Molar distalization with pendulum appliances in the mixed dentition: Effects on the position of unerupted canines and premolars

Utilization of a 3D Printed Orthodontic Distalizer for Tooth-Borne Hybrid Treatment in Class II Unilateral Malocclusions

This paper introduces a novel method of 3D designing and 3D printing of a hybrid orthodontic tooth-borne personalized distalizer for treatment of unilateral Class II malocclusion. Research objectives were to clinically utilize 3D printed distalizers, appraise feasibility of this technique and compare two different biocompatible photopolymers (white and transparent). Frequency of distalizers’ debonding and patients’ aesthetical perception was evaluated on the set of 12 complete orthodontic treatments. The mean duration of treatment period with a bonded distalizer was 6.4 months. All cases were adults with unilateral Class II malocclusion managed with a hybrid approach as a part of Invisalign® comprehensive treatment. Results showed that such perspective practice is feasible for 3D design and in-office 3D printing of a personalized distalizer. Results also showed no clinically significant differences between both studied biopolymers. The paper discusses an evaluation of such personalized distalizer functionality with regard to the current state of the art and compares to conventional prefabricated alternatives like a Carriere® Distalizer™ appliance. Research showed a preference of patients towards transparent biocompatible photopolymer instead of the white A2 shade. The paper concludes that additive manufacturing from dental resins is a viable method in personalization and in-office 3D printing of orthodontic auxiliaries, particularly distalizers. New materials for orthodontic 3D printing endow enhanced individualization, thus more efficient treatment.

Efficiency of the skeletonized Pendulum K appliance for non-compliance maxillary molar distalization : A clinical pilot study

PURPOSE

Conventional anchorage with exclusively intraorally anchored appliances for non-compliance molar distalization combines a palatal acrylic button with periodontal anchorage. This type of anchorage is critically discussed because of the temporary hygienic impairment of the palate and the uncertain anchoring quality of the button. A purely dentally/periodontally anchored Pendulum K appliance was developed, which is exclusively anchored via four occlusal rests. The aims of this pilot study were to examine the suitability of the skeletonized Pendulum K for distalization of maxillary molars, and to investigate the quality of this alternative anchoring modality.

PATIENTS AND METHODS

In all, 10 patients received skeletonized Pendulum K appliances attached to all maxillary premolars for bilateral molar distalization. Supporting anchorage through an acrylic button adjacent to the anterior palate was not used. The pendulum springs were initially activated on both sides with a distalization force of 220 cN each and provided with uprighting and toe-in bends. The specific force/moment system was regularly reactivated intraorally by adjustment of the distal screw.

RESULTS

The study demonstrates the suitability of the skeletonized Pendulum K appliance for the distalization of maxillary molars (3.28 ± 0.73 mm). Side effects on the molars were slight distal tipping (3.50 ± 2.51°/PP, 3.00 ± 1.41°/SN) and mesial inward rotation (average 2.75 ± 7.50° and 4.50 ± 12.77°). Significant anchorage loss occurred in the form of mesialization of the incisors by 1.40 ± 0.82 mm and of the first premolars by 2.28 ± 0.85 mm.

CONCLUSION

The skeletonized Pendulum K appliance allows compliance-free upper molar distalization. Exclusively dental/periodontal anchorage resulted in a lower percentage of molar distalization compared to a conventional anchoring preparation of the Pendulum K with a palatal acrylic button. Anchorage loss had a comparatively stronger effect on the anchoring premolars but less on the incisors. Typical side effects on the molars such as distal tipping and mesial inward rotation were remarkably low.

Transverse stability of Class II malocclusion correction with the pendulum appliance

INTRODUCTION

This study aimed to evaluate the stability of transverse changes after Class II malocclusion correction with the pendulum fixed distalizer, followed by preadjusted edgewise fixed orthodontic appliances.

METHODS

This longitudinal study was conducted in the maxillary dental casts of 20 Class II malocclusion subjects (mean age, 12.5 years; 14 females and 6 males). Eighty 3-dimensional maxillary dental casts were analyzed; 20 at the beginning of treatment, 20 after distalization, 20 after edgewise appliance debonding, and 20 at 5 years posttreatment. Maxillary transverse distances between canines, first premolars, second premolars, first molars, and second molars were analyzed using Geomagic Studio 5 (3D Systems, Rock Hill, SC).

RESULTS

There were no significant changes in intercanine distance during and after treatment. There were significant interfirst and intersecond premolar distance increases during treatment. There were significant interfirst and intersecond molar distance increases during the distalization phase. However, there were significant decreases in these distances at the end of treatment. There were no significant long-term posttreatment changes.

CONCLUSIONS

The intercanine distance remains stable during and after treatment. The interfirst and intersecond premolar distances significantly increase during treatment and remain stable after treatment. The interfirst and intersecond molar distances increase during the distalization phase, decrease at the end of treatment, and remain stable after treatment.

Treatment efficiency of mini-implant-borne distalization depending on age and second-molar eruption

OBJECTIVE

The aim of this study was to evaluate the efficiency of molar distalization depending on age and second-molar eruption using the Beneslider.

MATERIALS AND METHODS

Treatment of 51 patients (mean age 17.8 ± 9.6 years) was investigated retrospectively by means of pre- and posttreatment cephalograms. Patients were divided into three groups: 14 children with unerupted upper second molars (group 1), 23 adolescents with second molar in place (group 2), and 14 adults (group 3). The distalization forces applied were 2.4 N in group 1 and 5.0 N in groups 2 and 3. Treatment changes were evaluated and examined statistically for significant differences.

RESULTS

In all patients a Class I molar relationship was achieved. All mini-implants remained stable during treatment. Mean distalization distance as measured by the displacement of the center of resistance was 3.6 ± 1.9 mm (range 1.2-8.5 mm depending on treatment needs). Since no significant tipping was detected, the type of movement can be described as bodily movement. Mean overall distalization speed was 0.6 ± 0.4 mm per month. There were no statistical differences between the groups.

CONCLUSION

We found the Beneslider to be an effective appliance that enables bodily distalization in adequate treatment time. The higher resistance due to erupted second molars can be compensated by the use of higher forces without significantly reducing distalization speed.

Orthodontic treatment for distalising upper first molars in children and adolescents

BACKGROUND

When orthodontic treatment is provided with fixed appliances, it is sometimes necessary to move the upper molar teeth backwards (distalise) to create space or help to overcome anchorage requirements. This can be achieved with the use of extraoral or intraoral appliances. The most common appliance is extraoral headgear, which requires considerable patient co-operation. Further, reports of serious injuries have been published. Intraoral appliances have been developed to overcome such shortcomings. The comparative effects of extraoral and intraoral appliances have not been fully evaluated.

OBJECTIVES

To assess the effects of orthodontic treatment for distalising upper first molars in children and adolescents.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 10 December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 10 December 2012) and EMBASE via OVID (1980 to 10 December 2012). No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised clinical trials involving the use of removable or fixed orthodontic appliances intended to distalise upper first molars in children and adolescents.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration. We performed data extraction and assessment of the risk of bias independently and in duplicate. We contacted authors to clarify the inclusion criteria of the studies.

MAIN RESULTS

Ten studies, reporting data from 354 participants, were included in this review, the majority of which were carried out in a university dental hospital setting. The studies were published between 2005 and 2011 and were conducted in Europe and in Brazil. The age range of participants was from nine to 15 years, with an even distribution of males and females in seven of the studies, and a slight predominance of female patients in three of the studies. The quality of the studies was generally poor; seven studies were at an overall high risk of bias, three studies were at an unclear risk of bias, and we judged no study to be at low risk of bias.We carried out random-effects meta-analyses as appropriate for the primary clinical outcomes of movement of upper first molars (mm), and loss of anterior anchorage, where there were sufficient data reported in the primary studies. Four studies, involving 159 participants, compared a distalising appliance to an untreated control. Meta-analyses were not undertaken for all primary outcomes due to incomplete reporting of all summary statistics, expected outcomes, and differences between the types of appliances. The degree and direction of molar movement and loss of anterior anchorage varied with the type of appliance. Four studies, involving 150 participants, compared a distalising appliance versus headgear. The mean molar movement for intraoral distalising appliances was -2.20 mm and -1.04 mm for headgear. There was a statistically significant difference in mean distal molar movement (mean difference (MD) -1.45 mm; 95% confidence interval (CI) -2.74 to -0.15) favouring intraoral appliances compared to headgear (four studies, high or unclear risk of bias, 150 participants analysed). However, a statistically significant difference in mean mesial upper incisor movement (MD 1.82 mm; 95% CI 1.39 to 2.24) and overjet (fixed-effect: MD 1.64 mm; 95% CI 1.26 to 2.02; two studies, unclear risk of bias, 70 participants analysed) favoured headgear, i.e. there was less loss of anterior anchorage with headgear. We reported direct comparisons of intraoral appliances narratively due to the variation in interventions (three studies, high or unclear risk of bias, 93 participants randomised). All appliances were reported to provide some degree of distal movement, and loss of anterior anchorage varied with the type of appliance.No included studies reported on the incidence of adverse effects (harm, injury), number of attendances or rate of non-compliance.

AUTHORS' CONCLUSIONS

It is suggested that intraoral appliances are more effective than headgear in distalising upper first molars. However, this effect is counteracted by loss of anterior anchorage, which was not found to occur with headgear when compared with intraoral distalising appliance in a small number of studies. The number of trials assessing the effects of orthodontic treatment for distilisation is low, and the current evidence is of low or very low quality.

Effects of conventional anchorage on premolar root development during treatment with a pendulum appliance

OBJECTIVE

By metrically analyzing orthopantomograms, we aimed in this study to retrospectively investigate whether maxillary premolars used as anchoring teeth during molar distalization with pendulum appliances would reveal inhibited root development.

PATIENTS AND METHODS

The upper molars were distalized with a modified pendulum appliance (Pendulum K) in 36 adolescents (14 males, 22 females, mean age 12.3 years). Mean treatment period was 19.5 weeks. Orthopantomograms of each patient were taken at the start (time point T1) and after completion of molar distalization (time point T2). The enlargement of the posterior region was ascertained individually quadrant by quadrant for each radiograph, followed by measurement of the vestibular tooth lengths of the premolars whose root development was for the most part not yet complete. To assess further root development in the premolar region, the differences were calculated between tooth lengths at the start and end of treatment.

RESULTS

During treatment with the pendulum appliance a general increase in tooth lengths in the anchorage region was observed (1.37 +/- 1.70 mm, p<0.0001). Differentiated by dental age, we noted increases in tooth lengths of patients with second molars in the budding stage (patient group PG 1: 0.93 +/- 1.37 mm, p<0.0001) as well as of patients with fully-erupted second molars (patient group PG 2: 1.81 +/- 1.88 mm, p<0.0001). Both groups demonstrated greater increases in the second premolars than the first premolars; the increases group-wise were larger in PG 2 than PG 1. However, both the group comparison (PG 1 versus PG 2) and the side comparison (right versus left) (differentiated into first and second molars) showed no statistically relevant differences. Visual assessment of the radiographs revealed no evidence of treatment-related root deviations.

CONCLUSION

A highly complex system of forces acts on the anchoring teeth during molar distalization with the conventionally-anchored Pendulum K. However, the Pendulum K appliance's specific biomechanics make it possible to transfer the reactive forces and moments to the anchorage unit so that they remain within the physiological range, allowing uninhibited premolar root development. This also applies after completed eruption of the second molars, when the treatment period and hence duration of exposure to the active and reactive forces and moments arising during molar distalization are comparatively increased.

Comparative efficiency of Class II malocclusion treatment with the pendulum appliance or two maxillary premolar extractions and edgewise appliances [corrected]

The objective of this study was to compare, on study models and initial cephalograms, the efficiency of Class II malocclusion treatment with the pendulum appliance, and with two maxillary premolar extraction protocol. The sample consisted of 48 treated Class II malocclusion patients: group 1 comprised 22 patients (7 males, 15 females) treated with the pendulum appliance, with an initial mean age of 14.44 years and group 2, 26 patients (14 males, 12 females) treated with two maxillary premolar extractions at an initial mean age of 13.66 years. To compare the efficiency of each treatment protocol, the occlusal outcomes were evaluated on dental casts using the Peer Assessment Rating (PAR) Index and the treatment time (TT) of each group was calculated on clinical charts. The degree of treatment efficiency was calculated as the ratio between the percentage of occlusal improvement, evaluated through the PAR index, and TT. Statistical analysis was undertaken by means of t-tests. The findings demonstrated that the two maxillary premolar extraction protocol provided the occlusal outcomes in a shorter time (group 1: 45.7 months, group 2: 23.01 months) and, therefore, demonstrated greater treatment efficiency than the pendulum appliance.

Biomechanics of a modified Pendulum appliance--theoretical considerations and in vitro analysis of the force systems

The aim of this study was to analyse the acting forces and moments induced by a special orthodontic appliance, the Pendulum K, for molar distalization in the transverse and sagittal planes. The purpose-designed test set-up (artificial maxilla with anchorage unit and two electrothermodynamic molars, an electronic measuring unit, a unit with force-moment sensor, an analogue/digital converter, and a data read-out unit) allowed simulation of in vivo conditions on the one hand and precise determination of the force systems on the other. The appliances investigated were three specimens of the Pendulum K. In vitro measurement of the resulting force systems revealed that the forces and moments in the transverse and sagittal planes remained almost constant over a 3 mm measuring increment when the distal screw was continuously activated (10 activations/mm). Without reactivation of the incorporated distal screw, however, a marked decline in the force systems was recorded. The Pendulum K allows translatory distalization of the upper molars and thus dental arch expansion, dispensing with the need for permanent teeth to be extracted, subject to a corresponding indication. This is achieved by continuous adjustment of an incorporated distal screw and by specific pre-activations of the Pendulum springs.