Case Report

Distalization of maxillary molars

using a lever arm and mini-implant
Júlio de Araújo Gurgel, DDS, MSc, PhD1
Célia Regina Maio Pinzan-Vercelino, DDS, MSc, PhD2
Fausto Silva Bramante, DDS, MSc, PhD3
Alan Poy Rivera, DDS4

1Professor and Program

Director, Master in
Orthodontics Program,
University Center of
Maranhão (UNICEUMA),
São Luís, Maranhão, Brazil;
Professor and Program
Director, Program of
Orthodontics, Pontifical
Catholic University Madre
y Maestra, Santiago de
los Caballeros, Dominican
Republic.
2Assistant Professor,
This article describes the orthodontic treatment of a young woman with a Class II
malocclusion and maxillomandibular prognathism. One orthodontic mini-
implant was placed in the posterior area of the palate to provide anchorage for
a transpalatal arch. The force for molar distalization was applied using an elastic
chain from the lever arm inserted on the transpalatal arch to the mini-implant.
Two sliding jigs were applied buccally as a complement for Class II malocclusion
correction. This system created an efficient mechanotherapy for maxillary molar
distalization. The active treatment period was 19 months. Normal overjet and
reduction of maxillomandibular prognathism were obtained, and labial balance

Department of
was improved. Orthodontics (Chic) 2013;14:e140–e149. doi: 10.11607/ortho.604
Orthodontics, University
Center of Maranhão
(UNICEUMA), São Key words: orthodontic mini-implant, Class II malocclusion correction,
Luís, Maranhão, Brazil; molar distalization appliance
Professor, Program of

Orthodontics, Pontifical
Catholic University Madre
y Maestra, Santiago de
los Caballeros, Dominican
Republic.
3Assistant Professor,
Department of
Orthodontics, University
Center of Maranhão
(UNICEUMA), São
Luís, Maranhão, Brazil.
Professor and Program
Director, Program of
Orthodontics, Pontifical
Catholic University Madre
y Maestra, Santiago de
los Caballeros, Dominican
Republic.
4Graduate Student,
Program of Orthodontics,
Pontifical Catholic
University Madre y
Maestra, Santiago de los
Caballeros, Dominican
Republic.
CORRESPONDENCE
Dr Júlio de Araújo Gurgel
R. Cel José Braz, 480 Centro
17501-570 Marília - SP -
Brazil
©2013 by Quintessence
Publishing Co Inc.
T
he distalization of maxillary molars is commonly used for correcting mo-
lar relationships, especially in Class II malocclusions, providing intra-arch
space to correct the dental occlusion. During many years, the main ap-
pliance indicated for molar distalization was facebow headgear (HG), which re-
quires good patient cooperation. As a result of the unesthetic appearance of
HG, the orthodontic literature has presented different maxillary molar distaliz-
ing orthodontic appliance alternatives that use other force systems to induce
orthodontic movement.1–8 The molar distalization appliances more commonly
used to replace HG are pendulum, nickel titanium (NiTi) coils, transpalatal
arches (TPAs), and distal jets.5–8 These appliances exert a distalization force
on maxillary molars, causing distal tipping of the molars, anchorage loss ex-
pressed as mesial movement and tipping of the canines and the first or sec-
ond premolars, and proclination of the incisors. The presence of these side
effects creates an undesirable increase in treatment time.9–11
Temporary anchorage devices (TADs) provide skeletal anchorage, which has
shown superior stability when compared with other dental anchorage modalities.
Among the types of TADs, mini-implants represent the simplest way to obtain an-
chorage for different types of tooth movement, including molar distalization.1,2,4
Mini-implants require placement in a position that favors orthodontic mechanics
while preserving anatomical and dental structures. For this purpose, the associa-
tion or modification of orthodontic appliances is necessary in some situations to
achieve desirable dental movement. This case report presents a maxillary molar
distalization method that combines the use of a mini-implant placed in the pala-
tal posterior area and the TPA joined through an elastomeric chain to produce a
system of forces to distalize the molars, avoiding possible side effects.

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 Case Report

a b c

d e f

g h

Fig 1   Pretreatment extraoral and intraoral photographs.

CASE REPORT

Case summary
The patient, aged 17 years and 2 months, presented for orthodontic treat-
ment. Her major reason for seeking treatment was lip incompetence. Facial
analysis showed a convex profile, proportional facial thirds, obtuse nasolabial
angle, protrusion of the lips, and a normal menton-cervical line. Frontal facial
analysis demonstrated facial symmetry, a consonant smile, filled buccal cor-
ridors, coincident midlines, and lip incompetence (Fig 1).
Analysis of the dental casts showed half-cusp Class II molar and canine re-
lationships. Overjet and overbite measured 5 and 4 mm, respectively. Mild ir-
regularity of the maxillary and mandibular teeth was observed without tooth
loss or significant rotations (Fig 2).

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Case Report Distalization of maxillary molars using a lever arm and mini-implant

a b c

d e

Fig 2   Pretreatment dental casts.

a b

Fig 3  Pretreatment radiographs: (a) panoramic; (b) cephalometric.

The panoramic radiograph demonstrated normal shape and size of skeletal

and dental structures of the jaws. The third molars had not erupted, and the
roots were still in formation. There was no sign of active periodontal disease
(Fig 3a).
Cephalometrically, she had a skeletal Class II relationship (ANB = 4 degrees)
with an accentuated protruded maxilla and a protruded mandible (SNA = 80
degrees; SNB = 84 degrees). The maxillary and mandibular incisors were pro-
clined (UI-NA = 27 degrees; LI-NB = 36 degrees). The vertical cephalometric
values were normal (Fig 3b and Table 1).

Treatment objectives
Based on the initial diagnosis, the following treatment objectives were devel-
oped: (1) correction of molar relationship; (2) correction of canine relationship;
(3) dental alignment; (4) reduction of maxillomandibular prognathism; and
(5) improvement in soft tissue, mainly eliminating the lip incompetence.

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 Gurgel et al
Case Report
Table 1   Cephalometric measurements pretreatment and posttreatment
Measurements Pretreatment Posttreatment
SNA (degrees) 84 84
SNB (degrees) 80 80
ANB (degrees) 4 4
SND (degrees) 77 77
SN-Gn (degrees) 66 66
SN-OP (degrees) 10 13
SN-GoMe (degrees) 34 35
Interincisal angle (degrees) 112 117
UI-NA (degrees) 27 23
UI-NA (mm) 9 5
LI-NB (degrees) 36 35
LI-NB (mm) 8 8
H-line–NB (degrees) 15 15
Pog-NB (mm) 2 2
UL–E-line (mm) –1 –3
LL–E-line (mm) 2 0

Treatment alternatives
To achieve the objectives proposed, three treatment options were suggested
to the patient.

1. Distalization with HG. Treatment of a Class II malocclusion without signif-

icant crowding in the mandibular arch can be performed with distaliza-
tion of the maxillary molars. The Kloehn HG (KHG) was proposed for use
24 hours per day12 in order to obtain molar distalization. However, this pro-
posal was immediately rejected by the patient on the basis that the KHG
has an unesthetic appearance that would cause embarrassment since the
hours of use would have included periods of social activity.
2. Intraoral molar distalization appliance. The patient received the explana-
tion that this type of appliance needs minimum patient compliance to ob-
tain success. However, to retract the anterior teeth and correct the side
effects produced by the distalizing appliance, extraoral devices are recom-
mended. Therefore, actually, some patient compliance would be still nec-
essary, and this dependence could hinder correction of the malocclusion,
increasing the treatment time.9
3. TAD. As previously described in the literature, the distalization of the mo-
lars can be achieved by combining the use of a mini-implant in the palate
and a TPA.7 This system for molar distalization usually generates a force
vector that passes above to the center of resistance of maxillary molars,
creating a moment that results in distal tipping of the roots. To distalize
the molar crowns, Class II elastics are recommended. Therefore, some pa-
tient compliance is still necessary, but the compliance required is reduced
because the roots are already distally tipped by the forces induced by the
mini-implant system. Due to the simplicity of use and esthetic appearance,
the patient chose this system for intraoral molar distalization. The use of
the mini-implant and the TPA seemed to be the most appropriate alterna-
tive to reduce treatment time since, to date, no study has described side
effects related to similar systems.

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Case Report Distalization of maxillary molars using a lever arm and mini-implant

Fig 4 (above left)   Mini-implant in the center of the palate between the maxillary first permanent
molars and modified TPA, assembled with 1.2-mm SS wire welded onto the maxillary first molar
bands and with a hook at the omega loop to attach a power chain.

Fig 5 (above)   Progress panoramic radiograph of maxillary first molars distalized with distal root
inclination.

Fig 6   Sliding jig made with 0.019 × 0.025–inch SS wire.

Treatment progress
A 1.6 × 1 × 6–mm mini-implant (Dewimed) was placed in the middle of the
median palatine suture. In order to increase the distance between the TPA and
the mini-implant, a modification was done in the TPA design, including an an-
terior extension to work like a lever arm. To build the TPA, a 1.2-mm stainless
steel (SS) wire was used, reaching from the maxillary first molar bands to the
mesial surface of the first premolars. A 0.020-inch SS wire hook was welded
onto the anterior portion of the TPA loop (Fig 4). Extraction of the two maxil-
lary third molars was indicated.
A 0.022-inch-slot preadjusted edgewise appliance was placed to initi-
ate leveling and alignment, starting with 0.014-inch NiTi wire, followed by
0.016 × 0.021–inch NiTi thermal activated wire, 0.019 × 0.025–inch NiTi wire,
and 0.019 × 0.025–inch SS wire.
One month after the 0.019 × 0.025–inch SS wire was inserted, the distaliza-
tion system was activated. Medium elastic chains were used, reaching from
the mini-implant to the hook of the TPA, creating a monthly average force of
485 g, measured at each visit with a calibrated tension gauge.
Three months after the start of the distalization phase, a control panoramic
radiograph was taken, which revealed significant distal inclination of the roots
of the maxillary first molars (Fig 5). In order to obtain the distalization of the
crowns, two sliding jigs were adapted at the accessory rectangular tubes of the
maxillary first molars; both were made using 0.019 × 0.025–inch SS wire. The
Class II intermaxillary elastic (3/16-inch) with medium force was used from the
sliding jig to the mandibular first molar and replaced every 48 hours (Fig 6).

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 Gurgel et al
Case Report

a b c

d e f

g h

Fig 7   Posttreatment extraoral and intraoral photographs.

After 5 months of use, the sliding jigs were removed and replaced by Class II
elastics with the same size/force to correct sagittal and occlusal positioning of
the canines. Stripping of the mandibular incisors was performed to eliminate
the tooth size discrepancy and to improve the inclination of the mandibular
incisors.
The total treatment time was 19 months. The fixed appliances were re-
moved at the same time as the mini-implant and TPA. For retention, maxillary
and mandibular bonded canine-to-canine retainers (0.0195-inch coaxial wire)
were used.13,14 The patient was instructed to continue with this retainer for at
least a year, after which the quality of oral hygiene in the area of the retainer
would be reevaluated, and a decision would be made regarding the mainte-
nance or replacement of the retainer.

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Case Report Distalization of maxillary molars using a lever arm and mini-implant

a b c

d e

Fig 8   Posttreatment dental casts.

Fig 9  Superimposition of pretreatment (dotted line) and posttreatment

(solid line) cephalometric tracings.

Results
The posttreatment photographs demonstrate a good facial profile with com-
petent lips (Fig 7). The final occlusion showed a Class I molar relationship on
the right and left sides as well as normal overjet and overbite (Fig 8). The ceph-
alometric superimposition demonstrated reduction of the maxillomandibular
prognathism and improvement of the lip relationship (Fig 9). The panoramic
radiograph showed satisfactory root parallelism (Fig 10).

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 Gurgel et al
Case Report

a b

Fig 10  Posttreatment panoramic (a) and cephalometric (b) radiographs.

DISCUSSION

TADs have allowed innovations in different orthodontic treatments. However,

for the correct utilization of this new type of anchor it is necessary to under-
stand that the biomechanics of orthodontic movement are changed when the
TADs are applied. Also, it should be noted that TADs have been shown to be
effective only for dental movement and are considered as a potential indica-
tion only for orthodontic corrections. In addition, one should consider that the
numeric reference values of the obtained results still need to be replicated
before being considered normal for patients who are treated orthodontically.15
The use of headgear applies various vectors of forces to obtain different
kinds of dental movement. According to the range of force described in the lit-
erature, heavier forces create dental and skeletal effects; however, the smaller
forces are used only for distal molar movement.12 A force of about 200 g on
each molar is used for the distalization of maxillary molars.16 Recently, it has
been observed that the movement of teeth through the anchorage with TADs
is variable and depends mainly on the point of application. The forces should
be smaller when applied directly to the molars, while the forces transferred to
the molars should be higher in value.15
In addition to measuring the force intensity, the direction of the force should
also be observed, confirming the basic concepts of biomechanics. A change
in the anchorage device merits a better understanding of the generated forces
since these components should provide the same force moments. In this case
report, the movement was generated by the application of force between a
midpalatal mini-implant to a hook that was located mesial to the maxillary first
molars. This force vector created a moment that resulted in distalization of the
roots of the maxillary molars. In terms of the force generated, two segments of
elastic chain modules made a force of 850 g. However, in a period of 1 week,
this force was reduced to an average of 485 g, resulting in an average force of
240 g for each molar. This reduction in the amount of force is due to degrada-
tion of the elastomer chain, estimated to be approximately 43% within 1 week
for the brand of elastic chain used.17 Since the distance between the force vec-
tor and the center of resistance of the molar was measured in the computed
tomograph as 4.25 mm, the moment of force for distalizing two molars on each
side can be measured around 2,000 g/mm. Although NiTi springs generate a
constant force, we decided not to use them to avoid any tongue discomfort.
The monthly replacement of elastic chains proved to be sufficient to maintain
the distalization of the roots. This pattern resembled that obtained by the use
of headgear, since the force vector follows the same biomechanical principles.

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Case Report Distalization of maxillary molars using a lever arm and mini-implant

Compared with other methods of intraoral distalization,11 the technique used

in this case report showed no side effects regarding tooth positioning, such as
anterior displacement of premolars and anterior teeth.
Following the initial distalization of maxillary molars, we found a case report
with a similar design to the one presented in the present article, using a larger
number of mini-implants and also a TPA with a lever arm to avoid the side effect
of molar rotation.3 Currently, the clinical application of mini-implants appears
to vary greatly, and there are several differing examples of how to best procure
orthodontic movement in the patient. Regarding molar distalization, the most
frequent proposals suggest using acrylic supports screwed into the anterior re-
gion of the palate and telescopic systems with springs to distalize the molars.4
The alternative method to molar distalization described here, combining a
mini-implant, a modified TPA, and intermaxillary elastics used with sliding jig
is simple, hygienic, and easy to perform. In addition, this distalization design is
versatile because it can be applied in children or adults because it allows the
application of different force magnitudes to move one or two teeth on each
side. For young patients at ages in which the median palatine suture has not
yet fused, it is possible to install two analogous paramedian mini-implants. In
this case report, the Class II intermaxillary elastics associated with the intraoral
SS sliding jig were used in order to increase the crown distalization of the max-
illary first molars. The force vector created by the elastics that pass below the
center of resistance enabled the distalization of the molar crowns. The com-
bination of the mini-implant, modified TPA, and intermaxillary elastics result-
ed in the translation movement of the molars. These results make all of the
aforementioned factors indispensable when obtaining correction of the Class
II dental occlusion presented by the patient. As with any orthodontic appli-
ance, treatment plans must be individualized, and a monthly evaluation of the
applied forces should be performed to allow them to remain effective during
the intervals between visits and to reduce treatment time. One aspect to be
observed is the palatal vault depth because the deeper the palatal vault, the
more root tipping may occur. Nevertheless, mesial tipping of the molar crown
will increase the archwire deflection, increasing the distalization of the maxillary
teeth, but the occlusal molar relation will be unstable.18 Clear communication
with the patient is important to improve compliance with the intermaxillary
elastics. One important point to discuss with the patient is that the time of
treatment is reduced when the intermaxillary elastics are used for Class II mal-
occlusion correction.
Furthermore, we reinforce the importance of the extraction of the third mo-
lars in order to facilitate the movement of the first and second molars. The
presence of the third molars in an advanced stage of development leads to an
alveolar position that is closer to or located in the oral cavity. The force levels
that we proposed were effective for the distalization of two molars on each
side, but may be considered ineffective for the movement of another tooth.
Increasing the average level of force in order to promote movement of the
third molars could substantially increase the force load on the mini-implant,
compromising its stability.
It is important to note that the level of force initially applied on the mini-
implant is well above the recommended amount.19,20 However, because the force
was generated by an elastomeric chain, it must be emphasized that the amount
of applied force is significantly reduced within the first hours after installation,
resulting in a force level that is compatible with those indicated for mini-implants.
The results observed in this case report reveal that adherence to biome-
chanical principles appear to be a key factor in the proper usage of TADs
as treatment tools. In cases in which it is not possible to favorably position
the TAD in regard to its proper biomechanics, TAD use is not indicated. In

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 Gurgel et al
Case Report
addition, the design of the orthodontic appliance to be used in conjunction
with the TAD should be simple, comfortable, and effective in order to result
in an efficient orthodontic correction. Regarding the biomechanics details, it
becomes clear that the initial distal inclination of the first molar roots yielded
favorable traction and locking of the rectangular steel arch. As a result, retrac-
tion of the maxillary teeth and reduction of overjet were obtained.18
This alternative use of mini-implants is indicated to replace HG in the cor-
rection of dental problems, and its use can also be suggested in Class II rela-
tionships that need a great amount of distalization.

CONCLUSIONS

In this case report, an alternative method to molar distalization, combining a

mini-implant, a modified TPA, and intermaxillary elastics used with sliding jigs,
was presented for dental correction of Class II malocclusions. The association
of these appliances allowed avoidance of the use of HG and other distalizers
that could promote undesirable dental movements of anchorage teeth. The
use of this device was demonstrated to be effective because it corrected the
malocclusion and was easily fabricated, comfortable to use, esthetic to the
patient, and easy to clean. The design of the arch can be customized to suit
biomechanical needs, generating moments for different amounts of distaliza-
tion of the molars in order to reduce overjet.

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