|Year : 2020 | Volume
| Issue : 2 | Page : 53-59
Carrière Distalizer appliance effect on electromyographic activity during class II correction
Maha M Mohamed PhD 1, Farouk A Hussein2
1 Department of Orthodontics, Faculty of Dental Medicine for Girls, Al-Azhar University, Cairo, Egypt
2 Department of Orthodontics, Faculty of Dental Medicine for Boys, Al-Azhar University, Cairo, Egypt
|Date of Submission||13-Jul-2019|
|Date of Acceptance||25-Nov-2019|
|Date of Web Publication||26-Sep-2020|
Maha M Mohamed
Lecturer of Orthodontics, Faculty of Dental Medicine for Girls, Al-Azhar University, Cairo
Source of Support: None, Conflict of Interest: None
The aim of this study was to assess the electromyographic (EMG) activity of oral muscles concomitant to class II malocclusion correction using Carrière Distalizer appliance.
Patients and methods
Ten female patients with age ranged between 18 and 21 years old were selected for this study. All patients were examined to fulfill the inclusion criteria. All patients in this underwent radiographic evaluation (panoramic and lateral cephalometric) and EMG evaluation before and after class II correction using Carrière Distalizer appliance.
Study duration for patients was 6 months. Actually, no significant changes occurred in skeletal measurements except increase angle of convexity. Regarding EMG measurements there is statistically significant increase in masseter muscle activity at rest and at occlusion after treatment. Carrière Distalizer appliance was able to correct class II molar relation into class I relation in adult patients. Finally the dentoalveolar changes including slight maxillary molar distalization, in addition to mesialization of the lower molars and proclination of the lower incisors which results in correction of class II malocclusion.
Successful correction of class II malocclusion was achieved with the Carrière Distalizer appliance and masseter muscle activity at rest and at occlusion after treatment was improved.
Keywords: Carrière Distalizer appliance, class II malocclusion, distalization, electromyographic activity
|How to cite this article:|
Mohamed MM, Hussein FA. Carrière Distalizer appliance effect on electromyographic activity during class II correction. Tanta Dent J 2020;17:53-9
|How to cite this URL:|
Mohamed MM, Hussein FA. Carrière Distalizer appliance effect on electromyographic activity during class II correction. Tanta Dent J [serial online] 2020 [cited 2020 Oct 31];17:53-9. Available from: http://www.tmj.eg.net/text.asp?2020/17/2/53/296175
| Introduction|| |
Class II malocclusion is one of the most frequent treatment problems facing orthodontists, representing nearly one third of all malocclusion . Functional or orthopedic appliance has been used to treat the malocclusions caused by skeletal factor. However, if the problem is dentoalveolar, several treatment options have been attempted such as extraction, at least, in one of the dental arches, dental arch expansion use of intramaxillary elastics or distalizing the first maxillary molar without extraction.
Distalization is indicating when there is moderate dental or skeletal protrusion of the upper arch, mild to moderate crowding and or when the extraction decision would highly jeopardize the facial esthetics. Distalization can be accomplished through the use of either extraoral (mainly headgear) or intraoral appliances. The major disadvantage of extraoral appliances is either unpleasant look or dependence on patient compliance making them a less favorable choice for the clinician as well as for the patient .
There are a variety of intraoral appliances available, such as the Pendulum , Distal Jet , Jones Jig , First Class  and Keles Slider  used for distalization and not depending on the patient's compliance. However, with most of these appliances, there is always loss of lower anterior anchorage as reported in a systematic review by Antonarakis and Kiliaridis. Mesial movement and tipping of the lower incisors along with the mesial movement of the premolars have been reported. Temporary anchorage devices have been used to limit this mesial movement and thus reinforcing the anchorage .
In 2004 a new appliance was introduced by Luis Carriere carrying his name; the Carrière Distalizer appliance . This appliance is designed to change a class II molar relation into a class I relation by uprighting and rotating the first maxillary molar and distalizing the whole posterior segment from the canine to the first molar before brackets or any other appliances are placed.
A reported case where an 11 years old male was presented with a class II subdivision malocclusion. A nonextraction treatment plan was designed where the Carrière Distalizer appliance was used. After 11 months of the first phase, a class I molar relationship had been achieved and adequate space has been created for the impacted canine .
Another reported case where a 27 years old male was presented with a class II subdivision malocclusion. A two-phase treatment plan was also designed in which a unilateral Carrière Distalizer appliance would be used on the left side initially to correct the class II molar relationship but the second phase consisted of Invisalign therapy. After 6 months of the first phase, a class I molar and canine relationship had been achieved .
Study showed a reported case where a 14 years old male presented with a class II on the right, midline deviation and crowding in the upper and lower anterior regions. A two-phase treatment plan was designed in which Carrière Distalizer appliance was used in both sides as a first phase treatment and the second phase consisted of Invisalign therapy. After 4 months, full class I relationship have been achieved .
Another study presented a reported case of a 23 years old male with a pronounced brachyfacial pattern and bimaxillary retrusive profile characteristic of class II, division 2 malocclusion. Carrière Distalizer appliance was used as a first phase treatment. Class I molar and canine relationships were achieved in 5 months .
A retrospective study was conducted to compare the patients' experience with the Carrière Distalizer appliance with that of the Forsus Fatigue Resistance Device. The results showed that the overall experience with the Carrière Distalizer appliance group was much better than that with the Forsus Fatigue Resistance Device group .
Another retrospective study, to compare the treatment effects of the Carrière Distalizer appliance with two different types of mandibular anchorage, was conducted. Full fixed orthodontic appliance was compared versus lingual arch. The results showed that successful correction of class II malocclusion was achieved with the Carrière Distalizer appliance in both groups, with minimal molar tipping. However, adverse effects common with class II elastics accompanied the correction at variable rates in the groups .
Electromyographic (EMG) activity of the masseter and temporalis muscles, before and after functional orthopedics was studied. The study showed increased EMG activity of the masseter and temporalis muscles in postural conditions of mandible and molar bite force after 12 months of treatment. After 12 months of treatment, the patient had lack of pain symptoms as well as an improvement in the balance of the mastication muscles, as demonstrated by EMG activity and maximum molar bite force .
The aim of this study was to assess the EMG activity of oral muscles concomitant to class II malocclusion correction using Carrière Distalizer appliance.
| Patients and Methods|| |
The present study was conducted on 10 female patients' ages 18–21 years old. These patients selected from those attending the outpatient clinic, Department of Orthodontics, Faculty of Oral and Dental Medicine for Girls, Al-Azhar University (Girls Branch). All procedures were explained for all patients, informed consent was assigned and Research Ethical Committee approval of Al-Azhar University was obtained.
Criteria of selection of the participants was fulfilled
All patients included in this study were subjected to the following records:
Extraoral photograph, intraoral photographs [Figure 1], impression of upper and lower arches to prepare orthodontic study, panoramic radiograph before and after, lateral cephalometric radiograph (Planmeca Company, Helsinki, Finland) before and after treatment. EMG records for masseter and temporalis muscles before and after treatment.
Inclusion criteria for this study were age range was 18–21 years old, females, had angle class II malocclusion, over jet was more than 5 mm, the posterior maxillary segment from the canine to maxillary second molar should be well aligned or at least on the same plane, and the patient must have good oral hygiene and should comply with instructional motivation to provide a reasonable prognosis. Patients with a history of orthodontic treatment or any systemic diseases that affect craniofacial growth were excluded.
Maxillary arch preparation
Extractions of maxillary wisdom teeth to facilitate distalization of teeth, the patients were referred to the Department of Surgery, Faculty of Dental Medicine for Girls, Al-Azhar University, for extraction of maxillary wisdom teeth. Carrière Distalizer appliance (Henry Schein Company, New York, USA) placement: for selecting the correct length, the supplied ruler was used. A measurement was taken from the midpoint of the buccal surface of the maxillary first molar to the midpoint of the labial surface of the maxillary canine. The labial surface of the maxillary canines and buccal surface of maxillary first molars were first polished using a low speed polishing brush. They were then deproteinized with 5.25% sodium hypochlorite (NaOCl) for 1 min followed by rinsing and then drying. This was done in order to increasing the bond strength . The enamel surfaces were subsequently etched by using 37% phosphoric acid (Meta Etchant; Meta Biomed Co. Ltd, Korea) for 30 s, rinsed and dried. The bonding agent was then applied (Trans bond TM XT Light Cure Adhesive; 3 M Unitek, New York, USA). The Carrière Distalizer appliance was first adjusted and seated on the buccal surface of maxillary first molars followed by adjustment and seating on the labial surface of the maxillary canine. It was then bonded using light cure composite (Trans bond TM Plus Color Change Adhesive; 3 M Unitek) [Figure 2].
Mandibular arch preparation
During the first visit after bonding of the Carrière Distalizer appliance, elastic separators were placed between the mandibular first and second molars bilaterally as a preparation before selection of suitable bands (Unitek TM Metal bands; 3 M Unitek) for fabrication of passive lingual arch.
Passive lingual arch
Separators were removed a week later, to place the lower second molar bands. The size of the bands was carefully chosen. An alginate impression (Tropicalgin; Zhermack, Hamburg, Germany) was then taken for the lower arch with the bands in place. Bands were removed from the teeth and placed in their imprint in the impression and secured in their place by sticky wax. Passive lingual arch was fabricated on the poured model using 1 mm round stainless-steel wire and soldered on the lingual surface of the two bands. After complete isolation and dryness, passive lingual arch was cemented on mandibular second permanent molars using glass ionomer cement (Medifill Silver Reinforced Glass Ionomer Cement; Promedica, Berlin, Germany) to avoid labial flaring lower incisors. A cast was then poured into hard stone (Modeltypo Extra-hard Stone; Ainworth Dental Company, Perth, Australia). The base was trimmed in order to have a very thin model and any anomalies were removed. The appliance was then checked for retention inside the patient's mouth.
Class II elastics (Oramco Company, New York, USA) were attached from the maxillary canine to the mandibular second molar bilaterally. During the first month 1/4 heavy elastics were used. The following months 3/16 heavy elastics were used. This was done according to the recommendation of Luis Carriere . The patients were instructed to wear the elastics 24 h daily except during mealtime and to change them daily.
Follow up period
The patients were asked to attend a follow up session every 4 weeks in order to check for the following: compliance of the patient, integrity of the Carrière Distalizer appliance and the passive lingual arch and amount of correction achieved. If failure of bonding to either Carrière Distalizer appliance or passive lingual arch took place, they were bonded immediately. The number of failure was noted down. In order to ensure patients' compliance, a similar technique to that of Veeroo et al.  was used to encourage their compliance, the participants were instructed to wear the intermaxillary class II elastics, and warned that otherwise extraction of the first premolars would take place. In order to assess the degree of compliance, each participant was given an empty plastic bag and instructed to insert all used elastics in the bag. Each participant was instructed to bring bag with her to the recall visit and the number of the used elastics was counted and compared with the number of days between the appointments. Deboning of Carrière Distalizer appliance occurred in one (10%) out of 10 bonded Carrière Distalizer appliances. The enamel surface of the maxillary canine and maxillary first molar was refreshed and the appliance was bonded again. And there is no deboning of passive lingual arch occurred.
The appliance was removed after either reaching a class I or a super class I molar relationship [Figure 3] and [Figure 4).
| Results|| |
The results indicated that error of method varied between 0.12 and 0.39 for the angular measurements and between 0.16 and 0.57 for the linear measurements . With the use of the Carrière Distalizer, class I molar and canine relationships were achieved in all of the patients in a mean of 6 months. [Table 1] presents the treatment changes skeletally as a result of distalization therapy. That show no significant change occur except for increase in angle of convexity. And [Table 2] showed dentoalveolar changes including slight maxillary molar distalization, in addition to mesialization of the lower molars and proclination of the lower incisors which results in correction of class II malocclusion.
|Table 1: Skeletal measurements prevalue and postvalue, mean, and SD of difference and significance of paired t test|
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|Table 2 Dental measurements prevalue and postvalue, mean, and SD of difference and significance of paired t test|
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| Discussion|| |
In the current study, masseter muscle showed an increased activity from postural rest position and maximum clenching after Carrière Distalizer appliance therapy, but it was statistically significant.
These observations corroborate the previous findings of other studies ,, but against findings of other study  which reported decreased masseter activity during maximal voluntary clenching after 3 months of treatment and attributed it to occlusal instability and/or lack of occlusal contacts of teeth in the posterior segments, occurring during bite jumping with Herbst appliance and activator, respectively.
The occlusal instability caused by changed tooth position and intermaxillary relations brought about by treatment reflected in a reduced EMG activity of masseter muscle during maximal clenching .
A stable occlusion has been shown to be a prerequisite for maximal muscle activity during biting. Muscle activity, during clenching, decreases with lessening numbers of posterior teeth in contact and drops dramatically when only the incisors are in contact.
When clenching in the intercuspal position is directed anteriorly (as with clenching with the twin-block), the superficial masseter muscles attain maximal activity . It has been found that during biting in the maximal occlusion a vast number of mechanoreceptors located in the periodontal ligaments of the posterior teeth are activated. This number is probably decreased in the incisor edge-to-edge position, whereby antagonistic tooth contacts are restricted to a few anteriorly located teeth with twin-block treatment.
Regarding EMG records of temporalis muscle [Figure 5], in the present study, the anterior temporalis showed an increased activity during postural rest position and maximum clenching after Carrière Distalizer appliance therapy but statistically not significant. A mild increase that was not significant can be attributed to the slowly adapting receptors in the tendon organs that are not stimulated enough to cause inhibition to the generation of further tension during maximal clenching. These findings were similar to the results of another study .
|Figure 5: Bar chart showing mean values of electromyographic records of temporalis muscle.|
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The results were not affected by the absence of patients' blinding who in the first place would not favor one intervention over the other. On the other hand, usually the absence of the operator's blinding could lead to performance bias by favoring intervention over the other. In addition, an external assessor blindly assessed the outcomes to avoid any detection bias . Another limitation of the study is that included females only and was restricted to one sex group and also restricted to age between 18 and 21 postpubertal group only for accuracy of evaluation of muscle activity as it affected by sex and age.
| Conclusion|| |
- Carrière Distalizer appliance was able to correct class II molar relation into class I relation in adult patients.
- No skeletal changes occurred, except for an increase in the lower facial height, anterior facial height, and angle of convexity.
- Carrière Distalizer appliance caused dentoalveolar changes including slight maxillary molar distalization, in addition to mesialization of the lower molars and proclination of the lower incisors which results in correction of class II malocclusion.
- Carrière Distalizer appliance caused EMG records changes including:
- For masseter muscle; at rest and at occlusion, a higher mean value was recorded posttreatment in comparison to pretreatment.
- For temporalis muscle; at rest, a higher mean value was recorded posttreatment in comparison to pretreatment, but this difference was not statistically significant (P = 0.87)
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]