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

Treatment of Class II NonCompliant Patients
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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Patient Compliance

 Definition - By Haynes
 A syndrome?
 Appliances?


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.

 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?


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


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.

Appliance description
 Passive tube and plunger
system
 Exact length of the tube
 Attachments?


 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.


 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).


 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 ?

 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.

♫ 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.

♫ 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 .


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.

♫ 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.


♫ 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.

Pancherz summarize…
 Class II molar
correction?
 Overjet correction?
 Overbite correction?


 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.


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).

 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.

 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?

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.

 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.

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.

 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.

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.


 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.


 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

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.

 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.


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.

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

 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.


 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


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.

 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?

 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.

 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.


 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 .

 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

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.

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.

Loop
Two loops

Length


 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.


Mechanism of Action


 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.

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.

 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 .

Maxillary/mandibular archwire?


 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.

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.

 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.


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 thewww.indiandentalacademy.com
patient.

Step 3

Step 1

Step 2


Step 4

Step 5

Step 7

Step 8

Step 6


Appliance insertion


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.


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.

 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.

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.


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 . www.indiandentalacademy.com

 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.

 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.

 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?


 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.

 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.

 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.

 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).

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

 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.

 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.

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.


 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.


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.


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)

 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.

 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.

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.


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

 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.


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.

 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.


♫ 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.

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.

♫ 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


♫ 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.

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.


 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.

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. www.indiandentalacademy.com

 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.

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.

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.

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.


 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. www.indiandentalacademy.com

 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.

 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.

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.

 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.


 The disadvantages  cost,
 decreased rate of movement,
 more frequent activation appointments,
 possible heavy metal toxicity,
 bulk.


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.


• 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.


 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.

 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.

 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.

 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.

 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.

 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.

♫ 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).


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.

 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.


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

 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.

♰ 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).

♰ 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?

 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.

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.

 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.

 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.

 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 .


 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

 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°.


 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.

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

 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.

♫ 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.


♫ 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.

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.


 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.

 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.

 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.

 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.


 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.

 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.

 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).

 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.

 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.

 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.)

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, providedwww.indiandentalacademy.com is available.
that a triple molar tube

Keles-Sayinsu Appliance


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.


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.

 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.


 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.

 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.

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 treatment.www.indiandentalacademy.com

 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. www.indiandentalacademy.com

 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.

 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.

 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.


‘ Diagnosis is the art of
seeing the same thing in a
different manner ’


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.

Thank you
For more details please visit


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

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