 MOLAR DISTALISATION

 INTRODUCTION
 In the early 90’s, non compliance therapies in various forms have become more prominent than ever
before. One of the non compliance therapies and fairly recent concept is the MOLAR DISTALIZATION
which has been effectively used in the correction of malocclusion. Advances in mechanotherapy and
changes in treatment concepts have reduced or minimized the need for extraction in severe
discrepancies. Various techniques are currently employed in non extraction therapy in the treatment
of a malocclusion. Early cephalometric studies have showed that little or no distal movement of
upper molars was produced by class II elastic treatment of that era.
 The head gear was reintroduced as a means of moving the upper molars back. patient compliance
plays a major role in success of head gear therapy. An appliance system independent of the patient
cooperation was the need of the hour and then evolved the molar distalizers.

 HISTORY
 The extraction/non extraction debate from the Angle era to the present day orthodontics does not
define an absolute indication for a specific treatment plan. Angle strongly believed in retaining teeth
provided by nature and molding the facial form through occlusion. Angle’s unweilding allegiance to
non extraction therapy was based on his own specific knowledge dentofacial growth and
development and to the concepts of facial beauty harmony.
 Case argued for therapeutic extractions in orthodontia based on the fact that inherited
inharmonious in contiguous structure over which we have no control makes it impossible for us to
place all the teeth in the arch without fulfilling the designs of an inherited deformity.
 Angle’s disciples like CHARLES TWEED and RAYMOND BEGG, BEGG, supported the need for extractions in
orthodontics. The dogma was “if in doubt extract” which led to blind extractions of the premolars
resulting in ‘dished in faces’. Gradually the awareness of soft tissue profile and function occlusal
concepts were introduced into orthodontics which put the mind of the orthodontist into thinking
twice before an extraction.
 Now we are at a soft spot to decide, to extract or not to extract and the dogma is “when in doubt do
not extract”. Presently the swing of pendulum towards the non extraction protocol.
 A boon in the hands of the orthodontist. It is important to understand the indications, the
biomechanical concepts and the contra indications of the Molar distalization appliance system.

 THE INDICATIONS FOR MOLAR DISTALIZATION

o In non-extraction treatment of Class II malocclusion cases.
o In low & average mandibular plane angle cases.
o In class I skeletal pattern cases.
o In patients with mild arch length discrepancy.
o In cases where the upper permanent molars have moved mesially due to early loss of
deciduous molars.
o In patients where the second molars extractions are planned or where it has not yet erupted.
o In second molar extraction cases where the third molars are well formed and erupting
properly.
 CONTRAINDICATIONS FOR MOLAR DISTALIZATION
o In high mandibular plane angle cases.
o Skeletal and Dental open bite
o Class II & III skeletal pattern
o Severe arch length discrepancy patients.
 CLASSIFICATION
 EXTRA ORAL
o Head gears
o Cervical pull
o Combination pull
o Kloehn.
 INTRA ORAL
o Removable appliances
o Fixed appliances
 Buccaly acting
 Palatally acting

The appliances used for molar distalization can be divided into

Removable appliances and Fixed appliances.
 Removable appliances are:
o Extra oral traction
o Removable appliances with finger springs
o Sliding jigs with intermaxillary elastics.

 The fixed appliances are

 Intramaxillary appliance
1. Wislons 3D appliance
2. Repelling Magnets
3. pendulum appliance
4. Niti based appliances : archwires – single loop, double loop; Compressed coil springs
5. Jones jig
6. Distal Jet
7. Fixed piston appliances
8. IBMD
9. K-loop
10. Franzulum appliance
11. First class appliance
 Intermaxillary appliance:
1. Herbst appliance
2. Jasper Jumper
3. Eureka Spring
4. Klapper superspring
 SAS supported distalization:

 EXTRA ORAL FORCES

o One of the earliest methods of molar distalization introduced and proved to be effective was
by extra oral forces employing use of the head gear.
o Components of Head Gear:
 Force delivering Unit:
 Force Generating Unit.
 The Anchor Unit:
 SELECTION OF HEADGEAR:
 Headgear anchorage location:
location: location of the anchorage unit determines the type of force that will
be applied to the unit. The relation of the force to the Cres of the unit to which it is applied
determines the effects that will be produced by the orthopedic force.
 High pull headgear:
headgear: this applies a superior (intrusive) and distal force to the maxilla and the
maxillary dentition.
 Cervical pull: this produces an inferior (extrusive) and distalising force on the maxilla.
 Combination headgear:
headgear: no moment is produced and a distalising force is applied to the maxilla.
 Since the Cres of the molar is located in the mid root region, force vectors above this point will result
in a distal root movement. Forces below this point will result in a distal crown movement. Similar
considerations apply to the maxilla.
 TYPES OF HEADGEARS:
 CERVICAL HEADGEAR:
 This was first introduced by SILAS KLOEHN in 1947. It is the most commonly used facebow in clinical
practice. Typically it is used in growing patients with decreased vertical dimension. The purpose of
the facebow is to restrict the forward growth of the maxilla. The vector of force is below the occlusal
plane producing both extrusive and distalising effects.

 Effects of cervical headgear:

o to erupt the entire upper jaw
o tends to move the upper jaw distally
o Steepen the occlusal plane.
o Expansion of the upper arch.

 when the outer bow is bent downwards:

 Forces that are produced are
 Positive moment on the occlusal plane is seen that tends to steepen the occlusal plane since the pull
is below the Cres.
 Extrusive force and a distalising force.
 When the outer bow and inner bow are in the same level,level, no moment is produced and there is a
net distalising and extrusive force.
 Advantages
 Direction of pull is advantageous in treatment of short face class II maxillary protrusive cases with
low MPA and deep bites.
 Disadvantages:
 It normally causes extrusion of the upper molars. This movement is seldom desirable except in
patients with reduced lower anterior facial height. It is contraindicated in patients with steep
mandibular planes and in open bite cases.

 Long term study on cervical headgear:

 Melsen et al in AJO 2003 studied
studied the intramaxillary molar displacement 7 years after treatment with
Kloehn headgear and cervical traction.
traction. Two groups of 10 patients were studied. In one group, the
outer bow was tilted upward by 200 and in another group, it was tilted down by 20 0. In the group
that had the outer bow tilted downwards, molar correction was faster. In both the groups, the
maxilla was moved backward and downward. A strong tendency of the molars to return to the key
ridge was demonstrated, and there was no evidence that the Class I relationship obtained by
extraoral traction was more stable than that obtained by functional or intramaxillary appliances.
 OCCIPITAL HEADGEAR:
 The occipital headgear consists of a headstrap which fits over the occiput of the head. The force
generated by a high pull (occipital) has both distalising and intrusive forces since the force is exerted
above the occlusal plane. Such forces are used in conditions where vertical control of the molars is
important. As growth guiding appliance, a high pull headgear can decrease the vertical development
of the maxilla, thereby allowing for autorotation of the mandible and maximizing the horizontal

expression of mandibular growth.

 b. occipital pull with force passing through Cres:- There is no moment that is created and hence
there is no change in the cant of the occlusal plane. Intrusive and distal components of force are

produced.
 c. occipital pull with long outer bow( force posterior to Cres):- The force system at the unit’s Cres
has a moment that tends to steepen the occlusal plane. Intrusive and distalising forces are produced.

This system might be required in class II open bite patients.

 Advantages:
 These headgears can be used in patients with steep mandibular planes and in cases wherein
mandibular growth is more vertical than horizontal. They can also be used in certain open bite cases
caused due to excessive eruption of buccal teeth.

 COMBINATION HEADGEAR:-
 Combination headgears have both occipital and cervical traction springs. This is perhaps the most
versatile type because the pull can be readily controlled by selecting the force level of the springs and
by controlling the length of the outer bow. For distal translation of the upper posteriors, a distal
traction is needed that passes through the Cres, neither above nor below. The combination type
headgear will allow a distal force straight through Cres by having equal occipital and cervical
components on the outer bow, which is angled upwards to allow the force to pass through the Cres.

 Based on occlusal plane requirements:

o Action desired Outer bow angulation
o distal force and flattening - outer bow above Cres
o distal force and steepening - outer bow below Cres
o distal force and no moment- outer bow at Cres

 TUBE PLATES:-
 Alain Benauwt (JCO 1972) explained the use of a removable appliance for distalizing the molars. The
appliance was originally devised by G.Vienne and later produced by A.Lorette.
 The appliances were introduced as the appliances with wires sliding in tubes.
 THE PRINCIPLE

 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 in the fixed part of the appliance and the other in the
removable part.
 THE APPLIANCE:- The movable part has an adams clasp and two parallel tubes embedded for the
molars to be moved distally. The stationary part contains the other clasps for the retention of the
plate and one tube which contains the other end of the horse shoe shaped active wire.
 ACTIVATION: Using the 139 plier, the wire coming out of the tube embedded in the stationary part is
bent, which makes the movable part slide distally.
 ADVANTAGES:- 1) The appliance is said to have a good retention as the movable part also
contributes to the retention.
 2) Unwanted displacement of teeth is minimized due to the clasp as it avoids molar rotation.
 3) Possible to add an extra oral appliance to support and reinforce stationary part. Progressive
expansion of the arch is also possible by changing the angulation of the tube in relation to saggital
plane. 4) Repair is easy.
 DISADVANTAGE:- A delicate appliance, since the two wires holding the movable part should do so
without binding.
 3. THE CETLIN APPLIANCE:- JCO 1983 Cetlin and Tenhoe

 The appliance involves a combination of extra oral force in the form of head gear and an intraoral
force in the form of a removable appliance.
 The Cetlin appliance utilises a removable appliance intraorally to tip the crowns distally and then an
extraoral force to upright the roots. So the intra oral removable appliance can be called the crown
mover while the extra oral force, the root mover.
 ANCHORAGE: The anchorage for the removable appliance is by proper adaptation to the palate, an
acrylic shield around the four maxillary incisors and a modified adams clasp on the first premolars.
 THE EXTRA ORAL FORCE: The extra Oral appliance is a headgear which is inserted into molar tube.
The headgear used is generally cervical or a high pull, depending on the usual consideration of the
skeletal pattern.
 THE APPLIANCE: 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 movement).
 THE FORCE APPLIED:- In the removable appliance, the spring is activated only 1 to 1.5 mm, mm,
measured along the occlusal of the molar and it supplies force on the molars of only 30 gms. gms. The
springs are placed as far gingivally as possible to minimize crown tipping and to cause molar
movement without irritation.
 The extra oral head gear on the other hand exerts a 150 gm force per tooth and is used to control
root position. The headgear is adviced to be worn for 12-14 hours/day.

 ACRYLIC CERVICAL OCCIPITAL APPLIANCE ACCO:- Developed by H.margolis.

 IT consists of acrylic palatal palatal section ,modified adams clasp on the Ist PM ,labial bow across
incisors for retention and finger spring against mesial aspect of first molars .
 The finger springs are activated approximately one half a cusp width in posterior direction,it can be
made of round or rectangular wire ,force applied of 100 – 125 gm .1 mm bite plate to disocclude the
posteriors. 24 hour wear is required.
 In original design the labial bow was bent to include helices between lateral and central incisors.
 A straight pull headgear or northwest headgear was inserted into helicesand worn night time ,only
one finger spring for one molar and for bilateral two appliances were needed
 ADVANTAGES: 1) Constant acting force enhancing rate of molar movement
2) Relative comfort easy to wear 3) Effective for asymmetric distal movement
 DISADVANTAGES:-
1. Tips crown distally ( less when close to Cres of molar)
2. High pull headgear in conjunction to ACCO (Cetlin,Tenhoeve)
3. Anchorage loss (overjet measured each visit, if anchorage loss exceeds 2 mm labial bow removed
and bracket the incisors ,100 gm class II elastics placed with a sectional archwire.
4. To control elastic reaction force lower arch anchorage controlled by lip bumper

 INTRAMAXILLRY APPLIANCES
 WILSON’S RAPID MOLAR DISTALIZATION
 Advocated by William L. Wilson & Robert C.Wilson (1984 JCO) under modular orthodontics.
 The Wilson treatment achieves molar distalization without extra oral forces.
 THE CONCEPT:- Newton’s' 3rd law of motion states that 'for every force, there is an equal and
opposite force', (i.e.) for every moment, there is a counter moment.
 Implicit in Newton’s' law is the concept that control of counter moments increases the efficiency of
the moment of force. Modular orthodontic units have been designed to control countermoments,
eliminate 'round trips', and reduce headgear use.
 DESIGN OF APPLIANCE:- Wilson advocates maxillary bimetric distalizing arches (BDA) and a
mandibular three dimensional lingual arch. The bimetric arch produces a coil spring action against
the molars and producing an anterior counter moment against the incisors, which is controlled by

the wearing of class II elastics.

 These, in turn, react with a 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 is controlled by 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 countermoments and produce a relatively friction free,
rapid distalizing of molars; without headgear and with preservation of mandibular arch integrity.
 Wilson's Schedule for Maximum Mandibular Anchorage
 6 ounce elastics for 5 days. 4 ounce elastics for 5 days and 2 ounce elastics for 11 days.
 For minimal mandibular anchorage:
anchorage:
 6 ounce for 10 days, 3 ounce for 11 days.

 REPELLING MAGNETS: Anthony A. Gianelly (AJO 1989) :-

 Design:- Nance appliance extends anteriorly to the incisor segment by means of an 0.045-inch wire
soldered to the lingual aspect of the premolars. The acrylic component is placed against both the

palatal vault and the incisors.

 Bilateral distal extensions (0.045-inch wire) with loops at the end are soldered to the labial aspect of
the premolar bands so that the loops approximate the molar tubes.
 Anchoring the modified Nance appliance to the first premolar encourages the distal drift of the
second premolars that normally occurs as first molars are moved posteriorly.
 The modified Nance appliance serves two functions:
1. Activation of the magnets
2. Contains the reaction force arising from the action of the magnets.
 Molars were moved distally 2.0 mm while the premolars moved anteriorly 2.1 mm. When 2 nd molars
were not present, the fastest molar movement was observed and Class I molar relationships were
attained within 2 to 5 months.
 Disadvantages :
1. Magnets tend to be expensive and bulky.
2. Magnetic force dissipates rapidly with increasing intermagnet distance.
3. Requires frequent recall reactivation appointment.
4. Because of these drawbacks, Darendeliler has concluded that magnets offer no
advantage over conventional systems in molar distalization.

 PENDULUM APPLIANCE:- JAMES J. HILGERS, JCO 1992

 The Pendulum Appliance is a hybrid that uses a large Nance acrylic button in the palate for
anchorage, along with .032" TMA springs that deliver a light, continuous force to the upper first
molars without affecting the palatal button. Thus, the appliance produces a broad, swinging arc— or
pendulum— of force from the midline of the palate to the upper molars.

 Fabrication:- The right and left Pendulum springs, formed from .032" TMA wire, wire, consist of a
recurved 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 close to the center of the palatal button as possible to maximize their
range of motion, to allow for easier insertion into the lingual sheaths, and to reduce forces to an
acceptable range.
 The anterior portion of the appliance can be retained in place with occlusally bonded rests or
soldered to bands on either the deciduous molars or the first and second bicuspids. The Nance button
should be made as large as possible to prevent any tissue impingement. It should extend to about
 5mm from the teeth, to avoid the highly vascular cuff of tissue near the teeth and to allow adequate
hygiene.
 If expansion of the upper arch is needed, a midpalatal jackscrew can be incorporated into the center
of the Nance button . The screw is activated one-quarter turn every three days, after a week or so for
patient adjustment, to produce a slow, stable expansion. This version is called a "Pend-X".
"Pend-X".
 Preactivation and Placement:- The springs should be bent parallel to the midline of the palate. About
one-third of this overactivation is lost in placement, and the remaining pressure is tolerated easily by
the patient. Once the appliance is cemented in place, each Pendulum spring is brought forward with
finger pressure, the mesial end of the recurved loop is grasped with a Weingart plier and the spring
is seated in the lingual sheath. . Distal pressure holds the spring in the sheath quite effectively, but an
elastic "O" ring can be used to secure it.
 As the molar is driven distally, it moves on an arc toward the midline of the appliance— in other
words, toward crossbite. This tendency can be counteracted by opening the adjustment loop slightly
to increase the expansion and molar rotation. Distal root tip can also be produced by adjusting this
horizontal loop on the Pendulum spring. Tipping back the recurved portion of the spring at the loop
causes a more direct distal movement of the molars.
 Reactivation: The spring is reactivated by pushing the centre of helix distally toward the midline with
a bird beak plier.
 Stabilization: Molars must be stabilized in their new distalized positions or they will rapidly drift back
mesially. It is also important to move the buccal segments into a Class I relationship to harness the
full advantages of the appliance. The molars can be stabilized in any of four ways:
1. The Nance portion is removed and a full upper fixed appliance is bonded. An upper utility
arch holds the molars back with the incisors as anchorage.
2. After removal of the Pendulum Appliance, a smaller, easier-to-clean Nance button ("Insta-
Nance”) is placed.
3. The entire upper arch is bonded and a continuous archwire with omega loops mesial to the
upper first molar tubes is placed.
4. A headgear is worn.
 Drawbacks of PA: 1) The pendulum appliance not only drives the molars distally, there is also a
slight lingual tipping. 2) Causes the anterior bite to open 3) Not very easy to fabricate.

 MODIFICATIONS IN PA:- SCUZZO JCO 1999 Nov

 The Modified Pendulum:
Pendulum: M-Pendulum.

 In the original design by Hillgers,

Hillgers, adjustable loop was distally oriented to compensate for the
tendency toward crossbite during distalization.
 M-Pendulum was designed by reversing the loop to the mesial to provide bodily movement of both
the roots and crowns of the maxillary molars, rather than tipping or rotation. After some
distalization has occurred, the loop is reactivated simply by opening it.
 Pendex-x:- If expansion of the upper arch is required then midpalatal jackscrew can be used, this
version of the appliance is called “Pendex-X” it can be opened at a rate of one quarter turn every
three days to produce slow and stable expansion.
 A Modified Pendulum Appliance for Anterior Anchorage Control:- PABLO ECHARRI JCO 2003
 In cases of extreme Overjet or where anchorage is critical, such as with reduced periodontal support,
the modified M-Pendulum was used with four removable arms, for both the first and second molars.
The internal diameter of the four stainless steel tubes embedded in the acrylic corresponds to that of
the removable TMA arms.
 The following case needed distalization only of the upper right first and second molars. The fixed left
spring was made with stainless steel wire for anchorage. The two removable right springs were
made with TMA wire


 Since the Pendulum Appliance drives the upper molars distally (with slight lingual tipping) quite
rapidly, there is a tendency for the anterior bite to open. This open bite generally corrects itself in
brachyfacial patients, but it can be a problem in dolichofacial types

 SCUZZO JCO 2000 April:- A further modification of the M- Pendulum appliance was made by using
removable TMA arms that can be reactivated outside the mouth.

 STUDIES EVALUATING PA
1. Ghosh and. Nanda. (AJO 1996)
2. Friedrich K. Byloff (1997 AO) part 1 & Part 2
3. Bussick & McNamara, AJO 2000March
 Ghosh and. Nanda. (AJO 1996) evaluated the effect of Hilgers PA on 41 patients , mean age 12 years
and 5 months. After molar distalization was completed and the pendulum appliance removed, a
utility arch was placed to prevent relapse.
 DENTAL EFFECT:-
 Sagittal Plane
 The correction of the Class II relationship was achieved by a mean maxillary first molar distalization
of 3.37 mm. Average distal tipping of 8.36°occurred in 1st molar. The second molar teeth were
distalized to a mean of 2.27 mm,and tipped distally 11.99°. There was a statistically significant
correlation between the amount of distalization and the amount of first molar tipping.
 Vertical plane
 The vertical change in molar position was insignificant. There was a mean intrusion of 0.47 mm in
second molar position
 Transverse plane
 The transverse width at the maxillary second premolars increased by 1.95 mm as they drifted distally
into a wider part of the arch.
 The arc described by the spring during its distal movement causes a mesiobuccal rotation instead of
distobuccal rotation. The width between the mesiobuccal cusps of the right and left first molar teeth
increased by 1.40 mm, whereas that between the distobuccal cusps showed no increase. The second
molar teeth also showed an expansion of 2.33 mm between the mesiobuccal cusps.
 Distalization of the maxillary first molars with this appliance therefore causes both distal as well as
buccal tipping of the second molars. The effect of distalization on the maxillary third molars was
extremely variable. No patient showed more than half of root formation on the third molar teeth,
and only the crowns were visible in most radiographs. The third molars showed a net distal tipping of
2.49°, but an insignificant amount of horizontal or vertical change in position 0.19 mm distalization
and 0.22 mm intrusion.

 Anchorage loss & effect on anterior segments:-

 Loss of anchorage was measured at the first premolar teeth. For every millimeter of distal molar
movement, the premolar moved mesially 0.75 mm.
 The overjet increased by 1.30 mm and the overbite decreased by 1.39 mm as a result of treatment.
The maxillary central incisor was proclined an average of 2.40° relative to the SN line.
 The upper lip protruded 0.31 mm and the lower lip protruded 0.95 mm relative to the E plane.

 Effect of eruption of the maxillary second molar:

 There were no statistically significant differences in maxillary first molar movement, as well as
anchorage loss between the group of 18 patients who had erupted maxillary second molars and the
23 who did not, indicating that the eruption of maxillary second molars had minimal effect on first
molar distalization.

 Skeletal effects with the pendulum appliance :

 The pendulum appliance caused insignificant changes in the cant of the palatal and occlusal planes.
The mandibular plane, on the other hand, showed a small backward rotation of 1.09° with
treatment, which caused a decrease in the overbite by 1.39 mm.
 Because there was no vertical change in the maxillary molar position and only an extrusion of 0.5
mm in mandibular first molar position, most of the backward mandibular rotation was caused by
distalizing the maxillary molar "into the wedge." The lower anterior face height, as a result,
increased by 2.79 mm.

 Effect based on MPA

 The patients in the sample were arbitrarily divided into three groups, based on their initial Frankfort
horizontal to mandibular plane angle (FMA) measurements.
 There was a trend for greater increase in FMA in group with FMA greater than 25°.
 Patients with high mandibular plane angles showed posterior mandibular rotation and increase in
lower face height, 4.13 mm as compared to 1.97 mm in average MPA group. The increase in the
lower face height as a result of molar distalization, was more than double in high angle group (4.13
mm) than in average group (1.97 mm).
 Friedrich K. Byloff (1997 AO) part 1 studied, the dental and skeletal effects of the pendulum
appliance, applying 200 to 250 g of force to the molars in 13 patients (age range 8 years to 13 years
5 months) by means of cephalometric radiographs.
 This study suggest that the pendulum appliance is effective in moving the maxillary first molars
distally at a mean monthly rate of 1.02 mm using an initial force of 200 to 250 g in a mean period of
4 months.
 Distal molar movement, molar and incisor tipping:
 The pendulum appliance produces 3.39 mm ±1.25 mm distal molar movement with a mean
bimolar intrusion of 1.17 mm ± 1.29 mm. This positive finding can be related to prevention of
dentoalveolar vertical growth by the rigid bonded appliance.
 Molar distal tipping of 14.5° ± 8.33° occurred. The trajectory of the TMA springs may account for the
excessive tipping found in this study. Maxillary expansion is possible for transverse deficiencies in
combination with distal molar movement. The pendulum appliance does not create dental or skeletal
bite opening.
 Anchorage loss: Second premolar anchorage loss found in this study was 1.63 mm (±1.37 mm) i.e.
29 %. Distal molar movement represented 71% of the space opened between molars and premolars.
Incisor anchorage loss was minimal
 Friedrich K. Byloff (1997 AO) part II:
 In this study, the appliance was modified by incorporating an uprighting bend into the distalizing
spring during the second phase of treatment to avoid excessive distal tipping of the maxillary molars.
Treatment changes were analyzed and compared with the previous study. Due to the initial
moderate dental transverse deficiency, 8 of the patients required maxillary expansion of 2 to 4 mm.
 Appliance design and activation:
 The major difference was the incorporation of the molar uprighting bends. An expansion screw was
added to the PA in 8 of the subjects who required 2 to 4 mm of transverse development; the
appliance was activated every seventh day to achieve a slow rate of expansion.
 Active treatment in this study, contrary to the previous one, consisted of two phases.
o 1. Distal molar crown movement: Molar distalization was done until an overcorrected Class I
relationship was obtained.
o 2. Molar root up righting: The appliance was modified by adding a bend to the spring design
to upright the molars by moving the roots distally.. The moment created was expected to
upright the molars. The springs were left slightly active in the sagittal plane to maintain the
position of the molar crowns. The appliance was left in place until the molar crown seemed to
be sufficiently uprighted.
 Treatment time:
 Mean total experimental time using the PA was 27.25 ± 7.12 weeks (6 months 3 weeks ± 7 weeks).
 1st phase of treatment, ( obtaining a super Class I relationship) the distal movement phase, took
16.45 ± 6.67 weeks.
 2nd phase -- to upright the maxillary molars required another 10.9 weeks.
 Thus the total treatment time was increased by 64.1%.
 Distal molar movement & molar tipping:
  The percentage of molar movement compared with total space opening decreased from 70.92 % to
64.16. Rate of movement was between 0.69 mm ± 0.29 mm and 1.20 mm ± 0.74 mm per month,
depending on the rate of uprighting. During the uprighting phase, the average monthly distal
movement of the apex was 1.01 mm ± 0.57 mm.
 Second molar eruption stages: In both study the position of the second molars didn’t influence the
amount of distal molar movement or premolar or incisor anchorage loss.
 Intrusion—extrusion: Increases in the premolar and incisor extrusion and decrease in molar intrusion
when compared with the first study might be a result of the vertical reactive component of the
uprighting bend.
 Anchorage loss: The price for more space opening and distal molar crown movement, and especially
for more root movement and reduced final tipping of the molars, was increased total treatment time
and 0.61 mm more anchorage loss at the premolars and 0.62 mm at the incisor edge level.
 The effects of the original pendulum appliance were not significantly changed by the incorporation
of the uprighting bends, although slightly more anchorage loss was noted on the maxillary incisal
edge.

 BONE ANCHORED PENDULUM APPLIANCE

 Screw inserted in the anterior paramedian region of the median palatal suture, 7-8 mm posterior to
the incisor foramen and 3-4 mm lateral to the median line. A 1.3 mm diameter drill is used to

maintain primary stability of the screw.

 Distalization appliances based on NiTi wires and coils:-
 Superelastic coils
 Superelastic archwire: single looped, double looped
 SUPER ELASTIC NiTi COILS
 Anthony A. Gianelly (AJO 1991) used Japanese NiTi super elastic coils, exerting 100 gm of force, force,
compressed against the maxillary first molars and moved the molars distally 1 to 1.5 mm/month.
mm/month.
 Coils are used in conjunction with a vertically slotted (0.020-inch) fixed appliance.
 A passive 0.016”x0.22-inch wire with stops that abut the distal wings of the premolar brackets is
inserted to ensure that the wire cannot move past the first premolars, thus placing the reaction force
on the Nance appliance. Coils are placed on the wire between the first premolars and the molars.
 The coils are activated 8 to 10 mm by compressing and maintaining them against the molars by
crimpable hooks or Gurin locks.
 Anchorage: A Nance-type appliance was cemented onto the first premolars. The appliance extends
from the incisors to the molar area and a bite plate is added to the incisal portion to disclude the
posterior teeth slightly
 Anchorage enhancement:
enhancement: To enhance anchorage further, a 0.018-inch uprighting spring is placed in
the vertical slot of the premolar brackets, directing the crowns distally.
 Class II mechanics are used only when anchorage loss is at least 1 mm. When Class II elastics are
attached, a rectangular wire with 10° of incisor lingual root torque is inserted in the mandibular arch
to maintain lower incisor position.
 100 gm superelastic coils can be used successfully in patients with Class II malocclusions to move
molars posteriorly at the rate of 1 to 1.5 mm/month with little or no cooperation from the patient.

 SUPER ELASTIC NiTi WIRES:-

 The use of shape memory, superelastic Nickel Titanium wires in distalizing the molars have been
discussed by Ranieri & Antony A.Gianelly in 1992.JCO
 FABRICATION : Gianelly used a superelastic NiTi arch wire here.
 A 100 gm Neosentalloy wire with regular arch form is placed over the maxillary arch. The
superelastic NiTi wire is an 0.018 X 0.025 inch wire that also applies 100 gm of force.
 The wire is 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 buccal tube
 C. Between the lateral incisors and canines

 A stop is then crimped on the arch wire at each of the posterior marks and a hook is then added for
inter-maxillary elastics between the lateral incisors and canines.
 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 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 longer than the available space, the excess will be deflected gingivally into the buccal fold.
 ACTION OF THE WIRE/APPLIANCE: The distalization of the molars occur as the wire returns to its
original shape, exerting a distal force of 100 gms against the molars and a reactionary mesial force
on the first premolars, canines and incisors. There is also a tendency for the premolars to move
buccally.
 THE ANCHORAGE:- The anchorage can be controlled by
 a. Placing a 100-150 gm class II elastics against the first premolars. (or)
 b. Placement of hooks between the lateral incisors and canines (or)
 c. A Nance appliance cemented to the first premolars.
 THE ADVANTAGE OF THE APPLIANCE:
 1. The appliance distalizes the molar at the rate of 1-2 mm per month with little loss of anchorage.
 2. The Neosentalloy wire is easy to insert even after all teeth have been bracketed or banded.

 Giancotti, & Cozza (JCO 1998 April) used double loop for simultaneous distalization of both molars.
 Superelastic nickel titanium wires have been found as effective as other means in producing distal
movement of the maxillary first molars. When the distalization is carried out before the second
molars have erupted, it can reliably produce 1-2mm of space. Once the second molars have erupted,
 however, the distal movement can be more difficult and time-consuming, and loss of anchorage is
likely. Author used Nickel Titanium Double-Loop System for Simultaneous distalization of First and
Second Molars.
 Appliance Design: The mandibular first and second molars and second bicuspids are banded, and
the remaining mandibular teeth are bonded. A lip bumper is placed to prevent any extrusion from

the use of Class II elastics.

 The maxillary molars and bicuspids are banded, and the anterior teeth are bonded.
 An 80g NeoSentalloy archwire (regular mandibular archform) is placed on the maxillary arch and
marked distal to the first bicuspid bracket and about 5mm distal to the first molar tube . Stops are
then crimped in the archwire at each mark (distal to 4 and 6)
 Two sectional nickel titanium archwires (one for each side) are prepared by crimping stops distal and
mesial to the second bicuspids and about 5mm distal to each second molar tube.
 Uprighting springs are inserted into the vertical slots of the first bicuspid and Class II elastics are
placed

 DISTAL JET : Distal jet was designed by Aldo Carano & Mauro in 1996.
 Appliance Design: Bilateral tubes of .036" internal diameter which is attached to an acrylic Nance

button. A NiTi coil spring and a 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
bands on the second premolars.
 Components:
 1. The Transpalatal connector – rigidly immobilizes 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 inserts
into the lingual sheath.
 4. The Distal stop - Prevents the spring from riding up on the vertical arm of the molar bayonet while
activation of the appliance.
 5. Nickel titanium springs - Two force ranges - 180 gms and 240 gms.
 6. Activation locks - To compress and activate the springs.
 7. Lock wrench - To engage and tighten the screw of the activation lock
 Activation: The Distal Jet is reactivated by sliding the clamp closer to the first molar once a month.
 Once distalization is complete, the appliance can be converted to a Nance retainer simply by
replacing the clamp-spring assemblies with cold-cure acrylic and cutting off the arms to the
premolars.
 Advantage of distal jet : 1) The appliance is relatively easy to fabricate, easy to insert, is well
tolerated and is esthetic. 2) Easy activation 3) Ease of conversion to a Nance holding arch to
maintain the distalized molar positions. 4) The Distal Jet also permits the simultaneous use of full
bonded appliances, possibly avoiding the need for two phases of treatment.
 MODIFICATIONS OF DISTAL JET : Bowman (1998 Sept JCO) described several modifications to the
original appliance.
 Conversion to Nance Holding Arch: Upon completion of molar distalization, the Distal Jet is
converted to a Nance holding arch to prevent further distal movement and consequent anchorage
loss. It can be done by these two methods:
 1. One way to stop movement of the bayonet wire through the tube is to flow a light-cured acrylic
around the coil spring, over the distal bayonet bend, and over the activation collar to produce a solid
extension from the molar bands to the acrylic button.
 2. Wrap an .014" stainless steel ligature wire around the end of the doubled back wire (extending
distally from the lingual sheath on the first molar band) and tie it around the tube just mesial to the
activation collar. The coil spring should be compressed completely and the set screw tightened to

prevent mesial movement of the molars.

 Adv.: The Distal Jet is a fixed palatal appliance that is most commonly used to distalize the maxillary
molars, either unilaterally or bilaterally.
 Disadvantage of Distal jet: Lies in activation. The appliance is activated by sliding a collar along the
supporting tube to compress a coil spring, then fixing the collar in place by tightening a small set-
screw. This procedure is sometimes difficult because of the small size of the screw, the moisture and
confined space of the intraoral environment, and food impaction in the screw head.
 In addition, activation requires the use of a small Allen wrench,
wrench, which has the risk of being
swallowed or aspirated.

 THE FIXED PISTON APPLIANCE: The appliance was described by Raphael U.Greenfield in 1997.
 The appliance proposed to achieve distal bodily movement of the molars without tipping the crown
with no loss of posterior anchorage.
 THE APPLIANCE: The components of the appliance are:
 a. Maxillary first molar and first bicuspid bands.
 b. 0.036" stainless steel tubing (soldered to the bicuspids).
 c.0.030" stainless steel wires (soldered to the first molar).
 d. Enlarged Nance button reinforced with an 0.040" stainless steel wire for control of anterior

anchorage.

 e. 0.055" hyperplastic nickel titanium open-coil springs - to provide a light but continuous force.
 THE ADVANTAGES: The fixed piston appliance has been proved to be effective in molar distalisation
and is said to have the following advantages:
1. Bodily movement of maxillary first molars (with no loss of posterior anchorage).
2. Minimum patient compliance.
3. Allows the use of head gear if needed.
4. In non-extraction cases, it is proved to reduce treatment time as it distalizes at the rate of
1mm per month.
5. Maintains the arch width after expansion with Haas or Hyrax appliances.
6. Uses a light, controlled force of only 1-2 ounce per tooth. Because of this there is no loss of
anterior anchorage and no inflammation of the palatal mucosa beneath and adjacent to the
modified Nance button.
7. Does not interfere with the occlusal plane, thus maintaining effective control over the vertical
dimensions.

 K-Loop:- Put forward by Valrun Kalra (JCO 1995)

 The K-Loop molar distalizer consists of
 1. A K-Loop to provide the forces and moments.
 2. 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 plastic deformation.
o The loop of the 'K' should be 8 mm long and 1.5 mm wide.
o The legs of the 'K' are to be bent down 20 ° and inserted into the molar tube and the
premolar bracket.
o The wires are marked at the mesial of the molar tube and the distal of the premolar bracket.
o Stops are bent into the wire 1 mm distal to the distal mark and 1 mm mesial to the mesial
mark. Each stop are well defined and are about 1.5mm long.
o These bends help keep the appliances away from the mucobuccal fold, allowing a 2mm
activation of the loop.

 The 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 movements are said to continue even after the forces dissipate.
 For additional molar movement, the reactivation is 2mm after 6 to 8 weeks.
 The premolars move forward by 1 mm during 4 mm of molar distalization (the anchorage loss). To
prevent anchorage loss a head gear (straight pull or high pull) with forces of 150 g to the premolars
can be used.
 Advantages:
1. Simple & efficient
2. Controls moment to force ratio to produce bodily movement
3. Easy fabrication and placement
4. Hygienic and comfortable to the patient
5. Low cost.

 Herbst Appliance:
 The Herbst appliance is completely tooth-borne and uses both the maxillary and mandibular
dentition to transfer the force exerted from the telescopic arms of the Herbst bite jumping
mechanism to the bases of the maxilla and the mandible. The telescopic system produces a
posterosuperiorly directed force on the maxillary posterior teeth and an anteriorly directed force on
the mandibular dentition. As a result, Class II molar correction generally is a combination of skeletal

and dentoalveolar changes irrespective

irrespective of facial morphology.
 The Herbst telescoping bitejumping mechanism places a distal and intrusive force on the maxillary
molars and the force vector passes occ1usally to the center of resistance. This force system produces
backward and upward movements of maxillary molars in conjunction with distal crown tipping. tipping.
Because of the intrusive effect, distal movements of maxillary molars do not tend to open the
mandible. These effects are similar to those produced by high-pull headgear.
headgear.
 In general, maxillary molar distalization
distalization has been shown to comprise approximately
approximately 25% to 40% of
molar correction with the banded Herbst appliance, whereas in the acrylic design it accounts for 20%
to 25% of the correction.
 The distalizing effects are reported to range from an average of 1.8 mm in the study by Franchi et al
(AJO 1999) to 2.8 mm in the study by Pancherez (AJO 1982). The intrusive effects are 1mm
approximately. The amount of distal and vertical movement of maxillary molars is found to be
independent of the presence of erupted 2nd molar.
 Stability: In a long-term study on the results of Herbst treatment, Pancherz (AJO 1991) compared
two groups of Herbst-treated patients with and without relapse in the occlusion. Skeletal and
dentoalveolar changes in the mandibular arch were found to be similar in both groups 5 years after
treatment. The reason for relapse was thought to be the anterior movements of maxillary dentition
owing to muscular influence from the lips or tongue, or to an unstable occlusal condition after
treatment.
 The Klapper Superspring II:-
 In 1997 Lewis Klapper introduced the Klapper Superspring for the correction of Class II malocclusions.
It resembles a Jasper Jumper with the substitution of a cable for the coil spring. In 1998 the cable
was wrapped with a coil.
 The Klapper Superspring II inserts from the mesial and is rigidly secured to the molar by an oval
attachment tube. The Klapper Superspring creates a moment on the molar, which is expressed
clinically as distal root tip, but extended wear of the appliance results in excessive distal root tipping.
 Because the Klapper Superspring inserts gingivally on the molar and cannot roll to the buccal as
readily as a Jasper Jumper, there may be a greater vertical component to the force vector. If this
were of clinical significance, a patient with a pronounced
pronounced curve of Spee would level more quickly with
the Klapper Superspring. However, extended wear should produce produce excessive intrusions and may
require removal before sagittal corrections have been completed.
 Disadvantages of the Klapper Superspring:
o 1. Requirement of a special molar tube,
o 2. Limitation to maximal opening,
o 3. Risk of injury to the patient if breakage occurs
occurs
o 4. Extended wear may cause excessive distal root tipping to the maxillary molar and more
intrusion to the molars and incisors than desired

 The Eureka Spring:

 The interarch Eureka Spring became available in 1996, has a pure compression action, and therefore
delivers linear force throughout its range. It permits unlimited mandibular movements and has good
patient acceptance.
 It can be used in Class II and Class III malocclusions, does not require molar tubes, and can be used
in conjunction with extraoral force.
 These springs come in two sizes and are converted at the time of insertion into left or right action;

therefore inventory is minimal.

 No auxiliary attachments are required. Because it is truly a compression spring, it is less prone to
breakage & curvilinear
curvilinear than Jasper Jumper. A constant force of 16 grams per millimeter is generated,
which permits the clinician to visually determine the force at any time and adjust the force as
needed. A cephalometric evaluation of the first 50 consecutively treated bilateral Class II patients
indicated the following:
1. Average anteroposterior correction was at the rate of 0.7mm per month.
2. For every 3 mm of anteroposterior correction, the maxillary
maxillary molars intruded 1 mm and the
mandibular incisors intruded 2 mm.
3. Maxillary dentition moved distally 1.5 mm & mandibular dentition moved mesially 1.5 mm.
4. No increase in anterior face height b/w the dolichocephalic and brachycephalic subgroups.
 5. As with the Jasper Jumper, intrusion of teeth occurs during
during treatment. However, unlike the
Jasper Jumper the amount of intrusive force can be altered by changing the force vector and
magnitude

 The First Class Appliance for Rapid Molar Distalization by ARTURO FORTINI, JCO 1999
 To minimize the anchorage loss, a new type of appliance for unilateral or bilateral distalization of the
maxillary first molars was developed.
 1. Vestibular components. Formative screws are soldered on the buccal sides of the first molar
bands, occlusal to the .022" × .028" single tubes, so they will not interfere with subsequent insertion
of the archwire.
 Split rings, welded to the second premolar or second deciduous molar bands, control the vestibular
screws.
 2. Palatal components. In the palatal aspect, the appliance is much like a modified Nance button, but
is wider and has a butterfly shape for added stability and support during retention The embedded .
045" wires should be in single sections, without welded joints, to prevent breakage.
 Sections of .045" tube are soldered to the palatal sides of the first molar bands for insertion of the
butterfly component of the appliance.
 These tubes allow the molars to be distalized without undesirable tipping. The butterfly section is
soldered to the second bicuspid or deciduous molar bands.
 Nickel titanium .010" × .045" coil springs, approximately 10mm each in length, are fully compressed
between the bicuspid solder joints and the tubes on the permanent molar. The author has treated 62
Class II cases with this appliance age range from 8.7 years to 14.5 years. The average time for

distalization was 42 days, with a range from 28 to 95 days.

 C-Space Regainer for Molar Distalization by KYU-RHIM CHUNG,

CHUNG, SU-JIN KO JCO 2000
 The C-space regainer consists of a labial framework, formed from .036" stainless steel wire, and an
acrylic splint. A closed helix, as wide in diameter as comfort will allow, is bent into the framework in
each canine region.
 The labial framework is extended distally to lie as close to the buccal molar tubes as possible,
allowing easy insertion into the headgear tubes and improving the precision of the distal-driving
force. The distal ends of the framework should be polished down for a loose fit in the molar tubes. A .
010" × .040" open-coil spring is soldered immediately distal to the helix.

 Appliance Placement
 The open-coil spring should be 130% of the
 length between the solder point and the mesial
 edge of the headgear tube. When compressed, it
 will exert 200g of force and move the molars distally about 1-1.5mm per month. Vertical control is
maintained by adjusting the wire framework occlusally or gingivally

 The Jones Jig: Jones Jig consists of a heavy round wire and a light wire projecting through the molar
tubes. Both wires are fixed to a fixed attachment sheath and hook. An anteriorly placed sliding
sheath when tied back activates the open coil spring contained between the two sheaths. The
desired result is distalization of the maxillary molar. A Nance palatal button is attached to the bands,
hich have been placed on the second premolars.
 The force generated by compression of the open coil spring is 70 to 75 grams, with this light force
several millimeters of molar distalization can be obtained in 3 to 4 months.

 The advantages of the Jones Jig: 1) light forces, 2) ease of activation, 3) it can be used without
bonding the anterior teeth.
 Disadvantages are: 1) distal tipping of the molars, 2) mesial tipping of the premolars

 The Lokar Molar Distalizing Appliance:

 The Lokar appliance inserts into the molar attachments with an appropriately sized rectangular
wire.
 A compression spring is activated by a sliding sleeve which is tied to the most distal tooth mesial of
the first molar by a ligature wire.
 There is flat guiding bar and the round posterior guiding rod. This guiding rod is soldered to the
mesially positioned sliding sleeve while the flat anterior guiding bar is soldered to the immovable
posterior sleeve.
 With this arrangement it can be visualized that on activation the coils spring is compressed by the sliding
sleeve and an increase in the guiding rod occurs

 This appliance can be best used with Nance palatal button. Advantages of this appliance are ease of
insertion, ease of activation minimal breakage.



 TRANSPALATAL ARCH-MOLAR DISTALISATION AND DEROTATION :-

 A mesiopalatal rotated molar can occupy 3 mm more space as the distance between the
mesiobuccal cusp and the distopalatal cusp is 13 mm and the mesiodistal width of the molar is 10
mm. Therefore 3 mm of space can be achieved in each arch by derotating the first permanent molar.
 The simplest method of derotating the molar is by using a Transpalatal arch. The palatal bar was
introduced by Goshgarian as an anchorage appliance and modified by Cetlin and Ten Hoeve as a
removable tooth moving appliance. It is made of .036-inch S.S. wire double backed at the ends so
that it can be inserted into a 0.036 x 0.072 inch horizontal lingual sheath.
 The palatal U shaped coffin loop can be made distally if an intrusive force is desired posterior to the
Cres of the molar to tip the molar crowns distally. This effect can be achieved if the palatal bar is
placed low in the oral cavity. TPA can be used for the following purposes
 1. Distalization 2. Rotation 3. Expansion 4. Vertical control 5. Torque 6. Anchorage control
 Rotation: To derotate the molars the TPA when inserted into the lingual sheath on one side the other
side should be so adjusted that the terminal on that side should lie distal and lateral to its sheath,
 To check the same configuration on the other side the method is repeated by first inserting the
terminal in that lingual sheath.
 Distalization: It can be used in two clinical conditions
o 1. When in a malocclusion, a class II molar relationship on one side & other side is normal.
o 2.When the both upper molars have to be distalized and the patient does not want headgear.
 When activated for distalizing the molar the active side should lie distal and lateral to its lingual
sheath as in the case of rotation control.

 THE CRICKETT APPLIANCE: WEST in 1984

 The Crickett’s appliance embraces the essential features of the quad Helix. But replaces the palatal
and lingual bars of upper and lower appliances with a quad and bi-helix respectively. The Crickett’s
lingual arms are embedded to provide an adjustable spring action directed to lingual surfaces of all
teeth, without the need for further soldering.
 The buccal arms are retained for attachment of elastics and for ease of insertion and removal of the
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 elgiloy. The
lingual arms from 0.030” yellow elgiloy and buccal arms from 0.045” blue elgiloy.


 ADVANTAGE: effective appliance for variety of tooth movements including distalization of molars.
 DISADVANTAGE: major limitation is when intrusion of anterior teeth has to be performed.

 REMOVABLE MOLAR DISTALIZATION SPLINT:- by Korrodi Ritto in the year 1995.

 The Removable Molar Distalization Splint can achieve better patient cooperation than some other
removable devices. Clear splint is made from 1.5mm Biocryl in a Biostar machine.
 If both upper first molar are to be moved distally at the same time, the splint extends from the area
of upper first or second premolar to the area of upper left premolar. If only one molar is distalized,
the splint extends to the terminal molar on the other side.
 Two internal clasps are used for retention and a Ni-Ti coil spring produces 220gm of distal force. The
coils are reactivated.


 ADVANTAGES:- 1)It1)It is smaller than conventional removable plates. 2) It is comfortable. 3) Esthetics
4. Better co operation of the patient. 5) Molar distalization even in cases of deep over bite.
 DISADVANTAGES: There is more amount of molar tipping than bodily molar distalization. (So it is
ideally used only in cases where the molars are mesially tipped prior to treatment).

 NANCE APPLIANCE AND COIL SPRING:-

 Developed by Peringer, Parmann and Droschl in the year 1997.
 The appliance consists of 2 premolar bands, connected by a soldered palatal framework and an
anterior acrylic shield for palatal support.
 Distalization is produced by the sentalloy coil springs (150-200gm) on sectional arch wires.


 MODIFIED NANCE APPLIANCE FOR UNILATERAL MOLAR DISTALIZATION:-
 The class I side of 0.036” SS wire framework was finished with an anteriorly projecting 0.036” arm
like that of quad heix. The active class II side has an arm which is soldered to the first bicuspid band.
 An 0.020” omega loop is soldered to the anterior end of framework which allows the distal end of
the loop to slide distally as it is opened by activation. A 10mm 0.09”x0.036” open coil spring is added
to the frame work between omega loop and first molar band.

 THE CARRIERE DISTALIZER: Developed by Carriere in the year 2004.

 Produce a distal rotational movement of maxillary first molars around their palatal roots when
necessary. Simultaneously produce a uniform force for distal molar movement. Independently move
each post segment from canine to molar as a unit. Eliminate wire changes. Minimize periodontal
reactions. The clinical evidence of achievement of these objectives will be the appearance of
interincisal diastemas and wide spaces mesial to canine The distalizer is made of mold injected
Nickel free stainless steel. The ‘Canine Pad’ which allows distal movement of canine along alveolar
ridge without tipping provides a hook for attachment of class II elastics. This pad is mesial end of the
arm that runs posteriorly over the 2 upper premolars in a slight curve.
 The posterior end of the arm is permanently attached ball that articulates in a socket on the molar

pad.
 Several anchorage procedures can be given:
 Passive lingual arch, Hamula lingual arch, Full mandibular fixed appliance, Lower Essix appliance &
Miniscrews

 Mandibular space regaining:

 Removable appliance can be used for regaining space in the lower arch but it is more fragile and
prone to breakage. If there is a unilateral loss of space a removable lingual arch can be used and
activated on one side by incorporating a loop which can be opened to provide distal tipping of the
molar but a reaction force is expressed downward on the cingulum which have the tendency to move
the incisors facially.
 If the space has been lost bilaterally, a lingual arch can be used but pitting posterior movement of
both the molars against the anchorage offered by the incisors means that significant forward
displacement of the incisors can be expected.

 LIP BUMPER
 To overcome this problem lip bumper can be used which is fitted into the tubes on the molar teeth,
the appliance presses against the lip and forces the molars to tip distally the appliance also alters the
forces of equilibrium against the incisors and helps in the forward movement of these teeth and
hence increase in the arch length. The lip bumper has a stainless steel wire, usually 0.045 inch thick
that spans the facial surface of the mandibular arch without contacting the teeth and is inserted into
tubes attached to the mandibular molars.
 Anteriorly, the wire is sometimes covered by plastic tubing or a shield made of acrylic or plastic that
holds the lower lip away from the mandibular incisors. Forces from the mentalis muscle are
translated to the mandibular molars, enabling them to move to an upright and distal position. At the
same time, the tongue may cause the mandibular incisors to tilt outward and the canines and
premolars to move buccally.
 The advantage of lingual arch over the lip bumper is that it can be used to maintain the space after
the space has been regained
 A 6 months study was done by Moshe Davidovitch published in AJO January 1997. Thirty-four
patients, age averages 7.9 to 13.1 years were taken for the study who had a crowding ranging from
3-8 mm. Patients were divided into two groups randomly into control group who did not receive any
treatment and the other was on lip bumper therapy. Alterations of mandibular incisor position were
measured from lateral Cephalometric radiographs. Mandibular left permanent first molar position
changes were determined from both lateral Cephalometric and tomographic radiographs
 Results shows that the forces produced during speech and swallowing were significantly more than the forces
produced at rest. This design was given by Hodge in AJO June 1997 he designed a MFD ( molar force device )
to measure the forces of lip pressure on the molar, this device was fixed on the molar tube into which was
seated the lip bumper. The analog data was converted into digital data. The study results show that there
was asymmetric distribution of the force from left to right side and ranged from 1.27 to 2.8 grams

 Mandibular Molar Distalization with Franzulum Appliance :- Friedrich, Stoff and Derendililer JCO 2000
 Appliance Design: The Franzulum Appliance’s anterior anchorage unit is an acrylic button, positioned
lingually and inferiorly to the mandibular anterior teeth, and extending from the mandibular left
canine to the mandibular right canine. The posterior distalizing unit uses nickel titanium coil springs,
about 18mm in length, which apply an initial force of 100-120g per side. A J-shaped wire passing
through each coil is inserted into the corresponding tube of the anchorage unit;
 the recurved posterior portion of the wire is engaged in the lingual sheath of the mandibular first
molar band. The anchorage unit is bonded with composite resin to the canines and first premolars.
The J-shaped distalizing unit is then ligated to the lingual sheaths of the molar bands, compressing
the coil springs. Thus, the active part of the appliance runs lingually at a level close to the center of
resistance of the molar, to produce an almost pure bodily movement. During the distalization phase,
the mandibular molars moved 4.5-5mm distally while the incisors moved 1mm anteriorly.
 The mandibular right molar crown tipped 4° distally, and the mandibular incisor crowns tipped 1°
labially. Thus, the movement of the incisor crown resulted in an anchorage loss of 1mm and 1°.

 IMPLANT SUPPORTED DISTALIZATION:

 Karaman - implant-supported modified distal jet appliance
 Graz implant supported pendulum
 Sugawara & Umemori SAS supported mandibular distalization
 Kyong JCO 2003

 Karaman (AO 2002 April ) A case report

 In this study, author used an implant-supported modified distal jet appliance that has the
advantages of implants and intraoral distalization appliances, and assessed its effect on dentofacial

structures.

 Molar bands with palatal tubes were fitted to the upper first molars. An anchorage screw three mm
in diameter and 14 mm in length was placed at the anterior palatal suture, two–three mm posterior
to the canalis incissivus under local anesthesia .
 Anchor wires 0.8 mm in diameter were soldered to the tubes for occlusal rests on the first premolars.
The 0.9-mm wire extended through each tube, ending in a bayonet bend that was inserted into the
palatal tube of the first molar band. For force application, Niti open-coil springs were adjusted.
 The implant-supported modified distal jet appliance was attached to the anchor premolars and
implant with light-cured composite adhesive. The screw was removed without anesthesia and with
no discomfort for the patient during the removal. Maxillary molar moved distally 5mm after 4
months of treatment and intruded by 2mm without movement of premolars. Upper incisor position,
MPA, and LAFH remained the same.
 The main advantages of the appliance are its stability against rotational movements. Adequate
distal movement of the molar tooth was achieved without the loss of anchorage.
 Irritation of the palatal mucosa and gingival hyperplasia didn’t occur because the patient could
maintain optimum oral hygiene.
 Distalization of Maxillary Molars with a Midpalatal Miniscrew by Kyung JCO 2003
 a miniscrew is fixed in the midpalatal suture for distalizing the maxillary molar. Power chain is
attached from the miniscrew to the transpalatal arch which is soldered to the maxillary molars. In a
11 year old patient molars distalized by 3.5 mm from the apices and 5mm from the crown in a 3
months period with a distal force of 400 grams
 In another 11 year old female patient same amount of space was achieved in nine months period.

 Sugawara & Umemori, (Ajo 2004Jan) :-

 The skeletal anchorage system (SAS) consists of titanium anchor plates and monocortical screws that
are temporarily placed in either the maxilla or the mandible, or in both, as absolute orthodontic
anchorage units, Distalization of the molars has been one of the most difficult biomechanical
problems in traditional orthodontics, particularly in adults and in the mandible, However, it has now
become possible to move molar's distally with the SAS to correct anterior crossbites, maxillary dental
protrusion, crowding, dental asymmetries without having to extract premolars.


 Skeletal anchorage system (SAS) uses pure titanium anchor plates and screws as absolute
orthodontic anchorage units. The anchor plates are monocortically placed at the piriform opening
rim, the zygomatic buttresses, and any regions of the mandibular cortical bone, Because the anchor
plates work as the onplant and the screws function as the implant, SAS enables the rigid anchorage
that results from the osseointegration effects in both the anchor plates and screws.
 SAS does not interfere with tooth movement. Therefore, it is possible to distalize the mandibular
molars with anchor plates placed at the anterior border of the mandibular ramus or mandibular
body
 The SAS has outstanding advantages not provided by the other mechanisms for distalizing the
mandibular molars.
 1. It is possible to intrude the mandibular molars with the SAS. Therefore the extrusion of the
mandibular molars after the tipping of the molar distalization can be corrected easily.
 2. En masse distalization of the mandibular buccal segments or the entire dentition is also possible if
the mandibular dentition is aligned.
 3. With the SAS, it is not always neccssary to extract the mandibular first or second premolars even
in patients with moderate to severe crowding.
 4. Molar relationship in patients with symmetric or asymmetric Class III molar relationship can be
corrected without having to extract mandibular premolars.