3. The search for new treatment modalities that avoid dental extractions
(especially premolars) has gained great importance in the practice of
contemporary orthodontics; this has created a growing tendency to avoid
any treatment that includes extractions. There are many non-extraction
treatment modalities for Class II malocclusion. One of them consists in
converting the Class II molar relation into a Class I molar relation; in order
to accomplish this; the upper first molars must be displaced distally.
4. Angle class II malocclusion represent 21% of egyptian population.
This distoclusion may be the result of a retrognathic mandible, or a
prognathic maxilla or a combination of both, although some
authors ( McNamara, Hilgers, Chaconas, Proffit) coincide in that
mandibular deficiencies are more common than maxillary
excesses.
5. Dentally, the mesiobuccal cusp of the first upper molar occludes
in front of the buccal groove of the first lower molar. The
disadvantage of this lies in the lack of available space in the
upper dental arch, creating the need to utilize appliances that
can generate or stretch the available space in order to act
distally and transversely.
7. One of the first appliances used for molar distalization
was the Head Gear, used by Angle in 1887.
(June 1, 1855 – August 11, 1930
Extraoral
8. • In 1961 Kloehn proposed the early treatment with the head gear
to redirect the growth of the maxilla and exert "a slight force
on the teeth that must be moved': The objective of Kloehn was
to distalize the upper molars in order to obtain a functional
relation with the lower teeth. Graber noticed that, when the
extra oral traction was used upon the first upper molar, when
the second upper molar had not fully erupted, the first molar
inclined distally but did not move in a bodily manner.
2004 - Dr. Richard S. Kloehn
9. • In order to prevent the inclination of the molar,
Cetlin in 1983 combined the extra oral force with an
intraoral force. He used the first force partially and
the intraoral force (with removable appliances) was
used full time.
12. The force of the removable appliances, used
constantly, inclines the crown distally and the
head gear controls the position of the root,
resulting in a bodily movement of the molar. The
principle of extra oral distalization is that the line
of action must pass through the center of
resistance of the molar. In order to accomplish a
successful distalization treatment the amount of
force applied and the time of use are very
important. 12 ounces or 300 g- 500 g per side is
recommended. The extra oral traction must be
worn for at least 12 hours a day, but preferably it
must be between 14 to 16 hours in average.
13.
14.
15.
16. • The extra oral arch must be separated 3 mm to 5 mm
from the anterior teeth approximately and must be
adjusted each time to obtain a desired movement.
18. • During distalization it must be sure that the molars do
not have any occlusal interferences, in case there are,
an anterior bite plane should be placed in order to aid in
the distalization.
Anterior bite plane
19. THE USE OF THE EXTRA ORAL ARCH CAN PROVOKE
MANY MOVEMENTS:
• A distal force and a flattening of the occlusal plane, in which the
extra oral traction must be applied over the center of resistance
of the molar.
• A distal force and a settlement of the occlusal plane, in which
the extra oral traction must be applied under the center of
resistance of the molar.
• A distal force without changes of the occlusal plane, in which the
extra oral traction passes through the center of resistance of the
molar.
21. Trying to obtain a fast and easy distalizing method, which would not
require patient cooperation, a fixed new modalities designed to distalize
upper molars, and to avoid extraction of teeth have been proposed.
Some authors have designed their own distalizers, like Wilson 1987
(Wilson distalizer), Miura 1988 (NiTi open coils), Gianelly 1988
(Magnets), Gianelly 1989 (Gianelly Jig), Jones and White 1992 (Jones
jig), Hilgers 1992 (Pendulum and Pendex), Greenfield 1995 (Fixed
piston), Valrun 1995 (K-Loop), Carano and Testa 1996 (Distal Jet),
Belussi 1997 (Belussi distalizer),
Jones jig Pendulum and Pendex
Distal Jet
22. • Veltri 1999 (Veltri distalizer), Prato 2000 (Nitinol spring molar
distalizer), Lanteri 2001 (Fast Back), Casasa and Rodriguez 2001
(CEOB-1), Bass 2001 (Sliding distalizing sistem), Echarri and
Scuzzo 2003 (Double modified pendulum), Carriere 2004 (Carriere
distalizer), Quiros 2005 (Quiros tecnique), Garcia and Gaitan 2006
(GG Distal Spring), among others. Although these appliances
distalize effectively, they produce discreet upper incisor
mesialization and proclination and upper molar distal inclination.
Fast Back
23. THERE ARE THREE VERY IMPORTANT POINTS THAT WE
MUST KEEP IN MIND-DURING FIRST UPPER MOLAR
DISTALIZATION:
1. The best moment to distalize the molars is before the second molars
are totally erupted. Distalization is recommended when there is a
space between the distal aspect of the first upper molar and the semi
erupted crown of the second molar.
24. 2. The distalizing movement tends to open the bite just like when we
place a pen in the closing movement of a pair of scissors; the more
we distalize the molar; the more we are going to open the bite. This
effect is favorable in patients with deep bites, but counterproductive
in patients with open bite or hyperdivergent growth tendency; this is
why this effect must be taken into consideration during distalization.
Hinge or scissor effect.
25. 3. Constant forces move teeth faster than intermittent forces.
Due to the fact that distalizing forces move teeth against the
normal mesial movement tendency; they were rejected for a
long time. But with the arrival of new elastic materials, many
orthodontists have reapplied this technique again.
Molar Distalizing Open Coil Springs 7"
Lengths
deliver gentle 100 grams of force to
achieve average 1mm to 1.5mm
distalization per month without patient
cooperation. Place over archwire and
anchor with stop hook and elastics or
Nance Appliance for maximum
effectiveness. Intermittent closed coil
sections allow for end stops when cut to
length. .045" I.D. (3) 7" lengths
26. THE DISTALIZING APPLIANCE MUST INCLUDE THE
FOLLOWING CHARACTERISTICS:
1. Must not require patient cooperation.
2. High degree of biomechanical control.
3. Compact design.
4. Minimal interference when the patient eats or speaks.
5. Absence of pain during the distalizing process.
6. Easy activation.
7. Compatibility with other orthodontic techniques.
8. Automatic cessation of the distalizing movement.
9. Must be easy to clean.
27. DISTALIZING INDICATIONS
• Unilateral or bilateral dental Class II relation.
• Increased overjet (up to 5 mm).
• Increased overbite (deep bite).
• Midline discrepancy.
28. • Minimal or non-existing
dental overcrowding.
• Patients with early mixed or
permanent dentition.
• Patients with upper
dentoalveolar protrusion.
• Patients with minimal
skeletal problems.
• Normo or hypodivergent
patients.
• Patients that do not accept
extractions.
29. • Another indication for upper molar distalization
is when we decide to extract a permanent
second molar (due to caries or other causes)
complicated with anterior overcrowding or an
ectopic canine. In these cases the third molar
will occupy the space of the extracted second-
molar.
32. • Overjet greater than 5 mm.
• In adult patients another type of treatment must be
employed.
33. RECOMMENDATIONS
• In young patients, the best moment to distalize is before the
second molars are totally erupted. The upper second molars erupt
normally without impaction; meanwhile the second premolar
follows the first molar distally.
• Distalize in the mixed or permanent dentition.
34. • In order to obtain a faster distalization, the extraction
of the third molars is recommended.
36. • Distalizers can provoke an undesired upper first molar
rotation and distal tipping.
37. • Distalizers can provoke an undesired upper first molar
rotation and distal tipping.
38. RECOMMENDATIONS
• Lace the anterior teeth with steel ligature or with an
acetate in order to minimize anterior proclination.
Acetate placed from premolar to premolar.
Steel ligature
39. • After the distalization is completed, place a moderate
or maximum anchorage to the distalized molars
(Chromosome arch, Viaro Nance, Nance button,
Transpalatine arch).
Chromosome arch Transpalatine arch with 4 bands.
40. Viaro Nance in mouth.
Viaro Nance in mouth three months after
cementation.
Chromosome arch
41. • The patient must have excellent oral hygiene
because the distalizing appliances retain food
particles
• Have a strict appointment control.
42. COLLATERAL EFFECTS OF
DISTALIZERS:
• Premature points in the palatine cusps.
• These appliances produce a mandibular posterior
rotation that will result in an anterior open bite.
43. • They procline the anterior segment.
• Bodily distal movement is difficult.
44. SUPER ELASTIC NITI COIL DISTALIZATION
(OPEN COILS)
• Open coils are the most simple
and cheap appliance used
successfully in maxillary molar
distalization since the beginning
of the twentieth century.
• These coils apply approximately
100 g of force and are placed
between the first or second
premolar and the upper first molar
on a 0.016" x 0.022" arch wire.
45. • We must compress the coil
10 mm in order to activate it.
This means that the coil, in a
passive state, is 10 mm
larger than the space
between the distal wing of
the brace of the first
premolar and the tube of the
first molar.
Passive coil.
46. • During distalization, the coil opens and loses force, in
this moment we can replace it with a larger one or we
can place a sliding acrylic pearl on the mesial or distal
end of the coil and compresses it again,
Sliding pearl.
47. • With the 100 g of activation,
the coil can distalize the upper
molar 1.5 mm per month, with
approximately 20% of anterior
anchorage loss.
• The compressed coil slides the
molar on the arch wire, which
can be continuous or
sectioned.
Active coil.
48. NiTi coil has more resilience and maintains a more constant
and light force than steel coil.
49. • Kelles studied the amount of millimeters distalized in a unilateral
manner with a NiTi open coil in combination with an anterior bite
plane. The NiTi coil was placed from the distal wing of the brace of
the first premolar to the tube of the first molar (the first premolars
were anchored with a Nance button). He determined that the NiTi coil
could move the molar distally 4.9 mm in 6.1 months with 5.2˚ of distal
tipping, but, as negative side effects there was also 1.3 mm of loss of
anterior anchorage due to mesial migration of the first premolar
(anchored with a Nance Button), there was also a 1.8 mm increase of
incisor proclination and 2.1 mm of overjet increase
Pearl on the distal aspect of
the second premolar.
51. ADVANTAGES
1. This method is easy to elaborate.
2. Easy to activate.
3. The cost is minimal.
4. Hygienic.
5. It does not depend upon patient compliance.
52. DISADVANTAGES
1. The distalized molars have an undesired tip.
2. There is anterosuperior anchorage loss.
Mesial premolar rotation due to lack of anchorage.
54. 2. In some occasions we can anchor the entire
anterior segment lacing it with 0.012" or 0.014"
stainless steel wire ligature or with a 0.060" acetate.
This will reduce anterior proclination.
55. 3. Place the open coil on heavy arch wires, keep in mind that the distal
movement will be faster if we place a coil with a great lumen combined with
a small diameter wire.
4. Use Class II elastics to counteract anterior proclination.
5. In cases of unilateral distalization, use midline elastics to prevent midline
displacement.
6, Activate the open coil everyone and a half months.
56. CASE NO. 1
TREATED BY THE FROG
DISTALIZER AND LIP
BUMPER
Distalized by: Shaker Mohsen
Finished by :Yaser Basheer
Under supervision of: Prof.Dr
Maher Fouda
62. CASE NO. 2
TREATED BY THE FROG
DISTALIZER AND LOWER ARCH
STRIPPING
Distalized by: Shaker Mohsen
Finished by :Yaser Basheer
Under supervision of: Prof.Dr
Maher Fouda
68. CASE NO. 3
TREATED BY THE FROG
DISTALIZER AND LOWER
ARCH STRIPPING
Distalized by: Shaker Mohsen
Finished by :Yaser Basheer
Under supervision of: Prof.Dr
Maher Fouda
75. CASE NO. 4
TREATED BY THE FROG
DISTALIZER AND LOWER
ARCH STRIPPING
Distalized by: Shaker Mohsen
Finished by :Yaser Basheer
Under supervision of: Prof.Dr Yaser Lotfy
82. CASE NO. 5
TREATED BY THE FROG
DISTALIZER AND FIRST
PREMOLARS EXTRACTION.
Distalized by: Shaker Mohsen
Finished by :Yaser Basheer
Under supervision of: Prof.Dr Maher
fouda
90. intraoral movement of maxillary first molars
before eruption of second maxillary molars
results in more effective molar movement and
less anchorage loss.
91. The strain on the anchorage teeth will increase when the first
and second molars are moved simultaneously. Thus, the
anchorage loss will be lower if the molars are moved before
eruption of second molars and the amount of lower
anchorage loss will result in less time consuming correction of
this side effect.
92. If there is an option to choose to move the maxillary
molars distally in the mixed dentition or in the
permanent dentition, it is an advantage to make this
intervention as an early treatment.
94. In permanent dentition with both second and
third molar present and space deficiency in the
maxilla the clinician can consider to extract the
second molars and then move the first molars
distally.
97. Noncompliance simultaneous distalization of the first and second
maxillary molars can be an efficient treatment option for the
correction of Class II molar relationship. However, anchorage loss
and individual variation have to be seriously considered.
Bilaterally symmetrical effectiveness should not be relied upon
98. Effect of maxillary second and third molar eruption
stage on molar distalization appears to be minimal.
Distalization by distal jet
99.
100. Panorax at the end of treatment with the third molar in place.
