Biomechanical considerations for total

distalization of the mandibular

dentition in the treatment of Class III
malocclusion
Jae Hyun Park1, Sungsu Heo1, Kiyoshi Tai, Yukio Kojima, Yoon-Ah Kook, and
Jong-Moon Chae

Class III malocclusions with mild to moderate skeletal discrepancies can be

camouflaged by orthodontic tooth movement. Conventional methods using
Class III elastics can correct Class III into Class I molar relationships. These
mechanics show side-effects such as labioversion and intrusion of the maxil-
lary incisors, extrusion of the maxillary molars, linguoversion and extrusion
of the mandibular incisors, and intrusion of the mandibular molars along
with flattening of the occlusal plane. Conventional mechanics can improve
occlusal relationships and some profile esthetics but may produce detrimen-
tal smile esthetics by reducing the amount of maxillary incisor exposure.
Recently, with the advent of temporary skeletal anchorage devices (TSADs),
clinicians are able to achieve total distalization of the mandibular dentition
and therefore improve the occlusal relationship without worsening smile
esthetics. With the use of TSADs, the en masse movement of an entire denti-
tion can be easily accomplished using a statically determinate force system,
which makes treatment plans easier and treatment results more predictable.
Finite element studies have identified the location of the center of resistance
of the entire dentition and simulated displacement of the dentition depend-
ing on the force angulations (FAs) and have thus provided the theoretical
basis for 3-dimensional tooth movement patterns. This article provides the
biomechanical considerations and clinical applications of total distalization
of the mandibular dentition depending on various FAs to the mandibular
occlusal plane for camouflage treatment of various types of skeletal Class III
malocclusions. (Semin Orthod 2020; 26:148–156) © 2020 Elsevier Inc. All
rights reserved.

Introduction
is one of the most prevalent complaints from
lass III malocclusion is a common skeletal Asian orthodontic patients.1 Skeletal Class III
C malocclusion and mandibular prognathism malocclusion is a challenging problem for

Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Ariz; International Scholar,
Graduate School of Dentistry, Kyung Hee University, Seoul, Korea; Private practice in Goodsmile orthodontic office, Cheongju, Korea; Postgradu-
ate Orthodontic Program, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Ariz; and private practice in orthodontics,
Okayama, Japan; Private Practice, Nagoya, Japan; Department of Orthodontics, Seoul St. Mary's Hospital, Catholic University, Seoul, Korea;
Department of Orthodontics, School of Dentistry, University of Wonkwang, Wonkwang Dental Research Institute, Iksan, Korea, Postgraduate
Orthodontic Program, Arizona School of Dentistry & Oral Health, A. T. Still University Mesa, Ariz, Daejeon Dental Hospital, 77 Doonsan ro,
Seo-Gu, Daejeon 35233, Korea.
Corresponding author. E-mail: jongmoon@wku.ac.kr
© 2020 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
https://doi.org/10.1053/j.sodo.2020.06.012
1
These authors (Jae Hyun Park and Sungsu Heo) contributed equally to this work.

148 Seminars in Orthodontics, Vol 26, No 3, 2020: pp 148 156

 Biomechanical considerations for total distalization of the mandibular dentition
orthodontists to manage due to its multifactorial
etiology.2
Orthodontists can correct a skeletal Class III
malocclusion with orthopedic and orthodontic
camouflage, and orthognathic surgery, depend-
ing on the severity of the malocclusion and stage
of the patient’s growth and development. Mild to
moderate skeletal Class III malocclusions have
been managed with orthodontic treatment only,
but proper diagnosis and treatment objectives
are imperative to prevent undesirable results.3-6
Conventional correction of a Class III to a Class I
molar relationship has been accomplished using
total distalization of the mandibular dentition
with the mandibular headgear and Class III elas-
tics.7-13 Unfortunately, Class III elastics showed
some negative effects such as labioversion and
intrusion of the maxillary incisors, which caused
reduction of maxillary incisor show and extru-
sion of the maxillary molars, actually worsening
an already long face.7-10 On the other hand, it
showed positive effects such as distalization and
uprighting of the mandibular dentition that pro-
duced dental correction and extrusion of the
maxillary molars, improving the facial profile fol-
lowing clockwise rotation of the mandible. Head-
gear showed excellent treatment results but
patient compliance was necessary.11-13
While distalization of the molars has been one
of the most challenging orthodontic procedures,
recently it became possible to distalize the whole
mandibular dentition using various temporary skel-
etal anchorage devices (TSADs).6,9,10,14-20 TSADs
are more reliable and efficient than conventional
methods because they allow for total distalization
of the mandibular dentition while reducing some
of the negative effects and need for patient cooper-
ation. Use of TSADs with a thorough understand-
ing of the biomechanical principles expands the
boundaries and scope of Class III malocclusion
treatment. However, the anterior alveolar bone
housing, posterior anatomical limitations, and
adverse effects on the temporomandibular joint
(TMJ) should be considered before planning dis-
talization, in order to avoid periodontal, occlusal
malfunction, and TMJ breakdown.21,22
Several biomechanical strategies have been
attempted to correct Class III malocclusions with
severe skeletal and dental variations,6-20 but there
have been few reports about the biomechanical
considerations for total distalization of the man-
dibular dentition. Therefore, this article aims to
149
address the biomechanical considerations and
clinical applications for total distalization of the
mandibular dentition depending on force angu-
lations (FAs) relative to the occlusal plane.
Center of resistance (CR)
Knowing the location of CR is essential for pre-
dicting biomechanical tooth movement because
it is dependent on the force direction and loca-
tion relative to CR of the dentition. When the
line of action passes through, below or above CR
of the mandibular dentition, changes ranging
from clockwise to counterclockwise rotation will
result (Fig. 1). The resultant tooth movement is
largely determined by the relationship between
the line of force and CR of the mandibular total
dentition. On this basis, a theoretical prediction
of movement of the entire dentition in three
dimensions can be made. The rotational ten-
dency is proportional to the moment of force,
which is calculated by multiplying the magnitude
of the force by the distance from CR to the line
of force (Fig. 2).
Finite element analysis
The finite element method (FEM) is a mathe-
matical tool that can be used to identify the loca-
tion of CR under given material properties
precisely. The use of finite-element models is
greatly helpful, not only for identifying CR of the
dentition, but also for predicting the expected
displacement pattern of the dentition given a
specific line of force.
A recent FEM study proposed that the vertical
position of CR of the total mandibular dentition
was located 13.5 mm apical to the incisal edge of
the mandibular central incisors, and the antero-
posterior position of CR was 25.0 mm posterior
to the incisal edge of the mandibular central inci-
sors.23 When a rigid continuous archwire is used,
the target segment becomes the whole mandibu-
lar dentition and CR can be localized in front of
the mesial root of the first molar (Fig. 3).23-26
In an FEM study,25 distalization force was
applied on the wire between the canine and first
premolar brackets at various FAs to the occlusal
plane ( 30° to +30°) to distalize the whole mandib-
ular dentition. This would be similar to clinical
applications using skeletal anchorage and Class III
elastics for Class III treatment.
150
Figure 1. Resultant movement of the total mandibular dentition and the relevant force vector. (A) Bodily distaliza-
tion; (B) Rotation (clockwise and counterclockwise). Red dot, the center of resistance of the total mandibular denti-
tion.
Tooth movement patterns depending on FAs and
clinical application
Various FAs ( 30° to +30°) relative to the occlu-
sal plane should be considered in the actual
clinical application using mandibular TSADs
and intra-arch elastics ( 30° to 0°), maxillary
Figure 2. The magnitude of the moments (curved
arrows) are determined by the perpendicular distan-
ces (dashed lines) from the line of the force (solid
arrow) to the center of resistance (red dot) and the
amount of the force (Mf = D £ f) depending on the
force angulations. (For interpretation of the referen-
ces to colour in this figure legend, the reader is
referred to the web version of this article.)
Park et al
TSADs and inter-arch elastics (15° to 30°), and
conventional Class III elastics (15° to 30°).
Case 1. Total distalization with TSADs around an FA
of 30°
An 18-year-old female patient presented with
the chief complaint of an unesthetic smile. The
diagnostic evaluation revealed a Class III facial
appearance with mild deficiency of the maxilla,
anterior edge to edge bite, moderate crowding
in the maxillary arch, moderate spacing in the
mandibular arch, and labioversion of the ante-
rior teeth in both arches (Fig. 4).
An FA of 308 using TSADs was effective for
slight distalization of the mandibular dentition
and to improve her smile esthetics, with
Figure 3. Estimated center of resistance of the man-
dibular dentition.23-26 The line of the force passes
through the center of resistance of the whole mandib-
ular dentition at a force angulation of 238 to the wire
between the canine and first premolar brackets.
 Biomechanical considerations for total distalization of the mandibular dentition 151

Figure 4. Case 1: Pretreatment photographs and radiographs.

clockwise rotation of the mandibular occlusal
plane by a differential intrusion of the mandibu-
lar anterior and posterior teeth. This created an
intermaxillary space that allowed extrusion of
her maxillary anterior teeth. If conventional
mechanics with Class III elastics had been used,
the mandibular occlusal plane would have
flattened, resulting in reduction of maxillary inci-
sor display and deterioration of smile esthetics.
The force vector in this patient was designed by
inserting TSADs between the mandibular premo-
lars. The line of force passed below CR of the
entire mandibular dentition and, thereby, it
rotated clockwise and intruded (Figs. 5 and 6).

Figure 5. Case 1: Total distalization with TSADs around a force angulation (FA) of 30°.
152
Figure 6. Case 1: Posttreatment photographs, lateral
cephalogram, and cephalometric superimposition.
Case 2: Total distalization with TSADs around an FA
of 15°
A 22-year-old male patient presented with an
anterior crossbite and open bite with full cusp
Class III canine and molar relationships (Fig. 7).
An FA of 158 using TSADs in the mandibular
buccal shelf (MBS) was effective in correcting his
severe Class III malocclusion relationship by distali-
zation and vertical control of the mandibular denti-
tion followed by correction of the anterior crossbite
and open bite, even without extraction of the man-
dibular premolars. Vertical control of the molars
Figure 7. Case 2: Pretreatment photographs and
radiographs.
Park et al
- PdegaT was accomplished by applying the proper FA. After
26 months of treatment, Class I canine and molar
relationships were achieved. The patient’s profile
was improved by retraction of his lower lip and
elimination of his lip incompetency (Figs. 8 and 9).
Case 3: Total distalization with ramal plate around
an FA of 0°
A 21-year-old male patient (see Kook et al19
for details) presented with a chief complaint of
“I cannot chew properly.” He had a Class III bra-
chyfacial pattern with a well-developed chin and
shallow overbite. He had an anterior crossbite on
his maxillary right lateral incisor and lateral
open bites with a frontal and lateral tongue-
thrust habit (Fig. 10)
Treatment resulted in more than 4 mm of dis-
talization of the mandibular dentition and coun-
terclockwise rotation of the mandibular occlusal
plane to correct a severe Class III dental relation-
ship and to increase the overbite. An FA of 08
using a ramal plate was beneficial in producing
distalization with moderate extrusion of the ante-
rior teeth. In this patient, the mandibular molars
were extruded due to uprighting of his posterior
teeth during distalization and leveling of the
curve of Spee. This may have helped to improve
his facial appearance by clockwise rotation of the
mandible. That is why careful consideration of
the mechanics is needed to resolve the deep
curve of Spee on a case-by-case basis (Figs. 11
and 12).
Case 4. Total distalization with Class III elastics
around an FA of 15°
A 15-year-old female patient presented with a
chief complaint of chewing difficulties and man-
dibular protrusion. She had a mandibular pro-
trusive appearance with an anterior edge-to-edge
bite but acceptable exposure of the maxillary
anterior teeth when smiling. The vertical posi-
tion of her maxillary incisors and interincisal
angle were normal, but her mandibular occlusal
plane was steep, resulting in minimal or no over-
bite (Fig. 13).
Using conventional Class III elastics, an FA of
158 was effective for correcting the Class III mal-
occlusion with the anterior edge-to-edge bite by
distalization of the whole mandibular dentition
and counter-clockwise rotation of the mandibu-
lar occlusal plane and clockwise rotation of the
mandible. This was also helpful for improving
her facial profile by reducing the mandibular
 Biomechanical considerations for total distalization of the mandibular dentition 153

Figure 8. Case 2: Total distalization with TSADs placed between the second premolars and first molars or between
the first and second molars around a force angulation (FA) of 15°.

protrusion. Up and down elastics should be used
to prevent severe labioversion of the maxillary
anterior teeth and more efficient extrusion of
the mandibular anterior teeth (Figs. 14 and 15).
Case 5. Total distalization with TSADs and Class III
elastics around an FA of 30°
A 13-year-old female patient transferred from
a private orthodontic office to the department of
orthodontics with the chief complaint of an ante-
rior open bite. She displayed a skeletal Class III
appearance but had an acceptable profile due to
her hyperdivergent facial pattern. The vertical
exposure of her maxillary incisors was normal,
but her mandibular occlusal plane was steep,
causing an anterior open bite (Fig. 16).
An FA of 308 using maxillary TSADs and Class
III elastics was effective in correcting the Class III
malocclusion and anterior open bite by distaliza-
tion of the whole mandibular dentition and
counterclockwise rotation of the mandibular
occlusal plane. This was accomplished without
producing the biomechanical side effects in the
maxillary dentition commonly caused by conven-
tional Class III elastics (Figs. 17 and 18).

Figure 9. Case 2: Posttreatment photographs, lateral

cephalogram, and cephalometric superimposition. Figure 10. Case 3: Pretreatment photographs and
radiographs.
154 Park et al

Figure 11. Case 3: Total distalization with ramal plates around a force angulation (FA) of 0°.

Figure 13. Case 4: Pretreatment photographs and

radiographs.

Figure 12. Case 3: Posttreatment photographs, lateral

cephalogram, and cephalometric superimposition.

Figure 14. Case 4: Total distalization with Class III elastics around a force angulation (FA) of 15°.
 Biomechanical considerations for total distalization of the mandibular dentition
Figure 15. Case 4: Posttreatment photographs, lateral
cephalogram, and cephalometric superimposition.
Conclusions
Skeletal Class III malocclusions can be corrected
conservatively (without extraction or orthog-
nathic surgery) by applying proper FAs to the
mandibular occlusal plane to distalize and rotate
the mandibular dentition. The mechanics of
total mandibular distalization patterns were sum-
marized, emphasizing FAs relative to the mandib-
ular occlusal plane using a 3-dimensional finite
Figure 17. Case 5: Total distalization with TSADs and Class III elastics around a force angulation (FA) of 30°.
155
Figure 16. Case 5: Pretreatment photographs and
radiographs.
element simulation and suggested efficient clini-
cal application of the FAs to correct various Class
III malocclusions. Selective use of FAs using
TSADs or Class III elastics with a thorough
understanding of the biomechanics and anatom-
ical limitations can produce proper, controlled
distalization of the mandibular dentition.
Acknowledgment
The authors thank Steven Park for his help with
the preparation of the manuscript.
156 Park et al
Figure 18. Case 5: Progress photographs, lateral ceph-
alogram, and cephalometric superimposition.
References
1. Im DH, Kim TW, Nahm DS, et al. Current trends in
orthodontic patients in Seoul National University. Korean
J Orthod. 2003;33:63–72.
2. Proffit WR, Fields HW, Larson B, et al. Contemporary
Orthodontics-e-Book. 6th ed. St. Louis, MO: Mosby; 2018.
3. Burns NR, Musich DR, Martin C, et al. Class III camou-
flage treatment: what are the limits? Am J Orthod Dentofa-
cial Orthop. 2010;137. 9.e1-9.e13.
4. Farronato G, Garagiola U, Farronato D, et al. Temporary
lip paresthesia during orthodontic molar distalization:
report of a case. Am J Orthod Dentofacial Orthop.
2008;133:898–901.
5. Sarikaya S, Haydar B, Ci ger S, et al. Changes in alveolar
bone thickness due to retraction of anterior teeth. Am J
Orthod Dentofacial Orthop. 2002;122:15–26.
6. Ngan P, Moon W. Evolution of Class III treatment in ortho-
dontics. Am J Orthod Dentofacial Orthop. 2015;148:22–36.
7. Saito I, Yamaki M, Hanada K. Nonsurgical treatment of
adult open bite using edgewise appliance combined with
high-pull headgear and Class III elastics. Angle Orthod.
2005;75:277–283.
8. Hu H, Chen J, Guo J, et al. Distalization of the mandibu-
lar dentition of an adult with a skeletal Class III malocclu-
sion. Am J Orthod Dentofacial Orthop. 2012;142:854–862.
9. Nakamura M, Kawanabe N, Kataoka T, et al. Comparative
evaluation of treatment outcomes between temporary
anchorage devices and Class III elastics in Class III maloc-
clusions. Am J Orthod Dentofacial Orthop. 2017;151:1116–
1124.
10. He S, Gao J, Wamalwa P, et al. Camouflage treatment of
skeletal Class III malocclusion with multiloop edgewise
arch wire and modified Class III elastics by maxillary
mini-implant anchorage. Angle Orthod. 2013;83:630–640.
11. Lima CEO, Lima MTO. Directional force treatment for
an adult with Class III malocclusion and open bite. Am J
Orthod Dentofacial Orthop. 2006;129:817–824.
12. Rey D, Angel D, Oberti G, et al. Treatment and posttreat-
ment effects of mandibular cervical headgear followed by
fixed appliances in Class III malocclusion. Am J Orthod
Dentofacial Orthop. 2008;133:371–378.
13. Kuroda Y, Kuroda S, Alexander RG, et al. Adult Class III
treatment using a J-hook headgear to the mandibular
arch. Angle Orthod. 2010;80:336–343.
14. Chung K, Kim SH, Kook Y. C-orthodontic microimplant
for distalization of mandibular dentition in Class III cor-
rection. Angle Orthod. 2005;75:119–128.
15. Chung KR, Kim SH, Choo H, et al. Distalization of the
mandibular dentition with mini-implants to correct a
Class III malocclusion with a midline deviation. Am J
Orthod Dentofacial Orthop. 2010;137:135–146.
16. Oh YH, Park HS, Kwon TG. Treatment effects of microim-
plant-aided sliding mechanics on distal retraction of poste-
rior teeth. Am J Orthod Dentofacial Orthop. 2011;139:470–481.
17. Kuroda S, Tanaka E. Application of temporary anchorage
devices for the treatment of adult Class III malocclusions.
Semin Orthod. 2011;17:91–97.
18. Baek SH, Il-Yang IH, Kim KW. Treatment of Class III mal-
occlusions using miniplate and mini-implant anchorage.
Semin Orthod. 2011;17:98–107.
19. Kook YA, Park JH, Bayome M, et al. Distalization of the
mandibular dentition with a ramal plate for skeletal Class
III malocclusion correction. Am J Orthod Dentofacial
Orthop. 2016;150:364–377.
20. Tai K, Park JH, Tatamiya M, et al. Distal movement of the
mandibular dentition with temporary skeletal anchorage
devices to correct a Class III malocclusion. Am J Orthod
Dentofacial Orthop. 2013;144:715–725.
21. Kim SJ, Choi TH, Baik HS, et al. Mandibular posterior
anatomic limit for molar distalization. Am J Orthod Dentofa-
cial Orthop. 2014;146:190–197.
22. Wyatt WE. Preventing adverse effects on the temporo-
mandibular joint through orthodontic treatment. Am J
Orthod Dentofacial Orthop. 1987;91:493–499.
23. Jo AR, Mo SS, Lee KJ, et al. Finite-element analysis of the
center of resistance of the mandibular dentition. Korean J
Orthod. 2017;47:21–30.
24. Oh MB, Mo SS, Hwang CJ, et al. The 3-dimensional zone
of the center of resistance of the mandibular posterior
teeth segment. Am J Orthod Dentofacial Orthop. 2019;156:
365–374.
25. Chae JM, Park JH, Kojima Y, et al. Biomechanical analysis
for total distalization of the mandibular dentition: a finite
element study. Am J Orthod Dentofacial Orthop. 2019;155:
388–397.
26. Kawamura J, Park JH, Kojima Y, et al. Biomechanical anal-
ysis for total mesialization of the mandibular dentition: a
finite element study. Orthod Craniofac Res. 2019;22:
329–336.