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Biomechanical considerations for total distalization of the mandibular

dentition in the treatment of Class III malocclusion

Jae Hyun Park , Sungsu Heo , Kiyoshi Tai , Yukio Kojima ,

Yoon-Ah Kook , Jong-Moon Chae

PII: S1073-8746(20)30027-X
DOI: https://doi.org/10.1053/j.sodo.2020.06.012
Reference: YSODO 611

To appear in: Seminars in Orthodontics

Please cite this article as: Jae Hyun Park , Sungsu Heo , Kiyoshi Tai , Yukio Kojima ,
Yoon-Ah Kook , Jong-Moon Chae , Biomechanical considerations for total distalization of the
mandibular dentition in the treatment of Class III malocclusion, Seminars in Orthodontics (2020), doi:
https://doi.org/10.1053/j.sodo.2020.06.012

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 Biomechanical considerations for total distalization of the

mandibular dentition in the treatment of Class III malocclusion

Jae Hyun Park,a Sungsu Heo,b Kiyoshi Tai,c Yukio Kojima,d Yoon-Ah Kook,e

Jong-Moon Chaef

a
Professor and Chair, Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral

Health, A.T. Still University, Mesa, Ariz; International Scholar, Graduate School of Dentistry,

Kyung Hee University, Seoul, Korea.

b
Private practice in Goodsmile orthodontic office, Cheongju, Korea.
c
Visiting adjunct professor, Postgraduate Orthodontic Program, Arizona School of Dentistry

& Oral Health, A.T. Still University, Mesa, Ariz; and private practice in orthodontics,

Okayama, Japan.
d
Private Practice, Nagoya, Japan.
e
Professor, Department of Orthodontics, Seoul St. Mary's Hospital, Catholic University,

Seoul, Korea
f
Professor, Department of Orthodontics, School of Dentistry, University of Wonkwang,

Wonkwang Dental Research Institute, Iksan, Korea; Visiting Scholar, Postgraduate

Orthodontic Program, Arizona School of Dentistry & Oral Health, A. T. Still University,

Mesa, Ariz.

These authors (Jae Hyun Park and Sungsu Heo) contributed equally to this work.

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Corresponding Author; Jong-Moon Chae, Department of Orthodontics, School of Dentistry,

Wonkwang University, Daejeon Dental Hospital, 77 Doonsan–ro, Seo-Gu, Daejeon, 35233,

Korea Tel ; +82-42-366-1103, Fax ; +82-42-366-1115 / E-mail ; jongmoon@wku.ac.kr

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 Biomechanical considerations in total distalization of the mandibular

dentition in the treatment of Class III malocclusion

Abstract

Class III malocclusions with mild to moderate skeletal discrepancies can be camouflaged by

orthodontic tooth movement. Conventional methods using Class III elastics can correct Class

III into Class I molar relationships. These mechanics show side-effects such as labioversion

and intrusion of the maxillary incisors, extrusion of the maxillary molars, linguoversion and

extrusion of the mandibular incisors, and intrusion of the mandibular molars along with

flattening of the occlusal plane. Conventional mechanics can improve occlusal relationships

and some profile esthetics but may produce detrimental smile esthetics by reducing the

amount of maxillary incisor exposure. Recently, with the advent of temporary skeletal

anchorage devices (TSADs), clinicians are able to achieve total distalization of the

mandibular dentition and therefore improve the occlusal relationship without worsening smile

esthetics. With the use of TSADs, the en masse movement of an entire dentition can be easily

accomplished using a statically determinate force system, which makes treatment plans easier

and treatment results more predictable. Finite element studies have identified the location of

the center of resistance of the entire dentition and simulated displacement of the dentition

depending on the force angulations and have thus provided the theoretical basis for 3-

dimensional tooth movement patterns. This article provides the biomechanical considerations

and clinical applications of total distalization of the mandibular dentition depending on

various force angulations to the mandibular occlusal plane for camouflage treatment of

various types of skeletal Class III malocclusions.

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Introduction

Class III malocclusion is a common skeletal malocclusion and mandibular prognathism is

one of the most prevalent complaints from Asian orthodontic patients.1 Skeletal Class III

malocclusion is a challenging problem for orthodontists to manage due to its multifactorial

etiology.2

Orthodontists can correct a skeletal Class III malocclusion with orthopedic and orthodontic

camouflage, and orthognathic surgery, depending on the severity of the malocclusion and

stage of the patient’s growth and development. Mild to moderate skeletal Class III

malocclusions have been managed with orthodontic treatment only, but proper diagnosis and

treatment objectives are imperative to prevent undesirable results.3-6 Conventional correction

of a Class III to a Class I molar relationship has been accomplished using total distalization of

the mandibular dentition with headgear and Class III elastics.7-13 Unfortunately, Class III

elastics showed some negative effects such as labioversion and intrusion of the maxillary

incisors, which caused reduction of maxillary incisor show and extrusion of the maxillary

molars, actually worsening an already long face.7-10 On the other hand, it showed positive

effects such as distalization and uprighting of the mandibular dentition that produced dental

correction and extrusion of the maxillary molars, improving the facial profile following

clockwise rotation of the mandible. Headgear showed excellent treatment results but patient

compliance was necessary.11-13

While distalization of the molars has been one of the most challenging orthodontic

procedures, recently it became possible to distalize the whole mandibular dentition using

various temporary skeletal anchorage devices (TSADs).6,9,10,14-20 TSADs are more reliable

and efficient than conventional methods because they allow for total distalization of the

mandibular dentition while reducing some of the negative effects and need for patient
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cooperation. Use of TSADs with a thorough understanding of t biomechanical principles

expands the boundaries and scope of Class III malocclusion treatment. However, the anterior

alveolar bone housing, posterior anatomical limitations, and adverse effects on the

temporomandibular joint (TMJ) should be considered before planning distalization, in order

to avoid periodontal, occlusal malfunction, and TMJ breakdown.21,22

Several biomechanical strategies have been attempted to correct Class III malocclusions

with severe skeletal and dental variations,6-20 but there have been few reports about the

biomechanical considerations for total distalization of the mandibular dentition. Therefore,

this article aims to address the biomechanical considerations and clinical applications for total

distalization of the mandibular dentition depending on force angulations relative to the

occlusal plane.

Center of Resistance (CR)

Knowing the location of CR is essential for predicting biomechanical tooth movement

because movement is dependent on the force direction and location relative to CR of the

dentition. When the line of action passes through, below or above CR of the mandibular

dentition, changes ranging from clockwise to counterclockwise rotation will result (Fig. 1).

The resultant tooth movement is largely determined by the relationship between the line of

force and CR of the mandibular total dentition. On this basis, a theoretical prediction of

movement of the entire dentition in three dimensions can be made. The rotational tendency is

proportional to the moment of force, which is calculated by multiplying the magnitude of the

force by the distance from CR to the line of force (Fig. 2).

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Finite element analysis

The finite element method (FEM) is a mathematical tool that can be used to identify the

location of CR under given material properties precisely. The use of finite-element models is

greatly helpful, not only for identifying CR of the dentition, but also for predicting the

expected displacement pattern of the dentition given a specific line of force.

A recent FEM study proposed that the vertical position of CR of the total mandibular

dentition was located 13.5 mm apical to the incisal edge of the mandibular central incisors,

and the anteroposterior position of CR was 25.0 mm posterior to the incisal edge of the

mandibular central incisors.23 When a rigid continuous archwire is used, the target segment

becomes the whole mandibular dentition and CR can be localized in front of the mesial root

of the first molar (Fig. 3).23-26

In an FEM study,25 distalization force was applied on the wire between the canine and first

premolar brackets at various force angulations to the occlusal plane (-30° to +30°) to distalize

the whole mandibular dentition. This would be similar to clinical applications using skeletal

anchorage and Class III elastics for Class III treatment.

Tooth movement patterns depending on force angulations and clinical application

Various force angulations (-30° to +30°) relative to the occlusal plane should be considered

in the actual clinical application using mandibular TSADs and intra-arch elastics (-30° to 0°),

maxillary TSADs and inter-arch elastics (15° to 30°), and conventional Class III elastics (15°

to 30°).

Case 1. Total distalization with TSADs around a force angulation of -30°

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 An 18-year-old female patient presented with the chief complaint of an unesthetic smile.

The diagnostic evaluation revealed a Class III facial appearance with mild deficiency of the

maxilla, anterior edge to edge bite, moderate crowding in the maxillary arch, moderate

spacing in the mandibular arch, and labioversion of the anterior teeth in both arches (Fig. 4).

A force angulation of -30˚ using TSADs was effective for slight distalization of the

mandibular dentition and to improve her smile esthetics, with clockwise rotation of the

mandibular occlusal plane by intrusion of the mandibular anterior teeth and extrusion of the

mandibular molars. This created an intermaxillary space that allowed extrusion of her

maxillary anterior teeth. If conventional mechanics with Class III elastics had been used, the

mandibular occlusal plane would have flattened, resulting in reduction of maxillary incisor

display and deterioration of smile esthetics. The force vector in this patient was designed by

inserting TSADs between the mandibular premolars. The line of force passed below CR of

the entire mandibular dentition and, thereby, it rotated clockwise and intruded (Figs. 5 and 6).

Case 2: Total distalization with TSADs around a force angulation of -15°

A 22-year-old male patient presented with an anterior crossbite and open bite with full cusp

Class III canine and molar relationships (Fig. 7).

A force angulation of 15˚ using TSADs in the mandibular buccal shelf (MBS) was

effective in correcting his severe Class III malocclusion relationship by distalization and

vertical control of the mandibular dentition followed by correction of the anterior crossbite

and open bite, even without extraction of the mandibular premolars. Vertical control of the

molars was accomplished by applying the proper force angulation. After 26 months of

treatment, Class I canine and molar relationships were achieved. The patient’s profile was

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improved by retraction of his lower lip and elimination of his lip incompetency (Figs. 8 and

9).

Case 3: Total distalization with ramal plate around a force angulation of 0°

A 21-year-old male patient (see Kook et al19 for details) presented with a chief complaint

of “I cannot chew properly.” He had a Class III brachyfacial pattern with a well-developed

chin and shallow overbite. He had an anterior crossbite on his maxillary right lateral incisor

and lateral open bites with a frontal and lateral tongue-thrust habit (Fig. 10)

Treatment resulted in more than 4 mm of distalization of the mandibular dentition and

counterclockwise rotation of the mandibular occlusal plane to correct a severe Class III dental

relationship and to increase the overbite. A force angulation of 0˚ using a ramal plate was

beneficial in producing distalization with moderate extrusion of the anterior teeth. In this

patient, the mandibular molars were extruded due to uprighting of his posterior teeth during

distalization and leveling of the curve of Spee. This may have helped to improve his facial

appearance by clockwise rotation of the mandible. That is why careful consideration of the

mechanics is needed to resolve the deep curve of Spee on a case-by-case basis (Figs. 11 and

12).

Case 4. Total distalization with Class III elastics around a force angulation of 15°

A 15-year-old female patient presented with a chief complaint of chewing difficulties and

mandibular protrusion. She had a mandibular protrusive appearance with an anterior edge-to-

edge bite but acceptable exposure of the maxillary anterior teeth when smiling. The vertical

position of her maxillary incisors and interincisal angle were normal, but her mandibular

occlusal plane was steep, resulting in minimal or no overbite (Fig. 13).

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 Using conventional Class III elastics, a force angulation of 15˚ was effective for correcting

the Class III malocclusion with the anterior edge-to-edge bite by distalization of the whole

mandibular dentition and counter-clockwise rotation of the mandibular occlusal plane and

clockwise rotation of the mandible. This was also helpful for improving her facial profile by

reducing the mandibular protrusion. Up and down elastics should be used to prevent severe

labioversion of the maxillary anterior teeth and more efficient extrusion of the mandibular

anterior teeth (Figs. 14 and 15).

Case 5. Total distalization with TSADs and Class III elastics around a force angulation of

30°

A 13-year-old female patient transferred from a private orthodontic office to the

department of orthodontics with the chief complaint of an anterior open bite. She displayed a

skeletal Class III appearance but had an acceptable profile due to her hyperdivergent facial

pattern. The vertical exposure of her maxillary incisors was normal, but her mandibular

occlusal plane was steep, causing an anterior open bite (Fig. 16).

A force angulation of 30˚ using maxillary TSADs and Class III elastics was effective in

correcting the Class III malocclusion and anterior open bite by distalization of the whole

mandibular dentition and counter clockwise rotation of the mandibular occlusal plane. This

was accomplished without producing the biomechanical side effects in the maxillary

dentition commonly caused by conventional Class III elastics (Figs. 17 and 18).

Conclusions

Skeletal Class III malocclusions can be corrected conservatively (without extraction or

orthognathic surgery) by applying proper force angulations to the mandibular occlusal plane
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to distalize and rotate the mandibular dentition. The mechanics of total mandibular

distalization patterns were summarized, emphasizing force angulations relative to the

mandibular occlusal plane using a 3-dimensional finite element simulation and suggested

efficient clinical application of the force angulations to correct various Class III

malocclusions. Selective use of force angulations using TSADs or Class III elastics with a

thorough understanding of the biomechanics and anatomical limitations can produce proper,

controlled distalization of the mandibular dentition.

Acknowledgment

The authors thank Steven Park for his help with the preparation of the manuscript.

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FIGURE LEGENDS

Fig 1. Resultant movement of the total mandibular dentition and the relevant force vector. (A)

Bodily distalization; (B) Rotation (clockwise and counterclockwise). Red dot, the center of

resistance of the total mandibular dentition.

Fig 2. The magnitude of the moments (curved arrows) are determined by the perpendicular

distances (dashed lines) from the line of the force (solid arrow) to the center of resistance (red

dot) and the amount of the force (Mf = D × 𝑓) depending on the force angulations.

Fig 3. Estimated center of resistance of the mandibular dentition.23-26 The line of the force

passes through the center of resistance of the whole mandibular dentition at a force

angulation of -23˚ to the wire between the canine and first premolar brackets.

Fig 4. Case 1: Pretreatment facial and intraoral photographs and lateral cephalogram.

Fig 5. Case 1: Total distalization with TSADs around a force angulation of -30°.

Fig 6. Case 1: Posttreatment facial and intraoral photographs, lateral cephalogram, and

cephalometric superimposition.

Fig 7. Case 2: Pretreatment facial and intraoral photographs and lateral cephalogram.

Fig 8. Case 2: Total distalization with TSADs placed between the second premolars and first

molars or between the first and second molars around a force angulation of -15°.

Fig 9. Case 2: Posttreatment facial and intraoral photographs, lateral cephalogram, and

cephalometric superimposition.

Fig 10. Case 3: Pretreatment facial and intraoral photographs and lateral cephalogram.

Fig 11. Case 3: Total distalization with ramal plates around a force angulation of 0°.

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Fig 12. Case 3: Posttreatment facial and intraoral photographs, lateral cephalogram, and

cephalometric superimposition.

Fig 13. Case 4: Pretreatment facial and intraoral photographs and lateral cephalogram.

Fig 14. Case 4: Total distalization with Class III elastics around a force angulation of 15°.

Fig 15. Case 4: Posttreatment facial and intraoral photographs, lateral cephalogram, and

cephalometric superimposition.

Fig 16. Case 5: Pretreatment facial and intraoral photographs and lateral cephalogram.

Fig 17. Case 5: Total distalization with TSADs and Class III elastics around a force

angulation of 30°.

Fig 18. Case 5: Posttreatment facial and intraoral photographs, lateral cephalogram, and

cephalometric superimposition.

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