TECHNO BYTES

Three-dimensional analysis of tooth

movements after palatal miniscrew-supported
molar distalization
€ khan Serhat Duran,a Serkan Go
Go € rgu
€ lu  luc
€ ,b and Furkan Dindarog
Ankara, Turkey

Introduction: The aim of this prospective clinical study was to evaluate the dentoalveolar effects of a palatal
miniscrew-supported molar distalization appliance using a 3-dimensional reverse engineering method.
Methods: This study sample comprised 21 patients at an average age of 13.6 years with a bilateral Class II
molar relationship. Distalization was performed using skeletal anchorage. Dental casts were obtained just before
treatment and after appliance removal, and they were scanned with a 3-dimensional dental scanner. The digital
dental cast images were aligned. Four points and 2 lines were determined on each tooth, and the correlations
between tooth movements and the linear and angular changes were analyzed 3 dimensionally. Results: In
the sagittal direction, the first molars showed a mean linear movement of 4.10 6 1.57 mm, with distal tipping
of 11.02
; the central incisors showed a mean distal movement of 0.95 6 0.40 mm, with retroclination of
1.59 6 0.59
. In the vertical direction, only the first molars showed intrusion, with a mean value of
–0.59 6 0.50 mm. Rotation of the first molars was 4.92
6 3.09
. The second molars had the greatest rotation.
The highest correlation among tooth movements was found between the first and second molars. Conclusions:
Through support from the anterior palatal region, the maxillary first molars were distalized without anchorage
loss. Furthermore, movement was observed in all 3 planes of space with reduction from the posterior to the ante-
rior in the maxillary arch. (Am J Orthod Dentofacial Orthop 2016;150:188-97)

M
axillary molar distalization is a nonextraction
treatment modality to gain space in the maxil-
lary arch. The indication for maxillary molar
distalization is a Class II dental relationship (due to
mesial migration of maxillary posterior teeth) or a minor
skeletal Class II relationship and mild or no mandibular
tooth size–arch length discrepancy.1 The traditional
method used for maxillary molar distalization is head-
gear (extraoral anchorage). However, headgear has
some disadvantages; it is esthetically unacceptable and
needs patient compliance.2 These disadvantages led to
From the Department of Orthodontics, Dental Sciences Center, G€
ulhane Military
Medical Academy, Ankara, Turkey.
a
Research assistant.
b
Associate professor.
c
Research assistant.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: G€okhan Serhat Duran, Department of Orthodontics,
Dental Sciences Center, G€ ulhane Military Medical Academy, Etlik, Ankara,
Turkey; e-mail, gsduran@gata.edu.tr.
Submitted, August 2015; revised and accepted, December 2015.
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists. All rights
reserved.
http://dx.doi.org/10.1016/j.ajodo.2015.12.024
188
the development of intraoral distalization methods
that do not require patient cooperation: eg, magnets,3
nickel-titanium open-coil springs,4 pendulum appli-
ance,5 Keles slider appliance,6 distal jet appliance,7 and
several other methods. The common and unwanted
side effect of these noncompliance methods is the mesial
drift of the premolars and the incisors: ie, anchorage
loss.8 To prevent anchorage loss, intraoral distalization
methods take support from the skeletal structures with
the help of temporary anchorage devices such as endo-
sseous implants, miniplates, and miniscrews.9 Implants
and miniplates have some disadvantages such as high
costs and the need for additional surgery for placement
and removal. Miniscrews, on the other hand, are
preferred because they are cheaper and less invasive
than other methods.10 Additionally, they can be easily
placed in several skeletal regions. The anterior palate is
considered to be a safe region for miniscrew insertion
because it is far from the tooth roots and important
anatomic structures.11,12 Another advantage of palatal
anchored distalization mechanics is that there is no
need to use full fixed appliances during the
distalization period. Many authors have examined the
effects of intraoral distalization performed with
Duran, G€org€
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Fig 1. Preparation of the appliance: A, abutments over the miniscrew heads; B, hyrax screw was bent
and adapted to the abutments and the molar bands at a 90
angle to produce the distalization force; C,
intraoral view of the distalization appliance.
support from the miniscrews placed in this region.9
However, the tooth movements were generally analyzed
2 dimensionally on cephalometric radiographs and
dental cast photocopies in these studies. The recently
emerged prominent opinion for the 3-dimensional
(3D) analysis of tooth movements is the reverse engi-
neering method. Until today, this method was used to
analyze facial soft tissues, and skeletal and dental
changes.13 Few studies have analyzed the dentoalveolar
changes after molar distalization with digital casts.14,15
In this study, we aimed to evaluate how the maxillary
teeth move in space with advanced reverse engineering
software 3 dimensionally after maxillary first molar
distalization through direct support from the
miniscrews placed in the anterior palatal region.
MATERIAL AND METHODS
Ethical approval for this prospective clinical study
was obtained from the Ethical Committee of G€ ulhane
Military Medical Academy in Ankara, Turkey. The pa-
tients signed consent forms before the study. The study
was conducted with 21 subjects with an average age of
13.6 years, who were referred to the Department of Or-
thodontics of G€ ulhane Military Medical Academy for
treatment. The study group consisted of 9 girls and 12
boys, and the mean age varied between 12.3 and
15.3 years. The subjects had skeletal Class I or mild Class
II relationships (ANB, 2
-5
), with a normal facial vertical
growth pattern, bilateral Class II molar relationship with
moderate crowding (#5 mm), fully erupted maxillary
second molars and premolars, and mild or no crowding
in the mandibular arch (#3 mm). No orthodontic treat-
ment was performed in the mandibular arch before or
during the distalization period.
Two miniscrews, 1.7 mm in diameter and 8 mm in
length (Forestadent, Pforzheim, Germany), were placed
in the anterior palatal region corresponding to 6 mm
posterior to the incisive papilla and 2 mm lateral to the
American Journal of Orthodontics and Dentofacial Orthopedics
189
sutura palatina media using the self-drilling method.16
A hyrax screw (Forestadent) was placed parallel to the
occlusal plane by rotating it 90
so that it could open
in the sagittal direction; hyrax arms were welded to the
molar bands and abutments using a laser welding device
(Tornado SL 75; Siro Lasertec, Pforzheim, Germany).
One week after the placement of the miniscrews, the
initial (T0) dental casts were obtained and the appliance
was adapted; then the distalization period began (Fig 1).
The screw was activated by 0.2 mm every 5 days by the
patient, and distalization was controlled every 4 weeks.
Distalization was continued until a super-Class I molar
relationship was achieved. At the end of distalization,
the appliance was removed, the dental casts were taken
(T1), the appliance was recemented for anchorage, and
the treatment was continued (Fig 2).
The dental casts from T0 and T1 were scanned with
an optical dental scanner (Activity 850; Smart Optics,
Bochum, Germany); the scans were converted into digi-
tal data, and the data were imported into reverse engi-
neering software (Rapidform; INUS Technology, Seoul,
South Korea) for the alignment phase. The T0 and T1
digital models of the same subject were aligned with
the best fit (surface-to-surface matching) method17
(Fig 3). The alignment procedure was performed on sta-
ble anatomic reference points such as the palatal rugae
with limited manual process selection and deselection
of this area.18 In this study, a standardized coordinate
system was defined on the occlusal plane at T0 for all
subjects (Fig 4). Aligned digital models were imported
to 3-matic Research software (Materialise, Haasrode,
Belgium) for linear and angular measurements. Refer-
ence points and lines on each tooth in every model
were determined by the same investigator (G.S.D.)
(Figs 5 and 6). The reference points and lines on the
T0 and T1 models were transported into the aligned
model (T0-T1). The distance between reference
points was measured on the aligned models linearly in
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Fig 2. Intraoral photographs: A, pretreatment; B, postdistalization; C, end of treatment.

Fig 3. Digital models: A, pretreatment (T0); B, posttreatment (T1); C, superimposed (T0-T1).

millimeters (Fig 7) in the x, y, and z axes (Fig 6). Similarly,
the angles between reference lines were measured in de-
grees, and tipping, inclination, and rotation values were
obtained (Fig 8).
Statistical analysis
All statistical analyses and descriptive calculations
were made using SPSS for Windows software (version
20.0; SPSS, Armonk, NY). The means, standard devia-
tions, and minimum and maximum values of the linear
and angular changes in the x, y, and z planes were
calculated for all teeth. The total amount of linear move-
ment (D) was calculated using the Euclidian distance
formula.
The correlations among total linear movement
amounts among the different teeth were evaluated using
the Spearman rank correlation (r: positive linear correla-
tion if r . 0; negative linear correlation if r \ 0). The
correlation was considered very weak if the coefficient
was 0 to #0.25; weak, 0.26 to #0.49; moderate, 0.50
to #0.69; strong, 0.70 to #0.89; and very strong,
0.90 to #1.00. For evaluation of the methodologic

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Fig 4. Reference coordinate system and directions: A, frontal view; B, sagittal view; C, occlusal view.
X(1), Buccal direction (posterior teeth) and distal direction (anterior teeth); X(), palatal direction (pos-
terior teeth) and mesial direction (anterior teeth); Y(1), distal direction (posterior teeth) and retroclina-
tion (anterior teeth); Y(), mesial direction (posterior teeth) and proclination (anterior teeth); Z(),
intrusion; Z(1), extrusion.

errors, 15 patients were randomly selected from the 21
patients. Pretreatment and posttreatment measure-
ments were repeated after 1 month by the same investi-
gator, and intraobserver reliability was calculated using
intraclass correlation coefficients for every
measurement.
RESULTS
Intraobserver reliability values (intraclass correlation
coefficients) varied from 0.81 to 0.96 for all measure-
ments. The average monthly distalization rate was
1.02 mm, and the mean duration of distalization was
5.30 6 1.46 months (minimum, 3.9 months; maximum,
7.20 months). The survival rate of the paramedian mini-
screws in our study was high; no miniscrew failure was
observed. The amounts of the total movement and the
linear movements in the transversal (x), sagittal (y),
and vertical (z) planes for all teeth are presented in
Table I.
When the amounts of total linear movement in all 3
planes were evaluated, the movement of the maxillary
first molars was 4.67 6 1.32 mm. These changes were
2.79 6 1.05 mm for the second premolars and
3.77 6 1.33 mm for the second molars. The lowest total
movement was observed in the lateral incisors as
0.91 6 0.47 mm.
The linear movement (y-axis) of the first molars was
4.10 6 1.57 mm in the sagittal direction. The mean
distal movement of the second premolars was
2.90 6 1.08 mm. The lowest distal movement amount,
which decreased toward the anterior teeth, was
observed for the central incisors as 0.59 6 0.37 mm.
The distal movement of the second molars was
3.30 6 1.25 mm.
For angular movements (yz-axis), the amounts of
mean distal tipping were 11.02
6 5.32
for the first
molars and 6.21
6 3.49
for the second premolars in
the sagittal direction. The mean retroclination amount
of the central incisors was 1.59
6 0.91
(Table II).
In the transversal direction (x-axis), movement of the
first molars was 0.69 6 0.44 mm in the palatal direction,
and the mean movement of the second molars was
–1.16 6 0.55 mm buccally. The amounts of sponta-
neous palatal movement of the canines and the first
and second premolars were 0.77 6 0.39 mm,
0.46 6 0.36 mm, and 0.51 6 0.28 mm, respectively.

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192 Duran, G€org€
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Fig 5. Reference points: A, occlusal view; B, frontal view; C, sagittal view. 1, Mesio-occlusal point; 2,
disto-occlusal point; 3, cusp tips of canines and premolars, and medial points of incisors and molars; 4,
facial axis (FA)19 point.

Fig 6. Reference lines: A, T0; B, T1; C, superimposed models (T0-T1). 1, Line between cusp tip and
facial axis points (T0); 2, line between cusp tip and facial axis points (T1); 3, line between mesiodistal
occlusal points (T0); 4, line between mesiodistal occlusal points (T1).

In the transversal direction angularly (xz-axis), the
mean palatal tipping of the first molars was
–5.23
6 2.31
, and the mean buccal tipping of the
second molars was 7.75
6 4.07
. The mean distal
angulation amount of the central incisors was 1.03

6 0.59
.
In the vertical direction, only the first molars showed
intrusion, with a mean value of 0.59 6 0.50 mm. Of all
other teeth, the canines showed the greatest extrusion,
at 1.44 6 0.80 mm.
The second molars had the highest rotation mesio-
buccally at 7.89
6 5.57
, and the central incisors
showed the lowest rotation of 1.98
6 1.62
. The rota-
tion of the first molars was 4.92
6 3.09
. The coeffi-
cients for the correlations between total movement
amounts and their statistical significance levels are pre-
sented in Table III.
DISCUSSION
In this study, we analyzed the angular and linear 3D
tooth movements of the maxillary arch after molar dis-
talization performed with the support of skeletal
anchorage from the anterior palatal region. With the
excellent survival rate of miniscrews inserted into the

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Fig 7. Linear measurement on superimposed models (T0-T1).

Fig 8. Angular measurements: A, yz(1) distal tipping (posterior teeth) and posterior inclination (ante-
rior teeth); yz() mesial tipping (posterior teeth) and anterior inclination (anterior teeth); B, xz(1) palatal
inclination (posterior teeth) and mesial angulation (anterior teeth); xz() buccal inclination (posterior
teeth) and distal angulation (anterior teeth); C, xy(1) mesiobuccal rotation; xy() distobuccal rotation.

anterior palatal region, full fixed appliances were not molars. Thereby, it was possible to determine how the
required, and no active force was applied to the teeth potential spontaneous movements occurred in these
during the distalization period except for the first teeth 3 dimensionally. Only a few authors have

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Table I. Linear movements

Distance (mm) x-axis (mm) y-axis (mm) z-axis (mm)
Tooth
number Min Max Mean SD Min Max Mean SD Min Max Mean SD Min Max Mean SD
1 0.27 1.67 0.95 0.40 0.01 0.87 0.34 0.21 0.01 1.62 0.59 0.37 0.02 1.13 0.38 0.32
2 0.01 1.98 0.91 0.47 0.04 1.10 0.49 0.28 0.03 1.93 0.64 0.45 0.05 1.43 0.46 0.32
3 0.65 3.50 2.00 0.72 0.23 1.84 0.77 0.39 0.05 2.74 0.93 0.63 0.44 5.20 1.44 0.80
4 0.75 4.13 1.99 1.02 0.02 1.45 0.46 0.36 0.35 3.95 1.61 0.94 0.01 1.63 0.70 0.40
5 1.20 4.96 2.79 1.05 0.10 1.12 0.51 0.28 1.19 5.37 2.90 1.08 0.08 1.28 0.52 0.30
6 2.13 7.69 4.67 1.32 0.03 1.86 0.69 0.44 0.86 6.98 4.10 1.57 0.01 2.30 0.59 0.50
7 1.34 7.81 3.77 1.33 0.21 2.26 1.16 0.55 1.15 6.54 3.30 1.25 0.05 4.15 1.03 0.76

Min, Minimum; Max, maximum.

Table II. Angular tooth movements

xz (
) yz (
) xy (
)
Tooth
number Min Max Mean SD Min Max Mean SD Min Max Mean SD
1 0.14 2.73 1.03 0.59 0.02 4.10 1.59 0.91 0.02 7.87 1.98 1.62
2 0.02 5.25 1.83 1.35 0.30 8.51 3.05 2.11 0.98 7.63 3.38 1.58
3 0.65 9.77 3.63 2.29 0.43 8.24 4.29 2.43 0.59 9.90 3.84 3.13
4 0.46 6.26 2.31 1.52 0.73 11.25 4.85 3.18 0.35 10.86 4.44 2.25
5 0.20 7.46 3.75 1.84 0.60 11.56 6.21 3.49 1.59 8.66 4.86 1.96
6 1.16 9.63 5.23 2.31 2.13 22.06 11.02 5.32 0.53 11.96 4.92 3.09
7 1.47 19.57 7.75 4.07 1.37 19.87 9.06 4.77 1.87 20.70 7.89 5.57

Min, Minimum; Max, maximum.

adverse effect on molar distalization,23 some authors

Table III. Spearman coefficients between mean total
have suggested that there is no such effect, or the effect
tooth movements (Euclidian distance) of all patients
is minimal.5 A recent systematic review reported that no
Tooth studies have a high evidential value, and the second and
number 1 2 3 4 5 6 7 third molars have a minimal effect on the movement of
1 1
the first molars based on current studies.23 We paid
2 0.561z 1
3 0.347* 0.074 1 attention to the fact that all teeth, including the
4 0.078 0.054 0.424y 1 second molars but not the third molars, had erupted
5 0.012 0.009 0.571z 0.604z 1 and were properly lined across the buccopalatal direc-
6 0.037 0.022 0.022 0.087 0.393* 1 tion. In this way, the movement of the second molars
7 0.166 0.105 0.224 0.279 0.279 0.688z 1
was also analyzed, and the potential effect of eruption
*P \0.05; yP \0.01; zP \0.001. on distalization was eliminated. In this study, there
was no prerequisite for the presence and eruption of
the third molars.
investigated the potential spontaneous movements of The anterior palatal region is where the temporary
other teeth in the maxillary arch upon molar distaliza- skeletal anchorage units are inserted to prevent
tion.20,21 The use of reverse engineering software to anchorage loss during molar distalization.24 The anterior
evaluate tooth movements is a recent approach.22 Based palatal region is preferred because it is far from the roots
on the 3D analyses, there were movements of the ante- and the anatomic structures, provides adequate bone
rior and posterior teeth in various amounts in all 3 support, and is associated with high success rates.11
planes. There was a correlation in the combined move- Baumgaertel12 stated that the first premolars have the
ment among the measurements of the teeth. The highest greatest cortical bone thickness in the palatal region.
correlation value was 0.68 (r), observed for the first and Distalization was performed using direct anchorage
second molars, on which the force has a direct effect. with miniscrews for adequate anchorage support; thus,
Contrary to the opinions suggesting that the pres- anchorage loss was prevented, and the spontaneous
ence or eruption of the second and third molars has an movements could be observed for all teeth. Although

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the palatal region provides adequate bone support, it is
recommended to use 2 screws in a similar way as in our
study and to create a screw angle of 60
to 70
with the
occlusal plane.25
The conventional method to measure the amount of
movement of the molars and incisors from distalization
is to use lateral cephalometric radiographies and dental
cast photocopies.26 Cephalometric radiographs involve
radiation and may cause errors in landmark identifica-
tion because of superimpositions of symmetrical
anatomic structures.27 Three-dimensional evaluations
cannot be performed alone in either method; therefore,
these 2 methods should be used in combination. It is
possible to make a reliable and an accurate 3D evalua-
tion of tooth movements with digital models alone.26
It is reported that pretreatment and posttreatment digi-
tal models can be reliably aligned without the need for a
reference plane using reverse engineering software and
the best-fit mathematical superimposition method.17
This method uses the iterative closest point algorithm
and needs stable regions on different models for super-
imposition. In a study, the maxillary digital models were
superimposed on stable miniscrews in extraction pa-
tients, and it was stated that the palatal rugae region
is stable and could be included for alignment to evaluate
orthodontic tooth movements.28,29 This area was found
to be stable throughout a person's lifetime and also has
been used for establishing identity in forensics.15 The
validity of this method was evaluated in extraction pa-
tients22 and even in patients treated with orthopedic ap-
pliances such as rapid maxillary expansion and maxillary
protraction headgear.30 The authors of these studies
concluded that the method is clinically reliable. It was
reported that using digital models to evaluate dental
changes after distalization treatment is reliable and has
minor measurement differences when compared with
conventional superimposition methods.26 With this
method, the movement of each tooth over the arch
can be analyzed in all 3 planes of the space and measure-
ments can be performed frequently, since digital models
do not involve radiation.
It has been reported that the mean distalization
amounts in the sagittal direction after distalization are
3.34 mm with tooth-borne intraoral distalization
methods and 5.10 mm with skeletal anchorage.31 In
our study, the mean distalization of the maxillary first
molars was 4.10 mm in the sagittal plane (y-axis) after
a mean distalization duration of 5.30 months, which
was consistent with the literature. The mean amount
of total movement was 4.67 mm. Mean overall distaliza-
tion speeds were reported to be 0.6 mm per month with
the Beneslider appliance14,32 and 0.7 mm per month
with a skeletally anchored pendulum device.33 In our
American Journal of Orthodontics and Dentofacial Orthopedics
195
study, the speed was greater than with these anchored
distalization appliances, at 1.02 mm per month. Distal
movement decreases as the distance from the first mo-
lars increases, and the total movement amount of the
central incisors was 0.95 mm, with distal movement of
0.6 mm in the y-axis. It is known that the tension of
transseptal fibers is involved in the amounts of distal
movement of the teeth and the correlations. The distal
movements of the posterior teeth and the backward
movements of the anterior teeth that were observed in
varying amounts can contribute to the correction of
anterior crowding; therefore, this is likely to shorten
the treatment with fixed orthodontic appliances, the sec-
ond stage of treatment.
Distal tipping of the first molars is an expected reac-
tion after distalization treatment.34 It is reported in the
literature that the molars have distal tipping varying
from 3
to 12
after distalization with skeletal
anchorage.31 In our study, the distal tipping of the first
molars was 11.02
. This result appears close to the upper
limit of the above-mentioned range. According to an
opinion in this regard, the whole force is delivered to
the tooth on which the force is applied because of the
stability of the skeletal anchorage unit during distaliza-
tion with skeletal anchorage methods. However, the
pressure caused by the force on the tooth is reduced
by the potential anchorage losses (mesial movement of
premolars and anterior teeth) in intraoral or other
tissue-supported distalization methods. This, in turn, re-
sults in greater tipping of the molars in skeletal
anchorage methods.9 According to our results, distal
tipping was reduced toward the anterior region. The
amounts of retroclination of the central and lateral inci-
sors were 1.98
and 3.38
, respectively.
Although the greatest movement was observed in the
sagittal plane (y-axis) after distalization, there was
movement of the first molars in the vertical (z-axis)
and transversal (x-axis) planes at minimal levels
(0.60 mm intrusion and 0.69 mm buccal, respectively).
The type of movement is determined by the rigid
connection between the screw and the teeth, and the
relationship between the force exerting direction and
the resistance center of the molars. The slight changes
in the vertical and transversal directions are believed to
be a result of the force exerting direction and the rigidity
of the appliance. The vertical and transversal changes
were similarly slight for the other teeth on which an
active force was not applied. The greatest vertical move-
ment was observed for the canines, with a mean extru-
sion of 1.44 mm. Although the vertical direction can
be controlled with a rigid appliance, the first molars
cannot follow the arch form because the movement
goes toward the posterior side along the transversal
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196
direction. A posterior crossbite risk occurs when exces-
sive distalization is required. This effect is the greatest
disadvantage of the appliance design.
No authors have investigated the rotational changes
of all teeth over the maxillary arch during distalization.
We observed different amounts of rotation for all teeth;
we found that the mean rotation of the first molars was
4.92
, and the second molars had the greatest rotation
(mean, 7.89
). The movements of the second molars
after distalization are based on many factors such as
morphology, locations, and spongious bone.35 However,
it is believed that the appliance design for the control of
buccal movements and rotations of the second molars
can be developed to involve these teeth.
Although we examined angular changes, how such
changes occur in the root movements could not be
examined; this was the limitation of our study. Root
movements can be examined only with 3D imaging
techniques such as cone-beam computed tomography
and computed tomography. There is a need for studies
that evaluate the angular changes by imaging the roots
and crowns together.
CONCLUSIONS
With support from the palatal region, the maxillary
first molars were distalized by an average amount of
4.10 mm, with 11.02
of distal tipping and 0.60 mm
of intrusion. Distal movements were observed in the di-
rection of the force at different levels for all maxillary
teeth upon distalization. Furthermore, movements
were observed in all 3 planes of space with reduction
from the posterior to the anterior in the maxillary arch.
The highest correlation between the movements of the
teeth was observed between the first and second molars.
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July 2016  Vol 150  Issue 1