SYSTEMATIC REVIEW

Are orthodontic distalizers reinforced with the

temporary skeletal anchorage devices effective?
Piotr Fudaleja and Joanna Antoszewskab
Nijmegen, The Netherlands, and Wroclaw, Poland

Introduction: Our objective was to perform a systematic review of studies pertaining to the distalization of
teeth with appliances reinforced with temporary skeletal anchorage devices. Methods: PubMed, Embase,
Cochrane Central Register of Controlled Trials, Web of Knowledge, Ovid, and Scopus were searched until
the second week of August 2010 to identify all articles reporting on the use of orthodontic implants or miniplates
in distalization of teeth. The quality of the relevant studies was ranked on an 11-point scale, from low to high
quality. Results: Twelve relevant articles were identified. The distal movement of the maxillary molars was
from 3.3 to 6.4 mm; the concomitant molar distal tipping was from 0.80
to 12.20
. The maxillary incisors re-
mained stable during molar distalization. The assessment of study quality showed that 8 studies were of low
and 4 of medium quality. Conclusions: Molar distalizers reinforced with the temporary skeletal anchorage
devices seem to effectively move molars distally without unwanted mesial incisor tipping. Because of the lack
of high-quality studies, however, the findings of this study should be interpreted with caution. (Am J Orthod
Dentofacial Orthop 2011;139:722-9)

D
istalization of the molars has become a popular
nonextraction treatment alternative in some
patients with Class II malocclusions. There are nu-
merous methods to move teeth distally; some techniques
require a patient’s active compliance, whereas others do
not. Because patients’ cooperation during orthodontic
treatment is frequently problematic, the appliances that
eliminate the need for compliance are usually deemed su-
perior to those demanding cooperation. Although popu-
lar noncompliance appliances, such as the pendulum1
and the distal jet,2 are effective in distalizing molars, the
distalization process is associated with the concomitant
loss of anterior anchorage. Sfondrini et al3 critically eval-
uated various appliances used for molar distalization and
found that most noncompliant appliances were associ-
ated with mesial movement or tipping of the incisors,
a
Assistant professor, Department of Orthodontics and Oral Biology, Radboud
University Nijmegen Medical Centre, Nijmegen, The Netherlands; Assistant
professor, Department of Orthodontics, Palacky University, Olomouc, Czech
Republic.
b
Assisstant professor, Department of Dentofacial Orthopedics and Orthodon-
tics, Wroclaw Medical University, Wroclaw, Poland.
The authors report no commercial, proprietary, or commercial interest in the
products of companies described in this article.
Reprint requests to: Piotr Fudalej, Department of Orthodontics and Craniofacial
Biology, Radboud University Nijmegen Medical Centre, 309 Dentistry, PO Box
9101, 6500 HB Nijmegen, The Netherlands; e-mail, P.Fudalej@dent.umcn.nl.
Submitted, August 2010; revised, December 2010; accepted, January 2011.
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2011.01.019
722
synonymous with loss of anchorage. Similar conclusions
were made by Antonarakis and Kiliaridis,4 who systemat-
ically reviewed the effects of noncompliance tooth-borne
distalizers. They found that distalization of molars is re-
lated to unavoidable loss of anchorage, which was
observed as premolar mesial movement and incisor mesial
crown and tipping movements.
To reinforce anchorage and reduce unwanted move-
ment of the incisors and premolars, a temporary skele-
tal anchorage device (TSAD) can be used. The TSAD is
defined as a device that is temporarily fixed in bone for
reinforcement of orthodontic anchorage.5 Because
a TSAD is stable, it provides absolute anchorage. To
date, many distalization appliance designs incorporat-
ing TSADs have been developed. They range from the
skeletal anchorage system (SAS) with miniplates placed
in the zygomatic region in the maxilla6 or retromolar
region of the mandible7 to appliances supported by
a single orthodontic implant in the anterior palate.8 Al-
though the current studies suggest that these appli-
ances might be effective in moving molars distally, an
in-depth analysis is needed to investigate also other as-
pects of distalization, such as a rate and duration of
molar movement. Therefore, the objectives of this sys-
tematic review were to evaluate the effectiveness of the
distalization of molars with distalizers supported with
TSADs and to compare the effectiveness of TSAD-
reinforced distalizers with tooth-borne noncompliance
distalization appliances.
Fudalej and Antoszewska
MATERIAL AND METHODS
PubMed, Embase, Cochrane Central Register of Con-
trolled Trials, Web of Knowledge, Ovid, and Scopus were
searched until the second week of August of 2010 to
identify all articles reporting on the use of TSADs in dis-
talization of molars. The search strategy used in this
review is shown in Table I.
Based on the data from titles and abstracts of the
retrieved studies, both authors independently selected
articles that met the following inclusion criteria.
1. Studies on human subjects, published in English.
2. Studies that included clear descriptions of the dis-
talization appliance and the technique.
3. Prospective or retrospective original studies (case
reports and review and summary articles were
excluded).
4. Studies with minimum 10 subjects in the sample.
The reference lists of these articles were perused, and
references related to the articles were followed up. If
there was disagreement between the authors, inclusion
of the study was confirmed by mutual agreement.
From the identified articles, the authors indepen-
dently extracted data referring to year of publication,
type of study, sample size, site of implant or miniplate
placement, type of distalizing appliance, magnitude of
force exerted on the teeth, duration of treatment, age
at the start of treatment, presence of second molars, cal-
culation of the method error, amounts of molar retrac-
tion and tipping, and changes of the position of the
central incisors (Table II).
According to the Centre for Reviews and Dissemina-
tion, evaluation of methodologic quality gives an indica-
tion of the strength of evidence provided by the study
because flaws in the design or conduct of a study can re-
sult in bias.9 However, no single approach for assessing
methodologic soundness is appropriate to all systematic
reviews. The best approach should be determined by
contextual, pragmatic, and methodologic consider-
ations. Therefore, quality assessment performed inde-
pendently by the authors comprised evaluation of the
selection process (including information about whether
the sample consisted of consecutively treated patients),
sample size estimation, adequacy of outcome measures,
adequacy of method error estimation, and adequacy of
statistical analysis (Table III). If there was disagreement
between the authors, consensus was reached after dis-
cussion. The quality of the studies was ranked on an
11-point scale and assessed accordingly: high, with a to-
tal score of 11 points; medium high, with a total score 9
or 10 points; medium, with a total score 7 or 8 points;
and low, with a total score below 7 points.
American Journal of Orthodontics and Dentofacial Orthopedics
723
Table I. Search strategy
1. orthodontic*
2. micro-implant* OR microimplant* OR “micro implant*”
3. mini-implant* OR “mini implant*”
4. “orthodontic implant*”
5. “mini-plate*” OR “mini plate*”
6. “palatal implant*” OR “midpalatal implant*”
7. “buccal implant*”
8. miniscrew* OR mini-screw* OR “mini screw*”
9. microscrew* OR micro-screw* OR “micro screw*”
10. 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9
11. 1 AND 10
Statistical analysis
A meta-analysis of the results of the studies that used
comparable techniques of distalization was planned
with the aid of the RevMan software (version 5.0, The
Nordic Cochrane Centre, Copenhagen, Denmark).10 Het-
erogeneity of the studies was assessed first by calculating
the I2 index.11 According to the recommendation of
the Cochrane Collaboration, if heterogeneity is high
(I2, .75%), a meta-analysis might produce misleading
results, and omitting it from a systematic review
should be considered.10
RESULTS
The search of PubMed yielded 357 publications;
Embase, 272; Cochrane Central, 45; ISI Web of Knowl-
edge, 802; Ovid, 919; and the Scopus, 518; there was
overlap among the databases. Application of the inclu-
sion and exclusion criteria and follow-up on the referred
studies allowed identification of 12 relevant publications
(Fig, Table II).
Heterogenity of the results of the investigation
with a similar technique of distalization was high
(.85%).8,12-18 A meta-analysis was not performed for
this reason.
In total, 223 subjects (78 male, 145 female) were ex-
amined. However, 2 studies most likely evaluated the
outcome in the same samples.8,12 The mean age at the
start of molar distalization in the evaluated samples
ranged from 13 years13 to 27.3 years.19 Overall, in 6
studies, the samples comprised teenagers; in 3 studies,
adults; and in 1 study, the sample included teenagers
and adults.20 Onça
g et al16 did not report on the mean
age at the start of treatment, and Gelg€ or et al8 gave
only the age range at the start of distalization.
In 6 studies (153 subjects), an area adjacent to the
median suture in the anterior region of the hard palate
was chosen as the site for placement of the orthodontic
implant; the anchorage devices were also placed in the
infrazygomatic crest region (2 studies, 42 subjects) and
the anterior margin of the mandibular ramus (1 study,
June 2011  Vol 139  Issue 6
724 Fudalej and Antoszewska

Table II. Characteristics of the samples, distalization techniques, and outcomes in the included studies.
Type of Age at
study; start
consecutive of
patients (Y, N); treatment Site of TSAD
control group Sample in years placement diameter, Osseointegration Distalization Magnitude
Study (Y, N) size (SD) of the TSAD length (Y or N) appliance of force
Cornelis and Retrospective; 17 (15 27.3 (NR) Infrazygomatic crest Miniplate N Elastics attached 150 g
De Clerck, Y; N female, to maxillary
200719 2 male) fixed appliance
Escobar Retrospective; 15 (6 girls, 13 (2.1) Anterior palate 2 implants: N Modified 250 g
et al, Y; N 9 boys) 2.0 mm, pendulum
200713 11 mm appliance
Gelg€or et al, Prospective; 25 (18 girls, 13.8 (NR) Anterior palate 1.8 mm, N Transpalatal bar 250 g
200412 NR; N 7 boys) 14 mm between
premolars
supported by
implant and
nickel-titanium
open coil between
premolar
and molar on the
buccal side
Gelg€
or et al, Retrospective; 20 (8 girls, NR (NR); Anterior palate 1.8 mm, N Transpalatal bar 250 g
20078* N; Y 12 boys) range, 14 mm between
11.6- premolars
15.1 supported by
implant and
nickel-titanium
open coil
between premolar
and molar
on the buccal side
Gelg€
or et al, Retrospective; 20 (11 girls, NR (NR); Anterior palate 1.8 mm, N Appliance 250 g
20078y N; Y 9 boys) range, 14 mm consisting
12.3- of acrylic
15.4 palatal button
attached to
implant,
premolar rests,
and nickel-
titanium
open coils on the
lingual side
Kinzinger Retrospective; 10 (8 girls, 12.1 (NR) Anterior palate 1.6 mm, N Distal jet 200 g
et al, N; N 2 boys) 8-9 mm
200914
Kircelli Prospective; 10 (9 girls, 13.5 (1.8) Anterior palate 2.0 mm, N Pendulum NR
et al, NR; N 1 boy) 8 mm appliance
200615
Oberti et al, Prospective; 16 (4 girls, 14.3 (NR) Anterior palate 2 implants: N Dual–force 250-300 g
200917 NR; N 12 boys) 2.0 mm, distalizer
11 mm
Oncag Retrospective; 15 (9 girls, NR (NR) Anterior palate 3.8 mm; Y Pendulum springs 300 g
et al, Y; Y 6 boys) 9 mm made of beta
200716 nickel-titanium
wire
Park et al, Retrospective; 13 (8 girls, 17.9 (5.7) 9 patients: Mn implants various NR Nickel-titanium 200 g
200520 Y; N 5 boys) distal to second molars coils and
or in retromolar area; 2 elastomeric
patients: Mx implants in thread
buccal alveolar bone
between second
premolars and first
molars; 2 patients: both
Mn and Mx implants
Polat-Ozsoy Retrospective; 22 (15 girls, 13.6 (2.0) Anterior palate 2.0 mm, 8 mm N Pendulum appliance 230 g
et al, N; Y 7 boys)
200818

June 2011  Vol 139  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Fudalej and Antoszewska 725

Table II. Continued

Type of
study; Age at start
consecutive of
patients (Y, N); treatment Site of TSAD
control group Sample in years placement diameter, Osseointegration Distalization Magnitude
Study (Y, N) size (SD) of the TSAD length (Y or N) appliance of force
Sugawara Retrospective; 15 (12 26.9 (NR) Anterior margin Titanium N SAS NR
et al, 20047 N; N female, 3 of mandibular plates
male) ramus
Sugawara Retrospective; 25 (22 23.9 (NR) Infrazygomatic Titanium N SAS NR
et al., N; N female, 3 crest plates
20066 male)

Amount of
central incisor
Amount mesial movement/
of molar Monthly tipping (mm/
);
Treatment distal rate of molar negative value for
duration Presence of Method movement/ movement distal movement/ Success
Study in months (SD) second molars error tipping (mm/
) (mm) tipping rate
Cornelis and 7.0 (2.0) 100% N 3.3/1.8 0.5 1.4/NR 100%
De Clerck,
200719
Escobar et al, 7.8 (NR) NR Intraclass 6.0/11.2 0.8 –0.5/–2.5 Unclear
200713 correlation
coefficient
Gelg€
or et al, 4.6 (NR) 88% Dahlberg’s 3.9/8.8 0.8 0.5/1.0 NR
200412 method
Gelg€
or et al, 4.6 (NR) 90% Dahlberg’s 4.0/9.1 0.7 –0.5/–1.1 NR
20078* method 1
correlational
analysis
Gelg€
or et al, 5.4 (NR) 85% Dahlberg’s 3.9/0.8 0.7 –0.1/–0.1 NR
20078y method 1
correlational
analysis
Kinzinger et al, 6.7 (NR) 20% fully N 3.8/3.0 0.6 –0.4/–0.6 NR
200914 erupted,
25% erupting
Kircelli et al, 7 (1.8) NR Spearman 6.4/10.9 0.9 –0.2/–0.6 NR
200615 correlation
coefficient
between
repeated
measurements
Oberti et al, 5 (NR) Unerupted Intraclass 5.9/5.6 1.2 –0.5/–0.8 NR
200917 or just correlation
recently coefficient
erupted
Oncag et al, 6.2 (NR) NR ANOVA test 4.0/12.2 0.6 Right side, 0.1/1.0 NR
200716 Left side, –2/–0.6
Park et al, 200520 12.3 (5.7) Mostly Paired t test Mn first * Mn central 90%
present molars, 2.9/5 incisors, NR
Polat-Ozsoy 6.8 (1.7) 13.6% Spearman 4.8/9.1 0.7 –0.1/–1.7 Unclear
et al, 200818 correlation
coefficient
between repeated
measurements
Sugawara 28.9 (NR) 100% Unclear 3.5/NR; 0.1 NR NR
et al, 20047 tipping ratio,
46.3%
Sugawara 19 (NR) 100% Unclear 3.8 mm crown, 0.2 NR NR
et al, 20066 3.2 mm root

Y, yes; N, no; NR, not reported; Mn, mandibular; Mx, maxillary.

*Group 1 evaluated by Gelg€or et al8; ygroup 2 evaluated by Gelg€
or et al.8

American Journal of Orthodontics and Dentofacial Orthopedics June 2011  Vol 139  Issue 6
726 Fudalej and Antoszewska

Table III. Assessment of the study quality

A. E. F. G.
Description of B. C. D. Choice of Adequacy of Adequacy of Judged
selection Prospective or Consecutive Sample outcome method error statistical Quality quality
Study process retrospective cases size measure analysis analysis score standard
Points 0, 1, or 2 0 or 2 0 or 1 0 or 1 0, 1, or 2 0, 1, or 2 0 or 1
Cornelis and 2 0 1 0 1 0 1 5 Low
De Clerck,
200719
Escobar et al, 1 0 1 0 2 1 1 6 Low
200713
Gelg€or et al, 1 2 1 1 2 1 0 8 Medium
200412
Gelg€or et al, 1 0 0 1 2 1 1 6 Low
20078
Kinzinger 0 0 0 0 2 0 1 3 Low
et al,
200914
Kircelli et al, 1 2 1 0 2 0 1 7 Medium
200615
Oberti et al, 2 2 0 0 2 1 1 8 Medium
200917
Oncag et al, 1 0 0 0 2 1 1 5 Low
200716
Park et al, 2 0 1 0 2 1 1 7 Medium
200520
Polat-Ozsoy 1 0 0 1 2 0 1 5 Low
et al,
200818
Sugawara 2 0 0 0 1 0 0 3 Low
et al,
20047
Sugawara 2 0 0 1 1 0 0 4 Low
et al,
20066

Description of quality score assignment:

A: 0, if inadequate description; 1, if some details of sample selection missing; 2, if in-depth description of sample selection.
B: 0, if retrospective; 2, if prospective.
C: 0, if sample comprised unconsecutive patients or no information regarding this was included; 1, if sample comprised consecutive patients.
D: 0, if \20 subjects; 1, if $20 subjects.
E: 0, if inadequate outcome measure; 1, if partially adequate outcome measure; 2, if adequate outcome measure.
F: 0, if method error not evaluated; 1, if partially adequate method error analysis; 2, if adequate method error.
G: 0, if inadequate; 1, if adequate.

15 subjects). The pendulum appliance was used most
frequently to distalize the molars. In subjects in whom
miniplates were placed, elastomeric power chains
attached to the fixed orthodontic appliance were used.
The duration of treatment ranged from 4.6 to 28.9
months. However, in most studies, distalization of mo-
lars did not last more than 8 months. In the studies
that reported treatment time exceeding 8 months, en-
masse retraction of the whole dentition was carried out.
The mean distal movement (Table II) of the maxillary
molars ranged from 3.5 to 6.4 mm. Concomitant distal
tipping ranged from 0.80
to 12.20
(Table II). The posi-
tion of the central incisors was largely stable; only Cornelis
and De Clerck19 found a statistically significant retraction
by 1.4 mm (P \0.05), and Oberti et al17 detected 0.5 mm
of retraction of the central incisors (P \0.05).
The assessment of the quality showed that 8 studies
were of low quality, and 4 studies demonstrated medium
quality. In general, the methodologic soundness of the
studies was compromised by retrospective designs with-
out inclusion of consecutively treated patients, inade-
quate sample sizes, and lack of analysis of method errors.
DISCUSSION
In this study, we aimed to review articles that had
evaluated the effectiveness of orthodontic distalizers re-
inforced with TSADs. A systematic review seemed the
most appropriate, because its methodology makes

June 2011  Vol 139  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Fudalej and Antoszewska 727

QUOROM Flow Diagram

Potentially relevant articles Manual search; relevant

after search of the electronic articles
databases (n = 3)
(n = 1215)

Excluded articles, non-

English (n= 85)
Articles retrieved for more
detailed evaluation (n = 1130)
Excluded articles, non-
human studies, reviews
(n= 242)

Articles retrieved for more

detailed evaluation (n = 888)
Included articles (n = 9)
Excluded articles, not
relevant to the subject of
the present study, case
reports, description of
technique, < 10 subjects
in sample (n = 879)

Total number of included

articles (n = 12)

Fig. Flowchart illustrating the selection of relevant articles.

possible identification, appraisal, and synthesis of most
available evidence. Depending on the quality of the in-
cluded studies, a systematic review can provide various
levels of scientific evidence ranging from the highest,
if only randomized clinical trials are included, to the low-
est, if only retrospective investigations are reviewed.21 In
the latter case, a systematic review summarizes what is
already known, indicates the weaknesses of the studies,
and highlights the areas requiring further research.
This systematic review included only nonrandomized
prospective and retrospective studies. The methodolo-
gies of these investigations were generally of low and
medium quality (Table III). Consequentially, our findings
should be interpreted with caution, and conclusions that
can be drawn from them are necessarily tentative.
These results suggest that the TSADs used as anchors
supporting distalizing appliances reduce the unwanted
side effects of tooth-borne appliances. Antonarakis
and Kiliaridis4 found in their systematic review that
tooth-borne distalizers could move maxillary molars dis-
tally on average 2.9 mm; however, the associated unde-
sirable incisor mesial movement was 1.8 mm. Our
findings indicate that reinforcement of anchorage with
orthodontic implants or miniplates increased the
amount of molar distalization. The distal movements of
the maxillary molars in the studies with comparable dis-
talization techniques were from 3.9 to 6.4 mm.8,12-18 At
the same time, the maxillary incisors remained stable.
This implies better outcomes produced by TSAD-
reinforced distalization devices than by tooth-borne
appliances.
A distal movement of the molars is the effect of
bodily tooth movement and tipping, which is usually
not desired clinically. The findings of the studies that
used similar techniques of distalization showed that
the distalization of molars was associated with 3.0
to
12.20
of distal tipping.8,12-18 Only Gelg€or et al8 found
minimal molar tipping (0.80
) in 1 of their 2 study
groups. This was also found by Antonarakis and Kiliari-
dis,4 who reported 5.40
of molar distal tipping after the
use of tooth-borne distalizing appliances. The greater
molar distal tipping observed in patients with the TSADs
might have resulted from excessive pressure exerted on
the molars by the distalizers. Assuming that the force
values generated by the tooth-borne and TSADs-
supported appliances were comparable, less pressure
was applied to the molars in subjects with the tooth-
borne appliances than in those with the TSADs because,

American Journal of Orthodontics and Dentofacial Orthopedics June 2011  Vol 139  Issue 6
728
in the former group, the force was dissipated also in the
anterior direction, causing mesial movement or tipping
of the maxillary incisors. In subjects with TSADs, this
was not possible because of the stability of the implants.
Nonintegrated TSADs placed in the paramedian re-
gion of the anterior palate were used to reinforce distal-
ization appliances in most studies in this review. In
comparison with osseointegrated TSADs, nonintegrated
TSADs offer several advantages to the clinician, such as
immediate loading, simpler surgery, lower cost, and less
discomfort to the patient. Our results suggest that non-
integrated TSADs were successful in anchorage rein-
forcement during distalization. However, few data
regarding failure rates limit the strength of this conclu-
sion. Only the authors of 2 studies showed the propor-
tions of successfully and unsuccessfully treated
patients.13,18 Escobar et al13 reported that the treatment
of 2 patients was unsuccessful (success rate, 87%) be-
cause of tissue inflammation and failure of the screw.
They, however, used a modified pendulum appliance at-
tached to the palate with 2 screws. It is unclear whether
all TSADs in the remaining subjects were stable. Polat-
Ozsoy et al18 reported the lack of stability of 4 TSADs
in 3 subjects. Because most patients wore distalization
appliances supported by 2 TSADs, instability of the
TSADs was noticed during accidental damage of the dis-
talizing spring or at the appliance removal. Although the
clinical success rate in the study by Polat-Ozsoy et al was
100%, it is difficult to generalize these data because
other investigators used distalization appliances sup-
ported by a single palatal implant. It is possible, then,
that loosening of the implant in such cases could lead
to clinical failure. Therefore, conclusions regarding the
effectiveness of the nonintegrated TSADs can be made
only after more data concerning rates of successful
and unsuccessful outcomes are obtained.
The rates of molar distalization achieved with differ-
ent devices, calculated as millimeters of molar distal
movement per month, can be an important factor for
a clinician during selection of the distalization appli-
ance. The results of this review showed that the mean
distal movement of the maxillary molars was 0.7 mm
(SD, 0.3 mm) per month (range, 0.2-1.2 mm). The slow-
est rate was observed for the SAS system described
by Sugawara et al6; a similar technique was used by
Cornelis and De Clerck,19 and the fastest was when the
dual-force distalizer was used.17 The slowest distaliza-
tion rate found for the SAS was most likely because
the whole maxillary dentition was distalized simulta-
neously, since the distal force was applied to the fixed
appliances worn by the patient. Conversely, the fastest
rate of distalization was achieved when the force was
applied to the molars only. The use of the dual-force
June 2011  Vol 139  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Fudalej and Antoszewska
distalizer allowed obtaining the highest rate of molar
distal movement from 2 force systems: 1 from the palatal
and 1 from the buccal side, exerting pressure on the mo-
lars. The difference in the rate of distalization, however,
might be clinically meaningless because distalization is
usually followed by a phase of comprehensive treatment,
which can cancel the effects of rapid distalization.
Therefore, it is possible that a comparable overall treat-
ment outcome can be achieved faster with the SAS rather
than with the dual-force distalizer.
Erupted second maxillary molars might affect the
rate of distalization. According to Kinzinger et al22 and
Karlsson and Bondemark,23 efficiency of distalization
is greater if it is started before the eruption of the second
molars. The results of this study, however, do not sup-
port this claim unambiguously. Although the greatest
monthly distal movement of maxillary first molars was
noted in the patients treated with the dual-force distal-
izer whose maxillary second molars were unerupted or
just recently erupted, other groups differing in the num-
ber of erupted second molars showed comparable rates
of distalization.17 For example, in the samples investi-
gated by Gelg€ or et al8,12 and Polat-Ozsoy et al,18 the
maxillary first molars were moved distally by 0.7 to 0.8
mm per month despite considerable differences in the
percentages of erupted second molars. In the groups ex-
amined by Gelg€ or et al,8,12 approximately 90% of the
second molars were erupted, whereas in the sample of
Polat-Ozsoy et al18 only 13.6% of second molars were
present. These findings suggest that presence or absence
of second molars might play a smaller role when im-
plant- or miniplate-supported distalization appliances
are used.
The molars are usually distalized early during ortho-
dontic therapy, and it is followed by other stages of com-
prehensive treatment. The position of the molars or the
inclination of the incisors achieved during distalization
might be affected during later stages of treatment.
Therefore, 2 important issues should be considered before
making conclusions regarding the effectiveness of TSAD-
supported distalizers. First, are the end-of-treatment
outcomes with TSADs better than those obtained with al-
ternative tooth-borne anchorage? Second, are outcomes
with TSADs more stable than conventional methods? Un-
fortunately, no studies included in our review addressed
these questions. All of them were focused on the short-
term effects of distalization. The lack of long-term evalu-
ations necessarily weakened the conclusions.
CONCLUSIONS
On the basis of this systematic review, the following
can be concluded.
Fudalej and Antoszewska
1. Orthodontic distalizers reinforced with the TSADs
seem to be effective in molar distalization. They
also appear to produce fewer unwanted side effects.
2. The methodologic soundness of the reviewed stud-
ies was relatively low.
3. The long-term effectiveness of TSAD-reinforced
molar distalization should be studied.
REFERENCES
1. Hilgers JJ. The pendulum appliance for Class II non-compliance
therapy. J Clin Orthod 1992;26:706-14.
2. Carano A, Testa M. The distal jet for upper molar distalization.
J Clin Orthod 1996;30:374-80.
3. Sfondrini MF, Cacciafesta V, Sfondrini G. Upper molar distaliza-
tion: a critical analysis. Orthod Craniofac Res 2002;5:114-26.
4. Antonarakis GS, Kiliaridis S. Maxillary molar distalization with
noncompliance intramaxillary appliances in Class II malocclusion.
A systematic review. Angle Orthod 2008;78:1133-40.
5. Cope JB. Temporary anchorage devices in orthodontics: a para-
digm shift. Semin Orthod 2005;11:3-9.
6. Sugawara J, Kanzaki R, Takahashi I, Nagasaka H, Nanda R. Distal
movement of maxillary molars in nongrowing patients with the
skeletal anchorage system. Am J Orthod Dentofacial Orthop
2006;129:723-33.
7. Sugawara J, Daimaruya T, Umemori M, Nagasaka H, Takahashi I,
Kawamura H, et al. Distal movement of mandibular molars in adult
patients with the skeletal anchorage system. Am J Orthod Dento-
facial Orthop 2004;125:130-8.
8. Gelg€or IE, Karaman AI, B€ uy€
ukyilmaz T. Comparison of 2 distaliza-
tion systems supported by intraosseous screws. Am J Orthod
Dentofacial Orthop 2007;131:161.e1-8.
9. Centre for Reviews and Dissemination. Systematic Reviews. CRD’s
guidance for undertaking reviews in healthcare. York, United King-
dom: University of York NHS Centre for Reviews and Dissemina-
tion; 2009.
10. The Cochrane Collaboration. In: Higgins JPT, Green S, editors.
Cochrane handbook for systematic reviews of interventions.
Chichester, United Kingdom: Wiley-Blackwell; 2008. p. 276-82.
American Journal of Orthodontics and Dentofacial Orthopedics
729
11. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring incon-
sistency in meta-analyses. BMJ 2003;327:557-60.
12. Gelg€or IE, B€uy€ukyilmaz T, Karaman AI, Dolanmaz D, Kalayci A.
Intraosseous screw-supported upper molar distalization. Angle
Orthod 2004;74:838-50.
13. Escobar SA, Tellez PA, Moncada CA, Villegas CA, Latorre CM,
Oberti G. Distalization of maxillary molars with the bone-supported
pendulum: a clinical study. Am J Orthod Dentofacial Orthop 2007;
131:545-9.
14. Kinzinger GS, G€ ulden N, Yildizhan F, Diedrich PR. Efficiency of
a skeletonized distal jet appliance supported by miniscrew anchor-
age for noncompliance maxillary molar distalization. Am J Orthod
Dentofacial Orthop 2009;136:578-86.
15. Kircelli BH, Pektaş ZO, Kircelli C. Maxillary molar distalization with
a bone-anchored pendulum appliance. Angle Orthod 2006;76:650-9.
16. Onça
g G, Seçkin O, Dinçer B, Arikan F. Osseointegrated implants
with pendulum springs for maxillary molar distalization: a cepha-
lometric study. Am J Orthod Dentofacial Orthop 2007;131:16-26.
17. Oberti G, Villegas C, Ealo M, Palacio JC, Baccetti T. Maxillary molar
distalization with the dual-force distalizer supported by
mini-implants: a clinical study. Am J Orthod Dentofacial Orthop
2009;135:282.e1-5.
18. Polat-Ozsoy O, Kircelli BH, Arman-Ozçirpici A, Pektaş ZO, Uçkan S.
Pendulum appliances with 2 anchorage designs: conventional an-
chorage vs bone anchorage. Am J Orthod Dentofacial Orthop
2008;133:339.e9-17.
19. Cornelis MA, De Clerck HJ. Maxillary molar distalization with mini-
plates assessed on digital models: a prospective clinical trial. Am J
Orthod Dentofacial Orthop 2007;132:373-7.
20. Park HS, Lee SK, Kwon OW. Group distal movement of teeth using
microscrew implant anchorage. Angle Orthod 2005;75:602-9.
21. Phillips B, Ball C, Sackett D, Badenoch D, Straus S, Haynes B, et al.
Centre for Evidence-Based Medicine. Levels of evidence. Available
at: www.cebm.net/index.aspx?o51025. Accessed on August 28,
2010.
22. Kinzinger GS, Fritz UB, Sander FG, Diedrich PR. Efficiency of a pendu-
lum appliance for molar distalization related to second and third molar
eruption stage. Am J Orthod Dentofacial Orthop 2004;125:8-23.
23. Karlsson I, Bondemark L. Intraoral maxillary molar distalization:
movement before and after eruption of second molars. Angle
Orthod 2006;76:923-9.
June 2011  Vol 139  Issue 6