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- DOI 10.18231/j.jco.2023.011
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Distalization, A unique weapon in an orthodontist’s armoury: A case series
- Author Details:
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Ashish Kamboj *
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S. S. Chopra
-
Atul Bali
-
Mohit Sharma
-
Prateek Mathur
-
Paras Angrish
Ashish Kamboj *
Introduction
Distalization is a well-documented technique employed to increase arch length. It is a conservative method of gaining space without sacrificing the dental units.[1] The process of molar distalization has been in practice for over a century and has evolved leaps and bound ever since. Numerous methods have been proposed over the years using both intra-oral and extra-oral appliances.[2], [3]
Traditionally, headgears were used as an extra-oral method of molar distalization. Though effective, headgears are highly dependent on patient compliance and therefore, intra-oral fixed appliances gained popularity. One such appliance that is widely used even today is known as the Pendulum appliance introduced by Hilgers in the year 1992.[4], [5] Anchorage planning and appliance design are the keys to a successful treatment outcome using the appliance. Certain adverse effects such as distal tipping of molars, an undesired increase in lower anterior facial height and mandibular clockwise rotation have been reported in literature.[6]
Temporary anchorage devices (TADs) have revolutionised the way anchorage is managed in contemporary orthodontics. TADs have been utilised in distalization as well and literature has suggested effective distalization with minimal tipping using the same. However, recent systematic reviews suggest that effective distalization can be achieved with both conventional and TAD mechanics without much clinically significant differences.[7] TADs have certain disadvantages like screw failures, approximation to root surfaces and associated pain.[8] Thus, TADs may be specifically employed in critical anchorage cases.
The present article describes two such cases which have been effectively treated using the conventional pendulum appliance with TADs along with aesthetically pleasing outcomes.
Case 1
A 11 years old female patient reported to a tertiary care dental centre with the chief complaint of Irregular upper front teeth. The patient started noticing the problem since the eruption of permanent teeth and desired correction of the same. The medical and dental history of the patient was non-contributory. The growth history revealed that the patient had not achieved menarche.
Clinical examination
Extra Oral: Patient’s face was proportional in the horizontal fifths and vertical thirds. The patient had a non-consonant smile arc and wide buccal corridors. The profile was straight with a deep mentolabial sulcus and an obtuse chin-throat angle. [[Figure 1] (a-c).
Intra Oral: Intra oral examination revealed severe crowding in the upper arch, rotated 15 and 25, blocked out 13, labially displaced 23, upper midline deviated to right by 2 mm, mild lower arch crowding end on molar relation and a non-specific canine relation. ([Figure 1] d-h).
Radiographic assessment
Orthopantamogram: revealed permanent dentition with the 3rd molars in various stages of eruption. No abnormality was detected. ([Figure 1] i)
Lateral Cephalogram: revealed mild class III skeletal bases with an average growth pattern. Proclination of the maxillary anteriors and a normal lower anterior facial height. Adequate molar-Ptv value ([Table 1] & [Figure 1] j).
|
Parameter |
Value |
|
SNA |
77 |
|
SNB |
80 |
|
ANB |
-3 |
|
Upper 1 to NA |
35° (9mm) |
|
Lower 1 to NB |
28° (4mm) |
|
LAFH: AFH |
54.4% |
|
Molar-Ptv |
16mm |
Problem list
Based on the clinical examination and radiographic assessment the following problem list was formulated:
Straight profile
Deep mentolabial sulcus
Severe crowding upper arch
Rotated 15 and 25
Blocked out 13
Labially displaced 23
Upper midline deviated to right by 2 mm
Molar relation end on and non-specific canine relation
Treatment objectives
Improvement of profile.
To improve smile aesthetics
Leveling and alignment of teeth.
Correction of midline
Achieve class I molar and canine relation bilaterally
Establishment of adequate overjet and overbite
Treatment plan
Phase I: Molar distalization with pendulum appliance. To achieve super class I relationship and correction of premolar rotation. TADs to retain molar correction.
Phase II: Leveling and alignment of arches and retraction of buccal segments into the space created. Bring canines into arch.
Treatment progress
Molar distalization using the pendulum appliance [[Figure 2] (a-b)]. Distalization was achieved in four months and E chains were employed for derotation of premolars [[Figure 2] (c & d)]
Bonding was done using 0.022” MBT pre-adjusted edgewise appliance and levelling and alignment was carried out [[Figure 2] (e & f)].
Post treatment status
At the end of treatment all objectives which included an aesthetically pleasing smile along with correction of canine and molar relations were achieved.[[Figure 3] (a-h)].
Radiographic comparison revealed an improvement in inclination of the maxillary anteriors [[Figure 3] (i-j)].
|
Parameter |
Pre-Treatment Value |
Post-Treatment Value |
|
SNA |
77 |
79 |
|
SNB |
80 |
81 |
|
ANB |
-3 |
-2 |
|
Upper 1 to NA |
35° (9mm) |
28° (4mm) |
|
Lower 1 to NB |
28° (4mm) |
20° (4mm) |
|
LAFH: AFH |
54.4% |
55.2% |
Case 2
A 19 years old female patient reported to a tertiary care dental centre with the chief complaint of Irregular upper front teeth. The medical and dental history of the patient was non-contributory.
Clinical examination
Extra Oral: Patient’s face was proportional in the horizontal fifths and vertical thirds. The patient had a non-consonant smile arc and wide buccal corridors. The profile was convex with an increased nasolabial angle. [[Figure 4] (a-c)]
Intra Oral: Intra oral examination revealed moderate crowding in the maxillary arch, mild crowding in the mandibular arch and end on molar and canine relations on the left and class II on the right side. ([Figure 4] (d-h)].
|
Parameter |
Value |
|
SNA |
83 |
|
SNB |
80 |
|
ANB |
3 |
|
Upper 1 to NA |
27° (6mm) |
|
Lower 1 to NB |
27° (5mm) |
|
LAFH: AFH |
56.2% |
|
Molar-Ptv |
17 mm |
|
Parameter |
Pre-Treatment Value |
Post-Treatment Value |
|
SNA |
83 |
82 |
|
SNB |
80 |
80 |
|
ANB |
3 |
2 |
|
Upper 1 to NA |
27° (6mm) |
20° (4mm) |
|
Lower 1 to NB |
27° (5mm) |
31° (6mm) |
|
LAFH: AFH |
56.2% |
57% |
Radiographic assessment
1. Orthopantamogram: revealed permanent dentition with the 3rd molars in various stages of eruption. Missing 38. No other abnormality was detected.[[Figure 4] i].
2.Lateral Cephalogram: revealed class I skeletal bases with an average growth pattern. Proclination of the maxillary anteriors and a normal lower anterior facial height. ([Table 3] &[Figure 4] j)
Problem list
Based on the clinical examination and radiographic assessment the following problem list was formulated:
Moderate crowding upper anteriors.
End on molar right side class II on left.
End on canine right side Class II on left.
Treatment objectives
To improve smile aesthetics.
Leveling and alignment of teeth.
Achieve class I molar and canine relation bilaterally.
Establishment of adequate over jet and overbite.
Treatment plan
Therapeutic extraction of 17 and 27.
Space gain in maxillary arch by bilateral molar distalisation.
Sequential canine and premolar retraction.
Leveling and alignment of arches and correction of rotations.
Treatment progress
Bonding was done using 0.022” MBT pre-adjusted edgewise appliance and levelling and alignment was carried out [[Figure 5] d-f].
Conclusion
Distalization is one of the most widely accepted modalities of gaining space. Case selection is vital in such cases as distalization may affect the lower anterior facial height adversely. A thorough clinical and radiographic assessment form the basic tenets of a successful treatment outcome. The intra-oral appliances are used popularly as these do not require patient compliance. With the recent advances in technology numerous distalization appliances have been introduced over the years.[9] However, the conventional appliances still remain as effective when utilized in the correct way and modified as per the specific requirement of a particular case.
Source of Funding
None.
Conflict of Interest
None.
References
- WR Profitt, HW Fields, BE Larson, DM Sarver. . Contemporary Orthodontics 2019. [Google Scholar]
- AJ Haas. Headgear therapy: the most efficient way to distalize molars. Semin Orthod 2000. [Google Scholar]
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- J Hilgers. The pendulum appliance: an update. Clin Impressions 1993. [Google Scholar]
- A Caprioglio, M Fontana, E Longoni, M Cozzani. Long-term evaluation of the molar movements following Pendulum and fixed appliances. Angle Orthod 2013. [Google Scholar]
- S Soheilifar. Maxillary molar distalization using conventional versus skeletal anchorage devices: A systematic review and meta-analysis. Int Orthod 2019. [Google Scholar]
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- GS Antonarakis, S Kiliaridis. Maxillary molar distalization with noncompliance intramaxillary appliances in class II malocclusion: a systematic review. Angle Orthod 2008. [Google Scholar]
- Introduction
- Case 1
- Clinical examination
- Radiographic assessment
- Problem list
- Treatment objectives
- Treatment plan
- Treatment progress
- Post treatment status
- Case 2
- Clinical examination
- Radiographic assessment
- Problem list
- Treatment objectives
- Treatment plan
- Treatment progress
- Conclusion
- Source of Funding
- Conflict of Interest