International Orthodontics 2020; 18: 96–104

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www.em-consulte.com
www.sciencedirect.com
Original article

Maxillary molar distalization in treatment of

angle class II malocclusion growing patients:
Uncontrolled clinical trial

Noha Ali Abdelhady, Marwa Ali Tawfik, Shaza Mohammed Hammad

Available online: 20 January 2020 Department of Orthodontics, Mansoura University, Mansoura, Egypt

Correspondence:
Noha Ali Abdelhady, Department of Orthodontics, Mansoura University,
Mansoura, Egypt.
noha_ali@mans.edu.eg

Keywords Summary
Orthodontics
Molar Distalization Objective > This study was conducted to evaluate the clinical effectiveness treatment effects of a
Miniscrew simple buccal technique for maxillary molar distalization using direct buccal skeletal anchorage.
Direct anchorage Materials and methods > After sample size calculation, fourteen female patients with bilateral
Class II molar relationship (age 11–14 years) were selected from the clinic of the Department of
Orthodontics, Faculty of Dentistry, Mansoura University, Egypt. After the application of the eligi-
bility criteria, only eleven patients remained to final evaluation. The criteria included: erupted
second maxillary molars, mild to moderate maxillary crowding not exceeding 6 mm with/without
increased overjet and non-extraction treatment in the lower arch. After alignment and levelling, a
miniscrew (1. 8 mm diameter – 0. 8 mm long) was placed buccally between the maxillary second
premolar and the first molar in each side. The maxillary molar distalization was done using
250 grams of force produced from NiTi closed coil spring stretched to a buccal miniscrew. Records
including cephalometric x-rays and study casts were taken for all patients before and after molar
distalization. Statistical evaluation was performed for the data obtained from analysis of cepha-
lometric tracing and cast photocopies.
Results > The maxillary first molars were distalized with a rate of 0. 89  0. 30 mm (95% CI 0.76–
1.02) (P < 0.001) and distalization amount of 4.09  0. 92 mm (CI 3.68–4.50) (P < 0.001). They
were distally tipped by 2.488  6. 16 (CI 0.26–5.21) (P = 0.073) and rotated distopalatally by
11.898  5.86 with negligible change in their vertical position about 0.11  0.63 mm (CI 0.40–
0.17) (P = 0.411). There was no anchorage loss evident by the distal movement of all the maxillary
teeth (P < 0.001). Overjet significantly reduced by 0. 86  0. 50 (CI 0.52–1.20) (P = 0.004).
Conclusions > Maxillary molar distalization using a closed coil and buccal miniscrew is an effective
and non-compliance dependent technique in a relatively short time.
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https://doi.org/10.1016/j.ortho.2019.11.003
© 2019 CEO. Published by Elsevier Masson SAS. All rights reserved.
Maxillary molar distalization in treatment of angle class II malocclusion growing patients: Uncontrolled clinical trial

Original article
Mots clés Résumé
Orthodontie
Distalisation molaire Distalisation molaire maxillaire dans le traitement des malocclusions de classe II d'angle
Mini-vis en période péripubertaire : essai clinique non contrôlé
Ancrage direct
Objectif > Cette étude a été menée pour évaluer les effets thérapeutiques d'une technique
vestibulaire simple avec ancrage direct squelettique vestibulaire pour la distalisation molaire
chez des patients en croissance.
Matériels et méthodes > Après calcul de puissance, quatorze patientes avec classe II bilatérale
(âge 11–14 ans) ont été sélectionnées dans le Département d'Orthodontie de la Faculté d'Odon-
tologie de l'université Mansoura en Égypte. Selon les critères d'éligibilité (secondes molaires en
place, encombrement arcade-dent modéré n'excédant pas 6 mm avec ou sans surplomb hori-
zontal, sans extractions à l'arcade mandibulaire), seulement onze patientes ont constitué
l'échantillon. Après alignement et nivellement, une mini-vis (diamètre 1,8 mm – longueur
0,8 mm) a été placée vestibulairement entre les deuxièmes prémolaires et premières molaires
maxillaires de chaque côté. La distalisation molaire a été réalisée avec une force de 250 g
produite par un ressort fermé en NiTi étiré jusqu'à la mini-vis vestibulaire. Des téléradiographies
de profil et des moulages ont été réalisés avant et après la distalisation. L'évaluation statistique a
été conduite à partir des données céphalométriques et des moulages.
Résultats > les premières molaires ont été distalées avec un taux de 0,89  0,30 mm/mois (95%
CI 0,76–1,02) (p < 0,001) et la quantité de distalisation était de 4,09  0,92 mm (CI 3,68–4,50)
(p < 0,001). Elles ont été distoversées de 2,488  6,16 (CI 0,26–5,21) (p = 0,073) et distorotées
de 11,898  5,86 avec un changement positionnel vertical négligeable de 0,11  0,63 mm (CI
0,40–0,17) (p = 0,411). Aucune perte d'ancrage évidente n'est apparue à la suite du mouve-
ment distal des molaires maxillaires (p < 0,001). Le surplomb horizontal a été réduit de 0,86
 0,50 (CI 0,52–1,20) (p = 0,004).
Conclusion > La distalisation molaire maxillaire avec ressort et mini-vis vestibulaires est une
technique effective avec une relative rapidité et ne sollicitant pas la compliance du patient.

Introduction [10,12–14]. Among these devices, miniscrews have gained

Maxillary molar distalization has gained popularity as a non-
extraction treatment modality in recent years as it provides
space for treatment of mild to moderate sagittal arch length
discrepancy [1]. Several appliances have been used for distal-
ization of the maxillary molars. They can be classified into
extraoral and intraoral appliances. The main problem with
the extraoral appliances such as headgear is the lack of patient
co-operation [2]. The non-compliance intraoral appliances have
gained popularity such as open coils [3], jones jig [4,5], distal jet
[6], Keles slider [7], and the pendulum [8,9]. Although they have
achieved effective results, they have demonstrated several side
effects including distal tipping, crown rotation and crucially
anchorage loss presented as the mesial movement of the
premolars, flaring of the incisors and increased overjet [1,10].
These side effects increase when these distalizers are used in
combination with conventional anchorage appliances such as
Nance button [10,11].
To remedy these side effects associated with the anchorage loss,
skeletal anchorage devices have been used in combination with
intraoral distalizers to provide resistance to the reciprocal forces
widespread acceptance because of ease of placement and
removal, the possibility of immediate loading and reasonable
cost compared to miniplates and palatal implant [13,15]. Min-
iscrews can be used to provide direct or indirect anchorage for
maxillary molar distalization. With direct anchorage, the forces
which result in reaction to maxillary molar distalization are
directly applied to the miniscrew and no loss of anchorage
occurs. Whereas in the case of indirect anchorage, the miniscrew
provides anchorage for the teeth receiving the reactive force
instead of conventional anchorage appliances as Nance palatal
button. This may cause an increased possibility of anchorage loss
in the form of mesial tipping of anchor teeth and proclination of
anterior teeth [16,17].
It was assumed that miniscrews placed in the buccal interra-
dicular region cause fewer complication related to the soft tissue
irritation particularly if placed in the attached gingiva [18].
However, there is no consensus about their effectiveness as a
skeletal anchorage tool. Until now no evidence based trial
evaluated this newly developed technique [1]. The main target
is to achieve a higher rate of bodily molar distalization with the
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 N.A. Abdelhady, M.A. Tawfik, S.M. Hammad
Original article
application of force vector through the molar centre of resis-
tance. So, this study was conducted in a trial to evaluate the
efficiency of a simple distalization technique using buccal min-
iscrews as a direct anchorage tool.
The primary outcomes of this study were the rate of molar distal
displacement and the treatment duration, i.e. the time to obtain
a normal molar relationship expressed in months and distal
tipping of the distalized molars. The secondary outcomes were
magnitude and mode of maxillary first molar rotation, move-
ment and inclination of maxillary premolars, anchorage loss in
terms of anterior movement and proclination of upper central
incisors, skeletal anteroposterior positional changes of the max-
illa and the mandible, the inclination of mandibular central
incisors, bite opening effect and soft tissue changes [1].
Materials and methods
Ethical approval for this prospective clinical study was obtained
from the Ethical Committee of Faculty of Dentistry, Mansoura
University, Egypt (No: A11091019). The sample size of the
present study was estimated using G*Power (version 3. 1. 9.
2) with regard to a previous study [7] (95% power; 5% signifi-
cance level; 1 tailed). The power analysis revealed that a mini-
mum sample size of 9 patients was convenient to detect
clinically significant meaningful differences. The sample was
increased to cover possible dropouts and increase the power
of the study. The sample comprised of 14 female patients.
However, 3 of them ceased treatment due to several personal
reasons leaving a sample of 11 female patients having an
average initial age of 12 years and 4 months at the beginning
of the treatment. This provided the data for 22 distalized molars.
The patients were recruited sequentially from the clinic of the
Department of Orthodontics, Faculty of Dentistry.
The inclusion criteria included:
 age range between 11 and 14 years;
 angle Class II relationship;
 permanent dentition with fully erupted upper first premolars,
second premolars;
 both upper second molars present;
 mild to moderate maxillary sagittal arch length discrepancy
and/or increased overjet;
 no or minimal crowding in the mandibular arch which could be
resolved with mild interproximal reduction;
 good oral hygiene.
The treatment plan was explained to the patients and their
parents. The parents of all patients signed informed consents
after agreement on the planned treatment procedures.
Treatment procedures
Bilateral levelling and alignment of the maxillary buccal seg-
ments were done using the appropriate archwire sequence for
each patient till attainment of full engagement of a
0.017  0.025-inch stainless steel segmental wire. The anterior
98
teeth remained free from brackets during the whole distaliza-
tion phase.
After alignment, the miniscrew (3M Unitek Orthodontic Prod-
ucts; Monrovia, California, United States) was placed in the
interradicular space between the maxillary second premolar
and the first molar in each side. It was inserted in the attached
mucosa at about 12 mm from the occlusal surface of the first
molar in line with the molar centre of resistance. The angulation
of the miniscrew was 308 to 458 to the occlusal plane.
Within 1 week, following the miniscrew insertion and after
checking the miniscrews stability, the active distalization phase
was initiated on both sides. A sectional piece of 0.017  0.025-
inch stainless steel wire was adapted to the buccal segment and
marked mesial to the first molar tube to make a stop (1.5-mm
long). The mesial part of the wire was bent about 2 3 mm
anterior to the bracket of the first premolar at a right angle. A
hook was made gingivally in the mesial end of the wire at the
level of the miniscrew. This allowed lessening of the vertical
component of force as the force vector was oriented parallel to
the occlusal plane [7]. The wire was adapted to the contour of
the buccal sulcus to avoid soft tissue irritation. Then the distal
end of the wire was fitted in the first molar tube and ligated to
the brackets of the first and second premolars on each side with
steel ligature ties to reduce the friction after insurance of no soft
tissue impingement.
A NiTi closed coil spring (Ortho Pro Associates) was engaged in
the hook and stretched to be attached in the miniscrew neck to
generate about 250 g of distalizing force [14,19] on each side.
By this force system, the distally directed force was applied at
the level of the centre of resistance of the molar from the
vestibular side parallel to the occlusal plane. The aim was to
promote more bodily distalization movement [7] (figure 1). For
the first application of the distalization force, the patient was
examined after 1 week to assess the miniscrew stability and
patient adherence to the oral hygiene instructions.
The patients were then scheduled on regular 4-week interval
recall visits for follow up and reactivation. At each appointment,
the miniscrew was checked for mobility and the soft tissue
around the miniscrew was checked and cleaned. To maintain
about 250 g of consistent force per side, the closed coil was
shortened to the appropriate length for further activations dur-
ing the recall visits. When the hook touched the mesial wing of
the first premolar bracket, the wire was replaced with a new one
to allow further activations when necessary. The monthly reac-
tivation was continued until overcorrection of the molar relation
(figures 2 and 3). Post-treatment records were then obtained
immediately and the time required to obtain a normal molars'
relationship by upper molars distalization was recorded.
Lateral cephalometric analysis
The cephalometric tracings and landmark identifications were
performed by the first author both manually, and digitally using
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Maxillary molar distalization in treatment of angle class II malocclusion growing patients: Uncontrolled clinical trial
Figure 1
Buccal distalization technique using a closed coil and buccal
interradicular miniscrew
Figure 2
Intraoral photographs of case 1 before and after distalization
with the appliance in place
MicroDicom viewer (MicroDicom viewer version 2. 0. 0 software,
Sofia, Bulgaria) to omit intra-examiner errors. The mean value
was recorded as the final measurement. All angular and linear
measurements were approximated to the nearest 0.58 mm or
0.5 mm.
To differentiate the right and left first maxillary molars, vertically
oriented wire markers were adapted to the molars long axes
and bent at a right angle to the buccal tube's slots. They were
inserted in the buccal tubes of the molars and held in position
with elastic ties before the acquisition of the cephalometric X-
ray. On the right molar, the wire marker was shorter and the tip
tome 18 > n81 > March 2020
Original article
Figure 3
Intraoral photographs of case 2 before and after distalization
with the appliance in place
of the wire was bent in a distal direction. In contrast, the wire
marker on the left side was longer and bent in a mesial direc-
tion. These wire markers were used to identify the molars
inclination to measure the molar tipping regardless of superim-
position [20] (figures 4 and 5).
Cast Analysis
Impressions of maxillary and mandibular dental arches were
taken before and immediately after the distalization. Reference
points were delineated on all the upper casts before scanning to
be used for cast analysis following the steps described by Erverdi
et al. [20]. The cusp tips of the posterior teeth and the incisal
edge of the central incisors were marked. Also, 2 points on the
median ends of the 3rd palatine rugae toward the midline were
marked as they were found to be a stable reference landmark to
construct the horizontal reference line (Rugae line, RL), [21,22].
Also, 2 points on the mid-palatine suture were marked to trace
the median palatal suture. It was established to act as a vertical
reference line (Midpalatal line, ML).
Then, photocopies of the pre-and post-distalization upper casts for
each case were obtained by scanning at 300 dpi resolution and a
100% scale on the same scanner (CanoScan LiDE 120, Vietnam)
Figure 4
Introral view of the wire markers, right (a) and left (b) sides
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 N.A. Abdelhady, M.A. Tawfik, S.M. Hammad
Original article
Figure 5
Cephalometric x-rays with wire markers for case 1 before(a), and after (b) distalization
with a 1 to 1 magnification ratio. Each maxillary cast was placed on
the scanner with its occlusal aspect facing down and centred on
the scanner. Afterward, image scanning and capture were done.
The cast measurements were performed both digitally using
MicroDicom viewer (version 2.0.0 software, Sofia, Bulgaria) and
manually. The scanned images were printed for manual analysis.
The sagittal linear and angular measurements were made for both
the right and left side independently (figure 6).
Statistical analysis of the data
The data were collected, tabulated and fed to the computer for
statistical analysis using the computer program SPSS (IBM SPSS
software package; IBM Corp, Armonk, NY, USA) version 20. 0. To
verify the normality of the distribution of data, The Kolmogorov–
Smirnov test was used. The significance of the obtained results
was judged at the 5% level. The tests used were paired t-test for
normally quantitative parameters, and Wilcoxon signed ranks
test for abnormally quantitative parameters, to compare
between two stages.
Results
The distalization of the maxillary first molars was achieved in an
average time of 4. 90  1.50 months in 11 female patients.
Statistical analysis for the data showed that maxillary teeth
were significantly displaced distally with a significant reduction
in the overjet (tables I and II). The maxillary first molars were
displaced distally to the vertical reference by about 4.09
 0.92 mm in 4.90  1.50 months (CI 3.68–4.50) (P < 0.001)
as a mean treatment time resulting in a monthly rate of 0.89
 0.30 mm (CI 0.76–1.02) (P < 0.001) of molar distalization. The
maxillary molars exhibited negligible extrusion in relation to the
SN plane with a value of 0.11  0.63 mm (CI 0.26–5.21)
(P = 0.073), which was evident by the minor change in the
overbite. The FMA angle showed a significant increase of about
100
0.598  0.74 (CI 1.09–0.10) (P = 0.024) although the SN-MP
angle did not increase significantly by 0.458  0.85 (CI 1.03–
0.12) (P = 0.107). But, the changes in both angles were close.
The soft tissue changes were assessed by the linear change of
the upper and lower lips in relation to Ricketts aesthetic line. The
upper lip showed significant retraction of 1.32  0.96 mm (CI
0.68–1.96) (P = 0.007) whereas the lower lip was insignificantly
changed. The upper lip significant change led to a significant
increase in the nasolabial angle by about 5.188  1.90 (CI 6.46–
3.90) (P < 0.001).
Discussion
Distalization is a common treatment modality used for space
gaining for treatment of mild to moderate sagittal arch length
discrepancy using several appliances [23]. In this prospective
study, evaluation of the dento-alveolar, skeletal and soft tissue
effects of a buccal distalization technique was done. This tech-
nique incorporated a closed coil spring stretched between a
hook of sectional wire and a buccal interradicular miniscrew.
The maxillary molars were distalized with overcorrection of
about 1–2 mm to anticipate against the space loss with upright-
ing of the distally inclined molars during the subsequent level-
ling and alignment stage. The molar distalization occurred with
distal tipping. The distally inclined molars have a high tendency
to move mesially and with molar uprighting, the crowns tend to
move in a more mesial direction than the roots resulting in space
loss [24,25].
The maxillary first molars were successfully displaced in a distal
direction by 3.98  1.20 in mean duration of 4.90  1.50
months. These results were slightly higher than those reported
by Yamada et al. [26] who reported approximately 3 mm of
molar distal movement. However, they were less than the results
reported by Cassetta and Altieri using miniscrew-supported distal
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Maxillary molar distalization in treatment of angle class II malocclusion growing patients: Uncontrolled clinical trial
Figure 6
Cast measurements. (1) (U1-RL): perpendicular distance from the
mid-point of the incisal edge of the maxillary central incisor to
the horizontal reference line (RL). (2) (U3-RL): perpendicular
distance from the cusp tip of the maxillary canine to the
horizontal reference line (RL). (3) (U4-RL): perpendicular distance
from the mid-point of the line connecting the buccal and palatal
cusp tips of the maxillary first premolar to the horizontal
reference line (RL). (4) (U5-RL): perpendicular distance from the
mid-point of the line connecting the buccal and palatal cusp tips
of the maxillary second premolar to the horizontal reference line
(RL). (5) (U6-RL): perpendicular distance from the meeting point
of the two diagonals traversing the cusp tips of the maxillary
first molar to the horizontal reference line (RL). (6): maxillary
inter-canine distance. (7): maxillary inter-first premolar distance.
(8): maxillary inter-second premolar distance. (9): maxillary
inter-first molar distance. (10): U4/ML angle, joining the line
crossing the buccal and palatal cusp tips of the upper first
premolar and the midline. (11): U5/ML angle, joining the line
crossing the buccal and palatal cusp tips of the upper second
premolar and the midline. (12): U6/ML angle, joining the line
crossing the mesiobuccal and distopalatal cusp tips of the upper
first molar and the midline
jet [27]. On the other hand, these results were in accordance with
those of Gelgor et al. [19]. The opened space in this study was
due to pure distalization movement without loss of anchorage
and utilized later for subsequent alignment and retraction of the
anterior teeth. Additionally, the achieved rate of molar distaliza-
tion was 0.89  0.30. The reported monthly rate of molar dis-
talization ranged from 0.6 to 1.2 mm using conventional
anchorage appliances such as the pendulum [24,28], Jones jig
[29], and open coils [3,20].
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Original article
The maxillary first molars exhibited a mean distal tipping of
2.488  6.16. The tipping of the maxillary molars provoked
with distalization has been reported on with several distali-
zation appliances as the pendulum [8,17,30–32], jones jig
[4,5,8], and the distal jet [6,13,27,33,34]. Nevertheless, less
tipping can be produced with the use of more rigid mechanics
as the heavy rod used by Bondemark et al. [35], Keles et al.
[12] and Cassette and Altieri [27] who reported more bodily
movement.
The mode of maxillary molar rotation was distopalatal with a
mean of 11.898  5.86 from the cast measurements. This may
be explained as the distalization force was applied from the
vestibular side to the centre of resistance. The molar would
rotate mesial-out or distal-in, as observed from the occlusal
aspect [36]. This is consistent with the results of Erverdi et al.
[20] using the buccally acting magnets and open coils. In con-
trast, Kinzinger et al. [13], using the palatally acting skeleton-
ized distal jet appliance, noted a rotation of a distobuccal mode.
However, Ghosh and Nanda [24] using the palatally acting
pendulum, also reported distopalatal rotation of the first molars.
This mode of rotation can be considered as a favourable side
effect in the management of Class II molar relationship as most
patients with Class II have their maxillary first molars rotated
mesially around their lingual roots [19,24] .
The maxillary inter-molar distance was constricted. These results
were in contrast to Yamada et al. [26] who reported stability of
the transverse arch dimensions during molar distalization. This
can be attributed to the molar rotation with the buccal applica-
tion of force.
The cephalometric observations of the vertical position of the
molar before and after distalization revealed insignificant molar
extrusion. This is in agreement with the results reported by
Bondemark et al. [35] and Gulati et al. [29]. This insignificant
vertical change can be attributed to the level of the distalization
force vector crossing the molar centre of resistance. Contrarily,
Bussick and McNamara [37], Kircali and Yüksel [14] and Gelgor
et al. [19] reported maxillary molar intrusion.
The maxillary premolars were displaced distally by the action of
the transseptal fibers. The premolars were rotated distopalatally
and this may be attributed to the buccal application of the
distalization force. The transverse arch dimensions at the pre-
molar's region were increased. This can be explained by the
distopalatal rotation of the premolars leading to buccal flaring.
Fuziy et al. [38] and Bolla et al. [33] reported minor expansion
between premolars cusp tips with the distal jet and pendulum
distalizers. The maxillary first premolars revealed mesial tipping
and this is consistent with the results of Gelgor et al. [19].
The results revealed a decrease in the overjet shown as maxil-
lary incisor retroclination by 5.368  1.45 and significant retrac-
tion of the maxillary incisors by 0.66  0.52 mm. This is in
accordance with Yamada et al. [26] but in contrast to Gelgor
et al. [19] and Ghosh and Nanda [24]. Whereas the overbite
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 N.A. Abdelhady, M.A. Tawfik, S.M. Hammad
Original article

TABLE I
Cephalometric results.

Pre-distalization Post-distalization Change Test P

(95%CI)
Mean W SD Mean W SD
Anteroposterior Skeletal measurements SNA 79.84  2.42 79.59  2.11 0.25  0.51 t = 1.618 0.137

SNB 76.09  1.99 76.27  1.99 0.18  0.51 t= 1.174 0.267

ANB 3.75  1.63 3.32  1.62 0.43  0.39 Z= 2.414 0.016*

Vertical Skeletal measurements FMA 26.91  3.04 27.50  2.75 0.59  0.74 t= 2.665 0.024*

SN-GoMe 34.50  3.79 34.95  3.53 0.45  0.85 t= 1.773 0.107

Dental angular measurements U1/SN 104.77  4.54 99.41  3.89 5.36  1.45 t = 12.262 < 0.001*

U4/SN 83.27  3.96 85.09  2.12 1.82  3.96 t= 1.521 0.159

U6/SN 71.18  3.70 68.70  6.00 2.48  6.16 t = 1.885 0.073

L1/MP 101.73  2.97 100.91  2.66 0.82  0.98 t = 2.764 0.020*

Interincisal angle 114.23  6.62 119. 91  5.30 5.68  2.65 t= 7.116 < 0.001*

Dental Linear measurements (mm) U1/VR 49. 45  4.03 48.64  3.35 0.82  0.81 t = 3.331 0.008*

U1/NA 4.23  1.65 3.45  1.31 0.77  0.65 Z= 2.877 0.004*

U6/VR 14.95  2.54 10. 86  2.41 4.09  0.92 t = 20.831 < 0.001*

U6/VR Rate 3.26  0.88 2.37  0.72 0.89  0.30 t = 14.048 < 0.001*

U6 SN 64.64  2.88 64.75  3.13 0.11  0.63 t= 0.839 0.411

Overjet (mm) 3.32  1.19 2.45  0.91 0.86  0.50 Z= 2.877 0.004*

Overbite (mm) 2.77  0.75 2.59  0.83 0.18  0.34 t = 1.789 0.104

Soft tissue Upper lip/E-line 0.14  1.98 1.18  2.23 1.32  0.96 Z= 2.699 0.007*

Lower lip/E-line 1.55  2.41 1.36  2.53 0.18  1.08 Z= 0.494 0.62

Nasolabial angle 100.36  9.20 105.55  10.42 5.18  1.90 t= 9.041 < 0.001*

VR: vertical reference plane was constructed by drawing a perpendicular line to the SN plane at the point of intersection of the anterior clinoid processes with the anterior wall of
Sella turcica. This vertical reference was chosen as these anatomical structures showed stability during growth [44]. Data expressed as mean  SD; SD: standard deviation; P:
Probability; Test used: Student's t-test (paired) & Wilcoxon signed rank.
*
Significance < 0.05.

showed an insignificant decrease. This can be attributed to the
incisors retroclination that compensated for the decrease of
overbite due to the wedging effect of the molar distalization.
This is similar to the results of Yamada et al. [26] and Park et al.
[39].
The SNA and SNB were insignificantly reduced. The A point was
retruded because of the retroclination of the maxillary incisors.
The B point may be retruded with the mandibular rotation in a
clockwise direction. This is in accordance with the results of
Yamada et al. [26]. The ANB angle inherently increased with the
changes in the SNA and ANB angles. However, this is in contrast
to the results of Gelgor et al. [19] who explained that the
pressure from the acrylic button covering the palatal screws
102
on the upper incisors cause their flaring despite the use of
skeletal anchorage.
The FMA and SN-MP angles increased and this is compatible with
the results of most distalization appliances as the molar distal-
ization often results in a clockwise mandibular rotation. This can
be attributed to the wedging effect as reported by Haydar and
Üner [5] with jones jig appliance and Fuziy et al. [38] and Bussick
and McNamara [37] using the pendulum appliance. However,
these results are in contrast to the constancy of the FMA reported
by Park et al. [39] and Yamada et al. [26]. The nasolabial angle
showed a significant increase and this is consistent with the
significant retraction of the upper lips. This can be attributed to
the distal displacement and retroclination of the upper incisors.

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Maxillary molar distalization in treatment of angle class II malocclusion growing patients: Uncontrolled clinical trial

Original article
TABLE II
Cast analysis results.

Pre-distalization Post-distalization Change Test P

(95%CI)
Mean W SD Mean W SD
Sagittal Linear measurement (mm) U1/RL 16.86  3.46 16.20  3.57 0.66  0.52 t= 5.937 < 0.001*

U3/RL 10.50  3.47 9.39  3.53 1.11  0.75 t= 6.920 < 0.001*

U4/RL 2.09  3.43 0.80  3.53 1.30  0.90 Z= 3.847 < 0.001*

U5/RL 4.84  3.75 6.59  3.82 1.75  1.12 Z= 3.936 < 0.001*

U6/RL 14.48  3.81 18.45  3.47 3.98  1.20 t= 15.546 < 0.001*

U6/RL Rate 3.2  1.0 4.01  1.07 0.83  0.19 t= 21.002 < 0.001*

Transverse Linear measurement (mm) Inter canine distance 34.77  2.20 36.41  1.92 1.64  0.78 t= 6.980 < 0.001*

Inter first premolar distance 41.59  2.51 44.00  2.77 2.41  0.94 t= 8.465 < 0.001*

Inter second premolar distance 46.68  2.43 47.86  2.04 1.18  0.56 t= 6.999 < 0.001*

Inter first molar distance 50.36  2.35 49.55  1.94 0.82  1.03 t = 2.631 0.025*

Dental Angular measurements (8) U4/ML 72.68  9.00 78.25  7.42 5.57  3.06 t= 8.535 < 0.001*

U5/ML 74.05  6.12 76.70  6.10 2.66  1.73 t= 7.218 < 0.001*

U6/ML 40.84  6.27 52.73  7.25 11.89  5.86 t= 9.515 < 0.001*

Data expressed as mean  SD; SD: standard deviation; P: Probability Test used: Student's t-test (paired) & Wilcoxon signed rank.
*
Significance < 0.05.

This is compatible with the results of Yamada et al. [26] but
against the results of Gelgor et al. [19].
One limitation of this study is the lack of a control group. This
may not be considered an absolute limitation because of the
short duration of the study to be affected by the normal growth
changes [5]. Another limitation is the absence of three-dimen-
sional evaluation of the distalization technique by superimposi-
tion of digital models [40]. A previous study evaluated the three-
dimensional movement of maxillary teeth after molar distali-
zation using digital models. However, Nalcaci et al. [41] found
an insignificant difference between the measurements
obtained from the digitized models, plaster model photocopies
and lateral cephalometric x-rays. All the patients in this study
had their maxillary second molars present on both sides. The
impact of the second molar presence on the rate of distal molar
movement has been a matter of controversy in the literature.
Gianelly [25] reported that simultaneous distalization of the first
and second molars has been associated with more anchorage
loss and time. On the contrary, a recent systematic review [42]
concluded that the second molar eruption has a negligible effect
on the first molar distalization regarding the amount, rate and
mode of distalization [42]. However, the distal tipping of the
maxillary first molars was less than the results reported by Bolla
et al. [33] using the distal jet in patients with unerupted second
molar. Additionally, Caprioglio et al. [43] demonstrated higher
molar tipping in case of sequential distalization of the second
molar followed by the first molar compared to simultaneous
distalization of both molars. This can be attributed to the change
of the centre of resistance of the molar to a lower position.
Conclusion
The advantages of this study were to provide a simple and
effective molar distalization technique using direct buccal
anchorage. This technique allowed the molar distalization with-
out the concomitant side effects with the conventional distal-
ization appliances. It neither required more lab work nor patient
co-operation. The main advantages of the appliance are the
possibility of bilateral or unilateral force application, immediate
loading of the miniscrew, and ease of insertion and removal.
Adequate distal movement of the molar tooth was achieved
without the loss of anchorage.
Disclosure of interest: the authors declare that they have no competing
interest.
103

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 N.A. Abdelhady, M.A. Tawfik, S.M. Hammad
Original article
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