density is more reliable to hold
traction. This placement will prevent the TAD rom coming into contact with the molar roots as the teeth distalize.
The recommended TAD length or placement in this position is 10 mm to 12 mm.
In the mandible. The suggested TAD placement in the mandibular arch is between the frst and second molar where
there is adequate dense cortical bone to hold the Class II elastic traction. The recommended TAD length or this
position is 8 mm.
Figure 17TADs are designed with heads that offer mechanisms
to receive the insertion of elastics for anchorage
maintenance. Case image courtesy of Dr. Dave
Paquette, Charlotte, North Carolina, USA.
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Sizing the ApplianceMeasure or the appropriate size distalizer by using calipers or the disposable Carriere DistalizerAppliance Ruler provided
with the appliance. There are 22 sizes available to accommodate the majority o case requirements or bonding rom cuspid,
or frst bicuspid, to frst molar.
Taking the Measurement
1. In cases with accessible cuspids, take the measurement rom the buccal surace
midpoint o the maxillary frst molar to the midpoint o the maxillary cuspid crown
(Figure 18).
2. In cases with an inaccessible high cuspid when the second maxillary molars are
present, take the measurement rom the buccal surace midpoint o the frst molar to
the buccal surace midpoint o the frst bicuspid. The appliance can then be bonded
to these teeth so that the posterior teeth can be distalized to provide space or the
blocked-out cuspid.
3. Use the measurement to choose the appropriate size appliance. When the measurement is between two sizes
(e.g., between 24 mm and 25 mm), select the appliance size based on the amount o rotation desired:
a. For more rotation, select the smaller size.
b. For less rotation, select the larger size.
Appliance Selection
R = Right DistalizerAppliance
L = Let DistalizerAppliance
Prepping the Teeth for Bonding
1. Isolate the area being bonded.
2.Clean the teeth being bonded with prophy paste (Figure 19).
3.Rinse the teeth thoroughly with water (Figure 20).
4.Dry the teeth with air (Figure 21).
5.Etch the suraces o the teeth being bonded appropriate to the adhesive
selected (Figure 22).
6.Rinse the teeth thoroughly with water (Figure 23).
7.Dry the etched teeth with a brie air burst. Ensure that the entire isolated area is
dry (Figure 24).
8.Prime the teeth being bonded with a uniorm coating o primer/sealant (Figure 25).
Figure 18
Figure 19
Figure 24
Figure 25
Figure 23
Figure 22
Figure 21
Figure 20
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Bonding the Appliance
1. Adhesive Application
a. Using a locking hemostat, orceps or tweezers, grasp the distalizer by the
arm (Figure 26a) and coat both pads o the appliance with a small amount o
light-curing adhesive, covering them completely (Figure 26b).
2. Placement
a. Use the instrument to position the appliance onto the appropriate teeth,
placing the posterior pad rst and then the anterior pad.
b. There is a vertical line engraved on the posterior pad to be used as a
reerence in aligning the pad coincident with the longitudinal axis o the
molar. Position the posterior pad in the center o the buccal surace o
the molar. In cases o exaggerated mesial molar rotations, the arm o the
distalizer can open laterally up to 45, easing placement.
c. Position the anterior pad on the mesial third o the vestibular surace o the
crown o the cuspid or rst bicuspid (not on the midline).
3. Alignment
a. Using the placement instrument, align the pads on the tooth suraces
(Figure 27).
b. Generally, little i any adjustment to the curvature o the appliance
arm is necessary.
c. Using the placement instrument, remove excess adhesive rom the tooth
surace while maintaining the appliance alignment.
4. Light Curing
a. Fully light cure the appliance pads, beginning with the molar, then the
cuspid or bicuspid (Figure 28).
Caution
I the distalizer requires adjustment prior to placement, place it on a solid, fat
surace and use gentle nger pressure on the middle o the arm (Figure 29).
Do not use an instrument to adjust the bar or the pad. Avoid making repeated
adjustments, bending and straightening the bar. Repeated bending will atigue
the appliance and may cause it to break. Avoid trying the appliance on the
patients teeth prior to bonding it; this action may contaminate the bonding pads
with saliva.
Figure 26b
Figure 27
Figure 28
Figure 26a
Figure 29I the distalizer requires adjustment prior to
placement, place it on a solid, at surace and use
gentle fnger pressure on the middle o the arm.
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Attachment and ActivationAttach the Class II elastic rom the selected source o anchorage, then stretch it to the hook provided on the maxillary
anterior pad o the appliance. Activation can be initiated immediately ater light-curing the appliance in place.
Elastics Traction
When the Carriere DistalizerAppliance is placed rom the cuspid to the molar, use orce 1, Class II elastics: 6 oz,
(PN 424-9F1). When the Carriere DistalizerAppliance is placed rom the 1st bicuspid to the molar, use orce 2,
Class II elastics: 8 oz, 3/16 (PN 424-9F2).
Instruct patients to wear elastics 24 hours a day except when eating because o the vertical orce vector that opening the
mouth while chewing produces. A predominantly vertical orce vector may result in a mild extrusion o the cuspids during
distalization. Night-time wear can compensate or this phenomenon because it produces a more horizontal vector o tractionbut will prolong the distalization period. Patients should change their elastics ater each time they eat.
Scheduling
Appointment checks at 6-week intervals should take only a ew minutes. Each is used to observe treatment progress, explain
the progress to the patient and praise and/or encourage compliance.
Typical 6-Week Appointment Protocol
1st Visit: Use mirror and foss. Check cooperation and ensure that contacts are open in the maxillary anteriors.
If using a lingual arch for anchorage, check the mandibular molar positions and monitor and control against unwanted
torque changes and anchorage loss at each visit.
Using an Essix appliance in the mandible or TADs for anchorage usually precludes the control problems that can occurwith a lingual arch; however, you must still check the condition o these appliances and replace them, i necessary.
TADs seldom fail; if they become loose, they can usually be tightened. With good compliance, there are seldom
emergencies with an Essix appliance. As mentioned previously, the Essix appliance has become the preerred
anchorage holding device or use with the Carriere DistalizerAppliance.
2nd VisitCheck cooperation visually with the mirror and monitor or unexpected side eects.
3rd VisitEvaluate whether the case has progressed to a Super Class I position and it is time to remove the appliance.
If so, schedule immediate removal and xed appliance bonding or aligner fabrication and begin the transitioning
steps, which are outlined later.
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Delegation and Precluding Emergencies
Protocols associated with the Carriere DistalizerAppliance are highly delegatable depending on your jurisdictional laws,
making it a highly efcient Class II corrector in terms o saving valuable doctor time.
There are seldom emergencies associated with the Carriere DistalizerAppliance because i one end o it becomes
debonded, the patient will generally play with the appliance until the other end debonds. To preclude debonding, ensure
that the appliance goes immediately rom its packaging to placement. Do not determine the size o the distalizer by placing
it in the mouth. Doing so contaminates the retention pad and compromises bond strength, which can cause debonding.
Patient Acceptance
Patient acceptance o and cooperation with using the Carriere DistalizerAppliance has been exceptional. The maxillary
incisors are ree o appliances and unless the mandibular arch needs to be bonded or anchorage, the mandible wears only
an invisible lingual arch or an Essix appliance, which are easily accommodated. Given its rounded contours, the distalizer
itsel is relatively comortable to wear and is used in the frst three to six months o treatment when compliance is best.
Having said that, there are still techniques useul or encouraging compliance.
Encouraging Compliance. Each clinician has methods or garnering patient compliance. Here are suggestions that
clinicians successul with the Carriere DistalizerAppliance have oered. Asking patients to make the choice between the
Carriere DistalizerAppliance and bulky alternative appliances can be an eective means o gaining commitment especiallywhen these appliances are also suggested as the contingency treatment or noncompliance. Moreover, being able to
avoid bicuspid extractions and shortening overall treatment time by 35% to 40% are excellent incentives or a ew months
o elastics wear. Adolescents who are looking orward to wearing their braces can be encouraged to wear elastics or the
proper amount o time because such compliance means that they will be wearing their braces sooner.
Patient Instructions
Celebrating Treatment Progress. You will necessarily advise patients to expect interincisal diastemas during this frst
stage o treatment and it is important to advocate the diastemas as something to celebratean important signal that the
appliance is working.
Instructing About Elastic Wear. Because o the vertical orce vector that opening the mouth while chewing produces,
instruct patients to wear elastics at all times except when eating. A predominantly vertical orce vector may result in a mild
extrusion o the cuspids. Night-time wear can compensate or this phenomenon because a closed mouth produces a more
horizontal vector o traction but this protocol will prolong the distalization period. Patients should change their elastics each
time ater they eat.
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Discouraging Improper Tongue Habits. Instruct patients not to allow their tongue to get under the horizontal arm o the
appliance. Doing so could result in lingual inclination o the maxillary bicuspids and vestibulization o the cuspids. Another
habit patients must avoid is placing the tip o the tongue in the space that the distalization creates between the maxillary
lateral incisors and cuspids. Mild inammation at the mucogingival border o the maxillary cuspids is an indication o this
habit, which may result in a widening o spaces mesial to the cuspids relative to the interincisal diastemas.
Handling Minimal Discomfort. Some patients may experience mild discomort or the frst three to fve days ater initial
elastic activation. Once the initial discomort subsides, however, it should not return. Recommend that patients chew as
much as possible to alleviate soreness in the least amount o time. Some clinicians recommend mild anti-inammatory
medications, but rarely.
Establishing the Goal. Patients respond positively to eeling that theyre
in control o their treatment and will appreciate having a visual cue to
recognize when theyve reached their goal. To employ this technique,
use a pencil to mark the crown long axis o the maxillary cuspid and the
embrasure between the mandibular cuspid and frst bicuspid (Figure 30),
then inorm the patient that theyll be able to tell that the distalization
phase o their treatment is fnished when the marks align.
Figure 30Use a pencil to mark the crown long axis o the
maxillary cuspid and the embrasure between the
mandibular cuspid and frst bicuspid so the patient will
know when the distalization phase is complete and will
eel more invested in their treatment.
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Carriere DistalizerAppliance Correction Dovetails Ideallywith Invisalign for Finishing Treatment
The Carriere DistalizerAppliance is the perect solution or patients who want Invisalign (Align Technologies, San Jose,
CA, USA) or other clear aligner treatment but display a Class II malocclusion. The small profle o the Carriere Distalizer
Appliance will satisy most patients who are concerned about esthetics and ater using it or the sagittal correction, the
clinician is ree to utilize any appliance systemincluding Invisalignto complete treatment. Teenagers are predisposed to
wearing Invisalign and easily understand how the Carriere DistalizerAppliance can jump start Class II treatment to provide
the indiscernible orthodontic correction they seek.
Transitioning from the Carriere DistalizerAppliance to Invisalign
Ater removing the Carriere DistalizerAppliance and Class II elastics, transition to an Essix appliance in the maxillary arch
until the Invisalign Aligners arrive. I you used a lingual arch or TADs or anchorage, transition to an Essix appliance or the
mandibular arch as well. I you used an Essix appliance or anchorage in the mandibular arch, maintain it until the aligners
arrive.
Taking Impressions for Invisalign Finishing Treatment
Clinicians take impressions or Invisalign and the Essix appliances by using PVS material or both or PVS or the aligners and
alginate or the Essix appliance. I using PVS material or both (and/or or models), a high-quality product is recommended
(e.g., or the heavy body: 3M/Espe Position Penta Quick impression material (a VPS alginate replacement); or the wash:
3M/Espe Imprint Garant Quick-Step Impression material).
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Transitioning to Fixed Appliances for Finishing Treatment
When transitioning rom the Carriere DistalizerAppliance to fxed appliances, it is advisable to have two bonding
appointments. Bond only the maxillary arch at the frst appointment. Run the round wire frst molar to frst molar and keep
the lingual archwire or Essix appliance in the mandibular arch until the next appointment (or as much as 10 weeks). At the
next appointment, you can then remove the lingual arch or Essix appliance and bond the mandibular arch. O course, i
you used fxed appliances or mandibular anchorage, you simply transition to fxed appliances in the maxillary arch. Ater
removing the distalizer, it is important to ligate the distalized teeth under the archwire using a .012" stainless steel ligature
wire tied in a fgure 8 rom the maxillary cuspids to the maxillary frst molars, maintaining the consolidation until the end o
treatment. It is necessary to ensure that the ligature wire remains completely passive to prevent the maxillary molars rom
derotating mesially.
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IndicationsIn this section we will present answers to questions in relation to the clinical use o the Carriere DistalizerAppliance.
This section provides specifcs as to the correct use o the device in order to prevent any issues that might appear i the
appliance is not adequately applied.
Question: Are there borderline cases in which you would lean toward using
elastics or IPR rather than theCarriere Distalizer Appliance?
Dr. Carrire: Since research indicates that 83% o maloccluded cases present with the maxillary frst molar rotated mesially,
I would use the Carriere DistalizerAppliance in such cases to create the space that allows the cuspid to occlude in perect
Class I.
Question: How would you address an open bite or a tendency toward open bite?Dr. Carrire: Open bites are oten a result o incorrect swallowing, chewing, speaking and tongue placement at rest.
I would frst train the patient to unction correctly and place the tongue properly, then use the Carriere DistalizerAppliance
or initial treatment.
Question: How would you address a skeletal Class II?
Dr. Carrire: I the patient is still growing, the Carriere DistalizerAppliance would be useul or a short period to time
or three months or so to take advantage o the active growth period.
I my diagnosis indicates that orthopedic treatment is advisable, I might attach a Twin Force Bite Corrector to the distal
portion o the horizontal arm o a Carriere DistalizerAppliance to take advantage o the Twin Force Bite Correctors
noncompliant advancement o the mandible. By combining these appliances, two treatment modalities are at work:orthodontic via the Carriere DistalizerAppliance; orthopedic via the Twin Force Appliance. Additionally, the Twin Force
Appliance provides the Carriere DistalizerAppliance noncompliant anchorage.
I, however, the Class II is pathological and the patient is not a good grower or has little growth capacity remaining, I
would not use the Carriere DistalizerAppliance in its current confguration because my diagnosis would not indicate such a
treatment approach.
Question: What is your protocol for using theCarriere Distalizer Appliance for early treatment?
Dr. Carrire: I bond the Carriere DistalizerAppliance to the maxillary frst permanent molar and deciduous cuspid and
shape a mandibular lingual archwire or anchorage, banding the mandibular frst permanent molar (including a buccal
tube and hook) or elastics traction. When the case reaches Class I, I remove the Carriere DistalizerAppliance and insert a
Hawley plate to retrude the maxillary incisors while keeping the posterior segment in place. I maintain the lingual archwire
and bands in the mandibular arch until the permanent teeth erupt to keep the space available so that when the second
temporary molars are lost, there will be ample space to accommodate the mandibular bicuspids when they erupt, which
osters better alignment o the mandibular arch.
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Question: Is theCarriere Distalizer Appliance an effective option to treat mandibular asymmetry?
Dr. Carrire: I the asymmetry is dentoalveolar, the Carriere DistalizerAppliance is a valuable treatment option. I would
bond the Carriere DistalizerAppliance to the mandibular frst molar and cuspid and use an Essix or anchorage in the
maxilla with buccal tubes on the frst or second maxillary molars or Class III elastics traction. Alternatively, I might bond the
maxillary arch and use buccal tubes on the frst or second molars or Class III elastics traction. Ater the cuspids come into
Class I, I would bond the mandibular arch and center the midline, closing the spaces opened.
Question: Why is it important that theCarriere Distalizer Appliance be used to treat asymmetry cases?
Dr. Carrire: The Carriere DistalizerAppliance works independently in each side o the dental arches and the activation
in each side can be selective in terms o amount and time o orce application. While asymmetry does not appear in a
high percentage o patients who present or treatment, ew i any other distalizing appliances can deal eectively with
asymmetry.
Loss of Anchorage/Unexpected Side Effects
Question: Describe an incidence of incorrect anchorage that could cause anchorage loss.
Dr. Carrire: One such case might include a patient in late mixed dentition whose deciduous molars are already lost but
whose mandibular bicuspids are not yet in place to assist with maintaining anchorage when using a lingual arch. In such a
case, the mandibular frst molars could extrude, causing the archwire to tip lingually and ineriorly surpassing the cingulum,
which produces anchorage loss and mandibular incisor protrusion. Sound diagnosis to determine appropriate anchorage
selection is o paramount importance or Carriere DistalizerAppliance treatment.
Question: If a clinician continues to experience cuspid extrusion, what might be the cause?
Dr. Carrire: I patients continually experience maxillary cuspid extrusion, the culprit is either incorrect placement o the
anterior pad o the Carriere DistalizerAppliance or the act that the patient is maintaining elastic wear while eating, which
creates a vertical vector o traction and causes an extrusive orce.
Question: Is mild mandibular molar extrusion something that is to be expected?
Dr. Carrire: Mild mandibular molar extrusion, usually less than 1 mm, is to be expected and is easily recovered rom normal
muscular unction and fxed appliances during the fnishing treatment phase.
Sources of Anchorage
Question: Are there additional methods clinicians might use to
increase anchorage when using a mandibular lingual archwire?
Dr. Carrire: For greater additional anchorage control, Dr. Clark
Colville, Seguin, Texas, fnds it valuable to include the second
molar in the lingual setup by extending the archwire distally
to the second molar, then up along the lingual groove onto
the occlusal surace where it is bonded. This protocol not onlyincreases anchorage, but it also disoccludes the posterior teeth to
oster better distalization and prevent the frst molar rom tipping
mesially and proclining the lower incisors (Figure 31a-b).
Figure 31a-bFor greater anchorage control, it can be useful to extend the lingual
archwire to the 2nd molar (or 1st bicuspid), bonding it occlusally.
Case photos courtesy of Dr. Clark Colville, Seguin, Texas, USA.
a
b
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CASE II: Age 25 years,
Carriere DistalizerAppliance
Treatment, 12 weeks
.014" Nitanium NiTi Archwires, 10 weeks
.014" x .025" Nitanium NiTi Archwires, 10 weeks
.017" x .025" Nitanium NiTi Archwires, 10 weeks
.019" x .025" Nitanium NiTi Archwires, 14 weeks
.019" x .025" CNA Beta Titanium
Archwires, 16 weeks
Total Treatment Time: 17 months
Pretreatment
Treatment Complete
Pretreatment
Carriere DistalizerBonded
Class I Achieved In12 Weeks
Treatment CompleteIn 17 months
Treatment Progress
CarriereSLB Bonded:Maxilla Only
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Carriere Oral ElasticsComplement the Carriere DistalizerAppliance with Carriere Oral Elastics, which were designed
specifcally to work seamlessly with this appliance and provide optimum results. These elastics
are available in two dierent orce levels or both stages o treatment, ensuring a smooth and
timely transition to a Class 1 platorm.
Carriere Self-Ligating Bracket System
Like the Carriere DistalizerAppliance, the Carriere Sel-Ligating Bracket (SLB) satisfes the
clinical need or delivering low orthodontic orces to stimulate efcient, biologically compatible
tooth movement while creating the least amount o trauma or patients. Its passive, sel-ligating
mechanism creates a solid, our-walled lumen which allows beginning light, superelastic archwires
to operate reely while providing continuous orce o low magnitude. Cases beneft rom the
gentle stimulation o cellular activity without totally occluding the blood vessels in the periodontal
ligament. Such occlusion impedes tooth movement and causes patient discomort. With light
orces, the suraces o the periodontal structures that the orthodontic orce histologically activates
are lessened, minimizing the possibility or periodontal damage. As treatment progresses,
superelastic edgewise wires in ever larger cross sections control teeth in three dimensions or
eective torque expression and rotational control.
SimplelockingmechanismopenswithaCarriere Opener Tool and closes
securely with a fnger or quick archwire changes.
Torqueinbaseandcompound-contouredpadprovidetheultimateinprecision,controlandt.
Dual-lockfastenerensuresthebracketslideremainsclosedthroughouttreatment.
Beveledslotedgesmesiallyanddistallyreducefrictionandimproveslidingmechanics.
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For more information on our products and educational offerings, please contact us:
In the U.S. 888.851.0533 | Outside the U.S. +(1) 760 448 8600 | Canada: CERUM 800.661.9567
To fax an order: 800.888.7244 | To email an order: [email protected]
CarriereSystem.com 2011 Ortho Organizers, Inc. All rights reserved. PN 999-252 Rev. 04/11.
Dr. Carrires philosophy o working in harmony with the bodyusing precision engineering to achieve
treatment-goals has led to a uniquely minimalist protocol or orthodontic correction. Using advanced
computer modeling and a scientifcally-based, systematic approach to treatment planning, Dr. Carrire
has pioneered a treatment path that is conservative, efcient, and optimally eective. He is widely
welcomed as a guest proessor and lecturer at various orthodontic schools and proessional meetings
throughout Europe and the USA.
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