Carriere Distalizer JCO Article

8/9/2019 Carriere Distalizer JCO Article

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A NEW CLASS II DISTALIZER ™ THE CARRIERE ® DISTALIZER CORRECTION APPLIANCE

As it appeared in the JCO, April 2004

ARTICLE


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The Carrière Distalizer* is a simple and effi-cient fixed functional appliance for Class IItreatment (Fig. 1). Developed by the author withadvanced computer technology, it represents anevolution of the Modular Sectional Arch. 1

The Distalizer is most effective in treatingClass II malocclusions without extractions.Brachyfacial patterns respond best to treatment;dolichofacial types are less responsive. The ap -pliance can also be used in many Class I caseswith mesially positioned maxillary molars or,with caution, in Class I cases with premaxillaryhypoplasia. Growing patients are ideal, butadults can be treated as well. Mixed dentitionClass II cases with fully erupted first molars arecandidates for first-phase treatment.

Biomechanics

The Carrière Distalizer is designed to cre-ate a Class I molar and canine relationship that Icall a Class I Platform of occlusion. This allowsthe case to be finished with any technique pre-ferred by the orthodontist (Fig. 2). The bio-mechanical objectives of the appliance are as

follows:• Produce a distal rotational movement of themaxillary first molars around their palatal rootswhen necessary.• Simultaneously produce a uniform force fordistal molar movement.• Independently move each posterior segment,from canine to molar, as a unit.

• Eliminate wire changes and thus the distortingcollateral forces that appear with every wire acti-vation in traditional methods.• Minimize periodontal reactions.

The clinical evidence of the achievement ofthese objectives will be the appearance of inter-incisal diastemas and wide spaces mesial to thecanines.

A New Class II Distalizer

LUIS CARRIÈRE, DDS, MSD

Fig. 2 Maxillary molars are distalized and rotated,providing platform for maxillary canines to oc cludein Class I relationship.Fig. 1 Carrière Distalizer.

*ClassOne Or thodontics, Inc., 5064 50th St., Lubbock, TX 79414.


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Appliance Design

The Distalizer is made of mold-injected,nickel-free stainless steel. It is bonded to thecanine and first molar as follows:

The canine pad, which allows distal move-ment of the canine along the alveolar ridge with-out tipping, provides a hook for the attachment ofClass II elastics (Fig. 3). This pad is the mesialend of an arm that runs posteriorly over the twoupper premolars in a slight curve. The posteriorend of the arm is a permanently attached ball thatarticulates in a socket on the molar pad (Fig. 4).

The ball and socket were designed withthree-dimensional virtual-reality models 2 to

Dr. Carrière is in the private practice of orthodontics at EscuelasPias, 109, 08017 Barcelona, Spain; e-mail: [email protected]. Hehas a finan cial interest in the product described in this arti cle.

Fig. 4 Ball-and-socket joint articulates for control of molar derotation while limiting undesirable movementsduring distalization.

Fig. 3 Carrière Distalizer with Class II elasticattached to hook on canine pad.


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resemble the human hip joint, providing maxi-mum freedom of movement in the appropriatedirection. Raised surfaces on the ball articulatewith corresponding depressions in the socket tolimit distal rotation to –15° on the longitudinalaxis. The joint also provides torque control ofboth the canine and molar (Fig. 5).

This posterior portion of the Distalizeraccomplishes three types of molar movement:1. Uprighting of the crown, if it is mesially in -clined (Fig. 6). Once the molar has been upright-ed, the articulation of the ball with the socketprevents distal tipping.2. Distal rotation around the palatal root. Whenthe maxillary first molar is mesially rotatedaround the palatal root, the molar occlusion mayappear to be Class I, while in reality it is Class IIwith the canines in a cusp-to-cusp relationship

(Fig. 7). When the molar has been derotated, theshoulder of the posterior base contacts the mesialarm to prevent overrotation.3. Distal displacement without concurrent distaltipping of the crown (Fig. 8).

Appliance Placement

The Distalizer comes in three sizes: 23mm,25mm, and 27mm. The appropriate size is deter-mined by measuring from the midpoint of themaxillary first molar’s buccal surface to the mid-point of the maxillary canine crown, using acaliper or the supplied “Dentometer” (Fig. 9). In

ew ass sta zer

Fig. 6 Correction of mesial molar inclination.Fig. 8 Bodily distalization of molar, combinedwith derotation.

Fig. 5 Ball-and-socket joint provides molar torquecontrol.

Fig. 7 With mesially rotated maxillary molars,canines cannot occlude in Class I relationship.


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a case with an inaccessible high canine and themaxillary second molars present, the measure-ment can be taken from the midpoint of the sec-ond molar crown to the midpoint of the firstpremolar. The appliance is bonded to these teeth,rather than to the first molar and canine. The posterior teeth can then be distalized to providespace for the blocked-out upper canine.

After the teeth to be bonded are etched, alight-cured adhesive is placed on the two bond -ing pads of the Distalizer. The molar attachmentis positioned in the center of the buccal surfacewith thumb pressure, then cured. There will beadequate time remaining to position the caninepad correctly before curing it.

Possible Sources of Anchorage

Anchorage must be carefully selected, de -pending on the patient’s skeletal and neuromus-cular pattern, to avoid protrusion of the lowerincisors. It may include one or more of the fol-lowing sources:

1. Passive Lingual Arch

A passive .036" lingual wire, completelyadapted to the mandibular dental anatomy, runsfrom molar to molar—the second molars if theyhave erupted (Fig. 10).

2. Hamula Lingual Arch

This .045" round stainless steel lingual wireis attached with Hamula First Fit* molar bands,which come with mesial and distal occlusalstops. Two segments of .021" × .025" wire aresoldered occlusally to the stops and are bondedto the occlusal surfaces of the premolars andmolars once the bands have been cemented. Theedgewise wire rests on the occlusal surfaceswithout any interference (Fig. 11).

3. Full Mandibular Fixed Appliance

In a nonextraction case with a severe curve

Carrière

*ClassOne Orthodontics, Inc., 5064 50th St., Lubbock, TX 79414.Fig. 9 Distalizer size determined by measuringfrom midpoint of maxillary first molar’s buccalsurface to midpoint of maxillary canine crown.

Fig. 10 Passive .036" lingual arch. Fig. 11 Hamula Lingual Arch.


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of Spee or mild crowding in the mandibular arch,it is advisable to bond lower brackets and prepareanchorage to support the Class II elastic traction.

4. Lower Essix Appliance

An Essix** appliance is another option forelastic attachment. The material used should be.040" Essix type A. For optimum stability of theelastics and mechanical retention, the applianceshould be fabricated with small composite

wedges bonded to the buccal surfaces of thelower molars and premolars. Hooks for elasticattachment are placed in the lower molar region.

5. Miniscrews

These implants can be used for a short peri-od at the beginning of orthodontic treatment. Be - cause they are not osseointegrated, they can beeasily inserted and removed. In the mandibulararch, for attachment of Class II elastics, they arebest placed through the attached gingiva betweenthe first and second molars. In the maxillary arch,miniscrews placed in the zygomatic buttress offeran alternative for elastic attachment in maximumanchorage cases for non-compliant patients.

Patient Instructions

Heavy, 6 1 ⁄ 2oz, 1 ⁄ 4" Class II elastics should beworn 24 hours a day, except during meals, inlow-angle cases with good perioral muscularstrength. Elastic wear can be limited to 14 hoursa day, including sleeping hours, in high-anglecases with lighter perioral musculature. The elas-

tics should not be worn while chewing becauseof the vertical force vector produced by thesemovements. A predominantly vertical vectormay be expressed in a mild extrusion of the ca -nines during distalization, which can easily becompensated for in the following stages of treat-ment. Night-time wear provides a more horizon-

tal vector of traction, but will prolong the distali-zation period.

The patient should be instructed not to usethe tongue to interfere with the Distalizer’s hori-zontal arm, because this could result in a lingualinclination of the upper premolars. Another habitto avoid is placing the tip of the tongue in thespaces created between the upper lateral incisorsand canines during distalization. This will beindicated by a mild redness at the mesiogingivalborder of the upper canines, and may result in a

widening of the spaces mesial to the canines inrelation to the interincisal diastema.

Patient acceptance of the Distalizer hasbeen gratifying, probably because the upper in -cisors are left free of appliances and the mandi-bular anterior region contains only an invisiblelingual arch or Essix appliance. Additionally, theDistalizer is relatively comfortable and is used inthe first three to six months of treatment, whencompliance is best. The patient’s morale is boost-ed by the immediate appearance of a diastemabetween the upper incisors, showing the progressof distalization. Avoidance of premolar extrac-tions is a good bargain for a few months of coop-eration with elastic wear.

Case Reports

These cases were treated with the CarrièreDistalizer. All three displayed wide interincisaldiastemas after three or four months of distaliza-tion (Figs. 12-14). The panoramic x-rays demon-strate the preserved axial parallelism of the max-illary cuspids, premolars, and first molars aftertheir distal displacement. Cephalometric tracings

show the distalization of the buccal segments andthe response of the other dentofacial structuresduring these short treatment periods.

REFERENCES

1. Carrière, J.: The Inverse Anchorage Technique in Fixed Ortho-dontic Treatment , Quintessence Publishing Co., Chicago, 1991.

2. Carrière, J. and Carrière, L: Softlanding treatment throughinverse anchorage and virtual reality, J. Clin. Orthod. 29:479-486, 1995.

**Registered trademark of Raintree Essix, Inc., 4001 Division St.,Metairie, LA 70002.



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Fig. 12 Case 1. A. 12-year-old female Class II, division 1 patient before treatment . B. Placement of CarrièreDistalizer. C. After three months of distalization. D. Superimposition of cephalometric tracings before andafter distalization.

Pretreatment Post-DistalizationSNA 83.5° 82.0°SNPg 79.0° 78.5°ANPg 4.5° 3.5°SN/ANS-PNS 7.5° 8.0°SN/GoGn 29.0° 29.0°ANS-PNS/GoGn 21.5° 21.0°1-GoGn 102.0° 104.0°1-NB 7.0° 8.0°

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Carrière


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Fig. 13 Case 2. A. 12-year-old female Class II, division 2 patient before treatment. B. Placement of CarrièreDistalizer. C. After four months of distalization. D. Superimposition of cephalometric tracings before andafter distalization.


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Fig. 14 Case 3. A. 11-year-old female Class II, division 1 patient with dolichocephalic pattern before treat-ment. B. Placement of Carrière Distalizer. C. After three months of distalization. D. Superimposition ofcephalometric tracings before and after distalization.


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Carrière


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Carriere Distalizer JCO Article