CLINICIAN’S CORNER

Distal movement of the maxillary molars

Anthony A. Gianelly, DMD, PhD, MDa

Boston, Mass.

Molars can be moved distally approximately 1 mm/month with little to no patient cooperation by
using intraarch compressed 100 gm NiTi coils or 100 gm looped NiTi wires against the molars
supported by a removable modified Nance appliance. When the molars are moved posteriorly by
these intraarch mechanisms, anchorage loss occurs and produces an increase in overjet that is
generally within acceptable limits. Although molars can be moved posteriorly at any age, an
advantageous treatment time is the late mixed dentition. (Am J Orthod Dentofacial Orthop 1998;
114:66-72.)

A common strategy to correct Class II

malocclusions by a nonextraction protocol is to
move the maxillary molars distally in the initial stage
of treatment to convert the Class II molar relation-
ship to a Class I. Because this approach is depen-
dant on the ability to move molars distally, there are
two observations that are particularly important to
me. One is that distal movement of the first molars
is easier to accomplish before the eruption of the
second molars.1 The second is that continuous
forces move teeth faster than intermittent forces.2
As an example, Armstrong1 routinely converted
Class II molar relationships to Class I in 3 to 4
months with continuous extra oral force in the
mixed dentition. On the other hand, when the same
force system was placed in persons in the early
permanent dentition, he cautioned that the “clinical
response . . . did not justify the use of continuous
extra-oral force.”
In summary, a favorable time to move molars
distally appears to be the mixed dentition, before
the eruption of the second molars; an efficient force
system to move molars distally is a continuously
acting force.
Many appliances are available to move molars
distally. The focus of this article will be on the use of
superelastic NiTi coils3 (Senetalloy coils, Gac, Cen-
tral Islip, N.Y.) and superelastic NiTi wires4 (Neo-
Senetalloy wire, Gac) developed by Miura, because
they apply constantly acting forces and require little
to no patient cooperation. As such, they can en-
hance our abilities to move molars distally.
The superelastic NiTi coils apply approximately
100 gm of force and are placed between the first
premolars and the first molars on 0.016 3 0.022
a
Boston University School of Dental Medicine.
Reprint requests to: Anthony A. Gianelly, DMD, PhD, MD, Boston
University, Goldman School of Dental Medicine, 100 East Newton Street,
Boston, MA 02118-2392.
Copyright © 1998 by the American Association of Orthodontists.
0889-5406/98/$5.00 1 0 8/1/85455
66
wires5 (Fig. 1). They are activated by compressing
them approximately 10 mm. This means that the
coils, in the passive state, are 10 mm longer than the
space between the distal wing of the bracket on the
first premolar and the molar tube. (This is an
empirically derived activation, principally to avoid
the need for reactivation as the molar moves distal-
ly.) Another method of activation is to place a
sliding lock in front of the coils and compressing the
coils by moving the lock 10 mm posteriorly before
fixing it in position (Fig. 2).
The compressed coils slide the molars along the
wire, which can be a sectional or continuous arch
wire. The distal end of the wire is left at least 5 mm
past the distal aspect of the molar tubes to allow the
molars to move over this distance (Fig. 1). For
patient comfort, the terminal portion of the wire is
bent palatally. Generally there is little to no irrita-
tion in the buccal fold.
The superelastic NiTi wire is an 0.018 3 0.025
inch wire that also applies 100 gm of force.6 To
move molars distally with this wire, a “loop” that
opens during deactivation is formed in the wire (Fig.
3). Because the wire cannot be bent in a conven-
tional sense, the loop is made as follows: two stops
are fixed on the arch wire, one at the distal of the
bracket on the first premolar and the other at the
terminal part of the molar tube (Fig. 3, A). This
means that the space between the stops is 5 to 6 mm
longer than the space between the bracket and the
mesial aspect of the molar tube. The wire is then
inserted into the molar tube, and, with a finger,
deflected into the buccal fold to make a loop. The
mesial stop is then placed against the first premolar
bracket and ligated (Fig. 3,B). It is helpful to cool
the wire with ice before insertion so that the wire
becomes softer and insertion is easier. The molars
are moved distally as the wire “flattens” to assume
its original shape. The movement with the NiTi wire
is friction free. Although the superelastic NiTi wire
can be used as a sectional or continuous arch wire, I
American Journal of Orthodontics and Dentofacial Orthopedics Gianelly 67
Volume 114, No. 1

prefer to use a sectional wire because a continuous

arch wire can produce movements that may not be
desirable.
The anchorage for the superelastic NiTi coils
and superelastic NiTi wires is a modified Nance
appliance. Until recently, the Nance appliance was
fixed to second primary molars when treatment was
started in the mixed dentition (Fig. 4) and to the first
premolars after these teeth had erupted (Fig. 2).
At present, a removable Nance appliance is
used; the framework is a transpalatal bar that is
inserted into compatible lingual sheaths on first
premolar bands (and on the second primary molar
bands in the mixed dentition) (Fig 5). The appli-
ance, which is inserted and removed from the distal
aspect of the sheaths, extends anteriorly to touch the
incisors and a 1 mm bite plate is added to disclude
the molars. For ease of construction on the working
model, the transpalatal bar is divided into two
sections and the male portion of each section is fit
into the corresponding lingual sheath (Fig. 5,A). In
addition, after cementation of the appliance, the
acrylic portion of the appliance is removed and
rebased for a more anatomic adaptation to the
palate.
The anchorage is also enhanced by ligating the Fig. 1. Illustration of superelastic NiTi coil. A, Coils are
second premolar, when present, to the first premolar compressed on 0.016 3 0.022 inch wire between the
by means of a ligature wire that encircles the second second premolar and the first molar. The wire extends 5
to 6 mm past the tube because the activated coil will
premolar and is tied to the first premolar bracket move the molar along the wire. Note terminal part of
(Fig. 6). The reason that the second premolars are wire bent toward palate; uprighting spring on the sec-
not used as abutments for the Nance appliance is ond premolar is used to support anchorage. B, Ex-
that the space between the second premolar brack- pected molar movement.
ets and first molar tubes is inconveniently small.
And if molar movement progresses with relatively
little anchorage loss, the ligature tie can be removed molar movement is the type of movement. Faster
to free the second premolar and allow it to drift movement occurs when the molar is tipped distally.
distally.
In a small group of patients, the use of magnets
RATE OF MOVEMENT often moved the crowns of the molars distally more
than 1 mm/month when the second molars were not
First molar crowns are moved distally at the rate
erupted; this suggests that movement occurs more
of approximately 1 mm/month, although there is
readily when only one tooth/side is moved.9
marked individual variation.7 As an example, Bon-
demark and Kurol7 moved both first and second END POINTS
molar crowns distally 4 mm in 16 weeks with repel-
Molars should be moved distally until they are
ling samarium cobalt magnets. The magnet system,
overcorrected by approximately 2 mm. The overcor-
which is also a non– cooperation based appliance,
rection is necessary for two main reasons:
generally moves molar crowns distally at a slightly
slower rate than superelastic NiTi coils.8 As the 1. Anchorage loss will invariably occur during
molars moved, the axial inclinations of the teeth the retraction of the premolars, canines, and
changed as the crowns moved distally more than the incisors and the overcorrection serves to com-
roots. pensate for this anchorage loss. In a sense, the
When these same investigators moved the mo- overcorrection is “prepared anchorage.” (An-
lars distally in a more bodily fashion by moving the chorage loss can be minimized if the premo-
molars along a rigid wire-tube assembly, the rate of lars and canines are allowed to drift distally
movement was only 0.5 mm/month.8 This suggests [Fig. 2].)
that one factor that influences the rate of distal 2. Molars that are moved distally by these pro-
68 Gianelly American Journal of Orthodontics and Dentofacial Orthopedics
July 1998

Fig. 2. A, NiTi coil activated by means of a sliding lock. B and C, Pre- and postradio-
graphs demonstrate molar movement. Note the change in axial inclination of the molars
and slight increase in overjet. (Treatment time, 4.5 months.) D and E, Molars stabilized with
a stopped 0.016 3 0.022 inch wire. Premolars have drifted distally to the Class I position.

cedures tip and the crown moves more pos-
teriorly than the root (Fig. 2). After overcor-
rection, the subsequent forward movement of
the molars to the Class I position aids in
uprighting the molars because the crowns
move mesially more than the roots as the
molars move anteriorly.
STABILIZATION OF THE MOLARS
Molars that have been moved distally have a
marked tendency to return mesially, particularly if
the second molars are present. This labile tendency
has been documented by Andreasen and Naessig10
who noted that 90% of the molar distal movement
produced by headgears was lost in 1 week when the
headgear was removed and no effort was made to
preserve the positions of the molars.
To maintain molar position, a headgear (prefer-
ably hi-pull for root uprighting) is recommended.
And a stopped 0.016 3 0.022 inch arch wire is
inserted (Fig. 2). When the molars are not severely
inclined distally, a 10° to 15° active tip back is used
in addition to the stop because the tip back impedes
mesial movement of the crowns. If the molars are
severely inclined distally, the tip back is made pas-
sive to avoid excessive distal inclination.
In addition, the molars are not used as anchor-
age for Class I forces for at least 4 to 5 months after
they have been moved distally because anchorage
loss can readily occur even with the use of headgear.
American Journal of Orthodontics and Dentofacial Orthopedics Gianelly 69
Volume 114, No. 1

Fig. 3. Illustration of superelastic NiTi wire. A, Stop placed on the wire distal to the first
premolar bracket and the distal aspect of the molar tube. B, Wire inserted into the molar
tube, deflected into the buccal sulcus, and ligated into the bracket of the first premolar
bracket. Uprighting spring on the first premolar is used to support anchorage. C, Expected
distal movement of the molar.

This reflects the unstable nature of the molars

immediately after they have been moved distally.
In effect, we recommend a 4 to 5 month “pause”
in retraction mechanics. This is not an inconve-
nience because the premolars and canines drift
distally during this time period1 (Fig 2). For this
reason, treatment proceeds advantageously while
molar position is stabilized because the premolars
drift close to or into the Class I position and the
canines drift at least 2 to 3 mm distally.

TIMING OF TREATMENT
As indicated previously, an optimal time to move
molars distally with these appliances is the mixed
dentition stage of development (preferably the late
mixed dentition) before the eruption of the second
molars (Fig. 2). Movement of the molars is the
fastest (at times exceeding 1 mm/month) and an-
chorage loss is the least when compared with treat-
ment after the eruption of the second molars. This
view is consistent with the previously cited observa-
tion by Armstrong1 who ligated headgears in pa-
tients and indicated that “clinical response in the
early permanent dentition did not justify the use of
continuous extra oral force.”

ANCHORAGE LOSS Fig. 4. Nance appliance in mixed dentition. A, Pre-

Anchorage loss will become evident as an in-
crease in overjet (or incisor crowding) when super-
elastic NiTi coils and superelastic NiTi wires are
used to move molars distally. The amount of an-
chorage loss produced by these appliances has not
been determined. However, it has been quantified
when using repelling magnets to move both the first
and second molars distally; the usual increase in
overjet was 2 mm when first and second molars were
treatment model. B, Intraoral photograph. Appliance is
cemented on the second primary molars. Compressed
coils were used to move the molars distally.
moved distally 4 mm.7 A similar amount of anchor-
age loss was also noted in another report that
evaluated the use of repelling magnets.11 This means
that two thirds of the space created by using the
70 Gianelly
Fig. 5. Removable Nance appliance. A, Transpalatal arch sectioned and connected with
acrylic. B, Nance in position. Note that the interdental acrylic is removed so that the appliance
can be removed. C, Palate after molars were moved with removable Nance appliance.
Fig. 6. Nance appliance with bands on first premolars.
Second premolars are ligated to the bands on the first
premolars.
repelling magnets to move both the first and second
molars distally represented molar movement and
one third of the space represented anchorage loss.
Because the magnet system is similar to the super-
elastic NiTi coils and superelastic NiTi wire, it
appears safe to assume that the anchorage loss with
these appliances would be comparable to the
amount determined for the repelling magnets. How-
ever, an important caveat is that there is marked
American Journal of Orthodontics and Dentofacial Orthopedics
July 1998
individual variation in patient response. At times,
the anchorage loss will be less than 2 mm. In other
patients, it can be far more than 2 mm.
From anecdotal reports, an estimate of the an-
chorage loss that occurs when moving first molars
distally with NiTi coils in the mixed dentition is that
it will not exceed 2 mm in most persons when the
molars are moved distally 4 to 5 mm.9,12 One
possible reason for this observation is that the
second molars are not near eruption (Fig. 2).
ANCHORAGE CONTROL
Anchorage loss is constantly evaluated by assess-
ing a change in overjet. The overjet is measured
immediately after placement of the appliance and
recorded in the same manner at each visit. No effort
is made to control incisor anchorage unless the
overjet increases by more than 2 mm. If the overjet
increases by 21 mm, 100 gm Class II elastics are
placed to maintain incisor position. They can be
attached to the premolars or on a sectional wire on
the incisor segment.
When Class II elastics are used, lower arch
anchorage is supported. One method for anchorage
control is to insert a lip bumper. An alternative,
when using a vertically slotted appliance, is to place
5° to 10° of lingual crown torque on the incisor
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 114, No. 1
segment with uprighting springs in the vertical slots
of the second premolar attachments, directing the
crowns distally.
When second molars are present, the overjet will
increase more than 2 mm in a large number of the
patients. This means that Class II elastics will be
used to control anchorage in these patients. How-
ever, it normally takes at least a few months for the
overjet to increase 2 mm. Therefore no anchorage
control is necessary in the initial stages of treatment.
SUCCESS RATE
The success rates of superelastic NiTi coils NiTi
superelastic wire to move molars distally have not
been systematically evaluated. My view is that there
are three age-related patient groupings and the
success rate and prognosis differ for each.
1. When first molars are moved distally in the
late mixed dentition stage of development,
the procedure is 90%1 successful. And molar
correction can be completed within 4 to 8
months.12
2. In the adolescent, when first molars are
moved distally after the eruption of the sec-
ond molars, they tend to move more slowly
and anchorage loss increases. Cusp to cusp
molar relationships are corrected reasonably
well. Full Class II relationships are much
more difficult to resolve. In most instances,
treatment is successful although incisor an-
chorage may require support to limit the
forward movement of these teeth to 2 mm.
3. In the adult, the success rate is highly variable
and more failures are noted.
To reiterate one important observation, the
large individual variation noted in some reports9,11
indicates that our ability to move molars distally in
any person is unpredictable. Success is anticipated if
the second molars are unerupted. When the second
molars are present and the rate of movement is less
than 1 mm/month and/or anchorage loss is ‘exces-
sive’, an alternative strategy is followed.
One option is to move only the second molars
distally. Once in position and stabilized, the first
molars are then moved posteriorly. This approach is
more conservative than moving both the first and
second molars distally at the same time and is
“safer” because anchorage loss tends to be less.
However, treatment time is generally increased by at
least 6 months because the molars are moved in
sequence.
An obvious question arises: when second molars
Gianelly 71
are present, why not routinely move the molars
distally in sequential fashion as this procedure is
“safer”? The reasons are convenience and treatment
time. The appliances are simpler to place against the
first molars and total treatment time is less if both
first and second molars are moved simultaneously.
In addition, both molars can be moved distally at the
same time with ample frequency to justify an at-
tempt at moving both together.
The second option is to change the treatment
plan to an extraction protocol unless contraindi-
cated. Extraction treatment is usually less compli-
cated when compared to nonextraction treatment
that involves moving the molars distally one at a
time and can be completed in less time.
THIRD MOLARS
Third molars that have erupted or are close to
erupting tend to impede the distal movement of the
first and second molars. For this reason, they are
removed when possible. However, the decision to
extract these teeth has important strategy implica-
tions. If third molars are removed, molar distal
movement to gain the space to resolve the maloc-
clusion is virtually mandatory because maxillary
premolar extraction is no longer tenable as it would
involve extracting four teeth in the same arch. After
third molars have been extracted and progress is
inadequate when moving both first and second
molars posteriorly at the same time, the procedure is
changed and the molars are moved in sequential
manner as described; second molar distal movement
is followed by first molar distal movement. The gain
in safety compensates for the increased time neces-
sary to complete molar distal movement.
CONCLUSION
Molars can routinely be moved distally with little to no
patient cooperation using intra arch superelastic NiTi
coils or superelastic NiTi wire in combination with a
modified Nance appliance. Because these appliances are
intraoral, they also create an anchorage problem, which,
in most instances, can be controlled with modest interven-
tion. Additionally, the degree of difficulty and prognosis
appears to be related to the stage of dental development
and the age of the patient. The highest success rate with
the fewest complications occurs when molars are moved
distally in the mixed dentition stage of development.
REFERENCES
1. Armstrong NM. Controlling the magnitude, duration and direction of extra oral
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2. Daskalogiannakis J, McLachlan KR. Canine retraction with rare earth magnets: an
investigation into the validity of the constant force hypothesis. Am J Orthod
Dentofacial Orthoped 1996;109:489-95.
72 Gianelly American Journal of Orthodontics and Dentofacial Orthopedics
July 1998

3. Miura F, Mogi M, Ohura Y, Karibe M. The super-elastic Japanese NiTi alloy wire
for use in orthodontics: Part III. studies of the Japanese NiTi coil springs. Am J
Orthod Dentofacial Orthop 1988;94:89-96.
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5. Gianelly AA, Bednar J, Dietz VS. Japanese NiTi coils used to move molars distally.
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NiTi wire. J Clin Orthod 1992;26:277-9.
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neously with repelling magnets. Eur J Orthod 1992;14:264-72.
8. Bondemark L, Kurol J, Bernhold M. Repelling magnets versus superelastic nickel
titanium coils in simultaneous distal movement of maxillary first and second
molars. Angle Orthod 1994;64:189-98.
9. Gianelly AA, Vaitas AS. The use of magnets to move molars distally. Am J Orthod
Dentofacial Orthop 1989;96:161-7.
10. Andreasen G, Naessig C. Experimental findings on mesial relapse of maxillary first
molars. Angle Orthod 1968;38:51-5.
11. Itoh T, Tokuda T, Kiyosue S, Matsumoto M, Chaconas S. Molar distalization with
repelling magnets. J Clin Orthod 1991;25:611-7.
12. Jones RD, White JM. Rapid Class II molar correction with an open-coil jig. J. Clin
Orthod 1992;26:551-664.

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