The European Journal of Orthodontics Advance Access published November 2, 2011

European Journal of Orthodontics 1 of 9 © The Author 2011. Published by Oxford University Press on behalf of the European Orthodontic Society.
doi:10.1093/ejo/cjr130 All rights reserved. For permissions, please email: journals.permissions@oup.com

Comparison of tooth displacement between buccal

mini-implants and palatal plate anchorage for molar
distalization: a finite element study
Il-Jun Yu*, Yoon-Ah Kook**, Sang-Jin Sung***, Kee-Joon Lee****,
Youn-Sic Chun***** and Sung-Seo Mo******
*Department of Orthodontics, The Catholic University of Korea, Seoul, **Department of Orthodontics, Seoul St Mary’s
Hospital, The Catholic University of Korea, Seoul, ***Department of Orthodontics, Asan Medical Center, University of
Ulsan, Seoul, ****Department of Orthodontics, College of Dentistry, Yonsei University, Seoul, *****Department of
Orthodontics, Ehwa Womans University Mokdong Hospital, Seoul and ******Department of Orthodontics, Yeouido
St Mary’s Hospital, The Catholic University of Korea, Seoul, Korea

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Correspondence to: Sung-Seo Mo, Department of Orthodontics, Yeouido St Mary’s Hospital, The Catholic
University of Korea, #62, Yeouido-dong, Yeongdeungpo-gu, Seoul 150-713, Korea. E-mail: dmoss1@hanmail.net

SUMMARY  The purposes of this study were to mechanically evaluate distalization modalities through
the application of skeletal anchorage using finite element analysis. Base models were constructed from
commercial teeth models. A finite element model was created and three treatment modalities were
modified to make 10 models. Modalities 1 and 2 placed mini-implants in the buccal side, and modality
3 placed a plate on the palatal side. Distalization with the palatal plate in modality 3 showed bodily
molar movement and insignificant displacement of the incisors. Placing mini-implants on the buccal
side in modalities 1 and 2 caused the first molar to be distally tipped and extruded, while the incisors
were labially flared and intruded. Distalization with the palatal plate rather than mini-implants on the
buccal side provided bodily molar movement without tipping or extrusion. It is recommended to use our
findings as a clinical guide for the application of skeletal anchorage devices for molar distalization.

Introduction
Headgear has been a conventional modality for Class II
malocclusion through distalization of molars or entire the
maxillary dentition. However, its main disadvantage is its
dependence on patient compliance, which is difficult due to
social and aesthetic concerns (Egolf et al., 1990; Lima Filho
et al., 2003).
To avoid this drawback, various non-compliance
appliances have been developed including the Keles slider,
repelling magnets, distal jet, and pendulum (Hilgers, 1992;
Bondemark et al., 1994; Bussick and McNamara, 2000;
Keles, 2001; Bolla et al., 2002; Bondemark and Karlsson,
2005). These devices applied continuous forces to distalize
maxillary molars, which might lead to distal tipping and
extrusion of the first molars, while the mesial reactive
forces might cause anchorage loss and labial flaring of
anterior teeth (Joseph and Butchart, 2000; Fuziy et al.,
2006).
To overcome these unwanted side-effects, skeletal
anchorage systems have been applied in previous studies
for molar distalization (Keles et al., 2003; Escobar et al.,
2007; Oncag et al., 2007; Kinzinger et al., 2009). Mini-
implants have been combined with pendulums and distal
jets to reinforce anchorage and prevent labial flaring.
A different system is indirect anchorage that splints
mini-implants to teeth between the canine and first premolar
for relief of posterior discrepancy by distalization of molars
and a direct anchorage using mini-implants between the
second premolar and first molar to apply retraction force to
hooks to prevent unwanted forward movement of the
anterior teeth during molar distalization (Cornelis and De
Clerck, 2007; Kim et al., 2008).
Recently, a mini-plate was applied on the palate to
efficiently distalize maxillary molars without invasive
procedures (Kook et al., 2010; Figure 1). However, the
resultant tooth displacement due to molar distalization
using skeletal anchorage has not been evaluated.
Therefore, the purposes of this study were to analyse the
displacement of central incisors and molars according to the
distalization modalities through the application of skeletal
anchorage using finite element analysis.
Materials and methods
Construction of finite element model
Commercial teeth models (Model-i21D-400G; Nissin
Dental Products, Kyoto, Japan) were three-dimensionally
scanned to produce the teeth images. Then, the images were
aligned on a broad dental arch form (Ormco®, Glendora,
California, USA) without curves of Spee and Wilson.
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The thickness of periodontal ligament was modelled
as a 0.25 mm layer of uniform thickness according to
Coolidge’s study (Coolidge, 1937). The alveolar bone
was designed to follow the cementoenamel junction
gingivally and extended 1 mm beyond the apecis (Block,
1987; Figure 2). Micro-arch® brackets (Tomy Co.,
Tokyo, Japan) were selected. In this study, the brackets
and archwire were assumed to be in no-play and
Figure 1  (A) Schematic figure of palatal plate. (B) Schematic figure of
maxillary molar distalization appliance using palatal plate.
Figure 2  The finite element analysis model. (A) Teeth; (B) teeth and
alveolar bone; Schematic line of axes (C) Y–Z plane; and (D) X–Z plane.
I. YU ET AL.
no-friction relationship, and all materials were considered
to be homogenous, isotropic, and have linear elasticity.
Materials’ properties (Young’s modulus and Poisson’s
ratio) were reported by previous studies (Tanne et al.,
1987; Sung et al., 2009; Table 1).
Determination of axes
Each model 3D co-ordinates [X, median (+) to lateral (−)
direction; Y, anterior (+) to posterior (−) direction; and Z,
supero (+) to inferior (−) direction]. For result presentation,
the central incisor was modelled by the midpoint of the
incisal edge and the apex while the first and second molars
were demonstrated by the four cusps and the palatal root
apex (Figure 2; Table 2).
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Installation of simulated distalization modalities on finite
element model
Models of three different distalization modalities were installed
on finite element models (FEMs) to produce 10 different
models according to the position of distalization arm.
Distalization modality 1: open-coil spring using indirect
skeletal anchorage.  Model 1.  Brackets were placed
on all teeth except the second premolar. A 0.019 × 0.025
inch SS archwire was engaged. To distalize the first
molar, 150 g of force was applied by open-coil spring
between the first premolar and the first molar. The first
premolar was connected to alveolar bone with 0.019 ×
0.025 SS wire in the FEM model to simulate the clinical
application of the indirect anchorage of a mini-implant
placed between the canine and the first premolar. The
first molars were connected by a 0.9 mm SS transpalatal
arch (TPA) to prevent rotation. The second molars were
excluded because they sometimes have not erupted or
have been strategically extracted (Figure 3A).
Distalization modality 2: open-coil spring and direct skeletal
anchorage.  Models 2, 3, and 4.  Brackets were placed on
all teeth except the second premolar. A 0.019 × 0.025 inch
SS archwire was engaged. To distalize the first molar, 150 g
of force was applied by open-coil spring between the first
premolar and the first molar. To prevent labial movement
of anterior teeth, a force of 150 g was applied between a
virtual position of a mini-implant (8 mm apical to archwire
Table 1  Mechanical properties of each tissue material used.
Young’s modulus (Mpa) Poisson’s ratio
Periodontal ligament 5.0 × 10−2 0.49
Alveolar bone 2.0 × 103 0.30
Tooth 2.0 × 104 0.30
Stainless steel 2.0 × 105 0.30
COMPARISON OF BUCCAL AND PALATAL APPROACHES FOR MOLAR DISTALIZATION 3 of 9

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Figure 3  (A) Indirect anchorage splinting mini-implants to teeth between the canine and the first
premolar. (B) Direct anchorage using mini-implants between the second premolar and the first molar to
apply retraction force to hook. (C and D) Palatal plate was assumed to be at the level of the first molars
centres, antero-posteriorly. The three indentations on the lever arms of the palatal plate were selected for
force application and were assumed to be at 4, 7, and 10 mm apical to the archwire. (E) Molar distalization
appliance including the second molars.

and 2 mm lateral to alveolar bone surface) and a 0.8 mm SS
retraction hook attached to the archwire between the lateral
incisor and canine. The first molars were connected by a 0.9
mm SS TPA to prevent rotation. The second molars were
excluded. The vertical height of the retraction hook was
decided to be 1, 4, and 7 mm in models 2, 3, and 4,
respectively (Figure 3B).
Distalization modality 3: palatal plate.  Models 5, 6,
and 7.  Brackets were placed on all teeth. A 0.019 × 0.025
inch SS archwire was engaged. A palatal plate was assumed
to be at the level of the first molars centres, antero-
posteriorly. The three notches on the lever arms of the
palatal plate were selected for force application and were
assumed to be at 4, 7, and 10 mm apical to the archwire
vertically and 13, 12.5, 12 mm lateral to mid-palate
horizontally, respectively. A 1.0 mm horseshoe SS palatal
arch connected the first molars. Two stainless steel hooks
(0.8 mm SS) were attached on the palatal arch close to the
lingual position of canine (Figure 1). For the first molar
distalization, a 150 g force was applied from one of the
three indentation positions of the palatal plate arm to the
palatal arch hook. The second molars were excluded for
the same reasons noted for model 1. The power vectors
for models 5, 6, and 7 were attached at the 4, 7, and 10 mm
lever arm indentations, respectively (Figure 3C and 3D).
Model 8.  This model was similar to model 7 but included
the second molar (Figure 3E).
Model 9.  This model was similar to model 7 but a cinch-
back bend was applied in the archwire distal to the first
molar tube to prevent sliding movement and imply en masse
distalization.
Model 10.  This model was similar to model 9 but included
the second molar.
Non-linear analysis was performed by ANSYS Ver.11
(Swanson Analysis System, Canonsburg, Pennsylvania,
USA) on HP XW6400 workstation (Hewlet-Packard Co.,
Palo Alto, California, USA).
4 of 9 I. YU ET AL.

Results were found in model 5. However, as the indentation used

Distalization by modality 1 using indirect anchorage
The first molar was shown to expand laterally with mesial-
out rotation (mesial side of the tooth is moved more laterally
than distal side of the tooth), uncontrolled distally tipped,
and extruded. The incisor was tipped anteriorly and intruded
(Figures 4, 5, 6, and 7; Table 2).
Distalization by modality 2 using direct anchorage
The displacement of the first molar widened laterally with
mesial-out rotation, uncontrolled distally tipped, and
extruded. However, the results for the incisor position were
relatively stable compared to model 1. However, flaring and
intrusion of the incisors increased as the vertical height rose
was close to the midpalatal suture, extrusion was replaced
with bodily movement. Finally, in model 7, which was
closest to the midpalatal suture, bodily movement and
intrusion were shown.
In model 8, the displacement of the first molar showed to
widen laterally with distal-out rotation with translation and
intrusion. However, the second molar showed to widen
laterally and was tipped distally with extrusion (Figures 4,
5, 6, and 7; Table 2).
Model 9 showed the displacement of the first molar to
widen laterally with distal-out rotation, translation, and
intrusion. However, the incisor was slightly tipped lingually
(Figures 4, 5, 6, and 7; Table 2).
Model 10 was similar to model 9, in that the maxillary

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second molar was tipped distally and extruded (Figures 4, 5,
from 4 to 7 mm in models 3 and 4, respectively (Figures 4,
6, and 7; Table 2).
5, 6, and 7; Table 2).

Distalization by modality 3 with palatal plate Discussion

The incisor position was very stable in models 5, 6, and 7
during distalization. The displacement of the first molar was
distal-out rotation (distal side of the tooth is moved more
laterally than mesial side of tooth), while modalities 1 and 2
were mesial-out. Controlled distal tipping and extrusion
Molar distalization is recommended for correction of
Class II malocclusion or maxillary crowding cases
without extraction. For better treatment results, in spite of
development of several intraoral appliances, it does not
perfectly prevent reciprocal mesial movement of anchorage

Figure 4  Contour image of the maxillary dentition in X-axis displacement. Original model (white mesh) and deformed model (colour). (A and B) Contour
plot of models 1 and 2, respectively, was 10 times magnified. As the orthodontic force is applied at buccal side, the mesial-out rotation of the first molar
(mesial side of the tooth is moved more laterally than distal side of the tooth) was observed. (C) Contour plot of model 7 was 20 times magnified. As the
orthodontic force is applied at palatal side, the distal-out rotation of the first molar (distal side of the tooth is moved more laterally than mesial side of tooth)
was observed. (D) Contour plot of model 8 was 40 times magnified. The second molar is moved laterally without large rotation because the distal-out
rotation of the first molar and rearward force are transferred to contact point between the first molar and the second molar. (E) Contour plot of model 9 was
40 times magnified. The second premolar is moved medianly by virtue of the distal-out rotation of the first molar. (F) Contour plot of model 10 was
40 times magnified. The distal-out rotation of the first molar, median movement of the second premolar, and lateral movement of the second molar are
observed.
Table 2  Values of displacement of teeth. MIE, middle incisal edge; RA, root apex; MBC, mesio-buccal cusp; MPC, mesio-palatal cusp; DBC, disto-buccal cusp; DPC, disto-palatal
cusp; PRA, palatal root apex.

Central incisor The first molar

MIE RA MBC MPC DBC DPC PRA

Model 1 Dx 6.30 × 10−3 −5.86 × 10−4 −4.12 × 10−2 −3.27 × 10−2 −1.75 × 10−2 −1.27 × 10−2 2.01 × 10−2
Dy 2.72 × 10−2 −1.29 × 10−2 −1.80 × 10−1 −1.59 × 10−1 −1.81 × 10−1 −1.56 × 10−1 7.60 ×m 10−2
Dz 2.34 × 10−2 −5.33 × 10−3 −5.19 × 10−2 −3.34 × 10−2 2.82 × 10−2 3.24× 10−2 3.02 × 10−2
Model 2 Dx 4.52 × 10−2 −1.05 × 10−2 −5.43 × 10−2 −4.50 × 10−2 −2.82 × 10−2 −2.28 × 10−2 2.39 × 10−2
Dy 1.52 × 10−5 −1.83 × 10−2 −1.75 × 10−1 −1.51 × 10−1 −1.75 × 10−1 −1.48 × 10−1 7.50 × 10−2
Dz 2.09 × 10−2 1.12 × 10−2 −4.66 × 10−2 −3.42 × 10−2 3.01 × 10−2 2.91 × 10−2 2.63 × 10−2
Model 3 Dx 4.86 × 10−2 −1.08 × 10−2 −4.87 × 10−2 −3.96 × 10−2 −2.34 × 10−2 −1.83 × 10−2 2.19 ×; 10−2
Dy 8.56 × 10−3 −2.39 × 10−2 −1.78 × 10−1 −1.55 × 10−1 −1.79 × 10−1 −1.53 × 10−1 7.63 × 10−2
Dz 3.07 × 10−2 1.09 × 10−2 −5.04 × 10−2 −3.50 × 10−2 2.84 × 10−2 2.99 × 10−1 2.74 × 10−2
Model 4 Dx 5.65 × 10−2 −1.24 × 10−2 −4.36 × 10−2 −3.47 × 10−2 −1.90 × 10−2 −1.40 × 10−2 2.01 × 10−2
Dy 1.66 × 10−2 −3.11 × 10−2 −1.81 × 10−1 −1.59 × 10−1 −1.82 × 10−1 −1.56 × 10−1 7.75 × 10−2
Dz 4.17 × 10−2 1.15 × 10−2 −5.39 × 10−2 −3.57 × 10−2 2.68 × 10−2 3.06 × 10−2 2.84 × 10−2

Central incisor The first molar The second molar

MIE RA MBC MPC DBC DPC PRA MBC MPC DBC DPC PRA

Model 5 Dx 2.72 × 10−3 −6.54 × 10−4 −3.38 × 10−2 −4.46 × 10−2 −6.12 × 10−2 −6.57 × 10−2 7.36 × 10−3 — — — — —
COMPARISON OF BUCCAL AND PALATAL APPROACHES FOR MOLAR DISTALIZATION

Dy 4.52 × 10−3 −2.25 × 10−3 −8.81 × 10−2 −1.16 × 10−1 −9.00 × 10−2 −1.15 × 10−1 3.67 × 10−3 — — — — —
Dz 3.98 × 10−3 −7.26 × 10−4 −1.73 × 10−2 −2.67 × 10−2 2.45 × 10−2 8.12 × 10−3 4.56 × 10−3 — — — — —
Model 6 Dx 1.12 × 10−3 −2.86 × 10−4 −1.85 × 10−2 −2.79 × 10−2 −4.30 × 10−2 −4.72 × 10−2 −2.57 × 10−3 — — — — —
Dy 1.92 × 10−3 −8.56 × 10−4 −5.13 × 10−2 −7.58 × 10−2 −5.27 × 10−2 −7.52 × 10−2 −1.32 × 10−2 — — — — —
Dz 1.60 × 10−3 −3.29 × 10−4 −5.82 × 10−3 −1.27 × 10−2 1.64 × 10−2 5.85 × 10−3 3.73 × 10−3 — — — — —
Model 7 Dx 1.32 × 10−4 −7.53 × 10−5 −3.29 × 10−3 −1.13 × 10−2 −2.45 × 10−2 −2.83 × 10−2 −4.16 × 10−2 — — — — —
Dy 1.61 × 10−3 −3.67 × 10−4 −1.44 × 10−2 −3.52 × 10−2 −1.52 × 10−2 −3.53 × 10−2 −2.96 × 10−2 — — — — —
Dz 8.39 × 10−4 −5.83 × 10−4 5.71 × 10−3 1.23 × 10−3 8.41 × 10−3 3.54 × 10−3 2.84 × 10−3 — — — — —
Model 8 Dx 1.00 × 10−4 −4.25 × 10−5 6.42 × 10−3 6.74 × 10−4 −9.16 × 10−3 −1.22 × 10−2 −1.38 × 10−2 −2.28 × 10−2 −2.37 × 10−2 −2.40 × 10−2 −2.37 × 10−2 6.93 × 10−3
Dy 1.27 × 10−3 −3.15 × 10−4 −8.03 × 10−3 −2.34 × 10−2 −8.56 × 10−3 −2.35 × 10−2 −2.76 × 10−2 −1.60 × 10−2 −1.71 × 10−2 −1.64 × 10−2 −1.67 × 10−2 4.44 × 10−3
Dz 7.43 × 10−4 −4.04 × 10−4 3.68 × 10−3 4.05 × 10−3 2.94 × 10−3 3.39 × 10−3 3.52 × 10−3 −2.46 × 10−3 −1.05 × 10−2 3.20 × 10−3 −4.13 × 10−3 −2.76 × 10−3
Model 9 Dx 7.30 × 10−4 −2.40 × 10−4 1.83 × 10−3 −5.89 × 10−3 −1.88 × 10−2 −2.27 × 10−2 −1.48 × 10−2 — — — — —
Dy −4.06 × 10−4 9.14 × 10−5 −1.40 × 10−2 −3.44 × 10−2 −1.47 × 10−2 −3.44 × 10−2 −2.92 × 10−2 — — — — —
Dz −2.18 × 10−4 2.06 × 10−4 4.29 × 10−3 2.63 × 10−3 6.89 × 10−3 4.79 × 10−3 4.46 × 10−3 — — — — —
Model 10 Dx 4.91 × 10−3 −1.51 × 10−3 1.18 × 10−2 6.91 × 10−3 −1.61 × 10−3 −4.27 × 10−3 −1.47 × 10−2 −1.34 × 10−2 −1.45 × 10−2 −1.53 × 10−2 −1.55 × 10−2 6.74 × 10−4
Dy −6.84 × 10−3 1.16 × 10−3 −6.40 × 10−3 −1.96 × 10−3 −6.82 × 10−3 −1.97 × 10−2 −2.64 × 10−2 −1.30 × 10−2 −1.53 × 10−2 −1.35 × 10−2 −1.48 × 10−2 3.29 × 10−3
Dz −3.52 × 10−3 2.71 × 10−3 2.79 × 10−3 5.81 × 10−3 1.15 × 10−3 4.33 × 10−3 4.85 × 10−2 −3.81 × 10−3 −7.14 × 10−3 1.38 × 10−3 −2.06 × 10−3 −3.17 × 10−4
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Figure 5  Contour image of the maxillary dentition in Y-axis displacement. Original model (white mesh) and deformed model (colour). (A) Model 1
contour plot was 10 times magnified. The first molar was showed uncontrolled distal tipping, and the incisor was tipped anteriorly. (B) The displacement
of the first molar showed uncontrolled distal tipping in model 2. (C) Contour plot of model 7 was 20 times magnified. The incisor position was very stable
and the first molar showed bodily movement. (D) Contour plot of model 8 was 40 times magnified. The first molar was translated but the second molar was
tipped distally. (E) Contour plot of model 9 was 40 times magnified. The first molar was translated and the incisor was slightly tipped lingually. (F) Contour
plot of model 10 was 40 times magnified. The first molar was translated but the second molar was tipped distally.

Figure 6  Contour image of the maxillary dentition in Z-axis displacement. Original model (white mesh) and deformed model (colour). (A) Model 1
contour plot was 10 times magnified. The first molar was extruded. The incisor was intruded. (B) The displacement of the first molar was extruded in model
2. (C) Contour plot of the model 7 was 20 times magnified. The incisor position was very stable and the first molar was intruded in model 7. (D) Contour
plot of model 8 was 40 times magnified. The displacement of the first molar showed intrusion. However, the second molar showed extrusion. (E) Contour
plot of model 9 was 40 times magnified. The first molar was intruded. (F) Contour plot of model 10 was 40 times magnified. The first molar was intruded
but the second molar was extruded.

teeth, the extrusion and distal tipping of the maxillary Recently, studies have been directed towards the use of
molars (Joseph and Butchart, 2000; Fuziy et al., 2006; skeletal anchorage devices. An example of indirect
Escobar et al., 2007). anchorage used a mini-implant splinted to a tooth to counter
 COMPARISON OF BUCCAL AND PALATAL APPROACHES FOR MOLAR DISTALIZATION

Figure 7  Tooth axies graph (incisor: midpoint of incisal edge to root apex; canine: cusp tip to root apex; and molar:mesio-palatal cusp tip to palatal root apex) magnified tooth displacement 70 times. A
solid line means before displacement and a dotted line means after displacement (circles, central incisor; squares, the first molar; and triangles the second molar). (A) The first molar showed uncontrolled
distal tipping and extruded and the incisor was tipped anteriorly and intruded. (B, C, and D) The displacement of the first molar showed uncontrolled distal tipping, and the incisor was intruded and proclined
as the vertical height rose from 1 to 7 mm in models 2, 3, and 4, respectively. (E, F, and G) Axies graph of the models 5, 6, and 7, respectively. The incisor position was very stable in models 5, 6, and 7. The
displacement of the first molar was controlled distal tipping and extruded in model 5. However, as the indentation used was close to the midpalatal suture, extrusion and distal tipping were replaced with
intrusion and bodily movement in model 7. (H) Axies graph of model 8, the first molar was translated and intruded. However, the second molar was tipped distally with extrusion. (I) Axies graph of model
9, the displacement of the first molar was translation and intrusion and the incisor was slightly tipped lingually. (J) Axies graph of model 10. Model 10 was similar to model 9 in that the second molar was
tipped distally and extruded.
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8 of 9
reciprocal mesial force (Kim et al., 2008). A direct
anchorage method to counter such force applied a mini-
implant connected with an elastic chain to a hook placed to
the anterior position on the archwire (Cornelis and De
Clerck, 2007). A third method placed a plate or mini-implant
in the palate to make the force direction pass through the
centre of resistance as closely as possible to distalize the
first molars (Kook et al., 2010).
Desirable treatment outcomes vary with the presence or
absence of molar inclination, rotation, and other factors. For
example, distal movement of the crown portion only can
effectively treat mesially tipped molars. But our study’s
model was assumed to have normal alignment, so bodily
movement was the primary concern for evaluation during
distalization. Occlusal relations can worsen if molar
extrusion during treatment causes open bite or clockwise
mandibular rotation. Distal tipping of the first molar can
cause premature contact, which in turn might lead to a
relapse. Therefore, the clinician should ensure intrusion or
maintenance of the pre-treatment molar position during
distalization.
Conventional measuring points for evaluating tooth
displacement have been imprecise, for example, the crown
centroids or cusp tips. Treatment results will be different
depending on the measuring points chosen to evaluate the
amount of teeth movement. If the first molar was tipped
distally, the mesial tips of the crown might show extrusive
movement, while the distal tips could intrude. In our study,
therefore, the functional mesio-palatal cusp tip and palatal
root apex of the first molar were the measuring points for
analysis of displacement (Table 2).
In modality 1, model 1, the incisor was tipped labially
with distortion of 019 × 025 inch SS wire and the first molar
was rotated mesial-out, extruded with uncontrolled distal
tipping. We thought this result occurred because the
distalization force was applied through a bracket level
below the furcation area, which has been reported to be a
centre of resistance (Dermaut et al., 1986; Figures 4, 5, 6,
and 7; Table 2).
In modality 2, models 2, 3, and 4, the displacement of the
first molar was similar to model 1 but the incisor results
varied according to the vertical height of the hook (Figures
4, 5, 6, and 7; Table 2). In model 2 (short hook), the incisor
was slightly intruded. If the distalization force had been
heavier, the incisor might have tipped lingually. However,
as the hooks’ vertical height increased, there was anchorage
loss resulting in labial tipping of the incisors.
In modality 3, models 5, 6, and 7, the anterior teeth were
stable. This was the most favourable outcome compared
with modalities 1 and 2, which applied mini-implants on the
buccal side. The first molar in modality 3 had a tendency to
rotate mesial-in because it was distalized on the palatal site.
The displacement of the first molar changed from controlled
tipping to bodily movement as the force vector was applied
to lever arm indentations vertically farther from the bracket
I. YU ET AL.
level. Therefore, model 7, showed the most desirable result
of bodily movement with intrusion during distalization
(Figures 4, 5, 6, and 7; Table 2).
Model 8 was assumed to include second molars. The
tooth movement was similar to model 7 but the second
molar was tipped distally and widened laterally without
rotation (Figures 4, 5, 6, and 7; Table 2). This movement
might be because the distalization force was applied through
the contact point between the first and second molar by
bodily movement of the first molar.
In modalities 1 and 2, the mini-implant was assumed to
be placed buccally to distalize the molar. As the molar
distalizing force was applied at the level of the bracket, the
first molar was tipped distally. After the first molar was
moved distally in modality 2, if the second premolar needed
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to be moved distally, the mini-implant must first be moved
because of the narrow inter-radicular space.
In contrast, modality 3 used a palatal plate on the palatal
side instead of a mini-implant on a buccal site, and it applied
force through near the center of resistance of the first molar.
The plate was placed on the non-tooth-bearing area near the
midpalatal suture, avoiding the problem of narrow inter-
radicular space on the buccal side for placing mini-implants
(Lee et al., 2009). Also, the thick cortical bone enabled
heavy force to be loaded (Lombardo et al., 2010; Moon
et al., 2010).
In model 8, the second molar was seen to widen laterally
and was tipped distally with extrusion. To avoid this
unwanted movement, the second molar needs to be first
bodily moved with a TPA before distalization of the first
molar. Moreover, models 9 and 10 were simulated group
distalizations. Park et al. (2005) reported a group
distalization using buccal mini-implants. These skeletal
anchorage devices ensure whole arch movement without
distalizing molars and anterior teeth separately. This
movement could improve molar occlusal relationship and
correct mild protrusion cases.
Placing the mini-implants between the buccal roots limits
the distal movement of the dentition (Lee et al., 2009). Also,
this movement causes tipping, especially in the molars, as
demonstrated in additional studies (Park et al., 2005).
Our report suggested that model 7 has the ideal vertical
height of 10mm, which indicates the indentation closest to
the midpalatal arch. The first molar showed distal bodily
movement, but its movement on the buccal side was limited
due to distal-out rotation. Also, movement of the anterior
portion was not as great as was expected. Therefore, to
minimize firstt molar distal-out rotation, we recommend
reinforcement of the TPA with a heavy wire to reduce
distortion, a modified lingual retractor by splinting all teeth
to minimize individual tooth movement (Kim et al., 2004)
or by palcing a mini-implant buccally to apply additional
buccal force (Oberti et al., 2009).
This study has some limitations, including only
calculating initial tooth displacement with finite element
COMPARISON OF BUCCAL AND PALATAL APPROACHES FOR MOLAR DISTALIZATION
analysis. In addition, the following clinical factors such as
occlusal force, differences in mechanical properties between
virtual models and biological tissues, and elastic recovery
force of archwires over time were not applied. However,
our findings could serve as a diagnostic and treatment guide
for clinicians in the application of skeletal anchorage
devices for molar distalization.
Conclusions
This study used finite element analysis to evaluate teeth
displacement according to three modalities of molar
distalization with skeletal anchorage devices. Modalities 1
and 2 placed mini-implants in the buccal side, and modality
3 placed a plate on the palatal side. Distalization with the
palatal plate showed bodily molar movement and insignificant
displacement of the incisors. Placing mini-implants on the
buccal side caused the first molar to be distally tipped and
extruded, while the incisors were labially flared and intruded.
It is recommended that our findings serve as a diagnostic and
treatment guide for clinicians in the application of skeletal
anchorage devices for molar distalization.
Funding
Prof. Kook, one of the authors, was involved in development
of palatal plate but that this study was done without any
financial support from a company.
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