Parpeon Journal of Orthodontic 13 (1991) 43-86 1 1991 European Orthodontic Society Molar distalization by intra-oral force application Norbert Jeckel and Thomas Rakosi Department of Orthodontics, University of Freiburg, West Germany SUMMARY The molar distal ing bow (MDB) guarantees controlled distal movement of the molars. It is easy to handle, can be removed at any time and can be worn almost full time. Since there is no extra-oral force, there are no unphysiological effects on the cervical spine and neck muscles or on the molars to be moved. Furthermore, there is no risk of injury by wearing the appliance. Modifications of the basic appliance broaden the range of applications. Introduction Norman William Kingsley in 1892 described for the first time a headgear apparatus with which a Class I relationship of the molars could be achieved through anchorage in the maxilla (Weinberger, 1926). Subsequently, extra-oral anchorage was rarely discussed until-Kloehn (1953) designed headgear as we know it today with extra-oral traction by a cervical elastic strap. Headgear offers the possibility of ortho- paedic changes, but there is the risk of injury for the patient (Postlethwaite, 1989); the elastic cervical strap puts an unphysiological strain on the cervical spine and on the neck muscles; and in some patients it causes irritation of the skin (Berg, 1974; Rebholz and Rakosi, 1977). Each of these shortcomings can be responsible for the patients reducing wear of the appliance. Gianelly e7 al. (1988) used the force of two magnets that repel each other for his exclusively intra-oral ‘Molar Distalizing System’ (MDS). The two premolars on both sides must be banded and connected with a palatal plate adjacent to the anterior part of the maxilla. Consequently, the appliance cannot be removed. Treatment with the Molar Bimetric Distaliz. ing Arch System’ is limited to the distalization of premolars (Diedrich, 1986). The molar distalizing bow (MDB)* described in this paper is an intra-oral removable appliance which can readily be worn most of the time with the prospects of favourable treatment response. Shape and function of the MDB The appliance consists of an 0.8-1.5-mm thick thermoplastic splint extending into the buccal sulcus (Fig. 1). The distalizing bow fits into the anterior slot (Fig. 1). The ends of the bow fit to conventional headgear tubes on the molars to be distalized (Fig. 1). The force can be generated either by coil springs around the bow or by loops within the bow itself (Fig. 2a). The amount of distal movement can be regulated with adjust- able stops (Fig. 2a). In its inactive state the central section of the MDB lies approximately 2 mm in front of and 1.5 mm above the anterior slot (Fig. 2b) ‘To activate the appliance the central section of the bow must be fitted in the anterior slot by manual pressure against the elastic resistance of the springs or loops so that the force generated is transmitted to the molar tubes. The molar tubes must be in the same plane as the anterior slot or just above it Subjects and methods Ten patients aged between 8 and 14 years were treated with the MDB. Five had already under- gone at least 4 months of previous headgear treatment without success. The other five patients had no previous treatment. The daily appliance wearing time was recorded by the patients, Tooth mobility was tested before, during, and 2 weeks after the end of the treatment using an electronical percussion test method (Periotest) described by Schulte et al. (1983) and d’Hoedt et al. (1985). Results The average length of daily wear was 17-18 hours, in some cases up to 22 hours. The ational patents are pending: INNOTEC, Postfach $542, D-7800 Freiburg 1B, Germany44 N. JECKEL AND T. RAKOSI Figure 1 Plaster model with border between completely covers the hard palate. appliance could be worn in school, except during language classes and sports. At meals the appliance was to be removed and cleaned. The initial distalizing forces were 2 N and after that, 5-6 N and higher. Two weeks after treatment had begun, the amount of distal movement was greater in the Patients who had undergone unsuccessful head- gear treatment (an average of |.4 mm rather than 0.6 mm). After 4 and 6 weeks, the previously treated patients showed an increase in distal movement to 2.3 and 3.1 mm, respectively, and the others an increase to 2.2 and 2.8 mm. As a result of distalization the amount of tooth mobil- ity was higher in the maxillary incisors than in the molars: but this was slight and there was no discernible movement, Two weeks after the end of the treatment all of the teeth were just as stable as at the commencement of treatment The analysis of the lateral skull radiograph shows no measurable difference in the axis of the incisors or in the angle of the maxillary inelina- tion before and after treatment. The measure- ment of the sulcus depth before and after treat- ment showed no significant reduction of the height of the alveolar bone. As a result of the compression of the gingival border, a false pocket with an average depth of about 3 mm was formed distal to the molars. A tomogram taken 9 days after completed distalization of a second molar shows an alveolar septum with a well- defined intact lamina dura at the mesial border In the backspace posterior to the distalized root tached and buccal mucosa drawn in to define the limb of the splint, The splint there is always sufficient bone regeneration to rebuild a lamina dura Modifications With certain modifications the MDB appliance can distalize the first molars following distal movement or extraction of the second molars, The appliance can also be used for unilateral first molar distalization, even after initial eruption of the second molar (Fig. 3a). Another modifica- tion makes it possible to distalize and align lower first molars (Fig, 3b) By applying an occlusal acrylic relief it is possible to achieve a simultaneous mandibular protraction in a construction bite. At the same lime the extrusion of the molars can be con- trolled (Fig, 3c) Discussion The molar distalizing bow (MDB) is primarily used after attempts at distalizing with conver tional means have failed, Due to its design and function, the appliance cannot intrude molars. With the MDB only orthodontic forces can develop. There is no orthopaedic effect on the maxilla in terms of inhibiting growth or changing inclination, The longer daily wearing time is responsible for the favourable results obtained with the MDB. Because patients accept the appliance well, they are willing to wear it for as long as 17 18 hours a day. Further advantages are that itMOLAR DISTALIZATION Figure 2 (a) Spring elastic dist ements: pressure spring around the bow (top): and double-looped bow (bottom) with adjustable stops. (b) The narrow middle of the passive bow isapproximately 2.0mm in front of and 1.5 mm above the anterior-vestibular groove anchorags section does not inter e with sleep, it can be removed at any time, and there is virtually no risk of injury Sufficient oral hygiene can be realized by cleaning the removed thermoplastic splint and the bow with a soft toothbrush, toothpaste, and with cold water. If necessary, applied fluoride liquid can be kept on the surface of the teeth by the covering splint for hours. Loosening of the teeth during treatment is evidence of the therapeutic effect on the molars, as well as a side effect on the incisors, The fact 45 i 7 Figure3 (a) P selective first molar distalization on the left with sin neous eruption of the second molar after 6 weeks of tr. with the MDB. (b) Lateral view of simultaneous molar distalization with the MDB in maxilla and mandible. (c) Lateral view splint ofan MDB with occlusal acrylic coverage for simultaneous protraction of the mandible in a construe- tion bite and additional control of the vertical development of the tooth to be distalized latal view of a plaster model of a patient with i that the incisors were loosened more than the molars to be distalized is due to the smaller root area of the anterior teeth. The degree of loosen- ing during treatment in each case was lower than46 is usual during the levelling phase of multi- banded treatment for example. Within the first 2 weeks after completion of treatment, a new lamina dura has almost formed and the inter- radicular bone septum restructured (Massler, 1954). The complete coverage of the vestibular and palatal surfaces, with the acrylic passing over the occlusal surfaces, create a static form of anchorage, preventing forward movement of the anterior part of the dentition. There are no transverse forces such as occur with headgear therapy. Thus, the inner bow does not have to be pre-bent to prevent cross-bite. Modifications to the basic appliance have broadened the range of applications. The narrow middle piece of the bow which prevents trans- verse force, allows selective unilateral molar distalization in the case of the unilateral loss of the Class I relationship of the first molars. By extending the palatal portion of the splint dis- tally and applying wire stops, the distalized second molars can be kept in place. In the same way premature mesial movement of the wisdom teeth can be prevented after the second molars have been extracted. In both cases distalization of the first molars takes place at the same time. The use of MDB in the mandible is not restricted to mokar distalization to correct crowding. The appliance has also been success- fully applied to preprosthetically uprighting tipped second molars after extraction of the first molars or as preparatory treatment prior to multibanded therapy. A prerequisite for success with minimal side effects is that the narrow middle section of the bow be positioned above the anterior slot before the bow is activated. This prevents the plate from becoming displaced when the bow is activated. The loop-shaped bow is particularly advantageous in young children during the mixed dentition when retention capa- city is limited. There is no vertical force during distalization with springs around the bow. Therefore, care must be taken that the molar tubes are posi- tioned in such a way that the distalizing bow is in the same plane as the anterior groove anchorage or just above it. N. JECKEL AND T. RAKOSI If these clinical and technical conditions are observed, the use of the MDB promises very satisfactory clinical results and can be a valuable alternative to conventional molar distalizing systems, Address for correspondence Dr Dr Norbert Jeckeland Prof. DrThomas Rakosi Universitatsklinik fiir Zahn-, Mund-, und Kie- ferheilkunde Abteilung Poliklinik fiir Kieferorthopidie Hugstetter StraBe 55 D-7800 Freiburg/Brsg. West Germany References Berg R 1974 Komplikationen bei Anwendung von Zervika: Jem Nackenzug. Informationen aus Orthodontie und Kieferorthopidie 1: 39-44 d'Hoedt B, Lukas D, Mithibradt L, Scholz W, Quante F, Topkaya A 1985 Das Periotestverfaren—Entwicklung und Klinische Prifung. Deutsche Zahndrztliche Zeitung 40: 113-125 Diedrich P 1986 Die Distalisierung endstindiger Primo- laren—eine Alternative in der prothetischen Versorgung der verkiirzten Zahnreihe. ‘Die Quintessenz’'—Kieferorth- opiidie 3: 505-516 Gianelly A A, Vaitis A S, Thomas W M, Berger D G 1988 Case report: Distalizing of molars with repelling magnets, Journal of Orthodontics 22: 40-43 Klochn $ J 1953 Orthodontics—force or persuasion. Angle Orthodontist 23: 56-66 Massler M_ 1954 Changes in lamina dura during tooth ‘movement. 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