©2017 JCO, Inc. May not be distributed without permission. www.jco-online.
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Lower-Molar Distalization with
Mini-Implant Anchorage in
Asymmetrical Class II Cases
FABRICIO PINELLI VALARELLI, DDS, MSc, PhD
MANOEL HEITOR BRITO, DDS, MSc
RODRIGO HERMONT CANÇADO, DDS, MSc, PhD
KARINA MARIA SALVATORE FREITAS, DDS, MSc, PhD
A bout half of all Class II malocclusions are
asymmetrical.1-3 If the upper molar is mesi-
ally displaced, the maxillary midline will deviate
toward the Class I side,2,4 and treatment will re-
quire either extraction of one upper premolar or
distal molar movement on the Class II side. In 61%
of asymmetrical Class II cases, however, where
the lower molar is distally displaced,1-3,5 the maxil-
lary midline will match the medium sagittal plane,
but the mandibular midline will deviate toward the
Class II side. If the profile is convex, asymmetrical
extractions (two upper premolars and one lower
premolar on the Class I side) are generally used
for correction. Another option is to extract four
premolars,6 but this will extend treatment time.7
Although extractions have been used to treat
Class II malocclusions in cases of crowding and
bimaxillary protrusion, no definitive treatment
protocol exists for patients with missing teeth. If
molar loss results in a free-end arch, extraction of
sound teeth should be avoided. The alternative ap-
proach, molar distalization, can be challenging due
to the biomechanics involved.8,9
Supporting molar distalization with tempo-
rary anchorage devices makes tooth movement
more efficient, preventing the anchorage loss that
occurs with intraoral toothborne appliances, and
requires minimal patient compliance.10,11 Not only
are mini-implants inexpensive and easy to insert
and remove, but they can be immediately load-
ed.11,12 When placed in the mandibular retromolar
area, they provide sufficient anchorage to move
86 © 2017 JCO, Inc.
the posterior teeth distally while performing en-
masse retraction of the incisors. This allows cor-
rection of the mandibular midline and can shorten
orthodontic treatment.8
Biomechanics
Lower-molar distalization with mini-implant
anchorage has a favorable prognosis, since the
molar movement occurs without reciprocal ante-
rior movement of the premolars, canines, and inci-
sors (Fig. 1). This allows simultaneous retraction
of the anterior teeth while avoiding side effects
such as protrusion.8 The posterior free end of the
arch and the required amount of distalization must
be carefully considered to avoid undesirable molar
movement.
Regardless of the anchorage system, there is
a posterior anatomical limit to molar distaliza-
tion.13 At the crown level, a single anatomical
structure, the mandibular ramus, restricts ortho-
dontic movement. When the crown is forced
against the cortical bone, the enamel comes in
direct contact with the bone, leading to necrosis.14
At the root level, the lingual cortical layer of the
mandibular body opposes tooth movement.13 When
the root contacts the internal cortical bone, the
movement is inhibited and the risk of root resorp-
tion increases.15,16 If the tooth contacts the external
cortical bone, it may cause alveolar bone loss,
gingival recession, or root exposure, compromis-
ing periodontal support.17
JCO/FEBRUARY 2017
 Dr. Valarelli
Dr. Valarelli is a Professor, Dr. Brito is a postgraduate student, and Drs. Cançado and Freitas are Professors, Department of Orthodontics, Ingá
Faculty, Rodovia PR 317, no. 6114, Maringá, Paraná 87035-510, Brazil. E-mail Dr. Freitas at kmsf@uol.com.br.
Fig. 1 Mechanics involved in lower-molar distal-
ization with mini-implant anchorage.
Case Report
A 26-year-old female sought orthodontic
treatment for her lower anterior crowding and bi-
maxillary protrusion (Fig. 2). She had a convex
profile, an inadequate lip seal, and a symmetrical
face. Intraoral examination showed a three-
fourths-cusp Class II, division 1, subdivision right
malocclusion with lower anterior crowding. The
maxillary midline was coincident with the medium
sagittal plane; the mandibular midline was devi-
ated 4mm to the Class II side. The upper and low-
er left third molars and lower left second molar
were missing, but the upper and lower right third
molars were present. Cephalometric analysis indi-
VOLUME LI NUMBER 2
Dr. Brito Dr. Cançado Dr. Freitas
cated maxillary protrusion with labially tipped
upper and lower incisors (Table 1).
The goal of treatment was to correct the
Class II subdivision right malocclusion, lower an-
terior crowding, and bimaxillary protrusion. Con-
ventional treatment would have involved the ex-
traction of one lower left and two upper premolars,
with an osseointegrated implant placed in the area
of the lower left second molar at the end of treat-
ment. An alternative was to extract the two upper
premolars and retract the upper anterior teeth, fol-
lowed by distalization of the lower left first molar
and retraction of the premolars and anterior teeth
using mini-implant anchorage. The patient chose
the second option.
The upper second premolars were selected
for extraction instead of the first premolars be-
cause they were narrower mesiodistally and would
thus require less anterior retraction. With slightly
more anchorage loss of the upper molars, the low-
er left molar would require less distalization.
After the extractions, an .022" Roth-prescrip-
tion preadjusted fixed appliance was bonded. Lev-
eling and alignment of the upper and lower arches
were performed using .014" and .020" nickel tita-
nium, .020" stainless steel, and .019" × .025" nick-
el titanium and stainless steel archwires. After
nine months of treatment, a 1.5mm × 6mm mini-
implant* was placed distal to the lower left first
*Morelli Ortodontia, Sorocaba, São Paulo, Brazil; www.morelli.
com.br.
87
Lower-Molar Distalization with Mini-Implant Anchorage

Fig. 2 26-year-old female patient with lower anterior crowding and bi-
maxillary protrusion before treatment.

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 Valarelli, Brito, Cançado, and Freitas

molar, and an elastic chain was attached to the
molar for distalization (Fig. 3). Although a canti-
lever would have been preferable from a mechan-
ical standpoint, it was too difficult to place in this
area due to the depth of the buccal groove and the
shallow alveolus.
The .019" × .025" stainless steel wires were
left in place for retraction of the maxillary ante-
rior teeth and distalization of the lower left quad-
rant (Fig. 4). Intermaxillary Class II elastics were
worn on the right side to aid in maxillary retraction
and mesialization of the lower right quadrant, un-
til Class I canine and molar relationships were
achieved (Fig. 5). After 19 months of treatment,
an elastic chain was attached from the mini-
implant to the lingual side of the lower left first
molar to correct the rotation that occurred during
distalization (Fig. 6). Distal movement of the low-
er left quadrant was completed in another four
months (Fig. 7). After three months of finishing,

TABLE 1
CEPHALOMETRIC ANALYSIS
Pretreatment Post-Treatment
SNA 86.0° 85.2°
Co-A 86.8mm 86.9mm
SNB 79.7° 79.3°
Co-Gn 107.2mm 107.5mm
ANB 6.2° 5.9°
Wits appraisal +2.3mm +2.2mm
FMA 29.5° 29.5°
SN-GoGn 32.1° 33.3°
Occlusal plane-SN 16.4° 17.5°
AIFH 61.3mm 61.5mm
U1-NA 26.9° 21.1°
U1-NA 4.0mm 1.6mm
U1-PP 25.0mm 25.3mm
U6-PtV 14.7mm 19.8mm
U6-PP 19.2mm 19.4mm
U6-SN 76.5° 79.7°
L1-NB 38.3° 31.5°
L1-NB 8.4mm 5.6mm
L1-GoMe 35.1mm 36.5mm
L6 apex-Symphysis 12.6mm 14.1mm
L6 crown-Symphysis 13.3mm 17.6mm
L6-GoMe 24.0mm 23.8mm
L6-GoMe 62.7° 51.7°
Molar relationship −3.2mm 7.2mm
Overjet 4.3mm 4.5mm
Overbite 2.3mm 3.4mm
ANL 110.5° 116.9°
Upper lip-S line 2.2mm −0.4mm
Lower lip-S line 6.1mm 2.7mm

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Lower-Molar Distalization with Mini-Implant Anchorage

Fig. 3 After nine months of treatment, leveling and alignment completed with .022" Roth-prescription pre-
adjusted brackets and .019" × .025" stainless steel archwires; mini-implant inserted distal to lower left first
molar to begin distalization with elastic chain.

A B C
Fig. 4 Progress of lower left distalization. A. After 11 months of treatment. B. After 13 months of treat-
ment. C. After 15 months of treatment, with continuous elastic chain attached from archwire to mini-
implant.

the fixed appliances were removed, an upper Haw-
ley retainer was delivered, and a lower 3-3 retain-
er made of .020" stainless steel wire was bonded.
Total treatment time was 26 months.
At the end of treatment, the patient had bi-
lateral Class II molar and Class I canine relation-
ships (Fig. 8A). Significant facial changes were
visible, including an improved profile and passive
lip seal. The final radiograph confirmed better
positioning of the upper and lower incisors, with
no incisor root resorption. There were no signifi-
cant sagittal or vertical alterations of the maxillary
or mandibular skeletal components in relation to
the cranial base (Fig. 8B). Maxillary incisor repo-
sitioning was achieved by retraction and upright-
ing; the upper molars moved mesially, with minor

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 Valarelli, Brito, Cançado, and Freitas

Fig. 5 After 16 months of treatment, retraction of maxillary anterior teeth and en-masse distalization of
lower left quadrant continued, with intermaxillary Class II elastics added on right side.

Fig. 6 Three months later, elastic chain attached from mini-implant to lingual side of lower left first molar
to correct rotation that occurred during distalization.

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Lower-Molar Distalization with Mini-Implant Anchorage
Fig. 7 Distalization of lower left quadrant after 21
months of treatment.
crown angulation. The mandibular superimposi-
tion showed lingual inclination and retraction of
the incisors, along with 1.5mm of molar distaliza-
tion at the root level and 4.3mm at the crown level.
No molar extrusion was observed, but distal tip-
ping occurred due to the direct application of force
from the mini-implant, which tipped the crown
more than the root. The upper and lower lips were
retruded in relation to the S-line, indicating lip
retraction within the profile (Table 1).
Discussion
When four premolars are extracted to correct
a Class II molar relationship and achieve coinci-
dence of the dental midlines, the success of treat-
ment depends on the patient’s compliance with
intermaxillary Class II and diagonal anterior elas-
tic wear. Treatment is simpler when extracting only
three premolars (two upper and one lower on the
Class I side), because a Class I molar relationship
is not required on the malocclusion side and the
midline correction is obtained by simultaneously
closing the extraction spaces.2
Turley and colleagues highlighted the diffi-
culty of maintaining anchorage when certain teeth
were missing.18 In our patient, the absence of the
second and third molars contraindicated extraction
of the lower left first premolar to correct the dental
92
midline and crowding, since an osseointegrated
implant would have been needed in the area of the
lower left second molar. We therefore decided to
distalize the left quadrant using mini-implant an-
chorage, even though the orthodontic mechanics
would be more difficult.
Our first choice would have been to distalize
the left molar alone, but because of its inclination,
en-masse retraction was needed. Although single-
tooth movement is generally effective, rotation and
distal tipping can occur because the force does not
pass through the tooth’s center of resistance.10,19 On
the other hand, when distal force is applied to the
anterior archwire hooks, connecting the archwire
directly to the posterior mini-implant with elastic
chain for en-masse movement will minimize indi-
vidual distal angulation.8,10 It is still difficult, how-
ever, to achieve pure translation.
Sugawara and colleagues obtained a mean
lower-first-molar distalization of 3.5mm ± 1.4mm
at the crown level and 1.8mm at the root level (in
other words, twice as much crown movement as
root apex movement), with a mean relapse of .3mm
at each level.9 Park and colleagues reported that
the primary effects of molar distalization with
mini-implant anchorage were distal angulation and
uprighting of the posterior teeth and distal move-
ment of the lower anterior teeth.8 In our patient,
the direct application of distal force to the molar
crown was probably the reason why we observed
4.3mm of crown movement but only 1.5mm of root
apex movement. Even though the molar was tipped
distally, as in other reports,8,9 this is not likely to
affect long-term stability because a good intercus-
pation and Class I molar relationship were achieved
in that region.9
The increase in lower anterior facial height
that tends to result from the wedge effect of dis-
talization did not occur in our patient—likely be-
cause of the intrusive action of the distal force
supported by mini-implant anchorage.10,20 Pre­
molar extractions on the Class II side corrected the
Class II subdivision malocclusion, while distaliza-
tion of the mandibular teeth on the Class I side
resolved the crowding and midline shift, improved
the facial profile, and allowed the lower left first
premolar to be maintained.
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Fig. 8 A. Patient after 26 months of treatment (continued on next page).

A

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Lower-Molar Distalization with Mini-Implant Anchorage
B
Fig. 8 (cont.) B. Superimposition of pre- and post-treatment cephalometric tracings.
REFERENCES
1. Alavi, D.G.; BeGole, E.A.; and Schneider, B.J.: Facial and
dental arch asymmetries in Class II subdivision malocclusion,
Am. J. Orthod. 93:38-46, 1988.
2. Janson, G.R.; Metaxas, A.; Woodside, D.G.; de Freitas, M.R.;
and Pinzan, A.: Three-dimensional evaluation of skeletal and
dental asymmetries in Class II subdivision malocclusions,
Am. J. Orthod. 119:406-418, 2001.
3. Rose, J.M.; Sadowsky, C.; BeGole, E.A.; and Moles, R.:
Mandibular skeletal and dental asymmetry in Class II subdi-
vision malocclusions, Am. J. Orthod. 105:489-495, 1994.
4. Janson, G.; Dainesi, E.A.; Henriques, J.F.; de Freitas, M.R.;
and de Lima, K.J.: Class II subdivision treatment success rate
with symmetric and asymmetric extraction protocols, Am. J.
Orthod. 124:257-264, 2003.
5. Janson, G.; de Lima, K.J.; Woodside, D.G.; Metaxas, A.; de
Freitas, M.R.; and Henriques, J.F.: Class II subdivision mal-
occlusion types and evaluation of their asymmetries, Am. J.
Orthod. 131:57-66, 2007.
6. Almeida, M.R.; Almeida-Pedrin, R.R.; Almeida, R.R.;
Pedrin, F.; Insabralde, C.M.; Guimarães Júnior, C.H.:
Application of biomechanics in correction of dental asymme-
try, Rev. Clin. Ortod. Dent. Press 7:92-98, 2009.
7. Fink, D.F. and Smith, R.J.: The duration of orthodontic treat-
ment, Am. J. Orthod. 102:45-51, 1992.
8. Park, H.S.; Lee, S.K.; and Kwon, O.W.: Group distal move-
ment of teeth using microscrew implant anchorage, Angle
Orthod. 75:602-609, 2005.
9. Sugawara, J.; Daimaruya, T.; Umemori, M.; Nagasaka, H.;
Takahashi, I.; Kawamura, H.; and Mitani, H.: Distal move-
ment of mandibular molars in adult patients with the skeletal
anchorage system, Am. J. Orthod. 125:130-138, 2004.
10. Oh, Y.H.; Park, H.S.; and Kwon, T.G.: Treatment effects of
microimplant-aided sliding mechanics on distal retraction of
posterior teeth, Am. J. Orthod. 139:470-481, 2011.
94
11. Yamada, K.; Kuroda, S.; Deguchi, T.; Takano-Yamamoto, T.;
and Yamashiro, T.: Distal movement of maxillary molars us-
ing miniscrew anchorage in the buccal interradicular region,
Angle Orthod. 79:78-84, 2009.
12. Park, H.S.; Kwon, T.G. and Sung, J.H.: Nonextraction treat-
ment with microscrew implants, Angle Orthod. 74:539-549,
2004.
13. Kim, S.J.; Choi, T.H.; Baik, H.S.; Park, Y.C.; and Lee, K.J.:
Mandibular posterior anatomic limit for molar distalization,
Am. J. Orthod. 146:190-197, 2014.
14. Mathews, D.P. and Kokich, V.G.: Palatally impacted canines:
The case for preorthodontic uncovering and autonomous
eruption, Am. J. Orthod. 143:450-458, 2013.
15. Kaley, J. and Phillips, C.: Factors related to root resorption in
edgewise practice, Angle Orthod. 61:125-132, 1991.
16. Wainwright, W.M.: Faciolingual tooth movement: Its influ-
ence on the root and cortical plate, Am. J. Orthod. 64:278-
302, 1973.
17. Garib, D.G.; Henriques, J.F.; Janson, G.; de Freitas, M.R.; and
Fernandes, A.Y.: Periodontal effects of rapid maxillary ex-
pansion with tooth-tissue-borne and tooth-borne expanders:
A computed tomography evaluation, Am. J. Orthod. 129:749-
758, 2006.
18. Turley, P.K.; Kean, C.; Schur, J.; Stefanac, J.; Gray, J.;
Hennes, J.; and Poon, L.C.: Orthodontic force application to
titanium endosseous implants, Angle Orthod. 58:151-162,
1988.
19. Gelgör, I.E.; Büyükyilmaz, T.; Karaman, A.I.; Dolanmaz, D.;
and Kalayci, A.: Intraosseous screw-supported upper molar
distalization, Angle Orthod. 74:838-850, 2004.
20. Chung, K.R.; Kim, S.H.; Choo, H.; Kook, Y.A.; and Cope,
J.B.: Distalization of the mandibular dentition with mini-
implants to correct a Class III malocclusion with a midline
deviation, Am. J. Orthod. 137:135-146, 2010.
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