ORIGINAL ARTICLE

Mandibular posterior anatomic limit for molar

distalization
Sung-Jin Kim,a Tae-Hyun Choi,a Hyoung-Seon Baik,b Young-Chel Park,b and Kee-Joon Leeb
Seoul, Korea

Introduction: The purpose of this study was to investigate the mandibular posterior anatomic limit for molar dis-
talization. Methods: Three-dimensional computed tomography scans were obtained on 34 adults with a skeletal
Class I normodivergent facial profile and a normal occlusion. Posterior available space was measured at the
crown and root levels along the posterior occlusal line connecting the buccal cusps of the first and second molars
on the axial slices. It was also measured at the occlusal level on the lateral cephalograms derived from the
computed tomography scans. The measurements on the cephalograms were used to predict the actual posterior
available space determined by computed tomography and to determine the presence of root contact with the
inner lingual cortex by linear regression and discriminant analyses, respectively. Results: The posterior avail-
able space was significantly smaller at the root level than at the crown level. Root contact was observed in
35.3% of the 68 roots. The posterior available space measured on the lateral cephalograms resulted in a regres-
sion equation with a coefficient of determination of 0.261 to predict actual available space and correctly identified
root contact in 66.2% of cases with a threshold value of 3.9 mm. Conclusions: The posterior anatomic limit ap-
peared to be the lingual cortex of the mandibular body. Computed tomography scans are recommended for pa-
tients who require significant mandibular molar distalization. (Am J Orthod Dentofacial Orthop 2014;146:190-7)

M
olar distalization is a nonextraction treatment
modality used to correct Class II or Class III
molar relationships1,2 and to relieve crowding
without adverse arch expansion, which can jeopardize
both esthetics and stability.3,4 Recently, its clinical
significance has increased because of the introduction
of temporary anchorage devices in orthodontic
treatment; these enable predictable molar distalization
with minimal patient compliance.5,6 Regardless of the
anchorage unit used for distalization, however, there is
a posterior anatomic limit beyond which orthodontic
tooth movement can barely be achieved. Although the
maxillary arch has a clear posterior limit—the maxillary
tuberosity—the limit for the mandibular arch is not
yet clear.
From the Department of Orthodontics, School of Dentistry, Yonsei University,
Seoul, Korea.
a
Lecturer.
b
Professor.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Supported by a faculty research grant of Yonsei University College of Dentistry
(6-2013-0090).
Address correspondence to: Kee-Joon Lee, Department of Orthodontics, School
of Dentistry, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752,
South Korea; e-mail, orthojn@yuhs.ac.
Submitted, January 2014; revised and accepted, April 2014.
0889-5406/$36.00
Copyright Ó 2014 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.04.021
190
Previous studies regarding the retromolar region have
focused on the posterior available space observed on
panoramic radiographs or lateral cephalograms to calcu-
late the posterior space discrepancy or to predict the
prognosis of third molar eruption.7-13 In most of these
studies, the anterior border of the ramus was presumed
to be the posterior limit of the mandibular arch, and
the available space was measured along the occlusal
plane.7,8,11-13 However, these 2-dimensional radio-
graphs have inherent sources of error, such as differential
magnification and distortion, and also they are projected
images that cannot represent the 3-dimensional (3D)
morphology of the mandibular ramus.14
Another issue that has received little attention to date
is the limitation to the alveolar bone housing for posterior
teeth caused by the inner and outer lingual cortexes of
the mandibular body. With regard to alveolar bone hous-
ing, it has been suggested that teeth should be moved
within the boundaries of cortical bones15 to form an “en-
velope of discrepancy,” which describes mainly incisor
movement in the sagittal plane and molar movement in
the coronal plane.16 However, little is known about the
alveolar bone housing for the distalization of the
mandibular molar, which might determine the posterior
limit. This is possibly due to the lack of an appropriate
diagnostic tool and the difficulty in anchorage prepara-
tion for mandibular molar distalization before the intro-
duction of temporary anchorage devices to orthodontics.
Kim et al 191

Recently, 3D computed tomography (CT) has become

Table I. Patient characteristics
widely used in dental practice, and it can provide accurate
anatomic information, such as cortical bone thickness Variable Mean SD Minimum Maximum
and interroot distance.17,18 Age (y) 22.0 3.7 18 29
The purposes of this study were to (1) determine the ANB (
) 2.9 0.8 1.4 3.9
SN-MP (
) 34.7 2.3 30.2 37.8
posterior anatomic limit by comparing the posterior
available spaces measured at various levels of the SN-MP, Sella-nasion to mandibular plane angle.
mandibular second molar on axial slices of 3D CT, and
(2) predict the posterior available space and the presence
of root contact with the inner lingual cortex of the
mandibular body using lateral cephalograms.

MATERIAL AND METHODS

This study was performed using a subset of CT
images of patients from a previous study, selected on
the basis of the following criteria: (1) adult skeletal Class
I patients with normodivergent facial profile
(age, .18 years; ANB, .0
and \4
; sella-nasion to
mandibular plane angle, .30
and \38
), (2) no
notable facial asymmetry, (3) normal overjet and over-
bite with Class I molar relationships, (4) crowding less
than 2 mm in both arches, (5) healthy periodontal state
with no noticeable alveolar bone loss, (6) no prostheses
or missing teeth except third molars, (7) intact roots with
no root anomalies such as idiopathic root resorption and
severe dilacerations, and (8) no history of orthodontic
treatment.17 Thirty-four patients met the criteria and
were included in this study. The characteristics of the
patients are shown in Table I.
The 3D CT scans were obtained using Hispeed Fig 1. Reference planes and landmarks for reorientation
Advantage (GE Medical Systems, Milwaukee, Wis) with of the reconstructed 3D images. LIE, Midpoint of the 2
the following settings: 120 kV, 180 mA, slice thickness mandibular central incisor tips; LR6-MB, mesiobuccal
cusp of the mandibular first molar; Po-R, right porion.
3.0 mm, and pitch 1.5. The CT images were saved as
DICOM files, each with a slice thickness of 1.0 mm.
The DICOM data were reconstructed into 3D images the axial slices of CT images. The shortest distance be-
using InVivoDental software (version 5.2; Anatomage, tween the mandibular second molar crown and the outer
San Jose, Calif). The reconstructed 3D images were cortex of the ramus was measured parallel to the poste-
reoriented with the mandibular occlusal plane as a hor- rior occlusal line (POL) connecting the buccal cusps of
izontal reference plane, connecting the midpoint of the the mandibular first and second molars at the occlusal
mandibular incisor tip and both mesiobuccal cusps of level (CROL), and 2 mm from the occlusal level (CR2mm)
the mandibular first molars to measure the posterior on the axial slices (Fig 2, A). The shortest distances be-
available space on the axial slices parallel to the mandib- tween the mandibular second molar root and the inner/
ular occlusal plane. The coronal plane was constructed outer lingual cortex of the mandibular body were then
parallel to the transporionic line, while passing through measured parallel to the POL, at depths of 2, 4, 6, 8,
the midpoint of the mandibular incisor tip, to generate and 10 mm (RLin-2,4,6,8,10mm, RLout-2,4,6,8,10mm) on the
CT-derived lateral cephalograms.19 The midsagittal axial slices with the proximal cementoenamel junction
plane was established at right angles to the horizontal as the reference level (Fig 2, B and C). The number and
and frontal planes, while passing through the midpoint percentage of the roots that were in contact with the in-
of the mandibular incisor tip (Fig 1). ner lingual cortex of the mandibular body were calcu-
The linear distances described below were measured lated at each measurement level. Lastly, the distance
using the InVivoDental software program. Measure- between the mandibular second molar and the anterior
ments at crown (CR) and root level (RL) were made on border of the ramus was measured parallel to the

American Journal of Orthodontics and Dentofacial Orthopedics August 2014  Vol 146  Issue 2
192 Kim et al

Fig 2. A, Axial slice at occlusal level: a, posterior available space measured at occlusal level; dotted
red line, posterior occlusal line connecting buccal cusps of the mandibular first and second molars.
B, Axial slice at root level. C, Close-up view of the white box in B; b, distance to the inner lingual cortex;
c, distance to the outer lingual cortex.

mandibular occlusal plane at the occlusal level (CephOL)

on the CT-derived half-skull cephalograms generated
with parallel projection, to eliminate the overlap of bilat-
eral structures (Fig 3).20

Statistical analysis
All measurements were performed twice, by the same
examiner (S.-J.K.), 2 weeks apart. The paired t test was
conducted to verify the reproducibility of the measure-
ments. The Dahlberg21 formula was used to calculate
method errors: Se 5 O(d2/2n), where d is the difference be-
tween measurements, and n is the number of pairs of mea-
surements. Since the paired t test showed no statistically
significant difference between the measurements of the
left and right sides, the averaged measurements were used.
To investigate the influence of the third molar on the
posterior available space, the 34 patients were divided
into 2 groups according to the presence of the mandibular
third molar: a third-molar group (n 5 23), in which both
mandibular third molars were present, and a nonthird-
molar group (n 5 11), in which both third molars were ex-
tracted or congenitally missing. Since the 2-sample t test
showed no significant differences between the 2 groups
for any measurement, subsequent statistical analyses
were performed on the whole sample, using SPSS for Win-
dows (version 18.0; SPSS, Chicago, Ill). One-way analysis Fig 3. Right half-skull cephalogram generated with paral-
of variance (ANOVA) and Tukey post-hoc tests were per- lel projection. Dotted red line, Mandibular occlusal plane;
formed to compare the measurements. The Pearson cor- yellow line, posterior available space.
relation analysis was used to investigate correlations
between CephOL and CRs/RLs. Simple linear regression of the 34 patients were divided into 2 groups: a contact
analysis was performed using RLin-10mm as the dependent group, in which the root was in contact with the lingual
variable and CephOL as the independent variable. cortex on at least 1 level, and a noncontact group, in
To perform a discriminant analysis with CephOL as a which the root was not in contact on any level. The
predictive variable, the 68 mandibular second molars 2-sample t test was performed to compare CephOL

August 2014  Vol 146  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Kim et al
Table II. Distance between the mandibular second molar and the anterior border of the ramus/outer lingual cortex of
the mandibular body (1-way ANOVA and Tukey post-hoc tests)
Between the crown and the anterior border of the ramus
CephOL CROL CR2mm
(n 5 34) (n 5 34) (n 5 34)
Mean 4.13a 11.43b 9.88c
SD 1.83 2.94 2.91
Post-hoc Tukey test (P \0.05)
a \b,c,d,e,f,g,h b .a,d,e,f,g,h c .a,g,h
between these 2 groups. An unstandardized canonic
discriminant function coefficient was calculated with a
constant for CephOL, leading to an equation that assigns
a score to each patient. The group centroid (mean score
for each group) was calculated, after which the critical
score (mean value of the 2 group centroids) was calcu-
lated. Since there was 1 predictive variable, the threshold
value of CephOL was calculated. Last, the classification
value of CephOL was tested.
RESULTS
The paired t test showed no statistically significant
difference between the measurements performed
2 weeks apart. The method errors ranged from 0.44 to
1.48 mm. When the posterior available space at the
crown level as measured on the CT-derived lateral ceph-
alograms was compared with that measured on the axial
slices, CephOL was significantly smaller than CROL and
CR2mm (P \0.05), indicating that the lateral cephalo-
grams understated the available space distal to the
mandibular second molars (Table II).
When comparing the distance to the outer cortex at
the crown and root levels on the axial slice (CRs and
RLouts), CROL and CR2mm were significantly larger than
RLout-8mm and RLout-10mm (P \0.05). This indicated
that that the outer lingual cortex of the mandibular
body, not the anterior border of the ramus, was the pos-
terior anatomic limit when the molar was distalized
along the POL. In addition, RLout-10mm was smaller
than RLout-2mm and RLout-4mm, indicating that the avail-
able space decreased as the level of the measurements
became closer to the root apex (Table II, Fig 4). With re-
gard to the distance to the inner cortex at root levels,
RLin-2mm and RLin-4mm were also significantly smaller
than RLin-8mm and RLin-10mm, indicating that similar to
the outer lingual cortex, the space was smaller at the
root apex (Table III, Fig 4).
In terms of the correlation between the distances
measured on the CT-derived lateral cephalograms and
those measured on the axial slices, CephOL exhibited
moderate statistically significant correlations with CRs
American Journal of Orthodontics and Dentofacial Orthopedics
193
Between the root and the outer lingual cortex of the mandible
RLout-2mm RLout-4mm RLout-6mm RLout-8mm RLout-10mm
(n 5 34) (n 5 34) (n 5 34) (n 5 34) (n 5 32) P value
9.07d 9.12e 8.57f 7.38g 6.71h \0.001
2.98 3.13 3.14 3.07 2.89
d \b e \b f \b g \b,c h \b,c,d,e
d .a,h e .a,h f .a g .a h .a
and RLs (r 5 0.512-0.676) (Table IV). Since RLin-10mm
was the smallest value among the RLin values, although
it was not significantly different from RLin-6mm and
RLin-8mm, and was considered to determine the clinical
amount of molar distalization, simple linear regression
analysis was performed to predict RLin-10mm with Ce-
phOL. This resulted in the following regression model,
which was statistically significant (P \0.01) (Table V).
RLin10mm 5 ð0:7153CephOL Þ  0:220
With regard to root contact with the inner lingual
cortex, the percentage of root contact increased as the
level became closer to the root apex, reaching 32.8%
at the 10-mm level apical to the cementoenamel junc-
tion (Table VI). Of the total roots, 35.3% were in contact
on at least 1 level, and these were assigned to the contact
group (n 5 24). The rest of the roots were assigned to the
noncontact group (n 5 48). When CephOL was compared
between the 2 groups, it was significantly smaller in the
contact group (P \0.01) (Table VII). Discriminant anal-
ysis yielded an unstandardized discriminant function
coefficient of CephOL and a calculated constant
(Table VIII), facilitating the following equation that pro-
vides an individual score for assigning a new patient to
the contact or the noncontact group.
Individual score50:5723ðCephOL Þ  2:362
The critical score was 0.131, and the threshold
value of CephOL was 3.900, indicating that a new
mandibular second molar with a CephOL lower than
3.9 mm is likely to have a root that is in contact with
the inner lingual cortex. The percentage of correctly
classified cases was 66.2% (Table IX).
DISCUSSION
Anatomic limits for orthodontic tooth movement can
be divided into 2 types according to level: crown level
and root level. At crown level, the only anatomic struc-
ture that can be encountered during orthodontic tooth
movement is the mandibular ramus, which is related to
the distalization of mandibular molars. When the crown
August 2014  Vol 146  Issue 2
194 Kim et al

Fig 4. Graph of the posterior available space at each level of measurement. Blue, Distance to the outer
lingual cortex; red, distance to the inner lingual cortex; OL, occlusal level; CEJ, cementoenamel junction.

Table III. Distance between the mandibular second molar root and the inner lingual cortex of the mandibular body
(1-way ANOVA and Tukey post-hoc tests)
RLin-2mm (n 5 34) RLin-4mm (n 5 34) RLin-6mm (n 5 34) RLin-8mm (n 5 34) RLin-10mm (n 5 32) P value
Mean 6.10a 5.87b 4.70c 3.67d 2.77e \0.001
SD 3.13 3.36 3.17 2.84 2.42
Post-hoc Tukey test (P \0.05)
a .d,e b .d,e - d \a,b e \a,b

Table IV. Correlations between the measurements on the lateral cephalograms and the axial CT slices with Pearson
correlation analysis
Correlation
coefficient
(P value) CROL CR2mm RLin-2mm RLout-2mm RLin-4mm RLout-4mm RLin-6mm RLout-6mm RLin-8mm RLout-8mm RLin-10mm RLout-10mm
CephOL 0.676y 0.639y 0.569y 0.556* 0.589y 0.557* 0.578y 0.570y 0.512* 0.574y 0.534* 0.633y
\0.001 \0.001 \0.001 0.001 \0.001 0.001 \0.001 \0.001 0.002 \0.001 0.002 \0.001

*P \0.01; yP \0.001.

alveolar bone limits tooth movement.23 When the root

Table V. Linear regression analysis
makes contact with the inner cortex, tooth movement
Independent Unstandardized slows, and the risk of root resorption is dramatically
variable coefficient Adjusted R2 P value increased.24,25 If the tooth moves farther to the outer
CephOL 0.715* 0.261 0.002
cortex, it can cause alveolar bone loss, gingival
(Constant) 0.220
Regression equation: RLin-10mm 5 (0.715 3 CephOL)  0.220 recession, and root exposure, compromising
periodontal support.26
*P \0.01; adjusted R2, adjusted coefficient of determination. The results of this study suggested that the posterior
available space was smaller at the root level than at the
of a tooth is forced against the cortical bone, enamel crown level, indicating that the posterior anatomic limit
makes direct contact with the bone, leading to pressure was not the anterior border of the ramus, but the lingual
necrosis.22 At the root level, the cortical layer of the cortex of the mandibular body. This is because the

August 2014  Vol 146  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Kim et al 195

Table VI. Numbers and percentages of root contacts with the inner lingual cortex of the mandible
2-mm level from 4-mm level from 6-mm level from 8-mm level from CEJ 10-mm level from CEJ
CEJ (n 5 68) CEJ (n 5 68) CEJ (n 5 68) (n 5 68) (n 5 64) Any levels (n 5 68)
Number 0 2 5 12 21 24
Percentage (%) 0 2.9 7.4 17.6 32.8 35.3
CEJ, Cementoenamel junction.

mandibular second molar roots were in contact with

Table VII. Comparison of CephOL between the contact
the inner lingual cortex, rendering distalization an
and noncontact groups (2-sample t test)
unfeasible treatment option in these cases.
Contact group Noncontact group Although radiation dose and the costs of cone-beam
(n 5 24) (n 5 44) P value CT are reportedly lower than those of multislice CT, they
Mean 3.12 4.68 0.001
are still higher than those of conventional 2-dimensional
SD 1.93 1.64
radiographs.29,30 Thus, not every patient can be assessed
via CT images, rendering the ability to predict the
available space from lateral cephalograms valuable.
Table VIII. Discriminant analysis
Correlation analysis yielded moderate correlations
Unstandardized canonic between the available spaces on the lateral
Predictive variable discriminant function coefficient cephalograms and the axial CT slices. The regression
CephOL 0.572 equation with RLin-10mm as a dependent variable, which
(Constant) 2.362
was the shortest distance among RLs in most roots, was
Individual score 5 0.572 3 (CephOL)  2.362.
Group centroid: contact group, 0.576; noncontact group, 0.314. also statistically significant. However, the adjusted
Critical score: 0.131. coefficient of determination was 0.261, reflecting the
Threshold of CephOL: 3.900. limitations of lateral cephalograms for determining the
actual available space.
With regard to the prediction of root contact, it was
identified in 66.2% with CephOL alone. Considering
Table IX. Classification results
that this was a result of univariate discriminant analysis,
Predicted group membership the lateral cephalograms appeared to provide limited but
Original group membership Contact group Noncontact group
valuable information regarding root contact. Based on
Contact group 66.7% (n 5 16) 33.3% (n 5 8)
these findings, CT is recommended for the evaluation
Noncontact group 34.1% (n 5 15) 65.9% (n 5 29) of the posterior available space in patients with CephOL
Overall accuracy (correctly classified patients in total): 66.2%. of less than 3.9 mm when significant molar distalization
is planned.
Another interesting finding was that the posterior limit
mandibular basal bone is V-shaped and diverged poste- at the occlusal level was actually located approximately
riorly, whereas the mandibular molars should be distal- 7 mm distal to the anterior border of the ramus as
ized along the POL to establish proper occlusion with observed on the lateral cephalograms. This is more poste-
opposing maxillary molars, leading to root contact riorly located than the limit previously suggested by Vaden
with the inner and outer lingual cortexes. The available et al,31 who reported that the posterior limit is 2 to 3 mm
space decreased as the level of measurement was closer distal to the anterior border of the ramus because of the
to the apex because the buccolingual inclination of the lingual shelf. The differences between the measurements
mandibular lingual border is steeper than that of the on the lateral cephalograms and the axial slices are due
mandibular second molar. to the fact that the mandibular second molar contacts
The mean distances between the root and the inner the internal oblique ridge when it is distalized along the
and outer lingual cortexes at a level of 10 mm from POL. The external oblique ridge, which is observed as
the cementoenamel junction were 2.87 and 6.73 mm, the anterior border of the ramus on lateral cephalograms,
respectively. Considering that the reasonable amount is located anterolateral to the internal oblique ridge.
of molar distalization is approximately 3 mm, the avail- This study had some limitations. First, it was conduct-
able space appeared to be appropriate.6,27,28 However, ed on subjects with a skeletal Class I normodivergent
individual variations were considerable; a third of the facial profile. Accordingly, the resulting data might not

American Journal of Orthodontics and Dentofacial Orthopedics August 2014  Vol 146  Issue 2
196
be directly applicable to patients with horizontal or ver-
tical skeletal discrepancies, which can affect the remod-
eling pattern of the mandible during growth.32 Further
studies are needed to evaluate these measurements in
patients with varying degrees of skeletal discrepancies.
Second, soft tissue distal to the mandibular second molar
was not taken into account. Generally, there is thick soft
tissue overlying the retromolar pad area that can result in
considerably distalized molars being partially covered by
the soft tissue. Clinically, an acceptable amount of
attached gingiva should be present around the distalized
molar to maintain periodontal health; the lack of
attached gingiva can be a limiting factor for molar distal-
ization.27
CONCLUSIONS
1. In patients with skeletal Class I normodivergent
facial profiles, the posterior anatomic limit for molar
distalization was the lingual cortex of the mandib-
ular body.
2. Lateral cephalograms provided limited but valuable
information for predicting the posterior available
space and the presence of root contact with the
inner lingual cortex.
3. CT evaluation is recommended in patients requiring
significant molar distalization, when the lateral
cephalograms show posterior available space less
than 3.9 mm.
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