CASE REPORT

M Sakata Orthodontic appliances made

B Sa’do
S Nakata of organic polymer used in the
T Morishita metal allergic patient can
A Nakasima
withstand orthognathic
surgery

Authors’ affiliations: Abstract: We developed an orthodontic appliance completely

M. Sakata, B. Sa’do, S. Nakata, T. Morishita, made of organic polymer. The appliance was used for many
A. Nakasima, Department of Orthodontics,
years and proved very effective. It was used for the treatment of
Faculty of Dentistry, Kyushu University,
Fukuoka, Japan patients with metal allergy, and as a result, it is believed to be
the best choice for treating metal allergics. In this report, we are
Correspondence to:
presenting a surgical case with Class III malocclusion for a
Shunsuke Nakata
Department of Orthodontics patient with metal allergy, and the concept of the appliance is
Faculty of Dentistry briefly discussed.
Kyushu University
Maidashi 3-1-1, Higashi-ku
Key words: metal allergy; organic polymer; orthodontic
Fukuoka 812-8582,
appliances; orthodontic treatment
Japan
Tel.: +81 92 642 6462
Fax: +81 92 642 6398
E-mail: shun@dent.kyushu-u.ac.jp

Introduction

It is not uncommon for an orthodontist to come across

Dates:
Accepted 23 September 2001
To cite this article:
Orthod. Craniofacial Res. 5, 2002; 179–184
M Sakata, B Sa’do, S Nakata, T Morishita,
A Nakasima:
Orthodontic appliances made of organic polymer
used in the metal allergic patient can withstand
orthognathic surgery
Copyright Ó Blackwell Munksgaard 2002
ISSN 1397–5927
a patient who suffers from metal allergies. As most
orthodontic appliances are made of metal or they
include metals, delivery of orthodontic treatment
becomes rather cumbersome in such occasions. In our
clinic, we have encountered several cases of metal
allergic patients, but were able to treat them success-
fully with non-metallic appliances. We are reporting
here a surgical case with skeletal Class III malocclusion
that was treated using the appliances developed in our
department. They are made of organic polymer
(Q.C.M., Chikami Miltec Inc., Otesuji, Kochi, Japan) (1).
Sakata et al. Organic polymer appliances

Fig. 1. Facial photographs of the patient on admission.

The entire armamentarium is a non-metallic ortho- Case report

dontic appliance system; from brackets to wire, and
auxiliaries. This particular case worked out perfectly, This 16 years and 4-month-old female with the chief
and we are encouraged to use it more routinely espe- complaint of mandibular protrusion and facial asym-
cially in the allergic patient. metry was admitted to our department (Fig. 1). Her

Fig. 2. Intraoral appearance of the patient on admission.

180 Orthod Craniofacial Res 5, 2002/179–184

 Sakata et al. Organic polymer appliances

Table 1. Cephalometric values of the patient before, during and after treatment

On admittance Before surgery After surgery Fixed appliances removed

FH to SN 9.3 9.8 9.4 9.6

SNA 77.5 78.3 80.2 80.1
SNB 80.9 77.4 78.3 76.9
Facial plane 89.3 86.4 87.1 86.1
A–B plane 6.1 0.6 2.2 3.9
Angle of convexity 185.2 176.7 175.0 172.9
Y-axis 59.6 62.5 61.3 62.5
Ramus inclination 84.8 91.5 85.0 90.9
Mandibular plane 25.8 26.8 22.3 27.1
Gonial angle 121.0 115.3 117.3 116.1
U1 to SN 103.7 108.9 109.9 103.6
U1 to FH 112.9 118.7 119.2 113.2
Interincisal angle 129.0 115.1 116.9 118.5
L1 to mandibular plane 92.2 99.4 101.7 101.2

clinical history revealed that she had an edge-to-edge
malocclusion at 8 years of age. Subsequently, it devel-
oped into a skeletal Class III malocclusion at age 13.
Clinical examination revealed rashes on the face, ears,
neck, and elbows. She was subjected to a patch test,
and was found to be allergic to nickel (Ni3+), cobalt
(Co3+), cobalt-chrome (Co-Cr3+), mercury (Hg3+), gold
(Au3+), and platinum (Pt2+). Based on these laboratory
results the patient was advised to have all her metallic
fillings replaced with composite ones. Shortly after the
removal of metal from her mouth, rashes disappeared
gradually.
Intraoral examination showed a crossbite from first
right molar to left lateral incisor. The lower dental midline
had deviated 3 mm to the right. The upper arch was
slightly narrow with minimal crowding. Overbite was
+1.0 mm and the overjet –2.0 mm (Fig. 2). She had
clicking in her left temporomandibular joint, but without
pain. On the lateral cephalometric film the A–B angle was
measured as –3.4° (Table 1). Based on these and other
routine diagnostic data, skeletal Class III malocclusion
with mandibular deviation to the right was diagnosed.
Following orthodontic treatment, orthognathic surgery
with bilateral sagittal split ramus osteotomy was planned.
As the patient was allergic to metals, an appliance
made of organic polymer (Q.C.M. appliance, Chikami
Miltec Inc., Kochi, Japan) was employed for pre- and
post-surgical orthodontic treatment. The appliance

Fig. 3. Intraoral views of the levelling phase.

Orthod Craniofacial Res 5, 2002/179–184 181

Sakata et al. Organic polymer appliances
Fig. 4. Intraoral photographs of the patient: (left) before axillary
expansion; (right) after expansion.
was placed on both arches, and the initial levelling
took about 4 months (Fig. 3). Because the upper jaw
was narrow, not enough room was available to bring
the lateral incisors into alignment within the arch.
Consequently, lateral expansion (about 2 mm) was
carried out by incorporating an overlay plastic wire
made of polyethene terephtalate of 1.2 mm diameter
(Fig. 4). The necessary expansion was achieved in
6 months.
Fig. 6. Posttreatment facial photographs.
182 Orthod Craniofacial Res 5, 2002/179–184
Fig. 5. Intermaxillary fixation with elastics.
At the setback surgery the left and right sides were
moved back 8 and 5 mm, respectively. Hooks were
bonded directly onto the plastic brackets, and surgical
threads were used instead of surgical wire for inter-
maxillary fixation (Fig. 5). Rigid fixation was employed
to stabilize the distal and proximal segments. The fix-
ation screws were fabricated from 99.7% titanium.
The surgery improved the facial symmetry (Fig. 6)
and the dental midlines were coincident. The overbite

Fig. 7. Occlusion after treatment.
was established at +2.0 mm and the overjet at +3.0 mm
(Fig. 7). Short Class III elastics and chin cap lined with
sponge and gauze padding were used for night time
wear for a month following surgery. Final detailing and
intercuspation was achieved by up and down, and
short Class III elastics.
For retention a Q.C.M. retainer (Chikami Miltec Inc.,
Kochi, Japan) (1, 2) was employed for the upper jaw,
and Fiber-Splint Multi-Layer (Morimura Co., Tokyo,
Japan) was bonded on the lingual side of the anteriors
of the lower jaw (Fig. 8).
Discussion
Treatment of the metal-allergic patient can be quite
challenging, and it is not uncommon for an ortho-
dontic practitioner to encounter patients with varying
degrees of metal allergy. To overcome the problems
associated with metal allergies and to minimize
patients’ suffering, materials that are presumably non-
allergic are commonly substituted. Typically, these
Fig. 8. The Q.C.M. retainer.
Sakata et al. Organic polymer appliances
intraoral substitutions would be ceramic brackets,
coated wires and similar materials. Because there are
still limits to the effectiveness of such precautionary
measures, we had chosen to treat our patients with a
totally non-metallic appliance made of organic poly-
mer (3). The one concern we had was that because the
appliance was made of plastic we thought it might not
withstand some of the rigours of treatment such as
maxillary expansion, or intermaxillary fixation. Much to
our delight, however, this case proved that the appli-
ance can work well. We were encouraged to carry out
more treatments on similar cases with this appliance. It
is not only non-allergic, but also aesthetic.
This material and technique requires strategically
positioned alterations for ease of manipulation. As can
be seen in Fig. 9, the edges of the wire are rounded and
the bracket has a ‘C’ cross-section. The wire is engaged
by snapping into place within the bracket slot. For
removal it is usually best to peel away the wire from
Fig. 9. Cross-section of polymer appliance: (A) polymer wire; (B)
polymer bracket; (C) wire snapped in place. (Reprinted with per-
mission from J Clin Orthod October, 2001).
Orthod Craniofacial Res 5, 2002/179–184 183
Sakata et al. Organic polymer appliances
anterior brackets and slide it out from the posterior
brackets. These are preformed wires. It is possible to
change the shape of the wires under gentle heat. This is
similar to the way an optometrist adjusts the temples of
eyeglass frames. Unfortunately, such manipulation can
be problematic, and is not recommended as a routine
practice.
184 Orthod Craniofacial Res 5, 2002/179–184
References
1. Sa’do B, Nakata S, Morishita T, Nakasima A. The new esthetic
maxillary retainer wires made of organic polymer. J Clin Orthod
2001;35:322–4.
2. Watanabe M, Nakata S, Morishita T. Organic polymer wire for
esthetic maxillary retainers. J Clin Orthod 1996;30:266–71.
3. Morishita T, Sa’do B, Nakata S, Nakasima A. Orthodontic appliance
made of organic polymer. J Clin Orthod 2001;35:632–40.