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ThePendulumApplianceforClassIINonComplianceTherapyJCOONLINE.COMJournalofClinicalOrthodontics

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ThePendulumApplianceforClassIINonComplianceTherapy
VOLUME26:NUMBER11:PAGES(706714)1992
JAMESJ.HILGERS,DDS,MS
OrthodontistshavelongsoughtmethodsofcorrectingClassIImalocclusionswithoutstrainingthelowerarchandwithouttheneedforstrictpatientcompliance.Inthe
1990s,noncompliancetherapiesinvariousformshavebecomemoreprominentthaneverbefore.
ThisarticledescribesanewmechanismforClassIInoncompliancetreatment.ThePendulumAppliance( Fig.1 )isahybridthatusesalargeNanceacrylicbuttoninthe
palateforanchorage,alongwith.032" TMAspringsthatdeliveralight,continuousforcetotheupperfirstmolarswithoutaffectingthepalatalbutton.Thus,the
applianceproducesabroad,swingingarcorpendulumofforcefromthemidlineofthepalatetotheuppermolars.

Fabrication
TherightandleftPendulumsprings,formedfrom.032"TMAwire,consistofarecurvedmolarinsertionwire,asmallhorizontaladjustmentloop,aclosedhelix,anda
loopforretentionintheacrylicbutton( Fig.2 ).
Thespringsareextendedasclosetothecenterofthepalatalbuttonaspossibletomaximizetheirrangeofmotion,toallowforeasierinsertionintothelingualsheaths,
andtoreduceforcestoanacceptablerange( Fig.3 ).ThespringsarealsomountedascloseaspossibletothedistalaspectsoftheNancebutton,whichstillpermits
accesstotheacrylicforpolishing.Tongueirritationduringswallowingisminimizedbyextendingthespringsdistaltothebutton.Thelingualsheathsontheuppermolars
shouldbe.036"sothatthe.032"wirefitsloosely.
Theanteriorportionoftheappliancecanberetainedinseveralways.Inthefirstappliancesthatweremade,theNancebuttonwasheldinplacewithocclusallybonded
restsoneitherthedeciduousmolarsorthefirstandsecondbicuspids.Althoughthisworkedwell,Iwasconcernedthatifthebondsfractured,therewouldbelittleto
holdtheappliance.
Atpresent,themoststablemethodofretentionistobandtheupperfirstbicuspidsorfirstdeciduousmolars,solderaretainingwiretothebands,andusetheseteethas
themajoranterioranchoragefortheappliance.OcclusallybondedrestsontheuppersecondbicuspidsorseconddeciduousmolarsaddevenmorestabilitytotheNance
buttonthesestopscanberemovedlaterintreatmenttoallowthesecondbicuspidstodriftdistally.Bandingthefirstbicuspidsisnotdifficult,sincethemolarand
bicuspidportionsoftheappliancearecementedindividually.
TheNancebuttonshouldbemadeaslargeaspossibletopreventanytissueimpingement.Itshouldextendtoabout5mmfromtheteeth,toavoidthehighlyvascular
cuffoftissueneartheteethandtoallowadequatehygiene.
Thebuttoncanbemadeintheofficeusinglightcuredacrylicanda Triad machine( Fig.4 ).Theanteriorretentionloopsarefixedinplaceonthemodelwithputty,then
solderedtothebicuspidbands.Aroundedballofacrylicispressedupagainstthepalatalvault.ThePendulumspringsaretheninserted,andtheacrylicissmoothedwith
amoistenedfingerandtrimmedwithaBardParkerknife.TheacryliciscuredforfiveminutesintheTriadmachine,andtheedgesofthebuttonareroundedandhighly
polished.
Ifexpansionoftheupperarchisneeded,amidpalataljackscrewcanbeincorporatedintothecenteroftheNancebutton( Fig.5 ).TheacrylicshouldbecutwithaJoe
Dandydiscbeforethejackscrewisopened.Thescrewisactivatedonequarterturneverythreedays,afteraweekorsoforpatientadjustment,toproduceaslow,stable
expansion.
Thisversionoftheapplianceiscalleda"PendX".ThePendulumspringsaresoefficientinexpandingandrotatingtheupperfirstmolarsthatIusethePendXforthreeor
fourmonthsatthebeginningoftreatmentwheneveranyexpansionorchangeinanteriorarchformisindicated( Fig.6 ).

PreactivationandPlacement
AlthoughthePendulumspringscanbeactivatedintraorally,itismuchmoreefficienttopreactivatethembeforeapplianceplacement.Ifsignificantdistalmolarmovement
isrequired,thespringsshouldbebentparalleltothemidlineofthepalate(orperpendiculartothebodyoftheappliance, Fig.7 ).Thismightseemtobean
overactivation,butIhavefoundthataboutonethirdofitislostinplacement,andtheremainingpressureistoleratedeasilybythepatient.
Themolarbandsarecementedwithoutthespringsengaged,andtheanteriorportionoftheapplianceisthencementedinplace.Iftheapplianceistobebondedrather
thanbanded,asyringecanbeusedtodispensetheadhesiveovertherestsontheappliance,andtheNancebuttoncanbeheldinplacewithfingerpressurewhilethe
adhesivesets.Theadhesiveshouldbesmoothedoutwithasealantmixtureandastyrofoamminispongeafterbeingextrudedbythesyringe.
ThepatientshouldbecautionedthatthePendulumspringswillbeclosetothepalatewhiletheNanceportionoftheapplianceisbeingcemented.Mostpatientstolerate
thisprocedurewellifitisexplainedbeforehand,especiallywhencareistakentopreventimpingementofthespringsonthepalate.
Oncetheapplianceisinplace,eachPendulumspringisbroughtforwardwithfingerpressure,themesialendoftherecurvedloopisgraspedwithaWeingartplier( Fig.8
),andthespringisseatedinthelingualsheath.Thesmallhorizontaladjustmentloopallowsforsomelingualcompressionofthespringduringplacement.Ifmolar
rotationhasbeenbuiltintotherecurvedportionofthespring,itmaybeeasiertograspthebaseofthisportionwiththeplier.Distalpressureholdsthespringinthe
sheathquiteeffectively,butanelastic"O"ringcanbeusedifdesiredtomakesurethespringdoesn'tcomeoutduringtoothbrushing.
Asthemolarisdrivendistally,itmovesonanarctowardthemidlineoftheapplianceinotherwords,towardcrossbite( Fig.9 ).Thistendencycanbecounteractedby
openingtheadjustmentloopslightlytoincreasetheexpansionandmolarrotation.DistalroottipcanalsobeproducedbyadjustingthishorizontallooponthePendulum
spring.Tippingbacktherecurvedportionofthespringattheloopcausesamoredirectdistalmovementofthemolars.

ReactivationandStabilization
Thepatientshouldbeseenabouteverythreeweekssothespringpressurecanbechecked.Ifreactivationisneeded,thespringisremovedfromthelingualsheath.The
centerofthehelixisthenheldwithabirdbeakplier,andthespringisreactivatedbypushingitdistallytowardthemidline( Fig.10 ).Itisthenreinsertedinthesheath.
Oncethemolarshavebeenmoveddistally,theymustbestabilizedintheirnewpositionsortheywillrapidlydriftbackmesially.Itisalsoimportanttomovethebuccal
segmentsintoaClassIrelationshiptoharnessthefulladvantagesoftheappliance.Theuppermolarbandsneednotberemovedwiththerestoftheappliancethiscan
behelpfuliftheclinicianwishestoplaceatranspalatalbarorNanceapplianceimmediatelyafterremovalofthePendulum.
Themolarscanbestabilizedinanyoffourways:
1.TheNanceportionisremovedandafullupperfixedapplianceisbonded.Anupperutilityarchholdsthemolarsbackwiththeincisorsasanchorage.Thebuccal
segmentsarethenretracted,usuallywithelastomericchain,toconsolidatethespacesthathavebeenopened( Fig.11 ).
2.AfterremovalofthePendulumAppliance,asmaller,easiertocleanNancebutton("InstaNance")isplacedimmediatelytoholdthemolarsbackandallowtheupper
buccalsegmentstodriftdistallyasthetransseptalfibersreorient.An.036"preformedlingualcribisinsertedintothelingualsheaths( Fig.12 ).AsmallballofTriadlight
curedacrylicisformedovertheretentionloopofthecribintheverticalportionofthepalatalvault,smoothedwithamoistenedfinger,andcuredwithalightsourcefor
oneminute.IhavefoundthisInstaNancetobethemoststableanddependablewaytomaintainmolarpositions,anditcanbefabricatedatchairsideatthesame
appointmentasthePendulumApplianceremoval.
3.Theentireupperarchisbondedorbanded,andacontinuousarchwirewithomegaloopsmesialtotheupperfirstmolartubesisplaced.Thus,theentirearchisused
foranchoragewhilethebuccalsegmentsaremoveddistally,andthefirstmolarsarepreventedfrommovingmesiallyalongthewire( Fig.13 ).Thisapproachcanbe
combinedwiththeInstaNance( Fig.14 ).
4.Aheadgeariswornforafewmonthswhilethebuccalsegmentsdriftdistally.Althoughthismethodrequiressomepatientcompliance,itistypicallyforashorterperiod
thanwetraditionallyhaveusedheadgear.

DiagnosticCriteria
SincethePendulumAppliancedrivestheuppermolarsdistally(withslightlingualtipping)quiterapidly,thereisatendencyfortheanteriorbitetoopen.Thisopenbite
generallycorrectsitselfinbrachyfacialpatients,butitcanbeaproblemindolichofacialtypes,especiallythosewithtonguethrusthabits.Istillrecommendtreating
verticalgrowthpatternsconservativelywithextractions,directionalheadgears,andtranspalatalbars.Thebiteopeningtendencycanbeencouragedinbrachyfacial

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patientsbybondingtheNanceportionoftheappliancetotheocclusalsurfacesofthebicuspidsordeciduousmolars,thusfreeingtheocclusionsomewhat.
Distalmovementofthemolarsappearstobemostefficientbeforetheuppersecondmolarshaveerupted,whichplacessomeemphasisontreatmenttiming.However,as
seeninseveralofthecasesinthisarticle,themolarswillstillmoveevenafterthesecondmolarshavefullyerupted.Whenagreatdealofdistalmovementisneededandit
ispreferablenottoextracttheupperfirstbicuspids,itmaybebeneficialtoremovetheuppersecondmolarsandletthethirdmolarsdriftintoplace.Thiscreatesroomin
thecorticaltroughandeliminatesthebuttressingeffectoftheuppersecondandthirdmolarsagainstthefirstmolars.
Ihavealsofoundthatthemolarscanbemovedmuchmoreeffectivelywhentheyarebeingactivelyexpanded,aswiththePendXversionoftheappliance.Therestof
ClassIItreatmentismadeeasierwhenasmuchofthistoothmovementandexpansionaspossibleisaccomplishedintheinitialphaseoftreatment.
UnilateralClassIIpatientsalsobenefitgreatlyfromPendulumtherapy.AlthoughmostunilateralClassIImalocclusionsarereallybilateraloncetheocclusionhasbeen
freed,therearesomecaseswhereforwardpositioningofonemolar,duetoearlylossofdeciduousteethandmesialdriftingofthemolar,istherootcauseofthe
malocclusion.APendulumspringononesidecanregainspacewithoutputtingunduestrainonotherpartsoftheupperarch.
Similarly,thePendulumAppliancecanbeusedtoregainspacelostthroughmesialdriftingoftheupperfirstmolars,becauseofeitherearlylossoftheseconddeciduous
molarsorimpactionofthefirstmolarsunderthedistalcrowncontourofthedeciduousmolars.RapiddistalizationoftheupperfirstmolarsandstabilizationwithanInsta
Nanceprovidespacefortheeruptingsecondbicuspids.

Conclusion
PatienttoleranceofthePendulumAppliancehasbeenexcellentmostadapttotheappliancewithinaweek.IfthePendulumspringsareplaceddistallyenough,thereis
nodifficultywithtongueirritationduringswallowing.
Initialclinicalfindingshavebeenencouraging.Itisnotunusualtoseeasmuchas5mmofdistalmolarmovementinthreetofourmonths( Fig.14 ).Aslongasthespace
isproperlymaintained,mostofthenecessaryClassIIcorrectionaswellasexpansionandimprovementofarchformcanbeachievedwithlittleornoneedforpatient
compliance.

Figures

Fig.1StandardPendulumAppliance.

Fig.2A.OcclusalviewofPendulumspring,withsmallhorizontaladjustmentloopatmidspan.B.DimensionsofaveragesizePendulumspringinmm(actualspan
dependsonpalatalwidth).C.Distalviewofspringrecurvedportionthatfitsintolingualsheathisverticallyoriented.D.Lateralviewofspringnotestepupfrom
retentiveportion,allowingspringtobeplacedmoreocclusallyandreducingextrusiveforces.

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Fig.3A.PendulumAppliancewithspringsengaged.B.Forcedeliveredby.032"TMAspringwithvaryingamountsofactivation.

Fig.4A.Anteriorretentionloopsfixedinplacewithputty,thensolderedtobicuspidbands.B.Acrylicballpressedagainstpalate,Pendulumspringsinsertedinto
sheaths,andacrylicsmoothedandtrimmed.

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Fig.5A.PendulumAppliancewithpalatalexpansionscrew("PendX").Notestabilizingocclusalreststoimproveapplianceretention.B.Eightweeksafterappliance
placement,upperarchlengthhasbeenincreasedby9mm,andslightexpansionhasimprovedupperarchform.

Fig.6A.PendXversionimmediatelyafterplacement.B.Fourweeksafterplacement.C.Eightweeksafterplacement.

Fig.7PendulumApplianceaftercementationandbeforeinsertionofsprings.Springsarepreactivatedtolieparalleltomidsagittalplane,whichproduces60of
activationafterinsertionintolingualsheaths.

Fig.8Pendulumspringbroughtforwardwithfingerpressure,andmesialendofrecurvedloopgraspedwithWeingartplierforinsertionintosheath.

Fig.9A.Springmovesmolaronpendulumarc,producingcrossbitetendency.B.Periodicexpansionofhorizontaladjustmentloop(inthiscase,15%)compensatesfor
lingualmolarmovement.

Fig.10ForintraoralreactivationofPendulumspring,centerofhelixisheldwithbirdbeakplierwhilespringispusheddistally.

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Fig.11A.UpperarchbondedafterremovalofPendulumAppliance.B.Utilityarchholdsmolarpositionswhilebuccalsegmentsareretractedwithelastomericchain.

Fig.12A.DimensionsoftypicalInstaNancecribmadeof.036"stainlesssteelwire(mm).Threepreformedsizesmeetmostneeds.B.Preformedcribinsertedinto
lingualsheaths,withwirekeptawayfrompalatalvault.C.Smallballoflightcuredacrylicplacedinpalatalvaultandwirebentintoacrylic.Acrylicissmoothedand
roundedwithfingerpressure,thencuredwithalightsource.

Fig.13A.UpperarchcompletelybondedafterremovalofPendulumAppliance.B.Continuousarchwirewithomegastopsmesialtomolarsisplaced,andelastomeric
chainisusedtoretractbuccalsegments.C.Spaceconsolidateddistaltolateralincisors.

Fig.14A.ClassIIpatientbeforetreatment.B.After10weeksoftreatmentwithPendXAppliance.C.InstaNanceapplianceandfullybondedupperarchafterremoval
ofPendX.D.CorrectionofClassIImalocclusionandwideningofupperarchimmediatelyafterPendXremoval.

Footnotes
1.TMA:RegisteredtrademarkofOrmcoCorporation,1332S.LoneHillAve.,Glendora,CA91740.
2.Triad:RegisteredtrademarkofDentsplyInternationalInc.,York,PA17405.

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