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1. METHODS OF GAINING
SPACE.
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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2. Key-stoning procedureHarry G.Barrer JCO Aug 1975
A. Malposed incisors
B. interproximal relationship after key stoning
Rounded surfaces slip and
rotate.
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3. Key-stoning procedure:
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4. Nonsurgical rapid maxillary alveolar
expansion in adults:a clinical evaluation.
Chester S. Handelman, Angle Orthodontist, 1997 vol 67
•Late teens and early 20’s questionable.
•Sutures: rigid and fuse.
•SA-RME.
Non Surgical Maxillary expansion:
Pain, swelling, ulceration, flared posterior teeth, bite opening,
gingival recession, and perforation of the buccal alveolus.
Vanarsdall: in children, gingival recession and dehiscence of bone
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5. • 5 adults with transverse deficiency- treated
nonsurgically using Haas appliance.
•RMAE- expansion centered in the alveolar process of
maxilla rather than the body.(lateral walls of the
palate)
•Bilateral/unilateral crossbites, arch constriction.
2 quarter turns/day
Haas appliance
Later 1 quarter turn/day
U 1 no separation.
12 weeks retention.
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6. Displaces the alveolus with the teeth rather than
expanding the teeth through the alveolus.
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7. bilateral
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8. Unilateral
crossbite –
left
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9. www.indiandentalacademy.com
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10. www.indiandentalacademy.com
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11. RMAE acceptable alternative to SA-RME in adults for maxi deficiency.
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12. Nickel-Titanium Palatal expander.
2 properties: Shape memory & superelasticity.
Exists in more than 1 crystal structure.
Lower temp-martensite.
temp:94degree
Transition
Higher temp-austenite {phase transition}
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13. MOLAR DISTALIZATION
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14. Indications for Molar distalization
1. In a growing child
- to relieve mild crowding
- causes permanent increase in arch
length of about 2mm on each side.
2. Late mixed dentition
-
When lower E space –utilized for relief of
anterior crowding,
-
Upper molars distalized to get a class I
relation
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15. Indications for Molar distalization
3. Non-growing patient
-
To regain lost arch length
-
Blocking out of canines
4. Upper second molar extraction
-
Lower arch normal
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16. Indications for Molar distalization


Class I malocclusion- with highly placed canine/impacted
canine
Lack of space for eruption of premolars due to mesial
migration of permanent first molars
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17. Indications for Molar distalization

Good soft tissue profile

Borderline cases

Mild to moderate space discrepancy with missing
3 rd molars/2 nd molars not yet erupted

End on molar relation with mild to moderate
space requirement.

Cases with less than full cusp class II molar
relation.
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18. Case selection
1. Normal or near normal mandibular arch
2. Late mixed dentition-ideal
- Early permanent dentition-growth still left in maxillary
tuberosity area.- 16-17 yrs-males
14-15 yrs-females
3. Molars
placed normally- buccopalatally.
4. 3rd molars-absent –stacking of upper molars – unsuitable
5. Profile considerations- well developed nose & chin
6. High MPA- contraindicated-wedging effect
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19. Classification
1.
Location of appliance

Extra-oral

Intra-oral
2. Position of appliance in mouth

Buccal

Palatal
3. Type of tooth movement

Bodily movement

Tipping movement
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20. Classification
4. Compliance needed from patient
 Maximum compliance
 Minimum or No compliance
5. Type of appliance

Removable

Fixed
6. Arches involved
Intra-arch
Inter-arch
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21. Various appliances used for
Molar Distalization :










Head gears
Pendulum appliance.
Coil springs Niti and S.Steel
Distal jet
K loop
Jones Jig
Magnet
Wilson’s Bimetric loop
Use of super elastic NiTi
Franzulum appliance.
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22. Various appliances used for Molar
Distalization










ACCO
Crozat appliance
Crickett appliance
Modified Nance lingual appliance
Schmuth and Muller double plates
Claspring
Removable molar distalization splint
Fixed piston appliance
Using implants
Fixed functional appliance
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23. Distalization using Headgears

Very efficient

Reciprocal forces are not transmitted to other teeth

Molar movements depends on direction of force in relation to
the C Res of the molar & magnitude of force
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24. Biomechanics of Headgears:

C Res

Moments
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25. Cervical Headgear



Short face Class II
maxillary protrusive
cases with low MPA
& Deepbites
Extrusive & distalizing
effect
Lower anterior facial
height is less.
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26. High pull Headgear




Produces intrusive &
Posterior direction of pull
Long face class II
patients with high MPA
Force through C Res –
Intrusion & distal
movement of molar
6-8 months – class IIclass I
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27. Straight pull headgear

Class II Malocclusion with
no vertical problems

Prevent anterior
migration of maxillary
teeth, translate them
posteriorly
Adv-effective, no reciprocal forces
Disadv- Patient compliance
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28. Modification of the Bimetric arch

Class II correction- Distalization + expands caninepremolar area- unlocks the occlusion

A mild-moderate class II div 2 with normal mandibular
arch-easily corrected
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29. Modification of the Bimetric arch
Archwire design:
 .016”premium wire
 Premolars bonded if
expansion is
required
 Teardrop shaped
loop
 Bite opening bend
 Mild toe-in
 2mm activation
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30. Elastic load reduction principle:

Class II elastics – used sequentially
T.P Green – 1st week
Pink - 2nd week
Yellow – next 2-3 weeks

Initial heavy force- to resist forward
pushing force of new wire- force
transferred distally

Later Molar uprights-mesially directed
archwire force decreases- support with
light forces.

Extrusive component of class II- kept
to a minimum www.indiandentalacademy.com

1mm/month.wire
activated for 3
visits.

Borderline
cases –Non Ext
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31. K-Loop molar distalizing
appliance Valrun Kalra – JCO 1995

K-loop – forces - .017 x .025 TMA

Nance button – anchorage

8mm long , 1.5 mm wide

Legs- 20 degree bend

Inserted into molar and first
premolar tube, marked

Stops bent 1mm distal , 1mm
mesial

Stops- 1.5mm long
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32. 
Reactivated by 2mm 6-8 weeks later.

molars move by 4mm, premolars by 1mm

Anchorage can be reinforced by headgear
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33. K- loop Appliance
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34. Distalization of Molars with
Repelling Magnets Gianelley etal JCO 1988

Anchorage – Modified Nance
appliance

Wire extending from 1st
premolars

Acrylic button anteriorly
contacting the incisors

Auxiliary wire with a loop at its
end soldered - premolars bands
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35. Distalization of Molars with
Repelling Magnets

Incisor brackets – passive
sectional wire- maintain incisor
alignment

Repelling surfaces of magnets
brought into contact by passing
an .014 ligature through the loop,
then tying back a washer anterior
to the magnets

Force- 200-225 gms , dropped as
space opened

3mm in 7 weeks

Anchor loss – 1mm
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36. Molar distalization with Superelastic
NiTi wire
Gianelly JCO 1992

100gm Neosentalloy upper
archwire

3 markings

Stops crimped, hook added

Insert wire such that posterior
stop abuts mesial end of molar
tube, anterior stop abuts distal of
premolar.Xs wire deflected gi

Anchorage reinforced by class II,
or Nance appliance
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100g
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37. Molar distalization with
Superelastic NiTi wire
Case report :

12 yr / F

Unilateral class II

Class II elastic against
upper 1st premolar

Overcorrected- 4 months
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38. NiTi Double Loop system for simultaneous
distalization of first and second molars
Giancotti JCO 1998

Mandibular molars and 2nd premolars
banded, other teeth bonded

Lip bumper- prevent extrusion

Maxillary molars and bicuspids –
banded, aligned

80 gm Neosentalloy – maxillary
archwire placed – marked
1.
Distal to 1st premolar
2.
5mm distal to 1st molar tube

Stops crimped on markings
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39. NiTi Double Loop system for
simultaneous distalization of first and
second molars

2 Sectional NiTi archwires
– crimp stops
1.
Mesial and distal to 2nd
premolar
2.
5mm distal to 2nd molar
tube

Uprighting springs on 1st
bicuspids

Class II elastics

Simultaneous, bodily
movement
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40. 24yr/f, class II div I
5months- overcorrected
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41. NiTi Double Loop system for simultaneous
distalization of first and second molars

Useful technique – Class II div I

Minimal patient co-operation

Ideal for simultaneous distalization U7 easier ‘.’ anatomy.

Due to stretching of transeptal fibers, 1 st molars can be distalized using
lighter 80 gm force

Anchorage easily controlled , without need for TPA/Nance’.’light forces
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42. NiTi Open Coil Springs
Dia 0.012”
Lumen 0.030
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43. Pendulum Appliance for class II noncompliance therapy
JAMES J.HILGERS,JCO 1992

Nance button for anchorage

.032” sTMA springs-light
continuous forces

Broad swinging arc
(Pendulum) of force from
midline of palate to upper
molars
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44. Pendulum Appliance
Fabrication :
Pendulum springs
consist
Recurved molar insertion
wire
1.
Horizontal adjustment
loop
2.
Closed helix
3.
Loop for retention in
acrylic button

Springs- close to center
of Nance button
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45. Springs close to center of
palatal button:to maxi range
of action, easy insertion.
Retaining wire is soldered to
the U4 and extended into
acrylic.
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46. Pendulum Appliance

Nance button- extend to about 5mm
from teeth

Anterior retention loops fixed on
model, later soldered to bicuspid
bands

Acrylic pressed against the palatal
vault

Pendulum springs inserted
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47. Pendulum Appliance
Pend-X
Expansion needed:
Jack-screw-One-quarter turn
every 3 days
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48. Pre activation and placement
After cementation,before
activation:
Springs prefabricated to lie
parallel to midsagittal plane,
Which produces 60* of
activation after insertion.
As the molar distalizes it
moves on an arc towards
midline-counteracted by
opening horizontal loop
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49. Intra oral reactivation:
Center of helix held with bird
beak plier while, spring is
pushed distally & reinsert.
Stabilization:
•Nance button
•Upper utility arch- anterior segment- anchorage.
•Full arch bonding:continuous wire with omega loop.
•Head gears ?
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50. Pendulum Appliance

Unilateral correction
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51. Pendulum Appliance
Conclusion :

Excellent patient tolerance

Upto 5mm distalization in 4 months

Distalization + Expansion

Patient compliance not needed
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52. Franzulum appliance
Friedrich Byloff et al

Anterior anchorage : acrylic
button-5mm wide

Rests on canine and
premolars - .032”S.Steel
wire

Tube from acrylic button to
receive active component

NiTi coil springs-100200g/side

JCO2000 sep
J-shaped wire inserted into
tube
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53. Franzulum appliance:
Niti spring over J shaped
wire
Inserted into tube of anterior
anchorage unit
•Anchor unit bonded
with composite.
•Close to CR of molarpure bodily movement.
compressed
Tied into lingual sheath
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54. Case report

11yrs 10mts / M







end on molar relationship
Space deficiency in both the
arches
Premolars blocked out
Fixed appliance with cervical
headgear and Cl II elastics
End of treatment; Class I molar
relation, no significant change in
facial profile
U6:3mm,L6:6mm Lower incisors
proclined. Extrusion of U&L 6
Long term stability????
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55. Distal jet Appliance
Aldo Carano, Mauro Testa JCO 1996

Lingual molar distalizing
appliance

Appliance design :
Wire extending from acrylic
through tube ends in a bayonet
bend-inserted into lingual sheath


Coil spring clamped on tube

Clamp

Anchor wire to 2nd premolar
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.036” int dia
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56. Distal jet Appliance

Reactivation- sliding clamp
closer to first molar,once a
month.

After distalization –
- clamp-spring assemblyacrylic,
- premolar arms cut off.
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57. Distal jet Appliance
Case report

18/F, Class II div I

No skeletal abnormalities

Non-extraction therapy (3rd molars
removed)

Distal jet

4 months- Class I ,2mm-L, 3mm-R
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58. Distal jet Appliance
Advantages :
 Bodily movement
 Easy insertion
 Well tolerated
 Esthetic
 Unilateral, Bilateral
 Permits simultaneous use of full bonded appliances.
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59. Open Coil Jig
Jones, White –JCO 1992 Oct
NiTi springs 70-75g
Nance button attached to
U5
Assembly tied in place
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60. Open Coil Jig
3
1.
Fixed Sheath
4.
Hook
5.
Sliding Sheath
6.
5
Light wire
3.
6
Heavy round wire
2.
4
1
Open coil spring
4-5mm of distal
movement.
2
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61. Conclusion





Borderline cases
Space gaining procedures
Simplicity
Clinical effectiveness
Patient compliance factor
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62. Distraction Osteogenesis:





New bone formation b/w the surfaces of bone
segments gradually separated by incremental traction.
Tension-stimulates new bone parallel to vector of
distraction.
tension in surrounding soft tissues, initiating a
sequence of adaptive changes termed as distraction
histogenesis.
Skin, fascia, bl vessels, nerves, muscles, cartilage,
periosteum.
Illizarov.
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63. Mandibular Sympyseal distraction.








Mandibular symphyseal distraction- space gaining.
Intra oral mandibular distraction device.
More stable results.
Corticotomy.
Latent period.5-7days.(fibro vascular bridge)
Activation.optimum rate: 1mm/day(0.5mm-premature
ossification,2mm-fibrous CT , ischemia)
Consolidation (remodeling) concomitant soft tissue
expansion.
Retention.
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64. Thank you
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