ntoimrsbs

is

o

Class III Correction UsingBiocreative Therapy (C-Therapy)Kyu-Rhim Chung, Seong-Hun Kim, and HyeRan Choo

This article reviews several clinical applications of the C-type temporary

skeletal anchorage devices, such as a C-Implant, C-Tube Mini-Plate, or

C-palatal Mini-Plate that are used for camouflaging mild-to-moderate

Class III skeletal malocclusions. The treatment strategy was established

following the principles of biocreative C-therapy. (Semin Orthod 2011;17:

108-123.) © 2011 Elsevier Inc. All rights reserved.

donltfrutst

A skeletal Class III malocclusion can be attrib-utable to a hypoplastic maxilla relative to a

ormal mandible, a hyperplastic mandible relativeo a normal maxilla, or a combination of a hyp-plastic maxilla to a hyperplastic mandible to vary-

ng degrees.1-3 Although early orthopedic treat-ent may improve the anteroposterior

elationship of the maxilla and mandible, exces-ive or latent mandibular growth during the pu-ertal growth spurt can induce a recurrence of thekeletal Class III malocclusion.4-6

If residual growth is minimal and the skeletaldiscrepancy is within the boundaries of camou-flage treatment with orthodontic tooth movement,conventional orthodontic biomechanics can beused to achieve an acceptable overjet and overbite.When the skeletal Class III discrepancy is beyondthe limit of dentoalveolar compensation, orthog-nathic surgery is inevitable to correct the maloc-clusion, usually after the patient’s general growthis complete.7,8 Conventional orthodontic mechan-cs are used to decompensate the dentition beforeurgical correction of the jaw position. However,

President, Korean Society of Speedy Orthodontics; Associate Pro-fessor, Department of Orthodontics, College of Dentistry, Kyung HeeUniversity, Seoul, Korea and Visiting Assistant Professor, Divisionof Orthodontics, University of California, San Francisco, CA;Craniofacial Orthodontist, The Children’s Hospital of Philadelphiaand Clinical Associate, University of Pennsylvania School of DentalMedicine.

Address correspondence to Seong-Hun Kim, DMD, MSD, PhD,Department of Orthodontics, College of Dentistry, Kyung Hee Uni-versity, #,1Hoegi-dong, Dongdaemun-gu, Seoul 130-701, Republicf Korea. E-mails: bravortho@hanmail.net; bravortho@khu.ac.kr

© 2011 Elsevier Inc. All rights reserved.1073-8746/11/1702-0$30.00/0

doi:10.1053/j.sodo.2010.12.004

108 Seminars in Orthodontics, Vol 17, N

ecompensation of the lower dentition by the usef conventional biomechanics is often accompa-ied by undesirable distalization of the mandibu-

ar dentition. This is a consequence of Newton’shird law of motion, which states that “For everyorce action, there is an equal and opposite forceeaction.” The use of absolute skeletal anchoragenits, such as mini-implants or mini-plates, allows

he orthodontist to achieve presurgical decompen-ation without being concerned with an unwantedooth movement (Fig 1).9 A novel treatment phi-

losophy with a temporary skeletal anchorage de-vice (TSAD) has been advocated and clinicallyapplied in Korea by Chung since 1999 and hasbeen referred to as the Biocreative or C-thera-py.10-18 The C-therapy implements simplified orth-odontic biomechanics and significantly reducesthe orthodontic adjustment time each visit. Thistreatment protocol involves selective limited use offixed orthodontic appliances only on the teeththat need to be moved and is very well tolerated bythe patients compared with full-mouth fixed orth-odontic appliances.

The treatment strategy for correcting Class IIImalocclusions should be differentially used de-pending on the amount of skeletal and dentaldiscrepancies as well as the status of the somaticgrowth of the patient. The C-therapy uses a fewspecially designed TSADs (C-Implant, C-TubeMini-Plate, and C-palatal Mini-Plate) as the coretreatment armamentarium. This treatment con-cept is based on the fact that the partially os-seointegrated TSADs can endure multidirectionalheavy orthodontic and orthopedic forces with betterstability, thereby enabling more effective and effi-

cient tooth movement in a shorter time frame.16-18

o 2 (June), 2011: pp 108-123

b(Cag

iaiefC2

109Class III Correction With C-Therapy

C-Type TSADs

The C-type TSADs are designed to bear multidi-rectional heavy forces with greater stability, whichis essential to move multiple teeth at the sametime, resulting in a shorter treatment time. Inaddition, the total number of C-type TSADsneeded to achieve the orthodontic tooth move-ment remains minimal because of its high stabilityagainst multidirectional heavy force. There are 3options for the C-type TSADs: C-Implant, C-TubeMini-Plate, and C-palatal Mini-Plate.

C-Implant

The C-Implant (Fig 2A) is a 2-piece orthodonticmini-implant system (C Implant Co, Seoul, Korea)composed of an implant body and an implanthead.11 The standard dimension of the C-Implant

ody used for orthodontic anchorage is 8.5 mmlength) � 1.8 mm (diameter). The surface of-Implant body is SLA, or “sandblasting, large-grit,nd acid-etching treated,” which increases the de-

ree of osseointegration between the bone and the f

mplant body and establishes a greater stabilitygainst rotational and torquing forces.17-21 Thenside of the C-Implant body has a 0.8-mm diam-ter lumen for insertion of the head part, whichorms a friction-grip joint with the body part. The-Implant head is available in 3 different lengths (1,, and 3 mm).

C-Tube Mini-Plate

The C-Tube Mini-Plate (Fig 2B) is an orthodonti-cally modified surgical fixation system made ofpure titanium (Gebrüder Martin GmbH & Co.KG, Tuttlingen, Germany, and Jin Biomed Co.,Bucheon, Korea).14,22-24 This Mini-Plate is aptlynamed because the free end of the Mini-Plate isrolled to form a tube-shape head part with 0.036-inlumen to engage orthodontic arch wires. The sub-mucosal fixation part of the C-Tube Mini-Plate isusually I-shape and has 2 holes for 2 Mini-PlateAnchoring Screws (MPAS) securing the stability ofthe plate against heavy-duty forces.25 The MPAS

Figure 1. C-Implants were placed between the man-dibular first and second bicuspids to decompensatethe mandibular incisors before orthognathic sur-gery. Note the use of C-Implants prevented the un-necessary distalization of mandibular molars duringdecompensation. (A) Pretreatment. (B) Immedi-ately before surgery showing proclination and intru-sion of the mandibular incisors. (C) After surgery.(Color version of figure is available online.)

or the Mini-Plate is a self-drilling self tapping mini-

PtofTmnTrfr

110 Chung et al

screw of 1.5 mm in diameter and 4 mm in length.The clinical applications of C-Tube Mini-Plate areoften used in the correction of Class II or Class IIImalocclusions as well as cases of Class I bimaxillaryprotrusion patients.

C-Palatal Mini-Plate

The C-palatal Mini-Plate (Fig 2C) is also made ofpure titanium in the form of a cross-shape surgicalfixation plate.15,23,26 The vertical portion of Mini-

late has 3 holes for placement of the MPAS andhe horizontal arms that remain exposed to theral cavity have holes that are often used as hooksor orthodontic coil springs and/or elastics chains.his Mini-Plate is placed at the junction where theidpalatal suture bisects the imaginary line con-ecting the midpoint of the maxillary first molars.he C-palatal Mini-Plate is often used for en masseetraction of the maxillary anterior teeth as well asor intrusion of the maxillary posterior teeth toeduce an anterior open bite malocclusion.27

BiocreativeTherapy Treatment PlanningPrinciples for Class III CorrectionTreatment planning using the C-Therapy (Fig 3) is

Figure 2. Schematic illustrations of C-type TSAD: (A)friction grip mechanism; (B) C-Tube Mini-Plate, a tub(MPAS); (C) C-Palatal Mini-Plate, 2-3 MPAS are usedversion of figure is available online.)

based on the Tweed-Merrifield-Chung (TMC) pyr-

amid. This pyramid is structured by the use of a3-dimensional dental, skeletal, and soft-tissueassessment scheme by adding transverse diag-nostic components to the conventional sagittaldiagnosis of the Tweed Triangle.28,29 In brief,the position of the lower incisor viewed in thelateral cephalogram is an important compo-nent, although the incisor-mandibular planeangle, Frankfort-mandibular plane angle, andFrankfort-mandibular incisor angle are stillthe primary parameters in the TMC pyramidwhen the sagittal component is assessed. Inaddition, the angle formed by the Frankfort-Horizontal plane to a line tangent to the mostprotrusive points of the upper and lower lips(Z-angle) provides important information re-

Figure 3. Schematic illustration of the TMC pyramid.

mplant, an assembly of 2 parts (head and body) by ape head supported by 2 Mini-Plate Anchoring Screwsthe para-sagittal plane to support the wings. (Color

C-Ie-sha

on

(Color version of figure is available online.)

111Class III Correction With C-Therapy

garding soft tissue esthetics. The transversecomponent is evaluated for a maxillary and/ormandibular canting, facial asymmetry, as wellas maxillary width discrepancy on the occlusallevel and basal bone level with either an an-teroposterior cephalogram or cone-beam com-puted tomography. In this paper, the discus-sion will be limited to the clinical applicationof the biocreative therapy biomechanics thatuse C-Implants and C-Tube Mini-Plates in thecorrection of skeletal and/or dental Class III

Figure 4. In a 13-year-old female patient: (A-C) pretrfirst bicuspids were extracted. Note the 2 mandibularfixed orthodontic appliances in retracting the anterioversion of figure is available online.)

malocclusions.

Dental Compensation for ClassIII Malocclusion Using C-Implants

Extraction of the MandibularFirst Bicuspids Followed by Alignmentand Retraction of the Mandibular AnteriorTeeth Using Mandibular Posterior C-Implants

When crowding is localized to the anteriorpart of the lower dentition, the mandibularfirst bicuspids are often extracted. The man-

ent; (D-F) 2 months into the treatment after all theerior C-Implants replaced the conventional posteriorth. (G-I) Finishing stage. (J-L) Posttreatment. (Color

eatmpostr tee

dibular anterior teeth are then retracted

oaispmtqmemp

pwi4wmttilfwtoLmtutCsbl

hs. (

112 Chung et al

against C-Implants bilaterally placed in eitherthe maxillary or mandibular inter-radicularspace between the second bicuspid and firstmolar teeth. Although the retraction against amaxillary posterior C-Implant involves patientcompliance for wearing Class III intermaxil-lary elastics, the retraction force vector is morefavorable for achieving a proper overjet andoverbite. The retraction against the mandibu-lar posterior C-Implant is fully controlled bythe orthodontist independent of patient coop-eration.12 However, the intrusive component

f the retraction force vector can hinder thechievement of a proper overjet and overbitef the preexisting overbite is shallow. Figure 4hows a 13-year-old female patient who dis-layed poor cooperation during her treat-ent. The orthodontic treatment strategy was,

herefore, modified to the biomechanics re-uiring minimal compliance (Fig 4A-C). Theaxillary first bicuspids on both sides were

xtracted to create room for alignment of theaxillary canines. Immediately after C-Im-

Figure 5. In a 17-year-old male patient: intraoral phointermaxillary elastics against the C-Implant. (A) Premaxillary elastics to the maxillary posterior C-Implaposttreatment. The total treatment time was 10 mont

lants were place on each side of the mandible s

osteriorly, the mandibular anterior teethere retracted against the C-Implants to elim-

nate the use of intermaxillary elastics (FigD-F). The extraction spaces in the mandibleere completely closed after 4 months of enasse retraction of the mandibular anterior

eeth. Orthodontic brackets were placed onhe rest of mandibular teeth and final, detail-ng and refining of the occlusion during theast stage of orthodontic therapy were per-ormed (Fig 4G-I). The total treatment timeas approximately 11 months with a stable

reatment outcome, although the overjet andverbite remained relatively shallow (Fig 4J-). To prevent an unnecessary intrusion of theandibular anterior teeth during the retrac-

ion, a retraction hook with a long arm can besed to minimize the intrusive component of

he retraction force vector. In addition, the-Implant can be placed in a more oblique way

o the head part of a 2-piece C-Implant assem-ly can be located closer to the occlusal plane

evel without compromising the stability of

aphs showing the tip back mechanics using Class IIIment; (B) 2 months after the use of Class III inter-(C) 5 months of Class III elastics application; (D)Color version of figure is available online.)

togrtreatnts;

keletal anchorage. If the maxillary dental

eatm

113Class III Correction With C-Therapy

arch is slightly constricted before treatment, atranspalatal arch or quad-helix can be addedto expand the maxillary arch.

Distalization of the Full MandibularDentition With Class III IntermaxillaryElastics Against Maxillary Posterior C-Implants

In conventional orthodontic mechanics, anonextraction treatment plan that uses ClassIII intermaxillary elastics is often the treat-ment of choice to camouflage a Class III mal-occlusion unless there is a significant tooth-size-arch-length discrepancy. The molar tip-

Figure 6. Lateral cephalometric radiographs of the pClass III intermaxillary elastics application. (C) Posttr

Figure 7. The use of multiple sliding jigs in combmaxillary posterior C-Implant. (A) View of intraoral apPanoramic radiograph after distalization of the mand

online.)

back mechanism originating from the Tweed-Merrifield philosophy combined with Class IIIintermaxillary elastics has often been used asan effective treatment approach to distalizemandibular posterior teeth. In patients with aClass III malocclusion, the maxillary incisorsare often severely proclined before treatment,making the use of Class III intermaxillary elas-tics impractical. This type of unfavorable toothmovement (the further proclination of maxil-lary anterior teeth) can be prevented with theuse of skeletal anchorage. The use of TSADscan further eliminate the need of fixed orth-odontic appliances on the full maxillary den-

t in Figure 5. (A) Pretreatment. (B) 2 months afterent.

on with Class III intermaxillary elastics against thece. (B) Panoramic radiograph before treatment. (C)r second molars. (Color version of figure is available

atien

inatiplianibula

tmim

114 Chung et al

tition until the last stage of orthodontic ther-apy (Figs 5 and 6). In addition to the use of aip-back mechanism, the C-Therapy often uses

ultiple sliding jigs connected to the Class IIIntermaxillary elastics and hooked against the

axillary posterior C-Implants (Fig 7).30

The sliding jig is fabricated chair-side using a0.018 � 0.025-inch stainless-steel wire and isan effective tool to distalize the mandibularposterior teeth segmentally and creating roomfor the subsequent retraction of the mandibu-

Figure 8. In a 15-year-old female patient: asymmetricment; (D-F) 2 months after the Class III force applicmonths of the distalization force application. Three 5months after force application. The maxillary and maof figure is available online.)

lar anterior teeth.

Figure 8 shows a 15-year-old female patient witha Class III malocclusion and a 3.5-mm dental mid-line discrepancy. A minimal amount of fixed orth-odontic appliances in conjunction with TSADswere used to correct the problem (Fig 8A-C). C-Implants were placed bilaterally in the inter-radicular space between the maxillary secondbicuspid and first molar. The full fixed orth-odontic appliances were placed only on themandibular dentition and a 0.016 � 0.022-inch stainless-steel arch wire was engaged to

lization of the mandibular dentition. (A-C) Pretreat-against the maxillary posterior C Implants; (G-I) 5

inch 3 oz elastics were used to the right side, (J- L) 8ular dental midline is now coincident. (Color version

distaation/16-ndib

the mandibular arch. The mandibular second

po

115Class III Correction With C-Therapy

molars (the 7s) were tipped back against den-tal anchorage composed of 10 mandibular an-terior teeth, that is from the right second bi-cuspid to the left second bicuspid toothreferred to as the “10-2 system” by the Tweedphilosophy (Fig 8D-F). Concurrently, retractionforce was applied using Class III intermaxillaryelastics against the C-implant (right side 3 timesheavier force than the left side) to correct themandibular dental midline throughout the retrac-tion period (Fig 8G-I). After approximately 8months of C-therapy, the ideal overjet and overbitewith a coincident dental midline were achievedfrom the differential mandibular retraction againstthe C-Implant (Fig 8J-L). The facial profile was alsosignificantly improved (Fig 9).

Figure 9. In the patient from Figure 8: (A) pretreatretreatment lateral cephalogram; (D) posttreatment

nline.)

Advancement of the MaxillaryAnterior Teeth and Retraction of theFull Mandibular Dentition Using C-Implant

Figure 10 illustrates a clinical application of C-Implants placed at the posterior maxilla to cor-rect a Class III malocclusion. The patient pre-sented with a Class III malocclusion withlocalized anterior crowding and retroclinedmaxillary anterior teeth. C-Implants were placedin the posterior region of the maxilla to createanchorage for the retraction force required forthe mandibular dentition with Class III inter-maxillary elastics and were also used as anchor-age to simultaneously advance the maxillary an-terior teeth with the use of open-coil springs.

t facial profile; (B) posttreatment facial profile; (C)ral cephalogram. (Color version of figure is available

menlate

ismmapsst(td

116 Chung et al

Distalization of the Full MandibularDentition Using Open-Coil SpringsAgainst the Mandibular Posterior C-Implants

Figure 11 illustrates an example of C-Implantapplication as an anchor for the intra-arch dis-talization of mandibular posterior teeth. Thismethod does not require the patient’s coopera-tion in wearing elastics to distalize the mandib-ular teeth.31 The C-implant was placed at thenterradicular space between the mandibularecond bicuspid and first molar teeth. After theandibular third molars were removed, the firstolar alone was individually pushed back using

n open-coil spring directly against the C-Im-lant (direct anchorage). Simultaneously theecond molar tooth was distalized by a coilpring pushing against the second bicuspidooth, which was in turn ligated to the C-Implantindirect anchorage). This helped to increasehe efficiency of retracting the full mandibularentition.

Dental Compensationfor Class III MalocclusionCorrection Using a C-Tube Mini-Plate

When the placement of a C-Implant becomes

challenging because of an insufficient interra-

dicular space, a C-Tube Mini-Plate can be placedat the retromolar pad to distalize the entire man-dibular dentition (Fig 12).24,32 After palpatingthe retromolar triangle and external obliqueridge, 2 small incisions were made (3 mm each,5 mm apart) along the external oblique ridge(Fig 12A). After the periosteal elevator com-pletes the tunneling between the 2 incisions, anI-shape Mini-Plate was inserted through the peri-osteal tunnel and fixed with 2 MPAS while thetube-shape head of the Mini-Plate remaining wasexposed to the oral cavity (Fig 12B). One or 2sutures are recommended after fixing the Mini-Plates. Although the tube-shape head of theMini-Plate often becomes embedded by somethick retromolar gingival tissue, a brass wire ex-tension arm that is connected to the tube-shapehead before the placement of the Mini-Plate canalways give access to the mini-plate skeletal an-chorage, which is essential to distalizing themandibular teeth (Fig 13).

With the increased stability of a Mini-Plate,derived from the increased contact surface be-tween the bone and 2 MPAS, a C-Tube Mini-Plate can resist much heavier forces during thesimultaneous distalization of multiple mandib-ular teeth.25 In addition, the anatomic loca-

Figure 10. In a 17-year-old female patient: themaxillary anterior teeth are being advanced andthe full mandibular dentition was simultaneouslyretracted against the C-Implants. (A) Insertion ofClass III elastics; (B) 1 month after the Class IIIforce application against the maxillary posterior CImplants; (C) 6 months of force application.(Color version of figure is available online.)

tion of C-Tube Mini-Plate placement inher-

gure

117Class III Correction With C-Therapy

ently excludes the risk of damaging rootsduring the course of distalizing multiple teethbecause the anchoring screws can be placedfar from the root tips. Moreover, the tube-shaped head of Mini-Plate can be locatedmuch closer to the occlusal plane and gener-ates a greater horizontal vector of distalizationforce than C-Implants. As seen in the C-Im-plant applications, a sliding jig is a commondevice used for segmentally distalizing themandibular teeth. A lingual arch maintainingthe transverse dimension of the mandibulardentition is strongly recommended to avoidunwanted widening of the arch form duringthe sliding jig-mediated distalization of the

Figure 11. In a 28-year-old male patient: distalizationagainst the mandibular posterior C-Implants. (A, Bapplication; (E, F) posttreatment. (Color version of fi

mandibular posterior teeth (Fig 14).

Figure 15 shows the case of a 23-year-old malepatient who was seeking orthodontic treatmentafter experiencing bite changes. The patient re-ported that his bottom teeth seemed to be becom-ing more crooked and his front bite had alsochanged to an underbite during the last couple ofyears. After a comprehensive assessment, the pa-tient was diagnosed with a dental and skeletal ClassIII malocclusion caused by latent mandibulargrowth (Fig 15A-C). A C-Tube Mini-Plate wasplaced at the retromolar pad area on each sideand the brackets were placed only on the mandib-ular posterior teeth with a lingual arch connectingthe first bicuspid of each side during the activedistalization of the mandibular posterior teeth.

he full mandibular dentition using open-coil springsretreatment; (C, D) 4 months of open-coil spring

is available online.)

of t) P

Orthodontic brackets were used for the alignment

118 Chung et al

of the mandibular anterior teeth only for the last 3months of active treatment (Fig 15D-F). Therewere no fixed orthodontic appliances placed onthe maxillary arch, apart from the maxillary ante-rior teeth, during the entire active orthodontictreatment (Figs 15 and 16).

Figure 12. (A) I-shape C-Tube Mini-Plate on the righof a C-Tube Mini-Plate to distalize the mandibular righonline.)

Figure 13. (A) Brass wire extension arm connected taccess to the Mini-Plate in case the Mini-Plate is embed

Intraoral application. (Color version of figure is available

Figures 17–19 show a case that exemplifies aC-Therapy solution to Class III malocclusion cor-rection using C-Tube Mini-Plates and a single-arch orthodontic fixed appliance of the mandi-ble. This 31-year-old female patient has a historyof previous orthodontic treatment in her early

romolar pad of a dry skull. (B) Intraoral applicationuspids and molars. (Color version of figure is available

C-Tube Mini-Plate. This extension allows continuedby thick gingival tissues. (B) Radiographic image. (C)

t rett bic

o theded

online.)

re is

119Class III Correction With C-Therapy

20s to correct her Class III malocclusion. Shethen noticed the change of her bite and relapseof Class III malocclusion (Fig 17A-C). She wasvery reluctant to the idea of wearing anotherseries of full braces because of her social situa-tion. The treatment strategy was then directed touse an appliance with minimal visibility duringher Class III malocclusion correction. In addi-tion, the treatment strategy would have to aim atminimizing the amount of maxillary tooth move-ment because the patient already had severegingival recession on the maxillary left canine.

The decision was made to distalize the full man-dibular dentition to de-crowd and retract the man-dibular anterior teeth. The mandibular third mo-lars were extracted, and C-Tube Mini-Plates wereplaced in the retromolar pad area to maximize theamount of distal movement of the second molarsusing sliding jigs. After the retraction of her man-dibular second molars, the first molar and bicus-pids were in turn distalized by the use of open-coil

Figure 14. Sliding jigs are commonly used auxiliarieteeth in the Biocreative Therapy. (A) Pretreatment. (Bmandibular anterior dentition is strongly recommendthe sliding jig-mediated distalization of mandibular pomonths after force application. (Color version of figu

springs against the adjacent tooth anchored by the

Mini-Plate (Fig 18). The comparison of pretreat-ment and posttreatment lateral cephalograms il-lustrates a significant distalization of the mandib-ular teeth while minimal changes occurred in themaxillary dentition (Fig 19). Of the 13-monthstotal treatment time, only the last 3 months oforthodontic therapy used full fixed orthodonticappliances on the maxillary teeth to refine thefinal occlusion (Fig 17D-F). The C-Therapy for thiscase did not require any degree of patient cooper-ation related to intermaxillary elastics throughoutthe treatment.

In addition to the clinical applications intro-duced here, a C-Tube Mini-Plate placed in themandibular retromolar pad area is often used todistalize the maxillary posterior teeth using ClassII intermaxillary elastics so that mild to moder-ate maxillary dental crowding in a Class III mal-occlusion can be resolved without unfavorableproclincation of the maxillary anterior teeth.The amount of distalization required in the

the segmental distalization of mandibular posteriorlingual arch maintaining the transverse dimension ofo avoid unwanted widening of the arch form duringior teeth. (C) 5 months after force application. (D) 7available online.)

s for) Aed tster

mandibular dentition to establish a Class I molar

on the retromolar pads; (G-I) posttreatment. (Color version of figure is available online.)

120 Chung et al

Figure 16. Lateral cephalograms of the patient in Figure 15: (A) pretreatment; (B) posttreatment. A counter

Figure 15. In a 23-year-old male patient: a relapsed Class III malocclusion resulted from late mandibular growth.(A-C) Pretreatment; (D-F) 5 months into the retraction of mandibular posterior teeth against C-Tube Mini-Plates

clock-wise mandibular plane rotation was observed.

p sttrea

121Class III Correction With C-Therapy

and canine relationships also increases. The C-Tube Mini-Plate placed in the retromolar padarea can provide excellent stability in resistingsimultaneous multidirectional retraction forcesfor the maxillary and mandibular teeth.

Figure 17. In a 31-year-old female patient: a relapseriodontal condition. (A-C) Pretreatment; (D-F) po

Conclusions

The biocreative therapy (C-therapy) is a treatmentphilosophy that was developed to target the pa-tient’s chief complaint using a variety of TSADs

lass III malocclusion with a severely compromisedtment. (Color version of figure is available online.)

Figure 18. Mandibular occlusal intraoral views ofthe patient in Figure 17. (A) Pretreatment; (B) 3months into the distalization of mandibular poste-rior teeth; (C) 7 months after the initiation oforthodontic therapy. (Color version of figure is

ed C

available online.)

gure

122 Chung et al

without unwanted side effects of conventionalorthodontic biomechanics. The treatment proto-col requires placement of fixed appliances only onthe teeth to be moved. Therefore, the duration ofwearing full orthodontic appliances is minimized,with a much more comfortable orthodontic expe-rience for many patients. The simplified orthodon-tic biomechanics using TSADs results in a signifi-cantly reduced treatment time, which benefitsboth patients and orthodontists. Proper selection,insertion, and use of optimal TSADs for each treat-ment situation, following the principles of “Biocre-ative Therapy,” is essential for successful and reli-able treatment outcomes.

AcknowledgmentsThis study was partly supported by the Korean Society ofSpeedy Orthodontics and by a grant from the Kyung HeeUniversity.

References1. Sugawara J, Asano T, Endo N, et al: Long-term effects of

chin cap therapy on skeletal profile in mandibular prog-nathism. Am J Orthod Dentofac Orthop 98:127-133, 1990

2. Ishikawa H, Nakamura S, Kim C, et al: Individual growth inClass III malocclusions and its relationship to the chin cupeffects. Am J Orthod Dentofac Orthop 114:337-346, 1998

3. Khatoon T, Tanaka E, Tanne K: Craniofacial morphol-ogy in orthodontically treated patients of Class III withstable and unstable treatment outcomes. Am J Orthod

Figure 19. Lateral cephalograms of the patient in Fi

Dentofac Orthop 117:681-690, 2000

4. Sato S: Case report: Developmental characterizationof skeletal Class III malocclusion. Angle Orthod 64:105-111,1994

5. Mitani H, Sato K, Sugawara J: Growth of mandibularprognathism after growth peak. Am J Orthod DentofacOrthop 104:330-336, 1993

6. Kook YA, Kim SH: Treatment of Class III relapse due tolate mandibular growth using miniscrew anchorage.J Clin Orthod 42:400-411, 2008

7. Bailey LT, Proffit WR, White RP Jr: Trends in surgicaltreatment of Class III skeletal relationships. Int J AdultOrthodon Orthognath Surg 10:108-118, 1995

8. Bailey LJ, Haltiwanger LH, Blakey GH, et al: Who seekssurgical-orthodontic treatment: A current review. Int JAdult Orthodon Orthognath Surg 16:280-292, 2001

9. Kim SH, Kook YA, Lee W, et al: Two-component mini-implant as an efficient tool for orthognathic patients.Am J Orthod Dentofac Orthop 135:110-117, 2009

10. Chung KR (ed): Textbook of Speedy Orthodontics.Seoul, Jeesung Publishing Group, 2001

11. Chung KR, Kim SH, Kook YA: The C-orthodontic micro-implant. J Clin Orthod 38:478-486, 2004

12. Chung KR, Nelson G, Kim SH, et al: Severe bidentoal-veolar protrusion treated with orthodontic microim-plant-dependent en masse retraction. Am J OrthodDentofac Orthop 132:105-115, 2007

13. Chung KR, Cho JH, Kim SH, et al: Unusual extractiontreatment in Class II division 1 using C-orthodontic mini-implants. Angle Orthod 77:155-166, 2007

14. Chung KR, Kim SH, Mo SS, et al: Division 1 malocclu-sion treated by orthodontic miniplate with tube. ProgOrthod 6:172-186, 2005

15. Chung KR, Kook YA, Kim SH, et al: Malocclusion treatedby combining a lingual retractor and a palatal plate.

s 17 and 18: (A) pretreatment; (B) posttreatment.

Am J Orthod Dentofac Orthop 133:112-123, 2008

123Class III Correction With C-Therapy

16. Kim SH, Hwang YS, Ferreira A, et al: Analysis of tempo-rary skeletal anchorage devices used for en masse retrac-tion: A preliminary study. Am J Orthod Dentofac Orthop136:268-276, 2009

17. Chung KR, Kim SH, Kook YA, et al: Anterior torque controlusing partial-osseointegrated mini-implants: Biocreative ther-apy type I technique. World J Orthod 9:95-104, 2008

18. Chung KR, Kim SH, Kook YA, et al: Anterior torquecontrol using partial-osseointegrated mini-implants: Bio-creative therapy type II technique. World J Orthod9:105-113, 2008

19. Kim SH, Cho JH, Chung KR, et al: Removal torquevalues of surface-treated mini-implants after loading.Am J Orthod Dentofac Orthop 134:36-43, 2008

20. Seo W, Kim SH, Chung KR, et al: A pilot study of theosseointegration potential of a surface-treated mini-im-plant: Bone contact of implants retrieved from patients.World J Orthod 10:202-210, 2009

21. Kim SH, Lee SJ, Cho IS, et al: Rotational resistance of surface-treated mini-implants. Angle Orthod 79:899-907, 2009

22. Chung KR, Kim YS, Linton JL, et al: The miniplate with tubefor skeletal anchorage. J Clin Orthod 36:407-412, 2002

23. Kim SH, Lee KB, Chung KR, et al: Severe bimaxillaryprotrusion with adult periodontitis treated by cortico-tomy and compression osteogenesis. Korean. J Orthod39:54-65, 2009

24. Chung KR, Kim SH, Kang YG, et al: Orthodontic mini-plate with tube as an efficient tool for borderline cases.

Am J Orthod Dentofac Orthop, in press

25. Kim GT, Kim SH, Choi YS, et al: Computed Tomography(CBCT) evaluation of orthodontic mini-plate anchoringscrews (MPAS) placed in the posterior maxilla. Korean.Am J Orthod Dentofac Orthop 136:628.e1-10, 2009

26. Chung KR, Kim SH, Kook YA: C-palatal plate, in Cope JB(ed): Orthotads: The Clinical Guide and Atlas: Dallas,Texas Under Dog Media, 2007

27. Chung KR, Mitsugi M, Lee BS, et al: Speedy surgicalorthodontic treatment with skeletal anchorage inadults—sagittal correction and open bite correction.J Oral Maxillofac Surg 67:2130-2148, 2009

28. Tweed CH: The diagnostic facial triangle in the con-trol of treatment objectives. Am J Orthod 55:651-657,1969

29. Merrifield LL: Edgewise sequential directional force technol-ogy. J the Charles H. Tweed Foundation 1986;14: 22-37

30. Chung KR, Kim SH, Kook YA: C-orthodontic microim-plant for distalization of mandibular dentition in ClassIII correction. Angle Orthod 75:119-128, 2005

31. Chung KR, Kim SH, Chaffee M, et al: Distalization tocorrect unilateral class II malocclusion using partiallyintegrated mini implants. Korean. Am J Orthod Dento-fac Orthop 138:810-819, 2010

32. Chung KR, Kim SH, Choo H, et al: Distalization of thelower dentition using mandibular orthodontic mini im-plants to treat a dental Class III malocclusion with amidline deviation. m J Orthod Dentofac Orthop 137:

135-146, 2010