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REVIEW

Effective Means of Intraoral Molar Distalization - An Overview

D. N. KapoorOIArvp Razdan' OlSridhar Kannan'O '

Correction of Class II malocclusion without extractions requires maxillary molar distalization by means of intraoral or ext raoral forces. Although headgears have proven undoubtly useful in the correction of this skeletal anomaly. the constancy of forces and the dependence on pat ient co-operation is of concern.

Since the 1980s various intra arch devices have been in troduced such as the K loop (V. Kalra) . NiTi coil springs (Gianelly) . Superelastic NiT! wires (Locatelli) . Repell ing magnets (Gianelly) . Fixed Piston appliance (Green field). Pendulum appliance (Hilgers) . Lokar Distalizer (SCOII). Distal Jet (Carano) as well as combination of extraoral and intraoral b rces (Cetlin and Tenhoeve) . Researchers have bcused on the simplicity and efficiency of Ihe se intraarch devices . which improves the continuity and constancy of forces . Oral hygiene is easier to maintain and the need for patient compl iance is

eliminated . A modified Nance appliance

these force delivery systems to increase anchorage during distal movement or keep the molars in position fonowing distal movement. This paper presentation is an anempt to update information regarding various intra oral distalizing appliances available currently and discusses patients treated successfully by using NiTi coil springs (Ortho organizer) by distalization for correction of class II molar relationship .

has olten been applied in conjunction with

Introduction:

Correction of Class II malocclusion without extractions requ ires maxillary molar distalization by means of intraoral or extraoral forces. Although headgears have proven useful in the co rrection of skeletal problems , as well as in providing anchorage for extraction cases, the dependence on pal ient cooperation is heavy. William Ki ngsley (1892) described for the first time headgear apparatus with which Class I molar relationship of the molar could be achieved successfully. Kloehn in 1947 started a long and beneficial series of investigations and clinical appl ications of occipital anchorage to the maxillary

.•

Professor

01 Dental Sciences. K .G : s , Med i ca l College , lucknow

Po st Graduate Student , Department of Orthodont ics. Faculty 01 De nt al Sc i ences . K . G .' s. Med ic al C olle ge . lucknow

and Head. Department of Qf thodontics. Faculty

Post Graduate Student. Department of Onhod on tics. Faculty of De ntal Science s. K.G : s. Med ica l College , Lucknow

dentition. The headgears over the years have shown to be effective in maxillary molar distalization with movements in all planes of space. With the recent trend more towards non extraction treatment, several intra arch devices have been advocated to distalize molars in the upper arch. Researchers have focused on the simplicity and efficiency of these intraarch devices, which improves the continuity and constancy of forces . Oral hygiene is easier to maintain and the need for palient compliance is eliminated. Certain principles , as outlined by Burstone' must be borne in mind . when designing an ideal intraoral molar dislalization appliance. Molar distalization is a lechnique that has added a new column in the practice of every onhodonfist to produce consistent, predictable and high quality results. The goals of practicising with efficiency and profitability are positively affected. Since space is easier to gain in the maxillary arch than in the mandible because of increased trabecular structure of supporting bone and increased anchorage afforded by pa latal vault . the distatl:t.ation of maxi ll ary molar becomes 01

132 Effective Means of Intraoral Molar Distafization - An Overv i ew - D. N. Kapoor / Anup Razdan / Sridhar Kannan

significant value for the treatment of cases with mild to mode rate arch discrepancy and Class II molar relationship associated with a normal mandible.

Indications:

• An end on or full Angle 's class II molar re lation- ship due to maxillary protrusion. impacted. unerupted and ectopic eruption of cuspids.

• Situation requiring distal movement of molars

• Mild to moderate arch discrepancy.

• Class II molar relationship associated with normal mandible.

Timing:

A favourable time to move molars distally appears to be in the mixed dentition, be fore the eruption of the second molars, and an efficientlorce system to move molars distally is a conti nuously acting force .

Principles of Appliance Design :

• Magnitude of forces and moments.

Moment to force ratio.

Constancy

of fo rce and

moments.

• Bracket friction.

• Min imal

loss of an te rior

anchorage .

• Bodily movement of molars to avoid lengthening of treatment and unstable results.

• Ease of use.

• Cost.

• Minimal chairtime for placement and reactivation.

Limitations:

• High angle retrognalhic type of pattern

• Third molars that have erupted or close to eruption impede distalization

• Treatment in vertical growth pattern should be done conservatively with extraction The present study is an attempt to updat e

informat ion regarding va rio us int raoral

appliances available. This article will also present and discuss results obtained in lew patients trea ted

i n the Department of O rth odontics , Fa culty of Dental Sciences, King George's Medical College, Lucknow after distalization using Nance appliance and NiTi coil springs.

distal izi ng

Intra Oral Methods for Distalizing Molars

1. Ae pelling Magnet s

Intra arch repelling magnets (Fig . 1) used to distalize molars were introduced by Gianelly et aF (1988). These are prefabricated repelling Samarium- Cobalt magnet (SmC05) with a pole face 2 x 5 m. The magnets are attached to headgear tube of

maxillary first molar bands and repelling surfaces are brought into contact by 0.14" ligature wire. Forces measure to 200-225 gms but drop substant ially as space opens beyond 1 mm . Movement of 3 mm is see n in 7 weeks if second molars are absent and 0.75- 1 mm per month if present. Anchorage is reinforced by Nance

appliance and Class II elastics against an 0.016" )(

0.022 " sectional arch wi re. The

rate of molar

dislalization using magna force is less than that observed with conventional mechanotherapy. This is in ag re ement with the findings of Owman et al. ':< and is supported by the work of Samuels~ that tooth movement is proportional to force with some biologically defined limits.

Fig . , .- Repell ing Magnets

2. 3-D Bimetri c Di sta lizing Arch

These are modular phase appliances designed for mu lt idi rectional functional class II treatment and were introduced by Wilson and Wi lson ~ ( 1987) . Maxillary molars and buccal segments are distalized bilaterally or unilaterally without headgear.lt is

excellent

dis talizes molars to end on pOSition and allows posteriorly locked mandible to advance immediately t o Class I position. C lass II elastics allows the functional release of any mandibular growth potential.

The anterior segment is of 0.022" Tru chrome arch while posterior segment is of 0.040" end section with

omega loops. Elgiloy open coil sp rings of 0.0 10" x 0.045" are placed between omega loop and buccal tubes for activation. Movement achieved is 3 mm in 2 months. Signi fican t increase in inter bicuspid width is possible wi th 3 D Bimetric Distalizing Arch (Fig . 2) acting as 24 hour bucc inator muscl e restrictor. Arch should be adjusted free of bucca l

teeth to avoid impingement of cheeks . II

retracts

rapidl y and is useful even in int rusion of anterior

if given in C l ass It Oiv 2 cases . II

(J

lod Dnhod Soc 2002 : 35 :131-142)

, 33

teeth . It is no l recommended syndrome patients.

for long f ace

. It is no l recommended syndrome patients. for long f ace Fig. 2: 8ime/ric Oistalizing
. It is no l recommended syndrome patients. for long f ace Fig. 2: 8ime/ric Oistalizing

Fig. 2: 8ime/ric Oistalizing Arch

3. Superelast ic NiTi Wire :

Locatelli et af 6 (1992) used a 100 gm NeoSentalloy wire (superetastic Nickel-Titanium wire (Fig. 3) wi th shape memory for molar

distalization. Cnmp stops just distal to first premolar bracket are placed 5-7 mm distal to anterior opening of molar tube and hooks between lateral incisors and canines . Excess wire is deflected gingivally into buccal fold . As wire returns to original shape , it exerts 100 gm distal force against molars.

Anchorage control is by

exerting force of 100-150 gm and is reinforced with Nance app liance cemented to premolars. II first molars do not move atleast 1 mm per month a 200 gm O.OIS" x 0.025" NeoSentalloy wire can be placed . Advantage lies in its ease of insertion even atler all teeth have been bracketed.

placi ng Class II elastics

all teeth have been bracketed. placi ng Class II elastics Fig. 3: Superelas/ic NiT; Wire 4.

Fig. 3: Superelas/ic NiT; Wire

4. Jone s Jig (Fig . 4, 5)

Jones

and While 7 (1992) used

an open co il

NiTi spring

to deliver 70-75 gm s of

force over a

compression range of 1.5 mm to the mola rs.

Anchorage is from Nance app liance which can be

anached to

or deciduous second molars. Reactivation of coil springs requi res liUle chair time. Patients are seen

at 4 - 5 week intervals and is a rapid method of correction 01 Class II relationships . Correction usually lakes place in 120-180 days .

either first premolars. second premola rs

in 120-180 days . either first premolars. second premola rs Fig. 4: Jones JIG Fig. 5:

Fig. 4: Jones JIG

first premolars. second premola rs Fig. 4: Jones JIG Fig. 5: Jones JIG 5. Lokar Mol

Fig. 5: Jones JIG

5. Lokar Mol ar Distalizer :

Lokar Ois talizer was in troduced by Scotl s (1992). The prefabricated assembly (Fig. 6) consists of mesial sliding component inserted into archwi re lube of molars . Lokar appliance is best in

sliding component inserted into archwi re lube of molars . Lokar appliance is best in Fig.

Fig. 6: Lokar Molar Distalizer

134 Elfec!ive Means of Intrao ral Molar Ols taliza tion . An Overview - D. N. Kapoor/Anup RazdanlSridhar Kannan

conjunction with Nance button constructed on second premolars (Fig. 7). Molar tubes are not used. therefo re ex l raoral and li p bumper forces may be applied concurrently. T he Lokar Distalizer is activat ed by com pressing spring 1 to 2 mm short of compl ete compression and movement is 1-3 mm in 5·6 weeks. This appliance is offset to the buccal and rests along the buccal sur1ace of premolars.

Fig. 7: Lokar Molar Dislalizer

6. Pendulum Appliance

This device was designed by Hilgers 9 (1992) and is a hyb rid appliance (Fi g. 8.9) using Nance acryl ic button in palate for an ch orage along with 0.032" TMA springs del ivering light continuous broad

Fig. 8: Pendulum Appliance

Fig . 9: Pend X Pendulum Applian ce

swmging arc or pendulum of forces to upper (irst

molars. The lingual sheath is made

easy fit of 0.032 " TMA spring. Ac ti vation before appliance placement i.e. by spring being paraUelt o mid sagittal plane which produces 60 0 activation after insertion. Force exerted is 200·250 gm per side and movement achieved is 5 mm in 3·4

months. Pendulum can also be incorporated with mid palatal jack screw for ex pansion along with distalizatlon (Pend-X) (Fig, 10). The screw is activated one quart er every 3 days. It is not recommended for dolichofacial types with tongue thrusting.

of 0.036 " for

Fig . 10: Pend·X·Pendulurn With MID palata l Jack screw for expansion along with Oistafizalion

·f. Modified pendulum

Scuzzo et al. lO (1999) modified Ih e ori ginal appliance and called it Pendu lum M and claimed Ihat Pendulum M (Fig. 11) ensures true bodily movemenl of molar crowns and roots. Horizontal pendulum loop was inverted from the basic design. Activation is by Simply opening it. This act ivat ion produces buccal and distal uprighting of molar roots and thus a true bodily movement Springs are activated to 40.45 0 resulting in 125 gms of force

on each side. Ter mi nal ends are straight rat her than

and there is little need

looped in origina l appliance for reactivation.

F ;g. I I : Modif ied Pendulum

(J Ind Orthod Soc 2002; 35:131-142)

135

8. Fixed piston appliance:

Most intraoral distaliz ing appl iance tend to tip

maxillary molar crowns distally. Green field 11 (1995) designed an applian ce for bod ily movement of

appl iance components

maxillary molars. Th e

comprises o f bicuspids) and

molars). Nance ca n be reinf orced with 0 .040 " SS

0 .03 6- SS tu bi ng (s oldered to 0. 030' SS wires (soldered to first

wire

(for control of anterior anchorage ). Superelastic

NiTi

wi re hav ing 0 .055 ' (i nterna l diameter) is used

and 2 mm split ring s as stops to mesial of buccal and lingual tubes are added every 6-8 weeks. Force exerted is 50 gms per tooth and movement achieved is 1 mm per month. It does not in terfere with occlusal plane 12 thus maintaining control of vertical dimension

1 2 thus maintaining control of vertical dimension Fig. '2: Fixed Piston Appliance 9. K·loop molar

Fig. '2: Fixed Piston Appliance

9. K·loop molar dlstallzing appliance:

Int roduced by Kalra ' 3 (1995). Th is app liance

consists of a K-Ioop to provide force and a Nance bulton to resist anchorage . K· loop is made of

mm

long and 1.5 mm wide and is placed between first premolar and first molar (Fig . 13). Activation is by 20 degree bends in appliance that produce moments that counteract the tipping moments created by the force of appliance . Thus molar undergoes translatory movement instead of tipping. Root movement

0 . 01 r )( 0 . 05 " T MA wire with each l oop being 8

.l~-

'~

.~ ---

" .~.~.•'

.

l

,

" "

_

'

--

.

.

,1

Fig. 13: K-Loop Molar Distalizing Appliance

continues eve n after the force has dissipated . Single activation produces 4 mm distal molar movement in 6 to 8 weeks and 1 mm anchorage loss is seen dlJring 4 mm molar distalization.

10. Dist al jet:

Carano and Testa '· ( 1996) designed an

appliance that can be used for either unilateral or bilateral Class II correction . It consists of bilateral tubes of 0.036' internal diameter anached to acrylic

springs exerting a

force of 150 gms for children and 250 gms for adults is recommended. The spr ings are clamped on the

tube to exert a dis tal achieved as the force

of resistance. Reactivation is done by sliding the

clamp closer to first molar once a month. Once distalizalion is completed the appliance can be converted to a Nance retainer or passive Nance appliance. Movement of 2-3 mm is seen in 4 months.

force . Bodily movement is passes close to the ce nter

Nance bulton (Fig . 14). NiTi coil

close to the ce nter Nance bulton (Fig . 14). NiTi coil Fig. 14: Distal Jet

Fig. 14: Distal Jet

11 . Modified Distal jet

Quick and Harris 1s

appliance:

(2000) modified the original

Distal Jet appliance. The basis of the modification is the rear entry of sliding section into lingual molar sheath so that the appliance pulls rather than pushes the molar distally (Fig. 15). The doubled back wire

pulls rather than pushes the molar distally (Fig. 15). The doubled back wire Fig . 15:

Fig . 15: Modified Distal Jet Appliance

136 Eflect lv e Means 01 Intraoral Molar Dista hzallO n • An Ove rvi ew - D. N . Kapoor/ Anup Razdan / Sridhar Ka nn an

is inserled into the lingual sheath from the distal

side. Either 0.030

preferred wire for sliding. Desired activation produced is by compressing the coil spring between distal end of the lube and the stop soldered to the

is the most

or 0 .032 " wire

sliding wire . To reactivate the appliance. the safety ligature is cut and the sliding wire is pulled oul distally and a new longer section of coil is placed

over wire . No

simplifying the activation procedure.

screw or Allen wrench is used, thus

12. Fixed palatal Expander :

Maxillary arch constriction and mesiopalatal rolalion of upper first molars are two components of mosl C l ass II malo cc lusions that must be correcled either before or during sagiltal correction . Snodgrass 16 (1996) designed an appliance (Fig. 16) and incorporated rota lion and dislalization components of Pendulum appliance in his neN design. It consisted of a framework 01 11 mm expansion screw, two 0.032" TMA Pendulum springs and occlusal rests. Springs were preactivated 8-10 mm distally and the screw is activated twice a day IiU desired expansion is achieved. II is useful in treating unilateral class II with midline discrepancies.

Fig. 16: Fixed Palatal Expander

13. NITI Coli Springs:

Pieringer et a/ 17 (1997) used SentaUoy red coil

springs (G AG) exert i ng a sectional arch wires from

(Fig . 17) . The concept of using coil springs for dislalization was introduced by Miura who used

force 01 150-200 gms on firs t prem olars to molars

Fig. 17: NITi Coil Springs

100 gms superelastic coils . Gianelly l1 used

Japanese NiT! coil springs exerting 100 gms of force to move maxillary molars distally. Movement achieved is I·the 1.5 mm pe r month. Anchorage un it is anterior acrylic button lor pa latal support. Oistalization is accomplished early in treatment and any undesired the movements can be correcled in succeeding phases.

14. Supers p ri ng II :

The Super spring II designed by Klapper 1 ' (1999) is a flexible spring element that attaches between the maxillary molar and mandibular canine

(Fig . 18).

It is designed to rest In the vestibule .

making it impervious to occlusal damage and

Fig. t 8 : Supe(spring 1/

allowing for good hygiene. The

loop is twisted like a J hook into Ihe mandibular archwire. On the maxillary end , a special oval tube serves as the maxillary first molar attachment.

During opening and closing movements, tower helical

attachment hinges on Ihe mandibular archwire throl,lgh an arc of 90 ° (Fig . 19) . A longer spring is used for nonextraction cases and shorter springs for

cases . Moderate continuous

full Class II extraction

dislaHzing force upto 5 oz Is exerted . Excellent for

TMO patients who require orthodontic treatment after splint therapy.

spring's open he tical

Fig. 19: Sup8fspring II

(J

Ind Orthod Soc 2002 ; 35 :131-142)

137

15. First Class Appliance:

With the objective 10 minimize anchorage loss Forlini et al 20 (1999) devised an appliance (Fig. 20) tor rapid distalizalion of maxillary first and second molars. T he vestibu lar component comprised of formative screws soldered to the buccal side of fi rst molar bands. Split rings a re welded to second premolars and stop screws maintain distal position of molars atier active movement has been completed . Palatal component comp r ised 01 wider butterfly shaped button . Ni Ti coil spring (0 .010 " x 0.045") of 10 mm length was used to achieve bodily movement of 4-8 mm in 28-95 days.

used to achieve bodily movement of 4-8 mm in 28-95 days. Fig. 20: First Class Appliance

Fig. 20: First Class Appliance

16. Palatal Orthodontic Implants:

Idea of implant in median maxillary sulure for anchorage was originally by Triaca 2 \. Mannchen 22 (1999) implanted miniat ure gol d fixation screws into t he alveolar bone between roots of teeth in young patients. Maxillary sutu re is a more reliable location than the alveolar bone between roots of teeth , fo r anc horage in adul t s. T he bas ic p rinciple of t he appliance is to provide a rigid platform that is not attac hed to any single tooth . A yoke shaped palatal b ar · 0.036 )( 0.072 " made of Re ma loy stainless

steel wire with 4.5

mm long 0.022 x 0.02 8"

recta ngular tubes

are attached

on each end. 0.022 "

(Fig. 21). Damon

SL brackets

are wel ded to molar

(Fig. 21). Damon SL brackets are wel ded to mola r Fig . 21 : Palatal

Fig . 21 : Palatal Orthodontic Implants

ban ds for receiv ing sectional arch wires . Distal ization can be accomplished either with sagillaly preactivated delta loops and long vertical legs or with st raight sectional wires and push coil springs.

17. Franzulum Applian ce :

Gain ing space in the mandible is more difficul t than in the maxil la. The most commonly used int raoral appliances are lip bumpe rs. lingual arches and removable appliances with screws or springs which depend on patient compliance for their success. 8yloff et al 23 (2000) devised the Franzulum appliance based on pendulum for distaliz- i ng mandibular molars (Fig. 22) . The anterior anchorage unit comprised of an acrylic bullon positioned lingually and inferiorly to mandibular anterior teeth and extending from mandibular canine to canine. The acrylic should be aUeas! 5 mm wide

canine to canine. The acrylic should be aUeas! 5 mm wide Fig. 22: Franzulum Appliance to

Fig. 22: Franzulum Appliance

to avoid mucosal trauma and to dissipate the reactive force produced by the reactive components. Rests on the cani ne and first premolars are made of 0.032~ stainless steel wires and tubes between the second premolars and first molars receive the active

components (Fig. 23) . Th e poste rior distalizing unit uses NiT ; coil spri ngs (GAC) about 18 mm length which apply an initial force of 100-120 gms per side .

T he active

part of the appliance runs lingually at a

level close to the center of resistance of the molars to produce an almost pure bodily movement.

to the center of resistance of the molars to produce an almost pure bodily movement. Fig

Fig . 23: Franzulum Appliance

138 Effective Means of Intraoral Molar Dista li zat io n - An Overview - D. N . Kapoor/ Anup Razdan / Sridhar Kannan

18. C-Space Regainer :

Chung st al 24 (2000) used a removable appliance called Ihe C-Space Regainer to achieve bodily molar movement without significant incisor flaring. It consists of a labial framework formed from

0.036 " SS wire , and an acrylic splint. A closed helix is bent into the framework in each canine region (Fig . 24) . An open coil spring (0. 0 10 "xO.040 ") is soldered distal to the helix and 0.028 " ball clasps are used to retain the appliance. Open coil spring should be 130% of lenglh between soldered point

compressed it

and mesial edge of head gear. When

will exert 200 gms of force and move molars distally about 1-1.5 mm per month .

,

Fig. 24 : C-Space Regainer

Critical Appraisal:

In the mixed dentition, the appliance should

not be placed until full development of the maxillary first molar rools. In most Class II cases , the intraoral distalizing appliances accomplishes its goal within six months without the need for patient cooperation . In all of these systems, orthodontic forces are applied to the crowns of the upper first molars and the molar movement consists mainly of tipping and rolation of the crowns as openly

Carano 14

acclaimed by Gianelly2. Jones 1 , Hitgers 9 ,

Kalra'l. None of the Intraoral appliances for molar distalization have been completely successful in avoiding undesirable bi omechanical side eHects as . advocated by Jecke~5. Although Scuzzo st a/ 10 modified pendulum appliance and Green fields at a/ II fixed piston appliance have claimed that thei r appliance can produce true bodily movement of the

maxillary molars, we strongly believe that unless a

supplementa l force system is used to provide a

moment that torques the root distally, a significant amount of anchorage may be lost as the molar assumes an upright position . Patient compliance

with headgear

movement. Since distalization is usually accomplished early in treatment and any undesired movements can be corrected later on, second phase of molar uprighting is necessary in which patients often must wea r headgear. So, we recommend distalization with Nance appliance and coil springs which is easy to fabricate. econom ical and effective for achieving the main objective of molar correction from class II to class I.

is usually required to attain net bod ily

Presentation of cases treated by dlstalizing molars using Nance holding and NiTI open coils springs.

Case 1

A 12 years old female came with a complaint

of protruding upper front teeth. The patient had good facial esthetics and harmony of facial lines. She presented with end on molar relationship on both sides with overjet of 7 mm and overbite of 5 .5 mm . Maxillary arch length discrepancy was 8 mm. Upper incisor inclination to SN and PP was 118 0 and 128 0 respectively and in cisal edge 5 mm in front of NA line. Upper molar to PTV was 9 mm. Both 8NA and SNB were within average normal range. TuberOSity space was suHicient to accommodate both th ird molars. Treatment plan involved distalization of first motars to overcorrected Class I relation , Nance holding arch was attached to first premolars and 010 x 030 NiTi open coil spring (Ortho Organizers) was compressed 10 mm in excess of interbracket span between first premolars and first molars. Du ring this period of stabilization Class " elastics were applied on upper premolars from lower molar ( lower stabilizing arch was placed beforehand). The desired molar relation was achieved within 4 months and then a modified Nance was given on first molar for stabilization. Upper Molar to PTV decreased to 7 mm and bite was opened by 3.5 mm. Cephalometric super- imposition showed bodily movement of molars du rin g distalization wit h insignificant tipping and an ancho rage loss of 1 mm (Table 1) .

Case 2

A 13 years old female came with a complaint

of forwardly placed upper front teeth . The patient had good facial esthetics and harmony of facial lines. 8he presented with end on molar re lationship on

(J

Ind Orlhod Soc 2002 : 35 :131-142)

139

Case 1 12YrslFemaie Linear Measurements Pre-Tt Post Tt Tt Change PTV-U6 9 7 2 PTV-UI
Case 1
12YrslFemaie
Linear Measurements
Pre-Tt
Post Tt Tt Change
PTV-U6
9
7
2
PTV-UI
52
50.5
1.5
Ove~et
7
1.5
5.5
OverMe
55
2
3.5
60.2
61.1
0.9
--
/'---
-~
-----
I
r.·.
~_ ' '/:
·
i
/
AIII
\' 1 ' .,
Post Tt Tt Change
Post Tt Tt Change

U6-PP

84

1

Ul-PP

116

12

SN-U6

71

73

2

SN-U1

118

116

2

71 73 2 SN-U1 1 1 8 1 1 6 2 Table 1 both sides with

Table 1

both sides with overjet of 6 mm and overbite of 6 mm. Maxillary arch length discrepancy was 8 mm. Upper incisor inclination to SN and PP was 102 0 and

11 5 0 respectively and incisal edge 5 mm in front of

NA line. Upper molar to PTV

and S NB were wi thin average norma l range. Tu berosity space was sufficient 10 accommodate both third mola rs. Treatment plan involved dislalizalion of first molars 10 ove rcorrec ted Class I relat i on , Nan ce h olding arch was attached 10 f irst premo l ars and

was 7 mm . 80th SNA

010 x 030 NiTi open

was comp re ssed 10

span between first premo lars and first molars. The desired molar relation was achieved within 4Y2 months and then a modified Nance was given on

stabilizatio n. Upp er Molar to PT V

decreased to 6 mm and bile was opened by 3 mm. Cephalometric superimposition showed bodily movement of molars during distalization along with insignificant lipping and an anchorage loss of 1 mm (Table 2) .

first mo lar for

coil sp ring (Ortho Organizers) mm in excess of interbracket

Case 2 13YrslFemaie Angular Measurements Post Tt Tt Change Pre-Tt Post Tt Tt Change 6
Case 2
13YrslFemaie
Angular Measurements
Post Tt Tt Change
Pre-Tt
Post Tt Tt Change
6
4
U6-PP
70
67
3
49
5
U1-PP
115
106
9
3
3
SN-U6
60
65
5
3
3
SNoUt
102
101
67.5
0.5

Table 2

140 Effective Means of Intraoral Molar Distalization . An Overview - D. N. Kapoor/Anup Aazdan /Sridhar Kannan

Case 3

A

15 years old female came with a complaint

of irregularity of upper front teeth and labially blocked out cani nes. The patie nt had good facia l esthetics and harmony of facial lines. She presented with Class II molar relation of 4 mm on both sides with ove~etof 3 mm and overbite of 5 mm. Maxillary arch length discrepancy was 7 mm . Upper incisor inclination to SN was 91 0 and to Palatal plan e was 102° and incisal edge 4 .5 mm in front of NA line. Upper molar to PTV w as 15 mm. Both SNA and SNB was wit hin average normal range. Tuberosity space was sufficient to accommodate both third molars.

molar relation with overjet of 7 mm and overbite of 6 mm. Maxillary arch length discrepancy was 10

and PP was

mm .

Tuberosity space was sufficient to accommodate both third molars. Treatme n t plan involved distalization of f irst molars to overcorrected Class I relation , Nance holding arch was attached to first premolars and

mm . Upper incisor in clination to SN

108 0 and 11 ~ . Upp er

molar to PTV was 11

010 x 030 NiTi open coil spring (Ortho Organizers) was compressed 10 mm in excess of interbracket span between first premolars and first molars. The

ac hie ved within

desired mo l a r re l atio n was

5 months and then a modified Nance was given

Angular Measur~ 'lP'1I ,

Pre-Tt

Post n Tt Change

U6·PP

83

86

3

U1-PP

102

5

SN-U6

71

SN4Jl

91

15V-.m.Ie

Pre-Tt

Post TI Tt Change

15

11

4

44

47

3

3

3

0

5

3

2

65.4 66.5

1.1

3 3 3 0 5 3 2 65.4 66.5 1.1 Table 3 Treatment plan involved distalization

Table 3

Treatment plan involved distalization of first

and second mola rs en masse to overcorrected Class I re lation , Nance holding arch was attached to first premolars for anchorage and 0.010 x

0.030 NiTi open

was compressed 10 mm in excess of interbracket span between first premolars and first molars. The desired Class I molar relation was achieved within 5 months. Upper Molar to PTV decreased to 11 mm and bite was opened by 2 mm . Cephalo- metric superimposition showed that the mola rs

coil sp ring (Ortho Organizers)

during distalization had lipped and an anchorage loss of 1 mm on right and 1.5 mm on left side was observed (Table 3).

Case 4

A 14 years old female came with a complaint

of forwardly placed upper front teeth. The patient had

good facial esthetics. Sh e presented with Class II

on first molar for stabi lization. Upper Molar to PTV

bite was opened by

3 mm . Cephalometric superimposition showed

that the molars during distalizalion had tipped an d

decreased to a mm and

an anchorage loss of 1.5 mm was observe d

(Table 4).

Case 5

A

13 years old female came with a comp laint

of forwardly placed chin. She had mandibular prognathism and anterior cross bite. After the case was analyzed it was found that there was maxi lla ry deficiency and dentoalveolar retrusion with mild maxillary anterior crowding and had horizontal growth pattern . Lower facial height was decreased and pa tient was given delaire for a period of 6 months. ANB decreased from -5 to - 1. SNA advanced by 2" and SNB decreased by 2" Le . 78° to 8D" (S NA) and 83° to 81 ° (SNB ,l. - SN inc reased

(J Ind OnhOd Soc 2002: 35:131-142)

141

Angular Measuremenls

Pre-Tt

Po st Tt Tt Change

3

7

6

U6-PP

62

65

U1 -PP

117

110

SN -U6

55

59

SN-Ul

108

102

110 SN -U6 5 5 5 9 SN-Ul 108 102 Case 4 14 Y rs/Fema1e Tabte

Case 4

14 Yrs/Fema1e

5 5 5 9 SN-Ul 108 102 Case 4 14 Y rs/Fema1e Tabte 4 l mear

Tabte 4

l mear Measurements

Pre-Tt

Post Tt Tt Ch ange

PTV-U6

11

8

3

PTV-U1

57

55

2

Overjel

7

3

4

0vertli1.

6

3

3

POS1: FH

68.1

67.8

1.7

Atii:TH

6 3 3 POS1: FH 68.1 67.8 1.7 Atii:TH from 110 0 to 116 0 Le.

from 110 0 to 116 0 Le. signifying dentoalveolar protrusion . IMPA decreased from 85.6° to 840 and FMA i n crease d by 2 °. After t his skeletal correction , molars were in an end on relatio nship wi th mild maxillary anterior crowding and dentoalveolar protrusion. These factors led to distalization of molars to achieve Class I molar re lationship an d eliminate crowding . Distalizat ion was accomplished by NiTi open coil springs and molars were dislalize 3 mm from each side to achieve super Class I molar relation (Table 5) .

Summary

Five patients req uiring molar distalization

rangin g in age from 12 10 15 years we re se lected for the study. The Nance appliance consisted of two premolar bands , connected by a soldered

palatal framework, and

for palatal support. The button was large enough to provide adequate anchorage and stability. extending to about 5 mm from the teeth. Actual dist alization was done by NiTi Coit spri ngs on sectio nal arch wires . Molars moved distally 1 to

en anterior acrylic sh ield

Ca se S 15Yrs/Female Angular Measurements linear Measurements Pre-Tt Post TI Tt Change Pre-TI Post
Ca se S
15Yrs/Female
Angular Measurements
linear Measurements
Pre-Tt
Post TI Tt Change
Pre-TI
Post Tt TI Change
10
t2
2
U6-PP
90
84
6
49
59
10
U1·PP
121
122
1
-,
2
3
n
SN-U6
80
3
7
2
5
SN-Ul
110
11<
71
70
1
;'.1>: ", :<11. ('
xl l"<
:li:y;

Table 5

142 Effective Means of Intraoral Molar Dislal izalion - An Overview - D. N. Kapoor/Anup Aazdan /Sridhar Kannan

1.5 mm/month with 8 to 10 mm activation of 100 gm coils with little loss of anchorage . Since the reaction force of the coil moves the wire anteriorly, the function of the stop agains t the premolar brackets is to ensure that the wire cannot move past the first premolars thus placing the reaction force on the Nance appliance . Accordingly the anchorage unit remains the palate as well as incisors. The appliance did not interfere with the occlusal plane, thus maintaining control, of the vertical dimension. None of our patients has made any negative comments about the comfort, feel or ease of speech of the Nance appliance. No signs

of

pala tal irri tation was observed during the course

of

treatment.

Inferences:

Molar distalization if done on careful selected cases with critically planned biomechanics can correct molar relation and provide some useful arch length in mild to moderate discrepancy. It is observed that premolar move forward approximate ly 1 mm in about 4-5 mm of molar distalization .The amount of anchorage loss with NiTi coil springs is similar to that reported with magnets. K-Ioop , pendulum . If necessary anchorage can be reinforced by attaching

a straight pull or high pull headgear wi th a fo rce of

150 gm to the premolars. The Nance appliance appea rs to be an effe ctive method 01 moving maxillary posterior teeth distally. With both intra oral and intra maxillary fixat ion . it does not require patient compliance . Our results indicate however that complex three dimensional movements occur along with the desired distalization . No correlation could be established between amount of distalization or duration of treatment and the amount of tipping .

Since distalization is usually accomplished early in treatment, any undesired movements can be corrected in succeeding phases. Therefore we

strongly believe that the advantages of the Nance

app liance with disadvantages.

Ni Ti coil springs outweigh their

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