MOLAR
DISTALIZATION
Class II Malocclusion
Non-Extraction treatment
Non-Compliance therapies
Treatment - Molar Distalization
Space regaining procedure
-Mesial migration of first permanent molars
Indications for Molar distalization
1. In a growing child
- to relieve mild crowding
- causes permanent increase in arch
length of about 2mm on each side.
2. Late mixed dentition
-
When lower E space utilized for relief of
anterior crowding,
Upper molars distalized to get a class I
relation
Indications for Molar distalization
3. Non-growing patient
-
To regain lost arch length
Blocking out of canines
4. Upper second molar extraction
-
Lower arch normal
Indications for Molar distalization
Class I malocclusion- with highly placed canine/impacted
canine
Lack of space for eruption of premolars due to mesial migration
of permanent first molars
Indications for Molar distalization
End on molar relationship with
mild to moderate space
requirement
Cases with less than a full
cusp class II molar relationship
Indications for Molar distalization
Good soft tissue profile
Borderline cases
Mild to moderate space
discrepancy with missing 3rd
molars/2nd molars not yet erupted
Indications for Molar distalization
Axial inclination : Mesially
angulated upper molars
Normal or Hypodivergant
growth pattern
Late mixed dentition with mild
crowding of anteriors
Case selection
1. Normal or near normal mandibular arch
2. Late mixed dentition-ideal
- Early permanent dentition-growth still left in maxillary
tuberosity area.- 16-17 yrs-males
14-15 yrs-females
3. Molars placed normally- buccolingually
4. 3rd molars-absent stacking of upper molars unsuitable
5. Profile considerations- well developed nose & chin
6. High MPA- contraindicated-wedging effect
7. Space discrepancy- not very severe
Classification
1.
Location of appliance
Extra-oral
Intra-oral
2. Position of appliance in mouth
Buccal
Palatal
3. Type of tooth movement
Bodily movement
Tipping movement
Classification
4. Compliance needed from patient
Maximum compliance
Minimum or No compliance
5. Type of appliance
Removable
Fixed
6. Arches involved
Intra-arch
Inter-arch
Various appliances used for Molar
Distalization :
Headgears
Wilson Bimetric arch design
ACCO
Crozat appliance
Crickett appliance
Modified Nance Lingual appliance
Non-extraction treatment
Schmuth and muller double plates
Molar distalization with magnets
Various appliances used for Molar
Distalization
Use of Super elastic NiTi
Jones Jig
The Pendulum appliance
Claspring
Removable molar distalization splint
Fixed piston appliance
The K-loop appliance
The distal jet
Using Implants
Fixed functional appliances
Distalization using Headgears
Very efficient
Reciprocal forces are not transmitted to other teeth
Molar movements depends on direction of force in relation to
the C Res of the molar & magnitude of force
Biomechanics of Headgears:
C Res
Moments
Straight pull headgear
Class II Malocclusion with no
vertical problems
Prevent anterior migration
of maxillary teeth, translate
them posteriorly
Buccal force to molar Expansion of inner bow
Cervical Headgear
Short face Class II
maxillary protrusive
cases with low MPA &
Deepbites
Extrusive & distalizing
effect
High pull Headgear
Adv-effective, no reciprocal forces
Disadv- Patient compliance
Produces intrusive &
Posterior direction of pull
Long face class II patients
with high MPA
Force through c res
Intrusion & distal
movement of molar
6-8 months class II-classI
Bimetric system for Molar Distalization
Dr.Wilson-Tandem yoke
with bimetric arches for
molar distalization
Tandem yoke-.045 round
tube slides on .040 end
section of the bimetric loop.
.018 retractor
.045 coil spring for
distalizing
Intermaxillary traction
Coil spring- between molar
tube & the yoke
Elastics- 12 hours a day
Headgear at night
The Omega adjustable stop
to modify & control arch
length
Crimpable .040tube
.061 Omega loop
Coil springs &
intermaxillary hooks.
Bimetric arch modified by Dr. Jayade
Class II correction- Distalization + expands caninepremolar area- unlocks the occlusion
A mild-moderate class II div 2 with normal mandibular
arch-easily corrected
Bimetric arch modified by Dr. Jayade
Archwire design:
.016premium wire
Premolars bonded if
expansion is required
Teardrop shaped loop
Bite opening bend
Mild toe-in
2mm activation
Elastic load reduction principle:
Class II elastics used sequentially
T.P Green 1st week
Pink - 2nd week
Yellow next 2-3 weeks
Initial heavy force- to resist forward
pushing force of new wire- force
transferred distally
Later Molar uprights-mesially directed
archwire force decreases- support with
light forces.
Extrusive component of class II- kept to a
minimum
Borderline cases Non extraction
ACCO Appliance
JCO1969
Removable appliance with headgear
Distal mass movement of buccal segments
Dr.Leonard Margolis harness growthlater springs added for distal tooth
movement
Northwest Headgear12hrs/day, counteracts
anterior component of force
Appliance design:
Labial bow: .022 x .028 wire
Loops to receive NWHG
between the central and
lateral on each side
Wire covered with acrylic for
good retention
Appliance design:
Clasps :.030 or .031 wire
Modified ring clasp
Finger springs : .021 X .025
Acrylic :3-4 mm away from
lingual surfaces of teeth
distal to lever arm of finger
springs
Enough bite plane in anterior
segment, so that the
posterior occlusion is just
cleared when the lower
anteriors are in contact
with the bite plane
Treatment progression :
A. Placement of finger springs for first appliance
If 7,6,5,4 present, 2 finger springs engaged
B. Second appliance
After distalization on one side
Leave first appliance as retainer
C. Cuspid retraction
Third appliance to retract both cuspids
Nonextraction treatment
Cetlin & Ten Hoeve, JCO 1983
Space Gaining in the Mandibular Arch With the Lip Bumper
.045 SS wire covered with tubing
U-shaped loops adjustment areas
And stops mesial to the molar tubes.
Placed on most distal molar
Recent studies- Ram Nanda etal
- AJO 1991 Jun
Posterior movement of mandibular incisors are very minimal
Nonextraction treatment
Cetlin & Ten Hoeve, JCO 1983
Space gaining in the maxillary arch
Combination of extraoral force and an
intraoral force
Inraoral
Anchorage adaptation to palate &
acrylic shield around incisors
Bite plane
Adams clasp on premolars
Springs on molars activated by 1-1.5
mm force -30 gms
Exraoral
Cervical or high pull headgear
150 gms / side ; 12 -14 hrs/day
Nonextraction treatment
Cetlin & Ten Hoeve, JCO 1983
Palatal bar as an adjunct in space
gaining in the maxillary arch
Unilateral distalization
Modified Nance and Lingual appliances
for unilateral tooth movement Ghafari JCO 1985
Nance holding arch :
Palatal arch attached to first molar
bands , embedded in an acrylic
"button"
space maintainer in the maxillary
arch,
support maxillary posterior
anchorage during tooth movement
Modified Nance holding arch and
modified lingual arch:
Anchorage for unilateral
distalization of posterior teeth
No patient compliance required
Modified Nance and Lingual appliances
for unilateral tooth movement
Modified Nance holding arch
12 yrs/M
Skeletal & Dental class I
Right side- distoocclusion
2nd premolar- 3.5 mm space
R 1st PM & molars banded
Segmental .019 x .025 NiTi
Open coil spring
4 months
No labial movement of incisors
Modified Nance and Lingual appliances
for unilateral tooth movement
Modified Lingual arch
13 yr /F
Skeletal class I
Lingually positioned R 5
3.2 mm space
Lingual arch from L6 to R4
Coil spring from R 4-6 on a
segmental .019 x .025 NiTi
K-Loop Molar Distalizing Appliance
Valrun Kalra JCO 1995
K-loop forces - .017 x .025 TMA
Nance button anchorage
8mm long , 1.5 mm wide
Legs- 20 degree bend
Inserted into molar and first
premolar tube, marked
Stops bent 1mm distal , 1mm
mesial
Stops- 1.5mm long
K-Loop Molar Distalizing Appliance
Valrun Kalra JCO 1995
Reactivated 2mm 6-8
weeks later
Molars move by 4mm,
premolars by 1mm
Anchorage can be
reinforced by headgear
K- loop Appliance
Removable molar distalization splint
Dr. Karrodi Ritto JCO 1995
Splint 1.5mm Biocryl-Biostar machine
More esthetic & comfortable
Bilateral- 1st premolar- 1st premolar
Unilateral Premolar Opposite Molar
Two internal clasps retention
NiTi open coil spring- 220 gm force
1.5mm-2mm/month
Distalization of Molars with
Repelling Magnets Gianelley etal JCO 1988
Anchorage Modified Nance
appliance
Wire extending from 1st
premolars
Acrylic button anteriorly
contacting the incisors
Auxillary wire with a loop at its
end soldered - premolars bands
Distalization of Molars with
Repelling Magnets
Incisor brackets passive
sectional wire- maintain incisor
alignment
Repelling surfaces of magnets
brought into contact by passing an
.014 ligature through the loop,
then tying back a washer anterior
to the magnets
Force- 200-225 gms , dropped as
space opened
3mm in 7 weeks
Anchor loss 1mm
Japanese NiTi coils used to move
molars distally
-Gianelly AJO 1991
100 gm superelastic coils
Nance appliance with bite plate
in anterior region
.016 x .022 wire with stops
abutting distal wings of premolar
and molars
Coil between 1st premolar and
the molars
.018 uprighting spring placed in
vertical slot of premolars,directing
crowns distally
Japanese NiTi coils used to move
molars distally
2nd molars erupted- Class II elastics
Rectangular wire 10 degree lingual root torque
Once distalized, Coils &Nance appliance are removed, insert .
016 x .022 wire with stops + High pull headgear to upright
roots of molars
Molar distalization with Superelastic
NiTi wire Gianelly JCO 1992
100gm Neosentalloy upper
archwire
3 markings
Stops crimped, hook added
Insert wire such that posterior
stop abuts mesial end of molar
tube, anterior stop abuts distal of
premolar
Anchorage reinforced by class II,
or Nance appliance
Molar distalization with Superelastic
NiTi wire
Case report :
12 yr / F
Unilateral class II
Class II against upper 1st
premolar
Overcorrected- 4 months
NiTi Double Loop system for simultaneous
distalization of first and second molars
Giancotti JCO 1998
Mandibular molars and 2nd premolars
banded, other teeth bonded
Lip bumper- prevent extrusion
Maxillary molars and bicuspids
banded, aligned
80 gm Neosentalloy maxillary
archwire placed marked
1.
Distal to 1st premolar
2.
5mm distal to 1st molar tube
Stops crimped on markings
NiTi Double Loop system for simultaneous
distalization of first and second molars
Giancotti JCO 1998
Mandibular molars and 2nd premolars
banded, other teeth bonded
Lip bumper- prevent extrusion
Maxillary molars and bicuspids
banded, aligned
80 gm Neosentalloy maxillary
archwire placed marked
1.
Distal to 1st premolar
2.
5mm distal to 1st molar tube
Stops crimped on markings
NiTi Double Loop system for simultaneous
distalization of first and second molars
Sectional NiTi archwires
crimp stops
1.
Mesial and distal to 2nd
premolar
2.
5mm distal to 2nd molar tube
Uprighting springs on 1st
bicuspids
Class II elastics
Simultaneous, bodily
movement
24yr/f, class II div I
5months- overcorrected
NiTi Double Loop system for simultaneous
distalization of first and second molars
Minimal patient co-operation
Ideal for simultaneous distalization
Anchorage easily controlled , without need for TPA/Nance
Due to streching of transeptal fibres, 1st molars can be distalized
using lighter 80 gm force
Pendulum Appliance for class II non-compliance
therapy
JAMES J. HILGERS,JCO 1992
Nance button
.032 TMA springs
Broad swinging arc (Pendulum)
of force from midline of palate
to upper molars
Pendulum Appliance
Fabrication :
Pendulum springs consist of
1. Recurved molar insertion wire
2. Horizontal adjustment loop
3. Closed helix
4. Loop for retention in acrylic
button
.
Springs- close to center of Nance
button
.
Anterior portion- retentionocclusally bonded rests
- Band upper 1st
premolars, solder retaining
wire to the bands
Pendulum Appliance
Nance button- extend to about 5mm
from teeth
Anterior retention loops fixed on
model, later soldered to bicuspid
bands
Acrylic pressed against the palatal
vault
Pendulum springs inserted
Pendulum Appliance
Pend-X
Jack-screw-One-quarter turn
every 3 days
Pendulum Appliance
Preactivation and placement:
Springs bent parallel to midline of the
palate
Molar bands cemented
Anterior portion of appliance later
cemented
Pendulum spring brought forward &
engaged in lingual sheath
As molar distalizes, moves on an arc
towards midline- counteracted opening
horizontal loop
Pendulum Appliance
Reactivate if required
Reavtivated by pushing it distally towards the midline
Stabilize after correction
Nance appliance
Full arch bonding continous wire with omega loop
Headgear for few months
Pendulum Appliance
Unilateral correction
Pendulum Appliance
Conclusion :
Excellent patient tolerance
Upto 5mm distalization in 4 months
Distalization + Expansion
Patient compliance not needed
Modified Pendulum Appliance- Scuzzo- 2000 April
Removable arms
Removable pendulum
Franzulum appliance
Friedrich Byloff et al
Anterior anchorage :
acrylic button-5mm wide
Rests on canine and
premolars - .032 wire
Tube from acrylic button
to receive active
component
NiTi coil springs-100200g/side
J-shaped wireinserted into
tube
JCO2000 sep
Franzulum appliance
Anchor unit bonded with composite
J-shaped distalizing unit ligated to lingual
sheath
Active component close to C Res
Case report
11yrs 10mts / M
end on molar relationship
Space deficiency in both the arches
Premolars blocked out
Upper pendulum and lower Franzulum
Nance holding arch
Fixed appliance with cervical headgear
and Cl II elastics
End of treatment; Class I molar relation,
no signficant. Change in facial profile
Open Coil Jig
Jones, White JCO 1992 Oct
Richard D. Jones
American Orthodontics
Open coil NiTi spring
Nance appliance
Open Coil Jig
3
1.
Heavy round wire
2.
Light wire
3.
Fixed Sheath
4.
Hook
5.
Sliding Sheath
6.
Open coil spring
5
1
Open Coil Jig
Reactivation
4-5 mm distalization in 3-4 months
Advantages
Disadvantages-Tipping
- Cannot use with fully banded treatment
- Breakage
Lokar Molar Distalizing Appliance
A- Inserts into molar attachment with a rectangular wire
B- Compression spring
C- Sliding sleeve
D- Groove
E- Flat guiding bar
F- Round posterior guiding bar
G- Immovable posterior sleeve
Lokar Molar Distalizing Appliance
Nance button
Can be used in conjunction with complete edgewise
appliance
With headgear
Easy insertion, activation
Distal jet Appliance
Aldo Carano, Mauro Testa JCO 1996
Fixed lingual appliance
Appliance design :
Wire extending from acrylic
through tube ends in a bayonet
bend-inserted into lingual sheath
Coil spring
Clamp
Anchor wire to 2nd premolar
Distal jet Applaiance
Aldo Carano, Mauro Testa JCO 1996
Reactivation- sliding clamp
closer to first molar
After distalization
- clamp-spring assemblyacrylic,
- premolar arms cut off.
Distal jet Appliance
Case report
18/F, Class II divI
No skeletal abnormalities
Non-extraction therapy (3rd molars removed)
Distal jet
4 months- Class I ,2mm-L, 3mm-R
Distal jet Appliance
Advantages :
Bodily movement
Easy insertion
Well tolerated
Esthetic
Unilateral, Bilateral
Permits simultaneous use of full bonded appliances
Modifications of Distal jet Appliance
Andrew Quick, Angela Harris JCO 2000
Earlier :
Sliding collar-tightened- small set
screw- Allen wrench
Modification :
Rear entry of sliding section into the
molar sheath
Sliding wire- .032
Stop collar soldered to wire
Activation
Retention- solid tubing
Fixed piston appliance - Greenfield
.036 tubing- soldered to
biccuspids
.030 ss wires- first molars
Nance button
NiTi coil
Unilateral Distal Molar Distalization movement
with an Implant supported Distal jet appliance
Karaman et al- Angle Orthodontics-2002
Case :
11yr/M
Well balanced face
Straight profile
Class II molar relation on left side
Super class I on right side
Mandibular teeth- favorable alignment
Upper left 2nd premolar impacted
ANB- 0 degrees
Unilateral Distal Molar Distalization movement
with an Implant supported Distal jet appliance
Treatment objectives :
Class I molar relation
Eruption of impacted molar
Controlled eruption of erupting teeth
Treatment alternatives
Extraction of L 1st premolar
Extraction of L 1st premolar
Distalization of upper left molar
Unilateral Distal Molar Distalization movement
with an Implant supported Distal jet appliance
Appliance fabrication :
Molar bands with palatal tubes
Anchorage screw- 3mm dia, 14 mm
long
Anterior palatal suture, 2-3 mm
posterior to incisive papilla
Impressions for appliance
construction
1mm tube adjusted to implant
Unilateral Distal Molar Distalization movement
with an Implant supported Distal jet appliance
Anchor wires .8mm-soldered to tubes
for occlusal rests on premolars
.9mm wire extended through each tube
ending in a bayonet bend-palatal tube
of molar
NiTi open coil spring active on left
side only
Appliance attached to premolars
composite
Joint between implant & tube-secured
with composite
2 months- 4.5mm distalization
Space for canine-maintained
Conclusion
Borderline cases
Space gaining procedures
Simplicity
Clinical effectiveness
Patient compliance factor
