Beruflich Dokumente
Kultur Dokumente
1051/odfen/2014028
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
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.
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.
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.)
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.)
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.
Figure 7a, b, c, d
Figure 8a
Dr Thebault’s Tekka plate sectorial molar distalization with Distaler.
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.
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.
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
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
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.
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,
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.
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.
BIBLIOGRAPHY
1. Byloff F, Darendeliler MA, Stoff F. Mandibular molar distalization with the Franzulum
Appliance. J Clin Orthod 2000;34(9):518-23.