This document provides an overview of molar distalization techniques. It begins with an introduction discussing indications for molar distalization such as class II correction and arch length discrepancies. The document then covers the history of molar distalization approaches dating back to the late 1800s, followed by sections on biomechanical concepts, classifications of appliances, and criteria for selecting appliances. Numerous specific appliances are described, including pendulum, distal jet, and TPA approaches. The document concludes by stating there are advantages and disadvantages to both intraoral and extraoral distalization methods, and the optimal approach depends on each individual case.

2. MOLAR DISTALIZATION
Presented by:
Dr. Sri Monica R.,
2nd M.D.S.,
Dept. of Orthodontics.

3. CONTENTS
• Introduction
• History
• Indications & Contraindications
• Biomechanical concepts
• Classification of appliances
• Appliance selection criteria
• Appliance descriptions
• Conclusion
• References

4. INTRODUCTION
• Space deficiency (Arch length - tooth material
discrepency)

5. • Class II correction – non extraction
Distalization of maxillary molars
- intraoral (or) extraoral forces
• Patient’s compliance
• Presence of second & third molars

6. HISTORY
• William kingsley(1892) - headgear
• Oppenheim advocated that position of mandibular teeth is the
most correct & correction of class II done by molar distalization
without disturbing the mandibular teeth position.
1944 -

7. • Kloehn (1947) started a long and beneficial series of
investigations and clinical applications of cervical anchorage to
the maxillary dentition.

8. • Renfroe (1956) reported that lip bumper primarily
devised to hold hypertonic lower lip caused a distal
movement of lower molars sufficient to change class I to
Class II.
• Gould (1957) was first person to discuss about
unilateral distalization of molars with extra-oral force.
• Graber T.M. (1969) extracted the maxillary II molar and
distalized the first molar to correct class II div.I.

9. • In a growing child: - to relieve mild crowding
- causes permanent increase in arch length of about 2mm on
each side.
• Late mixed dentition:
- When lower E space –utilized for relief of anterior crowding,
- Upper molars distalized to get a class I relation
INDICATIONS

10. • Non-growing patient:
- To regain lost arch length
- Blocking out of canines
• Upper second molar extraction:
- Lower arch normal

11. • Profile : Straight profile
• Functional : Normal, healthy temperomandibular joint
Correct mandible to maxillary relationship
• Skeletal : Class I skeletal
Normal, short lower face height
Maxilla, normal transverse width
Brachycephalic growth pattern
Skeletal closed bite

12. • Dental : Class II molar relationship
Deep overbite
Permanent dentition
Maxillary first molar mesially inclined.
Preferably prior to eruption of second
molar.
Maxillary cuspids labially displaced.

13. CONTRAINDICATIONS
• Profile : Retrognathic profile
• Functional: Numerous signs and symptoms of TMJ.
Posteriorly and superiorly displaced condyles.
• Skeletal : Class II skeletal
Skeletal open
Excess lower face height
Constricted maxillary arch
Dolicocephalic growth pattern

14. • Dental : Class I or III molar relation.
Dental open bite
Maxillary first molar distally inclined.

15. Second Molar Extraction

16. Advantages:
• Reduction in amount and duration of appliance therapy.
• Facilitation of treatment using removable appliance.
• Faster eruption of third molar/surgical removal avoided.
• Facilitation of first molar distal movement.
• Less likelihood of relapse as good functional occlusion
• Mild premolar crowding is corrected without mechanotherapy.
• Natural contact area from canine to first molar retained.
• Results are stable as tongue space has not been
compromised.
• Since premolars are not extracted, more teeth available for
chewing.

17. Disadvantages:
• Too much tooth substance removed.
• Extraction site located far from area of correction in
moderate to severe anterior crowding.
• Possible impaction of third molar even with second
molar extraction.

18. Upper Molar Positioning
• Pterygoid vertical line (PTV) to distal surface of
first permanent molar.
Mean value:
• In patients age in years plus 3 mm until growth is
completed.
• In non-growing patients mean value is 18 mm.

20. MD
BIOMECHANICAL CONCEPTS

21. MD

22. MD

26. BP BP

27. P B

28. P B

29. P B

30. B
P
MD

31. B
P
MD

32. CLASSIFICATION OF APPLIANCES
 Location of appliance
 Extra-oral
 Intra-oral
 Position of appliance in mouth
 Buccal
 Palatal
 Type of tooth movement
 Bodily movement
 Tipping movement

33.  Compliance needed from patient
 Maximum compliance
 Minimum or No compliance
 Type of appliance
 Removable
 Fixed
 Arches involved
 Intra-arch
 Inter-arch

35. APPLIANCE SELECTION CRITERIA
• Regardless of approach, one should ponder several
issues before considering any of these appliances for
use:
1. Side effects
2. Case types
3. Arch length
4. Treatment timing
5. Patient co-operation

36. Side Effects:
Potential side effects -
• Did incisors flare
• If mandible is to be used as an anchor unit, did
anything occur in that arch.

37. Case Types:
• Consider individual case at hand and his/her needs.
• If mandibular dentition can be slightly mesialized, if this
in the case then Herbst or BDA may be appliance of
choice.
• If not pendulum and other intra-arch appliances can be
used.
• If you may not afford flaring of incisors then TPA or
headgear would be treatment of choice.

38. Arch Length:
• How much distalization is required.
• TPA has limited application of 2-3 mm, if in need of
greater amount of correction then Herbst and
headgear are of choice followed by pendulum,
Wilson BDA etc.

39. Treatment Timing:
• Perhaps best time to initiate distalization is late mixed
dentition and it may be too late after eruption of second
molar.
• Some synergistic effect as dentition transits from
primary to permanent as canines and premolars follow
molars as they moved distally. Thus appliances that
requires some anterior anchorage like pendulum may
dilute these results.

40. Patient Co-operation:
• If one lives by the sword, one dies by the
sword.
• Invariably appliances that require least in co-
operation come with side effects that have to
be considered

41. APPLIANCE DESCRIPTIONS
• Appliances with flexible distalization force system
- palatally positioned
- buccally positioned
- palatally & buccally positioned
• Appliances with rigid distalization force system
palatally positioned
• Hybrid appliances
• Trans palatal arches for molar rotation &/or
distalization

42. Cetlin appliance
• Cetlin & Hoeve (1983)

43. Pendulum Appliance
• James J Hilgers, 1992

44. • Movements observed:
- crown distal tipping
- mostly mesio-buccal rotation
- intrusion

45. • Byloff & Darendelier (1997) – attempted to correct molar
tipping
- incorporated uprightening bend (10-15º in sagittal plane)
after distalization & achievement of super class I molar
relation.
• Results:
- reduced molar tipping.
- more anchorage loss.
- 64.1% increased treatment time.

46. • Kinzinger et al.(2003) – K-Pendulum

48. • Distalization generated 1-2 mm within 6 weeks of insertion
• The PA can provide 4-5 mm of arch length on each side.
• Forces generated are in range of 3.5g/deg & generation of force
can be managed in 2 ways:
- step wise activation
- single step (Joseph & Butchart)
Joseph & Butchart (2000), stated that distalization of
molars is successfully achieved regardless of the status of
second or third molar teeth, patient’s age or molar
calcification.

49. Penguin pendulum appliance:

51. • Single drawback is in treating openbites.
• Due to fact that it uses, occlusal forces to help help
molar distalization; open bite casesshould probably deal
with upper bicuspid extraction.

53. Intra-oral bodily molar distalizer
(IBMD)
• Keles & Sayinsu (2000)
• Appliance has 2 parts: - anchorage unit: Nance acrylic
button
- active unit: 0.032×0.032” TMA spring
• 0.045” ss retaining wires attached to premolar bands.

54. • Class I molar relation achieved in about 7.5 months &
stabilization period of 2 months with conventional Nance
appliance, followed by fixed appliances as second
phase of overall treatment.

55. Distal jet
• Carano & Testa (1995)
Fixed, Palatally positioned distalization appliance
• Fortini et al., 1998 - dual control(buccal & palatal) using a buccal
screw.
• Celestino,1999 – inverted the telescopic units with 2 adjustable
locks, one for activation & other connected to lingual sheath of
molar band.
A Niti open coil spring was positioned between 2 locking clamps,
activated by the movement of mesial clamp towards the distal
one.

56. 0.036” tube
Anchor wire
Niti Coil spring
Activation collar
(screw clamp)
Stop

57. • Anchorage loss & tipping of premolars
• Less amount of molar tipping after partial or complete
eruption of second molars.
• Distalizing velocity for each molar was 0.6 mm for
month less than that of jones jig & pendulum appliance.

59. • Jay Bowman, JCO 1998
• Conversion to Nance Holding Arch
• Double-Set-Screw Distal Jet
Modifications

60. • Quick & Harris, JCO 2000.

61. • Dr. Fortini, Lupoli, & Parri (1999)
First Class Appliance
Welded split
rings
Soldered
formative screws

62. 0.045” wire
0.045” tube soldered
0.045” wire soldered
Niti 0.010” ×
0.045” coil springs
Stop

63. • Range of molar distalization was 4-8 mm, average of 4.8
mm
• The average time for distalization was 42 days with a
range from 28-95 days.
Advantages:
• Produce rapid distalization of first & second molars even
after complete eruption of second molars
• Can be used in deciduous as well as permanent dentition
• Distalizes molars bodily, without a tipping effect
• No anterior anchorage loss or change in vertical

64. K- Loop
• Introduced by Dr.Varun kalra in 1995.
Components:
1 - 0.017’’ x .025” TMA wire K loop
2 - Nance button to resist anchorage.

65. Reactivation sequence
• Open loop 1mm at (1)
• Open loop 1mm at (2)
• Open at (3) to regain the 200 bent of mesial and distal legs

68. Advantages:
• Simple yet efficient
• Controls the moment to force ratio to produce bodily
movement, controlled or uncontrolled tipping as desired.
• Easy to fabricate and place
• Hygienic and comfortable for the patient
• Requires minimal cooperation from the patient
• Low cost.

69. Compressed Springs
• Gianelly and co-workers.
• Springs made from compressed stainless steel or NiTi.
• First premolars are anchored by Nance holding arch.

73. Super-elastic NiTi Wire
Neosentalloy wire:
• 100gm
• 200gm -
0.017×0.025”

75. NiTi Double Loop System

76. • Gianelly et al (1989) – repelling magnets in
conjunction with Nance appliance
• Bondemark & Kurol – repelling cobalt magnets
• Rate of molar movement is 0.75 -1mm per
month
Magnets

77. Repelling Magnetic Appliance:
• Activation every two or four weeks.
• Not gained wide acceptance because the magnets tend
to be expensive and bulky.

81. Fixed Piston appliance
• Greenfield
• Components:
1. 0.036” stainless steel tubing (soldered to the
bicuspids)
2. 0.030” stainless steel wires (soldered to the 1st
molars)
3. Enlarged Nance button, reinforced with an 0.040”
stainless steel wire (for control of anterior anchorage)
4. 0.055” (internal diameter) super elastic Niti open coil

82. Advantages:
• Produces bodily movement of the max. 1st molars with no
loss of posterior anchorage.
• Does not require patient compliance for molar
distalization, but allows the use of headgear if needed.
Only proper oral hygiene is required of the patient.
• Reduces Rx time in non-extraction cases.
• Does not interfere with the occlusal plane, thus
maintaining control of the vertical dimensions.

83. Jones Jig
0.036” ss wire

85. Sliding Jig
• Auxillary sectional arch wires used to tip or move one or
a group of teeth in buccal segments distally without
disturbing anteriors.
• Made of 0.022 inch round wire and can also be made of
rectangular wire.

88. Bimetric Distalization Arch
• Developed by Wilson and Wilson.
0.045” round tube
0.040” end
section
0.045” coil spring

94. Crickett Appliance
• Developed by Dr. Robert M. Ricketts (1984), a
modification of crozat appliance.
0.032
”
0.038”
0.030
”
0.045”0.028”

95. ADVANTAGE
• The crickett is an effective appliance for variety of tooth
movements including distalization of molars.
DISADVANTAGE
• The major limitation of this appliance is when intrusion of
anterior teeth has to be performed.

96. Transpalatal Arch
• Developed by Nell
Delivery & Activation of TPA:
• Before cementing the TPA clinician should make
sure that the buccal tubes are parallel to each other
and to the mid saggital plane and that the occlusal
surfaces of the molar bands are parallel.

97. Activation:
• Cetlin (1992) has stated that distalization of one
upper 1st molar can be achieved by unilaterally
activating only one arm of TPA and the other arm is
rotated into position producing a distalizing force. Same
adjustment should be made on the opposite side six to
eight weeks later.

98. Assymetric Distalization
JCO,2001
• 0.032” TMA wire

99. Distalization - Microimplants
• Karaman (AO, 2002 April)
14
mm 3 mm
2-3 mm
0.8mm
0.9mm
NiTi open coil spring

100. • Maxillary molar moved distally 5mm after 4 months of
treatment and intruded by 2mm without movement of
premolars.
Advantages:
• Stability against rotational movements
• No loss of anchorage
• Ease of insertion & removal
• Immediate loading

101. • Kyung JCO 2003
• Molars distalized by 3.5 mm from the apices and 5mm
from the crown in a 3 months period

102. SAS
• Sugawara & Umemori, (Ajo 2004Jan)
• The anchor plates are monocortically placed at the
piriform opening rim, the zygomatic buttresses, and any
regions of the mandibular cortical bone.

103. Outstanding advantages
• Possible to intrude the mandibular molars
• En masse distalization of the mandibular buccal
segments or the entire dentition is also possible
• Not neccssary to extract the mandibular first or second
premolars in patients with moderate to severe crowding.
• Symmetric or asymmetric Class III molar relationship
can be corrected

104. Carrier Distalizer
• Developed by Carrier (2004)

105. MOLAR DISTALIZATION IN
LOWER ARCH
• Lip bumper
• Modified lingual appliance
• Distal jet for lower molar
• Franzulum appliance

106. LIP BUMPER
• Used for molar anchorage, prevention of poor lip habits
and creation of increased space for mandibular arch.
• Made of 0.045” stainless steel that spans the facial
structures of mandibular arch without contacting teeth
and inserted into molar tubes.

107. 0.045” tube
0.045” ss wire

110. MODIFIED LINGUAL APPLIANCE
Ghafari, JCO 1985

111. DISTAL JET FOR LOWER MOLAR
0.036” tube
soldered

112. FRANZULUM APPLIANCE
Freidrich Byloff et al., JCO 2000, sep
0.032” ss
wire
5 mm wide

113. CONCLUSION
• There are many advantages and disadvantages of both
the intra-oral and extra-oral methods.
• It should be remembered that patient selection for a
particular method of distalization is of utmost importance
and should not be overlooked.
• One should not select the patient for the appliance
rather the appliance should be for the patient

114. REFERENCES
• Papadopoulos, Orthodontic treatment of class II non-
compliant patient
• Ravindra Nanda : Bio-Mechanics in Orthodontics. Page.
265-281.
• McNamara & Brudon, New Edition, Page. 343 to 375 and
199 to 211.
• Graber and Vandarsadall, 3rd Eidtion, Page. 760 & 761.
• Seminars in Orthodontics, 2000.
• Karaman (AO 2002 April ) A case report
• Distalization of Maxillary Molars with a Midpalatal

115. • J Clin Orthod. 2001 Mar;35(3):174-8, Asymmetric
distalization with a TMA transpalatal arch, Mandurino
M, Balducci L.
• J Clin Orthod. 2000 Sep;34(9):518-23. Mandibular
molar distalization with the Franzulum Appliance. Byloff
F, Darendeliler MA, Stoff F.
• J Clin Orthod. 1984 Nov;18(11):806-10. the Crickett
appliance, Victor C. West
• JCO 1983, JUNE, Nonextraction Treatment, NORMAN
CETLIN, ANE TEN HOEVE

116. • 3D Bimetric Distalizing arch , Ortho book Wilson.
• J Clin Orthod. 1988 Jan;22(1):40-4, Distalization of
molars with repelling magnets. Gianelly AA, Vaitas
AS, Thomas WM, Berger DG
• JCO 1988, APRIL, Nickel Titanium Double-Loop System
for Simultaneous Distalization of First and Second
Molars, ALDO GIANCOTTI, DDS, MS, PAOLA COZZA,
MD, DDS, MS
• J Clin Orthod. 1999 Jun;33(6):322-8, The First Class
Appliance for rapid molar distalization, Fortini A, Lupoli
M, Parri M

117. • Distal movement of mandibular molars in adult patients
with the skeletal anchorage system, Junji Sugawara,
DDS, PhD et al., AJODO 2004 Volume 125, Issue 2,
Pages 130–138.
• J Clin Orthod. 1996 Jul;30(7):374-80, The distal jet for
upper molar distalization, Carano A, Testa M
• Angle Orthod. 2006 Nov;76(6):923-9, Intraoral maxillary
molar distalization, Karlsson I, Bondemark L.
• JIOS, 2002, 35; 131-142, Effective Means of Intraoral
Molar Distalization - An Overview

118. THANK YOU