Treatment of class ii non compliant /certified fixed orthodontic courses by Indian dental academy


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Treatment of class ii non compliant /certified fixed orthodontic courses by Indian dental academy

  1. 1. Treatment of Class II NonCompliant Patients INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Patient Compliance  Definition - By Haynes  A syndrome?  Appliances?
  3. 3. FACTORS ASSOCIATED WITH PATIENT COMPLIANCE  Allan and Hodgson(1968) to predict patient cooperation ?  30 subjects, 13 boys and 17 girls, with an age range of 12 to 18 years  Result?  Egolf, BeGole (AJO 1990) Major factors related to patient compliance with headgear and elastic wear ?  Young children (less than 12yrs) are better compliant patients than older ones.  McDonald -no association between severity of malocclusion and compliance.
  4. 4.  Cureton (AJO 1990)  important predictor of compliance?  Girls were found to be more compliant than boys.  The relationship between Socioeconomic status and compliance were conflicting.  Cureton(1993)-14 -16 yrs – least compliant.  Nanda (AJO 1998) patient compliance?  Patients with better compliance  high self-esteem, obedient, accommodating, self-confident, thankful, secure, polite, high academic achiever, self-conscious, and cheerful.  Agar (2005)-Age/gender difference-not significant  Conclusion?
  5. 5. Treat a Class II non-compliant patient-A challenge?  Fixed functional orthopedic appliances  Mechanism of action?  Result?  Fixed Intra-arch appliances  Class I force?  Result?  Interarch spring- force delivery systems
  6. 6. FIXED FUNCTIONAL ORTHOPEDIC APPLIANCES  HERBST APPLIANCE:  History:  Emil Herbst developed the first truly fixed functional appliance in 1909, and published his results with this appliance some 25 years later.  Interest in the Herbst appliance lay dormant for another 45 years until the classic paper by Pancherz.
  7. 7. Appliance description  Passive tube and plunger system  Exact length of the tube  Attachments?
  8. 8.  Generally, the Herbst appliance is used as a first- phase treatment in severe Class II malocclusions and is followed, after removal, by a second phase of edgewise mechanics.  Dischin introduced the Edgewise Herbst. The Edgewise Herbst appliance does not permit engagement of the mandibular canines and premolars but can reduce the overall treatment time.
  9. 9.  Pancherz (AJO 1985) –  The appliance has several advantages when compared to removable bite-jumping appliances (functional appliances), such as the activator, bionator, and Fränkel appliance:  (1) The Herbst appliance works 24 hours a day, (2) no cooperation from the patient is required, (3) treatment time is short (approximately 6 to 8 months).
  10. 10.  Important considerations in appliance construction to avoid problems with loose or broken bands:  All bands except those on the mandibular molars be formed individually of orthodontic band material at least 0.15 mm in thickness?  The upper and lower pivots on each side should be placed parallel to each other (when seen in the same plane). This will provide a correct and smooth function of the telescope mechanism.  The upper pivots be placed distally on the molar bands and the lower pivots mesially on the premolar bands.  The pivot openings on the tube and plunger be widened ?
  11. 11.  This study- analyses of dental casts and profile roentgenograms from twenty-two consecutive Class II, Division 1 malocclusion cases treated with the Herbst appliance for an average time period of 6 months.  None of the subjects had passed maximal pubertal growth.  Twenty untreated subjects with the same type of malocclusion, skeletal morphology and pubertal maturity served as a control group.  Before treatment all patients had a bilateral Class II molar relationship, a large overjet (mean, 8.2 mm), and a large overbite (mean, 5.5 mm).  Six months of treatment with the Herbst appliance resulted in Class I (or overcorrected Class I) molar relationships, normal overjet (mean, 3.0 mm) and normal overbite (mean, 2.5 mm) in all twenty-two subjects.
  12. 12. ♫ Sagittal cephalometric changes: ♫ The mandibular incisors proclined- 6.6° during 6 months of Herbst treatment. ♫ The position of the maxillary incisors was unaffected by treatment. ♫ The Herbst appliance had a restraining effect on maxillary growth and a stimulating effect on mandibular growth. ♫ Apparent mandibular length increased about three times more in the Herbst group than in the control group. ♫ Class II molar correction and overjet correction were about equally a result of skeletal and dental alterations.
  13. 13. ♫ Vertical cephalometric changes: ♫ vertical overbite was reduced - 3.0 mm . ♫ The mandibular incisors and maxillary molars were intruded during treatment, while eruption of the maxillary and mandibular second premolars and mandibular molars was enhanced . ♫ Vertical position of the mandibular incisors resulted from proclination of these teeth. ♫ As a result of the dental changes, the overbite was reduced and lower facial height was increased .
  14. 14. Temporomandibular joint: ♫ radiographs taken before and after Herbst treatment revealed no adverse structural changes in the condyle, fossa, and/or articular tubercle were seen in any of the subjects. Stability and relapse post treatment? ♫ Dental casts and lateral roentgenograms were analyzed twelve months after removal of the Herbst appliance in the first ten of the twenty-two cases presented earlier. A matching group of ten untreated Class II subjects was used for comparison.
  15. 15. ♫ Minor relapse of overjet and overbite was a common finding. This could be explained mainly by a relapse in lower incisor inclination after the Herbst appliance was removed. ♫ Posttreatment stability in sagittal dental arch relationships depended for the most part on a stable cuspal interdigitation of the upper and lower teeth. Partial relapse was seen in three of the ten cases because of unstable occlusal conditions.
  16. 16. ♫ The inhibitory influence of the appliance on sagittal maxillary growth was temporary. ♫ The stimulating effect of treatment on sagittal mandibular growth- permanent. ♫ The increase in mandibular length seen during the examination period of 18 months was significantly larger (p > 0.01) in the Herbst group (mean, 5.8 mm) than in the control group (mean, 4.0 mm) . ♫ The follow-up period of 12 months was too short to permit anydefinite conclusions to be drawn about the long-term effects of the Herbst appliance on mandibular growth. ♫ The increase in lower facial height seen during treatment was temporary. At the time of re-examination 12 months posttreatment, lower facial height was the same in the Herbst group as in the control group.
  17. 17. Pancherz summarize…  Class II molar correction?  Overjet correction?  Overbite correction?
  18. 18.  Valant and Sinclair(AJO 1989) showed that the lower dentition advanced significantly during Herbst therapy, and that at least 52% of the Class II correction came from dentoalveolar changes, with the rest resulting from mandibular growth.
  19. 19. Late Herbst Treatment  Pancherz (AJO1997) study was to analyze quantitatively the sagittal skeletal and dental changes contributing to Class II correction in patients treated with the Herbst appliance after the pubertal growth peak.  21 subjects with a Class II, Division 1 malocclusion treated during the skeletal maturity stages MP3-H and -I, corresponding to a period after the maximum of pubertal growth (late treatment).
  20. 20.  A comparison was made with 22 Herbst subjects treated during the skeletal maturity stages MP3-E and -F, corresponding to a period before the maximum of pubertal growth (early treatment).  Lateral head films from before and after Herbst therapy were analyzed.  As a result of the Herbst therapy, all patients attained a Class I or overcorrected Class I occlusal relationship.
  21. 21.  Class II molar correction - 6.1 mm was due to 37% skeletal and 63% dental changes.  Overjet correction -8.4 mm was due to 27 % skeletal and 73% dental changes.  Differences between the late and the early treated patients were only found for the dental changes.  The upper anterior teeth were retroclined and the lower anterior teeth were proclined more in the late cases.  Conclusion?  Proclination?
  22. 22. Class II Div 2 Malocclusion  Pancherz(AJO 1997) the sagittal skeletal and dental changes in Herbst treatment of 14 Class II, Division 2 malocclusions. Forty Class II, Division 1 Herbst subjects were used for comparison.  Lateral head films from before and after Herbst treatment were analyzed.  The results revealed that all patients were treated to Class I or overcorrected Class I molar and edge-to-edge incisor relationships.  The maxillary and mandibular skeletal changes were similar in both groups.  In the Class II, Division 2 subjects, sagittal molar and overjet corrections amounted to an average of 5.9 mm and 3.1 mm, respectively.
  23. 23.  When comparing the Class II, Division 2 with the Class II, Division 1 subjects, overjet correction was, significantly larger in the Class II, Division 1 subjects.  In the subjects with Class II, Division 2 malocclusions, the upper incisors were proclined , whereas in the subjects with Class II, Division 1 malocclusions, the incisors were retroclined.  The lower incisors were on the average proclined more in the Class II, Division 2 subjects (mean = 3.4 mm) than in the Class II, Division 1 subjects (mean = 2.4 mm)?  sagittal molar correction- no differences between the two malocclusion groups.  Proclination of the lower incisors during treatment (anchorage loss) is advantageous in this type of malocclusion.
  24. 24. Effect on condyle and chin  Ruf and Pancherz (AJO 1998) –  In 98 Class II Division 1 malocclusions treated with the Herbst appliance -“effective condylar growth” (a summation of condylar remodeling, glenoid fossa remodeling, and condylar position changes within the fossa) and its influence on the position of the chin was analyzed.  Lateral head films in habitual occlusion from before and after 0.6 years of Herbst treatment as well as 0.6 years and 3.1 years posttreatment were evaluated.  All patients were treated to Class I or overcorrected Class I dental arch relationships.
  25. 25.  Treatment period-effective condylar growth was relatively more backward directed and about three times larger than that in untreated subjects with ideal occlusion (Bolton Standards).  The corresponding chin position changes during the different examination periods were a mirror image of effective condylar growth provided no mandibular autorotation occurred.  In cases with anterior mandibular autorotation, relatively more forward and in cases with posterior mandibular autorotation relatively more backward directed chin position changes resulted.
  26. 26. Condyle-Fossa Relationship  Woodside (AJO1987) studied the appliance' s effect on the temporomandibular joint  the remodeling changes in the condyle and glenoid fossa following a period of progressively activated and continuously maintained mandibular advancement using the Herbst appliance.  Progressive mandibular advancement was achieved by adding stops to the telescopic arms of the appliance.
  27. 27.  Extensive remodeling and anterior relocation of the glenoid fossa, which contributed to anterior mandibular positioning and altered jaw relationships.  Concluded that not only condyle remodel in a superior and posterior direction, but, equally important, the entire TMJ fossa remodeled to accommodate the condyle's new, anterior position.
  28. 28.  John Voudouris.(AJO 2003)  Experiment done in both non-human primates and human patients with Herbst appliance (progressive advancement)  Assessment of condyle growth with Bjork method (metallic implant)  Fluorescent microscopy –sections with tetracycline vital stains-histologic sections of condyle & glenoid fosssa and implanted EMG electrode to assess LPM, superficial masseter & anterior temporalis.  Result- Increased condylar growth, anterior and inferior relocation of glenoid fossa and decreased EMG activity of muscles – support growth relativity hypothesis
  29. 29. Advantages Of Herbst Appliance  Larry White (JCO 1994)-:  Acceleration of condylar growth in children  Anterior displacement of the mandibular incisors with the Herbst appliance.  The upward and backward force generated by the Herbst prevents eruption of the maxillary molars  Constant force, which discomforts patients much less than intermittent pressures from headgears, elastics, or removable appliances.  Reduces maxillary convexity minimally, greatly diminishing the possibility of changing upper lip contour.
  30. 30.  Approximately one-half of the changes are dentoalveolar, so the Herbst- minimally growing patients as well as growing patients.  The ability to alter mandibular position permits the Herbst appliance to correct midline deviations of mandibular origin.  Multiple design possibilities allow the appliance to use whatever teeth are present.
  31. 31. Limitations of the Appliance  Breakage-rigid  A Class II bimaxillary protrusive patient  Since the Herbst affects the maxilla minimally, it shouldn't be used when the Class II malocclusion is due to a protracted maxilla.  For best results, the appliance should be worn for 9 to 15 months.  The absence of bicuspids at the conclusion of Herbst therapy jeopardizes the retention.  The cost of the appliance, since construction currently requires a rather expensive laboratory procedure.
  32. 32. Relapse after Herbst Treatment  Pancherz(AJO 1991) 45 cases were observed for at least 5 years (5 to 10 years) after treatment. The patients were divided into three groups with respect to stability or relapse in sagittal dental arch relationships in posttreatment period.  Stable (S) (n = 14), overjet unchanged or reduced and molar relationship in Class I.  Insignificant relapse (n = 16), overjet increased <1 mm and molar relationship in Class I.  Relapse (R) (n = 15), overjet increased >1 mm and molar relationship in Class I or Class II
  33. 33.  A comparison was made between 15 relapse and 14 stable cases at least 5 years after treatment.  Results- relapse in the overjet and sagittal molar relationship resulted mainly from post treatment maxillary and mandibular dental changes.
  34. 34.  In particular, the maxillary incisors and molars moved significantly to a more anterior position in the relapse group than in the stable group.  The interrelation between maxillary and mandibular post treatment growth was favorable and did not contribute to the occlusal relapse.  Persisting lip-tongue dysfunction habit (64%)and an unstable cuspal interdigitation(57%) after treatment-potential cause
  35. 35. Mandibular Anterior Repositioning Appliance • the MARA is an ingenious way to encourage patients to keep their mandibles thrust forward to avoid intentionally created, buccally place interferences.
  36. 36.  Advancing the mandible forward in precise increments can be achieved by the insertion a shims of varying length.  This method afford quicker and more accurate way of mandibular repositioning and could provide valuable information on the interplay between orthopedic and orthodontic results. The MARA has the potential to be used concurrently with edgewise mechanotherapy and can be continued into retention phase for stability.  Moreover incremental unilateral activation of the MARA is easier to obtain because of the incremental addition stops to obtain progressively more activation.  How is it different from Herbst?
  37. 37.  The disadvantages of the MARA include  the necessity for molar crowns.  Placement of crowns results in undesirable increase in anterior facial height, but a downward and backward mandibular rotation is not observed because of a concomitant increase in posterior face height.  On some patients the molar attached guide bars result in pronounced mobility to the mandibular first molars.  The MARA is as expensive as the Herbst appliance; and more clinical evaluations particularly regarding long-term effects, are needed.
  38. 38.  Jeffrey Breger (AJO 2003)-study was to investigate the MARA’s dental and skeletal effects on anterior, posterior, and vertical changes in 30 Class II patients.  The treatment group consisted of 12 boys with an average age of 11.2 years and 18 girls with an average age of 11.3 years.  A pretreatment cephalometric radiograph -2 weeks before treatment, and a posttreatment cephalometric radiograph- 6 weeks after removal of the MARA, with an average treatment time of 10.7 months.
  39. 39.  The results of the study showed that the MARA produced measurable treatment effects on the skeletal and dental elements of the craniofacial complex.  About 5.8-mm Class II molar correction was obtained by a 47% skeletal change (2.7 mm) and a 53% dental change (3.1 mm).  The 2.7-mm skeletal change was completely due to growth of the mandible.  The skeletal changes indicated that the MARA produced increases in mandibular length and in posterior and anterior face heights but had no headgear effect on the maxilla .
  40. 40.  In contrast, the dental changes were mainly due to the distalization of the maxillary molar (2.4 mm), which accounted for 77% of the total dental correction.  The mandibular molar moved forward about 0.7 mm, accounting for only 23% of the total dental correction.  Therefore, dental changes included distalization of the maxillary molar, forward movement of the mandibular molar and incisor, and a slight proclination of the mandibular incisor.  The MARA produced similar dentoalveolar changes as the Herbst and greater dentoalveolar changes than the Frankel II appliance
  41. 41. Mandibular Protraction Appliance  Advantages –  reduced cost, simple construction performed in the office, and no specially manufactured parts well suited for conditions where cost is a greater consideration.  The appliance can be used with the full arch edgewise technique, with the exception that the mandibular premolars cannot be bonded.  Disadvantages –  breakage, arch wire distortion, and a limitation in mandibular movements.
  42. 42. Mandibular Protraction Appliance -1  Appliance construction?  the lower archwire should have enough lingual torque in the anterior region  It should be tightly cinched back .  The maxillary edgewise archwire doesn't need a stop, tieback, or special torque adjustment.
  43. 43. Loop Two loops Length
  44. 44.  The angulation of these circle bends can vary to allow free sliding along the mandibular archwire.  One appliance circle was placed over the maxillary archwire against the molar tube, and the other circle against the mandibular archwire stop. Both circles are then closed completely with a plier.
  45. 45. Mechanism of Action
  46. 46.  Significant changes were seen within four months with this appliance.  Such radical improvement could not be accounted for solely by mandibular growth, but rather by dentoalveolar changes imposed by the appliance's constant pressure.  Drawbacksthe impossibility of bonding the lower bicuspids, appliance's limited mouth opening and frequent dislodgment of molar bands.
  47. 47. Mandibular Protraction Appliance No. 2 The MPA No. 2 was fabricated by making right-angle circles in two pieces of .032" stainless steel wire . The coils were made from .024" stainless steel wire with a Tweed loop-bending plier.
  48. 48.  One end of each wire was inserted through the other wire's loop , so that each wire passed through the other up to the limit of the wire coil .  The coil prevented the two wires from interfering with each other and ensures their correct relationship .
  49. 49. Maxillary/mandibular archwire?
  50. 50.  The 2-3mm distance between cuspid brackets and mandibular archwire circles allowed adjustments for asymmetries that may develop during treatment.  By simply sliding the archwire to one side or the other, the midline could be altered and more pressure put on one side of the mouth.  Both appliances permanently reposition the mandible forward and rely on a combination of condylar growth and dentoalveolar adaptation to achieve a Class I posterior occlusion.
  51. 51. The Mandibular Protraction Appliance No. 3  Limitations of MPA I & 2  Eliminated much of the archwire stress and permits a greater range of jaw motion while keeping the mandible in a protruded position.  The new appliance-resembles the Herbst, but its smaller size and improved function- tolerable than previously developed MPAs or Herbst appliances, and its ease of construction and insertion reduced stress and discomfort .  The MPA No. 3 allows almost unrestricted opening, to at least 50-55mm. As with the other MPAs, it can be used unilaterally.
  52. 52.  The versatile MPA No. 3 is no more effective in correcting malocclusions than previous models, but it has the following advantages:  It is more comfortable for the patient, and thus promotes better compliance.  It offers greater range of motion.  It is equally simple and inexpensive, but easier to place.  It can be used for mandibular positioning or dentoalveolar movement.  It causes less breakage of archwires and appliances and thus fewer emergency appointments.
  53. 53. The Mandibular Protraction Appliance No. 4  Carlos Filho The latest version, the MPA IV,was much easier to construct and install, and much more comfortable for the patient. The MPA IV is made up of the following parts:  “T” tube  Upper molar locking pin  Mandibular rod  The Mandibular Protraction Appliance has proven to be effective during approximately 10 years of clinical use. This fourth version seems to be as efficient as its antecedents, but was much more practical to construct, easy to manipulate, and comfortable for patient.
  54. 54. Step 3 Step 1 Step 2 Step 4
  55. 55. Step 5 Step 7 Step 8 Step 6
  56. 56. Appliance insertion
  57. 57. FIXED INTERARCH APPLIANCES      Three categories; extension springs such as the Saif Spring, curvilinear leaf springs as represented by the Jasper Jumper, compression springs first available as the Eureka Spring. These appliances use maxillary and mandibular teeth simultaneously to effect sagittal corrections.
  58. 58. Saif Spring  The Saif Spring consisted of two springs, one inside the other, with soldered loops on each end .  The springs were available in 7- and 1O-mm length, had an outside diameter of 3 mm.  200- 400 g/cm2 of force when the mouth was closed.
  59. 59.  Breakage was a constant problem with these extension springs.  In some patients these springs would last 3 weeks, whereas in others only 3 days could be expected.  Frequent appointments were required, but treatment was rapid.  The springs were a bit bulky ,hygiene was a problem, and patients experienced some limitation to mandibular opening.  The large forces generated by these springs may have accounted for the rapid correction observed.
  60. 60. Niti Interarch Spring  The NiTi Interarch Spring was introduced by GAC International in the early 1990s  the low force and high flexibility of nickel-titanium alloys could overcome the breakage problems of the Saif Spring.  Unfortunately, the low fatigue resistance of these alloys resulted in breakage frequency comparable to that of the Saif Spring and their clinical availability was short lived.
  61. 61. Curvilinear Leaf Springs  Jasper Jumper  This was the first clinically successful appliance to use a push force rather than the more common pull force of Class II elastics and extension springs.  Pull force?  a heavy coil spring encased in plastic that uses pivoting attachments at both ends. To permit a greater range of opening, an auxiliary frequently is used .
  62. 62.  Advantages Ease of insertion and activation and generation of intrusive forces on molars and incisors.  The Jasper Jumper can be used with full banded techniques, and has been shown to be effective in adults.  When used with an auxiliary wire , the Jasper Jumper affords a full range of mandibular movements.  Disadvantages large inventory, five sizes of left and right, breakage, and a lack of force when the mouth is held open slightly such as in sleeping mouth breathers.
  63. 63.  Buschang (Angle 1994) Orthopedic and orthodontic changes associated with Jasper Jumper therapy.  31 consecutively treated Class II patients.  Lateral cephalograms were taken immediately before appliance placement and immediately after appliance removal (mean interval of 0.4 years).  Matched to untreated controls based on age, sex, and mandibular plane angle.  The results -majority of Class II correction was due to dental, rather than skeletal change.  The maxillary incisors retroclined and the maxillary molars tipped distally. The mandibular incisors proclined & intruded and the mandibular molars translated and tipped mesially.
  64. 64.  Jasper’s3 “theory of two’s” suggests that a Class II correction with Jasper Jumper therapy can be equally partitioned between five components, as follows:  20% due to maxillary basal restraint  20% due to backward maxillary dento-alveolar movement  20% due to forward mandibular dento-alveolar movement  20% due to condylar growth stimulation  20% due to downward/forward glenoid fossa remodelling  Conclusion?
  65. 65.  Weiland (AJO 1995) 17 consecutive growing patients who had Class ll, Division 1 malocclusions.  Lateral cephalograms taken before treatment and immediately after removal of the Jumpers were analyzed.  Results:  Class l occlusal relationships- average treatment time of 6 months.  The correction of the Class ll malocclusion was a result of skeletal (40%) and dental (60%) changes.
  66. 66.  The dentoalveolar part of total molar relationship correction took place to the same extent in both jaws  overjet correction the maxillary dental changes outweighed the mandibular changes by far.  When compared with normal growth changes (Bolton standards), treatment with Jasper Jumpers distalizes the upper dentition and moves the lower teeth mesially.  Mandibular growth seems to be increased to some extent.  It was concluded that treatment with the Jasper Jumper appliance presents an effective method to correct Class ll malocclusion in growing patients.
  67. 67.  Jasper and McNamara (AJO 1995) described the use of a flexible force module (the Jasper Jumper) that could be incorporated into existing fixed appliances.  The flexible spring module provides greater freedom of mandibular movement than is possible with the more rigid mechanism of the Herbst appliance.  The treatment effects produced by the module include posterior movement of the maxillary buccal segments and anterior movement of the mandible or mandibular dentition or both.
  68. 68.  Dental asymmetries. The force module system also could be used in patients who had sagittal dental asymmetries. In a Class II subdivision-type patient, the maxillary arch wire can be tied back on the side of the existing Class I molar relationship.  In growing patients, changes in mandibular position and presumably changes in mandibular length are achieved after force module application.  However, it was assumed that the treatment effects produced by this flexible force module are similar to those of the Herbst appliance, due to the similarities in their mechanisms of action  When mandibular advancement is desired, generally the level of force generated by the module is greater (i.e., 6 to 8 ounces) than that when maxillary molar distilization is intended (2 to 4 ounces).
  69. 69. Relapse After Treatment  Ingervall (EJO 1998) Class II div I in 26 patients-age 13-25 yrs.  Mean treatment time of 5 months followed by retention (activator)of 7 months.  Results-Slight retrusion of maxilla and marked increase in mandibular prognathism.  Maxillary incisors and molars retruded and mandibular incisors and molars protruded.  At end of retention, partial relapse of the dento-alveolar structures-over correction indicated.  Skeletal effect in mandible-stable.  60% of overjet reduction and 75 % of molar correction was stable
  70. 70.  Castanon (1998)The Churro Jumper furnishes orthodontists with an effective and inexpensive alternative force system  When used as a Class II corrector, the Churro exerts a posterior force on the maxillary arch and an anterior force on the mandibular arch, much like the Jasper Jumper.
  71. 71.  Disadvantages:  The restriction of mouth opening to 30-40mm is intolerable for some patients.  Archwire breakage is common if larger wires are not used.  Patients with a low tolerance for discomfort will often break the appliance.  Patients who incessantly move their mouths with chewing, talking, and nervous tics will fare poorly with it.  Its maximum effectiveness depends on a permanent dentition to retain its effect.
  72. 72. Adjustable Bite Corrector  swivel adjustments at its ends, thereby eliminating the need for left and right models, thus reducing inventory by half.  The push force is from a nickel-titanium wire in the center lumen of the spring.
  73. 73.  The length of the Adjustable Bite Corrector can be increased as much as 4 mm by simply turning the ends of the spring.  This desirable adjustable feature permits the clinician to alter the applied force by merely rotating these ends.  Repair of the broken spring is quick and inexpensive.  The advantages over the parent design of the Jasper Jumper is the ability of the clinician to repair the broken appliance.  However the nickel-titanium wire placed in the center of the coil was subject to breakage, This problem probably would have been its most significant disadvantage.
  74. 74. Bite Fixer  In 1998 Ormco introduced the Bite Fixer, which is purported to be an improved Jasper Jumper because breakage was reduced.  This claim had not been verified by clinical reports, and it was difficult to find advantages of this device over those of the Jasper Jumper.
  75. 75. Klapper Superspring II  The Klapper Superspring II was appealing to Jasper Jumper -only two sizes are required and breakage may be less frequent.  The Klapper Superspring II inserted from the mesial and was rigidly secured to the molar by an oval attachment tube. (contrary to Jasper Jumper)
  76. 76.  The Klapper Superspring creates a moment on the molar, which is expressed clinically as distal root tip.  This moment can be desirable in some patients, but extended wear of the appliance could result in excessive distal root tip and molar extrusion.  Because the Klapper Superspring inserts gingivally on the molar and cannot roll to the buccal as readily as Jasper Jumper, the force vector has a greater vertical component.  If this were of clinical significance, a patient with a pronounced curve of Spee would level more quickly with the Klapper Superspring.
  77. 77.  However extended wear could produce excessive intrusion may require removal before sagittal correction have been completed.  The disadvantages the requirement of a special molar tube  limitation to maximal opening,  potential injury to the patient when breakage occurs  the rigid molar attachment forces the broken portion into soft tissue.
  78. 78. Forsus Nitinol flat spring  Force-225-250g - when it is compressed 5mm for initial activation.  Because it is made of nickel titanium, it delivers a consistent level of force  The flat spring was less comfortable to the patient than a Jasper Jumper, and on breakage more tissue irritation results, thus offers no advantage over the Jasper Jumper.
  79. 79. Interarch Compression Springs ♫ Advantages over extension and curvilinear counterparts, ♫ reduced spring fatigue, resulting in less breakage; ♫ increased extension, resulting in force application over a wider range of mouth positions; ♫ ability of the clinician to manipulate the vertical and horizontal vector of force. ♫ On full compression all these springs exert 225 ± 25gm/cm2of force, except for the Sabbagh, which delivers 300gm/cm2. ♫ However, Eureka Spring force is 160 ± 20 g/ cm2
  80. 80.  A cephalometric evaluation of the first 50 consecutively treated bilateral Class II patients indicated the following:  average anteroposterior correction was at the rate of 0.7mm per month.  For every 3 mm of anteroposterior correction, the maxillary molars intruded 1 mm and the mandibular incisors intruded 2 mm.  The maxillary dentition moved distally 1.5 mm, and mandibular dentition moved mesially 1.5 mm.  No increase occurred in anterior facial height between dolicocephalic and brachycephalic subgroups.
  81. 81. Eureka Spring  The Eureka Spring comes in two lengths, for extraction and nonextraction treatments; different models, which provide different means of connecting the ram to the arch wire ; and two force levels.
  82. 82.  Strengths- simplicity of design and hence miniaturization, tolerance of a wide variety of mouth shapes and oral musculatures, alteration in the amount and direction of force during treatment, and significantly less expense than the other interarch compression springs.  The weaknesses - breakage of the internal spring thereby requiring replacement of the plunger assembly, necessity for bands and a round tube on the molars.
  83. 83. ♫ De Vincenzo (Angle 2002)♫ 37 consecutively treated, noncompliant patients with bilateral Class II malocclusions. ♫ The average treatment -was 4 months. ♫ The Class II correction occurred almost entirely by dentoalveolar movement (90% dental;10% skeletal) and was almost equally distributed between the maxillary and mandibular dentitions. ♫ The rate of molar correction was 0.7 mm/mo. ♫ There was no change in anterior face height, mandibular plane angle, palatal plane angle, or gonial angle with treatment.
  84. 84. Twin Force ♫ The Twin Force - two plunger assemblies of the Eureka Spring, attaches sliding yolks to the distal ends of each plunger assembly,leaves the more proximal end free to slide through the other. ♫ Two rams emerge from the proximal ends of the plunger assemblies. ♫ At the mesial end - preassembled block is attached directly to the arch wire- distal end, an additional preassembled block can be placed -avoiding the need for a molar attachment and banding of the first molar.
  85. 85. ♫ At 60 mm mouth opening , considerable extra extension still exists ♫ This greatly increases the vertical component of the force vector and hence more intrusion is observed per millimeter of sagittal correction. ♫ The advantages - longer next extension distance, which permits the use of a shorter model that can be attached mesial of the maxillary molars, use without a molar band or tube, and minimal inventory
  86. 86. ♫ The disadvantages – ♫ increased size in one dimension, thereby limiting their use on some patients; ♫ a tendency for the twin cylinders to roll occasionally and hence interfere with the occlusion; ♫ a larger intrusion component to the force vector, which is not altered easily; ♫ and the need to replace the entire appliance on breaking. ♫ Because of a more complex design, the Twin Force is considerably more expensive than the Eureka Spring.
  87. 87. Forsus  Appliance?  Push force?  Longer length-spring  increases the overall diameter of the Forsus by 40% and its overall length by 5 mm compared with the Eureka spring.
  88. 88.  The Forsus completely disengages on mouth opening of 60 mm, and therefore left and right bypass auxiliary jigs should be used on patients opening wider than 53 mm.  The Forsus comes in a kit containing four lengths of push rods, left and right bypass auxiliary jigs, and split crimp spacers for small extensions of the push rods.  Of all the interarch compression springs, the Forsus is the least likely to break and therefore offers a advantage for those Class II patients with large buccal vestibules and flaccid perioral musculature.  However, its increased size limits its use in patients with smaller and tapered facial forms and active perioral musculature.  Greater overall diameter and length, disengagement on wide opening and cost are its major disadvantages.
  89. 89. Sabbagh Universal Spring  slotted-screw for partial adjustment of the distal aspect of the plunger assembly, which has been tapped and threaded to the inner portion of the molar assembly.  The plunger assembly thereby can be adjusted up to 4 mm.  A second open coil spring is inserted at the time of placement. The combination of external and internal spring permits an active extension force for 16 mm, the greatest of the interarch compressive springs.
  90. 90.  The Sabbagh disengages on mouth opening even more than does the Forsus and has limited use in patients who can open wider than about 48 mm  The maximum force - 300gm/cm2 the greatest of all the interarch compression and hence its side effects are also the most pronounced.  The Sabbagh has no advantages over the other compression springs unless more force is desired for the patient with an unusually large mouth.  The disadvantages -increased force, greatest overall length under maximum compression, bulky molar attachment area, limitation to patients with maximum opening of less than 48 mm .  Breakage is comparable to that of the Eureka Spring, whereas cost is considerably high.
  91. 91. Relapse  A cephalometric, retrospective study -Eureka Spring reported nearly 25% with a relapse in overjet correction of 2 mm or greater within the subsequent 4 months.  Overcorrection -undesirable side effects?  To avoid these undesirable effects, when correction has been obtained, the compression springs should be left in place for an additional 2 to 4 months but at a reduced force.  40 to 60 g/cm is sufficient to maintain the desired gains.  The prevention of post treatment relapse is an important aspect of the successful management of compression spring therapy.
  92. 92. FIXED INTRAARCH APPLIANCES  History:  Repelling magnets-Gianelly, Blechman, Bondemark &Kurol.  Superelastic Niti coils & wires-Gianelly.  Hilgers- Pendulum appliance.  Jones jig, Distal jet And other intraarch devices.
  93. 93. Magnets • Magneforce is possible translational molar movement with preservation of palatal anchorage. However, several reports indicate that molar tipping and anterior anchorage loss are comparable to those found in the Pendulum, Jones Jig, and Distal Jet.
  94. 94.  Gianelly (AjO 1989)  evaluated intra-arch placement of repelling magnets against the maxillary molars in conjunction with a modified Nance appliance cemented on the first premolars.  The acrylic palatal coverage of the Nance appliance extends anteriorly to the incisor segment by means of an 0.045-inch wire soldered to the lingual aspect of the premolars.  The acrylic component is placed against both the palatal vault and the incisors.  The reason that the modified Nance appliance was anchored to the first premolars was that to encourage the distal drift of the second premolars that normally occurs as first molars were moved posteriorly.
  95. 95.  Repelling magnets, used in conjunction with a modified Nance appliance, were well tolerated by patients and were used successfully to move molars distally with relatively minor anchorage loss.  Consistently, 80% of the space created represented distal movement of the molars. Thus for every 5 mm of space opened, the molars were moved posteriorly 4 mm while the premolar-incisor segment moved forward 1 mm.  patient cooperation was not necessary to move molars posteriorly.
  96. 96.  Blechman (AJO 1995) –  Static repelling magnets, with certain characteristic parameters, distalize molars rapidly without adverse effects that are clinically discernible.  Beneficial properties such as considerably reduced patient compliance requirements for force application, reduced mobility and discomfort, and mostly bodily movement are demonstrated clinically.
  97. 97. Magnets vs Niti coils  Bondemark & Kurol(Angle 1994)  Eighteen subjects, aged 12.5 to 18.3 years, with Class II malocclusion, deep overbite and moderate space deficiency in the maxilla were treated- repelling rare earth magnets on one side and superelastic nickel-titanium coils on the contralateral side for simultaneous distalization of maxillary first and second molars.  The force-225g .  Tooth movement was analyzed by measuring dental casts, lateral photographs of dental casts, and lateral skull radiographs before and after 6 months of treatment.
  98. 98.  Mean distal molar movement was 3.2 mm for the supercoils and 2.2 mm for the magnets.  Mean reduction of the overbite was 3.6 mm.  Complaints of discomfort were more frequent for the magnet sides?  Superelastic coils are more effective than repelling rare earth magnets in molar distalization.  Rapid force decay & bulky-magnets.
  99. 99.  The disadvantages  cost,  decreased rate of movement,  more frequent activation appointments,  possible heavy metal toxicity,  bulk.
  100. 100. Pendulum Appliance  Appliance parts?  Passive state?  Activation by attaching the free ends into the lingual sheaths on the molars creates a distalizing component of force.  Distopalatal arc molar movement.
  101. 101. • Opening loops are a part of the pendulum arms -clinician makes adjustments aseeded. • A midpalatal expansion jack screw –Pendex. • Unilateral movement can occur if only on arm is used.
  102. 102.  Ghosh and Nanda(AJO 1996) to determine the effects of the pendulum appliance on distalization of maxillary molars and the reciprocal effects on the anchor premolars and maxillary incisors.  Initial and follow-up cephalometric radiographs were obtained on 41 subjects (26 girls and 15 boys) who were treated with the pendulum appliance for bilateral distalization of the maxillary first molar teeth, for correction of the Class II molar relationship or for gaining space in the maxillary arch.  Dental, skeletal, and soft tissue changes were determined.
  103. 103.  The mean maxillary first molar distalization was 3.37 mm, with a distal tipping of 8.36°.  The mean reciprocal mesial movement of the first premolar was 2.55 mm, with a mesial tipping of 1.29°.  The maxillary first molar position intruded 0.1 mm, whereas the first premolar extruded 1.7 mm.  The transverse width between the mesiobuccal cusps of the first molars increased 1.40 mm.  The maxillary second molars were also distalized 2.27 mm, tipped distally 11.99°, and moved buccally 2.33 mm.  The effect of distalization on the maxillary third molars was extremely variable.
  104. 104.  The eruption of maxillary second molars had minimal effect on distalization of first molars.  The lower anterior face height increased by 2.79 mm.  This increase was greater in patients with higher Frankfortmandibular plane angle measurements.  The pendulum appliance is an effective and reliable method for distalizing maxillary molars, provided the anchor unit is adequately reinforced.  Its major advantages are minimal dependence on patient compliance, ease of fabrication, one-time activation, adjustment of the springs if necessary to correct minor transverse and vertical molar positions, and patientacceptance.
  105. 105.  The forces - 100 to 200 g/cm2 of force on the molar.  Movement is rapid, and to observe a 1-2 mm of space mesial to the first molar within 6 weeks not uncommon.  The Pendulum appliance provide 4 to 5 mm of arch length.  After the molars are distalized, the orthodontists constructs a new Nance button attached to the molars and retracts the premolars and anterior teeth using the newly positioned molars and Nance button as anchorage.  The pendulum appliance was most effective before the second molars have erupted, is readily adapted to phase I mixed dentition treatment plan.
  106. 106.  Dento-alveolar changes maxillary molar distalization with significant distal crowntipping and intrusion, mesial movement of the premolars, and anterior anchorage loss.  About 10 to 15 degrees of distal Molar tipping occurs, with one quarter to one third of increased arch length resulting from forward movement of the premolars and anterior teeth. Some have reported an increase in face height, whereas others detected little or no increase.’  That the Pendulum appliance relies on a Nance for anchorage was a disadvantage. Several studies have shown poor anchorage associated with a Nance button. A bony anchor in the palatal vault used to prevent this unfavorable reaction.
  107. 107.  Byloff and Darendeliler(Angle 1997) a sample consisting of 13 patients (9 females and 4 males, mean age 11 years 1 month [± 1 year 9 months])-dental Class II relationship with moderate space deficiency in the maxillary arch.  Pendulum Appliance-activated 45° (instead of 60°) force of 200 to 250 g - super Class I molar relationship was obtained.  Lateral headfilms were taken prior to treatment (T1) and on the day the appliance was removed (T2).  The sample was also analyzed, taking into consideration the eruption pattern of the maxillary second molars detected on panoramic X-rays.
  108. 108. ♫ The three eruption stages were: ♫ A. Maxillary second molar crowns above the level of the trifurcation of the first molars (four patients); ♫ B. Maxillary second molar crowns on the level of the bone surface of the maxillary alveolar crest (five patients); ♫ C. Half of the maxillary second molar crown erupted or in complete occlusion (four patients).
  109. 109. 1. The pendulum appliance - 3.39 mm ±1.25 mm distal molar movement with a mean bimolar intrusion of 1.17 mm ± 1.29 mm. 2. Maxillary expansion was possible for transverse deficiencies in combination with distal molar movement. 3. The pendulum appliance does not create dental or skeletal bite opening. 4. Incisor anchorage loss is minimal. 5. Important molar distal tipping of 14.5° ± 8.33° was evident. 6. There were no significant differences between second molar eruption stage groups concerning distal molar movement and molar tipping.
  110. 110.  Byloff and Darendeliler(Angle 1997)-Uprighting bends  During this first phase, the PAs were similar -overcorrected Class I relationship was obtained.  Molar root uprighting: When the necessary sagittal correction and the amount of space needed were obtained, the appliance was modified by adding a bend to the spring design to upright the molars by moving the roots distally.
  111. 111. The angle- 10° to 15°, using a Weingart plier . The moment created was expected to upright the molars. molar crown seemed to be sufficiently uprighted. Initiation of the second phase was marked on each patient's chart. A Nance palatal arch-anchorage
  112. 112.  Super Class I relationship- 4 months.  However, to upright the maxillary molars, another 10.9 weeks (mean) were required.  More bodily distal molar movement were found.  The introduction of an uprighting bend into the clinical management of the PA resulted in reduced molar tipping and 64.1% increased treatment time.  The effects of the original pendulum appliance were not significantly changed by the incorporation of the uprighting bends, although slightly more anchorage loss was noted on the maxillary incisal edge.  Second molar position did not influence either the amount of distal molar movement or premolar and incisor anchorage loss.
  113. 113. ♰ Bussick and McNamara(AJO 2000)♰ To examine the dentoalveolar and skeletal effects of the pendulum appliance in Class II patients at varying stages of dental development and with varying facial patterns (high, neutral, and low mandibular plane angles). ♰ Specifically, the amount and nature of the “distalization” of the maxillary first molars and the reciprocal effects on the anchoring maxillary first premolars and incisors were studied, as were skeletal changes in the sagittal and vertical dimensions of the face. ♰ Pretreatment and posttreatment cephalometric radiographs of 101 patients (45 boys and 56 girls).
  114. 114. ♰ maxillary first molar distalization was 5.7 mm, with a distal tipping of 10.6° & intruded 0.7 mm, ♰ The anchoring anterior teeth-1.8-mm anterior movement of the upper first premolars, with a mesial tipping of 1.5°& extruded 1.0 mm. ♰ Lower anterior facial height increased 2.2 mm; there was no significant difference in lower anterior facial height increase between patients of high, neutral, or low mandibular plane angles. ♰ In patients with erupted maxillary second molars, there was a slightly greater increase in lower anterior face height and in the mandibular plane angle and a slightly greater decrease in overbite in comparison to patients with unerupted second molars. Similar findings were observed in patients with second premolar anchorage versus those with second deciduous molar anchorage. ♰ Conclusion?
  115. 115.  Pendulum appliance related to the second and third molar eruption status-Kinzinger (AJO 2004)  A tooth bud acts like a fulcrum on the mesial neighbouring tooth.  Tipping of the first molar was greater when the second molars had not erupted.  In patients where second molar was erupted, tipping was greater when third molar bud was located in direction of tooth movement. Such cases, germectomy of third molar budsbodily distalization of both molars occurred.  However, greater distal forces was needed and anterior anchor loss was greater in distalizing both the molars.
  116. 116. Jones Jig  Appliance parts?  The force- compression of the open coil spring is7O to 75 g/cm2  With this light force, about half that generated by the Pendulum appliance, several of molar distalization can be obtained in 3 to 4 months.
  117. 117.  Many reports on the Jones Jig indicate magnitudes of molar distalization and anterior anchorage loss similar to those found for the Pendulum appliance, whereas one report found only about 25% anchorage loss -Jones and White(1992) because the force level used was 70 to 75 gm  Distal crown tipping of the molars was also similar to that produced by the Pendulum appliance and averaged 3 degrees for every millimeter of molar distalization. Again as with the Pendulum appliance, molar extrusion and mandibular hinge opening have been reported .  the appliance may be contraindicated in cases of extreme vertical growth patterns, because extrusion of the molars is not restricted.
  118. 118.  The advantages of the Jones Jig- light forces used, the ease of activation (simply place a new ligature tie), its incorporation into phase I treatment plans, and its use without bonding the anterior teeth.  The disadvantages of the Jones Jig - distal tipping of the molars and mesial tipping of the second premolars)’- force is coronal to the center of resistance of the root  The inability to use the Jones Jig with full banded treatment, because the rectangular tube is occupied, limits its use to phase 1 and interceptive treatments.  Breakage -easy distortion or loosening of the premolar band.  The Jones Jig is a proven orthodontic appliance that can obtain 4 to 5 mm of molar distalization.
  119. 119.  Nanda (AJO 2000)- Jones Jig vs Headgear.  to determine the effects of the Jones jig appliance on distal movement of maxillary molars and reciprocal effects on premolars and maxillary incisors.  Cephalometric radiographs before and after orthodontic treatment of 72 consecutively treated patients, 46 females and 26 males, were measured to define treatment changes attributed to the Jones jig .
  120. 120.  Comparative measurements were made on a matched sample of 35 patients (20 females and 15 males) treated with cervical headgear by the same clinician.  Both series of patients were treated to correct an Angle Class II molar relationship.  The molar correction in the Jones jig patients consisted primarily of molar distal movement. Dental, soft tissue, and skeletal changes were evaluated and compared for significant differences between techniques
  121. 121.  The results-mean maxillary first molar distal movement was 2.51 mm, with distal tipping of 7.53°, extruded 0.14 mm.  The mean reciprocal mesial movement of the maxillary premolar was 2.0 mm, with mesial tipping of 4.76°, extruded 1.88 mm.  The maxillary second molars were also moved distally 2.02 mm and tipped distally 7.89°.
  122. 122.  Significant differences between the Jones jig sample and the cervical headgear sample for lower lip to E-line and SNA. The Jones jig sample showed a mean decrease in lower lip to Eline of 0.25 mm versus 1.20 mm for the headgear sample. SNA decreased 0.40° for the Jones jig sample versus 1.20° for the headgear sample.  The Jones jig appliance demonstrated treatment results comparable with those of the sample treated with cervical headgear.
  123. 123. Lokar Molar Distalizer  The Lokar appliance inserts into the molar attachment with an appropriately sized rectangular wire.  A compression spring is activated by a sliding sleeve, which is tied to the most distal tooth mesial of the first molar by a ligature wire
  124. 124.  The guiding rod is soldered to the mesially position sleeve, and the flat anterior guiding bar is soldered to the immovable posterior sleeve.  With this arrangement, on activation the coil spring is compressed by the sliding sleeve, and an increase in the distal extension of guiding rod occurs.  This appliance is offset buccal , rests along the buccal surface of the premolars and is stabilized loosely mesially by the same ligature tie used to activate the sliding sleeve.
  125. 125. ♫ The Lokar distalizing appliance -best used with a Nance button but can be used without the button if sufficient anterior anchorage exists or little is required. ♫ The appliance can be used with complete edgewise and mixed dentition treatments, provided an extra rectangular tube is available on the molar attachment. ♫ A precise amount of force can be delivered. ♫ Other advantages of the Lokar Molar distalizer include ease of insertion, ease of activation and minimal breakage.
  126. 126. ♫ As in the Pendulum and Jones Jig, in the Lokar appliance the point of force application to the molar is coronal to the center of resistance in the root. ♫ For this reason, although no reports on the effects of the Lokar molar distalizer have appeared, distal crown tip at least equal to that found in the Pendulum and Jones Jig expected. ♫ In the Jones Jig a guide bar inserts into the molar tube, and therefore some resistance to root tip occurs. In the Lokar Molar Distalizer is more or less free to tip back.
  127. 127. Distal Jet • the line of force application is 4 to 5 mm apical of the centroid because of the bayonet bend, and therefore translation is more likely to occur.
  128. 128.  Distal tipping of the molars has been reported to be one degree per millimeter of distal crown movement.  An evaluation of previous studies showed 1 to 2 degrees of tipping per millimeter.  Of the arch length, about 70% of tipping resulted from molar distalization, and 30% resulted from anterior anchorage loss.  Few studies have shown 60% and 40%, respectively .  No molar extrusion, bite opening, or increased anterior face height were found.
  129. 129.  Advantages effective means to gain arch length, results in less molar tipping, can be used with or without full banded treatment, can be converted easily into a Nance holding arch, and is esthetically pleasing.  Disadvantages –  anchorage loss resulting from the Nance button and construction deep enough in the palate to be at or apical to the centroid in patients with shallow vaults.
  130. 130.  Nanda and Bowman(AJO 2001) analyzed molar distalization with the distal jet appliance, its effect on the anchor teeth, and the outcome at the completion of orthodontic treatment.  Pretreatment, after distalization, and posttreatment lateral cephalometric radiographs were evaluated for 21 adolescent girls and 12 adolescent boys- 12.8 ± 2.2 years.  The mean time for the correction of the Class II molar relationship was 6.7 ± 1.7 months, and the mean total treatment time was 25.7 ± 3.9 months.
  131. 131.  Results  that the distal jet appliance distalized the maxillary molars, but there was significant loss of anchorage. as has been reported with other similar intraoral distalization devices, such as the Jones jig and pendulum appliances.  However, the distal jet showed less tipping of the maxillary molars and better bodily movement of molars because the force was applied closer to the center of resistance.  There was no significant increase in lower face height.
  132. 132.  Carano and Bowman(Angle 2002)-Distal jet vs other intra arch devices.  evaluated distal jet alone , in a sample of 20 consecutively treated and growing subjects (11 females, nine males; mean starting age of 13) .  Pre- and post distalization cephalometric radiographs and dental models were analyzed to determine the dental and skeletal effects.  Class II molar relationships were corrected to Class I in about five months.
  133. 133.  The distalizing force on the maxillary molar - 71% molar distalization and 29% reciprocal anchorage loss measured at the maxillary first premolar(comparable to other types of intraoral methods of molar distalization.)  The maxillary first molars were moved distally an average of 3.2 mm/side, with 3.18 of distal crown tipping.  Net distalization was less than that seen with the pendulum.  However, the amount of molar tipping was significantly less than has been found with comparable intraoral distalizing appliances, including the pendulum.
  134. 134.  Less molar tipping (2.38 vs 4.38) and anchorage loss (0.9 mm/side vs 1.7 mm/side) were noted for subjects whose maxillary second molars were partly or completely erupted when compared with those with second molars that were not erupted distalization?  No significant vertical changes were observed during distalization  If the recovery from tipping of both molars and premolars (ie, uprighting to pretreatment angulations) is subtracted from the total space generated by distalization, the effective space for the pendulum, distal jet with brackets, and distal jet alone was estimated to be about the same (four mm/side).
  135. 135.  Comparison of two intra oral molar distalization appliancesDiatal jet vs Pendulum-McNamara(AJO 2005)  This retrospective study compared the dentoalveolar and skeletal effects on Class! II malocclusions of the distal jet with concurrent full fixed appliances and the pendulum appliance followed by fixed appliances.  32 subjects-12 years 3 months in the distal jet group and 12 years 6 months in pendulum group.  Distalization phase of treatment were 10 months in the distal jet grc1up and 7 months in the pendulum group, and the durations of the second phase of treatment with fixed appliances were 18 months in the distal jet group and 24 months in the pendulum group.  Lateral cephalogram- before treatment, after distalization, and after orthodontic treatment.
  136. 136.  During molar distalization, the pendulum subjects demonstrated significantly more distal molar movement and significantly less anchorage loss at both the premolars and the maxillary incisors than did the distal jet group.  The distal jet used simultaneously with fixed appliances and the pendulum were equal in their abilities to move the molars bodily.  No significant difference in mandibular plane angle-both groups.
  137. 137.  At the end of comprehensive treatment, the maxillary first molars were 0.6 mm mesial to their original positions in the distal jet group, and 0.5 mm distal in the pendulum group.  Nevertheless, total molar correction was identical in the 2 groups (3.0 mm), and both appliances were equally effective in achieving a Class I molar relationship at the end of treatment.  Simultaneous edgewise orthodontic treatment( during molar distalization in the distal jet group shortened the overall treatment time but produced significant flaring of both maxillary and mandibular incisors at the end of treatment.)
  138. 138. K-Loop Distalizer  Kalra (JCO 1995)introduced a molar distalizing appliance using rectangular TMA wire placed between the molar and first premolar and constructed in a multiloop configuration. This appliance delivered a distalizing force on the molar and a moment resulting in distal root tip.  This simple, effective appliance can be used with full edgewise technique, is available. that a triple molar tube
  139. 139. Keles-Sayinsu Appliance
  140. 140. Unlike most of the other molar distalization mechanics, this newly developed device achieved (1) bodily distal movement of maxillary molars and (2) eliminated dependence on patient cooperation and did not require headgear wear for molar root uprighting.
  141. 141. Keles Slider and Keles Jig: • Lingually soldered molar tube, which is apical of the center of resistance. • Generally, a spring-loaded wire is added in a Nance button instead of positioned against a palatal anchor. The anterior end is activated by a sliding lock screw.
  142. 142.  The Keles Slider is similar to the Distal Jet; and although no statistical evaluations have yet appeared, the appliance would be expected to perform at least as well.  However, the Keles Slider may be superior to the Distal Jet because of decreased friction resulting from a shorter length of molar tube and increased molar translation because of more apical placement of the molar tube.
  143. 143.  Keles (WJO 2002) evaluated two adolescent patients with Class II, Division 1 malocclusions  In one patient, the maxillary second molars were extracted for molar distalization.  In the other patient, the maxillary third molars were extracted for molar distalization.  The Keles Slider is composed of two premolar and two molar bands, and the anchorage unit is composed of a wide Nance button.  To achieve bodily distal movement, the point of distal force application was carried toward the center of resistance of the maxillary first molar on the palatal side.
  144. 144.  Nickel titanium coil springs were used, and 200 g of distal force was applied to the Class II first molars.  Results: Class II molars distalized bodily. There was minimal anchorage loss on premolars and little incisor proclination;  Distalization occurred more rapidly, and with less anchorage loss, in the patient with second molar extraction, when compared with the patient with third molar extraction.  Conclusion:  The Keles Slider can also be used for correction of unilateral Class II molar relationships.  Another advantage of this appliance is the ease of activation; chair time for activation is short and simple.
  145. 145. IMPLANTS • Palatal bone is probably the most suitable anchorage because of its histomorphology and the ease of application to this region. • Byloff and colleagues (2000) have successfully moved molars distally using a Graz-implant-supported Pendulum Appliance, but the implant must be surgically removed after orthodontic
  146. 146.  Karaman and colleagues(Angle 2002) used a modified distal jet appliance supported by a palatal implant placed at the anterior edge of the rugae region of the palate for unilateral molar distalization.  An anchorage screw three mm in diameter and 14 mm in length was placed at the anterior palatal suture, two– three mm posterior to the canalis incissivus under local anesthesia.
  147. 147.  After a treatment period of four months, the left maxillary molar had been moved 5 mm distally without anterior movement of the anchor premolars. There was a 2 mm intrusion of the left first molar.  Because the coil spring on the right arm was not activated, the position of the right molar showed no signs of change.  At the completion of treatment, the mandibular plane and the lower facial height remained unchanged.  The upper incisor position remained stable throughout treatment.  The lower incisor position remained unchanged.
  148. 148.  Park (JCO 2003)- the midpalate consists of cortical bone that is sufficient to support an entire miniscrew, so that the screw will not be affected by orthopedic forces.  Most of the soft tissue is thinner than 1mm,ensuring accurate placement of the miniscrew with biomechanical stability.  There is no waiting for osseointegration because the miniscrew is easily removed.  Inserting a miniscrew is difficult with a conventional straight screwdriver, which forms an oblique angle with the bone surface, changing the direction of the screw and increasing the likelihood of bone damage and implant failure.
  149. 149.  Therefore, a screwdriver in a contra-angular handpiece is required, and it must be longer than the depth of the palate to avoid contact with the maxillary anterior teeth.  Molar distalization was achieved in 4-5 months without anterior anchor loss.  Implants are an excellent alternative to other intra arch devices.
  150. 150. ‘ Diagnosis is the art of seeing the same thing in a different manner ’
  151. 151. Take Home Message  Class II patients-growing- fixed functional orthopedic appliances – MARA preferred?  Adult Class II patients-dentoalveolar correction requiredinterarch spring delivery systems- Eureka spring/Forsus?  Anchorage in lower arch reinforced with lingual arch, additional torque in the archwire /brackets, archwire cinched back- to prevent lower incisor flaring.  Class II-Mild to moderate arch length discrepancy with average skeletal profile-intra arch devices- Distal jet/Keles Slider.  Palatal anchor considered.
  152. 152. Thank you For more details please visit