Practice Pearls

Maxillary molar distalization with

the Indirect Palatal Miniscrew
for Anchorage and Distalization
Appliance (iPANDA)
Eduardo Yugo Suzuki, DDS, PhD1
Boonsiva Suzuki, DDS, PhD2

Aim: Distalization of the maxillary molars is an important treatment option for the
correction of Class II malocclusions. The purposes of this study were to introduce
the clinical application of the indirect Palatal miniscrew Anchorage and
Distalization Appliance (iPanda) and to describe the dental and skeletal effects
obtained with this innovative appliance. Methods: Pretreatment (TO), post-
distalization (T1), and posttreatment (T2) lateral cephalometric radiographs and
dental casts of 20 consecutively treated adult patients (mean age 23.2 ± 4.7
years) with Class II molar relationship were analyzed. All patients were treated
with the iPanda for maxillary molar distalization. The iPanda was anchored on a
pair of midpalatal miniscrew implants to deliver the distalizing force to the
maxillary first molars. The iPanda was the only appliance used during the
distalization phase of treatment. A paired t test analysis was used to statistically
assess the effects of treatment. Results: A Class I molar relationship was obtained
in a mean period of 3.2 ± 0.6 months. Cephalometric analysis demonstrated that
the maxillary first molars were significantly distalized by an average 4.5 ± 1.5 mm
(P < .001) and were intruded by a mean of 1.0 mm ± 0.8 mm (P < .05). No
significant change in the inclination of the first molars was observed. No
1Instructor, significant change in the mandibular plane was observed. Dental model analysis
Department
of Orthodontics, Faculty demonstrated an asymmetric pattern of distalization between right (4.5 ± 2.2 mm)
of Dentistry, Chiang Mai
University, Chiang Mai,
and left (3.1 ± 2.1 mm) first molars. The transverse width of the dental arch was
Thailand maintained. No significant rotation of the first molars was observed. Conclusions:
2Associate Professor,

Department of This study demonstrated that the innovative iPanda is effective to bodily distalize
Orthodontics, Faculty the maxillary molars into a Class I molar relationship and to provide maximum
of Dentistry, Chiang Mai
University, Chiang Mai, anchorage. Orthodontics (Chic) 2013;14:e228–e241. doi: 10.11607/ortho.982
Thailand

CORRESPONDENCE Key words: Miniscrew implants, Molar distalization, appliances

Dr Boonsiva Suzuki
Department of
Orthodontics, Faculty
of Dentistry Chiang Mai

D
University istalization of the maxillary molars is an important treatment option for
Suthep Road, Amphur the correction of Class II malocclusions.1-14 Conventional approaches to
Muang, Chiang Mai 50200,
Thailand distalize the maxillary molars include the use of extra- or intraoral de-
Email: vices.1-3 However, the esthetic and social concerns of headgear wear for molar
boonsiva@hotmail.com distalization and the control of anchorage loss with the use of intraoral molar
©2013 by Quintessence mechanics has stimulated several investigators to evaluate the possibility of
Publishing Co Inc. using miniscrew implants as anchorage devices.15-25

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 Practice Pearls
Miniscrew implants with reduced sizes allow their insertion in the interradicu-
lar bone between the roots of adjacent teeth, thus allowing the application of
relatively simple orthodontic force systems.26,27 However, the midpalatal suture
site should be considered as a safe and viable alternative for miniscrew place-
ment if the availability of interradicular bone between the roots is insufficient
to allow safe miniscrew placement.28-30 Moreover, miniscrews inserted into the
interradicular bone present disadvantages in performing distalization as they
may interfere with the dental movement.23,24
The midpalatal suture site is composed of dense cortical bone and has been
recommended as the best anchorage site in the maxilla.28-30 Moreover, be-
cause additional height is provided by the nasal crest, the midsagittal area of
the palate is regarded as a safe location for miniscrew implants.29 However,
miniscrew implants placed in the midpalate require additional accessories,
such as transpalatal bars or extension arms to allow their use.22,23,30 In addition,
there is a paucity of devices designed to allow the application of midpalatal
miniscrews in the distalization of the maxillary molars.
Several authors have described the use of conventional non-compliance
intraoral distalizing devices, such as the Distal Jet or Pendulum appliances,
anchored to miniscrews inserted at locations paramedian to the palatal suture,
to distalize the maxillary molars.19-21 Although these appliances can produce
significant amounts of distal movement, they are difficult to fabricate and the
use of the palatal acrylic button generates problems with maintaining proper
oral hygiene.21 Moreover, it has been demonstrated that these paramedian
miniscrews do not offer stationary anchorage during molar distalization.21
To overcome such difficulties, the authors have developed a simplified and
innovative distalization appliance that allows the effective use of midpalatal
miniscrew implants, the indirect Palatal miniscrew Anchorage and Distalization
Appliance (iPanda). The iPanda is easily connected to and removed from the
midpalatal miniscrews and allows either maximum anchorage or distalization of
the maxillary molars, or both in succession.
Therefore, the purposes of this study are to introduce the clinical application
of the iPanda and to describe the dental and skeletal effects obtained with this
innovative appliance.

MATERIALS AND METHODS

Twenty consecutively admitted adult patients diagnosed with dental Class II

malocclusions who had undergone previous orthodontic treatment with four-
premolar extractions were selected for this study. There were 12 female and
8 male patients. The mean age at the start of treatment was 23.2 years (range
from 16.6 to 35.3 years) (Table 1). Initial records showed molar Class II relation-
ship and large overjet. Extraction of the maxillary second molars combined
with the distalization of the first molars with the iPanda was the main treatment
option to restore a Class I molar relationship and reduce the large overjet.

IPanda fabrication
A custom-made iPanda was fabricated on the dental cast for each patient
(Fig 1a). A 0.9 mm round stainless steel archwire (Dentaurum, Ispringen,
Germany) was bent with a Young pliers instrument to produce a 2 mm wide
and 10 mm long teardrop loop (Fig 1d). The bent teardrop loop, in this ap-
pliance, was used to produce a custom-made self-locking system between
the heads of two midpalatal miniscrews and the iPanda appliance (Fig 2). This
self-locking system allows easy and quick connection to and removal from the
midpalatal miniscrews, without the need of any additional accessories, such as

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Practice Pearls Maxillary molar distalization with the iPANDA appliance

Table 1   Patient characteristics and distal tooth movement

Distal tooth movement (mm)*
Case Age Months U6R U6L
 1 16.6 3.0 4.1 3.8
 2 17.2 3.0 4.1 2.1
 3 22.6 2.5 2.0 3.4
 4 18.8 3.5 4.1 3.7
 5 19.2 2.5 1.5 1.9
 6 23.5 3.0 3.8 1.3
 7 18.6 4.0 3.8 3.9
 8 22.3 4.0 4.3 3.1
 9 26.0 2.5 1.7 3.6
10 21.2 2.5 1.6 3.1
11 23.4 3.0 3.7 3.9
12 24.3 3.0 2.2 1.3
13 25.6 4.0 3.8 4.1
14 26.3 3.5 2.5 2.7
15 24.2 3.0 3.1 3.4
16 32.2 4.0 4.0 1.6
17 35.3 4.0 3.8 2.2
18 19.6 3.0 1.8 3.2
19 22.3 2.5 1.7 1.6
20 25.6 3.0 3.0 1.8
Mean 23.2 3.2 3.0 2.8
SD 4.7 0.6 1.0 1.0
*Measurements performed on the dental cast (T0-T1)

a b

c d

Fig 1   Details of an iPanda. (a) The iPanda is fabricated for each patient on the dental cast. (b and c)
Extension arms connect the first molars with single round molar tubes. (d) Palatal bar with a long tear
drop loop to allow connection to the miniscrew heads.

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 Suzuki et al
Practice Pearls

Fig 2   Self-locking system allows easy and quick connection to and removal from the midpalatal mini-
screw heads. A minimum clearance space between the iPanda and the palatal mucosa is maintained,
thus avoiding impingement.

Fig 3  Nickel titanium closed coil springs deliver light and continuous distalizing forces the
maxillary molars.

ligatures or composite materials to stabilize the appliance. This innovative self-

locking system also eliminates the need for acrylic buttons in the palate, thus
facilitating the patient’s oral hygiene. Another advantage of this self-locking
system is the possibility of maintaining a minimum clearance space between
the palatal archwire and the palatal mucosa, thus avoiding risks of palatal bar
impingement on the palate.
Additional loops were incorporated bilaterally at the extended arms to allow
connection to the light wire single round tubes with hooks (Tomy International
Inc, Tokyo, Japan) that were bonded on the lingual side of the maxillary first
molars (Figs 1b and 1c). The distalizing force was delivered through the 100-cN
nickel titanium Sentalloy closed coil springs (GAC International, Bohemia, NY),
which were inserted bilaterally. The high springiness effect obtained from the
long arms of the iPanda appliance, combined with the nickel titanium closed
coil springs, allows light and continuous distalizing forces to be delivered bi-
laterally to the maxillary molars (Fig 3). Since the iPanda is firmly stabilized on
the pair of midpalatal miniscrew implants, it allows the use of asymmetric molar
distalizing forces without compromising the anchorage (Fig 4).
If simultaneous distalization of both first and second molars is planned, dis-
talizing forces of 200- to 300-cN nickel titanium closed coil springs can be
inserted bilaterally.

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Practice Pearls Maxillary molar distalization with the iPANDA appliance

Fig 4   Initial intraoral photographs of pre- and post-molar distalization with the iPanda.

Treatment progress
A pair of self-drilling, conical-type, titanium miniscrew implants (Dual Top Anchor
system, Jeil Medical Co, Seoul, Korea) of 1.6 mm diameter and 6 mm length
was inserted in the midpalatal suture of each of the patients following the
protocol described by Suzuki and Suzuki.26 An average distance of 10 mm be-
tween miniscrew implants was maintained in order to provide a stable skeletal
anchorage to the iPanda. The custom-made iPanda was connected to the
midpalatal miniscrews with the teardrop loop. Then, the single round tubes
were bonded bilaterally on the lingual surface of the maxillary first molars with
4-META/MMA-TBB resin cement (Superbond C&B, Sun Medical, Kyoto, Japan).
Distalizing force was applied bilaterally on the first maxillary molars. The ap-
pliances’ coil spring systems were activated to a distalization force of 100 cN.
Regular follow-up visits were conducted to re-activate the iPanda.
After the maxillary molar distalization had been completed, the iPanda was
maintained in position to serve as an indirect anchorage device to maintain
the molars in position while performing the distalization of the remaining teeth
(premolars, canines and the anterior incisors).

Cephalometric analysis
Lateral cephalometric radiographs, made before treatment (T0), post-distalization
(T1) and at the end of the treatment (T2), were used to evaluate the effects
of treatment with the iPanda, and to assess whether the palatal miniscrews
remained stationary during the treatment. Fifteen anatomic landmarks were
recorded to allow the measurement (Fig 5). All tracings were performed by a
single experienced investigator (BS). A custom-made computerized cephalo-
metric digitizer (Smart’n Ceph v 8.1 digitizer software, Y&B Products, Chiang
Mai, Thailand) was used to perform the measurements.

Error of the method

The errors associated with the method were computed using all lateral radio-
graphs in order to examine measurement reliability. Each film was measured
and digitized twice, with a three-week interval between the two repetitions.
Analysis of the mean differences between duplicate measurements were ana-
lyzed using a paired t test to show the systematic errors (P < 0.05).31 Differ-
ences between the measurements were 0.8 mm ± 0.4 mm (mean ± SD) for the
linear, and 1.8° ± 0.5° for the angular measurements, and were not statistically
significant.

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 Suzuki et al
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Fig 5  Cephalometric angular
and linear measurements. 1, SNA;
2, U1 to FH plane (U1-FH); 3, U6
to FH plane (U6-FH); 4, FH to
mandibular plane (Mand. Plane);
5, first molar cusp to the palatal
plane (U6-PP); 6, Upper incisal
edge to pterygoid vertical plane
(U1-PTV); 7, Upper molar cusp to
PTV (U6-PTV); 8, Posterior mini-
screw to FH plane (PMI-FH); 9,
Anterior miniscrew to FH plane
(AMI-FH); 10, Posterior miniscrew
to PTV (PMI-PTV);11, Anterior
miniscrew to PTV (AMI-PTV).

Fig 6  Dental cast analysis. A

coordinate system (x, y) was con-
structed using the midpalatal
miniscrews as reference land-
marks. α; angle formed between
the right maxillary molar and the
y axis; β, angle formed between
the left maxillary molar and the
y axis; AL, arch length measured
between the maxillary incisors
and the x axis; U6Rw, distance be-
tween the lingual cusp tip of the
right first maxillary molar and the
y axis; U6Rw, distance between
the lingual cusp tip of the left first
maxillary molar and the y axis;
MU6R, distance between the con-
tact point of the right first maxil-
lary molar and the x axis; MU6L,
distance between the contact
point of the left first maxillary mo-
lar and the x axis.

Dental cast analysis

The dental cast analysis was performed using the midpalatal miniscrew im-
plants as a stationary reference. Dental casts made at T0, T1 and T2 were pho-
tographed as digital images at fixed magnification with a resolution of 600 DPI
and then transferred to a computer. Each measurement was made on the com-
puter display monitor with custom-made software, Smart’n Align V 1.0 software
(Y&B Products, Chiang Mai, Thailand). A coordinate system (x, y) was construct-
ed using the midpalatal miniscrews as reference landmarks, with the y-axis run-
ning through the centers of the miniscrews, and the x-axis running through the
anterior miniscrew. Angular and linear measurements were as follows (Fig 6).

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Practice Pearls Maxillary molar distalization with the iPANDA appliance

Angular and Linear Measurements

• α and β: The angle formed between the constructed line passing through the
mesial and distal contact points of the first molars and the reference y-axis
(α and β) was calculated in order to identify any rotational changes that may
occur in the maxillary first molars during the distalization.
• AL: The arch length (AL) was defined as the distance between a tangent to
the incisal edges of the maxillary incisors and the x-axis. The AL measure-
ment allows the quantification of the retraction of the anterior incisors.
• U6Rw: The distance between the mesiolingual cusp tip of the right first max-
illary molar and the y-axis.
• U6Lw: The distance between the mesiolingual cusp tip of the left first maxil-
lary molar and the y-axis.
• Assessment of pre- and posttreatment U6Rw and U6Lw measurement allows
the identification of possible changes in the arch width on the right and left
maxillary arches, respectively.
• MU6R: The distance between the mesial contact point of the right first maxil-
lary molar and the x-axis.
• MU6L: The distance between the mesial contact point of the left first maxil-
lary molar and the x-axis.

Assessment of pre- and posttreatment MU6R and MU6L values allows the
calculation of the amount of distalization of the right and left molars, respectively.

Statistical analysis
The statistical analyses were performed using the SPSS program (SPSS Inc,
Chicago, Ill., USA) on a personal computer. The mean and the standard deviation
of the measurements were calculated. A paired t-test analysis was used to assess
the significance of the amount of two-dimensional displacement demonstrated
by the T0-T1 and T1-T2 values. Significance level was established at .05.

RESULTS

Molar distalization (T1-T0)

No problems or complications, such as appliance dislodgement or breakage,
were observed with the iPanda during the bilateral maxillary molars distaliza-
tion. No patient discomfort was observed during the distalization period. All
miniscrew implants were stable at the end of the maxillary molar distaliza-
tion. Cephalometric measurements indicated that the midpalatal miniscrews
remained stationary during distalization (Table 2).
Cephalometric analysis of the movement during the distalization period
(T1-T0) demonstrated that the maxillary first molars were distalized by a mean
of 4.5 ± 1.5 mm (P < .001) into a Class I molar relationship. An average of
3.2 ± 0.6 months was necessary to distalize the maxillary molars to a Class I re-
lationship (Table 1). Therefore, the approximate distalization rate was 1.4 mm/
month. No significant change in the inclination of the first molars (U6-FH) was
observed. In the distalization process, the first molars were intruded by a mean
of 1.0 mm ± 0.8 mm (P < .01). No significant change in the position of the up-
per incisors (U1-FH) was observed. No significant change in the mandibular
plane was observed (Table 2).
Dental cast analysis (T1-T0) demonstrated an asymmetric pattern of distal-
ization between right and left first molars. The right maxillary first molars were
distalized an average of 3.7 ± 2.4 mm (P < .001), while the left maxillary first
molars were distalized an average 5.2 ± 4.9 mm (P < .01) into a Class I molar

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Table 2   Changes in cephalometric and dental cast measurements from
pretreatment (T0) and post-distalization(T1)
Pretreatment Posttreatment Treatment
(T0) (T1) changes (T1-T0)
Variables Mean SD Mean SD Mean SD P Significance
Cephalometric variables
Angular
  SNA (degrees) 88.9 4.2 88.2 4.2 –0.6 1.7 0.358 NS
  U1-FH (degrees) 123.3 9.6 122.2 8.5 –1.2 5.6 0.602 NS
  U6-FH (degrees) –84.6 4.2 –82.8 6.0 1.8 4.0 0.276 NS
  Mandibular plane (degrees) 26.1 4.5 25.8 5.5 –0.3 4.2 0.854 NS
  AMI-FH (degrees) 76.2 7.7 77.7 8.4 1.5 3.0 0.676 NS
  PMI-FH (degrees) 80.3 13.6 79.5 10.9 –0.8 4.2 0.805 NS
Linear
  U1-PTV (mm) 67.7 5.3 66.5 7.0 –1.2 3.0 0.327 NS
  U6-PTV (mm) 32.7 5.3 28.2 5.2 –4.5 1.5 0.000 ***
  U6-PP (mm) 25.8 1.3 24.9 0.7 –1.0 0.8 0.019 *
  AMI-PTV (mm) 41.2 4.4 40.9 4.7 –0.4 4.6 0.574 NS
  PMI-PTV (mm) 29.0 5.1 31.6 4.8 2.6 5.0 0.425 NS

Dental cast variables

Angular
  α (degrees) 13.0 4.4 16.8 3.3 4.2 5.8 0.114 NS
  β (degrees) 11.9 8.8 9.8 4.8 –1.3 11.4 0.598 NS
Linear
  AL (mm) 49.2 11.5 48.4 10.8 –8.9 6.5 0.172 NS
  U6Rw (mm) 26.1 5.7 28.3 7.2 0.5 2.3 0.021 *
  U6Lw (mm) 29.9 6.7 33.2 8.3 1.6 2.7 0.029 *
  MU6R (mm) 6.1 4.9 11.6 4.8 3.7 2.4 0.005 **
  MU6L (mm) 7.2 4.5 10.0 3.5 5.2 4.9 0.005 **
NS, Non-significant; *P < .05; **P < .01; ***P < .001

relationship. The transverse width of the dental arch was increased by an aver-
age of 0.5 ± 2.3 mm and 1.6 ± 2.7 mm (P < .01), for the right and left segments,
respectively. There was no significant distal rotation of the first molars during
the distalization process (Table 2).

Treatment effects following molar distalization (T2-T1)

Following the maxillary molar distalization, the iPanda was maintained in posi-
tion throughout the orthodontic treatment period (T2-T1) to serve as an indi-
rect anchorage device to maintain the molars in position while performing the
distalization of the remaining teeth. Cephalometric measurements indicated
that the midpalatal miniscrews remained stationary throughout the orthodon-
tic treatment (Table 3).
Cephalometric analysis of the treatment effects with the iPanda following
the molar distalization (T2-T1) are shown in Table 3. No significant difference
in the position of the maxillary first molar between T1 and T2 was observed. In
the contraction of the anterior segment, the incisors were retracted by a mean
of 6.1 ± 6.5 mm (P < .05). The maxillary incisors significantly inclined palatally
by a mean of 12.9 ± 11.1° (P < .05). An average period of 8.7 ± 3.6 months
was necessary to perform the contraction of the anterior segment. The overall
treatment (T0-T1) effects of the iPanda are summarized in Fig 7.

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Practice Pearls Maxillary molar distalization with the iPANDA appliance

Table 3   Changes in cephalometric measurements from post-distalization(T1) and

posttreatment (T2)
Pretreatment Posttreatment Treatment
(T1) (T2) changes (T2-T1)
Variables Mean SD Mean SD Mean SD P Significance
Cephalometric variables
Angular
  SNA (degrees) 88.2 4.2 87.6 4.3 –0.6 4.2 0.708 NS
  U1-FH (degrees) 122.2 8.5 109.3 12.6 –12.9 11.1 0.022 *
  U6-FH (degrees) –82.8 6.0 –83.7 7.3 –1.0 8.3 0.770 NS
  Mandibular plane (degrees) 25.8 5.5 26.4 6.0 0.6 6.4 0.813 NS
  AMI-FH (degrees) 77.7 8.4 79.0 7.1 1.2 3.3 0.724 NS
  PMI-FH (degrees) 79.5 10.9 80.4 8.8 1.3 2.0 0.790 NS
Linear
  U1-PTV (mm) 66.5 7.0 60.3 6.0 –6.1 6.5 0.047 *
  U6-PTV (mm) 28.2 5.2 27.7 4.1 –0.5 6.1 0.824 NS
  U6-PP (mm) 24.9 0.7 25.4 2.6 0.5 2.1 0.560 NS
  AMI-PTV (mm) 40.9 4.7 38.5 5.2 –1.5 2.6 0.466 NS
  PMI-PTV (mm) 31.6 4.8 29.3 8.7 –1.7 3.7 0.379 NS
Dental cast variables
Angular
  α (degrees) 16.8 3.3 15.2 4.8 –1.7 4.4 0.349 NS
  β (degrees) 9.8 4.8 9.4 4.5 –0.3 4.0 0.831 NS
Linear
  AL (mm) 48.4 10.8 41.5 13.4 –6.8 7.0 0.041 *
  U6Rw (mm) 28.3 7.2 26.0 6.1 –2.3 1.9 0.020 *
  U6Lw (mm) 33.2 8.3 30.7 7.4 –2.5 2.1 0.022 *
  MU6R (mm) 11.6 4.8 11.5 4.9 –0.2 1.2 0.715 NS
  MU6L (mm) 10.0 3.5 11.5 3.2 1.6 3.8 0.314 NS
NS, Non-significant; *P < .05; **P < .01; ***P < .001

Fig 7   Diagram of the dental changes following the use of the iPanda.
*P < .05, **P < .01, ***P < .001

Dental cast analysis (T2-T1) demonstrated that the transverse width of the
dental arch was reduced by an average of 2.3 ± 1.9 mm and 2.5 ± 2.1 mm
(P < .05) during the contraction phase. The maxillary incisors were retracted by
an average of 6.8 ± 7.0 mm (P < .05) (Table 3).

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DISCUSSION

In this study, the authors introduce an innovative non-compliance iPanda to

perform the maxillary molar distalization in Class II malocclusions and describe
the dental and skeletal effects obtained with this appliance.

Molar distalization (T1-T0)

Cephalometric analysis of the distalization process (T0-T1) demonstrated that
a significant amount of maxillary molar distalization (4.5 mm) with no signifi-
cant distal tipping was obtained with the iPanda. The results demonstrated
an increased amount of molar distalization compared to the results of similar
studies using conventional non-compliance intraoral appliances and miniscrew
supported distalizers.3-14,17-25 Bolla et al have evaluated the dental and skel-
etal effects of the Distal Jet appliance in growing patients.8 The authors have
reported a significant amount of maxillary molar distalization of 3.2 mm with a
distal tipping of 3.1°. Papadopoulos et al reported 4.0 mm of maxillary distal
movement with the non-compliance FCA.14 Chiu et al compared the effect of
the Distal Jet and Pendulum appliances to distalize molars and observed that
both appliances were able to achieve 3.0 mm of distal movement.4 However, in
these studies only growing patients with maxillary second molars not emerged
into the oral cavity were included. Moreover, some amount of anchorage loss
measured at the premolar area has often been reported.8-12
The increased amount of molar distalization obtained in the present study
was also higher than in similar studies using miniplates and miniscrews as an-
chorage.17-25 Sugawara et al24 reported that the maxillary molars were moved
distally by approximately 4.0 mm at the crown level with miniplate anchor-
age. Yamada et al25 reported an average molar distalization of 2.8 mm and
distal tipping of 4.8 degrees with miniscrews inserted in the interradicular
space. The increased amount of distalization obtained in the present study
can be explained by three main factors: (1) the miniscrew implant inserted in
the midpalatal suture did not interfere with the path of distal movement of
the maxillary molars, allowing a large amount of movement (compared to the
interradicular miniscrews); (2) the second maxillary molars were extracted, pro-
ducing an edentulous area with new bone formation for the distalization of the
first molars; and (3) the nickel titanium Sentalloy closed coil springs used light
and continuous forces, applied directly to the maxillary first molars.
In the present study, no significant distal tipping was obtained with the iPanda.
The explanation for the controlled body movement is the design of the iPanda.
The use of the round buccal tubes (0.9 mm diameter) sliding though the large
diameter palatal bar (0.9 mm diameter) prevents the molars from tipping dis-
tally. It also avoids the distal rotation of the maxillary first molars during distal-
ization. The bodily movement observed in the present study contrasts with the
studies using non-compliance devices that often generate a significant amount
of distal tipping during the distalization process.3-14 Moreover, distalizing de-
vices using miniplates and miniscrews often generate a significant amount of
distal tipping during the distalization process.24,25
In the present study, although the treatment was performed in a group of
adult patients, the rate of molar distalization was 1.4 mm per month. This rate
is higher than that achieved in similar studies involving either non-compliance
intraoral appliances in growing patients, distalizing devices using miniplates,
or miniscrews.2,24,25
Conventional, non-compliance intraoral appliances designed to produce
molar distalization often result in some amount of molar extrusion and sub-
sequent clockwise mandibular rotation.3-8 In the present study, however, the
first molars were intruded by an average of 1.0 mm during the distalization

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Practice Pearls Maxillary molar distalization with the iPANDA appliance

process. This result is similar to that of Yamada et al25 (0.6 mm), who used
miniscrews inserted into the interradicular spaces to distalize the molars. This
result suggests that clockwise rotation of the mandible could be prevented by
intrusive force produced by the miniscrew-supported distalizing appliances.25
In the present study, cephalometric analysis demonstrated that the midpala-
tal miniscrews were stable and remained stationary throughout the orthodontic
treatment. Therefore, the pair of miniscrews in the palate was used as a reliable
stationary reference landmark to allow the superimposition of pre-distalization,
post-distalization, and posttreatment dental casts. Moreover, it allowed for the
construction of a coordinate system that permitted accurate comparison be-
tween the amounts of distalization in the right and left segments. This mea-
surement method facilitates the identification of sagittal and transverse dental
changes using the dental casts.
Dental cast analysis (T1-T0) identified an asymmetric pattern of distalization
between right and left first molars. Differences in the amount of molar distal-
ization can be explained by the different amounts of distalization required to
achieve a Class I molar relationship. The results indicated that the iPanda has
the potential to provide different amounts of molar distalization between right
and left segments without compromising the anchorage. Only a few studies
describe the asymmetric effects of distalizing devices. Yamada et al25, using
buccal miniscrews to distalize molars, described different amounts of distal-
ization between right and left segments. However, their measurements were
performed on lateral cephalometric films, which may not reliably distinguish
between right and left sides.
Dental cast analysis also demonstrated that the transverse intermolar width
was increased, since both right and left molars moved buccally (0.5 mm and
1.6 mm, respectively) as the result of the distalization. This effect was attributed
to the large amount of distalization obtained and to the design of the palatal
bar of the iPanda that guided the molars parallel to the posterior part of the
maxillary arch. The results are in agreement with those of several previous stud-
ies reporting the use of noncompliance distalization devices.8,14

Treatment effects following molar distalization (T2-T1)

Cephalometric analysis of the treatment effects with the iPanda (T1-T2) dem-
onstrated that following the maxillary first molar distalization, the iPanda was
still effective in maintaining the amount of distalization obtained in the dis-
talization period (T0-T1) and in providing additional maximum anchorage to
the molars during the retraction of the anterior teeth. A significant amount of
incisor retraction was possible without compromising the anchorage on the
posterior teeth.
In the present study, the overcorrection of molar distalization was performed
during the retraction of the anterior segment in order to achieve a full Class I
molar relationship. The iPanda was actively maintained in position, aided by
an elastomeric chain in order to provide additional anchorage to the maxil-
lary first molars during the anterior retraction (Fig 8). In this system, the small
amount of continuous distalizing force was used to reinforce the maxillary
first molar anchorage while avoiding any undesirable mesial movement of the
molars, therefore providing a “dynamic anchorage” of the molars. This dy-
namic anchorage of the molars has been shown to be effective in eliminating
the risks of mesial movement of the molars that is often observed during the
retraction phase. Wehrbein et al32 evaluated the anchorage capacity of pala-
tally inserted Orthosystem implants for anchorage reinforcement of posterior
teeth. The authors observed that even more rigid palatal bars (1.2 × 1.2 mm)
allowed some mesial movement of molars during the retraction of the ante-
rior segments.32

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 Suzuki et al
Practice Pearls
Fig 8   “Dynamic anchorage” of the molar is pro-
vided by an elastomeric chain.

Interestingly, with the dynamic anchorage of the molars, a small but not sig-
nificant amount of distalization, as observed in the MU6L, was obtained during
the retraction phase (T2-T1).
The results indicate that the iPanda is effective in anchoring the maxillary
molars throughout the orthodontic treatment.
Dental model analysis (T2-T1) confirmed the cephalometric findings that the
maxillary first molar remained stationary (in the sagittal dimension) throughout
the retraction of the anterior teeth. A large amount of maxillary incisor retrac-
tion was possible with the iPanda without compromising the anchorage of the
molars. The results indicated that the iPanda was not only efficient in maintain-
ing the amount of molar distalization, but also efficient in providing maximum
anchorage to the molars during anterior retraction. This is an advantage, since
most non-compliance distalizers must be replaced by a Nance button, after dis-
talization has been completed until the second phase of treatment with fixed
appliances, to prevent, or at least minimize, the possible anchorage loss (mesi-
alization of the maxillary molars).14
Model analysis also demonstrated that the intermolar width (transverse di-
mension) was decreased to values similar to the initial values following the
removal of the palatal bar. The results indicated that although the iPanda had
a tendency to produce the buccoversion of the molars during the distalization
process, the intermolar width returned to the initial values after the distalizing
force was removed during the contraction phase of the treatment. Therefore, a
transient-pattern maxillary expansion is caused by the iPanda.
Most of the intraoral distalization devices involving miniscrew implants are mere
adaptations of the pre-existing, conventional non-compliance intraoral devices,
such as Distal Jet and Pendulum appliances, in order to avoid the undesirable an-
chor loss.15-21 These appliances are often adapted to allow connection to the para-
median miniscrew implants through the acrylic Nance button in order to obtain
skeletal anchorage. However, as in the conventional intraoral distalizers, the palatal
acrylic Nance button generates problems with maintaining proper oral hygiene.
Recently, a modification in the appliance design has been developed to
eliminate the acrylic palatal button, thus avoiding oral hygiene concerns.
Kinzinger et al.21 designed a modified distal jet appliance that is anchored to
short paramedian miniscrew implants without the acrylic Nance button. How-
ever, the authors observed that paramedian miniscrew implants with short
lengths could not remain stationary during the maxillary molar distalization.21
Practical clinical approaches have been described to indirectly connect these
palatal bars to the miniscrew head through the use of light-cured composites
or bonding materials, thereby obtaining a rigid fixation palatal bar-screw.23,30
However, these methods do not allow the easy replacement of the palatal bar
during regular activation visits, nor do they allow adequate oral hygiene. More-
over, by the end of treatment, the removal of the miniscrew may be made dif-
ficult by the presence of composite material.

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Practice Pearls Maxillary molar distalization with the iPANDA appliance

In this study, the iPanda could be easily connected to and removed from the
heads of midpalatal miniscrew implants using a self-locking system. This simple
and effective mechanism avoids the accidental dislodgement of the palatal bar,
while allowing the orthodontist to simply remove or replace the palatal bar at
regular visits. Because the self-locking system does not require any additional
accessories, such as acrylic buttons in the palate, ligatures, or composite ma-
terials to remain stationary inside the patient’s mouth, it facilitates the main-
tenance of oral hygiene. Another advantage of this self-locking system is the
possibility of maintaining a minimum clearance space between the palatal bar
and the palatal mucosa, thus avoiding risks of palatal bar impingement on the
palate.
The clinical application of the iPanda is not limited to maxillary molar dis-
talization; it can also be used as an effective appliance to anchor the maxillary
molars when maximum anchorage is required. Because midpalatal miniscrew
implants, used to anchor the iPanda, are located far from the dental roots and
consequently do not interfere with the dental movement, they do not need to
be replaced following the molar distalization. In the present study, after the
maxillary molar distalization had been completed, the iPanda was maintained
in position to serve as an indirect anchorage device to maintain the molars in
position while performing the distalization of the remaining teeth (premolars,
canines and the anterior incisors).
Because the maxillary molars are efficiently anchored to the midpalatal mini-
screws through the iPanda, no adaptations in the conventional biomechanics
or force systems, such as adjustable long hooks or lever arms, are necessary to
perform the closure of the extraction spaces. As a result, the iPanda allows flex-
ibility to the orthodontist to apply either sliding or contraction loop mechanics
for the orthodontic treatment.
In this study, extractions of the maxillary second molars combined with the
distalization of the first molars with the iPanda were the main treatment op-
tion to restore a Class I molar relationship and reduce the large overjet for this
group of patients. However, the iPanda can also be used in non-extraction
cases to distalize both the first and second molars simultaneously with the ap-
plication of heavier distalizing forces (200 to 300 cN).

CONCLUSIONS

A midpalatal, miniscrew-supported appliance, the iPanda, has been described

as an alternative that allows non-compliance maxillary molar distalization while
providing improved palatal mucosal hygiene capacity by dispensing with the
acrylic button. The iPanda has shown to be effective, not only to distalize the
maxillary molars, but also to provide skeletal anchorage to the maxillary molars
throughout the orthodontic treatment.
Further studies are necessary to evaluate the total treatment changes follow-
ing the use of the iPanda.

ACKNOWLEDGMENTS
The authors acknowledge the assistance of Dr. M. Kevin O Carroll, Professor Emeritus of the
University of Mississippi School of Dentistry, USA, and Faculty Consultant, Chiang Mai University
Faculty of Dentistry, Thailand, in the preparation of the manuscript. This study was supported by
grant from the Faculty of Dentistry, Chiang Mai University, and grant number RSA 5480029 from
the Thailand Research Funding.

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 Suzuki et al
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