Dr. Soja Sara George, et al.

44

Maxillary Molar Distalization with Modified Trans Palatal

Arch and Mini-Implants
Dr.Soja Sara George*, Dr.Vijay Reddy**, Dr.Deepti Reddy***, Dr.Renu Parmar****

Abstract
Mini implants have been used to eliminate headgear wear and to establish stationary anchorage. In this
case report, distalization was achieved with a modified TPA with soldered J-hooks, which were coupled to
palatal implant with e-chains. Two mini screws of dimension of 8 mm length and 1.8 mm diameter were
nd st
placed interdentally between 2 premolar and 1 molar. The results showed that the maxillary molars
were distalized bodily without causing anchorage loss or distal tipping, extrusion or rotation of the molars.
Final results showed improvement in lip profile, smile esthetics and achievement of class I molar and
canine relationships. In conclusion, palatal interdental implants can be used effectively for maintenance of
anchorage and in space-gaining procedures.
Key words: Mini screws, Distalization, Maxillary molars.

A ngle’s Class II Division l malocclusion has

been described as the most common
malocclusion in orthodontic practice. In treatment
springs, Wilson arches, and sliding jigs with Class
II inter-maxillary elastics. On the contrary,
techniques that rely less on patient cooperation
of Angle’s class II malocclusion with anterior have also been routinely used like repelling
crowding and increased over jet, distalization of magnets, transpalatal arches, compressed coil
maxillary molars or extraction of premolars is often springs, and the Herbst appliance. Though all
1
the preferred treatment alternative. these techniques distalize maxillary molars
effectively however, the major limiting factor is
Patients with orthognathic facial profiles, end-on anchor loss; characterized by distal tipping of
inter-arch molar relationship, mild to moderate maxillary molars, proclination of teeth anterior to
space requirement (nearly 3-4 mm on either side) the molars resulting in an increased overjet.
2

and a good soft tissue balance are often ideal

candidates for maxillary molar distalization. With the introduction of skeletal anchorage system
However, distalization of the permanent molars it has now become possible to translate permanent
has been one of the most difficult biomechanical molars distally whilst simultaneously correcting
problems in conventional orthodontics, particularly maxillary incisor protrusion, crowding, and dental
in adult patients. asymmetries without anchor loss. Temporary
anchorage devices such as endosseous implants,
Various treatment modalities for molar distalization miniplates, onplants, or mini screws provide
have been tried including those that depend on absolute anchorage for many complicated
patient compliance, such as extra-oral traction orthodontic tooth movements including intrusion,
using headgears, removable appliances with finger en-masse retraction and distalisation of molars.
*
Consultant orthodontist, Hyderabad,Andhra Pradesh.
**
Professor, Department of Orthodontics, Sri Sai College The case report demonstrates an effective
of dental surgery,Vikarabad, Andhra Pradesh. technique of maxillary molar distalization in
***
Professor & Head of the department, Department of tandem with anchorage preservation using
Orthodontics, Sri Sai College of dental surgery,Vikarabad,
miniscrew supported transpalatal arch.
Andhra Pradesh.
****
Consultant orthodontist, Bangalore,Karnataka.
Correspondence address: [email protected]

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 Dr. Soja Sara George, et al. 45

CASE REPORT:

A 13 Yr old female presented with the chief

complaint of irregularly placed upper front teeth
and an unpleasing smile.

On extra-oral examination, the patient exhibited

convex profile with slightly incompetent lips
(Interlabial gap of 5mm), acute naso-labial angle, a
consonant smile arc, adequate incisal display at
rest (4 mm) and full maxillary incisal display during

smile, with a mild degree of chin retrusion and

prominent nose. (Figure 1)

Fig. 1 – Pretreatment extra oral photographs:

13 year old patient with a slightly convex
profile, mild retro-positioned chin, consonant
smile arch with minimal lip incompetence

Intra-orally, the patient demonstrated an end-on

inter-arch molar and canine relationship on both,
the left and the right sides. Peg shaped maxillary
lateral incisors (12, 22), a moderate degree of
maxillary (04 mm) and mandiblular (06 mm)
anterior crowding, an increased overjet (04 mm)
and non-coinciding dental midlines. (Figure 2)

Lateral cephalogram showed, class I skeletal

˚
pattern (ANB=02 ) with vertical growth pattern of
34˚ (GoGn - SN) and the CVMI – showed 20-30%
growth remaining. Steiner analysis showed that
both the upper and lower incisors were proclined
and protracted. The nasolabial angle was acute at
0
85 . There were no signs and symptoms of
temporomandibular disorders. Distance from the
pterygoid vertical to distal of maxillary molar
showed that maxillary molar was mesialised by
3mm. Based on the cephalometric findings, the
patient was diagnosed with skeletal Class I with
severe crowding.

Treatment objectives were to align and level the

teeth in both arches, to achieve Class I canine and
molar relationship and ideal over jet and overbite,
reshaping of peg shaped laterals, to obtain a
balanced facial profile and to improve smile

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 Dr. Soja Sara George, et al. 46

esthetics. The treatment objectives could be chin retrusion would be corrected with remaining
achieved by using one of the options: 1) Extraction growth (CVMI showed 20-30 % growth remaining).
of all first premolars. Extraction treatment was not 2) Distalization of the maxillary molars with mini-
opted considering her age, profile and prominent implants was opted, as this would correct the class
nose. Even though her profile was slightly convex II molar and canine relation, resolved crowding
with mild degree of chin retrusion, it was and proclination of the anteriors.
3
acceptable according to Indian soft tissue norms.
Inspite of her upper incisor proclination, her facial Conventional method of maxillary molar
esthetics was balanced and any mild degree of distalization (Eg: pendulum appliance, headgears)
were not used due their adverse effects of

Fig. 2- Pretreatment intra-oral photographs demonstrating peg-shaped maxillary laterals with end-on
molar and canine relationship bilaterally and lower anterior crowding

anchorage loss, increasing the mandibular plane

angle, proclination of anteriors and due to the
demand of patient compliance. Distalization with
mini implant was planned, as it gave bodily
movement of maxillary molars and vertical control.

The treatment proposed was, distalization of the

maxillary molars to correct the end-on molar
relationship, to resolve crowding and maxillary
teeth protrusion using palatally placed mini screws
for anchorage.

Fig. 3: Miniscrews placed palatally between the

nd st
2 premolar and the maxillary 1 molar with
customized TPA with soldered J-hooks

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 Dr. Soja Sara George, et al. 47

Two mini screws (Orlus, Ortholution, Seoul, Korea) of 0.036-inch (0.9 mm) hard round stainless steel
of dimension of 8 mm length and 1.8 mm diameter with soldered J-hooks was constructed in a way to
nd
were placed interdentally between 2 premolar extent it bilaterally from one molar to the other.
st
and 1 molar. A Modified transpalatal arch (TPA) (Figure 3)

nd st
Fig. 3 Miniscrews placed palatally between the 2 premolar and the maxillary 1 molar with customized
TPA with soldered J-hook

by e-chain applied from the J-hooks to the mini-

screws. The screws were placed 6-7 mm below
the free gingival margin, which was nearly the
region of maxillary molar trifurcation. (Figure 4)
Thus, the elastic traction was applied in a way that,
the distalizing force would pass close to the centre
of resistance of maxillary molars. Consequently,
the molars were translated bodily without any
untoward rotation or tipping. Also, while no
anchorage was derived from the anterior teeth
accordingly, there was no proclination of the
maxillary anteriors. (Figure5)

The patient was reviewed every 4 weeks and the

e-chain changed to maintain a constant
distalization force. The first molars were distalized
into an over-corrected Class I molar relationship,
which was confirmed in both post treatment
radiographs. (Figure 6 and 7)

Fig 4.Schematic representation with the The mini screws were retained in-situ post
biomechanical illustration distalization, and the TPA- miniscrew assembly
alternatively used as a retainer during the second
The J-hooks were positioned in the canine region
phase of fixed orthodontic mechanotherapy.
and the distalising force (200 gm) was generated

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 Dr. Soja Sara George, et al. 48

Fig 6–Post treatment extra oral photographs

Fig. 7– Post treatment intraoral photographs-The maxillary peg shaped laterals were built-up and normal
over-jet and over-bite established. The smile esthetics is many folds enhanced and the facial balance is
maintained.
0
This included a strap-up with 0.022’’ slot MBT nasolabial angle to 95 , which were in normal
prescription of the segment anterior to the range.
distalized molars. The arches were aligned,
leveled and the space gained was utilized to de- DISCUSSION
crowd the maxillary arch and for build-up of the
Molar distalization with head gears had
peg laterals to normal morphology.
disadvantages of patient compliance and duration
Post treatment facial photographs showed of wear. Various other intra oral distalizing
improvement in lip profile and smile esthetics. appliances used, cause anchor loss with maxillary
(Figure 6) Class I molar and canine relationships incisor proclination and increased over-jet.
were observed with a 3mm over jet and a 2mm
In this case report, molar distalization was
overbite. Cephalometric superimposition showed
achieved with a modified TPA with soldered J-
that the maxillary molars were distalised bodily by
0
hooks, which were coupled to palatal implant with
3mm. Mandibular plane angle reduced to 31 and
e-chains. This mini screw distalization system
effectively distalized molars into class I

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 Dr. Soja Sara George, et al. 49

relationship, without causing anchorage loss or untoward tipping or rotation of the teeth distalized.
distal tipping, extrusion or rotation of the molars. Further the amount of movement is controllable
For the implant placement on the buccal side, and it is also possible to apply asymmetric force on
4,3
where the inter-radicular space is smaller, the each side.
screw would have to be inserted more apically. But
such placement has been associated with With the introduction of miniscrews in the
inflammation leading to mini screw failure and can orthodontic armamentarium, molar distalization
cause patient discomfort. As the palatal mucosa is which was once considered difficult to achieve,
highly keratinized, the mini implant can be placed can now be performed with good prediction and
5, 6
as high as necessary without complications.
4 efficiency. Use of palatal implants has the
advantages of availability of more inter-dental
CONCLUSION space than buccal inter-dental space. However,
disadvantage of palatal inter-dental implants are
The advantages of mini screw anchorage over the possibilities of movement of adjacent teeth,
conventional mechanics include the elimination of also difficulty in surgical procedure than for the
patient compliance and the provision of absolute buccal implants.
anchorage, with no proclination of anteriors or

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