Can we increase patient's compliance by improving quality and efficiency of functional appliances?


Dental News Volume XXII, Number II, June, 2015


By Dr. Elie CALLABE



The PUL Concept 
4D Harmonizer: functional, sagittal, transversal and vertical. 

The PUL characteristics: “Propulseur Universel Light”.

The PUL is a new-generation multi-tasking removable appliance : 
- Better compliance: it has been lightened, thanks to its laser welded frame, its miniaturized mandibular advancing system and using TMA wire.
- Comfortable, light, aesthetic: It allows a good diction, can be worn at school.
- Physiological: gentle propulsion thanks to inserted coil springs (TMJ shocks absorbers).
- Universal: it is indicated to all Classes II, all facial typologies.
- Multi actions:  thanks to its Laser welded frame, it allows several simultaneous actions, saving treatment time. 
(Fig 1, 2, 3, 4, 5, 6)

Fig 1: PUL multi-tasks with TMA loop



Fig 2: PUL multi-tasks with anterior elastic and expansion screws


Fig 3

Fig 4

Fig 5

Fig 6



Clinical Effects

4D harmonization of malocclusions : sagittal, transversal, vertical and functional.
1- In young patients with hyperdivergent (dolychofacial) growth and multiple dysfunctions: oral breathing, deglutition and mastication (hypotonia).
The mandibular propulsion helps bi-labial contact and increases the pharyngeal space, improving nasal breathing.
The posterior occlusal contact induces a proprioceptive stimulation and contraction of the masseter temporal fibers, improving mastication.
 Improvement of the lingual function (position and deglutition) and natural correction of open-bites.
This leads to a change in growth direction, from dolycho to mesofacial.
(Fig 7, 8)

Fig 7: Before PUL

Fig 8: After PUL


2- In patients with hypodivergent (brachyfacial) growth: the mandibular propulsion and posterior nonocclusion lead to a change in the direction and neutralization of the temporo-masseter muscles and a suppression of the occlusal forces.
This induces rapid Class II correction by distalizing upper lateral teeth (mandibular anchorage) and overbite correction by natural extrusion of the posterior teeth.
(Fig 9)

Fig 9: Correction of Class II by mandibular anchorage


Protocol of treatment 

Three phases:
PUL multi-tasking 4D harmonization of the malocclusion: sagittal (Class II), transversal (expansion), vertical (deepbite or openbite), and functional (nasal breathing, swallowing and chewing muscles). Duration : from 6 to 12 months.
Fixed appliance low friction without or with few elastics. Duration: 12 months.
4D stabilization by PUL retainer. Night wearing.
(Fig 10, 11)

Fig 10: Early treatment: Hyperdivergent growth: before PUL, after PUL, and after braces

Fig 11: Teenager’s treatment: before PUL, after PUL, and after braces

Clinical cases

Class II malocclusions

Class II represent more than 75% of all malocclusions that orthodontist have to treat, about 30% of these patients have hyperdivergent facial growth.
Like every medical treatment, orthodontist began with a diagnosis. The aim is to treat the causes of malocclusion before or simultaneously treating symptoms.
In almost all malocclusions, the cause of the malocclusion are the functional dysfunctions like oral breathing, thumb sucking, hypotonic muscle or atypical deglutition. 

Case 1:  Syndrom of Class II division 1

Amandine , a young girl of 12 years old who complains from ectopic maxillary canines and lower crowding.
Functional diagnosis: Oral breathing, snoring (sleep apnea), past thumb sucking, labial inocclusion, gummy smile and short upper lip. 
(Fig 1, 2)

Fig 1

Fig 2

Dento-maxillary diagnosis: Full Class II, crowding, mandibular retrognathic, hyperdivergent facial growth. (Fig 3, 4)


Fig 3 


Fig 4

Treatment objectives are to stop the hyperdivergent growth by improving the functions and mandibular growth, and avoid extractions. 
Treatment plan:
PUL 4D harmonization: functional, sagittal, tranversal and vertical. PUL multi-tasks with expansion screws, wearing 22 hours a day . Duration 9 months. (Fig 5, 6, 7)


Fig 5



Fig 6



Fig 7

Alignment and finition by multibraces self ligating low friction. Duration 13 months.
(Fig 8, 9, 10)



Fig 8




Fig 9



Fig 10

4D stabilization by PUL retainer anti-relapse night wearing. Duration 12 months and decreasing. (Fig 11, 12, 13)



Fig 11



Fig 12

Fig 13


Discussion 

“Changing the functions for changing the shape” Linder-Arronson
The advantage of combination of these three phases is to reduce time of treatment and improve patient’s comfort and compliance thanks to the lightness of the PUL appliance. The benefit for the patient is obvious: facial aesthetics and non-extraction short treatment.


Fig 14




Fig 15


Fig 16


Case 2: Syndrom of Class II subdivision

Louis, teen-ager male of 14 years old who complains from upper incisors crowding. 
Diagnosis :
Class II subdivision, hypodivergent growth, deepbite. Full Class II on right side due to disto-position of the mandible. (Fig 1, 2)


Fig 1

Fig 2

Treatment plan
After explaining to the patient and his relatives, the different options, we decided to treat in three phases :
PUL 4D harmonization with a TMA maxillary loop to lighten it. Thanks to patient’s complaince the duration was only 9 months. (Fig 3, 4, 5, 6, 7)



Fig 3

Fig 4



Fig 5


Fig 6

Fig 7

Alignment and finition with multibraces selfligating low friction. Duration 12 months.
(Fig 8, 9)



Fig 8


Fig 9

4D Stabilization with PUL W retainer anti-relapse. (Fig 10, 11)





Fig 10



Fig 11

Discussion

Teen-ager Class II sudivision is classified between most difficult clinical cases because the risk of non-compliance with classical functional appliances.
The advantage of the PUL appliance is its lightness and aesthetics which benefit for patient’s better compliance, reducing time of treatment.
The other problem of these malocclusions is the risk of relapse. This problem is prevented by giving the patient the PUL W retainer anti-relapse appliance which is easy and comfortable to wear.
The most important for long term stability is the patient’s awereness of his treatment’s difficulty and the risk of relapse.
(Fig 12, 13, 14, 15)



Fig 12

Fig 13


Fig 14

Fig 15


References

- Cambiano, A., Controllo della divergenza nel trattamento delle malocclusioni di II classe. Tesi di specializzazione in ortodonzia. Università di Palermo ; anno accademico 2006-2007.
- Patti A., Perrier d’Arc G. I trattamenti ortodontici precoci. OrthoPlanet ed. 2006.
- Patti A. et coll : Traitement de la Classe II, Ed Quintescence, 2010
- Callabe E. Traitement de la Classe II hyperdivergente. Congres JO 2010-11-26 
- Eschard-Charbonnier C : Analyse des modifications dento-squelettiques apportées par le P.U.L. d'Elie Callabe.Etude rétrospective d'un échantillon de 30 cas traités : Thèse Cecsmo Université de Reims 2009
- Geyselinck H :Le Propulseur Universel Light et le traitement des classes II : étude d’efficacité (étude sur 60 cas) :Thèse Cecsmo Faculté de Lille 2009
- Dumotier A :Le propulseur universel « light » (PUL) et les activateurs monobloc : descriptif et effets thérapeutiques : Thèse Cecsmo Faculté de Marseille 2009
- Melka V :Evaluation clinique de la correction du décalage de classe II par un appareil amovible : le Propulseur Universel Light : Thèse Cecsmo Faculté de Montpellier 2009
- Joulia C : Comparaison des effets morphologiques de thérapeutiques fonctionnelles de classe II par la méthode Procuste. Thèse Cecsmo Faculté de Reims 2009
- Popelut R : Le propulseur universel light (PUL) au travers de deux études
rétrospectives. Thèse Cecsmo Faculté Paris VII 2010
- Martin S : Variation de la position de l'incisive mandibulaire dans le
sens sagittal chez une population de patients traités par PUL®
(étude céphalométrique de 20 cas). Thèse Cecsmo Faculté de Montpellier 2010
- Callabe E. Revue L’Orthodontiste N°157 : Novembre-Décembre 2010 : L’asymétrie chez l’Ado. 
- Callabe E, Morin JC : Bulletin PulConcept : Traitement de la récidive chez l’adulte : intérêt du PUL. Janvier 2011
- Callabe E : La contention Classe II Classe III. Bulletin Innovortho-News : Juillet 2010
- Penin X. (1999) Analyse et prévision de croissance crânienne par superposition procuste. Revue d'Orthopédie Dento-Faciale 33(2) pp275-286
- Patti A. : Traitement des Classes II, de la prévention à la chirurgie. Edition Quintessence International. Octobre 2010
- Callabe E: La Classe II division 1 brachyfaciale avec biproalvéolie. Revue L’Orthodontiste N°158. Février-Mars 2011 
- Callabe E : ORL et Syndrôme médical de l'hyperdivergence maxillo-faciale de l'enfant:HYPERLINK "http://www.pul-ortho.com/conf/03%20bis%20ORL%20et%20hyperdivergence%20maxillo%20faciale%20%5BMode%20de%20compatibilit%E9%5D.pdf" Importance de la collaboration Ortho // ORL. Conference Paris “Les journées de l’orthodontie”  www.pul-ortho.com Mars 2011
- Castelain C : Effets du Propulseur Universel Light selon la divergence faciale (étude statistique sur 56 cas) . Thèse de diplôme d’état de Doctorat en Chirurgie Dentaire. Faculté dentaire de Lille 2. Avril 2011
- Callabe E : Le syndrome médical de l’hyperdivergence. Revue L’Orthodontiste N°162 . Février-Mars 2012
- Brame JC : Le SAHOS et les ronchopathies : effets attendus et indésirables de l’orthèse d’avancée mandibulaire. Exemple du Snorlight. Thèse de diplôme d’état de Docteur en Chirurgie Dentaire. Faculté de Lille 2. Janvier 2012.
- Migliorati M : PUL: A New Functional Appliance for Class II Growing Patients. A Prospective Controlled Study." University of Genova Italy.


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