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Article available at http://www.jdao-journal.org or http://dx.doi.org/10.

1051/odfen/2014028

DOI: 10.1051/odfen/2014028 J Dentofacial Anom Orthod 2015;18:104


© The authors

Is mandibular molar distalization


feasible?
T. Dang1,3,5,6, J.-P. Forestier1,2,4,5,6, B. Thebault1,2
1 Docteur en chirurgie dentaire
2 Spécialiste qualifié en ODF
3 CECSMO 4
4 MCU-PH
5 Université Paris 7 Denis Diderot
6 Hôpital Pitié Salpêtriére AP-HP, Paris

ABSTRACT
Introduction: The mandibular molar is considered the most difficult tooth to
move. In certain clinical situations, it would seem useful to move it backward.
Is that feasible? When would it be indicated? Is it successful, and if so how?
Material and methods: We first review some fundamental principles and
present an update of the literature on mandibular molar distalization, then
analyze a retrospective series of 11 patients for whom mandibular molar
distalization was planned. The movement achieved was studied on dental
cephalometric superimposition with Delaire analysis. Results: the desired pure
distal translation was achieved in 2 of the 11 cases; distalization was
accompanied by coronary tip-back in 3 cases; in 4 cases, only coronary tip-
back was achieved, and apical tip-forward in 2 cases. Conclusion: Further
studies are needed to determine optimally effective and reproducible
distalization modalities for the mandibular molar.

KEY WORDS
Distalization, mandibular molar, bone screw, bone plate

INTRODUCTION
Context Organizing the space within the dental
arcade involves two essential factors: tooth
Orthodontic displacement of the mandib- size and arcade perimeter. The latter is de-
ular molar, other than extrusion, is reputed termined by the anterior, lateral and poster-
to be extremely difficult, due to the large ior edges, and the space occupied by the
root area and root anatomy3. arcade depends on 3D compensatory
In certain clinical situations, however, ex- curves.
treme measures may be taken to avoid In adjusting tooth crowding, any extrac-
irreversible or risk-laden procedures such tion is usually performed in the sector
as extraction or orthognathic surgery. where crowding is present, to limit and

Address for correspondence: Article received: 08-07-2014.


Tho Dang Accepted for publication: 15-08-2014.
Hôpital de la Pitié Salpêtrière
47-83 Boulevard de l’Hôpital This is an Open Access article distributed under the terms of the Creative Commons Attribution
75651 Paris Cedex 13 License (http://creativecommons.org/licenses/by/4.0),
nthodang@gmail.com which permits unrestricted use, distribution, and reproduction in any medium,
1
provided the original work is properly cited.
T. DANG, J.-P. FORESTIER, B. THEBAULT

facilitate orthodontic movement in with respect to the nose in Asian


the freed space. For example, in se- and African subjects;
vere anterior crowding associated to • Postoperative discomfort that
correction of mandibular incisor al- may be incompatible with the
veolar protrusion, the 1st premolars patient’s private or occupational
may classically be extracted. How- lifestyle (e.g., high level athlete);
ever, it might be interesting if the • Psychological issues in patients
space freed by the absence of the unwilling to experience facial
3rd molars could be transferred for- change, or fearing surgery;
ward, and if the mandibular molars • Financial cost of orthognathic
could be distalized. surgery: 12,000 in France,
While possibly indicated, class III 150,000 in Japan and 180,000
surgical correction has a number of in the USA;
drawbacks or relative contraindica- • Respiratory impact of mandibular
tions leading to abstention despite recession and associated risk of
skeletal malocclusion. Over and obstructive sleep apnea syn-
above the risks inherent to any sur- drome.
gery, such problems include: An interesting possibility would be
to correct class-III malocclusion by
• Esthetic defect induced by for-
distalizing the mandibular molar while
ward movement of the maxilla
controlling the vertical dimension.

INDICATIONS
Molar distalization may thus be in- • Esthetic contraindications for
dicated in the following cases: class III correction by maxillary
• To correct mandibular incisor protraction in certain ethnic
alveolar protrusion, with or with- groups;
out associated crowding; • Relative or absolute contraindica-
• To straighten a curve of Spee at tions for orthognathic surgery;
the expense of the posterior • Mandibular alveolar asymmetry.
sectors; Finally, it should be borne in mind
• Preoperative orthodontic prepara- that posterior displacement of the
tion of class III compensation; mandibular molar cannot exceed the
• Dental class III associated with anatomic envelope within which it is
skeletal class I malocclusion; possible: i.e., the mandibular lingual
• Moderate skeletal class III, to be cortical bone.
managed non-operatively by den- According to Ridouani7 (Fig. 1), 3 mm
toalveolar compensation; distalization is the anatomic limit.

UPDATE ON THE LITERATURE


The Table below presents reports Briefly, no studies with high
of results for molar distalization by level of evidence and sufficiently
pure lateral translation. reproducible design and results have

2 Dang T., Forestier J.-P., Thebault B. Is mandibular molar distalization feasible?


IS MANDIBULAR MOLAR DISTALIZATION FEASIBLE?

Figure 1
CT slice through the mandibular arcade after mandibular molar distalization by mini-
screws7. Note contact between the distal 37 and 47 root and the lingual cortical bone of
the mandibular body.

Authors Device Type of report Criticisms

Byloff et al.1 2000 Franzulum appliance Case report Non-significant single case;
(Fig. 2a, b, c) Vestibular version effect on
mandibular incisors.

Sugawara et al.8 2004 Distal osteosynthesis plate on 7, chain 15 case series Small series, 2 different protocols,
on 4 with plate or ligature of 4 with little detail of protocols.
plate and open spring in compression
(Fig. 3a, b)

Hisano et al.4 2007 TIM III (Fig. 4) Case report Non-significant single case.

Lim et al.5 2011 Mini-screw between 6 and 7 Case report Non-significant single case;
and sliding jig + chain (Fig. 5a, b, c) non-reproducible technique.

Ellouze and Darqué2 2012 Mini-screw between 5 and 6 and Illustrated Non-significant single case.
distalization en masse with springs in example in book
compression and traction (Fig. 6a, b)

Figure 2
(a, b) Lingual view of Franzulum appliance on plaster model. (c) Cephalometric superimpositions obtained by Byloff
et al.1 after molar distalization by Franzulum appliance. (See reproduction permissions at end of article.)

Rev Orthop Dento Faciale 2015;18:104. 3


T. DANG, J.-P. FORESTIER, B. THEBAULT

Figure 3
Sugawara et al.’s molar distaliza-
tion protocol 8. A: unitary molar
distalization; B: sector distaliza-
tion. (b) Cephalometric and oc-
clusographic superimpositions of
Sugawara et al.’s results8 (See
reproduction permissions at end
of article.)

Figure 4
Cephalometric superimpositions ob-
tained by Hisano et al.4: Phase 1 in
black, phase 2 in red. (See reproduc-
tion permissions at end of article.)

Figure 5a
Intra-oral photographs of Tai et al.’s9 molar distalization ‘‘sliding jig’’. (See reproduction permissions at end of article.)

4 Dang T., Forestier J.-P., Thebault B. Is mandibular molar distalization feasible?


IS MANDIBULAR MOLAR DISTALIZATION FEASIBLE?

Figure 5b
Cephalometric superimpositions obtained
by Lim et al.9 (See reproduction permis-
sions at end of article.)

Figure 6
(a) General and local structural superimpositions by Ellouze and Darqué2 (Reproduced with editor’s permission). Mandibu-
lar arcade distalization. Skeletal vertical control of hyperdivergence by vertical control of maxillary and mandibular molars.
Slight compensatory protrusion of mandibular incisors. (b) Panoramic radiograph, by Ellouze and Darqué2 (Reproduced
with editor’s permission). 1: 46 distalization, showing trace of the initial position of the mesial root of the distalized molar.
Displacement of mini-implant mesially to the distalized 46. 2: Surgical guide used to position mini-implant (1.3 x 7 mm) be-
tween 36 and 37 and distalization of molars.

Rev Orthop Dento Faciale 2015;18:104. 5


T. DANG, J.-P. FORESTIER, B. THEBAULT

identified a technique for mandibular The most interesting study, by


molar distalization by pure lateral Sugawara8, included only 15 patients
translation. (30 distalizations), with 2 different
protocols.

CASE SERIES AND SUPERIMPOSITIONS


Material and methods Cephalometric tracing of teleradio-
graphs on the Delaire Evolution soft-
Eleven cases of mandibular molar ware involved tracing the orthognathic,
distalization were retrospectively ana- topographic and dental Delaire analysis
lyzed, coming from three practi- points. The software’s ‘‘Compare’’ tool
tioners in private practice or hospital: provides mandibular superimposition
• 7 cases managed by Dr Jean- on the ‘‘No-Me’’ (notch and chin) axis,
Paul Forestier (JPF), in private registered on the ‘‘Me’’ (chin) point,
practice in Paris; displaying the change in molar axis
• 2 cases managed by Dr Benoı̂t with respect to these references. The
Thebault (BT), in private practice molar is shown by a cross, the mesio-
in Redon (France); distal axis of which is determined by
• 2 cases managed by Dr Tho the points ‘‘mim’’ (mesial inferior mo-
Dang (TD) under the supervision lar) and ‘‘mid’’ (distal inferior molar),
of Dr Jean-Paul Forestier in the and the long axis by the points ‘‘mio’’
Pitié-Salpêtrière Hospital, Paris. (occlusal inferior molar) and ‘‘mia’’ (api-
Indications were: cal inferior molar).
• Correction of anterior mandibular The radiographs from the different
crowding or of recurrence of radiology systems did not always in-
anterior crowding; clude a millimeter scale; scaling was
• Decompensation of class II mal- therefore harmonized using two points
occlusion for mandibular protrac- that were easily located and suffi-
tion surgery; ciently separate: ‘‘M’’ (metanasion)
• Correction of dental class III; and ‘‘Clp’’ (posterior clinoid process).
• Straightening of 2nd molars for Thus, measurements in millimeters
alteration of prosthesis fixed to could not be taken: displacement qual-
the 1st molar. ity could be assessed but not quanti-
Exclusion criteria were: fied. Moreover, angles could not be
• Simple coronal tip-back; measured as the software’s angle
• Lack of post-distalization radio- measurement tool is not part of the
graphs; ‘‘Compare’’ tool, so that angles cannot
• Asymmetric distalization in which be measured in superimpositions.
the distalized sector could not be Superimpositions were made on
identified on lateral teleradio- lateral teleradiographs taken before
graph for superimposition. and after distalization. In some

6 Dang T., Forestier J.-P., Thebault B. Is mandibular molar distalization feasible?


IS MANDIBULAR MOLAR DISTALIZATION FEASIBLE?

Figure 7a, b, c, d

cases, a third view was available, al- – Extraction of mandibular wisdom


lowing supplementary superimposi- teeth and positioning anchor
tion. screws between 4 and 5 (Fig. 7a).
– .016 x .022 Elgiloy Jaune wire
with open spring between 6 and
Protocols and clinical cases 7, closed spring between 5 and 4
and mesial keyhole in 4 with
• Dr Jean-Paul Forestier’s protocol metal ligature of the mini-screw
for molar distalization with mini- to the keyhole. The mini-screw
screw anchorage (Fig. 7a, b, c, d). serves as indirect anchorage.
– Gluing the mandibular arcade, Distalization is performed quickly
with the exception of the incisors after 38-48 extraction to take
and canines; bracketing 1st mo- advantage of distal 37-47 bone
lars with a pre-adjusted multi- remodeling and facilitate distal
attachment .018 Hilgers bracket. movement (Fig. 7b).
– Imposing tip-forward in molar – Imposing tip-forward on the 6
gluing and bracketing. glued teeth, and straightening
– Straightening using .016 x .016 by an underlay wire if necessary.
NeoSentalloy wires, bypassing – The open spring is displaced pro-
incisors and canines. gressively and the distalized teeth

Rev Orthop Dento Faciale 2015;18:104. 7


T. DANG, J.-P. FORESTIER, B. THEBAULT

Figure 8a
Dr Thebault’s Tekka plate sectorial molar distalization with Distaler.

are blocked by an omega loop in Dr Benoı̂t Thebault’s protocol


contact with the distalized tooth. for molar distalization with
The intrusion step between 5 and 6
anticipates the protrusion of the
mini-screw anchorage
mesial marginal crest of 6. Tip- • Patient 3 (Fig. 8 a, b)
forward onto the wire helps distal – Extraction of mandibular wisdom
repositioning of the apex of the teeth and positioning of Tekka
tipped-back teeth (Fig. 7, c and d). bone plate against the 6s.
– Treatment of incisors and ca- – Gluing 4 and 6 with pre-adjusted
nines, when the space created Roth .018 slot multi-attachment
by molar and premolar distaliza- bracket and positioning of Dista-
tion permits, by a .016 x .016 ler (in the 6 lip-bumper sheath)
NeoSentalloy NiTi shape-mem- with traction spring or chain
ory wire and metal ligature be- between scaffold and direct an-
tween 4 and mini-screw. chorage plate (Fig. 8a).
– Progression toward a .016 x .022 – Treatment of 7s.
NeoSentalloy then .016 x .022 – Withdrawal of Distaler once 6
Elgiloy Jaune wire. and 7 distalization is sufficient.
If the screw was positioned distally – Progressive treatment of premo-
to 37-47, a steel ligature using a .014 lars then incisors and straighten-
round wire at the screw neck ing by round NiTi wire and chain
emerges into the oral cavity along from plate to canine to maintain
the vestibule, enabling , first, 34 and an anterior sector distalizing com-
44 to be blocked by an open spring ponent during straightening.
when 7 is distalized, then the 7s to – Progression up to .017 x .025
be blocked when they are distalized, steel wire (Fig. 8b).
to fix their position.

8 Dang T., Forestier J.-P., Thebault B. Is mandibular molar distalization feasible?


IS MANDIBULAR MOLAR DISTALIZATION FEASIBLE?

Figure 8b
Intra-oral photographs of one of
Dr Thebault’s patients. Sectorial molar
distalization with Tekka plate and
Distaler.

Figure 9
Intra-oral photographs of one of
Dr Thebault’s patients. Sectorial
molar distalization with Tekka
plate. Note 37 and 47 crowns sunk
into distal mucosa.

Rev Orthop Dento Faciale 2015;18:104. 9


T. DANG, J.-P. FORESTIER, B. THEBAULT

• Patient 6 (Fig. 9) – .0174 x .025 steel wire with long


– Gluing mandibular arcade and scaffold clipped on a wire be-
straightening with round NiTi tween 3 and 4 and fitting a
wire up to .017 x .025 NiTi wire, traction spring between scaffold
with chain between 3 and plate and plate to act as direct anchor
to maintain a distalizing compo- until the desired incisor reposi-
nent during straightening. tioning is achieved.

RESULTS
Table I on the next page present • Situation after molar distalization:
the results. blue;
Summary of results: Table II. • When 3rd (postoperative) lateral
teleradiograph available, final
Delaire cephalometric superimposi-
situation: green (Fig. 10).
tion color code:
• Initial situation: red;

DISCUSSION
Radiograph availability
distalization was accompanied by api-
In some cases, radiographs were cal distalization.
available for start of treatment and
Ideally, the protocol should pro-
before avulsion (control).
spectively define the best time-points
In class II surgical cases, there for documenting the molar distaliza-
were more radiographs due to the tion, respecting the ALARA (As Low
need for pre- and post-operative As Reasonably Achievable) principle,
X-ray (up to 2 extra views). with the following sequence:
• Baseline documentation at start
Lateral view timing of treatment;
• Fitting the multi-attachment de-
In the case of patient 7, a lateral vice, extracting wisdom teeth,
view taken 4 months after distaliza- positioning anchorage, with or
tion of the crown showed apical without corticotomy;
repositioning, leaving time for the tip- • Start of molar distalization;
forward to manifest. In some cases, • End of molar distalization;
the end-of-treatment or postoperative • Start of mesial tooth distalization;
radiograph showed no such apical • Then end-of-distalization record,
repositioning, but in others, such as late enough to allow apical repo-
patient 9, there was no other view sitioning; this interval is to be
available showing whether coronary determined.

10 Dang T., Forestier J.-P., Thebault B. Is mandibular molar distalization feasible?


Rev Orthop Dento Faciale 2015;18:104. Age at start Indication for molar
Patient Practitioner Malocclusion Anchorage Result
of treatment distalization

1 16 years JPF Class II division 1 Sector 4 distalization, Extraction of 48 Mini- Apical tip-forward
subdivision G, and for fitting 43 restraint screw between 45
mandibular with conserved 83 and 46
alveolar protrusion

2 42 years JPF Class II division 2 Anterior crowding Extraction 38-48 Distalization by lateral
Mini-screw between translation
4 and 5

3 25 years BT Class II division 2 Anterior crowding Extraction 34-48 Coronary and apical
Bone plate on 6s distalization (coronary >
apical) + protrusion

IS MANDIBULAR MOLAR DISTALIZATION FEASIBLE?


4 17 years JPF Class II division 2 Anterior crowding and Extraction 34-48 Coronary and apical
decompensation before Bone plate on 6s distalization (coronary >
surgery apical) + intrusion

5 12 years JPF Class II division 2 Straightening curve of Spee Extraction 38-48 Coronary tip-back
by posterior sector Mini-screws between
44-45 and 35-36

6 18 years BT Class II division 2 Anterior crowding and Extraction 38-48 Apical tip-forward
decompensation before Bone plate on 6s and intrusion
surgery

7 14 years TD Class I DMD Anterior crowding and Extraction 38-48 TIM III Distalization by
correction of class III on maxillary wire lateral translation
Elgiloy Jaune .017 x .022
+ transpalatine wire

8 35 years JPF Class I DMD Correction of anterior Distal bone screws Coronary tip-back
crowding at 47 and 37 and protrusion

9 17 years TD Class III subdivision Correction of class III in Extraction 48 Coronary tip-back
D sector 4 and anterior Distal mini-screw at 47
crowding

10 36 years JPF Class II division 1 37-47 distalization to increase Attachment glued Coronary and apical
mesio-distal diameter of 36-46 to 36-46 implant-borne tip-back (coronary >
implant-borne crowns, crowns apical)
decompensation before
mandibular protraction surgery

11 30 years JPF Class II division Anterior crowding and Extraction of 38-48-75 Coronary tip-back
2 DMD, 35 agenesis incisor repositioning Distal mini-screw at 47
before mandibular and at agenesic 35
protraction surgery
11

Table I
T. DANG, J.-P. FORESTIER, B. THEBAULT

Movement achieved Number of patients Limitations of superimposition


on lateral teleradiographs in
Distalization by lateral translation 2
(Fig. 10a)
Delaire analysis
Distalization + coronary tip-back 3
Asymmetric cases are necessarily
(Fig. 10b) excluded from 2D superimposition,
as it is very difficult if not impossible
Coronary tip-back (Fig. 10c) 4 to identify the molar to be tracked,
especially when teeth are doubled or
Coronary tip-forward (Fig. 10d) 2
superimposed on another structure
TOTAL 11 such as an anchor plate.

Table II

Figure 10
Delaire cephalometric superimpositions. (a) Distalization with pure lateral translation; (b) distalization and coronary
tip-back; (c) apical tip-forward; (d) coronary tip-back only.

12 Dang T., Forestier J.-P., Thebault B. Is mandibular molar distalization feasible?


IS MANDIBULAR MOLAR DISTALIZATION FEASIBLE?

Precise superimposition requires very molar, between the roots of the 1st
high-quality X-ray, without doubling of mandibular molar).
anatomic structures other than in case Comparison concerned in some
of true asymmetry, using the same cases the 1st molar, but in others
equipment, with sufficient quality to the 2nd:
identify all anatomic structures. This
• Either due to absence of 36-46;
was not always the case for the radio-
• Or because movement could be
graphs available. Some, moreover, had
measured only on the 7s, which
not been taken in a digital format, and a
are easier to track than the 6 if an
digital image had to be taken from
anchor plate is superimposed;
X-rays displayed on a negatoscope;
• Or because the lateral teleradio-
this entails parallax error and the kind
graph was taken after isolated
of edge deformation encountered using
distalization of 7.
a wide-angle lens. Some lateral
Furthermore, while superimposition
teleradiographs were taken at 4 m,
on the ‘‘Me’’ (chin) point is unproble-
others at 1.5 m, making measurement
matic in mandibular protraction sur-
impossible. The superimposition results
gery, it comes up against its
were thus sometimes difficult to inter-
limitations if the patient has under-
pret. Scales could differ between treat-
gone genioplasty or changed posi-
ment phases if the patient had changed
tion.
radiologists or the radiologist had chan-
ged equipment. Cephalostat pitching 3D imaging with an orthonormal
and doubling of anatomic structures vi- landmark based on fixed anatomic
tiated interpretation of vertical molar elements (Treil analysis) could get
movement with respect to the basilar around these difficulties in assessing
edge. dental movement quality. But using
such radiation for such a purpose is
Moreover, 2D superimposition can-
ethically dubious.
not reveal rotational movement dur-
ing distalization, showing as reduced
inter-radicular distance. Diversity of protocols and
Furthermore, dental superimposi- indications
tion in Delaire analysis has the draw-
back of the teeth being represented The one common point in the se-
by a cross corresponding to the oc- lected cases was that molar distaliza-
clusal side of the tooth and the long tion was included in the treatment
axis. The mandibular molar, however, plan. Malocclusion, facial type (hypo-
may show very variable anatomy, or normo-divergent) and the objective
with roots of varying length and of distalization, on the other hand,
apices that are more or less distal, so varied. Some cases showed tip-back
that there may be a certain vertical only, or distalization by lateral transla-
and mesiodistal margin of error in si- tion associated with a tip-back com-
tuating the ‘‘mia’’ point (apical inferior ponent. The objective, however,

Rev Orthop Dento Faciale 2015;18:104. 13


T. DANG, J.-P. FORESTIER, B. THEBAULT

could in some cases be to straighten common. Moreover, in most cases


the curve of Spee by coronary tip- what was presented was a case report.
back, without necessarily seeking
apical distalization.
Given the diversity in baseline mal-
Iatrogenic effects of such dental
occlusion, dental formula, mini-screw movement, and long-term
sites and degree of crowding, the stability
protocols implemented likewise dif-
At end of treatment, certain cases
fered, and successful distalization
showed radicular resorption in molars
could not be attributed to one parti-
visible on panoramic X-ray. Although
cular protocol. In 2 cases (patients 2
without clinical impact for the patient,
and 7), pure lateral translation was
this was visible on X-ray, and rela-
achieved, with very different proto-
tively unpredictable. Retrospectively,
cols and anchorages. In other cases,
it was found to correspond to cases
results differed for the same protocol:
with no coronary movement but with
apical tip-forward in patient 1, coronary
apical tip-forward (patients 1 and 6).
tip-back in patient 4 after replacement
In case of movement in pure lateral
of an infected left bone plate by a
translation, patient 2 (38 years of
screw between 35 and 36. Finally, the
age) showed radicular resorption
objectives of molar positioning in class
while patient 7 (14 years of age) did
III correction do not require the same
not. Age may perhaps be a factor for
degree of distalization as would be
resorption.
needed for arcade preparation for man-
dibular protraction. Patient 8 displayed frontal shift of
the occlusion plane during treatment,
It is therefore difficult to draw conclu-
probably due to difference in height
sions from these findings, based on too
of the mini-screw anchorages. This
small a sample with too diverse proto-
possible side-effect had been over-
cols, and to determine whether one
looked.
device is more effective than another.
The literature review encountered the Finally, the question of the long-
same problem: apart from Sugawara’s term stability of these movements
study (15 patients, 30 displacements), remains unresolved. None of the
all the other publications were of case present cases allowed stability to be
reports, with too low a level of evidence demonstrated, due to lack of data or
for any conclusions to be drawn as to of post-treatment follow-up; the last
the reliability of one system or another. radiograph was, at best, a lateral tele-
Likewise, a given system used by two radiograph taken after ablation.
operators in two different patients
might not give the same result (e.g., Tai
et al.9 vs Lim et al.5). However, the Protocols and implementation in
literature review concerned mainly class dental chair
III correction in Asian populations,
where it is more frequent than in In assessing the efficacy of the
Europe, where class II is more various protocols described, efficiency

14 Dang T., Forestier J.-P., Thebault B. Is mandibular molar distalization feasible?


IS MANDIBULAR MOLAR DISTALIZATION FEASIBLE?

was not taken into account: some pro- risk/benefit-ratio of extracting premo-
tocols are easier than others to imple- lars adjacent to the crowded sector
ment in the clinical situation. Such versus extracting wisdom teeth and
factors include: distalizing the posterior teeth to cor-
• Ease of implementation in dental rect anterior crowding needs to be
chair: operator-dependent, or de- assessed in terms of length of treat-
legatable? ment and risk of complications.
• Time-consumingness: self-liga- It should be noted that temporary
turing? Preformed arch? anchorages require good coordination
• Number of, interval between and between the practitioner extracting
length of consultations; the wisdom teeth, who will also fit
• Materials costs, for practitioner the anchors, and the orthodontist,
and for patient; who should quickly initiate molar dis-
• Patient cooperation require- talization so as to take advantage of
ments. the bone remodeling induced by ex-
In practice, bone anchorage cre- traction.
ates a submucosal entry portal, with Finally, one adverse effect of molar
consequent risk of infectious compli- distalization concerns access to the
cations. Mini-screws may become wire distal to the 2nd molars, which
detached and have to be ablated and regularly sink under the retromolar
reinserted, necessarily in another mucosa, preventing access to the
site. Patient 8 complained of jugal distal side of the 7 tube, which may
discomfort throughout his treatment, have to be shortened, causing dis-
due to screw protrusion. Screw- comfort for the patient at each ma-
related complications included adja- nipulation, and sometimes preventing
cent cyst, occurring in about 6% of ablation unless the mucosal covering
cases. Patient 4 experienced bone is lifted.
plate infection, requiring replacement
All in all, comparing anchorage by
of the plate by a screw. Bone plates
mini-screw or mini-plate versus class-
are associated with a chronic inflam-
III elastic anchorage shows that lateral
mation rate exceeding 7%10.
translation can be achieved either way
Ablating a screw is straightforward, (patients 2 and 7). However, in the
but ablating an anchorage plate requires latter case the orthodontist requires
surgical revision and a further flap. the patient’s cooperation and imposes
Moreover, including arcade distali- on the temporomandibular joints, the
zation in a treatment plan requires elastic bands having to be worn con-
longer treatment than class III ortho- stantly, while the former makes no re-
surgical correction or Triaca front- quirements of cooperation but, in 10%
block distraction6 to correct anterior of cases, induces complications relat-
crowding. Likewise, the comparative ing to the bone anchorages10.

Rev Orthop Dento Faciale 2015;18:104. 15


T. DANG, J.-P. FORESTIER, B. THEBAULT

CONCLUSION
In 2014, mandibular molar distaliza- Mandibular molar distaliza- tion with
tion appeared feasible. Several is- the Frangulum Appliance, 518-523;
sues, however, remain in suspense: Figure 7, Copyright 2000.
• Which protocol, providing opti- Figure 3: Taken from Am J Orthod
mal reproducibility, has proved Dentofacial Orthop, 125, J Sugawara
effective in a sufficiently large et al., Distal movement of mandibular
sample? molars, in adult patients with the ske-
• With what efficiency? letal anchorage system, 9 pages,
• With what iatrogenic effects? Copyright 2004, with permission
Can they be quantified, Can they from Elsevier.
be predicted? Figure 4: Taken from Am J Orthod
• How stable are results over the Dentofacial Orthop, 131, Hisano M,
long term, notably in skeletal Chung CJ, Soma K, Nonsurgical cor-
class III correction? rection of skeletal Class III malocclu-
A prospective comparative rando- sion with lateral shift in an adult,
mized study will be needed to test chapter 6, 8 pages, Copyright 2007,
the efficacy of each protocol in speci- with permission from Elsevier.
fic clinical situations of malocclusion,
Figure 5a: Taken from Am J Orthod
of quality and quantity of planned
Dentofacial Orthop, 144, Tai K, Park
movement, with similar facial type,
JM, Tatamiya M, Kojima Y, Distal
and with a sufficiently large sample
movement of the mandibular denti-
to assess results on 3D CT or cone-
tion with temporary skeletal ancho-
beam measurement so as to over-
rage devices to correct a class III
come the drawbacks of 2D cephalo-
malocclusion, 10 pages, Copyright
metry. The number of acquisitions
2013, with permission from Elsevier.
and the corresponding interval(s) will
need to be determined in advance to Figure 5b: Taken from J Clin Orthod,
allow study of dental movement 45, Lim J-K, Jeon MJ, Kim JH,
during treatment. Comparison should Molar distalization with a miniscrew-
include efficiency from the practitio- anchored sliding jig, 368-377; Figure 9b,
ner’s point of view and iatrogenesis Copyright 2011.
from the patient’s.

Reproduction permission
Figure 2: Taken from J Clin Orthod, 34, Conflicts of interest: The author declares no
Byloff F, Darendeliler MA, Stoff F, conflict of interest.

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