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Contemporary Multiloop Edgewise Archwire (MEAW) Technique

: Old-fashioned but useful

Tae-Woo Kim (金泰佑) DDS MSD PhD

Professor

Department of Orthodontics

School of Dentistry, Seoul National University

AAO 2020 WINTER CONFERENCEJW Marriott Austin • Austin, Texas, USA • February 7-9, 2020

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1) 2013 A Combination of Mini-Implant and MEAW to Correct a Skeletal Class II Open Bite https://www.aaoinfo.org/node/625

2) 2014 Open bite treated by intruding posterior teeth; Methods, outcomes, stability and guidelines https://www.aaoinfo.org/node/2382

3) 2015 Orthodontic Treatment of Skeletal Class II Open Bite; 1) Closing the open bite and 2) Solving the A-P discrepancy

https://www.aaoinfo.org/node/4792

4) 2016 Ankylosis of Anterior Teethhttps://www.aaoinfo.org/meeting-archive/2016-annual-session#topbar

1) 2017 Second molar extraction for open bite treatmenthttps://annual-session.aaoinfo.org/meetings/2018-annual-session/

6) 2018 Molar intrusion with skeletal anchorage, from single tooth intrusion to canting correction and skeletal open bite

https://annual-session.aaoinfo.org/meetings/2018-annual-session/

E-handouts of Open bite lectures are available at

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Introduction

•Young Ho Kim & MEAW (Open bite, Class II, Class III, Finishing)

•Mechanics & Wire bending

Diagnosis and indications

•Differential diagnosis

•MEAW or Mini-implant

Successful Cases

•Extraction 77/77, 77/88, 88/88

Unsuccessful Cases

•DJD

Report on the literature

Retention and stability

•Four major etiologic factors – Mouth breathing, Tongue trusting, TMD, Weak muscle

77/88

Class II Class III

77/77 88/88

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MEAW technique

MEAW technique

Chicago, 2000, 5 6

http://meaw.com/

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Multiloop Edgewise Arch Wire (MEAW)

• 018x022 stainless steel

MEAWs are made of 018x022 ss wire.

Upper Lower

7

.022 X .028

8

018x022 stainless steel

•Class II correction

U: MEAW

L: Ideal arch wire

•Class III correction

U:Ideal arch wire

L: MEAW

Closing anterior open bite

U: MEAW

L: MEAWMEAWs can be used to correct Class II relation, Class III relation and open bite. To close the anterior open bite, MEAWs are used both in upper and lower arches.

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•Class II correction

U: MEAW, L: Ideal arch wire

5/16” Class II elastics

To correct Class II relationship, MEAW is applied in the maxillary arch and Ideal arch(019x025ss) is used in the mandibular arch. Class II 5/16” 6oz elastics are applied.

①

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•Class III correction

U: Ideal arch wire, L: MEAW

5/16” Class III elastics

To correct Class III relationship, MEAW is applied in the mandibular arch and ideal arch(019x025ss) is used in the maxillary arch. Class III 5/16” 6oz elastics are applied.

② ③

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•Openbite correction

U: MEAW, L: MEAW

3/16” up/down elastics

To close the anterior open bite, MEAWs are used both in maxillary and mandibular arches. 3/16” 6oz elastics are applied from the first upper loop to the first lower loop.

④

⑤

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•018x022 stainless steel

To make MEAWs, 4 to 5 L-shaped loops are made between teeth. 13 14

An 043-CK plier is used to make a MEAW.

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• Front cylinder: .045”• Middle cylinder: .060” • Rear cylinder: .075”

Tips have three cylindrical sections; front cylinder being of .045“ diameter, middle cylinder being of .060" diameter and the rear cylinder being of .075" diameter.

• Lower flat beak

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Cutter can be used for both round and rectangular wire up to .025" saving time and motion.

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Arch turret without torque

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19 20

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Check the symmetry and flatness.

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Between #2 and #3, the first L loop is made. 23 24

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13

6mm

2.5mm

4.5mm2

25 26

27 28

7 134567mm

8mm 6mm 7mm 6mm

2.5mm

4.5mm2

7mm

Sequentially, upper L loops are made. 29

7 134567mm

8mm 6mm 7mm 6mm

2.5mm

4.5mm2

7mm

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Upper MEAW shows L loops in perpendicular to the arch. The arch doesn’t have torques.

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20~25°

5~10°

To avoid gingival impingement or cheek mucosa irritation, L loops have a buccal tipping. The angle increases progressively distally.

31The arch is made flat.

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• Upper

The upper MEAW33

• Lower

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The lower MEAW

7 134567mm

8mm 6mm 7mm 6mm

2.5mm

4.5mm

7mm

8mm 6mm 6mm 7mm 6mm

2.5mm4.5mm

2

7mm

7 13456 2

Average size of L loops

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The final upper and lower MEAWs were made.

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Upper and lower MEAWs shows a good coordination.

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Tip back bends• Provides reverse curve of Spee

Tip back bends are applied to each loops, 3° to 5° .

Finally, the upper arch has a compensating curve and the lower arch has a reverse curve of Spee.

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Tip-back bends are applied to each loops.How many degrees do you bend?

1. Extrusion of anterior teeth is the main effect.2. Very slight intrusion of posterior teeth is also secondary effect, “Rocking

chair effect”.

“Rocking Chair”

v

Up & Down

elastics

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1. Extrusion of anterior teeth is the main effect.

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1. Extrusion of anterior teeth is the main effect.2. Very slight intrusion of posterior teeth is also secondary effect, “Rocking

chair effect”.

“Rocking Chair”

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1. Extrusion of anterior teeth is the main effect.2. Very slight intrusion of posterior teeth is also secondary effect, “Rocking

chair effect”.3. Distal tipping contributes to the correction of molar relationship.

“Rocking Chair”

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“Handle of a car”

1. Extrusion of anterior teeth is the main effect.2. Very slight intrusion of posterior teeth is also secondary effect, “Rocking

chair effect”.3. Distal tipping contributes to the correction of molar relationship. This

effect is increased by Class II elastics (In Class III, by Class III elastics). 4. .

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“Molar movement in open-bite”

Very slight intrusion + Distal tipping

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Reasons why I use MEAWs instead of curved TMA or NiTi wires?

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“Handle of a car”

Distal tipping or intrusion of a molar can be controlled very

accurately and effectively with a stiff stainless wire. And also the

load-deflection rate is decreased well with the L loops. 46

“Handle of a car”

1. If the handle is made of a flexible material, it would not be easy

to control well (tip-back and intrusion) and

2. it would be hard to adjust the wires (vertical or in-&-out steps)

for compensating the minute errors of bracket positioning. 47

Yang WS, Kim BH, Kim YH Angle Orthod 2001;71:103–109.

Regional Load Deflection Rate (LDR) of MEAW

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x2 x3 x8 x2 x3 x8

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Yang WS, Kim BH, Kim YH Angle Orthod 2001;71:103–109.

Regional Load Deflection Rate of MEAWHigher LDR

Lower LDR

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Yang WS, Kim BH, Kim YH Angle Orthod 2001;71:103–109.

Regional Load Deflection Rate of MEAW

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Indications

Mini-implant caseMolar intrusion (536480 )

MEAW caseIncisor extrusion (377589)

The left case was treated with the MEAW technique, extrusive mechanics. However, the right case was treated with the mini-implant mechanics, intrusive mechanics.What factors were considered to select the mechanics? 52

The first factor was ‘The initial amount of Incisal Display ’. Compare the height of incisal edge with the level of stomion.

Mini-implant caseMolar intrusion (536480 )

MEAW caseIncisor extrusion (377589)

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In the left case, the extrusion of the upper incisor is desirable. However, the right case allows a minimal extrusion of the upper incisor.

Mini-implant caseMolar intrusion (536480 )

MEAW caseIncisor extrusion (377589)

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Initial

The second factor was the ‘Lip Incompetency’. The right case presented of lip incompetency. However, the left case did not feel hard to close his lip (No ‘strains’ around lips).

Mini-implant caseMolar intrusion (536480 )

MEAW caseIncisor extrusion (377589)

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Debonding

After the orthodontic treatment with the mini-implant intrusion mechanics, the right case did not feel hard to close his lips.

Mini-implant caseMolar intrusion (536480 )

MEAW caseIncisor extrusion (377589)

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The third factor was the ‘Skeletal Class II pattern’. Both casesshowed a very similar skeletodentoalvelar pattern. However, the right case showed a little severer Class II pattern.

Mini-implant caseMolar intrusion (536480 )

MEAW caseIncisor extrusion (377589)

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Mean SDMEAW377589

Mini-implant536480

SNA 81.8 6.0 78.8 80.0

SNB 80.2 5.3 73.5 74.0

ANB 1.8 2.0 5.3 6.1

U1to FH 116.5 6.0 115.1 115.2

IMPA 90.2 5.4 98.4 96.2

IIA 126.2 8.0 113.3 115.6

FMA 26.8 1.8 33.3 33.1

SN-GoMe 32.8 4.3 43.8 40.8

AFH 136.4 6.8 144.5 143.0

ODI 73.3 5.9 78.2 76.8

APDI 86.0 4.0 84.5 78.1

ANBs were 5.3 and 6.1. APDIs were 84.5 and 78.1.

Mini-implant caseMolar intrusion (536480 )

MEAW caseIncisor extrusion (377589)

58Kim YH, Vietas JJ. Anteroposterior dysplasia indicator (APDI):

an adjunct to cephalometric differential diagnosis. Am J Orthod 1978;73:619-33.

Considering three factors, in the left case, the extrusion of incisors was proper. However, the right case needed the intrusion of upper posterior teeth and the autorotation of mandible.

Mini-implant caseMolar intrusion (536480 )

MEAW caseIncisor extrusion (377589)

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Please, compare real treatment results. We can select the adequate techniques differentially, considering three factors.

Mini-implant caseMolar intrusion (536480 )

MEAW caseIncisor extrusion (377589)

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Incisor extrusion (377589)

Graphically, the treatment procedures will be demonstrated. First, the left case treated with the extrusive mechanics, MEAW, will be shown. 61

Incisor extrusion (377589)

First, after leveling and decrowding, upper second and lower third molars were extracted. Second, MEAWs were applied to close the open bite by extruding the incisors. 62

Graphically, the right case treated with the mini-implant mechanics will be shown. He was treated with ‘intrusion’.

Molar intrusion (536480 )

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Leveling

During leveling, upper incisors were extruded a little, and some portion of the open bite was resolved.

Molar intrusion (536480 )

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Molar intrusion (536480 )

Leveling

After leveling, a mini-implant was placed in the mid-palatal area. 65

Molarintrusion

Next, upper molars were intruded in ‘en masse’ mode,and the open bite was closed by autorotation of mandible.

Molar intrusion (536480 )

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1. Incisal display 2. Lip incompetency 3. Skeletal pattern

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In summary,

Successful Case

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2003.3.11 2003.3.11

Female Mean(sd) 2003.11.25

18y 10m

SNA 81.6(3.2) 80.7

SNB 79.2(3.0) 74.2

ANB 2.5(1.8) 6.5

FMA 24.3(4.6) 42.6

ODI 72.2(5.5) 73.3

U1 to FH 116.0(5.8) 102.2

IMPA 95.9(6.4) 92.1

Interincisal angle

123.8(8.3) 123.1

Upper lip E-line

-0.9(2.2) 4.1

Lower lip E-line

0.6(2.3) 5.1

2003.11.25 Before orthodontic treatment2004.3.27

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2004.2.32004.9.11

2005.2.242005.5.8

2005.8.31Debonding

2005.8.31Debonding

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2005.8.31Debonding

Female Mean(sd) 2003.11.25 2005.8.31

18y 10m 20y 7m

SNA 81.6(3.2) 80.7 82.0

SNB 79.2(3.0) 74.2 75.3

ANB 2.5(1.8) 6.5 6.8

FMA 24.3(4.6) 42.6 39.2

ODI 72.2(5.5) 73.3 72.4

U1 to FH 116.0(5.8) 102.2 99.4

IMPA 95.9(6.4) 92.1 90.5

Interincisal angle

123.8(8.3) 123.1 131.0

Upper lip E-line

-0.9(2.2) 4.1 1.6

Lower lip E-line

0.6(2.3) 5.1 3.7

2005.8.31 Debonding

2003.11.25 Before

2005.8.31

2016.6.8Post-treatment 11Y 5M

Unsuccessful Case

DJD with CO-CR discrepancy

Unstable condylar position

DJD and Class II elastic bands

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TMD patients’ TMJs are like a broken hinge.

As the door isn’t closed well, it is hard to make a good occlusion in TMD patients, esp. with CO-CR discrepancy.

Normal DJD

Some patients show the forward mandibular shift by Class II elastic bands,

Normal DJD

instead of movements of teeth.

Normal DJD

When it is useless to use Class II elastic bands, total retraction of maxillary teeth by using skeletal anchorage may be considered.

Report on the literature

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MEAW technique

• Kim Y, Anterior openbite and its treatment with multiloopedgewise archwire. Angle Orthod. 1987:57(4):290–321. https://www.angle.org/doi/pdf/10.1043/0003-3219%281987%29057%3C0290%3AAOAITW%3E2.0.CO%3B2

Diagnosis – ODI, APDI, Combination factor, Extraction index

• Young H Kim, Overbite depth indicator with particular reference to anterior open-bite, Am J Orthod 65:586-611. https://doi.org/10.1016/0002-9416(74)90255-3

• Kim YH, Vietas JJ. Anteroposterior dysplasia indicator: an adjunct to cephalometric differential diagnosis. Am J Orthod. 1978 Jun;73(6):619-33. https://doi.org/10.1016/0002-9416(78)90223-3

• R. Silva Meza, Young H. Kim Cephalometric Analytic Procedure. http://orthofree.com/cms/assets/pdf/99.pdf

• Tanaka E, Sato S. Longitudinal alteration of the occlusal plane and development of different dentoskeletal frames during growth. Am J Orthod Dentofacial Orthop 2008;134:602-3, https://doi.org/10.1016/j.ajodo.2008.02.017. Am J Orthod DentofacialOrthop. 2008:134 (5):602.e1–602.e11. https://www.ajodo.org/article/S0889-5406(08)00776-2/pdf

Skeletodental changes with MEAW

• Toshiya Endo, Koji Kojima, Yoshiki Kobayashi, ShohachiShimooka, Cephalometric evaluation of anterior open-bite nonextraction treatment, using multiloop edgewise archwiretherapy, Odontology (2006) 94:51–58. https://link.springer.com/article/10.1007%2Fs10266-006-0061-5

• Seong-Cheol Moon, Young-II Chang, Cephalometric evaluation of anterior openbite malocclusions treated by multiloop edgewise archwire technique, Korean J Orthod, 1993:23(4): 565-606. (English abstract)

Stability

• Young H Him, Unae Kim Han, Diana D Lim, Ma Laarni P Serranon, Stability of anterior openbite correction with multiloop edgewise archwire therapy: A cephalometric follow-up study, Am J Orthod Dentofacial Orthop 2000;118:43-54

Case reports

• Marañón-Vásquez GA, Soldevilla Galarza LC, Tolentino Solis FA, Wilson C, Romano FL, Aesthetic and functional outcomes using a multiloopedgewise archwire for camouflage orthodontic treatment of a severe Class III open bite malocclusion, J Orthod. 2017 Sep;44(3):199-208. https://doi.org/10.1080/14653125.2017.1353789

• Marco Antonio Cruz-Escalantea, Aron Aliaga-Del Castillob, Luciano Soldevillac, Guilherme Jansond, Marilia Yatabee, Ricardo Voss ZuazolafExtreme. Extreme skeletal open bite correction with vertical elastics, Angle Orthod. 2017;87:911–923. https://doi.org/10.2319/042817-287.1

• Benedito Freitasa, Heloiza Freitasb, Pedro César F dos Santosc, Guilherme Jansond, Correction of Angle Class II division 1 malocclusion with a mandibular protraction appliances and multiloop edgewise archwire technique, Korean J Orthod 2014;44(5):268-277. http://dx.doi.org/10.4041/kjod.2014.44.5.268

Case reports

• Gerson Luiz Ulema Ribeiro, Saulo Regis, Jr, Tais de Morais Alves da Cunha, Marcos Adriano Sabatoski, Odilon Guariza-Filho, Orlando Motohiro Tanaka, Multiloop edgewise archwirein the treatment of a patient with an anterior open bite and a long face, Am J Orthod Dentofacial Orthop 2010;138:89-95. https://doi.org/10.1016/j.ajodo.2008.03.036

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Research

• Yang WS, Kim BH, Kim YH, A Study of the Regional Load Deflection Rate of Multiloop Edgewise Arch Wire, Angle Orthod 2001;71:103–109. https://www.angle.org/doi/full/10.1043/0003-3219%282001%29071%3C0103%3AASOTRL%3E2.0.CO%3B2

• Seung-Hak Baek , Soo-Jung Shin , Sug-Joon Ahn and Young-Il Chang, Initial effect of multiloop edgewise archwire on the mandibular dentition in Class III malocclusion subjects. A three-dimensional finite element study, European Journal of Orthodontics 30 (2008) 10–15. https://doi.org/10.1093/ejo/cjm098

Retention and stability

Atrophy of Masticatory muscles

Open biteWeak bite force

TMD symptoms

Anterior disc displacement

Condylar resorption

Vicious cycle

Pain in Movement

Tongue thrust

Mouth breathing

MEAW

Detailing

Strategies for retention

in open bite cases

1. After correction of open bite,

at the detailing stage, distally

tipped molars were corrected.

Detailing Retention

Strategies for retention

in open bite cases

2. During the detailing stage,

018x 022”ss with shoe hooks

were used with up & down

elastics. Elastic-wearing time

was decreased gradually from

24 hours to 0 hour, monitoring

the overbite & any bad habits.

Conceptually, the detailing

stage was regarded as a

retention period and it was

extended as long as possible.

Start of detailing

Debonding

Initial

3-year post-treatment

Strategies for retention

in open bite cases

3. Patients were educated

during active treatment and/or

post-treatment period to

masticate more than thirty

times for each spoon of food,

if TMJs had no discomfort.

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Strategies for retention

in open bite cases

4. At the stage of debonding, it

is recommended that the

occlusal contact areas be as

wide as possible.

Debonding

Initial

This may provide more

stable mandibular position

and maximum bite force.

Strategies for retention

in open bite cases

5. Mouth breathing, tongue

posture & habits are monitored

every year after debonding.

Frequent rhinitis and

mouth breathing may make

the tongue posture lower

and protruded. It may be a

relapse factor.

2000.12.18

(Initial)

Strategies for retention

in open bite cases

5. Mouth breathing, tongue

posture & habits are monitored

every year after debonding.

Frequent rhinitis and

mouth breathing may make

the tongue posture lower

and protruded. It may be a

relapse factor.

2018.12.21

post-treatment

13 years 9 months Fixed retainer + Labial buttons + U/D elastics

How to retain the result after debonding?1. Monitor the causes: TMJ pains, tongue thrust &

mouth breathing. 2. Use Fixed retainers(4-4). 3. When a relapse tendency found, apply labial

buttons (22/33) with u/d elastics 3/16” 6 oz.4. Instruct patients to chew many times during

eating meals (to increase muscle tonicity).5. Train swallowing without thrusting tongue.

How to make labial button?

1) Etching 2) Wash and dry 3) Primer application 4) Curing

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5) Place a Separator ring on cervical area

6) Inject Flowableresin in the ring. 7) Curing 8) Remove a

Separator

9) Polish and check the undercut.

Fixed retainer(4-to-4

3M Unitek 0.8mm Twist wire, REF 260-0321

2014.1.151 year after debonding

3M Unitek Twisted wire 0.8mm REF 260-032

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Strategies for retention in open bite treatment with MEAW are as follows;

1) After correction of an open bite, at the detailing stage, upright the distally tipped molars.

2) Check the etiologic factors.

- mouth breathing

- tongue thrusting

- weak masticatory muscle force

- tongue thrusting, and

- TMD.

In Summary

• MEAW technique can be used after leveling to correct Class II, Class III, and open bite malocclusion efficiently. The occlusal plane also can be changed. Third molars (or second molars) are extracted to remove the wedge or the posterior crowding.

• MEAW’s indication, successful cases, unsuccessful cases, pieces of literature, retention, and stability were presented.

• If wire bending ability is equipped, it will be one of the powerful and useful tools for open bite treatment.

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