CLINICIAN’S CORNER

Molar distalization with a partially integrated

mini-implant to correct unilateral Class II
malocclusion
Kyu-Rhim Chung,a Seong-Hun Kim,b Michael P. Chaffee,c and Gerald Nelsond
Seoul, Korea, Coeur d’Alene, Idaho, and San Francisco, Calif

This article illustrates a new treatment system combining segmented wire and osseointegrated mini-implants
for molar distalization without complex appliances. The procedures, advantages, efficacy, and indications for
this method are discussed. Two patients whose treatment plans included distal molar movement and
orthodontic mini-implant treatment were recruited. One patient required 1 molar to be uprighted, and the other
needed molar distalization to regain space lost for the missing maxillary right second premolar. C-implants
(diameter, 1.8 mm; length, 8.5 mm) were placed and, after 4 weeks of healing, were used as direct anchorage
and indirect anchorage simultaneously for correcting the asymmetric Class II molar relationship. Few ortho-
dontic attachments were necessary, and the teeth moved rapidly to the planned positions without detrimental
effects on the occlusion. The combination of segmented archwires, minimum bonded attachments, and a par-
tially osteointegrated mini-implant (C-implant) was a simple and effective treatment choice in distalization
treatment. (Am J Orthod Dentofacial Orthop 2010;138:810-9)

U
nilateral full-step Class II correction, with
asymmetry in the maxillary arch, can pose
a challenge for the orthodontist. Although vari-
ous treatment modalities have been developed and used
successfully over the years, many need intensive coop-
eration from the patient. Noncompliant mechanics can
be complicated and cumbersome. Unilateral premolar
extraction is usually an available treatment option
but can result in arch skewing or displacement of the
midline.
Headgears can be adjusted to provide a distalization
force on the Class II side.1-3 Removable appliances
designed to distalize molars have been advocated, but
both approaches require much patient cooperation.4,5
Fixed functional devices can provide a distalization
force to the maxillary posterior teeth but also influence
the mandibular dentition.6,7 Pendulum appliances and
a
b
President, Korean Society of Speedy Orthodontics, Seoul, Korea.
Assistant professor, Department of Orthodontics, School of Dentistry, Kyung
Hee University, Seoul, Korea.
c
Private practice, Coeur d’Alene, Idaho.
d
Clinical professor, Division of Orthodontics, University of California at San
Francisco.
The authors report no commercial, financial, or proprietary interest in the
products or companies described in this article.
Partly supported by the Korean Society of Speedy Orthodontics.
Reprint requests to: Seong-Hun Kim, Department of Orthodontics, School of
Dentistry, Kyung Hee University #1 Hoegi-dong, Dongdaemun-gu, Seoul 130-
701, South Korea; e-mail, bravortho@khu.ac.kr.
Submitted, February 2008; revised and accepted, July 2008.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.07.027
distal jets have been advocated and proven successful for
molar distalization. However, there are disadvantages,
including laboratory time and expense. Whereas these
appliances incorporate design components to attempt
to prevent anchorage loss, flaring of the anterior teeth
and increased overjet usually take place to a significant
extent. One negative sequela usually seen with these
appliances as posterior teeth distalize is increased
lower facial height because of clockwise mandibular
autorotation.8-11
In more recent years, treatment mechanics with skel-
etal anchorage combined with pendulum springs have
been devised primarily for molar distalization. However,
these biomechanical systems are somewhat complex
and require significant laboratory time and expense.
The distalization process is also delayed because of the
waiting period for these palatal implants to achieve
osseointegration.12-15 Sugawara et al16 demonstrated
the distalization capability of a skeletal anchorage
system involving titanium anchor plates. Although
effective, the surgical placement of a miniplate is more
difficult and invasive than that of a mini-implant.
Park17 showed the possibility of full-arch distalization
using mini-implants. However, these mini-implants
acted as auxiliaries for continuous archwire systems
during the whole orthodontic treatment.
We present 2 patients who had limited treatment in-
corporating unilateral molar distalization with skeletal
anchorage. The skeletal anchorage was provided by
a C-implant, introduced as a partially integrated mini-

810
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 6
Fig 1. C-implant dependent pushing mechanics: A, schematic illustration of C-implant; B and C,
0.017 3 0.025-in stainless steel archwire and open-coil spring.
implant system (Cimplant, Seoul, Korea). These rela-
tively simple treatment mechanics use direct or indirect
anchorage to achieve efficient, bodily molar distaliza-
tion, while minimizing undesirable vertical dimension
changes.
The biomechanics of molar distalization with push-
ing mechanics use partially osseointegrated C-implants.
A C-implant is composed of titanium grade V alloy; it is
self-tapping and threaded.18-25 Each C-implant has 2
components: the screw part has a diamter of 1.8 mm,
and the head part measures 2.5 mm in diameter. The
head is inserted into the screw and tapped into place.
Precise fit and friction retain the head during
treatment. The screw surface is sandblasted large grit
and acid-etched treated for optimal osseointegration ex-
cept for the upper 2 mm that is in contact with soft tis-
sues. Upper and lower structures are mechanically
interoriented; this means that they can have many vari-
ations. Especially, the head part can have different
lengths and different numbers of holes. According to
the treatment objectives, the head part can be changed
in midtreatment, without the need to remove the im-
planted screw. The 0.8-mm diameter hole of the head
part can receive archwires (Fig 1, A).
C-implants can provide absolute anchorage with the
advantage of resistance to rotation force and high stabil-
ity during force application.23-25 Direct anchorage can
be obtained by using a segmental archwire with an
open-coil spring to push the teeth independently
(Fig 1, B and C). Intrusive step bends are usually
made to the segmented archwire to minimize the extru-
sion tendency during distalization. Indirect anchorage
Chung et al 811
can also be established by attaching a wire ligature
wire from the C-implant to a bracket anterior to the
mini-implant. Mesial movement of anterior teeth can
thus be prevented.
CASE REPORTS
Patient 1
A man, aged 42 years 7 months, had a chief com-
plaint of loss of the maxillary right first molar and me-
sial inclination of the second molar. This condition
followed the extraction 2 years previously of the first
molar after a vertical fracture (Figs 2 and 3, A-C).
Pretreatment intraoral photographs showed bilateral
Class I canine relationships, and a Class I molar
relationship on the left side. There was a full-step Class
II second molar relationship on the right side because of
mesial drifting after the first molar extraction. There
was a slight anterior open-bite tendency. The maxillary
and mandibular midlines were coincident.
A panoramic radiograph at the initial examination
showed mesial drifting and tipping of the maxillary
right second molar (Fig 3, D). An implant fixture had
been placed into the missing molar position 2 months
previously. The implant was close to the second premo-
lar due to inadequate space for placement at the time of
surgery (Fig 3, D). The missing maxillary right first
molar allowed mesial inclination of the maxillary right
second molar into a full-step Class II second molar
relationship. The treatment plan was to place a partially
osseointegrated mini-implant that could endure
heavy and dynamic forces in the interradicular space
812 Chung et al
Fig 2. Pretreatment intraoral photographs of the first patient.
Fig 3. Pretreatment panoramic radiographs of the first
patient: A, vertical fracture was observed on the maxil-
lary right first molar; B, after extraction; C, 2 years after
extraction without space maintaining; D, dental fixture
was implanted in the extraction space.
between the maxillary right first and second premolars.
A segmental archwire with an open-coil spring was
planned to move the second molar distally into a Class
I second molar relationship.
A C-implant (diameter, 1.8 mm; length, 8.5 mm)
was implanted in the interradicular space between the
maxillary first and second premolars with a 45 apical
angulation to the long axis of the teeth (Fig 4). The an-
gular placement of the mini-implant allowed for less
American Journal of Orthodontics and Dentofacial Orthopedics
December 2010
chance of root contact because of greater interradicular
space in the apical areas of the roots26 (Fig 5).
The segmental stainless steel wire (0.017 3 0.025
in) was placed into the hole of the C-implant head to
the archwire slot of the second molar, and light ortho-
dontic force (50 g) was applied with an open-coil spring
immediately because that maxillary second molar
showed fast mesial tipping tendency in a short period
(Fig 6, A). One month later, a crimpable hook was
placed on the archwire to activate the open-coil spring,
and intrusive step bends were made to the segmental
archwire to prevent the extrusion tendency of the second
molar (Figs 6, B, and 7, A). The patient was examined
every 4 weeks to monitor progress (Figs 6, C and D,
and 7, B and C). Selective grinding was done on the
second molar to eliminate premature contacts as the
tooth distalized. Two months later, the second surgery
for the restorative implant was done. Four months
later, distal movement was stopped, and the prosthesis
was delivered.
The final photographs and the panoramic radiograph
show that adequate uprighting of the second molar
provided sufficient space for an implant crown with
normal dimensions (Figs 7, D, 8, and 9). The patient’s
preexisting occlusion was maintained. An anterior
open-bite tendency remained, but a minimal increase
in the anterior open bite was noted during treatment.
In this minor tooth-movement case, bracketing was
limited to the maxillary right first molar only (Fig 10).
The total treatment time was 3 months, after which
American Journal of Orthodontics and Dentofacial Orthopedics Chung et al 813
Volume 138, Number 6

Fig 4. Placement procedures of C-implant in the first patient: A-C, screw part placement after pilot
drilling; D-F, head part adaptation with head tapper.

the implant prosthesis was delivered in the regained

space (Fig 10). The C-implant was also stable during
the total treatment and successfully removed by using
topical anesthesia.

Patient 2
A woman, aged 22 years 7 months, visited for an or-
thodontic consultation. Her chief complaints were
crowding and jaw pain. She had a Class II Division 1
subdivision left malocclusion. A Class I molar and ca-
nine relationship was noted on the left side. On the right
side was a full-step Class II molar relationship. The
right canine was in Class III due to the maxillary mid-
line drift to the right. The maxillary right second premo-
lar was extracted because it was a blockout tooth,
allowing mesial drifting of the first and second molars
(Fig 11). The mandibular midline was coincident with
the facial midline. The maxillary midline was to the
right 2 mm, because of the previous second premolar
extraction. Mesial inclinations of the maxillary right
first, second, and third molars were noted in the pretreat-
ment panoramic radiograph. There were 2 treatment op-
tions: to maintain the asymmetric key relationship only
by conventional treatment mechanics, and to recapture
the premolar space to achieve a Class I symmetric key
relationship. The patient requested the space-regaining
treatment for the extracted premolars without changing
the midline condition.
Fig 5. Postplacement panoramic radiograph of the first
patient.
Therefore, the treatment goals involved recapturing
the space for the missing premolar and treating the patient
without extractions except the lower impacted third mo-
lars. Skeletal anchorage would allow distalization of the
maxillary right molars. After physical therapy and 2
months of stabilizing splint therapy, the temporomandib-
ular joint symptoms disappeared.
The mandibular third molars and the maxillary right
third molar were extracted. To improve the molar inter-
cuspation and reestablish a Class I occlusion on the right
side, a C-implant (diameter, 1.8 mm; length, 8.5 mm)
was placed in the interradicular space between the
maxillary right canine and the first premolar, with
a 75 apical angulation to the long tooth axis of the teeth
because of sufficient interradicular space. A 0.017 3
814 Chung et al American Journal of Orthodontics and Dentofacial Orthopedics
December 2010

Fig 6. Treatment progress intraoral photographs of the first patient: A, 1 week after immediate force
application; B, 1 month after force application; C, 2 months after force application, with the second
surgery performed for the dental implant; D, 3 months after force application, with sufficient upright-
ing and distalization without significant root resorption and vertical dimension change.

Fig 7. Treatment progress occlusal photographs of the first patient: A, 1 month after force applica-
tion; B, 2 months after force application, with the second surgery performed for the dental implant;
C, 3 months after force application; D, prosthesis was applied on the implant fixture.

0.025-in stainless steel segmented archwire was placed
that included the maxillary right canine to the right sec-
ond molar (Fig 12, A). Indirect anchorage was provided
by placing a ligature wire from the C-implant to the ca-
nine bracket, and the distalization process was begun
with an open-coil spring between the first and second
molars. At a subsequent appointment, direct anchorage
was added with a second segmental 0.016 3 0.022-in
stainless steel archwire from the C-implant to the first
molar utility arch slot, with the open-coil spring deliver-
ing the 100 g of distal force (Fig 12, B, C, and G). The
remaining full maxillary arch bonding was done after
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 6
Fig 8. Posttreatment intraoral photographs of the first patient.
Fig 9. Posttreatment panoramic radiograph of the first
patient.
a Class I molar relationship was established (Fig 12, D,
E, and H). Distal movement of the second molar was ob-
served, and excessive mesial movement of the canine
was prevented by the indirect anchorage from the liga-
ture wire. Distalization of the first and second molars
was accomplished by using full and segmental arch-
wires, along with the open-coil spring to provide a dis-
talizing force (Fig 12, E). To provide further anchorage,
a transpalatal stabilization wire was placed on the right
and left first premolars (Fig 13).
The final photographs and radiographs show ade-
quate molar distalization, with sufficient space for
implant placement and restoration of the second premo-
lar (Fig 14). Class I molar and canine relationships were
reestablished on the right side. The maxillary and man-
dibular midlines were coincident. Retention was
Chung et al 815
Fig 10. Periapical radiographs of the first patient: A, pre-
treatment; B, after molar distalization; C, after prosthesis
on the implant fixture; D, 1 year after treatment.
accomplished with maxillary and mandibular fixed
retainers. The final panoramic radiograph showed no
evidence of root resorption of the maxillary anterior
teeth. Although greater mesial root tipping of the
maxillary right first premolar would have been ideal,
sufficient mesiodistal space was recaptured to make
restoration of the second premolar possible (Fig 14).
The total treatment time was 12 months; then an implant
and a crown were placed. The C-implant was stable dur-
ing the total treatment period and successfully removed
with topical anesthesia.
816 Chung et al
Fig 11. Pretreatment intraoral photographs and panoramic radiograph of the second patient.
DISCUSSION
These 2 patients both had indirect and direct im-
plant anchorage to distalize and upright the molars.
Without implant anchorage, appliance complexity and
biomechanic demands would have been much greater.
Implant anchorage with a partially osseointegrated
mini-implant (C-implant) permited the use of few or-
thodontic attachments. Others have suggested similar
tactics.
Park et al27 showed a new molar uprighting method
with miniscrew anchorage in the retromolar area. Lee
et al28 suggested direct miniscrew anchorage without
the assistance of anchorage teeth for uprighting the
mandibular second molars. They mentioned that direct
application of force from the mini-impant to the target
tooth eliminates the possibility of unwanted movement
of the anchorage unit that can occur even with indirect
miniscrew anchorage as a result of technical errors in
passive bracket placement or a weak attachment be-
tween the miniscrew and the anchor tooth. Whereas
they advocated the principle of minimum usage of
a conventional mini-implant for the maximum upright-
ing effect, they also showed the application of multiple
mini-implants for uprighting 1 tooth.
In the clinical report of Derton et al,29 several
miniscrews were used for 3-dimensional movement of
tipped molars. Gracco et al30 also suggested the innova-
tive uprighter jet for preventing molar extrusion during
the uprighting procedure. But complex distalization ap-
pliances were needed, and the mini-implant was
positioned in an edentulous area.
American Journal of Orthodontics and Dentofacial Orthopedics
December 2010
We suggest using a partially osseointegrated mini-
implant because it allows easier and more accurate ap-
plication of force and vector, and even a rotational force
without dislodging the implant.31 A partially osseointe-
grated mini-implant can be placed toward the front of
the mouth with support lever arms that transfer force
and vector distally. Similar to a molar tube, the hole
of the C-implant head can support multiple forces or
moments that are sufficient to upright or distalize
a lingually tipped or rotated molar. This is a big advan-
tage in asymmetric movement of individual teeth, since
the force vector is better controlled. Removal of the
C-implant after active treatment is not difficult.
Even though a 4-week healing period is usually re-
quired for optimal osseointegration, a C-impant for
these mechanics was used immediately after placement.
The first patient had a rapid tipping tendency of the
target teeth (maxillary right second molar); therefore,
we decided to maintain the position of the second molar
using 0.017 3 0.025-in stainless steel wires and a slight
open-coil spring activation through the C-implant hole.
The segment wire was applied to the C-implant hole
passively, and the initial force was about 50 g. After 1
month of activation, the pushing force was increased
to 150 g, and intrusive bending was performed to the
segment archwire. Also, the C-implant in the second
patient needed to resist a light static load (Fig 12, A)
at an initial force after placement.
Also, this patient had a narrow interradicular space
between the maxillary right first and second premo-
lars. If a mini-implant with 6-mm bone contact is
American Journal of Orthodontics and Dentofacial Orthopedics Chung et al 817
Volume 138, Number 6

Fig 12. Treatment progress of the second patient: A, a 0.17 3 0.025-in stainless steel segmented
archwire was placed that included the maxillary right canine to the right second molar. A C-implant
(diameter, 1.8 mm; length, 8.5 mm) was placed between the maxillary right canine and first premolar
and used as indirect anchorage for molar distalization. B-D, At a subsequent appointment, direct an-
chorage was added with a second segmental .016 3 .022-in stainless steel archwire from the
C-implant to the first molar utility arch slot, with the open-coil spring delivering the distal force.
E, The remaining full maxillary arch bonding was done after a Class I molar relationship was established.
F, All the bonded appliances were removed after distalization. G, Panoramic radiograph 6 months after
immediate force application. H, Panoramic radiograph 11 months after force application.

placed at 45 to the dental axis, the distance can be
calculated as 6 mm of actual length of the screw
part multiplied by Cos 45 5 4.24 mm.26 A little
more angulation can be another choice if the mini-
implant will be placed in a narrow interradicular
space such as this patient had.
It is simple to activate the coil spring against the
target tooth by using a crimpable surgical hook. The
clinical tip to prevent the segmented wire from slipping
out of the C-implant during tooth distalization is to
squeeze the extended helix of the segmented archwire
in the front of the head part (Fig 12, B and D).
These 2 patients had a slight bite-opening tendency
during distalization, even though an intrusive force
was applied to the segmented archwire from the
C-implant, probably because of the slight extrusion
tendency of the distalized teeth. Intrusive step bends
were made to the segmented archwire during the
818 Chung et al American Journal of Orthodontics and Dentofacial Orthopedics
December 2010

Fig 13. Treatment progress occlusal photographs of the second patient: 0.9 mm diameter stainless
steel bonded transpalatal archwire was applied during asymmetric teeth distalization.

Fig 14. Posttreatment intraoral photographs and panoramic radiograph of the second patient.

finishing stage. We should have applied the intrusion
bends earlier in these patients. However, the healing
periods were insufficient for secondary stability of
the mini-implant in the first patient because of the
rapid tipping tendency of the maxillary second molar.
Also, a ligature wire to the mini-implant in the second
patient was insufficient for indirect anchorage
(Fig 12, B and C).
In patients who need torque control of the target
teeth, the clinician can fix a rectangular wire segment
into the hole in the implant head with composite resin.
The partially osseointegrated C-implant will support
this kind of force application.
These clinical reports illustrate the use of the C-
implant, with minimal orthodontic attachments and coil-
spring biomechanics to distalize tipped and rotated molars.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 6
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