Final Ld Copy Dr Shwetha

“MOLAR DISTALIZATION”
LIBRARY DISSERTATION
DR SHWETHA S PRASAD
BATCH: 2019 – 2022
DEPARTMENT OF ORTHODONTICS AND

DENTOFACIAL ORTHOPEDICS
DAYANANDA SAGAR COLLEGE OF DENTAL

SCIENCES
BANGALORE - 560078
CONTENTS
CONTENTS
1. Introduction
2. History of Distalization
3. Pioneering Researches
4. Indications of Molar Distalization
5. Favorable features for Molar Distalization
6. Contraindications of Molar Distalization
7. Unfavorable features for Molar Distalization
8. Considerations for Molar Distalization
9. Evaluation of Molar Distalization Feasibility
i) Upper molar position
ii) Role of second molar and third molar extraction
10. Advantages of Molar Distalization
11. Disadvantages of Molar Distalization
12. Classification of Molar Distalization
13. Appliances Used for Molar Distalization
14. Principals of Appliance Selection Criteria

CONTENTS
15. Treatment Planning and Sequence
16. Biomechanics
i) Basic Biomechanics
ii) Biomechanics considerations for molar distalization
17. Anchorage considerations in Molar distalization
i) Conventional anchorage designs
ii) Limits of conventional designs
iii) Alternate anchorage designs
18. Extraoral Molar distalization Appliances
19. Intraoral Molar Distalization Appliances
20. Retention after Molar Distalization
21. Assessment methods for Molar Distalization
22. Comparison of Various Appliances
23. Recent advancements
24. Conclusion
25. Bibliography
INTRODUCTION
INTRODUCTION
The omnipresent question faced practically every time orthodontists do a
treatment plan for the patient is “Do we need to extract teeth or can the necessary
space be created without extractions?” In the adult patients there is no clinically
significant growth in the bone structure; therefore, alternative solutions must be
found to obtain space in which the teeth can be moved to correct the malocclusion.[1]
Whenever there is a space deficiency, the methods of gaining space that strikes to
our mind first are - extraction, expansion and inter proximal stripping.
Extraction has been a controversial subject for as long as the specialty of
orthodontics has existed. Some authors believe that the extraction of premolars leads
to over retraction and retroclination of the incisors and cause the facial profile to
flatten, bring about premature anterior contacts and distally displace the mandible
and mandibular condyle.[2] Angle, proposed expansion of dental arches for nearly
every patient and extraction for orthodontic purpose was not necessary for stability
of results or for aesthetics. He believed that when teeth could be saved by dental
treatment, extraction of teeth for orthodontic purpose seemed particularly
inappropriate and unacceptable.[3] In recent years, the percentage of patients having
extraction as a part of orthodontic treatment has decreased considerably as
experiments has shown that premolar extraction does not necessarily guarantee
stability of teeth alignment.

INTRODUCTION
Current orthodontic philosophies have been oriented toward conservative
treatment modalities to avoid extractions and, at the same time, to try to eliminate
the need for patient cooperation. Consequently, developed was a popular method for
creating additional space within the arch by distalization of molars.[4]
Molar distalization is a technique which is used to move molar teeth,
especially permanent first molars, distally in an arch. Over the years, it has been
applied for various modalities of treatment planning in orthodontics for different
malocclusions. Molar distalization offers tantalizing possibilities for both attaining
Class I molar relationships and decrowding anterior teeth without removing
otherwise healthy teeth. Theoretically, if the patient’s molars are in a Class III
relationship, the situation can be addressed by distalizing the lower molars,
mesializing the upper molars, or combining both approaches.[5] It is also of significant
value for treatment of cases with minimal arch discrepancy and mild Class-II molar
relationship associated with normal mandible. Especially in cases wherein there is
premature exfoliation of deciduous molars or proximal caries which leads to arch
length discrepancy due to mesialisation of the permanent molar, distalizing the
molars treats its etiology by counteracting the mesial migration.
Several appliances have been advocated to distalize molars in the upper arch.
However, there are many challenges which tag along with it. Considering the surface
area of the multirooted tooth, it takes a considerable amount of time to distalize the
teeth. Another factor is the presence of second and third molars.

INTRODUCTION
Duration of therapeutic treatment has also been shown to increase if second
molars have erupted, and therefore distalization is often recommended prior to the
eruption of the full permanent dentition. A clinical study further argued that the
success of first molar distalization varies according to the stage of development of
the second and third molars. As a result, germectomy of wisdom teeth is
recommended before molar distalization.[6] Also, other areas of particular concern
during molar distalization are molar tipping and anterior movement of anchorage
teeth. If the first molar is tipped back rather than moved bodily, it will not only pose
occlusal problems but may not provide sufficient anchorage for distalizing the teeth
anterior to it. The occlusal problems would be mild extrusions as an effect of distal
tipping leading to backward rotation of the mandible because when maxillary molars
are distalize into the wedge of occlusion, they will prop open the bite.[7]
Recent advances in molar distalization has attempted to tackle the challenges
faced during the treatment modality. And the evolution in the appliance design also
provide more precise control in bodily movement of teeth enabling better treatment
options in orthodontics. The library dissertation is a compilation of the case selection
criteria for molar distalization, citing the molar distalizing appliances, both intra oral
and extra oral, and their advantages and disadvantages.

HISTORY OF DISTALIZATION
The concept of ‘distal driving’ of the maxillary posterior teeth has a long
orthodontic history. Since the early 1800, the headgear has been an integral part
of orthopaedic treatment. Since then, many authors have reported its use and
effects in the treatment of Class II Division 1 malocclusions. [8] Earlier, it was
used mainly to preserve anchorage; but it was later found to create space. So,
there are significant changes in dental parameters when patients were treated
with headgear. It was found that distalization of molar was an added benefit of
headgear appliance. It is this factor that made correction of class II malocclusion
easy by the application of headgear. The following are few notable milestones
which depicts the evolution of molar distalization.
1. Kingsley was the first person to try to move the maxillary teeth backwards in
1866 by means of headgear.
Figure 1. Early uses of extra oral anchorage for backward

movement of upper teeth as devised by Kingsley and Angle
1. Although Westcott & others had previously used the Head-cap for occipital
anchorage, Kingsley, 20 years later, reintroduced this method, & for 40 years it
proved the only successful method of handling extreme cases of malocclusion.
Figure 2 appliance advocated by Farrar
2. Farrar in the 1870’s, they both also made use of the Head-cap to retract them.
3. Angle in 1890’s also used the extra oral anchorage appliances, apparently with
reasonable success.
4. In 1898 Guilford talked about direction pull by activating rubber strands of the
"skull cap" above or below the ear. Recommended 16 hours of wear and advocated
use of light force.

Figure 3 "skull cap" by Guilford
5. Oppenheim advocated the use of occipital anchorage for moving maxillary
teeth distally into correct relationship without disturbing mandibular teeth. In 1944,
he treated a case with extra-oral anchorage for distalizing maxillary molar. Class II
elastic treatment was thought to be an easy and effective tool but early cephalometric
studies in 1940s showed little or no distal movement of upper molars.
6.Kloehn (1951) described the effects of cervical pull headgear. In 1953, he stated that
treatment during the mixed dentition must promote alveolar bone growth and tooth
eruption, with limited use of appliances to minimize tissue destruction or loss and to
produce a more stable result. His greatest innovation was to solder the outer bow to
the inner bow and, thus by raising or lowering the arms of the outer bow, he
controlled the adverse distal tipping of the molars that was always present with the
two-piece bow.
7.Thus, headgears were reintroduced as means of moving upper molars back. These
extra oral appliances were heavily dependent on patient cooperation, forces
generated were high and intermittent causing severe patient discomfort and
prolonged treatment time. Since patient compliance plays a major role in the
success of headgear therapy, an appliance system independent of patient
cooperation was the need of the hour. Hence evolved various intra oral molar
distalizers.
8. Renfroe (1956) reported that lip bumper primarily devised to hold hypertonic lower
lip caused a distal movement of lower molars sufficient to change class I to Class
II.
9. Gould (1957) was the first person to discuss about unilateral distalization of molars
with extra-oral force. His appliance consisted of a passive traction arch or Y bar,
shaped to the outer contour of the dental arch, which was fitted into buccal tubes
on the first permanent molars or deciduous second molars. Its shank protruded
between the lips, and into a closed tube on the yoke. Unilateral movement was
produced by offsetting the shank to the desired side.
10. Graber T-M. (1969) extracted the maxillary II molar and distalized the first molar
to correct class II div.1.
11. Hilgers (1992) introduced the pendulum appliance for molar distalization which
consisted of large Nance acrylic button in palate for anchorage and 0.032’’ titanium
molybdenum alloy (TMA) springs that provided light and continuous force to
maxillary first molars for their distalization without having any effect on Nance
palatal button.
12. 1999, A Modified Hilgers Pendulum appliance was introduced, known as the “M-
Pendulum appliance.” To remove unwanted tipping of maxillary molars by Hilgers.
13. 2000 a new non-integrated implant-supported device called the Graz Implant-
Supported Pendulum (GISP). It distalize maxillary 1st & 2nd molars in adults. It
consisted of 2 parts: the anchorage plate, which is fixed to the palatal bone via 4
miniscrews, and the removable part, which is a pendulum-type appliance.
14. 2003, Some authors examined the treatment effects produced by two types i.e the
Herbst appliance (acrylic splint and stainless-steel crown) followed by fixed
appliances, and the pendulum appliance followed by fixed appliances.
15. 2005, Kinzinger modified the standard pendulum appliance by integrating a distal
screw into its base and by special pre activation of the pendulum springs, called
Pendulum K.
POINEERING RESEARCHES
PIONEERING RESEARCHES
Below are some of the pioneering researches done regarding molar distalization.
Kingsley (1866) was the first person to try to move the maxillary teeth backwards,
with help of extra oral forces. In 1892 he described in Dental Cosmos, a technique
for driving the upper molars distally by means of a headgear without extraction of
any teeth.
1
Graber (1955) stated that in treatment of Class II cases, the greatest change
produced by orthodontic appliances is in the maxilla. Distal adjustment of tooth
position in the maxilla alone or in conjunction with mandibular growth, is the basis
for correction of the malocclusion. He noted that when using extra oral-traction on
the maxillary first molar, it tips distally and does not routinely distalize bodily.
2
Gould (1957) was the first person to discuss about unilateral distalization of the
molars with the help of extra oral force. He also used cervical and occipital pull head
caps for distalization of molars.
3
Kloehn S.J . (1961) described the effects of cervical pull headgear on seven
cases with Class II malocclusion. The treatment plan was to move maxillary teeth
distally without disturbing the position and balance of mandibular teeth. He found
that there was sufficient evidence of the distal movement of maxillary teeth by
cervical force. The forward growth of the dental arch and alveolar process was
inhibited in many cases.

4
George Anderson (1968) reported the experimental bindings on mesial relapse of
maxillary first molars after distalization with the help of headgear forces. For
maxillary first molars, the first week after orthodontic force removal is an extremely
critical time for holding the molars to a retracted position. The findings indicate that
the maxillary molars returned on the average to a position of between 0.2mm and
0.4mm from their original positions after having been moved distally on the average
of 1.2mm (200 gms) and 2.2 mm (400 gms) respectively.
5
Graber T.M. (l969) extracted the maxillary second molars and distalized the
first permanent mo1ar for correction of Class II div.1 malocclusion. He stated that
distal adjustment of tooth position in maxilla alone or in conjunction with
mandibular growth and elimination of functional retraction is the basis for correction
of the Class II malocclusion.
6
Alain (JCO 1972) explained the use of a removable appliance for distalizing the
molars. The appliance was originally devised by G. Vienne and later produced by
A. Lorette. The appliances were introduced as the appliances with wires sliding in
tubes.
7
Earl O. Bergersen (1972) did a cephalometric study of the clinical use of the
mandibular labial bumper. A total sample of 116 persons was used to determine what
effect the mandibular labial vestibular bumper has on the dentition. He found that
distal movement of the mandibular first molars occurs in approximately 95% of the
patients with the placement of the labial bumper in the lower arch.
8
Sheldon Baumrind (1979) reports quantitative findings on the displacement of
the maxilla and of the maxillary first molar to positions distal to those which they
occupied at the beginning of appliance therapy. Data from a sample of 198 Class II
cases treated with various appliances which deliver distally directed forces to the
maxilla were examined to determine the frequency of absolute distal displacement
of the upper first molar and that of the maxilla. Results showed distalization of
maxillary molars bodily with cervical and straight pull, High pull and combipull
headgears caused distal tipping of the molar crowns.
9
Garland H. Hershey et al (1981) did an investigation to evaluate and compare
the effectiveness of 5 face-bow types in delivering unilateral distal forces to their
inner bow terminals. The face-bow types evaluated were bilaterally symmetrical
soldered offsets, springs attachment, swivel offset and power arm. The result of the
theoretical and experimental study of five face bow types indicated that the power
arm unilateral face bow and swivel offset unilateral face-bow were effective in
delivering a clinically significant unilateral distal force.
10
Langford S.R. and Sims M.R. (1981) reported upper molar root resorption
because of distalization with the help of headgear. Complete destruction of one root
was found to have occurred. Examination of the extracted upper first molar roots
under a scanning electron microscope revealed extensive areas of superficial root
surface resorption, which was not detectable on radiograph of the teeth.

11
Cetlin (1983) to prevent tipping of the maxillary first molar while distalization,
combined extra oral force (Headgear) part time with intraoral force (removable-
appliance) full time. He states that such a combination will produce a constantly
acting force by the removable appliance which tips the crown distally while the
headgear controls root position, resulting in bodily distal movement of the molar.
12
William M. Odom (1983) did a cephalometric comparison of treatment
changes among cervical traction alone and cervical combined with banded upper
incisors. He found that treatment with Kloehn cervical appliance has actual
distalizing effect on upper molars than the cervical traction combined with banded
upper-incisors.
13
William l, Wilson 1984 the 3D Lingual Arch modular multipurpose appliance.
It is interchangeable and adjustable for many varied functions, and it is convertible
to a variety of other appliances for treatment use like mandibular anchorage for
molar distalizing without headgear.
14
Wieslander in 1984 constructed a special headgear-Herbst appliance and
treated in the very early mixed dentition. This active treatment was followed by a
period of 6 months. The changes in dentofacial pattern were registered after active
treatment in comparison to an untreated control group, the maxillary teeth in a
posterior direction (3.1 mm) was a combination of distal tooth movement (1.6 mm)
and a change in position of the base of the maxilla (1.5 mm).

15
Joseph Ghafari (1985) reported two cases treated with modified Nance
holding arch and one case with modified Lingual arch for unilateral distal tooth
movement. On cephalometric evaluation there was no labial flaring of upper and
lower anteriors.
16
Albert H. Owen (1987) presented a clinical review on the maxillary sagittal
appliance. It was to advance the maxillary incisors and to distalize the maxillary
molars, thereby increasing the arch length. He found a forward movement of upper
anteriors and minimal distalization of molars with increase in anterior face height
by 2.85mm. Presence of second molars minimized the effect of distalization.
17
Anthony A. Gianelly et al (1988) used Repelling Magnets for distalization of
molars. He noticed that rate of molar movement with second molars is usually 0.75-
1mm per month. Premolars and incisors moved anterior by 1 mm in 7 weeks.
18
Martina R. et al (1988) fabricated a special device which was capable of
measuring the force transmitted by various types of asymmetric facebows. All of
them were efficient in delivering a unilateral distal force. The results howled that 4
arch designs (Modified according to bonnefont with the outer left hand shortened
and soldered to the inner right arm and the outer right arm expanded) were the most
efficient (84% with 250 gms).

19
Robert S. Freeman (1988) used mandibular cervical gear to upright or to
move the molars distally. He took case of late mixed dentition with mild crowding in
the anterior region and medially tipped mandibular permanent molars. He noticed
an improved alignment of anterior teeth and the posterior spaces opened up.
20
John R. Valant (1988) used a modified Herbst appliance to increase the arch
length. He demonstrated that the use of such appliances produces a 10 mm increase
in the maxillary arch length after maxillary second molars were extracted. The
increased maxillary arch length was because of distalization of molars.
21
Gianelly et al 1989 demonstrated the use of magnets to move molars distally.
Repelling magnets, which were anchored to a modified Nance Appliance, cemented
on the 1st upper pre-molars, were activated against the maxillary 1st molars to move
them distally. Initial force produced was 200- 225gm, but dropped substantially as
space opened up (With 1 mm space between the magnets, applied force was only
75gms).
22
John R. Valant (1989) on the basis of dental cases and cephalometric records
of 32 consecutive Class II, division 1 cases treated with a modified Herbst appliance
concluded that 1) A significant distal bodily movement and tipping of the maxillary
first molars. 2) Maxillary arch length, inter canine width and intermolar width, were
increased significantly during treatment.

23
Nick Romandies , Joel M. Servos (1990) did a study on anterior and posterior
dental changes in second molar extraction cases. aAll the cases were treated with
0.22" slot fixed attachments. Compressed open coil springs were used between the
molars and canines and arch wire was twisted 90" distal to the canine bracket to
prevent the proclination of the anterior teeth. Results indicated that the first molars
can be reliably moved distally in second molar extraction cases with traditional fixed
appliance mechanics. A few of the patients showed as much as 4-6mm of distal
movement. On the average maxillary and mandibular first molars were distalized
2mm each side.
24
Gianelly et al, in 1991 demonstrated use of Japanese Niti coils to move molar
distally. 2 case reports have been published for this effect, 100gm superelastic coils
are used 1-1.5 mm movement per month was seen with 8 - 10mm activation of these
coils. A modified Nance appliance is used in conjunction. The coil force drives the
molar distally, wherein anchorage is received by Nance appliance. Coils are activated
with gurin locks. Uprighting spring may be placed in the vertical slot of the pre -
molar bracket to enhance anchorage. They used Japanese Niti superelastic coils,
exerting 100gms of force was compressed against the maxillary first molars and
moved the molars distally 1 to 1.5mm/month. Anchorage was obtained with a
modified Nance appliance cemented onto the first premolars in conjunction with a
fixed appliance.
25
Nobert Jeckel and Thomas Rakosi (1991) used molars distalization bow to
distalize the molars. It is an intraoral appliance having good control over the molars.
They took 10 patients with age range of 8 to 14 years. Average period of daily wear
was 17 - 18 hours. The analysis of the lateral cephalogram showed no measurable
difference in the axis of the incisors or in the angle of maxillary inclination before
and after treatment.
26
Robert G. Cash (1991) reported on an adult patient with a bilateral Class II
malocclusion and a anterior open bite who had treated without extractions, using a
Jasper Jumper appliance to distalize and intrude the maxillary molars. The post
treatment superimposition showed that molars moved distally.
27
Takami Itoh el al (1991) carried out a clinical study designed to measure the
molar distalization achieved with Repelling Magnets. Patients with early mixed
dentition who required distal molar movement were selected for molar distalization.
Molar distalization ranged from 0.5mm to 3.7mm, with an overall mean of 2.1mm.
28
Jones (1992) used an open coil jig for rapid Class II molar correction. Open coil,
Niti springs exhibiting 70-75 gms force over a compression range of 1-5mm to the
molars. The springs are used in conjunction with modified Nance appliance. It is a
predictable, rapid and painless method of distal driving of the molars.
29
Lars Bondermark and Juri Kurul (1992) analyzed the clinical and the
dentofacial effects of repelling SMCO5 (Samarium - Cobalt Magnets) for
distalization of maxillary first and second molars simultaneously. The mean molar
crown movement was 4.2mm and maxillary first molar tipped distally and rotated
distobuccaly by 8 and 8.5" respectively.
30
Tracy. J. Reiner 1992 used modified Nance appliance with repelling magnets
for unilateral distalization. She treated 12 patients aged 13-17 with unilateral Class
II, ranging from 2mm to 6 mm. The appliance was a modification of traditional
Nance holding arch. The Class II molars were distalized a mean of 0.19mm per week
with a maximum of 0.024mm per week.
31
Dr.Hilgers 1992introduced pendulum appliance which is a hybrid appliance
that consists of large Nance acrylic button and 0.032” TMA spring. This appliance
produces a broad, swing arc or pendulum of force from midline of the palate to the
upper molars hence was called the pendulum appliance,
32
Dween S. Muse, Michael J. Fillman (1993) conducted a study to determine
the magnitude and direction of maxillary and mandibular first molar and incisor
changes that occur during Class 11 molar correction with Wilson's Rapid molar
distalization. 19 patients received maxillary bimetricdistalizing arches (BDA) and
either a mandibular three dimensional lingual arch, with or without passive 0.016 x
0.016" utility arch or a traditional edgewise full banded, and bonded arch was used.
The arches were activated with open coil springs and Class II intermaxillary elastics.
The mean change in molar relation measured at the occlusal plane was 4.1mm. The
mean maxillary molar distalization was 2.16mm with 7.8° of tip. The rate of
maxillary molar movement was 0.56mm per month.

33
Bondemark et Al (1993) did a study of repelling magnets versus superelastic
nickel-titanium coils in simultaneous distal movement of maxillary first and second
molars. 18 subjects, with CI II malocclusion, deep overbite and moderate space
deficiency in the maxillary arch were treated. Repelling rare earth magnets on one
side and superelastic nickel - titanium coils on the contra-lateral side for
simultaneous distal driving of first and second molars. Force value calibrated at
225gms on both sides. Mean distal molar movement was 3.2mm for superelastic
coils and 2.2mm for the magnets. Complaints of discomfort were more frequent for
the magnet sides. Results indicate that superelastic coils are more effective than
repelling rare earth magnet for distal movement of molars.
34
MansPancherz et al (1993)studied the short and long term effect of the herbst
appliance on the maxillary complex in 45 patients who had Class II malocclusion.
During Herbst treatment the upper molars were distalized in 96% of the subject
(maximum 4.5mm) and upper molars were intruded in 69% of the subjects.
35
Miyajima and Nakamuro (1994) presented 2 case repots, showing concept of
"Distalization with driftodontics". In these cases alter distalization of molar, the
second pro-molar and then the first pre-molar and canines have drifted distally into
the space created. This has been attributed to the pull of transeptalfibres.
36
Blechman (1995) postulated a possible mechanism of action of repelling molar
distalization magnets. Initially time varying (non-static) electromagnetic fields were
used and it was though that the electrical component of these fields led to changes
in tissue response. HoweverBlechman has shown that even an application of a static

magnet field favourable tissue response is elicited. This proves the fact that even
magnetic field per se has effect on the tissues.
37
Greenfiled (1995) developed a fixed piston appliance for rapid CII correction.
This can provide bodily movement of maxillary first molars without extra oral
appliances and with no loss of posterior anchorage. It has a both, buccal and lingual,
fixed piston and tube assembly, with piston being soldered to the molars and tube
being soldered to the pre-molars. Niti coil is placed (0.036") on this piston and tube
assembly and bodily movement of molar is achieved. It required no patient
compliance and uses light controlled forces 1.5-2 ounce / tooth.
38
Korrodi Ritto (1995) designed the removal molar distalization splint. In cases
of excessive overbite with the molars in full occlusion the splint creates a separation
of 1-2mm distally per month. Some amount of distal tipping of molar takes place.
Hence the best cases treated with this appliance are those where the molars are
already mesially tipped. It is more comfortable and aesthetic for the patient and
therefore can be expected to achieve better co-operation.
39
Varun Kalra (1995) developed the K-loop molar distalizing appliance. Hence
distal driving is possible without tipping of molars and minimum anterior anchor
loss. K-loop 0.017" x 0.025" T.M.A. wire can be activated twice. Each loop of "K"
is 8mm long and 1.5mm wide. Legs of K are bent down and inserted into molar tube
and pre-molar bracket. It has the advantage of being simple and efficient, controls
tipping, of low cost and easy to fabricate.

40
Jasper and McNamara (1995) described the use of a flexible force module
(the Jasper Jumper) that can be incorporated into existing fixed appliances to correct
various types of sagittal malocclusion. The treatment effects produced posterior
movement of the maxillary buccal segments and anterior movement of the mandible.
41
Aldo Carano et al (1996) developed a distal jet appliance that can distalize
without the disadvantage of tipping and rotation. He used on 18 year old female and
10 year old male in mixed dentition, both presented with Class II division 1
malocclusion. In both patients, Class 1 relation ship was achieved in 4 months. The
appliances were well tolerated, esthetic and requires no patient cooperation.
43
Joydeep Ghosh (1996) conducted a study to determine the effects of the
pendulum appliance on distalization of maxillary molars and the reciprocal effects
on the anchor premolars and maxillary incisors. Initial and follow-up cephalometric
radiographs were obtained from the patients who were treated with the pendulum
appliance for bilateral distalization of the maxillary first molar teeth, for correction
of the Class II molar relationship or for gaining space in the maxillary arch. Dental,
skeletal, and soft tissue changes were determined. Its major advantages are minimal
dependence on patient compliance, ease of fabrication, one-time activation,
adjustment of the springs if necessary to correct minor transverse and vertical molar
positions, and patient-acceptance.

44
Martin Puente (1997) describes biomechanical action of combined edgewise
and modified Nance in Class II treatment. He used super elastic rectangular arch
wire with omega loops between the first molar and second premolar brackets. He
incorporated a Nance button which was soldered to the first premolar band and a
stainless steel framework consisting of omega loop just distal to the solder of the
premolar bands and he incorporated a niti coil spring between the omega loop and
the lingual tube of the first molar, which allows bodily distalization of the first
molars by compression of the omega loops thereby activating the niti coil spring
placed palatally. A distal movement of 0.75 to 7mm per month is achieved by this
appliance.
45
Maurice Corbett (1997) developed a fixed - removable nickel titanium
appliance (the Nickel Palatal Expander) that delivers a uniform, slow, continuous
force for maxillary expansion, molar rotation distalization and arch development.
The action of this appliance is made possible by harnessing nickel titanium
properties of shape memory and transition temperature of 94 degree Centigrade. It
can also be used for unilateral molar correction, unilateral posterior crossbite
correction distal rotation and expansion of molars and bicuspids and leveling,
alignment and rotation of buccal segments.
46
Pieringer et al (1997) designed to investigate the effects of Nance appliance
combined with Sentalloy coil springs. The control the vestibular screws and
modified Nance button with stainless steel framework that passes through the lingual
tube soldered to the first molars and the stainless steel framework is soldered to the
premolars. A 0.0'l0"x0.045" coil spring is placed between first molar and second
premolar band lingually to allow bodily distalization. Molar distalization is achieved
by 4-8mm in 42 days.
47
Aldo giancotti (1998) Paolacozza, described nickel titanium double- loop
system for simultaneous distalization of first and second molars, super elastic nickel
titanium wires have been found as effective as other means in producing distal
movement of the maxillary first molars. When the distalization is carried out before
the second molars have erupted, it can reliably produce 1-2mm of space. Once the
second molars have erupted, however, the distal movement can be more difficult and
time-consuming, and loss of anchorage is likely. The nickel titanium double-loop
system is a useful technique for class II treatment with minimal patient cooperation.
It is ideal for simultaneous first and second molar distalization in the permanent
dentition, when traditional intraoral forces may be ineffective in moving the first
molars. Second molars seem to be easier to move distally than first molars because of
the different anatomical shape of their roots and the lack of posterior obstacles.
Because of the stretching of transeptal fibers, the first molars can be distalized in this
system using lighter 80g nickel titanium wires, instead of the 100g or 200g wires
normally used for molar distalization. Anchorage can be controlled more easily with
light forces, eliminating the need for a transpalatal bar or nance appliance cemented
to the first premolars.

David. J. Harnick (1998) used a modified Wilson's biometric distalizing arch for
Class II correction which does not require any extra oral traction. He used bimetric
arch of 0.020" in anterior section and 0.045" in posterior section which fits into the
head gear tube. A 5mm long 0.040x0.010" open coil spring is compressed by an
omega loop. The resulting force moves the maxillary first molar distally. The
reciprocal anterior force is offset by Class 11 elastics. Mandibular arch is stabilized
by 0.017"x0.025"rectangular arch or lingual stabilizing unit. Class 1 molar relation
ship achieved in 4.5 months.
48
S.Jay Bowman (1998) describes several modifications of the distal jet which
includes conversion to Nance holding arch, double set screw distal jet for molar
rotation, molar expansion, modified mandibular distal jet, distal jet hex key handle.
49
Sumit Gulati (1998) conducted a study on 10 subjects to evaluate dental and
skeletal changes after intraoral molar distalization. The maxillary molars were
distalized with a sectional jig assembly. Sentalloy open coil springs were used to
exert 150 gm of force for a period of 12 weeks. A modified Nance appliance was
the main source of anchorage. The pre- and post distalization records included dental
study casts, clinical photographs, and cephalograms. The mean distal movement of
the first molar was 2.78 mm. It moved distally at the rate of 0.86 mm/month. There
was clinically some distal tipping (3.50°) and distopalatal rotation (2.40°). These
changes were statistically significant (p < 0.001). The second molars

accompanied the first molars and moved distally by nearly the same amount. There
was 1.00 mm increase in the overjet and 2.60° mesial tip of second premolar. The
changes in the facial skeleton and dentition bases were minimal and statistically not
significant. However, there was clockwise rotation of the mandible of 1.30° that was
statistically significant. This was the result of molar extrusion (1.60 mm).
50
Arturo Fortini et al (1999) to minimize this anchorage loss, they developed a
new type of appliance for unilateral or bilateral distalization of the maxillary first
molars. This is referred to as the First Class Appliance for rapid molar distalization,
which comprises of screws soldered buccally on first molars and split rings are
welded to the second premolars to control the vestibular screws. It produces rapid
distalization of the maxillary first and second molars, even when the second molars
are completely erupted. It reduces treatment time in Class II cases being treated on
a non extraction basis.
51
Giuseppe Scuzzo et al (1999) designed a Modified Pendulum Appliance for
maxillary molar distalization. The modification allows bodily movement of the
molars where in a horizontal pendulum loop is kept inverted. The loop can be
activated by simply opening the coil.
Giuseppe Scuzzo et al (1999) the horizontal Pendulum loop is inverted, it will
allow bodily movement of both the roots and crowns of the maxillary molars. Once
distal molar movement has occurred , the loop can be activated simply by opening
it. The activation produces buccal and/or distal uprighting of the molar roots and
thus a true bodily movement, rather than a simple tipping or rotation.

We call this modification the M-Pendulum. It is an effective and reliable method for
distalization of the maxillary molars.
52
Ahmet Keles et al (2000) designed an appliance to achieve maxillary molar
distalization. The intra oral bodily molar distalizer was composed of 2 parts: the
anchorage unit and the distalizing springs. The springs had 2 components: the
distalizer section of the spring applied a crown tipping force, while the uprighting
section of the spring applied a root uprighting force on the first molars. A total of
230g of distalizing force was used on both sides. After the distal movement of the
first molars, the maxillary molars were moved distally by an average of 5.23mm.
53
Giuseppe Scuzzo et al (April 2000) designed an appliance for non extraction
treatment of Class II malocclusion by molar distalization. The pendulum is a non
compliance device that uses 'I'MA arms as the active components and the modified
Nance button as anchorage support. The two 0.032" arms are embedded in the
acrylic. Each arm consists of a closed helix, a convex adjustable horizontal loop and
a terminal section that fits into a 0.036" lingual sheath on the maxillary molar band.
After some distalization the loop is reactivated outside the mouth. With the
removable arms distal movement can be continued at a rate of 1.5 mm per month.
54
Kyo-Rhim Chung (2000) designed a removable appliance called the "C-space
regainer" to achieve bodily molar movement without significant flaring. This
appliance can be used to intrude teeth as well as to move them distally or sagitally.
It consists of 2 parts, 0,036" stainless steel wire and acrylic splints. The stainless
steel framework is extended distally which pass through the head gear tube, closed
helix is bending into the frame work in each canine region. A 0.010x0.040 open coil
spring is soldered immediately distal to the helix and 0.028 ball end clasps are used
for retention. A Nance button is immediately given after distalization. When the
open coil is compressed, it will exert 200g of force and move the molars distally
about 1-1.5mm per month. Vertical control is maintained by adjusting the wire
framework occlusally or gingivally.
55
José Chaqués-Asensi (2001) conducted a study to determine the effects of the
Pendulum molar distalization appliance on the dentition and facial form. The sample
consisted of 26 patients who were treated with the Pendulum appliance. The patients,
10 boys and 16 girls, with a mean age of 11 years, 2 months. Treatment with the
Pendulum molar distalizing appliance appears to produce considerable distal
movement of the molars. Considerable distal tipping of the molars. A substantial
amount of anchorage loss, resulting in anterior movement of the first premolars and
incisors. Some increase in lower facial height and reduction in overbite.
56
Aldo Carano (2002) changes the distal jet Appliance to the locking
mechanism which plays the central role in both molar distalization and retention,
consists of three interacting components—lock, screw, and activation wrench.
Because the Distal Jet is contained entirely within the palatal vault, space availability
and patient comfort were the primary considerations in its original design. The
modifications reduce chair time, improve patient comfort, and enhance treatment
efficiency and reliability without changing the biomechanical foundation or core
philosophy of the Distal Jet.

57
S. h. Kyung et al (2003) described distalization of maxillary molars with a
midpalatal miniscrew is a traditional method of controlling anchorage during molar
distalization tend to cause unwanted movement of other teeth and to require patient
cooperation. These disadvantages can be overcome with skeletal anchorage, which is
gradually gaining acceptance among orthodontists.
58
Pablo Echarri (2003) reported two cases to demonstrate how to counteract
loss of anterior anchorage with the Hilgers Pendulum appliance, protrusion or
proclination of the incisors during molar distalization with the M-Pendulum,1,2
which has a mesially oriented loop and removable arms.
59
Kinzinger Et Al (2004) used a modified pendulum appliance, including a distal
screw and special pre activated pendulum springs (built-in straightening activation
and toe-in bending), for bilateral maxillary molar distalization in 36 adolescent
patients in various stages of the molar dentition. The patients were divided into 3
groups (PG 1-3) according to the stage of eruption of their second and third molars
and they concluded that young patients, the best time to start therapy with a pendulum
appliance is before the eruption of the second molars. In principle, treatment of any
sagittal arch length discrepancy is possible with a pendulum appliance, but, because
no skeletal effects can be expected during pendulum appliance therapy, the exclusive
focus of application has been and remains restricted to distalization in the
dentoalveolar region.
60
Luis Carriere (2004) designed CARRIERE DISTALIZER, is most effective
in treating class II malocclusion without extraction and in class I cases with mesially
positioned maxillary molars.

61
Greenfield (2005) introduced newest design of GMD this applies the distalizing
force only from the lingual of the maxillary molars, utilizing twin piston modules.
This is a unique appliance that allows the clinician to fully control molar distalization
in all three planes of space with light, continuous forces.
62
Kinzinger (2005) conducted study to assess dental anchorage qualities when the
pendulum appliance is used for distal molar movement. Thirty adolescents in various
dentition stages received a modified pendulum appliance with a distal screw and a
specially preactivated pendulum spring for bilateral molar distalization in the
maxilla. Dentoalveolar effects and side effects in the anchorage unit and in the molar
area were determined by cephalometric analysis, and concluded that deciduous
molars and premolars can be used for anchorage for molar distalization with a
pendulum appliance; however, anchorage with premolars only results in the least
pronounced dentoalveolar side effects. The anchorage quality of deciduous molar
and mixed deciduous molar/premolar anchorage is limited.
63
Patricia p. Chiu (2005) conducted a study compared the dentoalveolar and
skeletal effects on Class II malocclusions of the distal jet with concurrent full fixed
appliances and the pendulum appliance both followed by fixed appliances. He
concluded during molar distalization, the pendulum subjects showed significantly
more distal molar movement and significantly less anchorage loss at both the
premolars and the maxillary incisors than the distal jet subjects. At the end of
comprehensive treatment, the maxillary first molars were 0.6 mm mesial to their
original positions in the distal jet group and 0.5 mm distal in the pendulum group.
Nevertheless, total molar correction was identical in the 2 groups (3.0 mm), and both
appliances were equally effective in achieving a Class I molar relationship.
64
Erol Akin (2006) investigated to evaluate the skeletal and dentoalveolar
treatment effects of a segmented removable appliance [removable molar distalizer
(RMD)] for molar distalization. The RMD was effective in distal molar movement
and all patients attained a bilateral Class I molar relationship in an average period of
4.5 months. Hygiene problems and mucosal irritations, frequently found with fixed
intraoral distalization techniques, were not observed during the distalization period.
65
Gero S.M Kinzinger et al (2006) introduced MINISCREW- SUPPORTED
DISTAL JET APPLIANCE. Elimination of the acrylic palatal button improves the
patient’s access for oral hygiene. The MSDJ provide translation of the upper molar
without the constraints of patient cooperation. Mini screw support reduces
anchorage loss and flaring of the anterior teeth compared to conventional anchorage
methods.
66
Jungi Sugawara et al (2006) used SKELETAL ANCHORAGE SYSTEM for
the distal movement of maxillary molars in non growing patients to improve

malocclusion without having to extract the premolars. In this study they conclude
SAS is a viable modality of distalizing maxillary molars because it uses stable and
strong anchorage units. It enables not only single molar distalization but also en-
mass movement of the maxillary buccal segments with only minor oral surgery for
placing the titanium anchor plates at the zygomatic buttresses. They conclude this
technique is particularly useful for correcting class II malocclusions,
decompensation for class III surgical patients and malocclusion characterized by
maxillary anterior crowding.
67
Korkmaz Sayinsu (2006) examined the distalization of molars unilaterally in
patients with a unilateral Class II molar relationship utilizing a Keles Slider,
designed without a bite plane. The results showed that the maxillary first molars
were distalized bodily on average by 2.85 mm. The maxillary first premolars moved
forward bodily 2 mm and were extruded 2.03 mm. The mandibular incisors and
mandibular molars erupted 0.83 and 0.95 mm, respectively. The unilateral Keles
Slider distalized molars successfully to a Class I molar relationship.
68
Fernanda Angelieri (2006) conducted a study analyzed the distalization of
maxillary molars achieved by the pendulum appliance and its effect on the
anchorage teeth during and after fixed orthodontic treatment. The pendulum
appliance moved the maxillary molars distally, but with significant distal inclination,
protrusion of the anterior teeth, and increase in lower anterior facial height (LAFH)
due to the clockwise mandibular rotation. The pendulum appliance followed by fixed
orthodontic treatment corrected the Class II sagittal relationship, especially due to the
dento alveolar changes secondary to the spontaneous mandibular growth in the
anterior direction during fixed appliance treatment.
69
Kinzinger (2006) the pendulum appliance allows for rapid molar distalization
without the need for patient compliance. Its efficiency has been confirmed in a
number of clinical studies. However, the potential interactions and positional
changes between the deciduous molars used for dental anchorage and the erupted
and unerupted permanent teeth have yet to be clarified when this appliance is used
for molar distalization in the mixed dentition. At this stage of the mixed dentition,
premolar extraction or augmentation of the supporting area with extraoral headgear
offers a therapeutic alternative to intraoral distalization appliances with exclusively
dental anchorage.
70
Beyza Hanciglu Kircelli et al (2006) designed the bone-anchored pendulum
appliance (BAPA). This study was to evaluate the stability of the anchoring screw,
distalization of the maxillary molars, and the movement of teeth anterior to maxillary
first molars. A conventional pendulum appliance was modified to obtain anchorage
from an intraosseous screw instead of the premolars. Super Class I molar
relationship was achieved. The premolars tipped significantly distally. No anterior
incisor movement was detected. The BAPA was found to be are effective, minimally
invasive, and compliance-free intraoral distalization appliance for achieving both
molar and premolar distalization without any anchorage loss.

71
Giampietro Farronato et al (2007) introduced the transverse sagittal maxillary
expander the modification of rapid palatal expander indicated in patient with class
III malocclusion and maxillary crowding, or with maxillary hypoplasia and reduced
transverse and sagittal dimensions. The TSME increases the perimeter length of the
upper arch; it is easy to use, with placement and activation procedures as that of
palatal expander. Patient compliance is satisfactory.
72
Stefano Velo et al (2007) introduces an implant distal jet that reduces the
anchorage loss in class II treatment there is no complications from the simple and
relatively non-invasive surgical procedure, the MAS screw has shown excellent
stability and the screw is also fast and easy, miniscrew anchorage does not change
the shape or structure of the distal jet, thus ensuring patient comfort than compliance
with auxiliary devices.
73
Stetan F. Schutze (2007) evaluated skeletal and dentoalveolar changes due to
unilateral distalization with a modified pendulum appliance and to determine side
effects. Cephalograms and dental casts before and after distal movement of the
maxillary molars with pendulum appliances in 15 consecutively treated patients
were included in this study. Effective distal molar movement and less anchorage
loss at the front teeth are advantages of unilateral distalization.

74
Gero S. M. Kinzinger, MertEren and Peter R. Diedrich (2008) conducted a
study to compare the efficiency, both quantitatively and qualitatively, of various
appliance types with intra maxillary anchorage for non-compliance molar
distalization. The results show that non-compliance molar distalization is possible
with numerous different appliances. While molar distalization with standard
pendulum appliances exhibited the largest values for dental linear distalization, it
also resulted in concurrent, substantial therapeutically undesirable distal tipping.
However, specific modifications to the pendulum appliance allow achievement of
almost bodily molar distalization. Different outcomes are quoted in the studies for
the efficiency of loaded spring systems for distal molar movement, but it seems that
the first class appliance and the palatal distal jet are more efficient than the vestibular
Jones Jig. The studies identify anchorage loss as being found in the area of the incisors
rather than the area of the first premolars. There was a trend for more substantial
reciprocal side-effects to occur when only two teeth were included in the anchorage
unit. Vertical components acting on the molars, premolars, and incisors, such as
intrusion and extrusion, tended to be of secondary importance and, therefore, may
be disregarded.
75
Giovanni Oberti (2009) conducted a study to describe the clinical effects of a
bone supported molar distalizing appliance, the dual force distalizer. They
concluded that the dual force distalizer is a valid alternative distalizing appliance
that generates controlled molar distalization with a good rate of movement and no
loss of anchorage.
76
Mayara Paim Patel (2009) conducted a study to compare dento alveloar changes
of class II patients treated with Jones jig and pendulum appliances. They concluded
that the Jones Jig group showed greater mesial tipping and extrusion of the maxillary
second premolars. The mean amount and the monthly rates of first molar
distalization were similar in both groups.
77
Gero s. M. Kinzinger (2009) conducted a study to investigate the suitability of
the skeletonized distal jet for translatory molar distalization and to check the quality
of the supporting anchorage set up. They concluded that the skeletonized distal jet
appliance supported by additional miniscrew anchorage allows translatory molar
distalization.
78
Moschos A. Papadopoulos et al (2010) conducted a study to evaluate the
treatment effects of the First Class Appliance (FCA) used for the distalization of
maxillary first molars in patients with class II malocclusion and mixed dentition.
They concluded that the FCA is an efficient noncompliance appliance to distalize
molars in the mixed dentition without distal rotations.
79
Metin Nuret al (2012) conducted a study to evaluate the dentoalveolar,
skeletal, and soft tissue effects of the Zygoma-Gear Appliance (ZGA) when used for
bilateral distalization of the maxillary molars. They concluded that the Zygoma-
Gear Appliance (ZGA) appliance that showed a slight intrusion of Maxillary first
Molars and there was a decrease in overjet indicating that without anchorage loss
Maxillary molar distalization can be achieved in a short time with ZGA.

80
Cagla Sara et al (2013) The purpose of this study was to examine skeletal,
dental, and soft tissue effects of the Miniscrew Implant Supported Distalization
System (MISDS) and the Bone-Anchored Pendulum Appliance (BAPA) treated In
a Class II malocclusion, patients which is divided in to two groups. Both methods
provided absolute anchorage for distalization of posterior teeth; however, almost
translatory distal movement was encountered in the MISDS group, and substantial
distal tipping of the maxillary molars accompanied distalization in the BAPA group
81
Carlos Flores-Mira et al (2013) conducted a study to evaluate the efficiency of
molar distalization associated with the second and third molar eruption stage,
showed both linear and angular distalization appears to be minimal. This conclusion
is only based on low level of evidence clinical trials. The large variability in the
outcomes should be considered clinically
82
ENIS GURAY et al (JCO) 2014 This article introduces the EZ Slider* sliding
auxiliary for use with mini-implants in the distalization of posterior segments. To
prevent anchorage loss which prolongs treatment due to round-tripping and can lead
to labial bone loss and gingival-height deficiencies in patients with proclined
maxillary incisors. Distal tipping of the molars may require attachments such as up
righting springs to prevent early relapse. By comparison, though leveling of the
anterior teeth will inevitably require some round-tripping of the incisors, the
combination of a skeletally anchored EZ Slider with a .016" × .022" stainless steel
arch wire will allow the posterior teeth to upright spontaneously during distalization.
Were as, even with headgear and some intraoral-distalization appliances or even
skeletally anchored mechanics, the second molars can limit distal movement of the
first molars. The EZ Slider avoids this problem because only one tooth is distalized at
a time. Since EZ Slider mechanics can cause molar extrusion and premolar or canine
intrusion, the appliance should not be used in high-angle cases.
83
CASSIO EDVARD SVERZUT etal (2015) Temporary skeletal anchorage for
lower molar distalization can be provided by either mini- implants or miniplates.
The main disadvantages of mini-implants compared to miniplates are the reduced
load that can be supported and the tendency of the implant to migrate toward the
tooth being moved. Sugawara and colleagues proposed the use of a Mini plate for
lower-molar distalization in non growing patients. Sugawara and colleagues
reported needing 19-39 months to distalize lower molars with miniplate anchorage
in their adult patients. Miyahira and colleagues required only three months to
distalize and de-impact the lower right second molar with anchorage from a 2mm
“T” surgical plate. They concluded that the potential to safely and effectively
distalize and upright lower molars in growing patients opens new possibilities for
orthodontic treatment with miniplate anchorage. This innovative technique requires
further study to establish its risks and benefits.
84
Abhisek Ghosh et al .,(2018) conducted a study on skeletal anchorage
systems, the most popular being – Mini implants or micro-screws which have an
intra radicular site of placement. Their greatest advantage being the ease and
minimally invasive methods of placement and the commonest disadvantage being
early loosening during the course of treatment. A more rigid alternative was then
introduced called as the SAS-Skeletal Anchorage Systems (I-plate, Y-plate etc) with
its extra-radicular site of placement, which did overcome the high failure rates of a
regular mini-implant but then their placement required raising of flaps and extensive
surgical intervention. More recently an apt balance was achieved with the advent of
the Orthodontic Bone Screws (OBS) which not only had an extra-radicular site of
placement in the infrazygomatic crest of the maxilla and the buccal shelf area of
the mandible, with significantly less failure rates than regular mini-implants but also
doesn’t require extensive surgical intervention for their placement.

PIONEERING RESEARCHES IN APPLIANCES FOR MOLAR
DISTALIZATION OVER THE YEARS [11]
S. Name of the Invention Appliance Invented

No Researcher year
01 Gunell 1822 Extra-oral anchorage
02 Guilford 1866 Headgear for correcting
proclined upper teeth
03 Kingsley 1892 Headgear appliance
04 Oppenheim 1944 Occipital headgear
05 Renfroe 1956 Lip bumper
06 Gould 1957 Unilateral distalization
07 Klein 1957 Effectiveness of cervical
traction
08 Guerrero James 1959 ‘Atkinson Buccal bar’
09 Graber 1969 Philosophy of second molar
extraction in class II to
allow distalization of
buccal segment
10 Leonard 1969 Acrylic Cervical Occipital
Appliance (ACCO)
11 Hogs 1970 ‘Tandem Yoke’
12 Melson 1978 Effect of cervical traction
by using metallic implants
13 Cetlin and 1983 Non-Extraction approach
Tenhoeve by distalization of molar in
both arches
14 Tabash et al 1984 Dynamic extra-oral
anchorage
15 Taylor 1985 Crozat principles and
techniques
16 Glanelly et al 1988 Intra-arch repelling
magnets
17 Valant John 1989 Modified Herbst appliance
18 Cash Robert 1991 Bilateral ‘Jasper jumper’
19 Gianelly Bednar 1991 Japanese Niti super elastic
and Dietz coil
20 Jeckel and Rakosi 1991 ‘Molar Distalizing Bow’
21 Hilgers 1992 Pendulum appliance
22 Reiner 1992 Nance Holding Arch
23 Jones and White 1992 ‘Jones Jig’ appliance
24 Jasper and 1995 ‘Jasper Jumper’
Mcnamara
25 Kalra 1995 ‘K-Loop Molar Distalizer’
26 Greenfield 1995 ‘Fixed Piston’ appliance
27 Carano et al 1996 ‘Distal Jet’ appliance
28 Klapper 1997 ‘Klapper Super Spring’

29 Giancotti and 1998 ‘Niti Double Loop
Cozza Distalizer’
30 Starnes 1998 ‘Saif Spring’
31 Fortini, Lupoli and 1999 First class appliance
Parri
32 Chung, Park and 2000 ‘C’ space regainer
Ko Su Jin
33 Keles and Sayinsa 2000 ‘Intra-oral Bodily Molar
Distalizer’
34 Sugawara, 2006 Skeletal Anchorage System
Kanzaki, (SAS)
Takahashi,
Nagasaka and
Nanda
35 Kircelli, Pektas 2006 Bone Anchorage Pendulum
and Kireclli appliance (BAP)
INDICATIONS FOR MOLAR DISTALIZATION
INDICATIONS FOR MOLAR DISTALIZATION
Molar distalization procedures have been very useful in non-extraction borderline
case management. Careful selection of case is therefore mandatory. Over the years
the procedures have undergone much refinement to achieve treatment objective
more precisely. This has been made possible by a better understanding of bone
physiology, tooth movement, biomechanics and newer biomaterials. In certain
reasonably well-defined instances, the distal movement of upper buccal segments is
the mechanical treatment of choice. The indications for the distal movement of upper
buccal segment are described.
1. Mesial migration of the arch is said to be true indication for molar
distalization in order to mmaintain ideal maxillomandibular dental relation.
2. In cases where there is loss of space anterior to molar and permanent molars
have migrated mesially.
3. In cases where there is premature loss of deciduous teeth or wherein the
deciduous teeth have migrated forward.
4. In cases wherein there is arch length discrepancy due to caries present in a
permanent teeth or deciduous teeth anterior to permanent molars.
5. In cases where in the presence of tooth fractures of premolars or deciduous
molars leads to mesial migration of permanent molars.
6. When there are congenitally missing teeth which leads to mesial migration of
permanent molars.
FAVOURABLE FEATURES FOR MOLAR DISTALIZATION
1) Profile:
a) Straight profile is preferred as molar distalization will bring about changes in the
dental arch in anterior-posterior direction only, mainly for gaining space; and this
won’t bring about much of profile changes after the treatment.
2) Functional:
a) Usually a normal, healthy temporomandibular joint is preferred for molar
distalization.
b) Correct mandibular to maxillary relationship is preferred so as to not cause any
discrepancies.
3) Skeletal:
a) Class I skeletal relationship is preferred as more focus is laid on the
correction of dental relationship.
b) A normal to short lower face height case is preferred because distalization
leads to wedging effect in the posterior region resulting in increased vertical
height.
c) A normal transverse width of the maxillary dentition is preferred.
d) A brachycephalic growth pattern is preferred to minimize the wedging effect.
e) If there is presence of a skeletal closed bite, distalizing the molars will
alleviate it by causing wedging effect, thus prop opening the bite.
4) Dental:
a) Most importantly, molar distalization is indicated in Class II molar relationship and
distalizing the upper molar will help in achieving class I molar relationship.
b) In cases of deep overbite, distalization of the molar will help in prop opening the
bite due to wedging effect.
c) It is generally indicated in permanent dentition.
d) Molar distalization is indicated in cases where the first molar is mesialised or
mesially inclined.
e) Preferably prior to eruption of second molar, the angulation of third molars is
also to be taken into consideration.
f) In cases wherein the maxillary cuspids are labially displaced, distalizing the molar
will help in increasing the arch length.
g) Loss of arch length due to premature loss of second deciduous molar.

Clinical scenarios of molar distalization having beneficial outcome can be
summarized as:
1. Class-II molar relationship due to maxillary dentoalveolar protrusion
2. Class-II molar relationship due to impacted / high labially placed cuspids
3. Class-II Subdivision cases requiring unilateral distal molar movement.
st nd
4. Class-II molar relationship due to ectopic eruption of either 1 /2 bicuspid
5. In cases wherein there is midline discrepancy
6. Regaining the space loss due to mesial drift of 1st molars following premature loss
of deciduous teeth.
7. Anchorage loss during active orthodontic treatment.
8. Mandibular molar distalization can be done in cases of dental class III associated
with skeletal class I malocclusion.
9. To correct mandibular incisor alveolar protrusion, with or without associated
crowding;
CONTRAINDICATIONS FOR MOLAR DISTALIZATION
CONTRAINDICATIONS FOR MOLAR DISTALIZATION
The section below describes the contraindications for molar distalization in the
following conditions.
a. In cases wherein the growth pattern of the patient is vertical which further
accentuates the wedging effect if molars were distalized.
b. In clinical conditions like adenoid facies wherein distalizing the alveolar segment
leads to further constriction of airways.
c. In cases of high arched palate or long face syndrome, where the preferred
treatment will be to implement arch expansion without tipping the molars.
Therefore, in such cases, bonded RME is indicated which won’t further cause
increase in vertical height.
d. In Dental open bite cases, molar distalization is contraindicated as it will cause
wedging effect which will lead to backward rotation of the mandible.

UNFAVOURABLE FEATURES FOR MOLAR DISTALIZATION
UNFAVOURABLE FEATURES FOR MOLAR
DISTALIZATION
1) Profile:
a) A retrognathic profile is generally not indicated for molar distalization as it will
worsen the profile.
2) Functional:
a) Any existing signs and symptoms of temporomandibular joint dysfunction will
further accentuate the joint dysfunction after the molar is distalize.
b) A more posteriorly and superiorly displaced condyles tend to have an open bite
tendency and further distalizing molars will caused wedging effect.
3) Skeletal:
a) In a Class II skeletal relationship, it is very important to know where the defect lies,
whether the maxilla is forwardly placed or whether the mandible is backwardly
placed. Distalizing the molar when the mandible is already backwardly placed does
not help in achieving class I occlusion as it does not treat the etiology.
b) It is not preferred in cases of skeletal open bite as it will further lead to wedging
effect.
c) Molar distalization will cause backward rotation of the mandible which will further
increase the lower anterior facial height.

UNFAVOURABLE FEATURES FOR MOLAR DISTALIZATION
d) Molar distalization in already constricted maxillary arch will further cause tapering
of the arch leading to cross bite.
e) It is very important to know the growth pattern of the case. Distalizing the molars in
a dolichocephalic growth pattern will cause further worsening of the profile.
4) Dental:
a) The dental relationship of Class I molar relation.
b) If molar distalization is done in a patient with dental open bite, it will cause further
wedging effect, which will lead to worsening of the profile.
c) Since many studies have shown that the movement achieved during molar
distalization is seldom translation, distalizing a maxillary first molar which is
distally inclined, causes bite opening.
Clinical scenarios of molar distalization having detrimental outcome can be
summarized as:
1. Retrognathic profile (Class-II skeletal with orthognathic maxilla and
retrognathic mandible).
2. Skeletal and dental open bite
3. Excessive lower anterior facial height (Dolichocephalic facial form)
4. Constricted maxilla
5. Patients with Class-I or Class-III molar relation.

CONSIDERATIONS FOR MAXILLARY MOLAR DISTALIZATION
CONSIDERATIONS FOR MAXILLARY MOLAR
DISTALIZATION:
The criteria varied widely among the clinician but some of the most common
criteria are Class-II or end-to-end molar relationship with maxillary molar protrusion
with mesial inclination as explained earlier. Growing patients are ideal, as molar
extrusion can be compensated with ramal growth, so there won’t be any autorotation
of the mandible. It is basically done in mild or moderate crowding to increase the
total arch length. The best time to distalize the permanent first molar is when the
third/second molars or not yet erupted or if erupted, they must be in ideal positions.
Normal skeletal vertical development is favorable i.e. the facial proportion should
be with in normal limits. Another important aspect is that, the mandibular plane
angle must be low to moderate as in hypodivergent cases so as to negate the wedging
effect. And also, normal transverse development must be present too i.e. there must
be no cross bites. It becomes very crucial to have a good soft tissue drape.[12] And
lastly, like an orthodontic treatment, good patient cooperation plays a crucial role in
success of the treatment.

CONSIDERATIONS FOR MANDIBULAR MOLAR
DISTALIZATION:
Orthodontic displacement of the mandibular molar, other than extrusion, is reputed
to be extremely difficult, due to the large root area and root anatomy. In certain
clinical situations, however, extreme measures may be taken to avoid irreversible or
risk-laden procedures such as extraction or orthognathic surgery. Organizing the
space within the dental arcade involves two essential factors: tooth size and arcade
perimeter. The latter is determined by the anterior, lateral and posterior edges, and
the space occupied by the arcade depends on 3D compensatory curves. In adjusting
tooth crowding, any extraction is usually performed in the sector where crowding is
present, to limit and facilitate orthodontic movement in the freed space. For
example, in severe anterior crowding associated to correction of mandibular incisor
alveolar protrusion, the 1st premolars may classically be extracted. However, it
might be interesting if the space freed by the absence of the 3rd molars could be
transferred forward, and if the mandibular molars could be distalized. While
possibly indicated, class III surgical correction has a number of drawbacks or
relative contraindications leading to abstention despite skeletal malocclusion.[13]
Over and above the risks inherent to any surgery, such problems include: Esthetic
defect, postoperative discomfort leading which may be incompatible with lifestyle,
psychological issues and financial burden. Therefore, an interesting possibility
would be to correct class-III malocclusion by distalizing the mandibular molar while
controlling the vertical dimension.

Finally, it should be borne in mind that posterior displacement of the mandibular
molar cannot exceed the anatomic envelope within which it is possible: i.e., the
mandibular lingual cortical bone. According to Ridouani, 3 mm distalization is the
anatomic limit.
EVALUATION OF MOLAR DISTALIZATION FEASABILITY
EVALUATION OF MOLAR DISTALIZATION FEASABILTY
1) Maxillary molar position:
a) Rickets criterion:
Ricketts stated that the position of the maxillary molar (M1) should be that the
distal surface of the molar should be perpendicular to the pterygoid vertical(ptv).
The clinical norm is age+3 and clinical deviation is +/-3 mm. (growing patients). In
good skeletal and dental class I relationships, the facial axis normally crosses the
mesial cusp of M1. In non-growing patients mean value is 18 mm. If the distance
M1/PTV is shorter than the normal measurement, the possibility for distalization is
low and possible extractions will depend on growth potential and the presence of
3rd molar.[14]
Figure 4 Ricketts criterion for distalizing upper molar

b) Role of second molar and third molar extraction:
Extraction of second molar is often use in conjunction with distalization
of first molar. In last few years the extraction of second molar has become a matter
of great interest and controversy within dental profession. It has been argued that
when the second molar has not yet erupted, distalization of the first molar occurs by
tipping rather than by bodily movement. Several other authors agreed that the
eruption stage of the second molar had an impact on the distalization of the first
molar. Duration of therapeutic treatment has also been shown to increase if second
molars have erupted, and therefore distalization is often recommended prior to the
eruption of the full permanent dentition.
On the other hand, there have also been a few investigations that have concluded
that the position of the second molar when distalizing the first molar is of little
significance. The authors of these studies all found that there is no connection among
second molar budding stages, magnitude of molar distalization, and duration of
therapy. A clinical study further argued that the success of first molar distalization
varies according to the stage of development of the second and third molars. As a
result, germectomy of wisdom teeth was recommended to achieve bodily
distalization of both molars.[15]
Although a large number of studies reporting on maxillary molar distalization
have been published over the years, considerable controversy exists regarding upper
first molar distalization with respect to second and third molar eruption stage.
2) Mandibular molar position:
a) Anatomical limits:
Anatomical limit for mandibular molar distalization is the inferior alveolar nerve
canal, because the superior border of the inferior alveolar nerve canal may restrict
the distalization of the second molar root at the apex. Therefore, 3D morphometric
analysis of the mandible may provide a better understanding of the mandibular
anatomy and its correlations with the posterior mandibular space available for molar
distalization.
And also, ramus also plays a significant role in determining the amount of molar
distalization that can be done.
b) Role of second molar and third molar:
Mandibular molar distalization is limited by the proximity of the distal root of the
second molar to the lingual cortical plate rather than by the distance from the crown
of the second molar to the anterior border of the ramus. Therefore, the retromolar
distance at the root level must be analyzed. It can be expected that the retromolar
space is greater in patients with Class III malocclusion than in patients with Class I
malocclusion because Class III malocclusion is characterized by a large mandible.
However, various factors affect the outcome, such as cephalometric
characteristics, age, and sex, and these factors can act as confounders.
Using general linear mixed model analysis, it is possible to compare the retromolar
distances between mandibular prognathism and normal mandibular growth after
adjusting for factors that significantly affected the outcome.
It is assumed that in cases with the presence of third molars, it would be feasible to
undergo extraction prior to molar distalization. Therefore, the retromolar space is
measured without considering the presence of the third molars. In patients with
impacted third molars, the third molar crowns is often located in the anterior part of
the ramus, as there is limited space for eruption, and they are expected to have a
minimal effect on retromolar space distal to the second molar root.
For the third molars that had erupted, it is assumed that extraction will not cause
significant bony changes in the lingual cortical border of the mandible. According
to Kim et al., the presence of mandibular third molars has no significant effect on
the retromolar space measured in patients with Class III malocclusions.

ADVANTAGES OF MOLAR DISTALIZATION
ADVANTAGES:
The advantages of molar distslization technique can be listed as follows.
1) Facilitation of treatment using intra oral removable or fixed appliance. As many

appliances can be fabricated for removable usage, maintaining the oral hygiene
becomes easy. And if it is fixed, then patient compliance will be good.
2) There is less likelihood of relapse. Many studies have shown that the residual
maxillo-mandibular growth continued after the completion of orthodontic
treatment, but these changes did not affect the molar relationship.
3) By undergoing this technique to increase the arch length, faster eruption of third
molars can be anticipated or even the surgical removal of the tooth can be avoided.
4) Good functional occlusion is also maintained.
5) In cases of mild premolar crowding, space can be gained by increasing the arch
length by distalizing the molar. And also, premolar crowding is corrected without
mechanotherapy.
6) And also, the contact points are precisely maintained by using this technique.
Natural contact area from canine to first molar is retained.
7) Results are more stable as tongue space has not been compromised. So, tongue
does not have to undergo changes in its position.
8) And lastly, since premolars are not extracted, more teeth is made available for
functional processes like mastication etc.
DISADVANTAGES OF MOLAR DISTALIZATION
DISADVANTAGES:
The disadvantages of molar distalization technique can be summed up as follows.
1) As the molars are distalized, achieving pure translation is still a challenge so there
is always a tendency in creating crossbites.
2) Even though this technique has evolved from extra oral to intra oral, the
construction of few appliances is still considered to be delicate.
3) And lastly, there can be possible impaction of third molar even when the second
molar has been extracted for distalizing the first molar.

CLASSIFICATION OF MOLAR DISTALIZATION APPLIANCES
CLASSIFICATION OF MOLAR DISTALISATION APPLIANCES
Appliance systems which are designed to produce distal movement of first
molars have been available for over a century. Several methods are known to cause
molar distalization, none of which work for all patients in all patients in all
situations. Appliance traditionally used to distalize molar can be divide into the
following.
1) Location of appliance: Based on location, it can be classified into extra oral and
intra oral.
a) Extra oral appliance is one such appliance which has its components situated
outside the oral cavity.
Eg: Headgear
b) Intra oral appliance is one such appliance which has its components situated
inside the oral cavity.
Eg: pendulum, jones jig appliance
2) a) Removable: Orthodontic appliance which can be removed and replaced by
the patient.
Eg: Lip Bumper, Cetlin Appliance

b)Fixed: Orthodontic appliance which cannot be removed and replaced by the
patient.
Eg: Pendulum appliance, K. loop molar distalizer, Lokar appliance.
3) Arches involved: Based on the arches involved, it can be single or both the arches.
a) In Intra-arch, single arch is involved, ie. either maxilla or mandible.
Eg: Jones Jig, K. loop distalizer
b) In Inter-arch, both the arches are involved, ie. maxilla and mandible.
Eg: Sliding Jig, Fixed functional appliances
4) Position of appliance in mouth: Based on the location of appliance within the
mouth, it can be placed buccally or palatally/lingually.
a) Buccally situated appliance is the placement of the appliance on the side of

a tooth that is adjacent to (or the direction toward) the inside of the cheek.
b) Palatal situated appliance is the placement of the appliance on the side to lingual or
palatal (both oral), which refer to the side of a tooth adjacent to (or the direction
toward) the tongue or palate.

5) Type of tooth movement: Based on the type of movement, the appliance can
distalize the molar either bodily or by tipping.
a)Bodily movement or translation occurs when all points on the molar tooth
move an equal distance in the same direction.
b)Tipping movement (combined rotation and translation) occurs if the force does
not pass through the CR, the molar will translate as well as rotate around the CR.
Orthodontically, tipping movement is produced when a single force is applied
against the crown of the molar. The molar will then rotate around the centre of
resistance as well as translates along the line parallel to the line of force.
6) Compliance needed from patient: Patient compliance describes the degree to

which the patient will correctly follow the medical advice.
a) Maximum compliance is needed in case of headgear appliance.
b) Minimum or No compliance is needed in case the appliance is
placed intra orally and when it is generally fixed.

APPLIANCES USED FOR MOLAR DISTALIZATION
APPLIANCES USED FOR MOLAR DISTALIZATION:
Maxilla:
1) Extra oral: Head gear
a) Bilateral molar distalization
• Cervical pull head gear.
• Vertical pull headgear
• High pull headgear
• Combi pull head gear.
b) Unilateral molar distalization with unilateral face bows
• Power-arm face bow
• Soldered offset face bow
• Swivel offset face bow
• Spring-attachment face bow
2) Intra oral:
a) Hilgers mini distalization appliance
b) Modified Cetlin appliance

c) ACCO (acrylic cervical occipital appliance)
d) Wilson rapid molar distalization
e) Bimetric arch modified by Dr. JAYAPE
f) T.P.A
Mandible:
1) Lip bumper
2) Franzulum appliance.
3) Modified lingual appliance
4) Distal jet for lower molar
Inter arch appliances: (fixed functional appliances)
1) Herbst appliance
2) Jasper Jumper
3) Klapper super spring
4) 3D biometric distalizing arch

5) Sliding jig
6) Removable molar distalization splint
7) M.D.S (Molar distalization system)
8) Repelling magnets
9) Jones jig appliance
10) Lokar appliance
11) Super elastic NiTi wire
12) Pendulum appliance
13) HILGIR’S appliance
14) Grumax appliance
15) T-Rex appliance
16) Tracey/ Hilger MDA expander
17) K-pendulum
18) BI/quad pendulum
19) Gral implant supported pendulum
20) K loop
21) Fixed piston appliance
22) Intra oral bodily distalizer

23) The lingual distalizer system
24) C-space regainer
25) Distal jet
26) Nickel titanium double loop system
27) Crickett appliance
28) First class appliance
29) Sliding jig
30) Modified Nance and lingual appliances for unilateral tooth
movement.
31) Karad’s integrated distalization system
32) Modified sectional jig
33) Keles slider
34) Carriere distalizer
35) Vertical holding appliance
SAS(skeletal anchorage system):
1) Distalization using Micro implants
2) Using Y plates
3) Straumann orthosystem
4) Midplant system
5) Distalizing mid-palatal miniscrew
6) Frialit-2 implant system
7) Onplant system
8) Enmasse distalization using miniscrew anchorage
9) Zygoma gear appliance

APPLIANCE SELECTION CRITERIA
APPLIANCE SELECTION CRITERIA:
Regardless of approach, one should ponder several issues before considering any
of these appliances for use. Because, only when the right appliance is chosen, the
treatment results will meet patients satisfaction and also give good stability to the
end result.[16]
1) CASE TYPES:
One must consider individual case at hand and the patient’s needs and
requirement. If mandibular dentition can be slightly mesialized, then Herbst or BDA
(Bimetric Distalization Arch) may be appliance of choice. If not pendulum and other
intra-arch appliances can be used. And if the treatment objective does not require
flaring of the incisors, then TPA (Trans Palatal Arch) or headgear would be the
treatment of choice.
II) ADVERSE EFFECTS AND ANCHORAGE CONSIDERATION:
It is challenging to perform distalization of maxillary molars without tipping and
extrusion that could cause relapse. Traditionally, headgear has shown successful
results in Class II treatment. While its effect is a combination of distal movement of

molars, inhibition of maxillary growth, and rotation of the palate, it is dependent on
patient cooperation and may cause psychological distress. Also, it is difficult to
achieve bodily tooth movement.
To avoid the negative aspects of headgear, several intraoral appliances such as
distal jet, Herbst, and pendulum springs have been developed to distalize molars;
however, they have some drawbacks. For instance, the distal jet has been known to
lead to mesial rotation of the molars during distalization, and the pendulum appliance
has resulted in distal tipping of molars, anchorage loss, and a tendency for reciprocal
effects. In general, the side effects of these appliances are anchorage loss at the
reactive part causing flaring of the incisors, distal tipping, and rotation of the distalized
molars.[15]
To reduce these shortcomings, several studies have considered the application of
temporary anchorage devices (TADs). TADs have been applied to the buccal plate
of bone to achieve molar distalization. However, the buccal approach poses an
increased risk of contact with the roots of adjacent teeth, and the range of action
might be limited by the interradicular space in adolescents.
Adverse effects are a fact of life, especially in orthodontics. The questions, which
arise regarding side effects, are in an attempt at distalizing the molar teeth, what else
can happen? Did the incisors flare as a result of Treatment? Should the mandible
used as an anchor unit? Did anything occur in that arch?

III) ARCH LENGTH :
A next question to be asked is how much arch length is needed. Distalization of
the maxillary molar will increase the arch length and provide the necessary space
for teeth alignment and decrowding the anterior segment. If the arch length
discrepancy is 2 to 3 mm or if a space of 2 to 3 mm is needed, then a TPA can be
used. Similarly, arch length discrepancy of 5 mm, all other appliances can be used.
And if a space of more than 5 mm is required, headgear and Herbst appliance can
be used.
IV) TREATMENT TIMING:
Perhaps best time to initiate distalization is late mixed dentition and it may be too
late after eruption of second molar. There appears to be some synergistic effect as
dentition transits from primary to permanent. Because clinically erupting canines
and premolars often appear to follow molars as they moved distally. Thus,
appliances that require some anterior anchorage like pendulum may dilute these
results.
V) PATIENT COMPLIANCE:
This factor has probably driven modern day orthodontics more than any other
social issue. So appliances requiring least co-operation maybe chosen. Invariably
appliances that require least in co-operation come with side effects that have to be
considered.
TREATMENT PLANNING
TREATMENT PLANNING
There are two different approaches towards molar distalization. It is as follows:
a) Molar distalization started after completing the levelling and aligning phase of
fixed orthodontic treatment so that the patient will be on a rigid stainless-steel wire
which will be able to support the distalization appliance.
b) Molar distalization is started before or during the levelling and aligning phase
using appliance which does not depend on the support of wire or brackets of fixed
orthodontic appliance.
Incorporating molar distalization in the treatment plan will be left with the
clinician to choose one among these two. Depending on the age of the patient and
time constraints for the treatment, the clinician has to choose an approach for the
treatment.
The treatment approach is divided into two phases[17]:
1) First phase/ Space gaining phase:
The main objective of phase one of the molar distalizing mechanism would be to
distalize the upper molars bodily so that it would be feasible for the patients to
occlude in super class-I occlusion. i.e. it has to be over corrected. Generalized
spacing can also be achieved through dento-alveolar widening and growth. This
will provide the adequate space to distalize the posterior segment. Another
important criteria is to correct the molar inclination, rotation and cross bites if
present.
TREATMENT PLANNING
2) Second phase/ Consolidation phase:
In the second phase, the main objective would be to achieve Andrew’s six
keys to normal occlusion. At this point, it would be paramount to intrude
and retract the maxillary anterior segment with appropriate mechanics by
considering the posterior segment as anchorage unit. Concurrently, all other
malpositions are corrected and the adequate overjet and overbite must be
achieved. The detailing of the arch and also the occlusion must be done after
the closure of residual spaces.

BIOMECHANICS OF MOLAR DISTALIZATION
1) Basic Biomechanics:
The basis of orthodontic treatment lies in the clinical application of
biomechanical concepts. Mechanics is the discipline that describes the effect of
forces on bodies; biomechanics refers to the science of mechanics in relation to
biologic systems. Orthodontic treatment applies forces to teeth; the forces are
generated by a variety of orthodontic appliances. The mechanical principles that
need to be defined include the following:
A force: A force is that which changes or tends to change the position of rest
of a body or its uniform motion in a straight line. The forces used in orthodontics
are created by elastic or spring traction.
Force resolution: Forces may be resolved into component vectors which, in a
single plane of space, are at right angles to each other. The extraoral force
application to molars is considered to be the resultant force which, in the
discussion, are resolved into its components in the various planes of space.
Horizontal and vertical components of an orthodontic force:
Any force applied to a tooth can be broken up into its vertical and horizontal
components using the occlusal plane as the horizontal reference of an orthogonal
coordinate system. The calculations of magnitude and direction of the
components can be carried out geometrically as in Fig 5 or by using trigonometric
methods.
Figure 5 horizontal and vertical components of a force F applied to a

tooth
Effects of concurrent forces on a body
Concurrent forces depicted as vectors can be added together to calculate the
resultant by using the parallelogram method or by addition of their components in a

reference system. For the latter method, the horizontal and vertical components of
each of the two forces can be added to calculate the resultant as follows: If F1 =
h1+v1 and F2 = h2+v2, then R = F1+F2 = (h1+h2) + (v1+v2).
The parallelogram method used to derive resultant forces entails drawing the two
concurrent forces (F1 and F2 in Fig. 6) to scale at appropriate angulations. The ends
of these lines are joined together with a parallelogram. The diagonal of this
parallelogram from the point of force application, when measured and converted
using the specified scale, gives the magnitude of the resultant (R). The direction of
the resultant relative to any plane (e.g., the occlusal plane) can be determined using
a protractor.
Figure 6 The resultant (R) for two concurrent

forces F1 and F2 acting on a tooth.
The diagram below shows how to derive the resultant of two forces acting on an
upper molar, one at the tube level for its distal movement and another from the outer
bow of a headgear. (7 A) (The need for applying headgear force along with a
distalizing force will be explained in a later chapter on extra-oral appliances.) Since
the arrows representing the two forces are not meeting at one point, they are shifted
backwards along their respective lines of action till they meet. (7 B and C) A
parallelogram is then constructed to find their resultant. (7 D and E). Note that based
on the same law, the resultant could be moved along its line of action till its point of
application is on the tooth, if need be.
Figure 7 method to derive the resultant of two forces

having two different points of application
Force needed: The principle of extra oral distalization is that the line of action must
pass through the center of resistance of the molar. In order to accomplish a successful
distalization treatment the amount of force applied and the time of use are very
important. 12 ounces or 300 g- 500 g per side is recommended. For intra oral
appliances having coil springs, a force of 75-100 g per side is recommended.
Center of resistance: The C Res is an imaginary point at which the whole object
may be considered to be condensed, for understanding and for predicting its
displacement from the application of force/forces. The centre of resistance for an
upper molar is situated at the furcation of its roots (BURSTONE). For our ease in
understanding/ we often consider the C. Res. of any structure like a tooth, in its two
dimensional view. However, we need to remind ourselves that teeth and jaws are
three dimensional objects. In an occlusal perspective, the C Res lies on the long axis
of the tooth. In the facial, lingual and proximal perspectives, as mentioned above,
the location of C Res for molar is near the furcation of roots (Fig.8). When teeth are
rigidly connected, the C Res of the entire connected segment must be taken into
account as shown in[19] Fig. 9.

Figure 8 C Res of a lower molar in different

perspectives
Figure 9 C res of an unconnected molar,

of a segment in which a molar is
connected to incisors, and of the entire
connected quadrant
The position of Cres is not standardized and is not a fixed entity. It is subjected
to variation depending on root length and bone coverage and the condition of the
supporting structure.
Figure 10 normal versus teeth which are Figure 11 the different location of the
periodontally compromised with altered centre of resistance for periodontally
anteaes law (altered crown root clinical ratio) compromised teeth
In periodontally compromised teeth i.e. bone loss, the center of resistance is
displaced apically following the anatomical elements of the periodontium, thus
resulting in the expression of greater moments during force application and an
increase in the extrusion component of the applied force.
Line of action: The line of action of a force is usually represented by an arrow and
is the direction in which the force acts.
Distance of the line of action from the center of resistance:
When the line of actions passes through the center of resistance of a tooth, no tipping
will occur. Tipping, however, will occur if the line of action does not pass through
the center of resistance (C). The tipping takes place around a center of rotation
(R).[fig 12] The center of rotation varies and is dependent upon the relationship of
the line of action to the center of resistance of the toot.[17]
Figure 12 C Centre of
resistance, R center of rotation,
T line of action of force
Should the line of action (T) pass occlusally through the center of resistance, the
crown of the tooth will tip distally (and the root apex mesially). The farther the line
of action is from the center of resistance of a tooth, the greater is its tipping effect.
This principle is easily analyzed by applying the simple formula
M=TxP
M represent the moment producing the tipping; T represent the tension (extraoral
traction)
P represent the perpendicular distance from the center of resistance of the line of
action.
If the line of action (T) passes through the center of resistance, P must be zero, in
which case no tipping moment will occur. In other words, the line of action and the
center of resistance of the tooth are in a straight line.(Fig 13A)
On the other hand, if the line of action is moved farther away (above or below) from
the center of resistance of tooth (Fig.18 B and C) P is increased. Since M = T x P,
the tipping moment is proportionately increased. Thus, the control of tipping force
to a molar tooth based on the above principle is readily applicable.
Figure13 C Center of resistance, T Tension (line of action of force) P

Perpendicular distance, M moment
Basic displacements and their combinations: The two basic displacements are
translation and pure rotation. In between them are combinations of the two in
varying proportions. All these are produced depending on how a force is applied in
relation to the Center of resistance. They are best understood in the following order:
translation, combination of translation and rotation, and rotation.
Translation: When a force acts through the C Res, it causes translation of the
body, In translation, all points on the body move an equal distance in the same
direction, along straight lines parallel to the line of force. Remember that
translation or bodily displacement could occur in any plane - horizontal, vertical or
oblique depending on the direction of the force.
Figure 14 Direction of force passing through the center of resistance
Part translation and part rotation: We will now briefly see the importance of
keeping in focus the C. Res. in different perspectives that was mentioned earlier. If
we fail to do this and consider the tooth movement in only one plane, undesired tooth
movements could occur in other planes. For example, applying a medial force on
the lingual aspect of a molar tooth from the lingual sheath, the force passes through
the C. Res in an occlusal perspective causing translation. But the same force would
change its inclination (i'e', translate and rotate it in a crown-lingual root buccal
fashion), because it is acting away from the C. Res' in the distal perspective[20] (Fig
15).
Figure 15 the forces acting through the C Res in

the occlusal perspective becomes an eccentric
force in distal perspective and causes translation
plus rotation (lingual tipping)
Moments: Common sense will tell us that closer the force to the C Res, greater
will be the translational effect and lesser will be the rotational effect, and vice
versa. This gives us a method for calculating the rotational tendency or potential
for rotation, which is called the Moment. A moment is represented by a curved
arrow and the arrowhead denotes its clockwise or anti-clockwise sense.

Figure 16 Moments created varies depending on point of application of force
Moment from the application of a force couple - Pure rotation: Using the above
reasoning, let us see what happens when a force couple is applied on a body such
that the two forces F1 and F2 are equidistant from the C. Res. The translational
effects caused by the two forces will cancel out (dotted arrows in opposite
directions). But the moments MF1 and MF2, which are equal in magnitude, are
additive because they both have the same direction. Hence the total moment
generated will be equal to the force*2*the perpendicular distance of each force from
the C. Res. In other words, moment is the product of the single force multiplied by
the perpendicular distance between the two lines of forces (Fig 17). The moment
produced by the application of a couple causes pure rotation, meaning there is no
translation of the body at all.[20] The body rotates with the C. Res as it center.(Fig
18)
Figure 17 moment of a couple = force * perpendicular

distance between the two lines of force Figure 18 in pure rotation, all points on the body move
along arcs of concentric circles
2) Biomechanics required for molar distalization:
The components explained above holds good to execute bodily movements in any
tooth. However, the following criteria is exclusive for translation of molar
distalization.
Centre of resistance: To allow bodily movement of molars during its
distalization, the force applied must pass through the center of resistance.
Figure 19 force passing through

centre of resistance of maxillary molar
Line of force: The line of force must be parallel to the occlusal plane and must
also pass through the center of resistance of the molar in order to prevent untoward
movements like tipping, buccal flaring and rotation.
Figure 20 Force applied must be parallel to

occlusal plane
Application of power arm: As the force is applied below the center of resistance
(CR) of maxillary molars, they tend to tip mesially during the space closure and
uprighting of molars is often required during the finishing stage. Also it leads to
anchorage loss. Thus to overcome these problems, the force on molars should be
applied at their CR, which is at the trifurcation areas. Studies show the application
of power arm made up of rectangular stainless steel wire which is designed for
molar stabilization to be engaged in the miniscrew implant head slot and in the
auxillary molar tube for optimizing tooth movement. A removable power arm can
be attached to the headgear tube of molar tube during the retraction of anterior teeth.
Figure 21 Insertion of horizontal arm of the

power arm in the round tube (headgear tube)
from distal aspect
Force needed for molar distalization: For bodily movement the force system
applied at the crown must be equivalent to the force and moment of force at the
CR. Therefore force system having a force and a couple at the bracket is needed so
that a tooth can be moved bodily. The optimal force level for bodily movement
would be 70 to 120 gm.

SKELETAL AND DENTAL EFFECTS OF MOLAR DISTALIZATION
It is challenging to perform distalization of maxillary molars without tipping and
extrusion that could cause relapse. Traditionally, headgear has shown successful
results in Class II treatment. While its effect is a combination of distal movement of
molars, inhibition of maxillary growth, and rotation of the palate, it is dependent on
patient cooperation and may cause psychological distress. Also, it is difficult to
achieve bodily tooth movement. To avoid the negative aspects of headgear, several
intraoral appliances such as distal jet, Herbst, and pendulum springs have been
developed to distalize molars; however, they have some drawbacks. For instance,
the distal jet has been known to lead to mesial rotation of the molars during
distalization, and the pendulum appliance has resulted in distal tipping of molars,
anchorage loss, and a tendency for reciprocal effects. In general, the side effects of
these appliances are anchorage loss at the reactive part causing flaring of the
incisors, distal tipping, and rotation of the distalized molars.[18]

ANCHORAGE CONSIDERATIONS FOR MOLAR DISTALIZATION
ANCHORAGE CONSIDERATIONS FOR MOLAR
DISTALIZATION
1) Conventional anchorage designs:
Intra-oral appliances for non-compliance molar distalization are generally anchored
with an acrylic button or pad placed on the palatal mucosa in the palatine rugae
region that is usually attached to four deciduous molars or premolars using bonded
occlusal rests or preformed bands. This anchorage design during distal molar
movement using a modified Nance button has proven to be fundamentally
satisfactory. However, one must consider that, in isolation and when placed on the
resilient palatal mucosa, the anchoring capacity of the Nance anterior palatal button
may rely on hydrodynamic interaction only and may not provide a stationary
anchorage effect. Moreover, one must take individual differences such as those
regarding the palatal mucosa’s thickness, and the depth and width of the palatal vault
into account. While tongue pressure during swallowing may have an additional
vertically stabilizing effect, clinical studies have also shown that the Nance soft
tissue-supported holding arch’s anchoring efficacy should not be overestimated.[21]
Furthermore, there have been many reports of the mucosa being affected locally due
to disadvantageous oral hygiene conditions. Defective manufacture or exaggerated
activation of the active components can result in palatal impingement of the acrylic
button, and even pressure-induced ulcers are possible. Thus the anchorage system is
supported mainly by the periodontal anchoring ability of the teeth.

The resistance potential of these anchoring teeth is determined mainly by the size of
the surface available for anchorage, that is, the number of teeth to be used for that
purpose, root topography, level of attachment, and bone structure.
2) Limits of conventional design:
In children going through mixed dentition and in adults with a pathologic
periodontal situation or early tooth loss, the clinician’s ability to use the patient’s
own dentition for orthodontic anchorage is often limited. Research into intraoral
distalization appliances has shown that a clear anchorage loss occurs when only two
teeth are involved in the anchorage unit. The reactive segment should therefore be
formed if possible by four anchorage teeth interlocked with the acrylic button by
occlusal rests or preformed bands to become a “multiple-rooted anterior anchorage
tooth”, thus permitting equally-distributed periodontal loading. Both deciduous
molars and premolars are fundamentally suitable for establishing dental anchorage.
One must however be aware that the extent and quality of molar distalization
improves, and that there are fewer side effects in the anchorage teeth and incisor
region, when dental anchorage is achieved with premolars exclusively.[21]
Conversely, if only deciduous molars or a mix of pre- and deciduous molars are used
for anchorage, more emphatic side effects can be expected. Also, the anchoring
capacity of deciduous molars that have already been locally resorbed in the distal
root region are less able to provide stable anchorage.

Thus, whenever considering anchorage in deciduous molars, one should first check
to see if any of the teeth have already begun to loosen, so as to avoid having to
remove the appliance prematurely because anchoring capacity had initially been
overestimated. Certain dentition stages and certain local conditions in the maxilla
may be regarded as a relative contraindication for molar distalization with non-
compliance devices using conventional anchorage designs: In a histological survey
on human specimens, Rudzki Janson et al. investigated the effects of orthodontic
tooth movement on mixed dentition. At the start of treatment, they observed the
germ of an erupting upper canine in the maxilla in a crowded position with respect
to the first premolar. After a multiband appliance had been administered, they noted
an orthodontically-induced mesial movement of the first premolar during the
leveling phase via a continuous arch technique. Consequences that histological
analysis revealed were marked erosion of the alveolar and interradicular bone, as
well as root resorption in the first premolar region caused by resorptive activity of
the canine follicle. Dental crowding in the supporting zone can cause negative side
effects, for instance a lack of space between the first premolar and lateral incisor can
cause canine retention or ectopic and infra positioned canine eruption. Clinical
radiological studies report that adjacent teeth are at a higher risk for resorption when
upper canine ectopic eruption occurs. In case of critical topographic relationships
(i.e., tooth germ crowding and/or canine impaction, already erupted first premolars),
our findings as well as the results of a study by Kinzinger et al. should be considered
when deciding on therapy options: further uncontrolled reduction in space must be
avoided.
In particular, once first premolars have erupted, exclusively dentally-anchored
distalizing appliances should not be used if the canine germs are crowded. As a
treatment alternative to premolar extraction at this dentition stage, one can consider
widening the supporting zones using extra-orally-anchored headgear. Should this
treatment appliance be rejected, the stationary anchorage of intra-orally distalizing
appliances to orthodontic anchorage implants deserves consideration.
3) Alternate anchorage designs:
One can achieve intra-oral stationary anchorage not involving the teeth by using an
endosseous implant in the hard palate region, or miniscrews combined with
anchorage plates. As already mentioned, the combination of palatal implants with
pendulum appliances in particular can be regarded as serious alternative anchorage
designs. Furthermore, as molars are distalized, the pull of the transseptal fibers cause
spontaneous distal drifting of the premolars and canines. During subsequent active
distal movement, stationary anchorage is possible with a transpalatal arch or via
construction of “active anchorage”. Auxiliary anchorage using miniscrews
combined with occlusally-anchored open coil spring systems also offers the
following important advantages: treatment is possible even with a reduced number
of teeth and limited dental anchorage capacity in the supporting zone. And also, the
drifting of at least the second premolars that occurs concurrent with the molar
distalization, and subsequent molar stabilization by deactivating the active

components are possible. So, in conclusion, alternative anchorage designs for intra-
oral appliances for non-compliance maxillary molar distalization are possible to treat
children, adolescents and adults. In this regard, one must differentiate between
auxiliary anchorage designs with implants of reduced diameter from absolute
anchorage designs with fixtures of reduced length. In addition, facilitating proper
hygiene, other key advantages are fewer or no side effects on the remaining
dentition, advantageous biomechanics, and a wider range of indications.[21] One
must keep in mind that these anchorage options cannot be considered standard care
options for reasons other than their expense. In certain cases, however, the use of a
combination of these innovative appliances has already become a worthwhile
treatment alternative. Their advantages for both patient and clinician are
unambiguous and trend-setting.

EXTRA ORAL MOLAR DISTALIZING APPLIANCES
MOLAR DISTALIZING APPLIANCES
1) EXTRAORAL APPLIANCES
Head gear:
One of the earliest methods of molar distalization introduced and proved to be
effective was by the use of head gears. Even though the use of occipital anchorage
in treatment of malocclusion has been demonstrated in 1823 by Gunnel. The use of
extra oral forces for distalizing the upper molar was put forward and proved by
CASE in 1921. The extra oral force was used not only to retract the maxillary and
mandibular anteriors but also to distalize the molars.
Components of head gear
The principle components are:
1. Force Delivering Unit: Usually a J” hook or face bow that delivers force to
the intra oral location.
2. Force Generating Unit: This is the active unit. These are usually bands,
springs or elastics.
3. The Anchor Unit: The location depends on the direction of force (neck pad or
head cap).
The forces are delivered onto the dental arches by:
4. Face bow: Here the forces are delivered on the lst molar where the inner bow
engages the buccal tube.
5. The J-hooks: Engages the anterior part of the arch wire.
Face bows
Face bows are usually bilaterally symmetrical. They can also be asymmetrical
when unilateral forces are to be delivered.
The face bow consists of: The Inner bow: It is made of 0.045” or 0.052” hard
stainless steel wire. This wire engages on the tubes on the molar band, occlusal
to the tubes for the arch wire. (Preformed double or triple buccal tubes are
available for this purpose which are soldered or welded on the molar bands.) The
outer bow: The whisker bow - this acts as a media through which force is
transmitted to the inner bow.
Selection of headgear:
According to Profitt, the following factors have to be considered before
deciding the type of headgear:
There are three major decisions to be made in the selection of head gear.
First, headgear anchorage location must be chosen to provide a correct vertical
component of force to the skeletal and dental structures. A high pull head cap will
place a superior and distal force on the teeth and the maxilla. A cervical neck strap
will place an inferior and distal force on the teeth and skeletal structures. When the
head cap and neck strap are combined, the total direction can be varied by altering
the proportion of the total force provided by each component. If each delivers equal
forces, the resultant force is slightly upward and distal for both teeth and maxilla. The
choice of head gear configuration should be based on the facial pattern. The more
vertically excessive growth is present, the higher the direction of pull and vice versa.
The second decision is the attachment of the head gear to the dentition. The usual
arrangement is a face bow to tubes on the permanent first molars.
Finally, the decision is to be made to whether bodily or tipping movement of the
teeth or maxilla is desired. Since the centre of resistance for a molar is in the mid
root region, force vectors above this point should result in distal root movement.
Forces through the centre of resistance of the molar should cause bodily movement,
and vectors below this point should cause distal crown tipping. The length and
position of the outer headgear bow relative to the center of resistance along with the
form of anchorage (head gear, neck strap, or combination) determine the type of
molar movement. A cervical neck strap, a high short or low medium length outer bow
will produce distal crown tipping along with distal and extrusive molar movement.
The most commonly used headgear in molar distalization is cervical pull head gear.
CERVICAL PULL HEAD GEAR
The most widely used type is called the Kloehn type headgear, designed by Dr.Silas J.
Kloehn in l947. Typically it is indicated in growing patients with decreased vertical
dimension. The purpose of the facebow is to restrict the forward growth of the maxilla,
the vector of force is below the occlusal plane producing both extrusive and distalizing
effects.
Figure 22 Cervical pull head gear
Effects of cervical headgear:
● Extrusion of upper jaw
● Distal movement of maxilla
● Steepening of Occlusal plane.
● Expansion of the upper dental arch.

Advantages
The direction of pull is advantageous in treatment of short face class II
maxillary Protrusive cases with low MPA and deep bites.
Disadvantages
It normally causes extrusion of the upper molars. This movement is seldom
desirable except in patients with reduced lower anterior facial height.
It is contraindicated in patients with steep mandibular planes and in open bite
cases.
Andrew J. Hass in the year 2000 conducted a study of two groups of patients with
42 and 58 subjects respectively and presented substantive evidence that class II
skeletal and dental corrections done with Kloehn cervical head gear. It was
uncommonly stable and he concluded that the Kloehn cervical headgear to be the
most versatile and effective appliance developed to date in orthodontic and
orthopedic history.
OCCIPITAL or HIGH PULL HEADGEAR
The occipital headgear consists of a facebow which fits over the occipit of the
head. The force generated by a high pull (occipital) has both distalizing and intrusive
forces since the force is exerted above the occlusal plane. Here, the forces delivered
are parallel to the occlusal plane, eliminating the disadvantages of a cervical pull
extrusion. This means the force distalizes the molar without any or unwanted
extrusion. Such forces are used in conditions where vertical control of the molars is
important. As growth guiding appliance, a high pull headgear can decrease the
vertical development of the maxilla, thereby allowing for autorotation of the
mandible and maximizing the horizontal expression of mandibular growth.
Figure 23 Occipital or High pull headgear
Advantages:
These headgears can be used in patients with steep mandibular planes and in
cases where in mandibular growth is more vertical than horizontal

COMBINATION HEADGEAR
Combination headgear has both occipital and cervical traction springs. This
perhaps is the most versatile type because the pull can be readily controlled by
selecting the force level of the springs and by controlling the length of the outer bow,
According to Nanda, for distal translation of the upper posteriors, a distal traction is
needed that passes through the Cres, neither above nor below. The combination
type headgear will allow a distal force straight through Cres by having equal
occipital and cervical components on the outer bow, which is angled upwards to
allow the force to pass through the Cres.
Figure 24 Illustration of combination pull head gear
Based on occlusal plane requirements, to obtain a distal force and to flatten the
occlusal plane the outer bow should be adjusted above Cres.
To obtain a distal force and to steepen the occlusal plane the outer bow should be
adjusted below the Cres. To obtain a distal force with no moment the outer bow
should be adjusted at the Cres

Figure 25 Illustration of combination pull head gear
VERTICAL-PULL HEADGEAR
The main purpose of this headgear is to produce an intrusive direction of force to
maxillary teeth, with posteriorly directed forces. If the outer bow is hooked to the
headcap so that the line of force is perpendicular to the occlusal plane and through
the CR, pure intrusion may take place. Due to the multiple notches in the headcap,
this headgear is also very versatile, as the LFO orientation may be changed.
However, upon establishing the LFO, our principles of determining force systems
produced remains unchanged. In Figure, the head is divided into two components:
the anterior component from the LFO forward and the posterior component located
behind the LFO. If the outer bow is placed anywhere in the anterior compartment,
the moment created will be counterclockwise, and the forces produced will be
intrusive and posterior. If the outer bow is placed anywhere in the posterior section,
the moment will be clockwise and the vertical force will be intrusive, but the
horizontal force will be forward. If this latter force system is desired, it will require
inserting the inner bow into the buccal headgear tube from the distal.
Figure 26 Vertical Pull head gear
UNILATERAL MOLAR DISTALIZATION WITH UNILATERAL FACE
BOWS
Power-arm face bow:
Outer bow is longer and/or wider - to receive greater distal force.
Disadvantage - Generates lateral forces which tend to move the favoured molar
into lingual cross bite and other molar into buccal crossbite.
Figure 27 Power arm face bow

Soldered – Offset Face Bow :
Outer bow is attached to inner bow by a fixed soldered joint placed on the side
favoured to receive the greater distal force.
Figure 28 Soldered offset facebow
Swivel-Offset face bow :
Outer bow is attached to inner bow through a swivel joint located in an offset
partition on the side favored to receive the greater force
Figure 29 Swivel offset facebow

Spring – Attachment face bow
An open coil spring is warped around one of the inner bow terminal and
conventional bilateral face bow.
Figure 30 Spring attachment facebow
Disadvantages of using extra – oral forces for distalization can be
summarized as:
1) Patient co-operation is essential for timely wear of the appliance.
2) The appliances are usually not worn continuously. Thus, they are intermittent in
their action resulting in prolonged treatment time.
3) The elastic cervical strap puts an unphysiological strain on the cervical spine and
on the neck muscles.
4) In some patients it causes irritation of the skin.

INTRA ORAL MOLAR DISTALIZING APPLIANCES
INTRA ORAL APPLIANCES
1. HILGERS MINI DISTALIZATION APPLIANCE
Comprises of small, spindle type expander that is soldered to bands on maxillary
first premolars. Distalizing spring are made from 0.032 TMA wire secured to palatal
side of spindle with a flattened recurved loop fitted into a braiced 0.036 lingual
sheath. Once appliance is cemented the lingual arms are bonded to second premolars
or second deciduous molars to enhance anchorage. It is Clean and rigid and should
be used in patients with stronger masticatory muscular pattern (Brachyfacial class II
div.2) and in whom some forward movement of anterior dentition is acceptable or
even desirable.
Figure 31 Hilgers mini distalization appliance

Figure 32 appliance after activation
Acrylic nance button anchor the appliance against palatal mucosa. Appliance is
anchored to maxillary dentition by placing bands on maxillary second premolars.
Premolar bands are connected to palatal acrylic by way of 0.036” wire that is
soldered to lingual aspect of bands. Bilateral tubes with an internal diameter of
0.036” are embedded in palatal acrylic. A stainless steel piston lies within the lumen
of the tube and extends posteriorly making a lateral bayonet bend and inserting into
lingual sheath of maxillary first molar. An coil spring and an activation collar are
placed over each tube.
Recommended using nickel titanium springs that generate 240 gm in adults and
180 gm in children. Can also be modified by incorporating helical loops in bayonet
bend just anterior to lingual sheath. Adjustment of these loops can produce distal
molar rotation or upright mesially tipped maxillary molars. If expansion of molars is
desired, appliance should be constructed parallel to the line of occlusion. If molars

expansion is not necessary, appliance should be constructed with distalizing
mechanisms 5o inward to line of occlusion. Activation once in 6 weeks on average,
seven month of molar distalization with four activation is required.
2. MODIFIED CETLIN APPLIANCE
Given by Cetlin and Tenhoe.
Appliance involves combination of extra oral force in the form of head gear and
an intraoral force in the form of a removable appliance. Cetlin appliance tips the
crowns distally and the extra oral force uprights the roots.
Figure 33 Modified cetlin appliance
APPLIANCE:
Active part contains 0.028” stainless steel distalizing spring. Retention part
comprises of anterior 0.017” X 0.025” arch covered by a labial screen and 2 Adams
clasps on 1st premolars/1st deciduous molars. Anterior Bite plane causes

disocclusion which aids in distal movement of upper molars and in leveling the curve
of spee by lip bumper.
CLINICAL MANAGEMENT:
Worn 24 hr / day except during meals. Always used with extra oral force. An
activation of 1 to 1.5 mm/side gives approximately 30 g of distal force either
bilaterally or adjusted on alternative sides.
3. ACRYLIC CERVICAL OCCIPITAL APPLIANCE (ACCO)
Developed by Dr.Margolis(JCO/1969). Removable appliance used with headgear.
Used for Distal mass movement of buccal segments.
APPLIANCE:
Appliance consists of a modified Adams clasps on the first premolars Finger spring
against the mesial aspects of the first molars. 1 mm bite plate to dis occlude posterior
occlusion for the distal movement of molars. Labial bow in which helices are
included between lateral and central incisors. A Straight pull or Northwest
Headgear was inserted into the helices and was worn at night in conjunction with
the appliance.
Activation: one half cusp width, not more than 100-125gms of force.
Used 24 hrs/day.
Rate of movement: Approximately 1 mm / month.

Ideal case: Cooperative patients in mixed dentition stage in which maxillary
second molars have not yet erupted.
Molars over corrected by approximately 2 mm for following reasons.
a) Anchor loss occurs during retraction of anteriors over correction serves to
compensate for this anchorage loss.
b) Distal tipping movement produces more of root movement,
c) Forward movement of tooth due to Anchor loss will up right molars to Class- I
relation (as more of crown mesial movement occurs.)
Figure 34 The ACCO appliance intra oral view

Figure 35 The ACCO appliance entra oral view
4. WILSON’S BIMETRIC DISTALIZING ARCH (WILSON’S RAPID
MOLAR DISTALIZATION)
Advocated by William L. Wilson & Robert C.Wilson. The Wilson treatment
achieves molar distalization without extra oral forces.

THE CONCEPT
Newton’s' 3rd law of motion states that 'for every force, there is an equal and
opposite force', (i.e.) for every moment, there is a counter moment. Implicit in
Newton’s' law is the concept that control of counter moments increases the
efficiency of the moment of force. Modular orthodontic units have been designed to
control counter moments, eliminate 'round trips', and reduce headgear use.
DESIGN OF APPLIANCE
Wilson advocates maxillary biometric distalizing arches (BDA) and a mandibular
three dimensional lingual arch. The bimetric arch produces a coil spring action
against the molars and producing an anterior counter moment against the incisors,
which is controlled by the wearing of class II elastics. These, in turn, react with a
lower molar mesial force vector which is controlled by the 3D lingual arch with a
design for anchorage resistance. This is supplemented by molar buccal root torque
and cortical resistance to satisfy increased anchorage needs.
Figure 36 Activation
The vertical component of elastic force is controlled by using the elastic load
reduction principle, in which the elastic force is reduced to physiologically
acceptable levels. Mandibular anchorage and elastic load reduction control the
reactive counter moments and produce a relatively friction free, rapid distalizing of
molars; without headgear and with preservation of mandibular arch integrity. Arch
is bimetric in that the anterior segment is made from 0.022” SS Elastic hooks are
attached to the posterior segment in the region of the upper canines. Omega shaped
stop is located in the premolar region. 0.010” x 0.045” open round coil spring is
placed between the distal leg of the omega stop and the face bow tube. The
distalizing force on the molars is produced by the compression of the push coil spring
anchored by the pull of Class-II elastics. Wilson and Wilson advocated sequential
use of elastics with decreasing force values i.e. 5/16” 6-OZ in first week, similar
size 4-OZ in second and similar size 2-OZ in third and subsequent weeks of
treatment. Appliance is activated by placing loop forming plier into Omega loop,
forcing posterior leg distally. Elastic sequence begins again when reactivated.
Figure 37 Wilsons rapid molar distalizer

Wilson's Schedule for Maximum Mandibular Anchorage
1) 6 ounce elastics for 5 days.
2) 4 ounce elastics for 5 days and
3) 2 ounce elastics for 11 days.
For minimal mandibular anchorage:
1) 6 ounce for 10 days
2) 3 ounce for 11 days.
5. BIMETRIC ARCH MODIFIED BY DR. JAYADE
Archwire design:
An .016”premium wire is used. Premolars are bonded if expansion is required.
Teardrop shaped loop is fabricated between premolar and molar with Bite opening
bend & Mild toe-in is given. 2mm of activation is done by opening the loop.
Elastic load reduction principle:
Class II elastics are used sequentially. Initial heavy force- to resist forward
pushing force of new wire- force transferred distally Later Molar uprights-mesially
directed archwire force decreases- hence support with light forces.

Figure 38 measurement of the loop
Figure 39 Bimetric arch before activation
Figure 40 Bimetric arch after activation
1. TRANSPALATAL ARCH
TPA has several functions including –
a. molar stabilization
b. anchorage
c. molar distalization as well as other molar movement.
d. correction of molar rotation,

Cetlin (1992) has stated that distalization of one upper 1st molar can be achieved by
unilaterally activating only one arm of TPA and the other arm is rotated into position
producing a distalizing force.
Maxillary molars can be distalized unilaterally by using a standard transpalatal arch
in conjugation with extra oral traction according to Cetlin method. Asymmetric
distalization using a TMA TRANSPALATAL ARCH was introduced by
MALDURINO and BA1DUCCI in the year 2001.
Figure 41 Trans palatal arch appliance
APPLIANCE DESIGN
The TPA is constructed using a 0.032 inch TMA bars (TMA is more resilient than
stainless steel). The direction of insertion of the TPA into the occlusal molar tubes
is different. The arch is inserted from distal into anchor molar and mesiallv into the
molar which has to he distalized.

ACTVATION
When activated, the arch applies a mesio-buccal rotation to the anchor molar and
distally directed force on the opposite molar. The central omega loop is not needed
as TMA is not used for palatal expansion. TMA is activated monthly by bending the
end inserted from the distal by about 30º. TMA produces distally directed forces
anchor end bend at 30º.
CLINICAL CONSIDERATIONS
TMA may fracture in the oral cavity as it is more fragile. Since it causes mesio-buccal
rotation of the anchor molar, it should be combined with fixed orthodontic wire
between canine and second molar of the anchor side. This system can distalize only
one molar at a time. An extra oral force is worn at night to reinforce anchorage.
ADVANTAGES
TMA has better shape memory and resilience than stainless steel. The arch is simple
to construct. System is hygienic and economic. No anterior anchorage loss.
DISADVANTAGE
One possible disadvantage of this method is that only one molar can be distalized at
a time.
2. REMOVABLE MOLAR DISTALIZATION SPLINT:
This was developed by KorrodiRitto in the year 1995. The Removable Molar
Distalization Splint can achieve better patient cooperation than some other
removable devices.
APPLIANCE DESIGN
Clear splint is made from 1.5mm Biocryl in a Biostar machine. If both upper first
molar are to be moved distally at the same time, the splint extends from the area of
upper first or second premolar to the area of upper left premolar. If only one molar
is distalized, the splint extends to the terminal molar on the other side. Two internal
clasps are used for retention and a Ni- Ti coil spring produces 220gm of distal force.
The coils are reactivated. The splint creates a separation of 1 -2mm between the
maxillary and mandibular molars at the beginning of the treatment eliminating
lateral occlusal Forces and thereby helping distalization. After molar distalization,
the splint can be used to maintain molar position while anterior teeth are extracted.
Because this appliance is smaller compared to the other plates, it is more comfortable
and esthetic to the patient.
Figure 42 Removable molar distalization splint with coil

ADVANTAGES
It is smaller than conventional removable plates.
Esthetics
Better co operation of the patient. Molar distalization with this appliance is
possible even in cases of deep over bite.
DISADVANTAGES
There is more amount of molar tipping than bodily molar distalization. (So it is
ideally used only in. cases where the molars are mesially tipped prior to treatment).
3. LIP BUMPER THERAPY FOR DISTALIZATION
Lip bumper (LB) therapy may represent a management alternative for the resolution
of future space deficiency in the mandibular dental arch reducing the necessity for
tooth extractions. The primary objective of LB therapy is to reduce anterior dental
crowding by increasing the length and width of the mandibular dental arch. These
alterations can be attributed to the removal of lip pressure on the anterior teeth and
the concomitant distal forces exerted on the permanent first molars (M1). Hence, the
therapeutic effect of the LB will occur by the labial displacement of the incisors and
the distal inclination of the M1.

Figure 43 Lip bumper for distalization
ADVANTAGES:
A few studies suggest that the LB can maintain the position of the M1 or distalize
it, preserving or increasing the leeway space.
The wearing of LB increases the mandibular arch length by the distal movement of
the molars and the labial movement of the incisors increasing the arch perimeter,
thereby reducing crowding.
Another potential action of the LB is the prevention of the mesial migration of the
mandibular molars during the late mixed dentition phase.
DISADVANTAGES
If the LB distalizes the M1 crown while assisting in crowding resolution, it also
reduces the available distal space, altering the physiological eruption of the
permanent second molars (M2) and the available space for them. This may leave
many orthodontists reluctant to use this therapeutic approach.

With reduced body movement of the incisors, some issues such as the stability by
excessive buccal inclination movement and the likely compromised periodontal
response remain difficult concerns to account for.
One of the studies reported a greater chance of impacting the permanent M2 after
wearing the LB. Negative predictive factors include pretreatment M2 inclination and
LB treatment longer than 2 years. However, the risk of M2 eruption disturbances
seems to be more related to their previous position than the amount of distal
movement of M1. Thus, it is important to consider the M2 position and the available
space in the posterior molar region during the decision process. Otherwise,
improvements in the anterior dental arch spaces come at the cost of lack of space in
the posterior region.
4. MOLAR DISTALIZATION SYSTEM (MDS)
Uses two opposing magnets for each maxillary quadrant. mesial magnet of each
pair is mounted so that it can move freely along a sectional wire. A sliding yoke,
with ligation hooks mesial to the mesial magnet brings the repelling magnets
together to activate the magnetic force

Figure 44 Molar distalization system with sliding yoke
Primary molar or premolar in good condition is selected as the anchor tooth in each
quadrant This tooth is banded and a nance holding arch is placed to reinforce
anchorage Head gear tube is then soldered to band on the 1st molar. The distal end
of the MDS terminates in a three-pronged fork, with the middle prong for insertion
into the head gear tube.
Figure 45 Molar distalization system after it has created space
Magnets are in contact with each other and it produces a force of 220g. Constant
magnetic force results in rapid distal movement of the 1st molars, and a tooth
movement of 2 mm achieved with this system in a 3-week period This movement

separates the magnets, which must be reactivated by being placed back in contact
every 2 weeks. Molars moves almost bodily with slight distal tipping and rotation.
Because of the size of the magnets, patients generally complains of some discomfort
of the buccal mucosa.
5. REPELLING MAGNETS
Developed by Anthony A. Gianelly.
DESIGN
Nance appliance extends anteriorly to the incisor segment by means of an 0.045-
inch wire soldered to the lingual aspect of the premolars. The acrylic component is
placed against both the palatal vault and the incisors. Bilateral distal extensions
(0.045-inch wire) with loops at the end are soldered to the labial aspect of the
premolar bands so that the loops approximate the molar tubes. Anchoring the
modified Nance appliance to the first premolar encourages the distal drift of the
second premolars that normally occurs as first molars are moved posteriorly.
Figure 46 appliance with repelling magnets
Disadvantages
Magnets tend to be expensive and bulky.
Magnetic force dissipates rapidly with increasing intermagnet distance. Requires
frequent recall reactivation appointment. Because of these drawbacks, Darendeliler
has concluded that magnets offer no advantage over conventional systems in molar
distalization.
10, JONES JIG APPLINCE:
Jones Jig was developed by Richard D.Jones and J. Micheal Whitein the year
1992. Jones Jig uses an open coil spring NiTi to deliver 70-75gms of force over a
compression range of 1 -5mm to the Molars.
Figure 47 appliance uses an open coil spring

Figure 48 appliance after it has distalized the molars
APPLIANCE FABRICATION
A modified Nance appliance is used with the Jones Jig for ease of attachment to
first premolar, second premolar, or deciduous second molar. A 0.036” SS wire is bent
to the palate on the cast extending it as far as the canines and it is soldered to the anchor
bands. Acrylic button is fabricated about half inch in diameter. The Nance appliance
is cemented and the Jones Jig is laid in place on both sides. Reactivation is done
after every 4 -5 week’s intervals.
ADVANTAGES
The extent of forward movement of the anterior teeth while using the Jones Jig is
very minimal. Movement achieved is dental rather than skeletal.The Jones Jig along
with the open coil spring can be used without the need of a full banded upper arch.
The coils of Jig can be changed with minimal time and the use of arch wires and class
II elastics can be avoided.

DISADVANTAGE
The one possible drawback of this appliance to certain clinicians is that the Nance
button may cause palatal irritation.
The Jones Jig produces distal movement of the upper molar to a class I relationship.
It is predictable. rapid and painless method of correcting class II relationship without
the need of patient cooperation. Seda Hayder and OktayU’ner in the year 2000
conducted a study on 20 patients with Jones jig followed by fixed appliance therapy.
They concluded that rapid distalization of upper first molars with Jones jig appliance
followed by the use of extra oral appliance for anchorage control during distalization
of premolars to be more efficient.
10. LOKAR APPLIANCE
Figure 49 the lokar appliance

The Lokar appliance was developed by Dr. Lokar in the year 1994.
PARTS
1. Compression spring
2. Sliding sleeve
3. Groove
4. Flat guiding bar
5. Round posterior guiding bar
6. Immovable posterior sleeve
COMPONENTS
It consists of 2 basic components:
1. Mesial sliding component.
2. Component which inserts into the arch wire tube of the molar.
The distalizer is inserted into the arch wire tube of the first molar and the
application is adapted such that it is parallel to the plane of occlusion and as close to
the teeth as possible for comfort.
A 0.012” stainless steel ligature wire is hand twisted around the premolar bracket
before the Lokar appliance is fixed to the molar tube. This ligature wire is engaged
around the mesial sliding component of the distalizer and tightened to activate the
appliance.
The force is developed by NiTi-Coil springs which get compressed during
activation. The anchorage is by a Nance appliance, soldered to the premolars.
ACTIVATION
A0.012” stainless steel ligature wire is hand twisted twice around the premolar
bracket such that the free ends of the ligature face distally. One of the free ends is
then passed over the mesial sliding component of the mainframe and tightened to
activate the appliance. The force is delivered by the NiTi coil spring which gets
compressed during activation. The best activation is achieved by compressing the
spring by 2-3mm. Reactivation is done at 5 to 6 weeks interval.
12. MOLAR DISTALIZATION WITH SUPERELASTIC NITI WIRE
Described by Gianelly in 1992. A 100gm (Neosentalloy) super elastic NiTi Wire
with shape memory regular arch from is used. On this arch wire 3 points are marked
-Distal wing of first premolar bracket.5-7mm distal to the anterior opening of the
molar tube. Between the lateral incisors and canines Stops are crimped and hook
added at these points. Then Insert wire such that posterior stop abuts mesial end of
molar tube, anterior stop abuts distal of premolar

Figure 50 Neo Sentalloy 100g archwire. A. Stops crimped immediately distal to second premolar
bracket and 5- 7mm distal to anterior opening of molar tube. Hook added between lateral incisor and
canine. B. Wire inserted into molar tube and first premolar bracket, with excess deflected
gingivallyinto buccal fold. Distal molar movement as wire returns to original shape.
ACTION OF THE WIRE/APPLIANCE:
Since the wire is 5-7 mm longer than the available space, the excess will be deflected
gingivally into the buccal fold. Molars distalize as the wire returns to its original
shape, exerting a distal force of 100gms against the molars and a reactionary mesial
force on the first premolars, canines and incisors. There is also a tendency for the
premolars to move buccally.
RATE OF MOVEMENT
First molar crowns are moved distally at the rate of approximately 1 mm/month,
although there is marked individual variation.As an example, Bondemark and Kuro
moved both first and second molar crowns distally 4mm in 16 weeks with repelling
samarium cobalt magnets. The magnet system, which is also a non-cooperation
based appliance, generally moves molar crowns distally at a slightly slower rate than
superelastic NiTi coils. As the molars moved, the axial inclinations of the teeth
changed as the crowns moved distally more than the roots. When these same
investigators moved the molars distally in a more bodily fashion by moving the
molars along a rigid wire-tube assembly, the rate of movement was only 0.5
mm/month. This suggests that one factor that influences the rate of distal molar
movement is the type of movement. Faster movement occurs when the molar is
tipped distally. In a small group of patients, the use of magnets often moved the
crowns of the molars distally more than 1 mm/month when the second molars were
not erupted; this suggests that movement occurs more readily when only one
tooth/side is moved.
END POINTS
Molars should be moved distally until they are overcorrected by approximately 2
mm. The overcorrection is necessary for two main reasons: Anchorage loss will
invariably occur during the retraction of the premolars, canines, and incisors and the
overcorrection serves to compensate for this anchorage loss. In a sense, the
overcorrection is “prepared anchorage.” Anchorage loss can be minimized if the
premolars and canines are allowed to drift distally ) Molars that are moved distally
by these procedures tip and the crown moves more posteriorly than the root. After
overcorrection, the subsequent forward movement of the molars to the Class I
position aids in uprighting the molars because the crowns move mesially more than
the roots as the molars move anteriorly.

STABILIZATION OF THE MOLARS
Molars that have been moved distally have a marked tendency to return mesially,
particularly if the second molars are present. This labile tendency has been
documented by Andreasen and Naessig who noted that 90% of the molar distal
movement produced by headgears was lost in 1 week when the headgear was
removed and no effort was made to preserve the positions of the molars. To maintain
molar position, a headgear (preferably hi-pull for root uprighting) is recommended
and a stopped 0.016 × 0.022 inch arch wire is inserted. When the molars are not
severely inclined distally, a 10° to 15° active tip back is used in addition to the stop
because the tip back impedes mesial movement of the crowns. If the molars are
severely inclined distally, the tip back is made passive to avoid excessive distal
inclination. In addition, the molars are not used as anchorage for Class I forces for
at least 4 to 5 months after they have been moved distally because anchorage loss
can readily occur even with the use of headgear. This reflects the unstable nature of
the molars immediately after they have been moved distally. In effect, we
recommend a 4 to 5 month pause in retraction mechanics. This is not an
inconvenience because the premolars and canines drift distally during this time
period1. For this reason, treatment proceeds advantageously while molar position is
stabilized because the premolars drift close to or into the Class I position and the
canines drift at least 2 to 3 mm distally.

13. PENDULUM APPLIANCE
31
This was developed by James Hilger in the year l992. The pendulum appliance
is a hybrid appliance that uses a large Nance acrylic button in the palate for
anchorage, along 0.032” TMA spring that deliver continuous force to the inner first
molar without affecting the palatal button. Thus the appliance produces a broad
swinging or pendulum of force from the midline of palate to the upper molars.
Figure 51 the pendulum appliance
Diagnostic Criteria
Since the Pendulum Appliance drives the upper molars distally (with slight
lingual tipping) quite rapidly, there is a tendency for the anterior bite to open. This
open bite generally corrects itself in brachyfacial patients, but it can be a problem in
dolichofacial types, especially those with tongue-thrust habits. Author recommends
treating vertical growth patterns conservatively with extractions, directional
headgears, and transpalatal bars. The bite- opening tendency can be encouraged in
brachyfacial patients by bonding the Nance portion of the appliance to the occlusal
surfaces of the bicuspids or deciduous molars, thus freeing the occlusion somewhat.
Distal movement of the molars appears to be most efficient before the upper second
molars have erupted, which places some emphasis on treatment timing. However, as
seen in several of the cases, the molars will still move even after the second molars
have fully erupted. When a great deal of distal movement is needed and it is
preferable not to extract the upper first bicuspids, it may be beneficial to remove the
upper second molars and let the third molars drift into place. This creates room in
the cortical trough and eliminates the buttressing effect of the upper second and
third molars against the first molars The Pendulum Appliance can be used to
regain space lost through mesial drifting of the upper first molars, because of
either early loss of the second deciduous molars or impaction of the first molars
under the distal crown contour of the deciduous molars. Rapid distalization of the
upper first molars and stabilization with an Insta-Nance provide space for the
erupting second bicuspids
APPLIANCE DESIGN
The right and left pendulum springs formed from 0.032” TMA wire, consists of
a recurved molar insertion wire, a small horizontal adjustment loop, a closed helix
and a loop for retention in the acrylic button. Springs are extended as close to the
centre of the palatal button as possible to maximize their range of motion, to allow
for easier insertion into the lingual sheaths and to reduce forces to an acceptable
range. Springs are mounted as close as possible to the distal aspect of Nance button
which permits access to acrylic for polishing. Lingual sheath shouldbe 0.036” so that
0.032” wire fits loosely. Anterior part of appliance can he retained in many ways.
Initially it was by putting occlusally bonded rests on the deciduous molar or
premolar. This was not stable; tile most stable method was banding first premolar
and then soldering a retaining wire and then use this teeth as major anterior
anchorage source. Nance button should be made as large as possible to prevent any
tissue impingement. It should extend about 5m from teeth to allow adequate hygiene.
Jack Screw is incorporated into the Nance button if expansion is required. Screw is
activated about one- quarter turn every three days. This appliance is called pend-X.
Figure 52 A small horizontal adjustment loop, a closed helix and a loop for retention in the acrylic
button
PREACTIVATION AND PLACEMENT
Most efficient way to pre activate them is before appliance placement. For
significant distal molar movement, the spring is bent parallel to the midline of palate
or perpendicular to the body of the appliance. One third of activation is lost. Only
60º activation is obtained. Molar bands are cemented without springs engaged and
anterior portion of appliance is then cemented in place. Once appliance is placed the
pendulum spring is brought forward with finger pressure the mesial end of the
required loop is held with a weingart pliers and spring is seated in lingual sheath.
The horizontal adjustment loop allow for some lingual compression of spring
during placement. As the molar is driven distally, it moves on an arch towards the
midline of the appliance towards cross bite. This tendency can be counter acted by
opening the adjustment loop slightly to increase the expansion and molar retention.
Figure 53 Springs bent parallel to midline of the palate.
Figure 54 Pendulum springs brought forward and engaged in

lingual sheath
REACTIVAITON AND STABILIZATION
Patient should be recalled every 3 weeks. Activation of spring is done by holding
the helix with plier and pushing the spring distally toward midline and then
reinserted.
Figure 55 After movement of molars distally, they must be stabilized in their

new positions to prevent their drifting back mesially
Once the molars have been moved distally, they must be stabilized in their new
positions or they will rapidly drift back mesially. It is also important to move the
buccal segments into a Class I relationship to harness the full advantages of the
appliance. The upper molar bands need not be removed with the rest of the appliance;
this can be helpful if the clinician wishes to place a transpalatal bar or Nance
appliance immediately after removal of the Pendulum.
ADVANTAGE
Use of 0.032 TMA springs delivers continuous force to the upper first molar without
affecting the palatal button. Activation can he done before appliance placement.
DISADVANTAGE
Pure bodily movement of the molar is not seen, and hence a tendency towards
cross bite occurs.
MODIFICATIONS
I. M-PENDULUM
In 1999, Schuzzo, Pisani and Takernoto, introduced a modification to this appliance
called the M-PENDULUM appliance. This modification ensured a bodily movement
of molar crowns and roots.
APPLIANCE DESIGN
Horizontal loop is inverted mesially. This allows bodily movement of both roots
and crown of the Molars. Once distal movement has occurred, the loop is opened
and activated which produces a buccal and distal uprighting of root.The inverted loop
should not be activated until spring has deactivated following each phase of
distalization. A passive fit of the distal end of spring with no distal force applied to
the molar Crowns will allow backward tipping of Molar roots. The terminal ends of
M-PENDULUM springs are straight and not looped.
If the horizontal Pendulum loop is inverted, it will allow bodily movement of both
the roots and crowns of the maxillary molars.

Figure 56 The M pendulum appliance
Once distal molar movement has occurred, the loop can be activated simply by
opening it. The activation produces buccal and/or distal uprighting of the molar roots
and thus a true bodily movement, rather than a simple tipping or rotation
Figure 57 A. Original pendulum appliance loop and M pendulum inverted loop. B. Schematic diagrams of
modified loop action in distalization of maxillary molar.
Before intra-oral placement of the appliance, the Pendulum springs are activated
to about 40-45° with a Weingart plier, resulting in about 125g of force on each side.
This activation is repeated until the desired distalization of the molars is obtained.
The inverted loop should not be adjusted until the spring has deactivated following
each phase of distalization.

In fact, only a passive fit of the distal ends of the Pendulum springsin the lingual
sheaths, with no distal force applied to the molar crowns, will allow backward
tipping of the molar roots. The terminal ends of the M-Pendulum springs are straight,
rather than looped as in the original appliance.
II. MODIFIED PENDULUM APPLIANCE WITH REMOVABLE ARMS
Pisani and Takemoto along with vecchia in the year 2OOO introduced this particular
modification to the appliance.
APPLIANCE DESIGN
7mm - 9mm length of 0,032 TMA wire is doubled over to form bayonets. Each
bayonet is attached to an M-PENDULUM arm either by using Laser welder or by
wrapping 0.010” ligature around arm and soldering the unit. Each bayonet is
embedded in the soft acrylic that will be used to form Nance button producing
sheaths to insert the removable arm. The arms are activated in the working cast as
desired. The appliance is placed in the month and terminal ends of arms are inserted
into lingual molar hand sheath.Removable arms can be reactivated with debonding
the occlusal rest of Nance button.
ADVANTAGES
This modification produces a distal molar movement at a continuous rate of
1.5mm/month for as long as necessary as compared to the conventional pendulum or
M-Pendulum which produce 3mm distalization in 3 — 4 months.

III. MODIFIED PENDULUM APPLIANCE FOR ANTERIOR
ANCHORAGE CONTROL
This latest modification was introduced by PABLO ECHARRI and SCHUZZO
in the year 2003.
APPLIANCE DESIGN
This design consists of four removable arms for both first and second molars. The
internal diameter of 4 stainless steel tubes embedded in the acrylic corresponds to that
of removable TMA arms. The second molars are distalized after which arms are left
passively in place for anchorage and first molar arms are activated for distalization.
Pendulum is replaced with a Nance button after first molar distalization. A 0.016 SS
passive arch wire is placed to avoid any incisor protrusion. E-Chain is used to
distalize second and first bicuspids. If anterior anchorage is critical, palatal acrylic
should be kept out of contact with the incisors. Second bicuspid arm should not be
cut for spontaneous distalization to prevent incisor protrusion.
ADVANTAGES
Greater anchorage control — Very minimal incisor protrusion. Simultaneous
distalization of first and second Molars.
14. HILGER’S DISTALIZATION APPLIANCE
This appliance uses occlusally bonded hyrax expander without any palatal acrylic.
Locking wires soldered to molar bands allow appliance to act as an expander prior
to distalization. It uses 0.027” TMA springs laser welded to screw body. It is fixed
to the dentition by first premolar bands or by bondable occlusal rests. Expansion of
the arch is performed before distalization while the upper arch is stabilized by means
of full bracketing and sectional wires. After expansion, locking wires are cut off
allowing the molars to move distally
Figure 58 Hilgers distalizing appliance
15. GRUMRAX APPLIANCE
This appliance was developed by Grummons.
It is similar to PhD appliance.
However there are always occlusal rests on first premolar. The design of spring
includes horizontal adjustment loop and there are no locking wires. The appliance
can act in all planes of space by widening, distalization, controlling vertical
dimension.
16. T-REX APPLIANCE
Maxillary arch constriction and mesiopalatal rotation of the upper first molars are
two components of most Class II malocclusions that must be corrected either before
or during sagittal correction. The Haas rapid palatal expander can open the
midpalatal suture in growing children, but does not rotate or distalize the molars. On
the other hand, the Hilgers Pendulum Appliance relies on slower, more alveolar
expansion, which may allow more dental tipping. It is a fixed rapid palatal expander
that incorporates the rotation and distalization components of the Pendulum
Appliance. It can be used in the mixed or permanent dentition as an adjunct to the
treatment of mild Class II malocclusions.
APPLIANCE DESIGN
The metal framework of the appliance consists of an 11mm expansion screw,
occlusal rests, and two .032" TMA Pendulum springs. The screw and springs are
embedded in acrylic, since TMA wire cannot be soldered to stainless steel. The
springs are doubled back for insertion into .036" tubes that are spot-welded to the
maxillary first molar bands. The laboratory should preactivate the springs 8-10mm
distally, but keep them 5-6mm away from the palatal tissue.
Figure 59 the T rex appliance before and after insertion into the
lingual sheath
The expansion screw is soldered mesial to the molar tubes to make the appliance
rigid enough for rapid palatal expansion, while neutralizing the effect of the
Pendulum springs during the initial expansion phase.
The acrylic includes a broad Nance button for anterior anchorage during molar
distalization. This button should extend anteriorly to the first palatal rugae, but
should allow enough space posteriorly for intra-oral activation of the Pendulum
springs if needed.
Occlusal rests are critical for anchorage and for proper seating of the appliance.
In the mixed dentition, they should be bonded to all primary molars to allow continued
use of the appliance if a primary first molar exfoliates during treatment. In the
permanent dentition, the first bicuspids should be banded if possible, and occlusal
rests should be placed in the central grooves of the upper second bicuspids.
PLACEMENT AND ACTIVATION
The maxillary first molars are banded with fluoride-releasing cement, and the
occlusal rests are bonded to the appropriate teeth with any suitable composite
adhesive. The screw is activated twice a day until the desired expansion is
achieved—usually in about two weeks. The appliance should be left in place for at
least a month after the initial sutural opening before the Pendulum springs are
activated.
The springs are activated by cutting the mesial solder joints on the maxillary first
molars with a No. 557 bur. Additional intra-oral activation is possible by using a
Weingartplier to slide the TMA springs in and out of the .036" tubes
1. TRACEY/HILGER MDA EXPANDER
The appliance consists of compact Rapid Palatal expander RPE soldered to 1st
PM bands and 0.032” springs for distalization. To add rigidity to appliance while
allowing for expansion stainless steel ligature can be used to tie spring to screw
legs. After expansion- ligature wire released to allow for distalization. In addition,
bond on palatal side removed to allow for these teeth to drift distally along with the
maxillary first molar.

Figure 60 Tracey/Hilger MDA Expander
2. K- PENDULUM
It differs from the Pend -X appliance is that it is fitted with distal screw and integrated
uprighting activation. Distal screw divides the Nance button in 2 parts. Anterior part
provides anchorage and the posterior part includes pendulum springs. The activation
of distal screw can vary, depending on the requirements of each individual case.
When screw is activated, the sagittal center of rotation is repositioned and further
molar distalization occurs due to the repositioning of the arc and the resulting
automatic activation of spring. In this way, the pendulum- like cross-bite is
minimized, while there is no need to activate the adjustment loop which can result in
extrusion forces.
Figure 61 Pendulum K appliance, including distal screw and built-in up righting activation and toe-in bend at
pendulum springs for bilateral molar distalization in children and adolescents. A and B, typical design of
pendulum K. C. Treatment example (intra oral view after molar distalization)
Figure 62 Appliance uses palatal anchorage
3. BI/QUAD PENDULUM
Both appliances were introduced by Kinzinger et al. It consists of Nance button and
2/4 pendulum springs which allow for distalization of first and second molars. When
starting with the distalization of second molars, the first molars should be excluded
from the anchorage block, if possible, to allow them drift distally. After the second
molars are sufficiently distalized, their corresponding springs are deactivated to
increase the anchorage, for the distalization of the first molars that follows
4. GRAZ IMPLANT SUPPORTED PENDULUM
The pendulum appliance was modified by Byloff et al in 2000 to utilize an
implant for better anchorage control. To avoid mesial movement of anchor teeth,
extraoral anchorage such as headgears and intraoral Nance holding arches are
commonly used. Advances with implants have made it possible to use them as a
means of anchorage in adult orthodontic patients. Butwith orthodontic patients,
when only the question ofanchorage must be addressed, the retro molar area or the
palate as implant locations are preferred because they do not interfere with
orthodontic tooth movement. Site for Orthodontic Implants: The histomorphology
of the palatal bone shows that the median palatal region is the best location for an
endosseous implant.
Figure 63 Anchorage plate of the GISP, a surgical plate with 4 screw holes and 2 oval shaped cylinders.
IMPLANT LOADING AND APPLIANCE DESIGN
Implants are loaded after a period of approximately 12 to 24 weeks to allow
healing and Osseo integration, which seems to be a general rule in the use of
implants. Byloff described a newly designed palatal anchoring system, the Graz
implant-supported pendulum (GISP) .This system can be loaded within 2 weeks to
distalize and anchor maxillary first and second molars. The anchorage part of the
GISP consists of a simple surgical plate (15 X 10 mm) with 4 screw holes. Two
cylinders (10 mm long and 3.5 mm in diameter is soldered at right angles to the
center of the plate. The plate is fixed to the palatal bone via four 5-mm- long titanium
mini screws. The 2 cylinders perforate the palatal mucosa to enter the oral cavity.
The entire anchorage device is made of 100% Titanium. Implant is placed under
GA. Maxillary impression is taken after 2 weeks of healing. Removable PA is
fabricated. TMA springs are activated extra orally to generate 250g of force.
Because molars tend to tip back when distalized with a PA, an uprighting bend
(Byloff AO 1997) was introduced into the recurved end of the spring when
necessary. After the 8 months of molar distalization, the first and second premolars
have drifted distally, presumably under the influence of the elastic fibers that area.
The molars were almost in a full Class II relationship at the beginning of treatment.
5. K-LOOP
K loop distalizer was introduced by KALRA in the year 1998.
APPLIANCE DESIGN
The appliance consists of a K loopto provide the forces and moments and a Nance
button to resist anchorage. The K loop is made up of 0.017 X 0.025 ‘TMA which
can he activated twice as much as stainless steel before it undergoes permanent
deformation.Force produced by the TMA will also be half.
Figure 64 K loop appliance design
LOOP DESIGN
The loop of the K should be bent 8 mm in length and 1.5 mm wide. The legs of the
loop are bent down 20 degree and inserted into molar tube and Premolar bracket.
Wire is marked at the mesial of the molar tube distal of the premolar bracket. Stops
arc bent into the wire 1mm distal to distal mark and 1mm mesial to mesial mark.
Stop should be well defined and about 15 mm long. These bends help keep the
appliance away from mucco buccal fold, allowing a 2mm activation of the loop.
Figure 65 K loop bent at 20 degree and also includes mesial and distal stops
ACTIVATION
The 20 bends will produce moments that counteract the tipping moments created
by the force o I the appliance and these moments are reinforced b the moment of
activation as the loop is squeezed into place. Translatory movement of the molar is
obtained. K loop is placed at the centre between 1 premolar and molar to prevent any
extrusive or intrusive force. For additional molar movement, the appliance is
reactivated by 2mm after 6-8 weeks.
ADVANTAGES
The advantages of the K loop are. Simple and efficient. Controls M: F
ratio to produce bodily movement. Easy to fabricate and place. Hygienic and
comfortable, Minimal patient cooperation.
DISADVANTAGES
Improper placement of the loop could result in undesirable tooth movements
(extrusive or intrusive force).

6. THE FIXED PISTON APPLIANCE
The Fixed Piston Appliance introduced by Greenfield in 1995 can produce bodily
movement of maxillary first molars without the use of extra oral appliances and with
no loss of posterior anchorage.
Figure 66 Fixed piston appliance uses nance button for anchorage
APPLIANCE DESIGN
The appliance components are maxillary 1st molar and 1st premolar bands. 0.036”
stainless steel tubing (soldered to Bicuspids) 0.030” stainless steel wire (soldered to
first molars) Enlarged Nance button, reinforced with a 0.040” SS wire. 0.55”
(interior diameter) super elastic NiTi open coil spring.

Figure 67 Appliance uses 0.036" tubing which is soldered to bicuspids and 0.030" SS wires
soldered to first molars.
PROCEDURE
Bands should be fabricated for the maxillary firstmolars and l premolars and then
cemented. Care should be taken to check the buccal and lingual piston assemblies’
extension till the embrasure of the cuspid and first bicuspid to be long enough for
adequate distalization without breakage. A 0.040” SS wire is then adapted to the
palate and it is soldered to the bicuspid band. O.036’ stainless steel tubing should
be soldered to the buccal and lingual occlusal thirds of the bicuspid hands. These
tubes should extend parallel to the mesial surfaces of first Molars. Then solder the
0.030” SS wire to buccal and lingual surfaces of first molar hands. The piston
assemblies should be parallel both in occlusal and sagittal views but a slight palatal
cant from distal to mesial is recommended to prevent occlusal displacement of
Nance acrylic. Nance acrylic is then fabricated and 0.055’NiTi open coil spring is
placed to fit the entire length of buccal and lingual assemblies, The appliance is then
cemented in passive state. 2 mm split ring stops should he added mesial to the buccal
and lingual tubes on each piston assembly every 6 to 8 weeks; they provide a force
of 25ms of to each assembly or 50gm per tooth.

ADVANTAGES
The fixed piston appliance has the following advantages: Produces bodily movement
of maximum first molars with no loss of anchorage. Does not require the need of
patient compliance but allows the use of head gear if required. Reduced treatment
time. Uses a light controlled force of only 1.5-2 oz/ . Tooth does not interfere with
occlusal plane thus maintaining control of vertical dimension.
DISADVANTAGE
Excessive force levels can cause anchorage loss and can cause inflammation of the
palatal mucosa.
7. INTRA ORAL BODILY DISTALIZER
This appliance was developed by Ahmet Keles in the year 2000.
APPLIANCE DESIGN
The intra oral bodily molar distalizer consists of 2 parts An Anchorage
part — Nance button. Distalization part The distalizing part has
springs. These springs delivers two components of force - the distalizer section
of the spring delivers a crown tipping force, while the uprighting section delivers
a root tipping force. On the palatal side of the first molar bands 0.032x0.032 inch
slot size hinge cap palatal attachments are welded. A wide acrylic button is
constructed and attached to first premolar band with 0.045” SS wire. The acrylic
portion covers the palatal aspect of the incisors and hence causes an opening of
the bite thereby enhancing molar distalization. 0.032x0,032” TMA springs are
bent for a distalizing section and an uprighting section.
Figure 68 The intra oral body distalizer appliance
ACTIVATION
Activation is done by pulling from distal to mesial with Weingart pliers and then
seating into the slot of the hinge cap. A total 230gms of distal force is applied. After
distal movement is achieved, the class I molar is stabilized by a conventional Nance
appliance. This is attached to the hinge cap on the molars for 2 months before second
phase of treatment.
8. THE LINGUAL DISTALIZER SYSTEM
Introduced by Carano, Tesia and Siciliani in 1996.
APPLIANCE DESCRIPTION:
The active components of the lingual distalizer are two bilateral 0.9 mm tubes
connected to a Nance appliance. A bayonet wire is inserted into the lingual sheath of
the 1st molar bands. On the tube there is a stainless steel coil spring and a clamp. The
clamp can slide towards the molars and can be tightened in order to compress the
coil. At the time this article was written, stainless steel coil springs were used.
Recently NiTi spring have been used with no apparent advantage over stainless steel
coil spring. The force exerted by the spring begins at 180 g and decrease as space is
opened. Consequently, the TP is reactivated by sliding the clamp closer to the molar
once in mouth. A molar band and button attachment or a directed bonded button in
cases of partial tissue impaction is used.
Figure 69 A. Occlusal views of the upper arch (A) before and (B) after distalization
Maxillary Expansion: Maxillary expansion can be achieved by embedding
jackscrew in the palatal button.
Molar rotation: 3-5 simple helical loops in the bayonet wires of the distal jet can be
used to produce molar ration, by activating the loops with the utility plier before
seating the bands. E-chain is extended from bicuspid bands to molar bands to hold
them in position during insertion of the preactivated appliance.
9. C-SPACE REGAINER FOR MOLAR DISTALIZATION
Introduced by Kyu-Rhim Chung, Young-Guk Park and Su-Jin.
C-Space regainer is a removable appliance used to achieve bodily molar movement
without significant incisor flaring. This appliance can be used to intrude the teeth
as well as to move them distally or mesially.
INDICATIONS:
a) Mesial drift of first molar following premature loss of the deciduous molar in
the mixed dentition.
b) Mild arch length discrepancy treated by extraction of second or third molars
(with straight or flat facial profile)

c) Open bite
d) Class II malocclusion
e) Class III malocclusion
FABRICATION:
It consists of a labial framework, formed from 0.036” stainless steel wire and an
acrylic splint. A closed helix is bent into the framework in each canine region. The
labial framework is extended distally to lie as close to the buccal molar tubes as
possible, allowing easy insertion into the head gear tubes and improving the
precision of the distal driving force.
Figure 70 C space regainer for molar distalization
The distal end of the framework should be polished down for a loose fit in the
molar tubes. A 0.010”X 0.040” open coil spring is soldered immediately distal to
the helix and 0.028” ball clasps are used to retain the appliance.
The working cast is placed on a large glass slab for construction of the acrylic splint.
After the labial frame and ball clasps have been stabilized, a separating medium is
painted on it. The acrylic is normally applied to cover the crowns of all the anterior
teeth. The cast is immediately inverted on the glass slab and the acrylic extended
labially according to the amount of anchorage needed. After the acrylic has cured,
the plate is scalloped around the cervical margins leaving it thick enough to contact
the mandibular incisors.
If anterior protrusion is to be avoided, 0.028” ball end clasps are added facially
between the lateral incisors and canines, to serve as hooks for class-II elastics or J-
hook headgear traction. If maxillary expansion is needed, a midpalatal screw can be
incorporated in the midline of the acrylic and activated ¼ turn every 3 days.
10. DISTAL JET APPLIANCE
Developed by Dr. Carano and Dr. Testa in 1996.
Several methods have been proposed to distalize maxillary molars in Class II cases
without the need for patient cooperation. These include repelling
magnets,superelastic nickel titanium coils, nickel titanium wires,and a modified
Nance appliance with titanium molybdenum wires. In all these systems, orthodontic
forces are applied to the crowns of the upper first molars, and the molar movement
consists mainly of tipping and rotation of the crowns.Even though the initial distal
tipping is accomplished rapidly without patient cooperation, a second phase of molar

uprighting is necessary, in which patients often must wear headgear. Distal Jet
appliance that can distalize maxillary molars without the disadvantages of other
methods.
APPLIANCE DESIGN:
Bilateral tubes - 0.036” internal diameter. A coil spring and a screw clamp are slide
over each tube, wire extending from the acrylic through each tube ends in a bayonet
bends that is inserted into the lingual sheath of the first molar band. Anchor wire
from the nance button soldered to bands on the second premolars. NiTi coil springs
of 150gms of children and 250 gms for adult, appliance can be made of stainless
steel spring. It is reactivated by sliding the clamp closer to first molar once a month.
Once distalization is complete, the appliance can be converted to a nance retainer by
replacing the clamp spring assemblies with light cured/ cold cure acrylic and cutting
the arms of the premolar.
Figure 71 The distal jet appliance

ADVANTAGES :
1. Bodily movement with no loss of anchorage.
2. Easy to insert
3. Well tolerated & Esthetic
4. require no patient cooperation
5. Unilateral/ Bilateral correction
6. Permits simultaneous use of full bonded appliances
MODIFICATIONS OF DISTAL JET:
Bowman described several modifications to the original appliance.
I.CONVERSION TO NANCE HOLDING ARCH:
Upon completion of molar distalization, the Distal Jet is converted to a Nance
holding arch to prevent further distal movement and consequent anchorage loss.
It can be done by these two methods: One way to stop movement of the bayonet
wire through the tube is to flow a light-cured acrylic around the coil spring, over
the distal bayonet bend, and over the activation collar to produce a solid extension
from the molar bands to the acrylic button. Another way is by wrapping an .014"
stainless steel ligature wire around the end of the doubled back wire (extending
distally from the lingual sheath on the first molar band) and tie it around the tube
just mesial to the activation collar. The coil spring should be compressed
completely and the set screw tightened to prevent mesial movement of the molars.
II.DOUBLE -SET -SCREW DISTAL JET
A modification of the Distal Jet incorporating two set screws into the activation
collar permits an easier, cleaner, and more reliable conversion to a molar Nance
holding arch. The mesial set screw is
used during active distalization .The distal screw is set on the bayonet wire, locking
the two pieces together to prevent molar movement. The premolar supporting wires
are sectioned where they enter the acrylic button, using a high-speed handpiece and
diamond bur. The bayonet wire or tube can be bent with a three-prong plier to adjust
the pressure of theacrylic button against the palate.
Figure 72 The mesial set screw is used during active distalization. Lingual sheath on molar maybe
crimped to reduce any play of double back wire inserted into it.
Conversion of double-set-screw Distal Jet to Nance holding arch:
1. Upon completion of molar distalization, double-set-screw activation collar is
slid mesially to gain access to coil spring.
2. Free end of coil spring is grasped with plier. Coil spring is removed by peeling
it away from bayonet wire.
3. Distal end of tube, where bayonet wire enters, can now be seen.
4. Double set-screw collar is slid back to this junction, mesial set screw is locked
on tube, and distal screw is set on bayonet.
Quick & Angela Harris:
The Distal Jet is a fixed palatal appliance that is most commonly used to distalize
the maxillary molars, either unilaterally or bilaterally. Disadvantage of Distal jet lies
in activation. The appliance is activated by sliding a collar along the supporting tube
to compress a coil spring, then fixing the collar in place by tightening a small set-
screw. This procedure is sometimes difficult because of the small size of the screw,
the moisture and confined space of the intraoral environment, and food impaction
in the screw head. In addition, activation requires the use of a small Allen wrench,
which has the risk of being swallowed or aspirated.

11. NICKEL - TITANIUM DOUBLE LOOP SYSTEM
Aldo Giancotti and Paulo Cozza in the year 1998 introduced a new system using the
Neosentalloy for simultaneous distalization of the first and second molars.
Figure 73 Nickel titanium double loop system
APPLIANCE DESIGN
The mandibular first and second molars and second bicuspids should be banded and
remaining teeth are bonded. Lip bumper should be given to prevent any extrusion
from the use of class II elastics. Maxillary molars and bicuspids are banded and
anterior teeth bonded. Neosentalloy arch wire is then placed on the maxillary arch
and marked distal to the first premolar bracket and 5mm distal to the first molar tube.
Stops are then crimped in the arch wire. Two sectional Niti arch wires (on either
side) are prepared by crimping stops distal and mesial of the 2nd premolar bracket
and 5 mm distal to each second molar tube. Uprighting springs are inserted into
vertical slot of the 1st premolar and class II elastics are placed between mandibular
1st molar and maxillary canine bracket.

12. CRICKETT APPLIANCE
Dr. Robert M. Rickettshas developed and successfully used a modification of the
basic Crozat appliance, affectionately referred to by patients as the Crickett
(Crozat/Ricketts) appliance. This appliance embraces the essential features of the
quad helix using the basic form of the Crozat, but replacing the palatal and lingual
bars of the upper and lower appliances with a quad- and bi-helix, respectively . The
Crickett's lingual arms are extended to provide an adjustable spring action directed
to the lingual surfaces of all the teeth, without the need for further soldering. The
buccal arms are retained for the attachment of elastics and for ease of insertion and
removal of the appliance, as well as serving their original function as the site of
attachment for a heavy labial wire if labial control is indicated. Lingual clasp wires
on the gingival side of the molar crib provide adjustable clasp retention or stability,
in addition to those on the buccal as in the basic appliance. Upper palatal and lower
lingual main frames are constructed from .032" Yellow and .038" Blue Elgiloy,
respectively; the cribs, clasps, and occlusal rests from .028" Blue Elgiloy; the lingual
arms from .030" Yellow Elgiloy; and the buccal arms from .045" Blue Elgiloy. As
with the fixed quad helix, the Crickett can effect a variety of tooth movements,
including rotation, torquing, and distalization of molars. It is an effective appliance
for both lateral and anteroposterior expansion, as in cases showing minor post-
retention changes.
Patients accept an additional brief period of active therapy if removable appliances
can reverse the trend and establish a stable, ideal occlusion. Greater attention to
detail in intra- and inter-arch occlusal contacts is essential. With control of the molars
in the three planes of space— and its capacity for intra- and inter-arch elastic traction;
labio-lingual movement of all teeth, and rotation and torquing of the anteriors by the
addition of soldered accessory archwires— the Crickett is a most valuable appliance.
Despite the virtues of the Crickett, it has some limitations when intrusion of anterior
teeth is part of the treatment plan. However, some proponents of Crozat therapy3
report complete success in treating cases with extremely deep bites using only a
Crozat appliance. They suggest that the reduction of the deep bite occurs as a result
of controlled, intentional extrusion of the molars with consequent opening of the
bite.
Figure 74 The appliance has an adjustable spring action directed to lingual

surgaces of all teeth. Upper palatal and lower lingual main frames are constructed
from 0.032" yellow and 0.038" blue elgiloy respectively
Crickett therapy can be most useful in the ameliorative approach, for either
functional or esthetic improvement in a non-mutilated mouth. Vocational demands
on people in the theater, television, films, or other public activities often preclude the
use of fully fixed techniques. For these individuals, the Crickettis an acceptable
option because it is removable, and it interferes minimally with speech and
appearance when it is in place. Over the past four years, both upper and lower
Cricketts have been used with success on patients who would not have pursued
orthodontic therapy if their only option had been fully fixed— even lingual—
appliances. The Crickettis ideally suited for moving teeth to achieve stability when
orthopedic repositioning of the mandible is necessary in treating adult TMJ
disturbances. The appliance can also be used for those who need reconstructive
treatment with fixed or removable prostheses. A brief period of orthodontic
treatment with the unobtrusive, comfortable Crickett is easily accepted and often
facilitates the design and function of such prostheses. There is no place for the
Crickett appliance in tooth alignment and post-surgical fixation in orthognathic
surgery cases, unless splints are used for fixation. Similarly, it has little or no place
in fully banded or bonded treatment plans, except for brief treatment in which teeth
are moved to facilitate bracketing or to eliminate traumatic relationships that might
jeopardize bonded attachments. There is much greater application for the Crickett in
reclamative cases that call for tooth movements primarily to eliminate or minimize
the deleterious effects of missing teeth, malplaced teeth, and periodontal problems in
mutilated arches. The pursuit of esthetics beyond the functional needs of the case is
not part of this treatment objective.

13. FIRST CLASS APPLIANCE
This appliance was developed by Fortini, Lupoli, Parri in the year 1999. The FCA
is a new type of appliance for unilateral or bilateral molar distalization.
APPLIANCE DESIGN
Bands are placed on the maxillary first molars and on either the second premolars or
deciduous second molars.
The appliance mainly consists of 2 components
1. Vestibular Components
2. Palatal Components
Figure 75 The first class appliance

VESTIBULAR COMPONENTS
The vestibular components consist of formative screws that are soldered on the
buccal sides of first molar bands, occlusal to the 0.022” X 0.028” single tubes, so
that they do not interfere during the insertion of arch wire. Split rings, welded to
the second premolar act as a control for the vestibular screws. Stop screws are used
to maintain the distal positions of the molars after active movement has been
completed.
PALATAL COMPONENTS
The appliance in the palatal aspect is wider than the modified Nance appliance and
is butterfly shaped for added stability and support during retention. The 0.045” wires
that are embedded in acrylic should be in a single section without welded joints, to
prevent breakage. Sections of 0.045” tube are soldered to the palatal sides of first
molar bands for insertion of the butterfly component. These tubes allow the molars
to be distalized without undesirable tipping. Niti coil spring of 0.010”xO.045”and
about 10mm in length is inserted by fully compressing it between the solder joints
and tubes. These springs are designed to balance the action of the vestibular screws
thus preventing molar rotations.

Figure 76 Palatal components of the appliance
14. SLIDING JIG
Developed by Alfred Rechter in 1968.
It is auxillary sectional arch wires used to tip or move one or a group of teeth in buccal
segments distally without disturbing anteriors. To avoid friction or binding - made
of 0.022 inch round wire and can also be made of rectangular wire.
A sliding jig as suggested by Salzmann has proved most helpful in certain light wire
treatments to convey distal elastic force to the molar on one side only. It is well to
reinforce anchorage with extra-oral force when using these jigs.
An effective jig is made by soldering a two-inch length of .022 wire to a sliding hook
made of .036 tubing.
Inter-maxillary hook - soldered or bent-in. To move maxillary molar distally, eyelet
on distal end of jig must but against molar tube, mesial eyelet is located between
cuspid and first premolar bracket at least 2 mm anterior to premolar bracket.

Figure 77 The sliding jig appliance
31. MODIFIED NANCE APPLIANCE FOR UNILATERAL MOLAR
DISTALIZATION TRACY J. REINER - 1992
The appliance was a modification of the traditional Nance holding arch. The Class I
side of the .036" stainless steel wire framework was finished with an anteriorly
projecting .036" arm, like that of a quad-helix. This arm was designed to resist the
horizontal moment that would rotate the molar distally and cause expansion in the
bicuspid region.
The active, Class II side also had an arm bent similar to a quad-helix, with the
most anterior terminus soldered to a first bicuspid band. An .020” omega loop was
soldered to the anterior end of the framework, which allowed the distal end of the
loop to slide distally as it was opened for activation.

A 10mm, .09''×.036'' open-coil spring was added to the framework arm between the
omega loop and the first molar band assembly. Finally, a first molar band with a
6mm, .045" tube soldered on the
lingual was attached to the wire arm, with the framework running through the tube
so that the band assembly could slide.
Figure 78 Modified nance appliance for

unilateral molar distalization
After cementation of the appliance, the omega loop was opened enough to compress
the coil spring to a length of 7mm, which had previously been measured to deliver
about 150g on a force gauge. All the 10mm springs were cut from the same spool.
At succeeding appointments, each spring was measured to ensure it was kept at the
7mm compression. When the molar being moved distally achieved a Class I
relationship, the lingual molar tube was tied back to the distal helix with a metal
ligature, and the part of the appliance anterior to the molar was removed. This molar
anchorage allowed possible retraction of the anterior teeth while maintaining molar
position.
Figure 79 An acrylic jig was fabricated to fit

over the maxillary incisors.
Divots were placed in the posterior extension of the jig and in the solder joint
connecting the first molar band to its lingual tube. At each two-week appointment,
the distance between divots was measured with a divider
Figure 80 The distance between divots measured with

divider
If the incisors remained stable, the distance measured with the jig would
approximate the amount of molar distalization needed for Class II molar correction,
as measured from the initial study models. These two distances were statistically
correlated using Pearson's matched pairs.

32. KARAD’S INTEGRATED DISTALIZATION SYSTEM
Introduced by Ashok Karad 2008
This appliance system is designed on the following principles -
1. Light continuous forces
2. Desired M:F for bodily movement
3. 3-D molar control through out the distalization therapy
4. Maximum anchorage conservation
5. Eliminate need for new Nance button
6. Economic
Components
Distalizing springs - It is a triple helical spring made from 0.017×0.025” TMA. It
consists of 2 gingivally placed helices and 1 occlusally. Gingival loops are of equal
dimension while occlusal loop is longer but width remains the same.
Figure 81 A. triple helical distalizing spring made from 0.017 * 0.025" TMA wire. B. Dimesions of
average sized distalizing spring in mm. C. Compressed spring when activated
Mesial and distal legs of loop placed in premolar and molar bracket, 2 points are
marked. One on the distal surface of 1st premolar bracket and second on the mesial
to molar tube. Vertical stops 1mm high are bent into wire 1mm mesial to mesial
mark and 1mm distal to distal mark. These stops produce 2mm activation and also
helps to keep spring away from the muccobuccal fold. To counteract tipping forces,
distal leg bent at 15° occlusally.
Modified Nance button
It consists of large butterfly shaped acrylic button and occlusal rests made from
0.036” SS wire. It extends about 5mm away from teeth and is 2mm thick with rounded
margins.
Occlusal rests
These are made from 0.036” stainless steel wire and are placed on mesial & distal
pits of 1st premolars. Pits are micro etched with sandblaster for better bonding. After
distalization, rests are cutoff.
Figure 82 Modified nance button with occlusal rests

Guiding Tubes
These are 1.62mm SS crimpable tubes with an internal diameter 1.22mm to receive
1.05mm stainless steel wire. Their function is to guide molars in predetermined
direction. Once crimped, they holds molar in new position- during consolidation
phase. These tubes are placed on the lateral curvature of the palate parallel to
occlusal plane. Extends up to the interproximal area between 1st molar and 2nd
molar.
Figure 83 Crimpable tubes which guides the molars into predetermined direction
Sliding recurved molar insertion tube
These are 1.05mm SS sliding, crimpable tube from lingual sheath to guiding bar.
They consists of 3 parts-
1. Doubleback segment
2. Vertical segment
3. Horizontal sliding arm

It is difficult to insert in lingual sheath, it can be compressed/ trimmed with metal
trimming disc. It can also be made flat and soldered to molar bands
MECHANISM OF ACTIVATION
The distalizing spring is activated 2mm activation- light continuous force on the
molar. Because it lies Away from Cres, it produces tipping of the molar. The 15
degree bends- counteract tipping moments. Guiding tubes- controls tipping and
vertical and transverse position of molar during distalization
Figure 84 Photograph showing distalization with KIDS
33. MODIFIED NANCE AND LINGUAL APPLIANCES FOR UNILATERAL
TOOTH MOVEMENT
Developed by Ghafari in 1985.
The Nance holding arch consists of a palatal arch attached to first molar bands and
embedded in an acrylic "button" that lies against the palatal rugae.

It was designed to act as a space maintainer in the maxillary arch, and it has also
been used to support maxillary posterior anchorage during tooth movement.
The modified Nance holding arch and modified lingual arch provide anchorage for
unilateral distalization of posterior teeth. They offer the major advantage of control
and activation without relying on patient cooperation in wearing headgear, ACCO
appliances, or interarch elastics.
Figure 85 Modified nance and lingual appliance for unilateral tooth

movement
Type 1— Modified Nance Holding Arch
Patient was a 12-year-old boy with a dental and skeletal Class I, except for the
maxillary right first and second molars, which were in distooclusion. The
maxillary right second premolar was 8mm wide, but there was only 3.5m of space
available for its alignment between the first molar and first premolar.
A modified Nance appliance was inserted, supported by the maxillary left first
molar and right first premolar; the right first and second molars were banded, and a
segmental rectangular wire (.019"× .025" Nitinol) was inserted on the right first
premolar and molars. An open coil spring (.30mm × .9mm) was moderately
activated between first premolar and first molar. In two months, the space between
these teeth increased to 6mm.
After four months of treatment and three activations of the coil spring, the
maxillary right first and second molars were in neutroclusion. Pre- and post-
treatment lateral cephalograms showed no labial movement of the central incisors.
Figure 86 Modified nance holding arch
Type 2— Modified Lingual Arch
Patient was a 13-year-old girl with a skeletal and dental Class I, except for the
mandibular right first and second molars, which were in mesio occlusion. Only
3.2mm of space was available for a lingually positioned mandibular right second
premolar measuring 7.4mm mesiodistally.
A modified lingual arch appliance, supported by the left first molar and the right
first premolar, provided anchorage for distal movement of the right first and second
molars. This movement was achieved with an open coil spring (.30mm × .9mm)
between the first molar and first premolar on a segmental rectangular wire (.019" ×
.025" Nitinol). Three months into treatment, sufficient space had been gained for the
alignment of the second premolar.
MODIFIED SECTIONAL JIG
It is a simple intra-oral minimal compliance fixed appliance introduced in 1998
for simultaneous distalization of 1st and 2nd molars. The appliance takes the
advantage of NiTi coil spring. It results in rapid distalization with but anchorage loss
of anterior dental unit. It consists on anchorage unit and active unit.
Anchorage unit – It is a modified Nance button attached to 2nd premolar bands
with 0.032” stainless steel wire.
Active unit - It consists of active arm from a round 0.028” SS wire with a length of
30-35mm. 3mm long loop is constructed at distance of 8mm from wire end divides
the wire arm section into two sections - Smaller distal and longer mesial portion.
Figure 87 Appliance with 3 mm long loop and niti open coil

spring
NiTi open coil spring 25-30mm long with cross section of 0.010” and 0.030” helix
diameter inserted through the mesial end of the sectional wire. Two sliding tubes are
used for positional stabilization of the spring. The distal tube is placed close to the
loop of sectional wire and stabilizes the coil spring, preventing it sliding into the loop.
The mesial tube, put in place after insertion of the spring, is provided with a hook
and is placed close to the mesial end of the sectional wire, which is subsequently
bent gingivally. This bend prevents the coil spring from sliding away from the wire
anf ensures the there is no soft tissue impingement.
Ligature is tied between the open loop of active arm and gingival hook of molar
band which adds stability and prevent rotation of sectional archwire.
ACTIVATION
The spring is activated by ligating the hook of the mesial sliding tube to bracket
of 2nd premolar. Optimal activation of coil will exerts 80gms of force per side. The
patient is monitored at 4 weeks interval for further adjustments and activations.
34. KELES SLIDER
It was given by Ahmet Keles in 2002.
APPLIANCE CONSTRUCTION:
Maxillary first molars and first premolars were banded. Tubes (0.45- inch diameter,
Leone A 076-45; Leone, Italy) were soldered to the palatal side of the Class II first
molar bands. First premolar bands were attached to a wide acrylic Nance button with
1.1-mm diameter stainless steel retaining wires. The acrylic button also consisted of
an anterior bite plane. The purpose of creating an anterior bite plane was to disclude
the posterior teeth, enhance the molar distalization, and correct the anterior deep
bite. On the palatal side of the molars, 0.9-mm diameter stainless steel wires were
embedded into the acrylic at about 5-mm apical to the gingival margin of the first
molars. These wires passed through the tube and were oriented parallel to the occlusal
plane.
Figure 88 Keles slider
Figure 89 Appliance consists of 0.040" SS wire and niti coil spring

For molar distalization, a heavy Ni-Ti coil spring (2-cm long, 0.9-mm diameter,
and 0.016-inch thick) was placed between the screw on the wire and the tube, in full
compression. The amount of force generated with the full compression of the 2-cm
open coil was about 200 g. This force system allows consistent application of force
at the level of the center of resistance of the first molars.
Biomechanics of the force system of the Keles Slider-
• Distal force - center of resistance of the maxillary first molar
● A, acrylic anterior bite plane
● B, retaining wire for maxillary first premolar
● C, 0.036-inch diameter wire rod for distal sliding of maxillary first molar
● D, adjustable screw for activation of the coil spring
● E, 0.036-inch heavy Ni-Ti open coil spring
● F, special tube soldered to the first molar band.

Patients were seen once a month, and the screw was activated with the se of a special
wrench. Two months after the initial activation of the appliance, segmental arches
with 30-degree toe-in bends were engaged on the buccal side between the first molars
and the first premolars. This was done to prevent distobuccal rotation of the molars,
due toforce application from the palatal side. After distalization, the Keles Slider
was removed and molars were stabilized with a Nance appliance for 2 months prior
to second-phase orthodontic treatment; Nance appliance was maintained until the
end of canine distalization.
35. A NEW CLASS II DISTALIZER (CARRIERE DISTALIZER)
Developed by Luis Carriere in 2004.
The Carriere Distalizer is a simple and efficient fixed functional appliance for class
II treatment. Developed by Luis Carriere with advanced computer technology, it
represents an evolution of the Modular Sectional Arch. The Distalizer is most
effective in treating class II malocclusions without extractions. Brachyfacial patterns
respond best to treatment; dolichofacial types are less responsive. Growing patients
are ideal, but adults can be treated as well. Mixed dentition class II with fully erupted
first molars are candidates for first phase treatment.

APPLIANCE DESIGN:
The Distalizer is made of mold-injected, nickel-free stainless steel. It is bonded to
the canine and first molar as follows: The canine pad, which allows distal movement
of the canine along the alveolar ridge without tipping, provides a hook for the
attachment of the class II elastics.
This pad is the mesial end of an arm that runs posteriorly over the two upper
premolars in a slight curve. The postero-anterior arm is permanently attached that
articulates in a socket on the molar pad. The ball and socket were models to resemble
the human hip joint, providing maximum freedom of movement. The joint also
controls torque control of both canine and molar. designed with three dimensional
virtual-Reality
Figure 90 The Carriere distalizer; maxillary molars are distalized and rotated
providing platform for maxillary canines to occlude in class I relationship
Figure 91 Bell and socket joint articulates for control of molar derotation while
limiting undesirable movements during distalization; bodily distalization of molar,
combined with derotation
Posterior portion of the Distalizer accomplishes three types of molar movement:
1. Uprighting the crown, if it is mesially inclined. Once the molar has been
uprighted, the articulation of the ball with the socket prevents distal tipping.
2. Distal rotation around the palatal root
3. Distal displacement without concurrent distal tipping of the crown.
APPLIANCE PLACEMENT:
The Distalizer comes in three sizes: 23mm, 25mm and 27mm. The appropriate
size is determined by measuring from the midpoint of the maxillary first molars
buccal surface to the midpoint of the maxillary canine crown, using a caliper or the
supplied “Dentometer”.
Figure 92 Three sizes measured from the permanent molar
Anchorage control:
1. Passive Lingual Arch.
2. Full mandibular fixed appliance.
3. Lower Essix appliance.
4. Miniscrews.
36. VERTICAL HOLDING APPLIANCE
The VHA appliance has been recommended for treatment of high angle patients
where there is an important need for control of vertical dimension.

Figure 93 Vertical holding appliance
DESIGN
Banded maxillary permanent first molars connected with a 0.040-in chrome cobalt
wire with a dime-size acrylic button. Four helices were incorporated into the wire
configuration for flexibility. 2 helices are placed at the center of appliance and other
2 are placed distal to maxillary molar. The most mesial portion of this appliance i.e,
Acrylic button should lie on a line that connects mesial margins of maxillary first
molars. The button should be 2- 5mm away from the palate.
Figure 94 Indirect loading of palatal implant for distalizing the right

molars and correcting dental asymmetry.
The VHA achieves treatment objectives by the way of an intrusive & distally
directed force. The result is intrusion and distal movement of the molars. This is
fixed functional appliance since the forces are achieved from functional activity of
tongue.
37. STRAUMANN ORTHOSYSTEM
Wehrbein et al, in association with Straumann, introduced the Straumann
Orthosystem. This device consists of a short implant made of pure, sandblasted and
acid-etched titanium, which is inserted in the middle area of the palate. Wehrbein
and Deidrich illustrated the characteristics of the implant insertion and histologic
tissue reaction to the orthodontic loading. Wehrbein et al subsequently presented
their clinical experience in extraction treatment using a palatal implant for posterior
anchorage. Recently, Byloff et al presented an implant-supported device for molar
distalization. Palatal implants can be used for mesializing or distalizing maxillary
segments, correcting intercuspation, and dental asymmetries combined with midline
shifts.
CLINICAL MANAGEMENT
The Straumann Orthosystem includes a titanium palatal mini-implant, which
consists of an intraosseous screw (height, 4 or 6 mm; diameter, 3.3 mm), made of

pure titanium (grade 4) with a self-tapping thread structure that is sandblasted and
acid etched, a transmucosal smooth neck that is in contact with soft tissues (height,
2.5 or 4.5 mm), and an exposed part (height, 2 mm) upon which the healing cap is
fixed. During the same surgical phase as implant insertion, a protective resin splint is
constructed for the patient. Instructions are given to the patient to insure good oral
hygiene and correct use of the protective resin splint. The next visit is 7 to 10 days
after the surgery.
Even if 13 weeks are necessary for complete osseointegration prior to loading the
implant, it is possible to begin the laboratory phase by taking a precise silicon
impression after 10 weeks, when the patient comes for the second postsurgery visit.
In this phase, the healing cap connected to the implant is replaced by a transfer
analogue (ortho transfer coping; length, 8 mm; height, 8 mm). The laboratory
analogue (ortho analogue; diameter, 4.2 mm; length, 14 mm) permits an exact
reproduction of the implant position and angulation on the master plaster cast. The
orthodontic technician affixes the stainless steel cap (ortho post cap; diameter, 5 mm;
length, 3.6 mm or 5.6 mm) for orthodontic appliance placement.
SURGICAL PROCEDURE
Implants for orthodontic use should be designed for easy handling, rapid healing,
and minimal surgical trauma. Twenty-four hours before surgery patients are given
an antibiotic (broad-spectrum penicillin, or macrolide for patients with penicillin
intolerance) three times daily. Immediately before surgery they are instructed to
rinse their mouth with chlorhexidine digluconate for 60 seconds to reduce the
intraoral bacterial flora. Then a local anesthetic (articaine hydrochloride and
epinephrine hydrochloride) in adequate amounts is injected at the implant site. For
placing transmucosal Orthosystem® implants, the palatal mucosa is removed with a
mucosal trephine (Fig 94) and an elevator.
Then a pilot hole is created in the cortical bone of the hard palate with a 2.3-mm
round bur, followed by osteotomy preparation with the ortho profile drill (Fig 95).
The self-tapping implant is seated in the osteotomy by hand then slowly screwed to
place with a ratchet. During the 12- week healing period, the implant is covered with
a healing cap (Fig 96). Functional loading should be avoided during this time. Flange
fixtures are placed in a two-stage procedure. A unilateral mucoperiosteal flap is
elevated to expose the cortical bone. The implant position and implant length are
marked with a guide drill. The initial hole is then widened with a countersink drill
to prepare a shoulder in the cortical bone (Fig 97). Flange fixtures are seated
nonmanually with a mount post (Fig 98), until the flange comes to rest on the
shoulder. If the torque controller stops at 30 Newton/centimeter (Ncm) before the
implant is fully seated, a thread should be pretapped to avoid overheating the bone.
Once the implant is fully seated, a healing screw is placed (Fig 99). The
mucoperiosteal flap is then closed with interdental sutures and the wound is covered
with a deep drawn membrane, which obviates the need for additional oral hygiene.
Figure 95 Removal of palatal mucosa with

Figure 96 Ortho profile drill for creating implant
mucosal trephine
osteotomy.
Figure 97 Orthosystem implant with healing cap

in place
Figure 98 After elevation of palatal mucoperiosteal flap, a

countersink hole with a shoulder is drilled for the implant
flange.
Figure 99 The flange fixture is seated with a

mount post. Figure 100 After removing the mount post,
the healing screw is attached to the implant.
CLINICAL EXPERIENCE
The current Straumann Orthosystem kit presents a few advantages that improve the
clinical application:
1. It is possible to laser or solder the transpalatal arch directly to the ortho post
cap;
2. It is simple for the orthodontist to handle;
3. It is possible to treat asymmetrical cases because of the internal octagonal
design of the cap, which avoids bar rotation;

4. There is better adaptation to different palatal morphology, due to two
possible lengths of the ortho post cap.
5. The surgical implant insertion is simple, with minimal unfavorable sequelae.
The system does not require patient compliance.
6. The system can be used in all phases of therapy, moving the connection bar
from premolars to molars for posterior anchorage.
These advances have widened the use of the Straumann Orthosystem, allowing the
design and subsequent construction of distalizing devices for maxillary molars with
improved comfort and more efficient clinical results.
38. MIDPLANT SYSTEM
It was introduced by Maino et al in 2002.
The implant system consists of two components, an endosseous portion called the
Core, and a unit called the Orthodontic Implant Connection (Oric) that connects the
Core to the oral region. The Core is a single unit formed by a self-tapping screw and
a disc (support flange) manufactured with commercially pure titanium (Grade 2).
The thread is designed to be screwed into cancellous bone without
damaging the insertion site. The surface of the screw that interfaces the bone is
treated with an acid etching process (bone lock etching) or with titanium plasma
spray (TPS) to increase its surface area, thus enhancing its retention. The diameter
of the screw is 3.75 mm and there are five lengths: 4.5 mm, 5.0 mm, 6.0 mm, 7.0
mm, and 8.0 mm. The disc is 5.0 mm in diameter and a hexagonal nut is fixed to the
superior surface of the disc. On the palatal aspect of the Core there is a threaded hole
that permits the connection of different orthodontic connecting systems.
There are two types of orthodontic implant connectors, which are also made of
commercially pure titanium (Grade 4). Each has specific indications. Standard
connector (Oric cap) has a cylindrical transmucosal portion that is 5.5 mm in
diameter and is available in four lengths, depending on the thickness of the palatal
tissue.
This component also has an internal hexagonal design on its connecting surface,
which mates with the hexagonal nut of the Core. The use of a hexagonal design
prevents rotation of the inserted connector. The transmucosal portion is secured to
the Core through a fixation screw that has a threaded hole in its head to allow a
cover cap to be attached by means of a screw. A transpalatal bar, made of round or
rectangular wire, is used to connect the teeth to the implant and is positioned
between the transmucosal portion and the fixation screw.

Figure 101 Midplant design for indirect loading method
The cover cap, which has four rectangular slots (height, 1.3 mm; width,1.2mm),
is then secured to the fixation screw, enhancing the anteroposterior stability of the
transpalatal bar.
The special design of the Oric cap ensures that the wires are locked and the reactive
forces are tridimensionally controlled. This connector is indicated when the
anchorage units will not change during treatment. An example is Class II extraction
treatment involving maxillary premolar extraction under maximum anchorage
conditions. Maxillary molar stabilization is necessary throughout treatment The
second version of the implant connector, called the Oric E.A. (easy application), is
a winged connection platform with a central hole and retaining holes on the wings.
It is secured to the Core by a fixation screw. On the transmucosal surface, there
is a hexagonal device that ensures positional stability and prevents rotation. Acrylic
can be added to the platform to ensure that the platform is adapted to the palate
properly. Transpalatal bars connecting the teeth to the Oric E.A. are fixed to the
platform by light or self-curing composites and resins.

The Oric E.A. is more flexible because the anchorage units can be changed with
minor modifications. It is indicated when more than one anchorage unit is necessary.
An example is Class II non-extraction treatment involving the distal movement
of the maxillary molars, followed by the sequential retraction of the premolars,
canines, and incisors. The Oric E.A. can be used as anchorage when moving the
molars distally. It can then be modified slightly and serve as anchorage to maintain
molar position during premolar, canine, and incisor retraction.
39. DISTALIZATION-MIDPALATAL MINISCREW S.H. KYUNG, S.G.
HONG, Y.C. PARK
Traditional methods of controlling anchorage during molar distalization tend to
cause unwanted movement of other teeth and to require patient cooperation. These
disadvantages can be overcome with skeletal anchorage, which is gradually gaining
acceptance among orthodontists. Byloff and colleagues have successfully moved
molars distally using a Graz-implant-supported Pendulum Appliance,1 but the
implant must be surgically removed after orthodontic treatment.
Karaman and colleagues have distalized molars by implanting a screw, 3mm in
diameter and 14mm long, 2-3mm behind the incisal canal, but a screw of this size runs
the risk of damaging the surrounding structures. Wehrbein and Merz were able to
close an extraction space by inserting a smaller implant, 3.3mm in diameter and 4-
6mm long, in the midpalatal suture area. This is a simpler procedure and less
invasive for the patient than conventional endosseous implants.
Clinicians have assumed that because the palatal bone appears thin on a lateral
cephalogram, a wider midpalatal implant or a disc-type onplant is required. The
palatal area is examined in three dimensions, however, the available bone support is
greater than it appears cephalometrically. The nasal cavity is not appropriate for
intrabony anchorage because it extends laterally from the midpalatal suture and is,
in fact, too thin, but the nasal crest between the anterior nasal spine and the posterior
nasal spine is 2mm thicker than it appears on a lateral cephalogram. The nasal crest
has a triangular shape with a base of 5.4mm and a height of 5.6mm in the average
adult large enough for a miniscrew.
Except in the incisal canal, the midpalate consists of cortical bone that is sufficient
to support an entire miniscrew, so that the screw will not be affected by orthopedic
forces. In addition, there are no roots, nerves, or blood vessels in the palatal area to
complicate surgical screw placement. Most of the soft tissue is thinner than 1mm,
ensuring accurate placement of the miniscrew with biomechanical stability. There is
no waiting for osseointegration and no need for additional surgery, because the
miniscrew is easily removed.

PROCEDURE
Inserting a miniscrew is difficult with a conventional straight screwdriver, which
forms an oblique angle with the bone surface, changing the direction of the screw
and increasing the likelihood of bone damage and implant failure. Therefore, a
screwdriver in a contra-angular handpiece i s required, and it must be longer than
the depth of the palate to avoid contact with the maxillary anterior teeth. Because
the cortical bone can be damaged rather easily by frictional heat, the screw should
be inserted with irrigation at a rate of no more than 30 turns per minute. More
pressure is needed than in other areas due to the density of the bone. Care should be
taken not to let the power chain directly contact the soft tissue. Educating the patient
about oral hygiene around the miniscrew is also critical. Even though there is
keratinized tissue in this area, the soft tissue will proliferate readily with adequate
hygiene. Midpalatal miniscrew was inserted, and a distal force of about 400g was
applied with power chain.
40. FRIALIT-2 IMPLANT SYSTEM
Introduced by Keles et al in 2003.
Palatal implants have been used over the last two decades to eliminate headgear wear
and to establish stationary anchorage. In this case report, the stability of a palatal
implant for distalization of molars bodily and for anchorage maintenance was
assessed. The implant was a stepped screw titanium (4.5 mm diameter 3 8 mm
length), and it was placed in the palatal region for orthodontic purposes.
A surgical template containing a metal drill housing was prepared. Angulation of
the drill housing was controlled according to the radiologic tracing of the maxilla
transferred to a plaster cast section in the paramedian plane. The implant was placed
using a noninvasive technique (incision, flap, and suture elimination) and left
transmucosally to facilitate the surgical procedure and to reduce the number of
operations.
The paramedian region was selected (1) to avoid the connective tissues of the palatine
suture and (2) because it is considered to be a suitable host site for implant placement.
After three months of healing, the implant was osseointegrated and orthodontic
treatment was initiated. For molar distalization, the Keles Slider appliance was
modified and, instead of a Nance button, a palatal implant was used for anchorage.
The results showed that the molars were distalized bodily at five months, and no
anchorage loss was observed. At the end of the treatment, the smile was improved,
and an ideal Class I molar and canine relationship, an ideal overbite, and an ideal
overjet were all achieved. In conclusion, palatal implants can be used effectively for
anchorage maintenance and in space- gaining procedures. Use of a three-
dimensional surgical template eliminatedimplant placement errors, reduced chair
time, minimized trauma to the tissues, and enhanced osseointegration. This method
can be used effectively to achieve distalization of molars bodily without anchorage
loss.
A stepped screw titanium implant (4.5 mm diameter 3 8 mm length) (Frialit-2
Implant System, Synchro Screw implants, Friadent GmbH, Mannheim, Germany)
was placed in the palatal region for orthodontic purposes.
Figure 102 Frialit -2 implant system
APPLIANCE CONSTRUCTION
For molar distalization, Keles Slider appliance (patent pending) was modified
and, instead of using a Nance button for anchorage, the anchorage was obtained from
the palatal implant. This modification in the design eliminated the support of the
palatal soft tissues, first premolars, and anterior teeth. Maxillary first molars were
banded, and on the palatal side of the first molar bands, tubes of 0.045-inch diameter
were soldered (Leone A076-45, Firenze, Italy). A stainless steel wire of 0.040-inch
diameter was attached to the palatal implant and the wire oriented about five mm
apical to the gingival margin of the first molars, which passed through the
tube and oriented parallel to the occlusal plane. A Ni-Ti coil spring (Leone C1210-
45), two cm length, 0.045-inch diameter, and 0.010-inch thickness, was placed in
between the lock on the wire and the tube in full compression for molar distalization.
The amount of force generated with the full compression of the two cm open coil
was about 200 gm. This force system would allow application of consistent force at
the level of the center of resistance of the first molars.
The patient was seen once every month, and a Gurin lock (3M Unitek,
Orthodontic Products, Monrovia, Calif., 560-400) was activated with the Gurin lock
wrench (3M Unitek, 810-002). After the distalization, the coil springs were
removed, the locks were tightened and flushed to the tubes of the molar bands.
41. ONPLANT SYSTEM
Introduced by Bondemark et al in 2002.
In 1995, Block and Hoffmann presented a thin titanuim alloy disk (Onplant; Nobel
Biocare, Gothenburg, Sweden), which was textured and coated with hydroxyapatite
(HA) on one surface and had a threaded hole to receive an abutment on the opposite
side. The device was inserted subperiosteally and left unloaded for 16 weeks to allow
osseointegration. It was tested in two animal series, with promising results. As
expected, the Onplants did not move andhistologic comparison between loaded and
unloaded control devices revealed no significant differences.

The shear force needed to separate the Onplants from underlying bone was
approximately 700 N for the specimen tested. Since the Onplant does not have to be
inserted into bone, it can be placed in patients in various states of dental eruption,
avoiding the unerupted and erupted teeth. The Onplant system has potential for use as
absolute anchorage for intra-arch distal movement of the maxillary molars. In this
article, the authors demonstrate and evaluate molar distalization treatment with an
intra-arch device provided with the Onplant system for absolute anchorage.
The Onplant is a thin titanium alloy disk, 7.7 mm in diameter and 2 mm thick, that
is inserted subperiosteally. The Onplant surface that makes contact with bone is
textured and coated with a layer of HA 75 μm thick. The HA permits more favorable
osseointegration/biointegration.14 The surface facing the soft tissue is smooth
titanium alloy with an external hexagon that is protected by a cover screw, for
abutment connection. The corresponding abutment is a two-piece construction with
an internal hexagon toward the Onplant and an internal double hexagon facing a
cylinder, which makes it possible to connect a transpalatal bar. This concept,
together with the osseointegration, allows the building of a superstructure with
rotational stability in all planes.

Figure 103 Onplant system
Surgical procedure
Figure 104 The onplant disc and attachment screw; onplant uncovered for abutment placement
Presurgically, the patient received 2 g of amoxicillin as single-dose antibiotic-
prophylaxis. After local anaesthesia of the palate, a paramarginal incision with a
length of approximately 15 mm was made in the region from the lateral incisor to
the first premolar. A subperiosteal tunnel extending across the midline in the region
of the second premolar was prepared. The Onplant was inserted into the tunnel and
slid into a position with the hydroxyapatite surface directly on the bone, close to the
palatal midline. The incision was closed with a few interrupted suture and a
prefabricated, relieved, clear vacuum-form stent, lined with Viscogel (Dentsply,
York, PA, USA) tissue conditioner, was put in place.
The intention with the stent, which was to be kept in place for 24 hours during the
first week, was to prevent migration of the Onplant and hematoma formation. Seven
days post-surgery, the sutures were removed, and throughout the first week the
patient used a 0.1% chlorhexidine gluconate mouthrinse twice daily, in addition to
normal oral hygiene. After 16 weeks of healing, the transmucosal abutment was
placed. A small amount of local anesthesia was administered to the mucosa above
the Onplant. The cover screw of the Onplant was located with a dental probe and
exposed using a tissue punch. The cover screw was then removed and an abutment
screw with a healing cap was placed.
Orthodontic procedure
When the abutment connection was completed and the palatal soft tissue healed,
the transpalatal bar (anchorage bar) was readied. The healing cap over the abutment
was removed and an impression coping was secured on the abutment; a polyether
impression was taken to transfer the abutment position to a stone cast. When the
impression was removed, a special abutment replica was secured to the impression.
The impression with the abutment replica was poured in stone and fabrication of the
transpalatal bar could take place. The bar (1.3-mm diameter, spring hard stainless
steel) was welded with metal mesh on both ends to allow bonding to the palatal
surfaces of the anchorage teeth. As soon as the transpalatal bar was inserted, two
sectional arches (0.017×0.025-inch stainless steel) were attached bilaterally to
brackets and tubes on the second premolars and first and second molars,
respectively.
A nickel-titanium (Ni-Ti) open coil (Masel, Bristol, PA, USA) was inserted on
the sectional arch between the tube on the first molar and the bracket on the second
premolar. The open coil was compressed approximately 2.5 mm, providing a force
of approximately 150 g. Reactivation was performed every sixth week during the
molar distalization period. After the distal movement of the maxillary molars was
completed, the transpalatal bar was removed. A new transpalatal bar, attached to the
Onplant and bonded palatally to the first maxillary molars, was inserted to hold the
moved molars in place while the canines, premolars, and incisors were retracted into
a Class I relationship.
42. DISTAL MOVEMENT OF MAXILLARY MOLARS USING
MINISCREW ANCHORAGE IN THE BUCCAL INTERRADICULAR
REGION
It was introduced by Kazuyo Yamada, Shingo Kuroda, Toru Deguchi, Teruko
Takano-Yamamoto and Takashi Yamashiro in 2009. Placement of miniscrews in
the buccal interradicular bone is one of the most common approaches used to
provide skeletal anchorage. The interradicular space is a potentially
advantageous region for insertion because the miniscrew would cause fewer
complications related to soft tissue irritation, especially if placed through the
attached gingiva. However, miniscrews inserted into the interradicular space
should obstruct on tooth movement when adjacent teeth are moved in an
anterior-posterior direction.
The miniscrews provide sufficient anchorage for incisor retraction in Class II
treatment without unwanted orthodontic side effects. With Class II treatment in
premolar extraction cases, it has already been showed that miniscrew anchorage
could provide more effective incisor retraction than the traditional anchorage
method in which a headgear and a transpalatal arch were used. Apart from premolar
extraction cases, these devices could provide special benefit in nonextraction cases
in terms of retracting all dentition without producing adverse reciprocal movement.
The screws are inserted after leveling and aligning. No mucoperiosteal incision or
flap will be made; screw holes will be made with a 1.0 mm round bar and a twist
drill at 500 rpm with continuous normal saline solution irrigation. Screws are were
placed through the attached gingiva via a self-tapping method with continuous
irrigation. Each screw is inserted 5 or 6 mm into the alveolar bone at an angle of 20
to 30 degrees to the long axis of the proximal tooth, and the head of the screw is
adjusted to at least 2 mm above the mucosa. After placement, a dental radiograph
must be taken to evaluate the distance between the screw and the root.
Loading of screws will begin after 4 weeks after placement. The orthodontic load
can be applied by elastic chains or nickel-titanium (Ni-Ti) closing coil springs,
estimated at 200 g. Force is applied backward and upward as parallel to the occlusal
plane as possible (Figure 1).
Figure 105 The schema about molar distal movement

achieved with the miniscrew.
To avoid close screw proximity to the surrounding root, insertion site in the
buccal interradicular space between the maxillary second premolar and the first
molar is chosen as the interradicular space is widest in the maxillary buccal region.
Miniscrews with a 1.3 or 1.5mm diameter are placed at 20 to 30 degrees to the long
axis of the proximal tooth. Therefore, the interradicular distance might be longer
than 3 mm in the buccal root area around screws that are placed at an oblique angle.
Because of the implantation methods used, the maxillary molars can be moved to
the distal by approximately 3 mm without screw contact with the proximal root.
In addition, Deguchi et al reported that miniscrews placed at 30 degrees to the
tooth axis had a 1.5 times greater contact area with the surrounding cortical bone
than did those placed perpendicular to the tooth axis. This suggests that inserting
miniscrews at an oblique angle might contribute to their stability. Miniscrews placed
in the maxillary inter-radicular space provide successful molar distal movement of
2.8 mm without patient compliance and with no undesirable side effects such as
incisor proclination, clockwise mandibular rotation, or root resorption. Miniscrews
placed in the maxillary buccal inter-radicular space between the second premolar
and the first molar at an oblique angle were useful for moving maxillary molars
distally in non-growing patients. Molar distal movement was achieved without
active patient compliance or with no undesirable side effects such as incisor
proclination, clockwise mandibular rotation, or root resorption.
43. ZYGOMA-GEAR APPLIANCE
It was introduced by Metin Nur, Mehmet Bayram and Alper Pampu in 2010.
APPLIANCE DESIGN
The system consists of two zygomatic anchor plates (Multi Purpose Anchor MPI
1000, Tasarim Med, Istanbul, Turkey), an inner-bow, and heavy intraoral elastics
and the effective distalizing force vector of the ZGA is illustrated in Fig 105.
The zygomatic anchor is a titanium miniplate with three holes, which continues into
a round bar. The anchor plates are placed at the zygomatic buttress of the maxillae
under local anesthesia (Fig 2). The zygomatic buttress is palpated in the labial sulcus,
and a 1- to 2-cm-high vertical incision is made starting at the mucogingival junction
while maintaining contact with the bone. The lower aspect of the zygomatic process
of the maxilla is totally exposed by blunt dissection. The anchor plate is adjusted to
fit the contour of the lower face of each zygomatic process and fixed by three bone
screws (length, 7.0 mm). The body portions of them are positioned subperiosteally.
The round bars are intraorally exposed and positioned outside the dentition, so that
they never disturb the distalization of the maxillary molars.
After fixation, the incision site is closed and sutured. The free intraoral parts of the
miniplates are bent distally into hooks. The inner-bow is made from stainless steel
wire, 1.1 mm in diameter and designed like the inner part of a conventional facebow.
Two hooks are soldered onto the inner-bow at the lateral teeth regions, and U bends
are bent bilaterally in front of the upper first molars. The inner-bow is adjusted to
the headgear tubes on the upper first molar bands. A distally directed force is applied
to the upper molar teeth via the heavy intraoral elastics, which are placed between
the zygomatic plate and the inner-bow hooks.

Figure 106 Schematic illustration of components (A) and the effective distalizing force
vector of the ZGA (Zygoma-Gear Appliance) (B)
Figure 107 The zygomatic anchor plates adapted and fixed to the zygomatic butress.
44. INFRAZYGOMATIC CREST IMPLANT
Orthodontics in its century of existence have had a lot of landmarks in its evolution,
but very few can match the clinical impact made by micro-implants and the recently
introduced infra-zygomatic crest (IZC) and buccal shelf (BS) orthodontic bone
screws.
Figure 108 Infra Zygomatic Crest (IZC)
MAXILLARY INFRA-ZYGOMATIC CREST
1. The IZ crest is a palpable pillar of cortical bone between the zygomatic process
of maxilla and the alveolar process .
2. In younger individuals the IZ crest is between the maxillary second premolar
and first molar , whereas it is above the maxillary first molar in adults.
3. It has been used as osseous anchorage for maxillary canine retraction, anterior
4. retraction, en mass anterior retraction, or intrusion of the maxillary posterior
teeth.
5. Its thickness ranges from 5.5 to 8.8mm in adults.
6. The IZ crest consist of two plates-the buccal cortical plate and floor or lateral
wall of maxillary sinus –with cancellous bone between the plates
7. These plates provide bicortical fixation and possibly better primary miniscew
stability when the miniscrew penetrate into the maxillary sinus.
8. The maxillary sinus must be free of infection before screw insertion. Maxillary
sinusitis is a contraindication .
9. Therefore the clinician must check the medical history , palpate the buccal
cheeks tenderness, and check the clarity of maxillary sinus on panoramic and
PA radiograph before insertion of miniscrew in the IZ crest of maxilla.
DIMENSIONS OF IZC
The length of IZC screw were:
1. 2 x 12mm(Abso Anchor &Bioray)
2. 2 x 13mm (Lomas)
Also Anchor and Lomas were of cylindrical type, composed of parallel thread
along the whole length of the thread part. Bioray was a taper type implant
composed of increased inner and outer diameter at the end of the thread part
Figure 109 From left to right: AbsoAnchor (2.0 × 12 mm), Bioray (2.0 × 12 mm),
and Lomas (2.0 × 13 mm)
Figure 110 Bone screw specifications: IZC, BSS

a) While the regular size of a micro-implant ranges between 6 and 11 mm in
length and 1.3–2 mm in diameter depending on the clinical situation.
b) Bones screws are comparatively larger in size ranging from 10 to 14 mm in
length and a minimum diameter of 2 mm.
c) Head shapes may also vary just as micro-implants, the common being
mushroom shaped.
d) Micro-implant available in the market is made with an alloy of – titanium,
aluminum and vanadium (Ti6Al4Va) and bone screws are also available with
similar compositions but the choice of material is pure stainless steel.
e) Bone screws are generally placed in areas of (>1250 HU) quality bone (IZC )
and therefore requires greater fracture resistance. Stainless steel provides
greater fracture resistance than Ti alloy and is therefore the preferred material
of choice.
INDICATIONS OF IZC
1. Individual canine retraction
2. En-Mass retraction
3. Maxillary distalization
4. Open bite correction
5. Intrusion of maxillary posterior teeth

SITES FOR PLACING IZC SCREWS
The preferred site for placement of bone screws in the maxilla is the infra-
zygomatic crest which lies higher and lateral to the 1st and 2nd molar region.
Figure 111 Location of the IZC
a. According to Lin, bone screws to be placed in the1st and 2nd molar region .
b. According to Liou a more anterior placement, closer to the MB root of the 1st
molar.
Figure 112 Location of the IZC according to Liou (6) and Lin (7)
MINISCREW INSERTION IN IZ CREST OF MAXILLA
a. For placement of bone screws in the IZC (1st and 2nd molar region) – initial point
of insertion is inter-dentally between the 1st and the 2nd molar and 2 mm above
the muco-gingival junction in the alveolar mucosa.
b. The self-drilling screw is directed at 90° to the occlusal plane at this point.
Figure 113 Direction of self driving screw

c. In IZ crest of maxilla a self-drilling miniscrew can be inserted directly without
pilot drilling
d. After the initial notch in the bone is created after couple of turns to the driver, the
bone screw driver direction is changed by 55°–70° toward the tooth, downward,
which aid in Bypassing the roots of the teeth and directing the screw to the infra-
zygomatic area of the maxilla.
e. To avoid injury to the mesio buccal root of maxillary first molar.
f. The bone screw is screwed in till only the head of the screw is visible outside the
alveolar mucosa.
g. No pre-drilling, raising of flap or vertical slit in the mucosa is required for
insertion of IZC screws.
h. Immediate loading is possible and a force of up to 300–350 gms can be taken up
by a single bone screw.
BIOLOGICAL LIMITATION FOR PLACEMENT OF IZC FOR
DISTALIZATION
Ideally fully erupted third molars are to be removed to create space and aid in the
distalization process. For un-erupted third molars placed below the cement-enamel
junction of the 2nd molars in young individuals, distalization is possible without
their extraction.
FAILURES OF IZC
According to a recent study by Chang et al the IZC screw failure rate is <7%. Most
of the failures are due to:
a. Poor bone quality: Unfortunately, there is no reliable method for evaluating
bone quality. The sensation for poor bone quality, beneath sound layer of
cortical bone, is like punching through an egg shell, followed by a lack of screw
stability. Unless the TAD can be stabilized by deeper penetration, it is best to
remove it and try another site.
b. Immediate loading: SS screws are excellent TADs because they do not
osseointegrate and are easily repositioned to another site, if necessary.
c. Sinus floor: A low sinus between the roots of teeth is undesirable for an IZC
TAD site.
d. Movable mucosa: Unattached alveolar mucosa at the TAD site is usually
undesirable. However, Chang et al. found no significant difference in the
failure rate between movable mucosa and attached gingiva if the platform of
the screw is at least 5mm away from the soft tissue surface. The disadvantages
of the latter approach are a longer screw is required (~12mm) and it must be
carefully positioned for patient comfort.

INTER ARCH APPLIANCES
In the treatment of Class II division 1 malocclusions characterized by mandibular
inadequacy, functional and fixed appliances are used that allow forward positioning
of the mandibular to stimulate mandibular growth. These interarch appliances
mainly bring about skeletal correction of class II malocclusion. However, they have
undesired dental effects which also occur along with the desired skeletal effects with
the usage of functional appliances. Ie, they bring about distal and intrusive
movement of the maxillary molars, mesial movement of the mandibular molars,
retrusive movement of the maxillary incisors and labial tipping of the mandibular
incisors. Therefore, these appliances give an added benefit of distalizing the
maxillary molars.
In contrast to the removable functional appliances, fixed functional appliances
provide advantages, such as not requiring patient cooperation, and they can be used
along with brackets.
1. HERBST APPLIANCE
The Herbst appliance is a bite jumping device developed by Emil Herbst in 1905
used for class II correction. It was reintroduced by Pancherz in 1979.

Figure 114 The herbst appliance
APPLIANCE DESIGN
The Herbst appliance is completely tooth-borne and uses both the maxillary and
mandibular dentition to transfer the force exerted from the telescopic arms of the
Herbst bite jumping mechanism to the bases of the maxilla and the mandible. The
telescopic system produces a posterosuperiorly directed force on the maxillary
posterior teeth and an anteriorly directed force on the mandibular dentition. As a
result, Class II molar correction generally is a combination of skeletal and
dentoalveolar changes irrespective of facial morphology.
The Herbst telescoping bite jumping mechanism places a distal and intrusive force
on the maxillary molars and the force vector passes occlusally to the center of
resistance. This force system produces backward and upward movements of
maxillary molars in conjunction with distal crown tipping. Because of the intrusive
effect, distal movements of maxillary molars do not tend to open the mandible. These
effects are similar to those produced by high- pull headgear.

2. JASPER JUMPER
Figure 95 The jasper jumper
This appliance developed by James.J. Jasper is similar in concept to the Herbst
appliance and is used in conjunction with fixed appliance. The jumper mechanism,
which is available in a number of pre-selected sizes, is attached to the maxillary face
bow tube through the use of a soft wire with a ball on one end. The amount of
mandibular advancement is adjusted by lengthening the maxillary connecting wire.
The jumper mechanism fits over the lower arch wire. A lateral bayonet bend is
placed distal to the lower canines usually the brackets on the lower first premolars
(if present) are removed. A small acrylic ball is placed adjacent to the bayonet bend
and then the arch wire is placed through the hole on the anterior portion of the
jumper. A heavy arch wire is used in the mandibular dental arch in order to maintain
lower anchorage. There also is a danger of lower incisor proclination if the arch wire
is not tied back usually 6-9 months of jumper wear is necessary in order to correct a
mild Class-II problem in patients who still have some growth remaining. Additional
treatment time is required in patients with more severe problems.

INDICATIONS:
1. Dental class II malocclusion
2. Skeletal class II with maxillary excess as opposed to mandibular deficiency
3. Deep bite with retroclined mandibular incisors
CONTRAINDICATIONS:
1. Cases predisposed to root resorption.
2. Dental and skeletal open bites.
3. Vertical growth with high mandibular plane angle and excess LAFH.
4. Minimum buccal vestibular space.
The Jasper jumper is an interarch appliance which to an extent can be utilized for
molar distalization by making use of its possible advantages and disadvantages.
In general the appliance consistently causes the following effects. Displaces the
maxilla posteriorly. Tip the maxillary molar posteriorly and intrudes them. Tip the
maxillary incisors posteriorly and extrude them. These reciprocal actions of the
appliance can be used for molar distalization in selected cases.

3.KLAPPER SUPERSPRING II
The Super Spring II was developed by Klapper in the year 1999.
APPLIANCE DESIGN
Figure 116 The klapper superspring II
The super spring II is a flexible spring element that attaches between the Maxillary
Molar and the mandibular canine. It is designed to rest in the vestibule making it
impervious to occlusal damage and allowing for good hygiene. The spring’s open
helical loop is twisted like a ‘J’hook into the mandibular arch wire. On the maxillary
end a special oval tube serves as the maxillary first molar attachment. The spring
can be secured to the new tube with a stainless steel ligature. The new tube simplifies
adjustment and thus the position of the tube in the vestibule.
In opening and closing movements, the lower helical attachments hinges on
mandibular arch wire through an arc of about 90º.The Super Spring II provides a
moderate, continuous distalizing force with a simultaneous intensive mechanics over

a wide range of mandibular movement. The anteroposterior force can be adjusted
from about 0 - 5 oz by extending the anterior component wire and or changing the
angle of the posterior attachment wire. A horizontal attachment wire at the Maxillary
Molar tube will provide a more horizontal force against the Maxillary crowns and
less intrusion of mandibular anterior teeth, similarly a more vertical adjustment of
wire create more maxillary molar root distalization and more mandibular anterior
intrusion.
PATIENT MANAGEMENT
The Super Spring II new maxillary oval tube prevents any lateral movement of
the spring in the vestibule. Therefore only minor adjustments for individual
variations need to be made. With Super Spring II the initial dental discomfort
disappears within about 3 days.
CLINICAL APPLICATIONS
The Super Spring II can be used with fully bracketed appliances and it makes an
ideal auxiliary for various uses.In the late mixed dentition, while the mandibular
arch is fully bonded for anchorage, the maxillary molars can be distalized without
bonding the adjacent teeth. The Super Spring II moves both the crown and roots with
a moderate, continuous force and the adjacent teeth then follow the molar distally.
ADVANTAGES
1. Easy to use
2. No prolonged treatment time
3. Comfortable for the patient.
4. Minimal breakage chance
4.THREE DIMENSIONAL BIOMETRIC DISTALIZING ARCH
Three-dimensional bimetric maxillary distalization arches (3D-BMDA) was
introduced for the correction of Class II malocclusions by Wilson (1978) and Wilson
and Wilson (1980 , 1984 , 1987 , 1988 ). With this system, the maxillary molars are
distalized using an open coil spring and Class II elastics ( Wilson and Wilson, 1987
, 1988 ). Composed of maxillary and mandibular components, the 3D-Maxillary
Bimetric Distalizing Arch produces rapid, bilateral or unilateral, friction-free
distalization of the maxillary molars -- without the need for headgear (a real plus
when treating young, appearance-sensitive patients). The maxillary components
consist of a labial arch wire with an omega loop and a hook; anterior brackets;
compressed coil spring; and molar bands. The set-up is as follows:
The arch wire is ligated to the anterior brackets. Compressed coil spring is then
placed on the labial wire between the adjustable omega stop and the buccal tube.
The labial arch wire is then run through the buccal tubes of the molar bands.
This set-up allows the coil spring to apply distal pressure on the molar while the
omega stop allows for periodic reactivation of the spring as treatment progresses
Figure 117 The bimetric distalizing arch
The mandibular component is a fixed lingual arch wire -- running from molar to
molar -- which acts as an anchorage unit. It is extremely important to connect the
maxillary arch wire to the lower anchorage unit. This ensures that the maxillary
anteriors remain passive, while the molars are distalized...and it is easily done by
attaching an elastic -- from the hook on the maxillary arch wire to the hook on the
mandibular molar band. Elastics should remain in place at all times during active
therapy.
MANDIBULAR APPLIANCES
1. LIP BUMPER
The lip bumper is a fixed functional orthodontic appliance. It works by altering the
equilibrium between the cheeks, lips, and tongue and by transmitting force from
perioral muscles to the molars, where it is applied. The lip bumper has been used by
83
different clinicians for various purposes.
● Molar anchorage
● Therapy of habits
● Space gaining in the lower arch
Figure 118 The lip bumper

The differences in results, which were published in orthodontic literature probably,
are related to the fact that several types of lip bumpers are available and they can be
used in various ways. All three purposes listed previously can be obtained with it.
If used for an appropriate length of time, this lip bumper can help gain an
incredible amount of space in the lower arch while maintaining good control of the
molars and incisor.
CHARACTERISTICS OF THE LIP BUMPER.
The lip bumper has a removable part and a fixed part. The fixed part is composed of
two molar bands cemented to first, or if possible, second molars with 0.045-inch
tubes. These tubes have a 4° mesial offset to facilitate insertion and a stepout to
prevent gingival impingement. The removable part is essentially composed of a
0.045-inch stainless steel wire that runs in the lower vestibule from molar to molar
between the teeth, lip, and cheek.
The lip bumper must keep the cheeks and lip away from the lower dentoalveolar
area, and this shielding effect must be verified at each appointment.
The lip bumper should be wider buccally and flatter anteriorly than the natural
arch form it is designed to produce because the dentoalveolar widening and reshaping
are induced by the tongue and lip bumper without direct appliance force except for
the contact at the molar tubes. The lip bumper should not exert any expansion or
contraction on the molars. It must be easy for both the clinician and the patient to
insert and remove.

As the arches anterior to the molars respond to the reshaping and widening of the
lip bumper, they take on a wider natural arch form. Guidelines are given below for
obtaining optimal adaptation of the appliance:
a. Transverse position: The wire must be 2 mm from the lower canines and 3 to
4 mm from the premolars. Protection of the canine area is crucial, and the four-
looped bumper definitely is more effective.
b. Sagittal position: The lip bumper should not be more than 1 to 2 mm away
from the labial surface of the lower incisors. This position offers good support of the
lower lip for the anterior seal without rendering the appliance uncomfortable.
c. Vertical position: In the lateral segments, the wire must be positioned
generally at the middle third of the premolar and canine crowns. In the severest
cases, in which good vertical control is necessary, the bumper can be adapted to rest
deeper in the vestibule. The cheeks override the bumper during function, producing
an intrusive force on the lower molars. In the anterior region, depending on the
overbite, the bumper can be positioned at three different levels with respect to the
incisor crowns:
d. Incisal edge: This position usually is used during the initial phase of treatment.
It helps to upright mesially inclined molars because the lower lip tends to lift the
anterior part of the bumper, creating a longer lever effect on the molars.
e. Middle third: This is the position to use when a shielding effect on the incisors
is desired. The lower lip is kept away from the teeth, altering the equilibrium in favor
of the tongue. The incisors slowly translate labially.

f. Gingival level: This level is used when the orthodontist does not want to alter
the equilibrium between centripetal and centrifugal forces. Because the incisors are
still under the lower lip action, they maintain their position. The lip bumper must be
kept very close to the incisors. Activating the lip bumper. After space has been
obtained in the lower arch and bonding of the lower arch has been planned in a few
appointments.
2. THE FRANZULUM APPLIANCE
The Franzulum appliance is a new appliance used for distalizing mandibular molars
invented by Byloff and Darendeliler in the year 2000.
Figure 119 Tube from acrylic button to receive active component;
J shaped wire inserted into tube

APPLIANCE DESIG
The Franzulurn appliance’s anterior anchorage unit is an acrylic button, positioned
lingually and inferiorly to the mandibular anterior teeth and extending from
mandibular left canine to the right canine. The acrylic should be 5 mm wide to avoid
mucosal trauma and to dissipate the reactive forces produced by the distalizing
components.Rests on the canines and first prernolars are made from 0.32” stainless
steel wire. Tubes between the second prernolars and the first molars receive the active
components.
The posterior distalizing unit uses Nickel Titanium coil springs, about 18mm in
length which apply an initial force of 100-120 gm per side. A J- shaped wire passing
through each coil is inserted into the corresponding tube of the anchorage unit. The
secured portion of the wire is engaged in the lingual sheath of the mandibular first
molar band. The anchorage unit is bonded with composite resin to the canines and
first prernolars. The J-shaped distalising unit is then ligated to the lingual sheath of
the molar bands, Compressing the coil springs lingually at a level close to the centre
of resistance of molar to produce an almost pure bodily\movement. The Franzulum
appliance is an effective appliance in producing distalization of mandibular first
molars.
3. DISTAL JET FOR LOWER MOLAR
Introduced by aldocarano, dds, ms Recently introduced a Distal Jet appliance for
upper molar distalization. The same telescoping mechanism used in this appliance
can also be used to upright lower molars prior to the placement of prosthetics.
APPLIANCE DESIGN
Figure 120 Appliance design for lower molar distal jet; 0.036" tube soldered to
premoalr band
Solder an .036" tube to the premolar band, parallel to the occlusal plane, but below
the level of the edentulous ridge so as not to interfere with the occlusion. Orient the
tube so that a wire with a bayonet bend can be slid into the tube from the distal. Bend
a circle into the distal end of this wire, and attach it to the molar band with a screw.
Thus, the wire and molar band are held together, but are free to rotate around a
common axis.
Place an adjustable screw-clamp and a 150g nickel titanium open-coil spring over
the tube . Connect the two premolars with a soldered lingual wire to form the
anchorage unit. As the clamp is moved distally, the coil spring is compressed and a
distalizing force is applied. Because the connection of the molar band to the wire is
not rigid, the line of action of this force is at the level of the molar crown, and the
point of force application is at the screw. The molar crown will therefore be tipped
distally
Uprighting of lower molars is a common treatment objective in preprosthodontic
cases. The length of the edentulous space can make it difficult to control extrusive
or lateral movements with a conventional archwire--whether the wire is a flexible
alloy or rectangular stainless steel.
The lower Distal Jet provides absolute control of molar movement, with a
negligible extrusive component. In contrast to the upper Distal Jet, the absence of a
rigid connection to the molar moves the point of force application up to the level of
the molar crown, thus producing distal crown tipping.
Other advantages of the Distal Jet include its relatively low profile and comfort.
Like the maxillary version, it is simple to insert and requires no patient cooperation.
IMPLANT SUPPORTED DISTALIZATION
1. Karaman -implant-supported modified distal jet appliance
2. Graz implant supported pendulum
3. Sugawara & Umemori SAS supported mandibular distalization
4. Buccal shelf screw
5. Ramal mini plates and screws.
i. KARAMAN (2002)
The implant-supported modified distal jet appliance has the advantages of
implants and intraoral distalization appliances, and assessed its effect on dentofacial
structures. Molar bands with palatal tubes were fitted to the upper first molars. An
anchorage screw three mm in diameter and 14 mm in length was placed at the anterior
palatal suture, two–three mm posterior to the canalisincissivus under local
anesthesia. Anchor wires 0.8 mm in diameter were soldered to the tubes for occlusal
rests on the first premolars. The 0.9-mm wire extended through each tube, ending in
a bayonet bend that was inserted into the palatal tube of the first molar band.
Figure 121 The intraosseous karaman Screw
For force application, Niti open-coil springs were adjusted. The implant-supported
modified distal jet appliance was attached to the anchor premolars and implant with
light-cured composite adhesive. The screw was removed without anesthesia and
with no discomfort for the patient during the removal. Maxillary molar moved
distally 5mm after 4 months of treatment and intruded by 2mm without movement of
premolars. Upper incisor position, MPA, and LAFH remained the same. The main
advantages of the appliance are its stability against rotational movements.
Figure 122 The distalizing appliance

Adequate distal movement of the molar tooth was achieved without the loss of
anchorage. Irritation of the palatal mucosa and gingival hyperplasia didn’t occur
because the patient could maintain optimum oral hygiene.
ii.GRAZ IMPLANT SUPPORTED PENDULUM
Byloff et al (2000)
To avoid mesial movement of anchor teeth, extraoral anchorage such as headgears
and intraoral Nance holding arches are commonly used.
Advances with implants have made it possible to use them as a means of anchorage
in adult orthodontic patients. But with orthodontic patients, when only the question
of anchorage must be addressed, the retro molar area or the palate as implant
locations are preferred because they do not interfere with orthodontic tooth
movement. The histomorphology of the palatal bone shows that the median palatal
region is the best location for an endosseous implant.
Implant loading:
Implants are loaded after a period of approximately 12 to 24 weeks to allow healing
and osseointegration, which seems to be a general rule in the use of implants. Byloff
described a newly designed palatal anchoring system, the Graz implant-supported
pendulum (GISP) .This system can be loaded within 2 weeks to distalize and anchor
maxillary first and second molars.

iii. SKELETAL ANCHORAGE SYSTEM (SAS)
Figure 123 The skeletal anchorage system
It was introduced by Sugawara &Umemori, in 2004. The skeletal anchorage
system (SAS) consists of titanium anchor plates and monocortical screws that are
temporarily placed in either the maxilla or the mandible, or in both, as absolute
orthodontic anchorage units, Distalization of the molars has been one of the most
difficult biomechanical problems in traditional orthodontics, particularly in adults
and in the mandible, However, it has now become possible to move molars distally
with the SAS to correct anterior cross bites, maxillary dental protrusion, crowding,
and dental asymmetries without having to extractpremolars.

Skeletal anchorage system (SAS)uses pure titanium anchor plates and screws as
absolute orthodontic anchorage units. The anchor plates are monocortically placed
at the piriform opening rim, the zygomatic buttresses, and any regions of the
mandibular cortical bone. Because the anchor plates work as the onplant and the
screws function as the implant, SAS enables the rigid anchorage that results from
the osseointegration effects in both the anchor plates and screws. SAS does not
interfere with tooth movement, Therefore, it is possible to distalize the mandibular
molars with anchor plates placed at the anterior the mandibular ramus or mandibular
body.
The SAS has outstanding advantages not provided by the other mechanisms for
distalizing the mandibular molars. It is possible to intrude the mandibular molars
with the SAS. Therefore the extrusion of the mandibular molars after the tipping of
the molar distalization can be corrected easily. En masse distalization of the
mandibular buccal segments or the entire dentition is also possible if the
mandibular dentition is aligned. With the SAS, it is not always necessary to
extract the mandibular first or second premolars even in patients with moderate to
severe crowding. Molar relationship in patients with symmetric or asymmetric Class
III molar relationship can be corrected without having to extract mandibular
premolars.
iv. BUCCAL SHELF SCREW
The preferred site for placement of bone screws in themandible is the buccal shelf
area, which lies lower andlateral to the 2nd molar region. Buccalshelf bone screws
can also be placed in the external oblique ridge the mandible if the buccal shelf areais
found to be too thin or too deep.
Figure 124 Location of the buccal shelf area of the mandible
Bone screws in the mandible are available in two sizescommonly (manufacturer
specific) – 10 mm and 12 mmin length and 2 mm in diameter. Buccal shelf area in
theIndian population is mostly found to bethin and deep;therefore, the preferred
choice will be a 12‑mm screw.

The head and collar sizes of both the variants (10 and12 mm) are almost the same
but may vary according tothe choice of the manufacturer.
PLACEMENT OF BSS
For placement of bone screws in the BS area of mandible(2nd molar region), initial
point of insertion is inter-dentallybetween the 1st and the 2nd molar and 2 mm below
themucogingival junction. The self‑drilling screw is directedat 90° to the occlusal
plane at this point. After the initialnotch in the bone is created after couple of turns
to thedriver, the bone screw driver direction is changed by 60°–75° toward the tooth,
upward, which aid in bypassing theroots of the teeth and directing the screw to the
buccalshelf area of the mandible. sometimes pre‑drilling or vertical slit in the
mucosa isnecessary if the bone density is too thick, however, raisingof flap is never
required. Immediate loading is possibleand a force of up to 300–350 g can be taken
up by asingle bone screw.
BIOLOGICAL LIMITATIONS OF BSS
In the mandibular arch – the limits of distalizationis the proximity of the roots of the
2nd molar to thelingual cortical plate (angle of Inflection). Fordistalization in the
mandibular arch almost invariably3rd molar extraction is mandatory.

v. RAMAL MINIPLATES AND SCREWS
The retromolar fossa is an anatomically suitable skeletal anchorage site.Recently,
temporary skeletal anchorage devices (TSADs)have decreased the need for
extractions and surgical procedures. Distalization of themandibular molars enables
retraction of the incisors toachieve a positive overjet. Miniplates can withstand the
higher forces requiredto distalize the whole dentition, unlike
miniscrews.Sugawaraet alreported the use of miniplates formandibular distalization,
and they placed the miniplateson the mandibular body.
APPLIANCE DESCRIPTION
The ramal plates were placed in the retromolar fossa between the anterior border of
the mandibular ramus and the temporal crest. After a mucoperiosteal flap opening was
created in the retromolar area, an L-plate (Le Forte system; Jeil Medical Corp.,
Seoul, Korea) was adapted to fit the bone surface. The hook on the plate was located
3 mm lateral to the buccal surface of the second molar, and between the buccal
groove and 3 mm anterior to the distal surface anteroposteriorly. The third molars
were extracted during plate installation.

Figure 125 Ramal implant and screws
Each plate was fixated with two miniscrews 5 mm in length (with pilot drilling). The
flap was sutured over the plate and the hook was extended through the mucosa. The
anterior screw hole of the plate was cut occlusally to convert it into a hook for easier
placement of elastics or nickel-titanium closed-coil springs. The elastics or closed-
coil springs were connected to hooks that were crimped to the archwire between the
lateral incisors and canines after placement of the plate.

The hooks were adjusted to be in line with the facial axis points of the mandibular
dentition so that the traction forces were parallel to the occlusal plane. Power chain
elastics were connected from the plate hooks to the first molar bracket hooks to
deliver a force of 300 g per side and were replaced every 3 weeks.
The plates were placed after the leveling and alignment of the mandibular
dental arch was completed. The distalization started with a 0.019 × 0.025 inch
stainless steel archwire that was fully engaged, and ended when an acceptable overjet
was achieved.
TREATMENT STABILITY AFTER MOLAR DISTALIZATION
The goal of orthodontic treatment is to achieve proper function, esthetics, and
stability, but unstable treatment results can affect the function and esthetics. Hence,
the stability of treatment should be the primary concern of clinicians and patients.
However, posttreatment stability remains a significant challenge for orthodontists,
as it is difficult to achieve. Several studies have evaluated the treatment effects, and
the posttreatment changes after various mechanics were used to treat Class II
malocclusions, but there is some discrepancy in the results regarding the stability of
the treatment of Class II malocclusion, possibly owing the wide ranges of patient
ages and the different types of malocclusions. Concerning the stability of Class II
treatment with Herbst appliances, relapse was more frequent in adults (39%) than in
early adolescents (5%). Mihalik et al compared the outcomes of orthodontic
camouflage treatment with orthognathic surgery in adults and found that surgery
patients were nearly twice as likely to have a long term increase in overjet. Melsen
and Dalstra reported that molars distalized with cervical headgear had a strong
tendency to return to their initial sagittal position. Temporary skeletal anchorage
devices (TSADs) showed to be effective in the treatment of Class II malocclusions.
They have been applied to support distalizers such as bone-anchored pendulum
appliances and skeletal frog appliances. In addition, they have been placed into the
interradicular spaces to support the distalization of maxillary dentition via elastics.
Kuroda et al reported that the occlusion and profile were maintained after 5-year
post retention in a patient with Class II malocclusion treated using TSADs.
Furthermore, Ishihara et al reported that the treatment outcome in a patient with

Class II malocclusion treated using TSADs was stable with a small increase in the
overbite 4 years posttreatment. Nevertheless, there have not been any studies on the
assessment of the stability of the Class II treatment outcome using TSADs. Research
has shown that modified C-palatal plates (MCPPs) had been effectively used to
distalize the maxillary dental arches in adolescent and adult patients with Class II
molar relationship. These studies reported that distalization with MCPPs resulted in
bodily molar movement with minimal tipping and without molar extrusion.
Therefore, treatment with MCPPs has been recommended for Class II Division 1
treatment. Although improvement can be achieved through orthodontic treatment,
many studies have reported that there is a tendency for relapse to the original
malocclusion after the appliance is removed.
Ghosh and Nanda reported distal tipping of maxillary first and second molars at
the end of the distalization period of 8.4º and 12.0º, respectively with the pendulum
appliance. They stated that a tipping movement of the molars could correct the molar
relationship, but during retraction of the incisors, retention would be questionable.
Chiu et al and Burkhardt et al found that nearly 90% and 87% of the molar
distalization obtained during the first phase of treatment with Pendulum appliances
was lost during the second phase of treatment. Similarly, Caprioglio et al reported
that the first molars were distalized 4 mm with 10º of tipping with the pendulum
appliance, but almost half of the patients had relapsed during the fixed appliance
treatment. However, most of these studies were performed on growing patients, and
therefore, the mesial movement of the molars might be attributed in part to the
growth of the nasomaxillary complex.

Several studies reported that most posttreatment changes occur in the year
immediately after treatment and occlusion tends to stabilize after that, except for
mandibular incisors' contact point displacement, which tends to increase over the
years. Moreover, in a 10-year follow-up study, Al Yami et al stated that the
maximum movement takes place during the first 2 years posttreatment. Maniewicz
Wins et al reported in a systematic review that the only 2 factors found to be
predictive of relapse were significant treatment changes in molar and canine
relationships, but the evidence was limited. In addition, they reported that 14 factors
were found to not affect relapse, again with limited evidence. These factors were
divided into (1) pretreatment characteristics (molar relationship, overbite, incisor
inclination, SNA, SNB, ANB, and maxillary, mandibular, and intermaxillary plane
angles); (2) treatment characteristics (treatment timing, length of treatment,
retention time, and length of follow-up); and (3) posttreatment characteristics
(overjet and molar relationships). In addition, they also showed that severe
pretreatment dental sagittal relationship, extraction, and significant treatment
changes (except for molar and canine relationships) exhibited no conclusive
evidence regarding their effect on relapse. A recent study showed that the number
of years without retention and not wearing a fixed retainer had a significant increase
in the risk of lower incisor alignment instability.
Raucci et al reported that the predictors of stability of mandibular dental arch
dimensions after treatment with lip bumper followed by fixed appliance were the
increases in intermolar and interpremolar widths during lip bumper therapy.
Meanwhile, the predictor of relapse in maxillary dental arch dimensions after

treatment with transpalatal arch followed by fixed appliances was pretreatment
maxillary crowding. Several factors might affect the stability of the orthodontic
treatment outcome. These include gender, skeletal maturity, age, habits, muscular
functions, bite force, growth patterns, initial occlusion, treatment modality, changes
in arch form, and posttreatment occlusion. However, no consensus is reached
because studies have shown contradictory conclusions.

ASSESSMENT METHODS FOR MOLAR DISTALIZATION
In the literature, tooth movement is usually assessed via measurements made on
lateral cephalometric radiographs or photocopies of study models. Recently, the use
of 3D digital models has increased, and also can be used for this purpose.
Cephalometric radiographic measurement is a standard method used by
orthodontists to assess skeletal, dental, and soft tissue relationships, as well as the
results of orthodontic treatment. This approach, however, is based on two-
dimensional (2D) views of 3D structures, which causes information loss and
identification errors due to blurring, overlapping of anatomic structures, and the
superimposition of bilateral structures. Magnification errors, subjecting patients to
radiation exposure, and the inability to evaluate tooth movement in the transverse
direction are other disadvantages of cephalometric assessments. In addition, errors
associated with measuring small linear distances on cephalometric tracings further
compromise a quantitative assessment of the orthodontic movements of each tooth.
The photocopy method developed by Champagne14 is another method that requires
a plaster model, but provides only a 2D projection of a 3D structure. It has many
clinical drawbacks, such as difficulties in establishing reference points, a
complicated measurement process, and a 2D measurement of the 3D curvature of
the palatal vault. Despite the limitations of the cephalometric and photocopy
methods, both are used in the assessment of molar distalization because there has
been no other method that permitted superimposition. In recent years, 3D digital
models have gained increasing acceptance as an alternative to traditional plaster
models in orthodontics. Unlike plaster models, 3D digital models are not subject to
loss, fracture, or degradation. Digital storage eliminates the need for storage space,
which is required for traditional models.
In addition, tooth position can be measured accurately in three dimensions; the
measurement of inclination, which is unreliable with plaster models, is especially
accurate when this method is used. Furthermore, 3D mapping of tooth movement is
possible by superimposing dental changes on stable reference structures with the use
of digital sectioning techniques. The validity and efficiency of linear and angular
measurements created with 3D digital models have been investigated, and it was
confirmed that digital models offer a valid alternative to plaster models.
Laser scanners are one of the devices capable of constructing 3D shapes of the
dentition and occlusion with adequate accuracy and reliability. The disadvantages
of the laser scanning method are the relatively long times required for the 3D
scanning and analysis of dental casts, as well as the purchase costs of the scanner
and software. Additionally, analyzing the casts requires special training in order to
establish accuracy. Studies comparing direct measurements made from dental casts
with those made from 3D digitized models produced by surface laser scanners have
shown that the latter method is highly accurate for dental cast analysis.
COMPARISON OF MOLAR DISTALIZING APPLIANCES
Various devices have been put forward for the purpose of effective molar
distalization. Many clinical studies and research work involving the appliances have
been conducted to select the best of the available.
Each appliance has its own advantages and disadvantages. Therefore, while
selecting the appliance suitable for a particular clinical situation, it is important that
we understand the various pros and cons of the molar distalizers in comparison. For
example, it is essential to know which molar distalizer would produce bodily
movement when compared to the others. Similarly, other characteristic effects that
need to be taken into consideration are the mesial movement of the anterior teeth,
extrusion of the posteriors, tipping of the molars, time taken for the distalization and
combined distalization of the first and second molars and rotation.
Here in this discussion we have complied the work done by various researchers
to provide information including the above-mentioned factors regarding the
commonly used molar distalizing appliance systems.
In the year 1989, Gianelly et al used magnets and open coil springs to distalize
molars and they conclude that the molars showed a distal tipping with an anchorage
loss of 1mm. They suggested that this anchor loss could probably be reduced by
reinforcing the Modified Nance appliance perhaps with Class II elastics against a
0.016 X 0.022” sectional arch wire.

Later in this year 1992, Bondermark and Kurol used repelling magnets for
simultaneous distalization of the maxillary permanent first and second molars and
they observed that the molars moved 4.2mm distally with a distal tipping of 8 degree.
Subsequently in the year 1994, another study was conducted by them with
repelling magnets versus super elastic Nickel Titanium coils for simultaneous distal
molar movement of maxillary permanent first and second molars. It was observed
that with the modification of the appliance and the two distal extensions from the
Nance which passed through the palatal tubes of the molar bands, the molars were
distalized with minimal tipping and minimal tipping and minimal disto buccal
rotation. The magnetic force dropped more rapidly than the coil forces with the mean
force on the magnet side which showed a reduction from 225gm to 100gm while the
decline in the force for open coil spring was from 225gm to 180gm. The average
distal molar movement of molars was 3.2mm for the coils and 2.2mm for magnets
with minimal distal tipping. It was observed that one half of the distal movement of
molars treated with magnets was mainly related to tipping with an obvious risk of
relapse.
Intra oral molar distalizing appliances like the pendulum appliance and Jones
jig appliance marked its arrival in the year 1992 for Class II Noncompliance
treatment. Significant amount of distalization was achieved when these appliances
were used however true bodily movement was questionable.
Gosh and Nanda in the year 1996 studied the effects of pendulum appliance
on distalization of maxillary molars and reciprocal effects on anchor premolars and
maxillary incisors. According to their study, the maxillary first molars moved
distally by 3.37 mm with a distal tipping of 8.36 degree. There was also a reciprocal
mesial movement of the first premolars which was observed to be as 2.55mm and a
mesial tipping of 1.29 degree indicating an anchor loss.
The vertical change in first molar position was not significant. They claimed that the
stability of distally tipped molars is not certain and their use as an anchorage to
retract anterior teeth is questionable.it was suggested to improve the posterior
anchorage by up righting the molars with the use of a head gear.
Bussick et al in the year 2000 conducted another study with the pendulum
appliance and its dental and skeletal effects. It was conducted that the pendulum
appliance primarily affects the maxillary dentition with only secondary minor effects
on the soft tissue and the skeletal components. All maxillary molars were distalized
with an average distal molar movement of 5.7mm showing a distal tipping of 10.6
degree.
There was reciprocal anchorage loss in the premolars and incisors in a mesial
direction at an average of 1.8mm with a mesial tipping of 1.5 degree.
The maxillary molar distalization contribution to 76% of the total space opening
anterior to maxillary first molar whereas 24% was due to reciprocal anchorage loss of
maxillary premolars. It was noted that although a sufficient amount of molar
distalization was achieved using the pendulum appliance there was a considerable
amount of anchor loss with significant distal tipping of the molars which questioned
its stability.
The Jones Jig appliance also was used for effective molar distalization. Jones and
White in the year 1992, observed very little forward movement of the anterior teeth
if any in patients who began treatment with Jones Jig and Nance appliance.
Haydar et al in the year 2000 conducted a study comparing the Jones Jig molar
distalizer with extra oral traction and they concluded that distalization was faster
using Jones Jig which took just 2.3 months when compared to the extra oral traction
which needed almost ten months. However, a major disadvantage observed with
Jones Jig was that a significant mesial movement and protrusion of the anchorage
unit was observed. They suggested the use of headgear in the night for anchorage
control after treatment with the Jones Jig.

Although several methods were proposed to distalize maxillary molars, all these
system applied forces mainly to the crowns of the upper first molar which resulted
in its tipping and rotation.
The Distal Jet appliance was then introduced in the year 1996. Carano and Testa
compared the rate of distal molar movement of Distal Jet to that of magnets and
Jones Jig. They reported that distalization of molars using Distal Jet was achieved
without tipping and rotation.
Ngantung and Nanda in the year 2001 studied the post treatment evaluation
of the Distal Jet appliance. The average time for class II correction was 6.7 months.
The maxillary first molars were distalized by an average of 2.1mm with a distal
tipping of 3.3 degree. Mesial movement of the second premolar occurred by 2mm
with the premolar skipping distally. Labial tipping of the maxillary incisors was also
observed. This indicated an anchor loss present when using the distal jet appliance.
They reported that mere reduction of forces used for distalization did not reduce the
anchor loss as observed in the case of Jones Jig where in the coil springs producing
a force of 75gms used to distalize showed a more significant anchorage loss and
maxillary molar tipping when compared with the 240gms springs used in the distal
Jet appliance.
They further concluded that this appliance provided more bodily movement of
molars because the force was applied closer to the center of resistance of tooth
compared to other distalizing devices as mentioned earlier by Carano and Testa.
Following this, a very significant comparative study of distal jet appliance with
other appliances mainly the Jones Jig and Pendulum was done in the year 2002 by
Bolla et al. The study concluded that the Distal Jet appliance moved the first molars
distally at an average of 3.2mm per side with 3.1 degree of distal crown tipping. The
pendulum appliance produced the grants amount of the net distalization when
compared to Jones Jig and Distal Jet appliance; however it also showed greater molar
tipping. The Jones Jig appliance was the least effective in creating space because
only 1.6mm/side of space was obtained after up righting of the molars. The anchor
loss measured at the first premolar was 1.3mm/side with 2.8degree of distal crown
tipping. These are clinically comparable to other intra oral distalizing appliances.
Hence the Distal Jet appliance even though produced a lesser net distalization
compared with the pendulum, the amount of molar tipping was significantly less
than has been found with other appliances including the pendulum reducing the risk
of further anchorage loss.
A significant contribution in the field of intra oral molar distalizers was brought
about Ahmet Keles in the year 2000, where he introduced the Intra oral bodily molar
distalizer (IBMD).
This device incorporated a wider anchorage plate in order to enhance the
anchorage. The results showed the maxillary molars distalized bodily by 5.23mm on
average. The maxillary first premolars moved by 4.33mm mesially and were
extruded by 3.3mm. Maxillary incisors were found to be protruded by 4.7mm with
6.73degree labial tipping. This indicated a true bodily movement of the molar using
the IBMD. Distal tipping and extrusion of molars were not statistically significant.
Gosh and Nanda in their study evaluated the effect of pendulum appliance and
they claimed the stability of distally tipped molar was not certain thereby suggesting
the use of headgear for up righting of molars. Similarly, Gianelly et al, suggested
that he distalized molars needed to be stabilized for atleast 3-6 months while being
up righted with a passive 0.016”x0.022” arch wire with stops at the molars and a
high pull headgear.
Therefore, the use of headgear in pendulum appliance or the Gianelly et al
technique questioned its classification as a Non-Complaint Appliance.
Gosh and Nanda showed 2.55mm of premolars movement with 1.29degree
mesial tipping while using a pendulum appliance. This suggested that for every mm
of distal molar movement the premolars moved mesially by 0.75mm. This
anchorage loss was seen in conjugation with a molar distal tipping of 8.36degree.
The study of Keles on IBMD showed that for every mm of molar distalization,
0.82mm anchorage loss was observed. However, the highlight was that no distal
tipping of the molars was observed. This concluded that IBMD was a very effective
appliance to distalize molars bodily without using any extra oral appliance or other
intra oral mechanics when compared to other appliances like the Jones Jig distal and
the pendulum appliance.
Karlsoon and Bondemark in the year 2005 recently conducted a study
comparing the efficiency of extra oral appliance with an intra oral appliance for
distal molar movement of maxillary first molar and they concluded that the amount
of distal molar movement of the maxillary first molars was significantly higher and
more rapid with the intra oral appliance than the extra oral appliance.
Moderate and acceptable anchorage loss was produced with the intra oral
appliance implying increased over jet whereas the extra oral appliance created a
decreased over jet. From the above discussion, we understand that the efficacy of
the magnets in distalizing the molar though less than that of coil springs, the anchor
loss and distal tipping of the molars was minimal in comparison.
Interesting studies comparing the Jones Jig, pendulum appliance and the
Distal jet appliance conclude that the maximum distalization was achieved with the
chances of stability was questionable.

The distal jet appliance displayed more of bodily movement with minimal anchor
loss. Ahmet Keles IBMD has proven itself to be biomechanically superior to all the
other molar distalizing appliances. It produces bodily movement with mesial
movement of the anterior teeth with no significant extrusion or rotation.
It has been suggested that however capable, an intra oral molar distalizer be the
stability is always questionable. Some degree of tipping is also unavoidable. The use
of extra oral appliances like head gear and an intra oral nance palatal button is highly
recommended to achieve a biomechanically superior, physiologically acceptable and
stable result.
RECENT ADVANCES IN MOLAR DISTALIZATION
1. A reliable method for evaluating upper molar distalization:
superimposition of three-dimensional digital models:
In orthodontic practice, comprehensive diagnosis and treatment planning are
essential for a successful treatment outcome. Stone casts are one of the tools that
serve this purpose, and have long been the gold standard for measuring mesiodistal
tooth dimensions, calculating indices such as the Bolton index, and determining the
efficacy of orthodontic treatment. However, these study models have the
disadvantages of being prone to degradation, breakage, and loss. With the
introduction of digitized laser-scanned dental impressions that produce a three-
dimensional (3D) image of the teeth and dental arches, the disadvantages of the
study model have been surmounted. Moreover, the inconvenience of having to pour
and trim plaster casts and the need to store and retrieve the models each time a
patient is seen have been obviated. Now it is possible to view the dentition on a
computer screen by rotating virtual models to provide a 3D view, as with hand-held
models. In parallel with the use of 3D cephalometrics and 3D digital photography,
the popularity of digital models has increased, and the paperless office has
represented a great advance in practice efficiency.
The evaluation of orthodontic tooth movement requires the superimposition of
certain reference points or lines on either cephalometric radiographs or plaster
models.
The cranial base, maxilla, or mandible is used as the reference point for the
superimposition of serial cephalometric radiographs, while the superimposition of
plaster models has limitations due to a lack of anatomic reference points or areas.
With the development of 3D measuring devices, some investigators have performed
3D superimpositions of dental models to analyze tooth movement. The use of palatal
rugae as reference points for measuring tooth movement on both serial dental models
and 3D digital models has been investigated and reported to be a suitable reference
structure when studying serial models. So in conclusion, the use of 3D digital
modeling to assess the results of upper molar distalization is a reliable and valid
alternative to conventional measurement methods.
2. Upper Molar Distalization with Invisalign Treatment Accelerated by Photo

biomodulation:
Recent advances in the Invisalign system allow predictable distalization of posterior
teeth to facilitate treatment of Class II and Class III malocclusions. A sequential
approach can be used to maximize anchorage, but requires a large number of aligner
stages. Even with the weekly change protocol recently recommended by Align
Technology, it may take 40-50 weeks to distalize the posterior teeth, depending on
the amount of tooth movement needed. Previous various studies have demonstrated
that the use of OrthoPulse photobiomodulation (PBM) could accelerate bone
remodeling and orthodontic tooth movement, allowing patients to change Invisalign
aligners as often as every three days. PBM can be applied to accelerate sequential
distalization with the Invisalign system.

Photobiomodulation, also known as low-level light therapy, employs near-infrared
light (600- 1000nm) from a low-level laser or light-emitting diode. At the cellular
level, PBM is thought to activate the predominant mitochondrial photoacceptor,
cytochrome c oxidase, thus increasing mitochondrial adenosine triphosphate
production by means of an elevated proton concentration gradient across the inner
mitochondrial membrane. This effect facilitates tissue repair and bone remodeling
by raising metabolic activity in damaged areas. In addition, there is some evidence
that PBM therapy can reduce pain because of its anti-inflammatory properties. Data
from rat models have indicated that PBM can also accelerate tooth movement. One
study reported increases in osteoclast numbers on the pressure side of the targeted
molars and bone formation and cellular proliferation on the tension side. Clinical
studies investigating orthodontic treatment with fixed appliances and clear aligners
have found significantly increased tooth movement in the irradiated patients. A
systematic review of five human trials and 11 animal studies concluded that a
reasonable dose of PBM may reduce orthodontic treatment time; an evaluation of
18 clinical trials found evidence supporting the efficacy of laser therapy and PBM.
CONCLUSION
CONCLUSION
Distalizing teeth has always been a challenge to orthodontist of which molar
distalization is most difficult. Class II molar relationship can be corrected by several
methods. One possibility apart from extraction is by distalizing to create space in the
lateral segments for retraction of cuspid and anterior teeth. This type of
mechanotherapy is typically used in patient in maxillary skeletal and dento alveolar
protrusion. Many appliances have been proposed for distalizing removable and fixed
appliances. Although there are many advantages and disadvantages for both
methods, the main drawback of extraoral approach is the patient compliance. This
pitfall has been overcome by the intraoral appliances but they are not as effective as
extraoral appliance.
The need of the hour is an appliance which embodies the advantages of the
intraoral, extraoral methods and eliminates the disadvantages of both. In this space
age where advancements are being made each and every day, one should expect that
this lacuna will be filled in near future. The newer materials like Niti, Magnets, and
composite plastics will no doubt revolutionize the procedure of molar distalization.
Who knows one day the so called next generation force delivery system by
minimotors may be delivering effective distalizing forces on the molars intraorally.

CONCLUSION
But as of today, there is no all-in-one molar distalizing appliance. It is to know
the indications, contraindications, and modifications that are possible with
distalization method. To fight a borderline case distalization procedure is an
important weapon in the orthodontists’ armamentarium. It should be remembered
that patient selection for a particular method of distalization is of utmost importance
and should not be overlooked. Right appliance should be selected for the right patient
and one should not select the patient for the appliance, rather the appliance should
be selected for the patient.

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“MOLAR DISTALIZATION”

DEPARTMENT OF ORTHODONTICS AND

DAYANANDA SAGAR COLLEGE OF DENTAL

4. Indications of Molar Distalization

5. Favorable features for Molar Distalization

6. Contraindications of Molar Distalization

7. Unfavorable features for Molar Distalization

8. Considerations for Molar Distalization

9. Evaluation of Molar Distalization Feasibility

i) Upper molar position

ii) Role of second molar and third molar extraction

10. Advantages of Molar Distalization

11. Disadvantages of Molar Distalization

12. Classification of Molar Distalization

13. Appliances Used for Molar Distalization

14. Principals of Appliance Selection Criteria

15. Treatment Planning and Sequence

ii) Biomechanics considerations for molar distalization

17. Anchorage considerations in Molar distalization

i) Conventional anchorage designs

ii) Limits of conventional designs

iii) Alternate anchorage designs

18. Extraoral Molar distalization Appliances

19. Intraoral Molar Distalization Appliances

20. Retention after Molar Distalization

21. Assessment methods for Molar Distalization

22. Comparison of Various Appliances

23. Recent advancements

The omnipresent question faced practically every time orthodontists do a

space be created without extractions?” In the adult patients there is no clinically

significant growth in the bone structure; therefore, alternative solutions must be

Extraction has been a controversial subject for as long as the specialty of

treatment, extraction of teeth for orthodontic purpose seemed particularly

inappropriate and unacceptable.[3] In recent years, the percentage of patients having

extraction as a part of orthodontic treatment has decreased considerably as

stability of teeth alignment.

Current orthodontic philosophies have been oriented toward conservative

creating additional space within the arch by distalization of molars.[4]

Molar distalization is a technique which is used to move molar teeth,

applied for various modalities of treatment planning in orthodontics for different

malocclusions. Molar distalization offers tantalizing possibilities for both attaining

Class I molar relationships and decrowding anterior teeth without removing

relationship, the situation can be addressed by distalizing the lower molars,

mesializing the upper molars, or combining both approaches.[5] It is also of significant

relationship associated with normal mandible. Especially in cases wherein there is

premature exfoliation of deciduous molars or proximal caries which leads to arch

length discrepancy due to mesialisation of the permanent molar, distalizing the

molars treats its etiology by counteracting the mesial migration.

teeth. Another factor is the presence of second and third molars.

Duration of therapeutic treatment has also been shown to increase if second

success of first molar distalization varies according to the stage of development of

the second and third molars. As a result, germectomy of wisdom teeth is

recommended before molar distalization.[6] Also, other areas of particular concern

Recent advances in molar distalization has attempted to tackle the challenges

options in orthodontics. The library dissertation is a compilation of the case selection

and extra oral, and their advantages and disadvantages.

effects in the treatment of Class II Division 1 malocclusions. [8] Earlier, it was

headgear appliance. It is this factor that made correction of class II malocclusion

which depicts the evolution of molar distalization.

1866 by means of headgear.

Figure 1. Early uses of extra oral anchorage for backward

proved the only successful method of handling extreme cases of malocclusion.

Figure 2 appliance advocated by Farrar

use of light force.