MOLAR

DISTALIZATION

DR.PRASHANTH.G.S
DEPARTMENT OF ORTHODONTICS
BAPUJI DENTAL COLLEGE AND HOSPITAL
 CONTENTS
INTRODUCTION
HISTORY
INDICATIONS AND CONTRAINDICATIONS
APPLIANCE SELECTION CRITERIA
SECOND MOLAR EXTRACTION
UPPER MOLAR POSITIONING
CLASSIFICATION AND APPLIANCES
APPLIANCES
CONCLUSION
REFERENCES
 INTRODUCTION
Whenever there is space deficiency, the methods
of gaining space that strikes to our mind first are,
extraction, expansion and stripping.
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 unacceptable.
In 1930s, Charles Tweed observed relapse after
non-extraction expansion treatment and decided to
retreat with extraction.
 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.
Proximal stripping also has its own limitation.
So which one to opt?
Molar distalization, in recent years is evolved as
an alternative method of gaining space to
conventional methods where ever is indicated.
 HISTORY
Kingsley was the first person to try to move
the maxillary teeth backwards in 1892 by
means of headgear.
Oppenheim advocated that position of
mandibular teeth as being the most correct for
individual and 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.
 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.
Gould (1957) was first person to discuss
about unilateral distalization of molars with
extra-oral force.
Kloehn (1961) described the effects of
cervical pull headgear.
Graber T.M. (!969) extracted the maxillary
II molar and distalized the first molar to
correct class II div.I.
 INDICATIONS
Profile :
Straight profile
Functional
Normal, healthy temperomandibular joint
Correct mandible to maxillary relationship
Skeletal
Class I skeletal
Normal, short lower face height
Maxilla, normal transverse width
Brachycephalic growth pattern
Skeletal closed bite
 Dental
Class II molar relationship
Deep overbite
Permanent dentition
Maxillary first molar mesially inclined.
Preferably prior to eruption of second
molar.
Maxillary cuspids labially displaced.
Loss of arch length due to premature
loss of second deciduous molar.
 CONTRAINDICATIONS
Profile :
Retrognathic profile
Functional :
Numerous signs and symptoms of
temperomandibular joint.
Posteriorly and superiorly displaced condyles.
Skeletal :
Class II skeletal
Skeletal open
Excess lower face height
Constricted maxillary arch
Dolicocephalic growth pattern
Dental :
Class I or III molar relation.
Dental open bite
Maxillary first molar distally inclined.
 SECOND MOLAR
EXTRACTION
Extraction of second molar is often use
in conjunction with distillation of first
molar. In last few years the extraction
of second molar has become a matter
of great interest and controversy
within dental profession.
Advantages :
Reduction in amount and duration of appliance therapy.
Facilitation of treatment using removable appliance.
Faster eruption of third molar/surgical removal avoided.
Facilitation of first molar distal movement.
Less likelihood of relapse
Good functional occlusion
Mild premolar crowding is corrected without mechanotherapy.
Natural contact area from canine to first molar retained.
Results are stable as tongue space has not been compromised.
Since premolars are not extracted, more teeth available for
chewing.
 Disadvantages :
Too much tooth substance removed.
Extraction site located far from area of cancer in
moderate to severe anterior crowding.
Possible impaction of third molar even with
second molar extraction.
 UPPER MOLAR
POSITION
It is a linear measurement between
distal surface of maxillary first molar
and pterygoid vertical line (PTV). It is
an indication of the forward position of
upper molar and illustrates the
clinician whether or not sufficient
space is present for second and third
molars. This indicates or
contraindicates molar distalization.
 Itsmean value in patients age in
years plus 3 mm until growth is
completed.
In non-growing patients mean value
is 18 mm.
 CLASSIFICATION
Extra Oral
Bilateral
Unilateral
Intra-oral
Inter-arch
Intra-arch
 APPLIANCE SELECTION
CRITERIA
Regardless of approach, one should ponder
several issues before considering any of
these appliances for use :
Side Effects :
Potential side effects.
Did incisors flare
If mandible is to be used as an anchor unit,
did anything occur in that arch.
Side effects are a fact of life, especially in
orthodontics.
 Case types :
Consider individual case at hand and his/her
needs.
If mandibular dentition can be slightly
mesialized, if this in the case then Herbst or
BDA may be appliance of choice.
If not pendulum and other intra-arch
appliances can be used.
If you may not afford flaring of incisors then
TPA or headgear would be treatment of choice.
 Arch length :
How much distalization is required.
TPA has limited application of 2-3 mm, if in
need of greater amount of correction then
Herbst and headgear are of choice
followed by pendulum, Wilson BDA etc.
 Treatment timing :
Perhaps best time to initiate
distalization is late mixed dentition and it
may be too late after eruption of second
molar.
Some synergistic effect as dentition
transits from primary to permanent as
canines and premolars follow molars as they
moved distally. Thus appliances that
requires some anterior anchorage like
pendulum may dilute these results.
 Co-operation :
If one lives by the sword, one dies
by the sword.
Invariably appliances that require
least in co-operation come with side
effects that have to be considered.
 ATKINSON BUCCAL BAR
Used with minimum amount of class II
elastics of two ounces.
Move buccal segment posteriorly whether
second molar are present or not.
Long lever action puts greater force on upper
molar with very little force on anchorage unit.
Anchorage preparation is 6 to 6 lingual arch
that touches the lowest area of enamel on
four incisors.
 HERBST APPLIANCE
Emil Herbst in 1905.
Class II correction is by equal amounts
of dental and skeletal changes. Dental
changes include distalization of
maxillary molar and mesial movement
of mandibular molar and incisors.
Skeletal changes includes inhibition of
maxillary antero-posterior growth and to
produce an increase in mandibular
length and lower face height.
 Original design consist of placement of
bands on maxillary first premolar and molar
and mandibular first premolar, which were
connected with lingual bar to support
anterior teeth. The aches are connected with
telescopic adjustable piston mechanism to
produce a protrusive force on mandible.
New design by Larry white of New Mexico
used stainless steel crown on maxillary first
molar and removable mandibular occlusal
coverage acrylic splint. Which allows
temporary removal of mandibular
component to facilitate oral hygiene and
adjustments for erupting teeth.
 JASPER JUMPER
Flexible fixed appliance that delivers light
continuous force.
Can be used to move a single tooth or an
entire arch.
It can deliver functional, bite jumping,
distalizing force, elastic like force or
combination of these.
When appliance is fixed, mastication helps to
deliver intrusive and distalizing force on
upper molar, much as a high pull face bow
with occasional opening of posterior bite
similar to that seen in Herbst.
 SAGITTAL APPLIANCE
Used to develop arches by actively moving
teeth, in groups or singly in antero posterior
direction along crest of alveolar ridges.
With proper design can be used unilateral or
bilateral.
If second molars are intact, the primary
direction of development and arch will be of
anterior in an anterior direction (Class II div II).
If second molars are removed, primary
direction of movement of teeth will be
posterior segment in distal direction. (severe
anterior crowding).
 PENDULAM AND PENDEX
APPLIANCE
In 1992, Hilgers
Consists a large acrylic nance button that
covers midportion of palate. The acrylic pad is
connected to dentition by means of occlusal
rests that extends from lateral aspect of pad
and are bonded to occlusal surfaces of upper
first and second premolars. Posteriorly
directed springs, made of 0.032 TMA wire,
extends from distal aspect of palatal acrylic to
form a helical loop near the midline and then
extends laterally to insert into lingual sheath
on bands cemented on maxillary first molar.
 Springs deliver approximately 230 gms of
force per side.
Springs have adjustment loop that can be
manipulated to increase molar expansion,
rotation and distal root tip.
Pendix is eventually same as pendulum,
except for addition of palatal expansion
screw in midline.
Used in maxillary constriction.
This design features two wires that extends
from palatal aspect of maxillary first molars.
There provides stability and are removed
when distalization started.
 Another appliance of pendulum family is
termed the phd appliance. This version
features an all metal design with no acrylic
palate.
If midline expansion screw is to be activated,
a one turn per day protocol is followed for
initially for 28 days.
Because of anchorage considerations,
springs for distalization should be activated
at one side at a time.
Approximately 5 mm of distal molar
movement in 3-4 months.
Retention by quick nance, utility arch.
MINI DISTALIZATION APPLIANCE
Hilgers
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.
Clean and rigid
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 on even desirable.
 Caravo and Testa of Italy.
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
 WILSONS DISTALIZING ARCH
(BIMETRIC ARCH)
Developed by Wilson and Wilson.
Arch is bimetric in that anterior segment
is made from 0.022 stainless steel,
where as posterior segment are
attached to elastic hook in canine
region. An omega shaped stop is located
in premolar area. A 0.010 x 0.045
open wound coil spring is placed
between distal leg of Omega stop and
face bow tube.
 Distalizing force on the molars is produced
by compression of push coil spring
anchored by pull of class II elastics.
Posterior ends of Omega loop should
contact the face bow tubes on maxillary
first molar, and anterior section of arch
should approximate brackets on maxillary
anterior teeth. 5 mm section of 0.010 x
0.045 open wound coul is placed over
end of Williams arch bilaterally.
Advocated sequential use of elastics with
decreasing force values i.e. 5/16 6-OZ in
first week, similar size 4-OZ in 2and 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.
Lower arch should have a stiffer
rectangular arch wire or lingual arc.
 COMPRESSED SPRINGS
Gianelly and co-workers.
Springs made from compressed stainless steel
or NiTi used in conjunction with non-
cooperation based appliances.
NiTi coils are placed on a sectional wire made
from 0.016 x 0.022 stainless steel that
extends from premolar to first molar (second
premolar remains unbracketed). NiTi coil is
activated to about 10 mm o produce 100 gm.
First premolars are anchored by Nance
holding arch.
Coil springs can also be compressed by
placing a sliding gurin lock.
 DEFLECTION OF STRIGHT
WIRE
Gianely and associates.
Author demonstrated distalization of maxillary
molar with 100 gm NiTi wire (0.018 x 0.025 Neo
sentalloy) compressed between maxillary first
premolar and first molar with rimpable stops A
nance holding arch cemented to first premolar is
used as anchorage.
Kalra has developed a TMA arch wire
compressed between maxillary first premolar
and first molar.
Gianelly recommends that distance between
stops should be 5-6 mm longer than space
between bracket and molar tube.
 REPELLING MAGNETIC
APPLIANCE
First and second premolar are banded and an
impression is made. A palatal stabilizing plate is
fabricated and cemented in place. First molar
are also banded. An assembly containing
repelling magnets is placed into the molar tubes
on maxillary first molar and magnets are placed
in a repelling portion facing by ligating a sliding
yoke to an eyelet as premolar.
Activation every two or four weeks.
Not gained wide acceptance because the
magnets tend to be expensive and bulky.
 K-LOOP
Varun Kalra in 1995
Consists of K-loop to provide forces
and movements and Nance button to
provide anchorage.
0.017 x 0.025 TMA wire.
 Each loop of K is 8 mm large and 1.5 mm
wide. The leg of K are bent down to 20o and
inserted into molar tube and premolar
bracket. Wire is marked on mesial end molar
tube and distal of premolar bracket. Stops are
bent in wire 1 mm distal to distal mark and 1
mm mesial to mesial mark. Each stop is well
defined to about 1.5 mm long allowing 2 mm
activation of K-loop.
20o bends produce moments that counteract
tipping moments created by force of
appliance.
Reactivated to 2 mm after six to eight weeks
are reactivation produces a total of 4 mm of
distal molar movement.
Anchorage by nance arch to first premolar.
 SLIDING JIG
Auxillary sectional arch wires used to tip or
move one or a group of teeth in buccal
segments distally without disturbing anteriors.
Have bent in eyelets on each side.
To avoid friction should be made of 0.022
inch round wire and can also be made of
rectangular wire.
Location of intermaxillary hook on the jig,
soldered or bent-in, is on the occlusal area of
anterior eyelet of jig.
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.
MODIFIED NANCE APPLIANCE
Tracy J.Reiner
For unilateral distalization.
Made of 0.036 stainless steel
On Class I side it projects anteriorly like the
arm of Quad helix. This is to resists horizontal
movement that would rotate molar distally.
On Class II side also had an arch bent similar
to Quadhelix with anterior terminous soldered
to first bicuspid band. An 0.020 Omega loop
soldered to anterior end of frame work and
distal end of loop to slide distally as it was
opened for activation.
A 10 mm 0.09 x 0.036 open coil spring I
added to frame work between Omega loop
and first molar band.
First molar band was soldered to 6 mm
0.045 tube with frame work running through
the tube. So that band assembly could slide.
Activated by opening Omega loop to
compare coil spring to a length of 7 mm that
delivers 150 gm force.
Distalization is 0.019 mm per week.
MODIFIED NANCE APPLIANCE
Joseph Ghafari.
Consists of palatal arch attached to
first molar band on normal side and to
first premolar band on Class II side.
Both premolars and molars coil fitted
with molar tubes so that sectional arch
wire with compressed open coil spring
can be used between them.
 JONES JIG
Makes use of open coil NiTi spring to delivery
70-75 g of force. Over the compression range
of around 5 mm.
Modified Nance from one side anchor
premolar to other side premolar is used.
Band first molar and second premolar, attach
double tube on molar and bracket on
premolar.
Insert jones jig into molar tube and activate
the open coil spring by tying a liguature from
anterior hook of premolar bracket.
 MOLAR DISTALIZING
BOW :
Consists of 0.8 to 1.5 mm thick
thermoplastic splint extending into
buccal sulcus. The distalizing bow fits
into anterior slot. Ends of bow fits into
molar tubes (Head gear tube).
To activate the appliance, central
section of bow must be pressed and
fitted into anterior slot. This compresses
the coils and force is transmitted to
molar.
 SPACE REGAINERS :
Howleys appliance with active helical
spring.
Sling shot appliance
Kings appliance.
Clasp ring
To obtain distal movement of mesially
inclined first molar.
 TRANSPALTAL ARCH :
Robert A.Goshgarian of Illinois in 1972.
Lemons and Holmer (1961) have
indicated that in majority of Class II
cases, first molars are rotated mesially
A gain of 1-2 mm of arch length per
side achieved following corrections of
rotations. Partial class II correction
can also be noted.
 Cetlin (1992) stated that distalization of
upper first molar can be achieved by
unilaterally activating the appliance.
Rotation is placed in only one arm of TPA
and then the other arm is rotated into
position, producing distalizing force.
Same adjustment can be made opposite
side 6 to 8 weeks later.
 REMOVABLE MOLAR
DISTALIZATION SPLINT :
Major draw back of removable appliance in that
it requires patient co-operation.
Made of 1.5 mm biocryl in a biostar machine.
If both upper molars are to be moved distally,
splint extends from the area of upper right first
or second premolar to left first or second
premolar. If only one molar is to be moved,
splint extends to the terminal molar on opposite
side.
Two internal clasps are used of retention, and
NiTi open coil springs produces about 220 gm of
distal force molar are fitted with bonded button
or band.
 ACRYLIC CERVICAL
OCCIPITAL APPLIANCE :
H.Margolis.
Consists of acrylic palatal section,
Adams clasp on premolars, labial bow
that overlie incisors for retention and
finger spring against mesial aspect of
first molar.
 Finger springs which are activated in
posterior direction approximately one half of
cusp width, can be made of round or
rectangular wire and when activated excerts
no more than 100-125 gm of force.
Molars tip distally. A 1 mm bite plate is added
to palatal acrylic to disocclude posteriorly.
Appliance is intended to be worn 24 hours a
day, except during needs.
Disadvantage in molar tips distally. However
tipping is less when springs are closer to
center of resistance of molars.
 CRICKETT APPLIANCE :
Victor C.Welt.
Rickett developed and successfully used
modification of Crozat appliance
(Crozat/Rickett).
Embraces essential features of quadhelix but
replacing palatal and lingual bars of upper
and lower appliances with Quad and bi-helix
respectively.
Upper palatal and lower lingual bars are
constructed with 0.032 yellow and 0.038
blue elgiloy respectively. Cribs, clasps and
occlusal rests from 0.028 blue elgiloy lingual
arm from 0.030 yellow and buccal arm from
0.045 blue elgiloy.
 C-SPACE REGAINER :
Move molar bodily without significant
incisor flaring.
Can be used to intrude teeth as well as
to move them distally or sagittally (in
open bite cases).
 Labial framework of 0.036 stainless steel and
an acrylic splint. A closed helix as wide in
diameter as comfort permits bent in the region
of canines, labial framework extends distally to
lie as close to buccal molar tubes as pallible.
An 0.10 x 0.040 open coil spring soldered
immediately distal to helix and 0.028 ball
clasps to retain the appliance. Splint covers the
crown of anterior along with labial frame and
ball clasps. Open coil spring of 13 mm of
length between solder point and mesial end of
molar tube when compressed excerpts 200 gm
of force.
Vertical control is maintained by adjusting the
frame work occlusally or gingivally.
 FIXED PISTON
APPLIANCE
Unless a supplemental :
force is used to
provide a moment that torques the roots
distally, a significant amount of anchor may
be lost as molar relapses to an upright
position.
Maxillary first molar and first premolar bands,
0.036 stainless steel tubing to bicuspids,
0.030 stainless steel wire soldered to first
molar, enlarged nance with 0.040: stainless
steel ire reinforced, 0.055 internal diameter
NiTi open coil spring.
Solder 0036 tubing to buccal and lingual
occlusal thirds of premolar so that they
extend parallel to first molar.
Solder 0.030 stainless steel wires to buccal
and lingual surface of first molar band.
 TENDEM YOKE :
Consists of 0.04 end sections, which
provide rigidity and support intermaxillary
hooks and anterior arch bar of 0.22 true-
chronic for flexibility.
Produce rapid, friction free, 24 hours distal
movement of molars.
Molar tube is 0.018 x 0.025 or 0.022 x
0.028 with 0.045 round tube gingival.
Intermaxillary elastics are worn for 12 hours
a day for distalizing following which they are
removed and head gear is applied at night.
 MOLAR
DISTALIZATION IN
LOWER ARCH :
 LIP BUMPER :
used for molar anchorage, prevention of poor lip
habits and creation of increased space for
mandibular arch.
Made of 0.045 stainless steel that spans the
facial structures of mandibular arch without
contacting teeth and inserted into molar tubes.
Anteriorly wire is covered by plastic tubing or
acrylic shield to hold lip away from incisors.
Force from mentalis muscle is transmitted to
molar, enabling them to move to an upright and
distal portion
 MODIFIED LINGUAL
APPLIANCE :
Unilateral distalization.
Lingual arch from molar on normal
side to premolar on Class II side.
Both premolar and molar are fitted
with tubes so that sectional wire with
compressed open coil spring can be
used to distalize the molar.
 DISTAL JET FOR LOWER
MOLAR :
Used to upring lower molars prior to prosthesis.
Solder a 0.036 tube to premolar band. Parallel
to occlusal plane but below the edentulous ridge
orient tube so that wire with bayonet bend can
slide into tube from distal aspect. Bend a circle
in distal end of this wire and attach it to molar
tube with a screw so that wire and band are held
together but are free to rotate around common
axis.
Used adjustable screw clamp and open coil NiTi.
EXTRA-ORAL
BILATERAL :
 CERVICAL PULL (Low Pull or
Kloehn)
Inpatients with decreased vertical skeletal
dimension.
Restrict forward growth of maxilla and/or to
prevent the forward growth of maxillary
posteriors.
Force is below the occlusal plane producing
both extrusive and distalizing force.
Used in deep bite, hypodivergent bases.
Outer bow longer than inner and bent
upwards so that both point of force
application and line of force lie above the
centre of resistance of molar.
 OCCIPITAL PULL (High
Pull) :
Force above the occlusal plane and is
distalizing and intrusive.
Skeletal or dento-alveolar open bite
and/or steep mandibular plane angle
(hyperdivergent).
Outer bow same length as inner and
bent upwards so that line of force is
above centre of resistance of molar.
UNILATERAL
 Power Arm :
Outer bow is longer and/or wider than
other with wider and longer bow
located on the side and anticipated to
receive greater distal force.
Disadvantage is it also generates
lateral forces which tend to move the
favoured molar into lingual corssbite
and other molar into buccal crossbite.
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.
 Swivel-Offset face bow :
Outer bow is attached to inner bow
through a swivel joint located in an
offset partition on the side favoured to
receive the greater force.
 Spring Attachment face
bow :
An open coil spring is warped around
one of the inner bow terminal and
conventional bilateral face bow. On
the side favoured to receive greater
force.
 CONCLUSION :
There are many advantages and disadvantages of both
the intra-oral and extra-oral methods. Main drawback
of extra-oral approach is patient compliance. This pit
fall has been overcome by the intra-oral appliances but
are not effective as extra-oral appliances.
The need of the hour is an appliance which includes
advantages of both and eliminates disadvantages of
both.
It is imperative on our part to know indication,
contraindication and modifications that are possible
with distalization methods.
Patient selection is of atmost importance and
should not be overlooked. Right appliance for the right
patient at right time. Appliance should be selected for
patient not patient for appliance.
To fight a borderline case distalization is a important
weapon in orthodontists armamentarium .
 REFERENCES :
McNamara and Brudon, New Edition, Page. 343 to 375
and 199 to 211.
Graber and Vandarsadall, 3rd Eidtion, Page. 760 & 761.
Seminars in Orthodontics, 2000.
AJO : 79 : 1981 : 229-249, 1959 : 125-130, 1972 : 61 :
578-602.
Ravindra Nanda : Bio-Mechanics in Orthodontics. Page.
265-281.
JCO : 1991 : 24, 1992 : 25 : 402-404, 1985 : 19 : 30-33,
1992 : 25, 1994 : 28 : 43-49, 1993 : 27 : 74-81, 1995 :
29 : 298-301, 1995 : 29 : 396-397, 2000 : 34 : 32-35.
EJO : 1991 : 13 : 43-46.
Thank you