Indications

1. Non-extraction treatment of Class II malocclusion

2. Cases with Class II skeletal pattern

3. Straight profile, adequate maxillary lip support

4. Mild to moderate arch length discrepancy

5. Brachycephalic growth pattern– Normal / decreased LAFH

- Lower mandibular angle cases

6. Maxillary arch normal (transverse width)

Dental

i) Class II molar relationship

ii) Deep overbite
iii) Maxillary 1st molars are mesially inclined
iv) Loss of arch length due to premature loss of 2 nd dec. molars
v) Prior to eruption of maxillary 2nd molars
vi) Lower arch well aligned

Contraindications

1. Class II and Class II skeletal patterns

2. Inadequate lip support
3. Severe arch length discrepancy
4. Dolicofacial growth pattern - Increased LAFH
- High mandibular plane angle
- Skeletal open bite

Dental

(1) Class I / Class III molar relation

(2) Dental open bite

(3) Maxillary molars distally inclined

(4) Discrepancy in lower arch

Timing of Treatment

- Mixed dentition period, before eruption of 2 nd molars

- Efficient force system to distalize molars is a continuous acting force

Classification

I. (i) Extra oral appliances

- Headgear

(ii) Intraoral appliances

- Pendulum
- Jones Jig

II. (i) Removable appliances

- Lip Bumper
- Cetlin Appliance
- TMA – Trans Palatal Arch

(ii) Fixed appliances

- Pendulum appliance
- K. loop molar distalizer
- Lokar appliance

III. (i) Intra arch appliances

- Jones Jig
- K. loop distalizer

(ii) Inter arch appliances

- Sliding Jig
- Fixed functional appliances

Principles of Appliance Design (by Burstone)

- Magnitude of forces and moments

- Moment to force ratio
- Constancy of force and moments
- Bracket friction
- Minimal loss of anterior anchorage
- Bodily movement of molars
- Ease of use
- Cost

Extra Oral Appliances – Headgears

- One of the earliest methods of molar distalization

- Use of extra oral forces for retractions, the upper molars was put forward and
proved by Case in 1921.

Components of Headgears

Three main components

(1) Face Bow

(2) Force Element
(3) Head Cap / Cervical Strap

Types of Headgear

(1) Cervical headgears

(2) Occipital headgears
(3) Combination headgears

- Commonly used headgear for molar distalization is the cervical pull headgear.

- Duration – 12 – 14 hrs / day, Force – 150 – 200 g

- Distal driving of molars is carried out with the molars moving in a distobuccal
direction. Hence expansion of inner bow is necessary about 3 – 5mm from
the molar tube.

- Length of outer bow – should end adjacent to upper first molar for bodily
distalization.

- Extended outer bow / outer bow downwards – distal tipping of crown (line of
force below Cres).

- Shorter out bow / outer bow bent upward – distal tipping of root ahead of the
crowns.

- High angle cases – occipital head gears

- Low angle cases – cervical head gears

- Unilateral molar distalization

- According to Siatkowski’s (1997) review covering effects of unilateral head

gears, distal forces were found to exist on both sides, but was 3 times greater
on longer outer bow side. Lateral forces existed which could result in cross
bite.

- Proffit, significant distal positioning of upper posterior teeth with headgears,

occurs primarily in patients who have vertical growth and elongation of
maxillary teeth. Without this, it is difficult to distalize more than 2 – 3mm
unless the upper second molars are extracted.

Introduction & Historical Perspective

The concept of ‘distal driving’ of the maxillary posterior teeth has a long
orthodontic history in 1920s. 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. Thus headgears was 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.

To overcome these difficulties, more recently several intra oral appliances

employing palatal anchorage has been used to produce distal movement of
upper molars.

Distalization mechanics has found many supporters in its quarters since it

provides the arch with increase length which may correct arch relationship as
well as do away with extraction and loss of tooth. In some cases the operator
gets bonus of achieving expansion or molar derotation also.

Removable Appliances for Molar Distalization

Removable Molar Distalization Splint

The removable molar distalization appliance was put forward by Dr. A. Korrodi
Ritto, to overcome the drawbacks of patient co-operation, needed with other
removable appliances like the removable plates and headgears.

Appliance Design

The clear splint is made from 1.5 mm Biocryl in a Biostar machine. When both
upper first molars are to be moved distally at the same time, the splint extends
from the area of the upper right first or second premolar to the area of the upper
left first or second premolar. When molar dislalization is required only unilaterally,
the splint extends to the terminal molar on the opposite side.

Retention of the appliance is by two Internal clasps on the appliance. The

distalizing force is exerted by a Nickel-titanium open coil spring, which produces
a force of 220 gms at the beginning of treatment. The coils are reactivated when
they have been compressed as far as the bonded molar button or the molar
bond.

The splint creates a separation of 1 -2 mm between the maxillary and mandibular

molars at the beginning of treatment. This effectively eliminates lateral occlusal
forces and distalizes the molars at the rate of about "1.5 to 2mm” per month,
even in cases of excessive overbite where distalization is considered difficult.

Advantages

1. It is smaller than conventional removable plates

2. It is comfortable
3. Esthetics
4. Better patient co-operation

Disadvantage

There is more amount of molar tipping seen rather than bodily, molar
distalization. Therefore the best cases for treatment with this appliance are those
where the molars are already messily tipped.

Symmetric Distalization With A TMA Transpalatal Arch

The intra-oral distalization methods can all produce bodily distal movement of the
maxillary molars, but can also cause a mesial movement of the maxillary
premolars and canines, or a proclination of the mandibular incisors when class II
elastics are used. In addition, the loss of anterior anchorage often leads to
relapse of the maxillary molars during the correction of canine relationship.
overbite and over jet.

According to Cetlin's method, maxillary motors can be distalized unilaterally by

using a Goshgarian transpalatal arch in conjunction with extra-oral traction. A toe-
in-bend in the transpalatal arch applies a mesiobuccal rotation to the molar on
the side of the bend and a distally directed force against the molar on the
opposite side. This procedure does not cause a loss of anterior anchorage.

Appliance design

The transpalatal arch is made from the, 0.032 “TMA” wire. TMA is more resilient
and elastic than the stainless steel used in the conventional Goshgarian arch.
The central omega loop is not needed because the 'TMA' arch is not being used
for palatal expansion. If expansion is required, it should be carried out in advance
using a traditional transpalatal arch or other method. The direction of insertion of
the transpalatal arch is also different. The arch is inserted from distal into the
tube of the maxillary molar used as anchorage, and from the mesial into that of
Hie maxillary molar to be distalized. This makes the ‘TMA' arch more effective,
because the end inserted from the mesial. When activated, the arch applies a
mesiobuccal rotation to the anchor molar and a distally directed force to the
opposite molar.

The ‘TMA' arch is re-activated monthly by bending the end inserted from the
distal about 30O.

Advantages

This method has several advantages

1. ‘TMA’ has better shape memory and resilience than stainless steel
2. The arch is simple to construct
3. The system is hygienic and economic
4. This is no anterior anchorage loss; the premolars and canines spontaneously
follow the molar distally

Drawbacks

1. Because the ‘TMA' is more fragile than stainless steel, the arch must be bent
carefully, and fractures in the mouth are more common.

2. Since the 'TMA' arch rotates the anchor molar more mesiobuccally than a
conventional arch does. It should be combined with a fixed orthodontic
appliance using a rectangular arch-wire or a passive stainless steel wire
segment between the second molar and canine on the anchor side.

3. The system can only distalize one molar at a time, and therefore is
recommended for use with unilateral or slight bilateral class II molar
relationships.

4. An extra oral appliance should be worn at night to reinforce anchorage.

Tube Plates

Lain Benauwt explained the use of a removable appliance for distalizing the
molars. These appliances were introduced as the appliances with wires sliding in
tubes.
Appliance

The appliance consists of a stationary part and a movable part. Both these parts
are held together by a long horseshoe shaped wire which moves the movable
part by virtue of the elasticity of the wire. Each end of the wire is inserted into a
tube, one is the fixed part of the appliance and the other is the movable part.

The movable part has an Adam's Clasp for the molars to be moved distally. This
part also carries two parallel tubes embedded in it, one of which contains a guide
wire to prevent displacement and the other containing the end of the horseshoe
shaped active wire which contains a guide wire to prevent displacement and the
other containing the end of the horse shoe shaped active wire which creates the
backward movement.

The stationary part contains the other clasps for the retention of the plate and
one tube, which contains the other end of the horseshoe, shaped active wire.

Activation

Activation of the appliance is done using a 139 plier. The wire coming out of the
tube embedded in the stationary part is bent, which makes the movable part slide
distally. If it does not slide easily, the shape of this wire must be corrected.

Advantage

1. Retention of the appliance is very good. as the movable parts contribute to

the retention (due to incorporation of Adam's clasp).

2. It is very helpful in mixed dentition when deciduous molars are not too
retentive or are broken down or missing.

3. Unwanted displacement of teeth is minimized due to the Adam's Clasp who

holds the molar and avoids rotation.

4. An extra oral appliance can be used along with this appliance to support and
reinforce the stationary part or indirectly the anchorage.

5. Expansion is also possible al the same time as the distalization of the molar,
and is achieved by changing the angulation of the tubes in relation to the
sagittal plane.

6. Repair is easy.
Disadvantage

It is a delicate appliance. The two wires must hold the movable part without
binding.

The Crickett Appliance

Full banded techniques have wide social acceptance, but there is still a need for
an efficient removable appliance therapy for a significant number of adult
orthodontic patients, especially adults concerned with "TMJ" problems. In the
recent years Dr. Robert M. Ricketts has developed and successfully used a
modification of the basic "Crozat” appliance called the Crickett (Crozat / Ricketts)
appliance.

The appliance embraces the essential features of the quadhelix 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 sewing 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 stability, In addition to those on the buccal as in the basic appliance.

Upper palatal and lower lingual main frames are constructed from 0.032" yellow
and 0.038' blue Elgiloy respectively: the cribs, clasps and occlusal rests from
0.028” Blue Eligibly; the lingual arms from 0.030" yellow Elgioly; and the buccal
arms from 0.045” Blue Elgiloy.

The Crickett appliance can effect a variety of tooth movements, including

rotation, torquing and distalizalion of molars. It is an effective appliance for both
lateral and anteropostertor expansion.

Limitations

Intrusion of anterior team.

Cetlin Appliance

The appliance involves a combination of an extra-oral force in the form of

headgear and an infra oral force In the form of a removable appliance.
In molar distalization, bodily distal movement rather than distal tipping of the
maxillary molars Is essential. When there Is only a distal tipping, the molars
relapse messily, unrighting under their apices to comeback to its original position.

To overcome these drawbacks, the Ceflin appliance utilizes a removable

appliance intra orally to tip the crowns distally and then an extra oral force to
upright the roots. So the intra-oral removable appliance can be called the crown
mover while the extra-oral force, is the root mover.

Anchorage

The anchorage for the removable appliance is by proper adaptation to the palate,
an acrylic shield around the four maxillary incisor and a modified Adam's Clasp
on the first premolars.

Extra oral force

The extra oral appliance is a headgear, which is inserted into the molar tube. The
headgear used in generally a cervical or a high pull type, depending on the usual
consideration of skeletal pattern.

The removable appliance is worn 24 hours a day. The appliance also contains a
bite plane to disengage the molars (to aid in rapid molar movements).

The force applied

In the removable appliance, the spring is activated only 1 to 1.5mm, measured

along the occlusal surface of the molar and It supplies only 30 gms of force on
the molars. The springs are placed as far gingivally as possible to minimize
crown tipping and to cause molar movement without Irritation.

The removable appliance exerts a force, which moves the molar crowns distally,
with relative ease.

The extra oral headgear on the other hand exerts a force of 150 gm per tooth
and is used to control root position. The headgear is advised to be worn for 12-14
hours / day.

When using a cervical headgear, it is generally necessary to elevate the outer

bow to produce an appropriate “force couple” that will move the roots distally, by
directing the line of force above the outer of mass of the molar.

Pendulum Appliance

Hilgers first introduced pendulum appliance in 1992, for use in non-compliance

patients to distalize the maxillary first molars. This appliance produces a broad,
swinging arc or pendulum - of force from the midline of the palate to the upper
molars.

Fabrication

The right ant left pendulum springs, formed from 0.032" TMA wire, consists of a
re-curved molar insertion wire, a small horizontal adjustment loop, a closed helix
and a loop for retention In the acrylic button.

The springs are extended as dose to the center of the palatal button as possible
to;

- Maximize their range of motion

- Allow for easier Insertion into the lingual sheaths
- Reduce force to an acceptable range

The springs are also mounted as close as possible to the distal aspect of the
Nance button. Tongue irritation during swallowing is minimized by extending the
springs distal to the button.

The anterior portion of the appliance can be retained in several ways. The most
stable method of retention is to band the upper first bicuspids or first deciduous
molars, solder a retaining wire to the bands, and use these teeth as the major
anterior anchorage for the appliance.

The Nance button should be made as large as possible to prevent any tissue
Impingement. It should extend to about 5 mm from the teeth, to avoid to the
highly vascular cuff of tissue near the teeth and to allow adequate hygiene.

Pre-activation and placement

Although the pendulum springs can be activated intra-orally, it is more efficient to

pro-activate them before appliance placement. If significant distal molar
movement is required, the springs should be bent parallel to the midline of the
palate (or perpendicular to the body of the appliance).

The molar bands are cemented without the springs engaged, and the anterior
portion of the appliance is then cemented in place.

Once the appliance is in place, each pendulum spring is brought forward with
finger pressure, the mesial end of the recurred loop is grasped with a weignart
plier and the spring is seated in the lingual sheath. The small horizontal
adjustment loop allows for some lingual compression of the spring during
placement.
Due to the nature of the pendulum springs which are of constant length, the
maxillary molars have a tendency to go lingually when distalized. To compensate
for this short, coming, it is prudent to open the horizontal adjustment loop, which
lengthens the pendulum, spring and helps in preventing the unwanted lingual
movement.

Tipping back the recurved portion of the spring at the loop causes a more direct
distal movement of the molars.

Reaction

Reactivation, If needed. Is done after about 3 weeks. The springs are removed
from the lingual sheath, the helix is held with a bird beak plier and the spring is
reactivated by pushing it distally towards the midline. The springs are then
reinserted In the lingual sheaths.

After distalization, the molars are stabilized in one of the following ways:

- A full upper fixed appliance Is bonded. An upper utility arch holds the molars
back with the incisors as anchorage. The buccal segments are retracted
using an elastomeric chain.

- A smaller, easy to clean Nance button, also known as "Insta Nance” is placed
immediately.

- The upper arch is bonded or banded, and a continuous arch wire with omega
loops mesial to the upper first molar tubes is placed. Thus the entire arch is
used for anchorage while the buccal segments are moved distally. This
approach can be combined with the Insta-Nance.

- Headgear is used.

1. Very good patient tolerance

2. It has been shown to be effective in distalizing the molars.

3. The appliance can also be used to simultaneously expand the arch.

Drawbacks

1. Lingual tipping of molars

2. Difficult to fabricate
Jones Jig

The Jone Jig was first introduced by Richard D. Jones and J. Michael White.

Jones Jig is one of the appliances which accomplishes tooth movement without
the need for patient compliance. The appliance uses an open coil Nickel titanium
spring to deliver 70-75 gms. Over a compressive range 1 -5 mm to the molars.

Appliance fabrication

Anchorage for the Jones Jig is provided by a modified Nance appliance. The
modification in the Nance appliance is that. It can be attached either to the first
bicuspids, second bicuspids or even to the deciduous second molars.

In the first appointment, separators are placed between the first molars and the
anchor teeth.

In the second appointment, the teeth are banded and in impression made with
the bands on and the cast is poured in stone.

A 0.036” S.S. wire is adapted on to the palate of the cast, and extended as far as
the canine and then soldered to the anchor bands. Quick cure acrylic is then
added in a salt and pepper fashion to form a button about 1 inch in diameter. It is
not allowed to extend loo much anteriorly to prevent impingement on the incisive
papilla or the teeth.

On the third appointment, the Nance appliance to cemented to the teeth. The
Jones Jig is then placed on one or both sides as required.

The Jones Jig assembly consists of a mainframe of two prescriptions (0.018" x

0.022" respectively) which can be contoured in the anterior one third. It also
consists of a mainframe hook which is tied to the hook of the molar tube. The
force is delivered by a NiTi coil spring which acts along the mainframe wire, when
activated using a ligature. A 0.014" ligature wire is generally used to fasten the
eyelet tube to the premolar bracket, which compresses the NiTi coil springs. The
distal end of the mainframe consists of a keeper wire (0.018') which goes into the
archwire slot and a mainframe wire which enters the headgear slot of the molar
tube.

The extreme mesial end of the completed assembly should rest no further than
the distal 1/3'*' of the bicuspid. The excessive length of the mainframe, work can
be cut short if needed, but care must be taken to cut a corresponding length of
the NiTi coil spring also.
Activation

A 0.014” ligature wire is loosely lied around the buccal tube and the mainframe
hook. Then a 0.012" ligature wire is wound twice around the premolar bracket
and the mesial end passed through the eyelet tube. The ligature wire is then
tightened.

Over activation of the coil spring should be avoided. When over activated, it
results in excessive forces leading to unwanted tipping and palatal irritation along
the palatal button.

Reactivation

Reactivation takes very little chairtime and is done over a period of 4 - 5 weeks
interval.

Treatment Time

In Pseudo class II, where it is the rotated class I which needs to be corrected, the
treatment time is 80-120 days.

In true class II molar relationships, the corrected class I relationship can be

achieved in 120-180 days. However the treatment time is slightly increased in
brachyfacial patterns.

Advantages

The advantages of the Jone Jig appliance are that, it can achieve class I
relationship even when;

- 2nd motors erupted or unerupted

- In mixed and permanent dentition
- Unilateral as well as bilateral distalization
- Growing and non-growing patients

The appliance is also said to be a predictable, painless sand rapid method of

correcting class II relationship with minimum patient co-operation.

The Lokar Appliance

The Lokar appliance was developed by Dr. Loter In 1894.

Components

The appliance consists of two baste components. They are;

- A mesial sliding component
- A component which inserts Into Ins arch wire tube of the molar

The distalizer is inserted into 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 tor patient comfort.

A 0012” S.S. ligature wire b hand twisted around the premolar bracket before the
Lokar 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 delivered by NiTi Coil spring, which gets compressed during
activation.

Anchorage

The anchorage is by a Nance appliance, soldered to the premolars.

Activation

A 0.012" S.S. 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 2-3 mm.

Reactivation is done at 5-6 weeks interval.

K-Loop Molar Distalizer

The K-loop molar distalizer was developed by Vamn Kalra. The K-loop molar
distalizer consists of;

- A K-loop-to provide the forces and moments

- A Nance button -to resist anchorage.

The K-loop is made of 0.017- x 0.025" TMA wire. which can be activated twice as
much as stainless steel before it undergoes permanent deformation. A loop made
of 'TMA' also produces less than half the force of one made with stainless steel.

Each loop of the 'K' should be 8mm long and 1.5 mm wide. The legs of the 'K' are
bent down 20O and inserted into the molar tube and the premolar bracket. The
wire is marked at the mesial of the molar tube and the mesial of the premolar
bracket. Stops are bent into the wire '1mm' distal to the distal mark and '1mm'
mesial to the mesial mark. Each stop should be well-defined and about 1.5 mm
long. These bends help keep the appliance away from the mucobuccal fold,
allowing a 2mm activation of the K-loop.

The 120O bends in the appliance legs produce moments that counteract the
tipping moments created by the force of the appliance, and these moments are
reinforced by the moment of activation as the loop is squeezed into place. Thus,
the molar undergoes a translatory movement instead of tipping. Root movement
continues even after the force has dissipated. If an extrusive or intrusive force
against the molar is not desired, it is important to center the K-loop between the
first molar and the pre molar.

For additional molar movement, the appliance is reactivated 2 mm after 6-S

weeks. The loop is easy to remove from the molar tube, since the distal end of
the wire is not bent. In most cases, one reactivation, producing a total of as much
as 4m of distal molar movement is sufficient.

The palatal Nance button, held in place by wires extending from bands on the
first premolars or first deciduous molars, is primarily responsible for preventing
anterior movement of the first premolars. The button should be large enough to,
provide adequate anchorage and prevent tissue impingement, but should be kept
away from the teeth. The acrylic should not be built up so that the button acts as
a bite plane.

The premolars moved forward by about '1 mm’ during ‘4 mm' of molar
distalization. If necessary, the anchorage can be reinforced by attaching a
straight pull or high-pull headgear with a force of 150gm to the premolars.

Advantages

The K-loop molar distalizing appliance has the following advantages;

- Simple yet efficient

- Controls the moment-to-force ratio to produce bodily movement, controlled
tipping or uncontrolled tipping as desired
- Easy to fabricate and place
- Hygienic and comfortable for the patient
- Requires minimal patient co-operation low cost

The Distal Jet

The distal jet was designed by Akto Carano and Miiuro Testa in 1996.

Appliance design
The appliance consists of bilateral tubes of 0.036” internal diameter which are
attached to an acrylic name button. A NiTi Coil spring and screw clamp are slide
over each tube.

The wire extending from the acrylic, through each tube ends in a bayonet bend
that is inserted into the lingual sheath of the first molar band. An anchor wire from
the Nance button is soldered to the bands on the 2 nd premolars.

Components

1. The transpalatal connector - rigidly immobilize the premolars and provides a

support to the Nance button.

2. The Bayonet director unit - Lumen of the tube portion supports the molar
bayonet, while its outside diameter supports the spring and the activation
lock.

3. The molar bayonet - It is drawn out of the bayonet director unit during
distalization and Inserted into the lingual sheath. The distal step prevents the
spring from riding on the vertical arm of the molar bayonet while activating the
appliance.

4. NiTi springs – NiTi coil springs of 150 gm is used children and 250 gm used
for adults.

5. Stainless steel springs - The appliance can also ba fabricated with stainless
steel springs.

6. Activation locks - to compress and activate the springs.

7. Lock wrench - To engage and tighten (he screw of the activation lock.

Activation

The distal jet is activated by sliding the damp closer to the first molar once a
month.

Once the distalization is complete, the appliance can be converted to a Nance

retainer simply by replacing the clamp-spring assemblies with light-cured or cold
cure acrylic and cutting off the arms or the promoters.

Advantages
- Minimal patent discomfort
- Minimal or no molar tipping
- Ease of fabrication
- Ease of insertion
- Esthetically acceptable
- Well tolerated by patients
- Ease of conversion to a Nance holding arch to maintain the distalized molar
position
- It can be used with a full fixed appliance

There are several modifications to the died jet appliance, for different purposes.
They are;

1. Conversion to Nance holding arch

2. Double set screw distal Jet

3. Incorporation of helical loops into bayonet wire far molar rotation and up-
fighting

4. Incorporation of Jack screws for maxillary expansion

The Crozat Appliance

The crozat appliance is similar to the crickett appliance but has palatal and
lingual bars instead of stainless steel wire components.

Dr. Crozat viewed the appliance as acting in a truncated cone or funnel. As the
molars are being translated distally in a divergent direction, expansion must be
placed In the appliance to avoid the more roots striking the lingual cortical plate,
blocking movement. Over expansion can also impede distal movement by
emerging the roots against the buccal plate.

Treatment of a bilateral class II malocclusion with a good lower arch is begun

with rotation adjustments of the upper molars. First the measurement is made
between the lingual arms; and each crib clasp complex is rotated to increase this
measurement ½ mm per side. Once the rotation adjustment is begun every third
rotation adjustment, the molars are expanded to keep the teeth tracking back into
a more divergent portion of the arch. Once the molars are derotatad, class II
elastics are added to continue distal movement. Similar unilateral class II can
also treated, with crozat appliance.

Crozat Appliance
Dr. Crozat introduced this appliance in 1919. Dr. Crozat’s goal was to solve
crowing by the distal movement of molars. As he moved molars distally,
expansion of the appliance was necessary because the bony dental arch itself is
wider in the posterior regions.

Design and construction

The main body wire is constructed of 0.051 inch gold wire carefully bend to dear
the soft tissue. The lingual arms are of a lighter gauge than the body wire, usually
0.040” gold wire. The buccal arms on the upper appliance and are of 0.032” gold
wire.

The crib that holds the appliance in place is made of 0.028" gold wire. Great care
should be taken to construct the crib correctly to that it fits correctly. The labial
wires are and 0.032” gold wire, they ere soldered to the buccal arms in the upper
cribs and to the buccal side of the lower cribs in later stages of treatment.

Various springs and hooks of 0.032” goldwire are soldered to the labial wires.
These may be for individual tooth movements, such as torque or rotation or for
intra or Inter maxillary elastics.

With the high cost of gold, many Crozat appliance are constructed today of
stainless steel, Elgiloy or Nichrome wires. In the case of considerable damage to
the appliance, nothing has the malleability of gold or the case of case of repair.

The steps usually followed by Dr. Croat and his study club and their successors
are as follows;

1. Placement of the appliance and adjustment of teeth, appliance and occlusion

so that appliance is not damaged by action of cusps.

2. Rotation of first molars to proper positioned and setbacks to distal driving the
molars to develop arch space. As the molars move distally into a wider past of
the arch, some expansion is necessary.

3. Use of elastics, either class II or class III, from the labial arms to correct molar
relationships.

4. Addition of springs to the body wire to carry premolars into desired

relationships.

5. Addition of labial arches with individual pinds (finger springs) to finish closure
and torque the roots of the anterior teeth, with final detailing of individual
teeth, including rotations, with the use of pins and springs, continued use of
elastics as required.
6. Crozat appliance may be continued for retention.

Advantages

1. It can be used to con-eel arch form and correct the plane of occlusion.

2. It is very effective in same problems that require molar rotation, expansion

and tipping of certain teeth.

3. As a relative device, it is hygienic and long lasting.

4. It is also useful for some patients with temporomandibular joint problems and
with periodontal difficulties.

5. Since the teeth are moved slowly to new positioned by the light forces
exerted, their natural tendency to revert to pretreatment positions is lessened
10 a great degree.

Disadvantages

1. Appliance fabrication needs a good skill, if crip-clasp complex is not made

correctly, it simply will not grasp the tooth and movement like molar are not
possible. If lingual arms are misplaced, molar rotation will not occur cribs and
arms must be very precisely adjusted, otherwise unwanted torque is
introduced into the molars, and teeth may be depressed or torqued into
difficult maloccluded positions.

2. Adjustment and repair are time consuming.

3. Careful finishing with Corzat appliance takes time.

4. It is technically difficult to construct.

5. Requires much personal chair time w the part of the dentist.

6. Requires a high degree of co-operation from the patient.

7. The mechanism of distalization is complex, it Includes derotation adjustment,

expansion adjustment etc.

Wilson's Rapid Molar Distalization

Advocated by Robert C. Wilson

The appliance proposes to distalize the maxillary molars, while the mandibular
molars maintain the pre-treatment antero-posterior positions. The Wilson
treatment achieves molar distalization without extra oral forces.

Newton’s 3rd Law of motion stats that for every action, there is an equal and
opposite reaction i.e. for every moment, there is a counter moment.

Wilson advocates maxillary bimetric distalizing arches (BDA) and a mandibular 3-

dimensional lingual arch. The bimetric arch produces a coil spring action against
the molars and produce an anterior counter moment against, the incisors, which
is controlled by wearing Class II elastics. These in turn, react with the 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.

The vertical component of elastic force la controlled fey 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 distalization
of molars, without headgear and with preservation of mandibular arch integrity.

The delayed bracketing the premolar and second molars permit the use of
bypass mechanics of the 3D bimetric distalising arch in Modular first phase
treatment. This produces rapid, friction free distalization without headgear.

Patient co-operation with Class II elastics is required to prevent advancement of

maxillary incisors.

Wilsons Schedule for Maximum Mandibular Anchorage

- 6 Ounce elastics for 5 days

- 5 Ounce elastics for 5 days and
- 2 Ounce elastics for 11 days

For Minimal Mandibular Anchorage

- 6 Ounces for 10 days

- 2 Ounce for 11 days

Advantages
- No extra oral force
- Class II correction starts immediately (oven in mixed dentition)
- No reactionary maxillary incisor proclination
- Can be used in mixed dentition.

Disadvantages

- Longer treatment time (than originally proposed) that the treatment time was
6 - 10 weeks actually it takes 16 weeks.

- Distal tipping occurs frequently. The tipped molars have questionable stability.

- A significant proportion of the Class II correction was found to be due to

mesial movement of mandibular molars.

Fixed Piston Appliance

The appliance was described by Raphael U Green field in 1997.

The appliance proposed to achieve distal bodily movement of the molars without
tipping the crown with no loss or post anchorage.

Components

- Maxillary first molar and first bicuspid bands.

- 0.036" Stainless Steel tubing (soldered to the bicuspids)

- 0.030” Stainless Steel wires (Soldered to the first molars)

- Enlarged nance button, reinforced with an 0.040” Stainless Steel wire for
control of anterior anchorage.

- 0.055” hyperplastic NiTi open coil springs to provide a light but continuous
force.

Fabrication

- The first molars are banded with a double or triple tubes.

- The first bicuspids are then banded. Normally the buccal and lingual piston
assemblies should extend to the embrasure of the cuspid and first bi-cuspid
to be long enough for adequate distalization. In maximum molar distalization
however, the piston assembly may be extended beyond the first bicuspids.
- A full arch silicone / vinyl Impression is then taken such that the bands seal
accurately in the impression.

- The bands are then waxed and a working cast poured in stone.

- A 0.040” SS wire is then adapted to the palate and is brought posteriorly to

the gingival third of the bicuspid for soldering.

- A 0.036” SS tubing is then soldered to the buccal and lingual occlusal thirds of
the bicuspid bands.

- The 0.030” SS wire is soldered to the buccal and lingual surfaces of the first
molar bands. 0.040” SS nance wire is then soldered to the bicuspid bands.

Note: The piston assemblies must be parallel in both the occlusal and sagittal
views. A slight palatal cant from distal to mesial can however be given to prevent
occlusal displacements of the palatal acrylic.

- A thin layer of light curved acrylic is adapted on the cast and light cured.

- The appliance is then finished and polished.

- The 0.055" NiTi open coil springs are then measured to fit the entire length of
the buccal and lingual assemblies.

- A 2mm split ring stop Is then added to the mesial of the buccal and lingual
tube on each piston assembly every 6-8 wks. This provides around 25gms of
force to each piston assembly which works out to 50gms per tooth.

Advantages

- Produces bodily movement of maxillary (led molars with no loss of post

anchorage.

- Minimum patient compliance.

- In non-extraction cases, it to proved to reduce treatment time as it distalizes

at the rate of 1mm per month. Over corrections can be achieved in 6 to 9
months.

- Maintains the arch width after expansion with Hyrax appliances.

- Uses a light, controlled force of only 1-2 once per tooth. Because of this, there
is no loss of ant. Anchorage and no inflammation of the palatal mucosa
beneath and adjacent to the modified nance button.
- Does not interfere with the occlusal plane, thus maintaining effective control
over the vertical dimensions.

Molar Distalization by Magnets

Magnets have been used intra orally for a variety of reasons. More often for
retention of prosthesis.

In contemporary orthodontics, light continuous force (75 to 100 gms) are

commonly used to correct malocclusion with typical tooth movement of 0.5 mm /
week.

Miniature Samarium-cobalt (Sm-Co) magnets are used and they have been
proved to be an effective and efficient force delivery systems.

Ferrite, AInico or platinum cobalt have been tried but left out due to their very low
magnetic strength and hence larger size.

The magnets can either be used in the attractive or the repelling state. The
repelling stale in preferred.

It was found that the Sm-Co magnet; when used, exert very high forces of more
than 200 omi at small separations, while optimum orthodontic forces were
generated (75 to 180 gms), when separation was 0.5 to 1.00 mm.

Magnetic Force = (Separation)n

= (d)n

The force exerted by the magnets decrease from 200 gms at contact to about
409 gms at 2mm, with a rapid decrease of force at greater separations.

The magnets used showed good biocompatibility when they were coated.

The stainless steel coated samarium - cobalt magnets can recycled and showed
good biocompatibility.

The magnets

The magnets are 4 in number and they are encased in a steel sleeve with a finely
machined hole in the center and coated with a biocompatible polymer lo avoid
leaching out of products.

Two of the magnets are pre-set in regulation (on each wire) for easy insertion
bilaterally. Both repelling magnets on each wire are clamped together to avoid
possible loss of magnet.
Anchorage

The anchorage uses a modified nance palatal system comprising of a

transpalatal arch embedded in an acrylic button with a palatal wire running on the
palatal surface of posteriors and the angulation of the anteriors.

Bands

The molar bands used here have a double or even a triple buccal tube into which
the magnet mounting wires are inserted, The triple buccal tube was usually
preferred due to easier insertion. The tubes are always placed parallel to the
occlusal plane and in a way that they follow the buccal surface of the bicuspids
and cuspids.

Magnet Insertion

a) The straight end of the 0.016” mounting sectional wire was inserted into the
buccal slots of the first molar buccal tube. The magnets were placed such that
they had solid contact against the mesial side of the buccal tube and were
also placed far enough distally, so that the 0.16 mounting wire on the mesial
side (or the magnet) can be ligatad to the second bicuspid bracket.

b) Triple buccal tubes are used to provide the greatest contact between the
distal of the magnet and the first molar tube.

c) Approximately 3mm of the 0.16 wire extended beyond the distal portion of the
buccal tube. The molar was allowed to slide distally on the wire (No tie back
given).

d) After the mounting wire is fully inserted into the buccal tube, the mesial
portion of the wire is ligated into the 1st and 2nd premolars.

Activation

The mesial wire Is lightened sufficiently to force both magnets make contact.
thereby activating the appliance.

As the first molars distalize, the magnets begin to separate and the distalizing
forces degrade. The re-activation is done every 2 to 3 weeks and are done by
holding the magnets together by finger pressure and by lightening the ligature
wire, until there Is no slack in the wire. Using magnets, the amount of mean distal
molar movement was about 3.6nm, which was 1.2mm per month.
The amount of anterior movement Is 0.5mm which has to corrected In the later
stages with a fixed appliance.
The magnets need to be re-activated every 2-3 weeks as the forces degrade,
with separation of magnets.

Recent studies have shown that the magnets are not only biocompatible, but is
effect on bone surface show that induce a increased rate of osteogenesis and
lead to faster tooth movements.

Super Elastic NiTi Wires

The use or shape memory, super elastic NiTi wires indistalizing the molars have
bee discussed by John Bednar et al in 1992.

Procedure

- A 100gm Neosent alloy wire with regular arch form is placed over the
maxillary arch.

- The wire then marked in three places on each side.

a. At the distal wing of the first premolar bracket

b. 5-7 mm distal to the anterior opening of the molar tube
c. between the lateral incisor and canines

- A stop is then crimped on the arch wire at each of the posterior mark and a
hook Is attached between the lateral incisor and canines for the inter maxillary
elastics.

- The wire is then Inserted Into the molar tube until the posterior stop abuts the
tube. To place the wire through the first premolar bracket, the anterior stop is
grasped and the wire Is gently forced distally so that the stop is grasped and
the wire Is gently forced distally so that the stop abuts the distal wing of the
first premolar bracket, when ligated. Since the wire is 5-7 mm larger than the
available space, the excess will be deflected gingivally in the buccal fold.

Mechanism of Action

The distaization of the molars occur as the wire returns to its original shape,
exerting a distal force of 100 gms against the molar and a reactionary mesial
force on the first premolars, canines, and incisors.

There is also a tendency for the premolar to move buccally.

Anchorage

Anchorage can be controlled by;

- Placing 100-150gms Class II elastics against the first premolar or between
lateral incisors and canines.

- Nance appliance cemented to the first premolar.

Advantages

- The appliance distalized the molar at the rate or 1-2mm per month with little
loss of anchorage.

- The wire is easy to insert even after all the teeth have been bracketed or
bonded.

NiTi Double Loop System for Simultaneous Distalization of I & II Molars

Super elastic Nickel titanium wires have bean found as effective as other means
in producing distal movement of the Maxillary I molars.

When the distalizaton is carried out before the 2 nd molars have erupted. It can
reliably produce 1-2mm of space. One the 2 nd molars have erupted. However, the
distal movement can be more difficult and time consuming and loss of anchorage
is likely.

Appliance Design

The mandibular I & II molar and 2 nd bicuspid are banded, and the remaining
mandibular teeth are banded. A lip bumper Is placed to prevent any extrusion
from the use of class II elastics.

The maxillary molars & bicuspids are banded, and the teeth are bonded. The
arch is aligned as usual.

An 80g Neosent alloy archwire (Super elastic NiTi wire with shape memory. It is
trademark of GAG International) is placed on the maxillary arch and marked
distal to the I bicuspid bracket and about 5mm distal to the I molar tube. Stops
are then crimped in the arch wire at each mark.

Two sectional Niti arch wires - one for each side is prepared by crimping stops
distal and mesial to the 2nd bicuspids and about 5mm distal to each 2 nd molar
tube.
Uprighting springs are inserted into the vertical slots of the I bands and class II
elastics are placed between the mandibular I molars and axillary canine bracket
hooks.

This system produces simultaneous distal movement of I and II molars.

Discussion

The NiTi double loop system is a useful technique for Class II treatment with
minimal patient co-operation. It is ideal for simultaneous I and II molar
distalisation in the permanent dentition, when traditional intraoral forces may be
ineffective in moving the I molars, II molars easily move distally than the I molars
because of the different anatomic shape of roots and the lack of posts obstacles.

Because of the stretching of transeptal fibers, the I molars can be distalized using
lighter force of 80g Nickel Titanium wires, instead of 100g or 200g wires which is
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 premolars.

Although the force of the NiTi double loop system is applied in a Class I direction,
care must be taken in a dolicofacial patient with open bite tendency, because the
Intrusive force produced by the uprighting springs might cause an openbite to
develop.