6.

Distalization of molars

Distalization is a procedure, aimed at moving the teeth in a distal direction so as to

gain space . Kingsley was the first person to try to move the maxillary teeth
backwards in 1892 by means of headgear (Fig 1). Oppenheim advocated that
position of mandibular teeth as being the most correct for an 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 extraoral
anchorage for distalizing maxillary molar. Renfroe in1956 reported that lip
bumper primarily is a device to hold a hyper tonic lower lip away from the teeth.
He observed that reaction of the lip caused movement of the molars sufficient to
change their relationship from Class I to Class II malocclusion .Gould in 1957 was
the first person to discuss about unilateral distalization of molars with extra-oral
force .Graber 1969 extracted second molar to facilitate distalization of the
maxillary molars in selected class II division I malocclusion cases.
(Amit et. al, 2013; Kenneth et. al, 2015; rani et. al ,2016)

Figure(1) Kingsley's headgear (Roberts-Harry and Sandy, 2004)

Molar distalization includes many modalities, these can be either with fixed or
removal appliances and intra- or extra-oral the development of such appliances
where developed with advancements in biomechanics, technology and materials
that make delivery of light and constant force over a wide range of deactivation
possible, the intraoral appliance became more preferable as it reduces dependence
on patients compliance, these intraoral appliances can be either inter- or intra arch.
(chiu et.al,2005; Nada,2005;Antonarakis and kiliaridis ,2008)

Principles of appliance design includes: Minimal loss of anchorage, Ease of use,

Cost, Minimal chair time for placement and reactivation (Amit et al, 2013)

Timing of Distalization

Timing of distalization is very important since molar distalization is recognized to

be most easily accomplished when attempted in the late-mixed dentition stage,
before the eruption of the second permanent molars. Following the eruption of
those second molars, the potential for and the rate of distal molar movement is
seen to decrease.
Gianelly in 1989 and Worms et al in 1996 stated that when the second molars are
present, the treatment time predictably increases since there are two teeth to be
moved distally and when the first molars are moved distally in the late mixed
dentition stage, the procedure is 90% successful and molar correction can be
completed within 4 to 8 months. (Singhal and Garg, 2013)

Armstrong in 1971 suggests that this movement be complete before the eruption of
second permanent molar, Also Bussick and McNamara in 2000 noted in their
study on pendulum appliance that distalization is always preferable before
eruption of second molar because of minimal increase in lower facial height (LFH)
at that stage.
Another study by Kinzinger et al in 2004 evaluating the efficiency of pendulum
appliance for molar distalization related to second molars and third molars
eruption stage concluded that for young patients, the best time to start therapy with
pendulum appliance is before the eruption of the second molars. If 2nd molars are
present then more protrusion of incisors and Buccal drift of the 2nd molars must
be accepted, although Bondemark in 1998 didn’t identify any increase in
transversal arch via distalization with magnates.

Bolla et al in 2002 concluded that in patients treated with distal jet there is a
greater tipping (4.3°) in subjects whose second molar is unerupted since the center
of the resistance moved from trifurcation to more superiorly, but didn’t find any
difference in mean distalization between patients with erupted or unerupted second
molars. In contrast to distal tipping, it seems that anchorage loss is found to be
significantly less (1.7mm vs. 0.9 mm) with less extrusion (1.7 mm vs. 0.5mm)
measured at the first premolars for those subjects whose second molars were
erupted as compared with those with unerupted second molars (Singhal and Garg,
2013; Pratik et. al, 2014 )

Effect of distalization on 3rd molar

Distalization of molars that aimed at somehow creating space in the anterior part
of the arch and preventing premolar extractions, tends to create a space deficiency
in the posterior part of the arch. This may significantly affect the eruption of third
molars. premolar non-extraction approaches often lead to the impaction and
eventual extractions of the third molars. Richardson, for instance, found that in a
group of orthodontic patients who had been treated with non-extraction approach
in the lower arch, 56 % had eventual impaction of the lower third molars. In a later
study, she found once again that in another group of orthodontic patients who had
been treated with non-extraction approach , 54 % had eventual lower third molar
impactions, when compared with only 12 % of a group who had been treated with
premolar extractions. Similarly, Silling found that approximately 68 % of a group
of patients who had been treated with non-extraction approach showed eventual
impaction of mandibular third molars. (Kandasamy and Woods, 2005)

The effect of distislization on maxillary third molars is variable but in general no

distal movement but 4° of tipping is observed and despite this lack of statistical
significance, these positional changes of third molars can lead to impaction. When
adequate space does not already exist in the upper arch and distal forces are
applied to the first molars, the second molars are often driven disto-buccally, with
the Third molars becoming deeply impacted (Fig 2). This occurs essentially
because there is simply not enough tuberosity growth to accommodate all these
teeth in the arch .In addition, third molars that have erupted or are close to
erupting according to Gianelly tend to impede the distal movement of 1st and 2nd
molars. For this reason third molars should be removed when possible
(Papadopoulos et. al , 2004; Kandasamy and Woods, 2005; Singhal and Garg,
2013)
Figure(2) effect of distalization on 3rd molar (Kandasamy and Woods, 2005)

Other considerations for molar distalization (Pratik et. al, 2014 )

1. Growth pattern: Cases showing unfavorable or vertical growth tendency are

contraindicated for distal movements of upper buccal segments as it acts as a
wedge between maxilla and mandible.
2. Degree of Overbite: Distal movement of upper buccal segments is associated
with
spontaneous reduction in the overbite. This advantage in deep overbite cases is
however a disadvantage in Class III cases and open bite cases.
3. Age of the patient: An important factor, affecting even patients whom the
headgear force is of sufficient magnitude and duration, is the dental age of the
patient. Dewel in 1967and Hass in 1970 observed faster rate of molar distalization
in patients in mixed dentition to those in the adult dentition.
4. Presence of other force system: A force system applied for distalization of first
molars maybe negated or augmented but the presence of other force system like
intraoral or elastics, arch wires.

Objective of molar distalization :

1. To reposition mesially migrated maxillary molars which drifted mesially. This
condition may exist unilaterally or bilaterally. Such a procedure may be a part of
interceptive orthodontic procedure.
2. To correct class II dental relationship of no more than half cusp severity and
mild maxillary dentoalveolar protrusion. The mandibular arch may or not requires
orthodontic treatment. The profile of such a patient is normal or slightly protrusive
at the upper lip dur to dental/dentoalveolar protrusion class II patient
3. In class I malocclusion patients, molar distalization may possibly be used to
gain space needed to resolve minor crowding in the anterior segment. Up to 4 mm
of crowding can be resolved with molar distalization

 Indication or contraindication for molar distalization is given by the patient's

characteristics and the degree of movement intensity that needs to be
performed. It is important to bear in mind that due to its own characteristics,
mouth opening is performed on the condylar axis, so that if we need to
distalize one or several molars we must consider the following effects:
1) Distalization produces a downwards and backwards mandibular rotation, in a
clockwise direction.
2) It increases facial convexity angle.
3) It increases anterior facial height, particularly the lower third.
4) Distalization increases the mandibular plane angle with respect to the base
skull.
These effects may be extremely favorable in those patients with deep bite but
counterproductive in patients with open bite so these factors have to carefully
considered when performing distalization. The facial biotype and the patient's
cefalometric features are very important as it is more likely that we produce an
open bite in a dolichofacial patient with an open goniacangle than in a brachifacial
patient with a closedgoniac angle. Careful study of the characteristics and growth
patterns in young patients has to be performed when planning the case.

Indication of distalization

The Indication for molar distalization of maxillary first molar:

1. Unilateral or bilateral dental class II relation

2. Increased overjet (up to 5mm).

3. Increased overbite (deep bite)

4. Midline discrepancy

5. Minimal or non existing dental crowding

6. Patient with early mixed or permanent dentist

7. Patient with upper dentoalveolar protrusion

8. Patient with minimal skeletal problems

9. Normo or hypodivergent patients

10. Patient that do not accept extraction

11.Maxillary first molar mesially inclined

12. Loss of arch length due to premature loss of second deciduous molar
13. Another indication for upper molar distalization is when we decide to extract
permanent second molar(due to caries or other causes) complicated with anterior
overcoming or ectopic canine. In these cases the third molar will occupy the space
of extracted second molar.

Contraindications of distalization

1. Patient that grow vertically

2. Dolichocephalic patients.
3. Patients with tmj problems
4. Patients with openbite tendency
5. Overjet greater than 5 mm
6. In some cases with tongue protrusion