Biomechanical considerations for total

distalization of the maxillary dentition using

TSADs
Park JH, Kook YA, Kim YJ, Lee NK. Biomechanical considerations for total
distalization of the maxillary dentition using TSADs. Seminars in Orthodontics
2020 Sep 1 (Vol. 26, No. 3, pp. 139-147).

GUIDED BY:- PRESENTED BY:

DR. DIVYAROOP RAI DR MUFTI SHEHEER
DR. SHANTANU SHARMA JR-3
 This was the narrative review article published in the journal
seminar in orthodontics in September 2020.

 It compare biomechanics, treatment effects and long term stability of

distalization using buccal mini implants vs Modified C palatal plate
Introduction
• Distalization appliances except for extraoral appliances always develop
reciprocal, adverse side effects. The anterior teeth tend to move forward
during the distalization of the molars and need to be retracted against the
distalized molars.

• With dental implants, mini plates, and screws as an anchorage, the distal
movement of the anterior or posterior teeth (or both) without anchorage
loss has become possible.

• Among these devices, micro-screw implants have the advantages of easy

placement and removal, with minimal anatomical limitations because of
their small size and low cost.
Buccal mini screws for distalizastion

• Park et al in 2004 used micro implants for distalization of

maxillary and mandibular dentition.

• In the maxilla, four micro-screw implants were placed in the

buccal alveolar bone between the second premolars and first
molars and two in the palatal alveolar bone between the first and
second molars.

• In the mandible screws were placed in the bone distal to Park HS, Lee SK, Kwon OW. Group distal
movement of teeth using microscrew implant
mandibular second molars anchorage. Angle Orthod. 2005 Jul;75(4):602-9
• Yamada et al (2009) used only buccal screws between maxillary second
premolar and first molar to distalize the whole maxillary dentiton.

• After that Bechtold et al (2013) used 2 buccal screws one between

maxillary first and second premolar and another one between second
premolar and first molar.

Yamada K, Kuroda S, Deguchi T, et al. Distal movement of maxillary molars

using miniscrew anchorage in the buccal interradicular region. Angle Orthod.
2009;79:78–84.
BIOMECHANICS OF BUCCAL MINI
SCREWS

Bechtold TE, Kim JW, Choi TH, et al. Distalization pattern of the
maxillary arch depending on the number of orthodontic
miniscrews. Angle Orthod. 2013;83:266–273.
Modified C palatal plate
The buccal approach poses an increased risk of contact with the roots of adjacent
teeth, and the range of action might be limited by the interradicular space in
Adolescents.

Triaca et al have introduced the palate for skeletal anchorage.

Kook et al (2010) designed a modified C palatal plate(MCPP) for efficient

distalization.

Sa’aed et al 2013 compared treatment effects with MCPP appliances vs headgear

Kook YA, Kim SH, Chung KR. A modified palatal

anchorage plate for simple and efficient distalization. J
Clin Orthod. 2010
BIOMECHANICS OF MCPP
MCPPs used three wings (indentations) positioned 4, 7, and 10mm from the
wire level, the direction of the force delivered varied. Using the 10mm
indentation on the MCPP produced more bodily movement and intrusion of the
first molar than when the 4mm indentation was used.
The position of the palatal retraction arch (PRA) can be adjusted to modify the
force direction. When the PRA is short and located posteriorly, intrusion
occurs which is beneficial for high angle cases. On the other hand, when the
PRA is short and superior, extrusion occurs which is beneficial for low angle
cases.
Treatment effects:
Article year Study design intervention sample results

Yamada et al , angle 2009 Prospective Distalization using 24 maxillary Maxillary molar moved
orthod randomized clinical buccal miniscrews molar in 12 distal by 2.8 mm with
trail patients distal tipping of 4.8
degrees and intruded by
0.6 mm

Young hee oh et al, 2011 Retrospective Distalization using N=23 Maxilla : 1.4 -2.0mm
AJODO study. Pre and post mini implants distal movement with 3.5
treatment ceph and degree tipping
cast were analysed Mandible:1.6 -2.5 with 6.6
-8.3 degree tippping

Yu IJ et al 2011 Finite element Distalization with Palatal plate showed

Ejo study buccaL screws vs bodily molar movement
palatal plate while buccal screws
showing distal tipping and
extrusion of molar
Article year Study design intervention sample results

Kook et al 2014 Retrospective Distalization 40 distal movement of the

Ajodo study using MCPP maxillary maxillary first molar
lateral ceph molars was 3.3 ± 1.8 mm, with
obtained from distal tipping of
cbct 3.4 ±5.8 and intrusion of
1.8 ± 1.4 mm
Sa’aed et al, 2015 Retrospective Distalization MCPP-24; MCPP = 3.06 6 0.54
Angle orthod study using MCPP vs Headgear - mm and Headgear=1.8 6
headgear 21 0.58 mm
Article year Study design intervention sample results

Lee et al , 2018 Retrospective Distalization using N=40; MCPP=4.2 mm of distalization,

Angle orthod study using buccal mini screws MI=18 1.6 mm of intrusion of the
lateral ceph vs MCPP MCPP=2 first molar with 2degree tipping
2 MI = 2.0 mm
of distalization, 0.1 mm intrusion
of the first molar with 7.28 tipping
 From above studies Comparison between distalization using buccal mini
plates vs MCPP showed that MCPP shows more distal movement of
maxillary molars and more bodily movement compared with buccal mini
screws

 And also MCPP shows less distal tipping compared with buccal mini
screws
Long term stability after total maxillary arch distalization using buccal
miniscrews and MCPPs
Article year Study intervention sample results
design

Bechtold et 2020 Retrospecti Distalization N=38 4.2 mm of distal movement of U6 and 3.3 of occlusal
al , ve study with Mi vs Exp plane steepening. After 42 months retention period exp
Angle control group =19, group shows 0.6 mm mesial movement same as that of
orthod having minor Control control group
corrections 19

Shoaib et al 2019 Retrospecti Distalization N=69 Maxillary first molars showed a distal movement of
AJODO ve study with MCPP 3.44±1.08mm idistal crown tipping of 2.35±6.74, and
using intrusion of 1.42± 1.12mm. 3 years post treatment it
lateral showed 0.41± 0.25mmof mesial movement, 0.50 ±0.46
ceph mm of extrusion, and insignificant mesial crown tipping
(0.92 ±2.46; P = 0.06)

There is no difference in relapse after distalization using buccal mini screws and modified
palatal c plate. So, TSADs can provide a high degree of stability of the distal movement of
maxillary first molars and incisors.
Bonding second molars during total arch distalization
If a second molar is not included in the arch-wire, it tips distally since its
contact area with the first molar is located occlusal to the line of force
application

To prevent tipping and extrusion of the second molar, it is recommended

that a tube be bonded to the second molar
 CASE REPORT

 To maximize the total maxillary distalization effect of MCPPs, additional distalization

modalities may be necessary in the mandibular arch. For this, mandibular TSADs were
recommended rather than Class III elastics.

 A miniscrew might need to be placed between the first and second mandibular molars
to intrude the second molar or hold it in place.

 This procedure was applied in the case illustrated, in which a 12- year-old male had
flared incisors and incompetent lips as his chief complaints.
 The treatment time was 32 months. According to the lateral cephalometric
measurements, his maxillary incisor to FH decreased by 11°, IMPA also
decreased from 94° to 81° and his nasolabial angle increased by 9°.

 Considering his condition, it was not enough to correct the protrusion using
the MCPP and Class III elastics to retract the mandibular dentition, so two
minis-crews were placed between the mandibular first and second molars to
distalize the mandibular dentition.
The optimal force needed for total arch distalization with an MCPP was 120 gm to
move each molar, so the optimal force was about 250450 gm on each side.
For this amount of force, 34 loops of double elastomeric chains were used.
 Second and third molar position after total arch distalization

 The third molar inside the alveolar ridge may

serve as a fulcrum, opposing movement of the
first molar.

 Gianelly et al. recommended the maxillary third

molars should be extracted before distalization
of the posterior Teeth.

 Kinzinger et al.demonstrated that, if

distalization of the first and second molars is to
be done simultaneously, a germectomy of the
third molar is recommended first.
• Kook et al.demonstrated that there was no noticeable difference in the amount of
distalization and tipping of molars in adult subjects who retained their third molars
versus those who had them extracted.

• Lee et al. reported that maxillary distalization using MCPPs caused the unerupted
third molars to move backward and upward in growing patients.

• There is no conclusive evidence to show whether to retain or extract the third molar
before distalization. So, Additional long-term studies are necessary to better
understand positional changes of the second and third molars.
STRATEGY FOR EFFICIENT TOTAL ARCH DISTALIZATION

1. Maxillary total arch distalization with MCPPs: Class II patients with proclined
incisors and crowding can be treated with distalization using MCPPs.

2. Total distalization of the mandibular dentition using buccal mini-screws between

the first and second molars: For mandibular distalization, the mini-screws can also
be placed in different locations. To improve a deep bite, it is recommended that a
reverse curved arch-wire be used to intrude the mandibular incisors during total
arch distalization.
3. Upper torque control: To control maxillary incisor position during total arch
distalization, bonding of high torque anterior brackets (22° in central incisors and
13° in lateral incisors) or use of a torque spring is recommended to prevent
lingual tipping of the maxillary incisors during total arch distalization, especially
with lingually or normally inclined maxillary incisors
Conclusion

 For successful maxillary total arch distalization using TSADs, clinicians

must understand the amount of movement required and the difference in
biomechanics between buccal miniscrews and MCPPs.

 The appropriate selection of TSADs enables clinicians to widen the

boundaries of non-extraction treatment without requiring patient
compliance.
Treatment effects of microimplant-aided sliding
mechanics on distal retraction of posterior teeth
Young-Hee Oh,Hyo-Sang Park,Tae-Geon Kwon

Introduction
Our objective was to quantify the treatment effects of microimplant-aided mechanics on
group distal retraction of the posterior teeth.

Methods
The pretreatment and posttreatment cephalometric radiographs and dental casts of 23
patients (mean age, 22.1 ± 5.17 years), treated with distalization of the posterior teeth
against microimplant anchorage and without extraction of the premolars or other teeth
except the third molars, were used. The soft-tissue, skeletal, and dental measurements in the
vertical and anteroposterior dimensions were analyzed. The changes in interpremolar and
intermolar widths and rotations of the molars were analyzed with dental casts.
Results
The upper and lower lips were repositioned distally. The Frankfort horizontal
to mandibular plane angle was decreased in the adult group. The maxillary
posterior teeth were distalized by 1.4 to 2.0 mm with approximately 3.5° of
distal tipping, and the mandibular posterior teeth were also distalized by 1.6
to 2.5 mm with approximately 6.6° to 8.3° of distal tipping. The maxillary
posterior teeth showed intrusion by 1 mm. There were increases in arch
widths at the premolars and molars. The overall success of microimplants was
89.7%; a well-experienced clinician had a higher success rate (98%) than did
novices in this sample. The mean treatment time was 20 ± 4.9 months.
Conclusions
With microimplant-aided sliding mechanics, clinicians can distalize all
posterior teeth together with less distal tipping. The technique seems
effective and efficient to treat patients who have mild arch length
Distal Movement of Maxillary Molars Using Miniscrew Anchorage in
the Buccal Interradicular Region
Kazuyo Yamada; Shingo Kuroda; Toru Deguchi; Teruko Takano-Yamamoto;Takashi Yamashiro:Angle
Orthod (2009) 79 (1): 78–84.

Objective: To quantify the treatment effects of interradicular miniscrew anchorage

and to confirm the validity of the clinical usage of interradicular miniscrews in the
distal movement of maxillary molars in nonextraction treatment.
Materials and Methods: Twenty-four maxillary molars were moved to the distal
using miniscrews placed in the interradicular space between the second premolar
and the first molar at an oblique angle of 20 to 30 degrees to the long axis of the
proximal tooth. The teeth were evaluated as to how the molars were moved to the
distal with the use of lateral cephalograms and dental casts.
Results: Maxillary molars were moved to the distal by 2.8 mm with distal tipping
of 4.8 degrees and intruded by 0.6 mm. Maxillary incisors were moved to the distal
by 2.7 mm with palatal tipping of 4.3 degrees. Molar extrusion and/or consequent
mandibular rotation was not observed in any patient.
Conclusion: Miniscrews placed in the maxillary interradicular space provide
successful molar distal movement of 2.8 mm without patient compliance and with
no undesirable side effects such as incisor proclination, clockwise mandibular
rotation, or root resorption.
References
 Oh YH, Park HS, Kwon TG. Treatment effects of microimplant- aided sliding mechanics
on distal retraction of posterior teeth. Am J Orthod Dentofacial Orthop. 2011;139:470–
481.

 Bechtold TE, Kim JW, Choi TH, et al. Distalization pattern of the maxillary arch
depending on the number of orthodontic miniscrews. Angle Orthod. 2013;83:266–273.

 Yamada K, Kuroda S, Deguchi T, et al. Distal movement of maxillary molars using

miniscrew anchorage in the buccal interradicular region. Angle Orthod. 2009;79:78–84.

 Bechtold TE, Park YC, Kim KH, et al. Long-term stability of miniscrew anchored
maxillary molar distalization in Class II treatment. Angle Orthod. 2020;90:362–368.

 Sugawara J, Kanzaki R, Takahashi I, et al. Distal movement of maxillary molars in

nongrowing patients with the skeletal anchorage system. Am J Orthod Dentofacial
Orthop.2006;129:723–733.
• Lee SK, Abbas NH, Bayome M, et al. A comparison of treatment effects of total arch distalization using
modified C-palatal plate vs buccal miniscrews. Angle Orthod. 2018;88:45–51.

• Shoaib AM, Park JH, Bayome M, et al. Treatment stability after total maxillary arch distalization with
modified Cpalatal plates in adults. Am J Orthod Dentofacial Orthop. 2019;156:832–839.

• Lee YJ, Kook YA, Park JH, et al. Short-term cone-beam computed tomography evaluation of maxillary third
molar changes after total arch distalization in adolescents. Am J Orthod Dentofacial Orthop. 2019;155: 191–
197.

• Kook YA, Bayome M, Trang VT, et al. Treatment effects of a modified palatal anchorage plate for
distalization evaluated with cone-beam computed tomography. Am J Orthod Dentofacial Orthop.
2014;146:47–54.

• Sa’aed NL, Park CO, Bayome M, et al. Skeletal and dental effects of molar distalization using a modified
palatal anchorage plate in adolescents. Angle Orthod. 2015;85:657–664.

• Yu IJ, Kook YA, Sung SJ, et al. Comparison of tooth displacement between buccal mini-implants and palatal
plate anchorage for molar distalization: a finite element study. Eur J Orthod. 2014;36:394–402.
Thank you