Molar distalization

MOLAR DISTALIZATION
Supervisor Prof.Dr Maher Fouda
By: Bara’ Hanandah

Introduction
Treatment of Class II malocclusions frequently
requires distalization of maxillary molars into a Class
I relationship. A variety of treatment modalities
have been suggested, including those that are
heavily dependent on patient compliance such as
extraoral traction, removable appliances with finger
springs,Wilson arches, and sliding jigs with Class II
intermaxillary elastics) The techniques that rely
less on patient cooperation include repelling
magnets, transpalatal arches, compressed coil
springs, and the Herbst appliance.
American Journal of Orthodontics and Dentofacial Orthopedics December 1996

Gaining space in the mandible is more difficult
than in the maxilla. Extraoral appliances are
seldom attached to the mandibular molars
because of the pressure they place on the
condyles. The most commonly used intraoral
appliances are lip bumpers, lingual arches, and
removable appliances with screws or springs
(which depend on patient compliance for their
success ).
JCO/SEPTEMBER 2000

Other than the third molars and maxillary
canines, the mandibular second premolars have
the highest percentage of impaction. One of the
major causes is early extraction of the deciduous
predecessor, which can cause a mesial drift and
tilt of the molars that impedes the eruption of
the second premolar.

Placing an open-coil spring on the archwire
between the first molar and the first premolar is
the technique most commonly used to move the
migrated molars back to their original positions
and create enough space for the impacted tooth to
erupt. To prevent a reactive mesial drift of the
anterior teeth, however, the upper arch must be
anchored with a headgear and intermaxillary
Class III elastics.

Third molar angulation during and
after treatment in relation to
Impaction
It is suggested that premolar extraction therapy
has a favourable effect on maxillary third molar
angulation, while changes in mandibular third molar
angulation during treatment may be similar in
patients treated with and without premolar
extractions. The findings also indicate that distal
tipping of the maxillary third molars during active
treatment, more than 30 degrees of distal
angulation, and any mesial angulation relative to the
occlusal plane at the end of treatment, are risk
factors for subsequent impaction
European Journal of Orthodontics 27 (2005) 590–596

• In addition, mandibular third molars
angulated more than 40 degrees mesially
relative to the occlusal plane at the end of
treatment may be at increased risk of
impaction. Changes in third molar angulation
from one direction to another may be
common in both arches during the fi nal
stages of root development, and less than 50
per cent of erupted third molars assume an
ideal angulation in the dental arch.
European Journal of Orthodontics 27 (2005) 590–596

THIRD MOLARS Extraction
Third molars that have erupted or are close to
erupting tend to impede the distal movement of the
first and second molars. For this reason, they are
removed when possible. However, the decision to
extract these teeth has important strategy implications.
If third molars are removed, molar distal movement to
gain the space to resolve the malocclusion is virtually
mandatory because maxillary premolar extraction is no
longer tenable as it would involve extracting four teeth
in the same arch.
Gianelly -American Journal of Orthodontics and Dentofacial Orthopedics July 1998

After third molars have been extracted and
progress is inadequate when moving both first and
second molars posteriorly at the same time, the
procedure is changed and the molars are moved in
sequential manner as described; second molar
distal movement is followed by first molar distal
movement. The gain in safety compensates for the
increased time necessary to complete molar distal
movement.
Gianelly -American Journal of Orthodontics and Dentofacial Orthopedics July 1998

Using Removable Appliances
• RESISTANCE TO TOOTH MOVEMENT
(ANCHORAGE), 2
Distal movement of a buccal segment
Following extraction of an upper second molar
the first molar and both premolars of that side
may be moved distally, three teeth moving
against an anchorage of nine teeth. The labially
displaced canine is not included in either part
of the appliance.

An Atlas of Removable Orthodontic Appliances Second edition GORDON C. DICKSON &ALBERT E. WHEATLY

DIST AL MOVEMENT OF BUCCAL
SEGMENT (SCHWARZ)
Distal movement of an upper buccal segment after
extraction of the second molar can be accomplished
by means of the appliance illustrated. A hard metal
screw is placed with its long axis parallel to the line
of the segment to be moved and to the occlusal
plane. A short, steep inclined plane is incorporated
to assist anchorage by applying some forward
pressure to the lower incisors (Inset). A spur or half-
clasp on the left lateral incisor prevents this tooth
drifting distally.

Rate of activation
The screw is turned at the rate of one quarter-turn per week.
Construction
Screw: Hard metal (stainless steel) with guide pin
Spur:O.6mm stainless steel wire
Retention: Adams clasps on 64/46
Baseplate: Full palate with anterior inclined plane, divided by
two cuts, one across the screw and the other exactly
parallel with the buccal segment to be moved and with the
long axis of the screw

Cetlin appliance
Distalization Treatment:
Several different treatment modalities may be employed
to distalize the posterior dentition. Possibilities include
removable appliances such as a modified Cetlin appliance.
This type of appliance has a high acceptance among adult
patients because it facilitates good oral hygiene and allows
adaptation to lingual appliance during the initial phase. The
removable Cetlin appliance is constructed from 2 Adams
clasps on the first premolars, distalizing springs on the
second premolars and on the first molars, distalizing screws
between the first and second premolars, and an anterior
bite plane. The appliance does not include any metal clasps
from cuspid to cuspid due to esthetic consideration.

Modified Cetlin appliance. Note the distalization screws.
LINGUAL ORTHODONTICS © 1998 Rafi Romano

Acrylic cervical occipital (ACCO)
This appliance consists of an acrylic palatal
section (1 mm bite plate) to disclude the
posterior teeth, modified Adams clasps on the
first premolars, a labial bow across the incisors
for retention, finger springs against the mesial
aspects of the first molars for molar distalization
in association with an extraoral traction . With
the combined use of ACCO and headgear, molars
can be moved distally in a more bodily fashion.
The finger springs move the crowns, and the
headgear moves the roots .
Sfondrini et al. Upper molar distalization Orthod Craniofacial Res 5, 2002/114–126

Acrylic cervical occipital (ACCO)

A Removable Class II Appliance
for Simultaneous Distalization
and Expansion
Treatment of a case of Class II malocclusion
with maxillary arch constriction and anterior
crowding generally involves expanding the arch,
distalizing the molars, and aligning the anterior
teeth.This article introduces a removable
appliance that can simultaneously correct a
Vshaped upper archform and move the upper
molars distally.
JCO/OCTOBER 2005

Removable appliance for simultaneous molar
distalization and maxillary expansion.
JCO/OCTOBER 2005

The acrylic plate of the appliance is fabricated with
occlusal coverage to maintain anchorage, prevent
occlusal interferences, and control the vertical
dimension and molar tipping. Mechanical retention is
provided by Adams clasps on the first molars and
finger springs on the premolars. A Bertoni multiple-
sector palatal screw is embedded in the acrylic at the
level of the contact points of the first molars and
second premolars, bisecting the midpalatal raphe.
Placing the screw in this position and sectioning the
acrylic plate into three parts makes it possible to
simultaneously move the molars distally and expand
the anterior archform.
JCO/OCTOBER 2005

For distalization, the screw is activated in a
sagittal direction once a day during the first two
weeks. For expansion, a transverse activation is
begun in the second week with a quarter-rotation
per day. In the third week, both activations should
be reduced to every other day until the molars
have reached a Class I relationship and sufficient
expansion has been achieved. The appliance
should then be left in place for passive retention,
of about half the duration of the expansion.
JCO/OCTOBER 2005

13-year-old male Class II patient with retruded upper lateral incisors and canines in
supraversion before treatment.
Patient after 24 months of treatment with removable and fixed appliances.

Removable Molar Distalization Splint
Appliance Design
The clear splint is made from 1.5mm Biocryl in a Biostar
machine. If both upper first molars are to be moved distally
at the same time, the splint extends from the area of the
upper right first or second premolar to the area of the upper
left first or second premolar. If only one molar is to be
moved, the splint extends to the terminal molar on the
opposite side (Fig.). Two internal clasps are used for
retention, and a nickel titanium open-coil spring produces
about 220g of distal force at the beginning of treatment The
coils are reactivated when they have been compressed as far
as the bonded molar button or the molar band.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1995 Jun(396 - 397): Removable Molar Distalization Splint DR. A. KORRODI RIT

Fig. Appliance design for unilateral molar distalization.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1995 Jun(396 - 397): Removable Molar Distalization Splint DR. A. KORRODI RIT

A. Beginning of treatment with unilateral
molar distalization splint. B. After three
months of treatment. C. Distal movement
achieved in three months.

Using Extra-oral Traction
The use of headgear for the distal movement of
maxillary molar teeth has probably been the most
frequently used adjunct to fixed appliance
therapy over the last fifty years. Headgear was
originally described by pioneers such as Farrar,
Goddard and Kingsley and further modified by
Angle in 1888. The use of cervical headgear
increased in the1950s following the work of Kloehn.
It is still widely used today, however, there is a
perception that when possible, clinicians today
may be seeking and using other alternative options.

Dental Effect
Headgear being a tooth-borne appliance, produces
certain dental effects along with a skeletal change.
Headgears usually cause distalization of the maxillary
molars. Along with this, extrusion or intrusion of the
molar may also be seen if the extraoral attachment is
cervical or Occipital respectively. In most skeletal Class
II problems a cervical headgear is not desired as the
extrusion of the maxillary molar caused by the
inferiorly directed force which causes downward and
backward mandibular rotation, thus worsening the
problem.

(A) Standard face bow, (B) Loop style face bow, (C) Loop style, short outer bow
(A)
(B)
(C)

Distal movement of buccal segments with
the "en masse" removable appliance
upper removable appliances to which an Interlandi
headgear was attached through a face-bow . At the
first visit the removable appliance only was fitted with
instructions for it to be worn full time, including
meals. Not until this had been achieved was the
headgear added. The short outer bow was angled
slightly upward to permit application of the extraoral
force through the center of resistance of the first
molar to minimize tipping of the dentition. A force of
200 to 300 gm per side was applied, and the children
were requested to wear their headgear every night
and for a few hours in the evening as well. A diary was
to be kept so that the clinician could check on
progress. American Journal of Orthodontics and Dentofacial Orthopedics Orlon et aL 243 Volume 109, No, 3

Interlandi headgear with safety cord. Relatively short outer bow runs parallel to occlusal
plane and direction of force follows this line. B, Close-up of nylon safety cord and deepened
slots in C-piece of Interlandi headgear. Cord is tailored individually for each patient and the knot
is tucked away on inner side of C-piece. C, Close-up of terminal portion of face-bow and molar
buccal tube. Bow is stopped with Z-shaped vertical bend, fabricated in vertical plane. Terminal 3
mm of bow have been crimped slightly to help prevent accidental dislodging of face-bow.

American Journal of Orthodontics and Dentofacial Orthopedics Orlon et aL 243 Volume 109, No, 3

A, Most standard en masse upper removable appliance design: Adams clasps on upper first
molars and first premolars with headgear tubes taped and soldered to bridges of molar clasps.
L-shaped rests are contoured to lie in palatal and mesioocclusal fissures of upper first molars.
Midline screw provides requisite expansion and baseplate is saddled and finished in heat cured
acrylic. B,Appliance with double clasps on upper left and right first molars and second
premolars and headgear tubes on molar portion only of double clasps. T-shaped occlusal rests,
emerging from acrylic distal to upper second premolars, are provided by modified cross clasps.
Acrylic-trimmed palatal to upper first premolars prevents these teeth from being expanded. C,
Appliance with double clasps on upper right and left first and second premolars and headgear
tubes opposite upper second premolars. T-shaped occlusal rests are used. Distopalatally 0.028-
inch self-supporting springs engage upper right and left first and second molars to move these
teeth buccally. D, Appliance clasped on upper canines and first molars. Occlusal rests engage in
distal fossae of first molars and do not extend over oblique ridge. clasps, 0.032 inch (0.8 mm); all
double clasps, 0.032 inch

A,En masse upper removable appliance with acrylic
extended forward and built up into flat anterior biteplane.
(See tooth indentations.) Acrylic, trimmed to even curve, has
allowed spontaneous alignment of upper right central incisor
and left canine. B, Occlusal view of upper arch showing buccal
exclusion of upper canines, C, Same patient as in B after
buccal segment retraction. Recurved palatal wire is adjusted
to move upper lateral incisors labially and then maintain
upper incisor position. Marked spontaneous alignment of
upper canines is seen. Wire must be adjusted away from
upper right canine for further improvement to occur.

A, En masse appliance to encourage closure of anterior open bite.
Acrylic covers occlusal surfaces of all buccal segment teeth. Standard
clasping but "flying" EOT tubes are processed into acrylic. This
headgear tube position facilitates buccal segment intrusion. Upper
and lower incisors are free to erupt, but lower posteriors are
inhibited, encouraging upward and forward hinging of mandible and
closure of open bite. B, High-pull headgear attached to short outer
bow to apply intrusive mechanics described in AY C, Standard design
en masse appliance with self-supporting 0.028-inch wire spurs
engaging mesial to upper right lateral and upper left central incisors.
As screw is opened, these teeth are moved laterally. D, Appliance
shown in C after 3.5 months of expansion. Upper labial segment
crowding is alleviated, with sufficient space for upper right central
incisor, which already shows some spontaneous alignment (cf, C).

The en masse removable appliance,
modified according to individual patient
requirements and with a detachable face-bow,
is an effective method of distalizing the buccal
segments.
American Journal of Orthodontics and Dentofacial Orthopedics Orlon et aL 243 Volume 109, No, 3

The molar distalizing bow (MDB)
The molar distalizing bow (MDB) guarantees
controlled distal movement of the molars. It is
easy to handle, can be removed at any time and
can be worn almost full time. Since there is no
extra-oral force, there are no unphysiological
effects on the cervical spine and neck muscles or
on the molars to be moved. Furthermore, there
is no risk of injury by wearing the appliance.
Modifications of the basic appliance broaden the
range of applications.
N. JECKEL AND T. RAKOSI European Journal of Orthodontics 13(1991)41-46

Shape and function of the MDB
The appliance consists of an 0.8-1.5-mm thick
thermoplastic splint extending into the buccal
sulcus (Fig. 1). The distalizing bow fits into the
anterior slot (Fig. 1). The ends of the bow fit to
conventional headgear tubes on the molars to be
distalized (Fig. 1). The force can be generated either
by coil springs around the bow or by loops within
the bow itself (Fig. 2a). The amount of distal
movement can be regulated with adjustable stops
(Fig. 2a). In its inactive state the central section of
the MDB lies approximately 2 mm in front of and
1.5 mm above the anterior slot (Fig. 2b).

To activate the appliance the central section of
the bow must be fitted in the anterior slot by
manual pressure against the elastic resistance of
the springs or loops so that the force generated
Is transmitted to the molar tubes. The molar
tubes must be in the same plane as the anterior
slot or just above it.

(a) Spring—elastic distalizing
elements: pressure spring
around the bow (top): and
double-looped bow (bottom)
with adjustable stops, (b) The
narrow middle section of the
passive bow is approximately
2.0 mm in front of and 1.5 mm
above the anterior-vestibular
groove anchorage.

Lateral view of simultaneous molar distalization with the MDB in
maxilla and mandible

Plaster model with border between attached and buccal mucosa drawn in to define the
limb of the splint. The splint completely covers the hard palate.

Springs and Wires
Perhaps the simplest, cheapest, and oldest of
these devices is the compressed-coil spring.
Gianelly and colleagues recommended placing
nickel titanium coil springs on .016" × .022"
stainless steel sectional wires from first
premolar to first molar. When compressed, each
coil produces approximately 100g of force to
move the molar distally along the wire.

Ni–Ti coil springs
• Gianelly et al. have developed another distalization
system consisting of 100 g Ni–Ti superelastic coil
springs placed on a passive 0.016” · 0.022” wire
between first molar and first premolar. In addition, a
Nance-type appliance is cemented onto the first
premolars. To enhance anchorage further, an 0.018”
uprighting spring is placed in the vertical slot of the
premolar bracket, directing the crown distally ,and
Class II elastics are used. Because the line of force
action lies occlusally and buccally in respect to the
centre of resistance of the molar, we would expect the
molar to be distally tipped and rotated. These side-
effects have been confirmed by Pieringer et al, who
reported a distal-crown tipping of maxillary molars
and a buccal tipping of the maxillary incisors in all the
patients treated with such appliance.
Orthod Craniofacial Res 5, 2002/114–126

Biomechanical force system produced by Ni–Ti coil springs.

Superelastic nickel titanium wire used to move maxillary molars distally.

Biomechanical force system produced by Ni–Ti wire.

Nickel Titanium Double-Loop System for
Simultaneous Distalization of First and
Second Molars

Appliance Design
1. The mandibular first and second molars and second bicuspids are banded,
and the remaining mandibular teeth are bonded. A lip bumper is placed to
prevent any extrusion from the use of Class II elastics.
2. The maxillary molars and bicuspids are banded, and the anterior teeth are
bonded. The arch is aligned as usual.
3. An 80g NeoSentalloy archwire (regular mandibular archform recommended)
is placed on the maxillary arch and marked distal to the first bicuspid
bracket and about 5mm distal to the first molar tube (the distobuccal cusp
can be used as a landmark). Stops are then crimped in the archwire at each
mark.
4. Two sectional nickel titanium archwires (one for each side) are prepared by
crimping stops distal and mesial to the second bicuspids and about 5mm
distal to each second molar tube (Fig. 1).
5. Uprighting springs are inserted into the vertical slots of the first bicuspid
bands, and Class II elastics (6oz, 5/16") are placed between the mandibular
first molars and the maxillary canine bracket hooks.This system produces
simultaneous and bodily distal movement of the first and second molars
(Fig. 1).
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1998 Apr(255 - 260): Nickel Titanium Double-Loop System for Simultaneous Distalization

Wilson bimetric distalizing arch (BDA)
system
It consists of a buccal upper arch with an open
coil spring pushing against the first molar bands.
Patient co-operation with Class II intermaxillary
elastics is required to prevent advancement of the
maxillary incisors. Anchorage in the lower arch is
reinforced by means of a 3-D lower lingual arch
contacting the cingulae of the incisors and
attached to the lingual of the mandibular first
molars. If maximum anchorage is required, a full
fixed appliance can be bonded on the lower arch.

Wilson Bimetric Distalizing Arch and lower full-fixed bonded appliance.

Pendulum
It consists of a Nance button that incorporates four
occlusal rests that are bonded either to the deciduous
molars or to the first and second bicuspids. An alternative
method is to solder retaining wires to bands on
the maxillary first bicuspids. Two TMA 0.032” springs
inserted into an 0.036” lingual sheath on the maxillary
molar bands are used as active elements for molar
distalization. The springs are mounted as close to the
centre and distal edge of the button as possible to
produce a broad, swinging arc (or pendulum) of force

Biomechanical force system produced by the Pendulum – occlusal view.

Each spring consists of a closed helix, an
omegashaped adjustable horizontal loop for molar
expansion and prevention of the cross-bite following
the palatal movement of the molar . The force is
applied occlusally in respect to the centre of resistance
of the molar. Therefore, the molars are not distalized in
a bodily fashion, but distal tipping is expected. If
expansion of the maxillary arch is indicated, then a
midline screw is added to the appliance (Pend-X). An
alternative is a fixed rapid palatal expander that
incorporates the rotation and distalization components
of the Pendulum appliance

Distal-Jet
Carano and Testa described the design and use of this appliance.
Bilateral tubes of 0.036” internal diameter are attached to an
acrylic Nance button. A Ni–Ti coil spring and a screw clamp are slid
over each tube. The wire from the acrylic ends in a bayonet bend
and inserts into a palatal sheath on the molar band. An anchor
wire from the Nance button is soldered to the bands on the first or
second premolars. The Distal-Jet is reactivated by sliding the clamp
closer to the first molar once a month. The force acts close to the
centre of resistance of the molars , thus, we would expect less
molar tipping and a better bodily movement compared with other
intraoral distalizing devices. The force, however, is applied
palatally. Therefore, the rotational control of the molars during
distalization is quite difficult and, once distalized, the mesial
rotation is a common finding.

Biomechanical force system produced by the Distal-Jet – sagittal
view.

First class
It consists of vestibular and palatal components.
Screws are soldered on the buccal sides of the first
molar bands, occlusal to the single tubes. Split rings
welded to the second premolar bands control the
vestibular screws. In the palatal aspect the appliance is
much like a modified Nance button, but it is wider and
has a butterfly shape for added stability and support.
Ni–Ti coil springs are fully compressed between the
bicuspid joints and the tubes on the first molars.

FCA
After completion of molar distalization,
applianceis transformed into modified Nance
holding arch

Biomechanical force system produced by the First-Class – sagittal view.

The Greenfield Lingual Distalizer
• The Greenfield Molar Distalizer (GMD),
introduced in March 1995,1 is a fixed appliance
with buccal and lingual pistons on each side .
Placing the pistons at the gingival level reduces
the distance of the applied force from the
center of resistance of the molar , minimizing
the crown-tipping moments that are seen with
other distalizers. Thus, the GMD produces
bodily molar movement with almost no tipping
JCO/SEPTEMBER 2005

Original Greenfield Molar Distalizer
(GMD),
with parallel buccal and lingual pistons
banded to first premolars and first
permanent molars.
2Pistons placed at gingival level to avoid
crown-tipping moments.
JCO/SEPTEMBER 2005

A. 2mm split-ring stops placed every eight weeks for reactivation. B. Stop held with
contra-angle optical plier. C. Stop squeezed over mesial end of piston. D. Compression
of superelastic nickel titanium opencoil spring, producing activation of about 50g.

A. New Greenfield Lingual Distalizer (GLD), with Twin Piston Modules on lingual
side only. B. Occlusal piston is at gingival level, as in original GMD, but palatal
piston is at least 5mm deeper in palatal vault.
Components of Twin Piston Module: .030"
stainless steel wire assembly and .036" sleeve,
each with .045" stainless steel extension;
superelastic nickel titanium open-coil springs
with .055“ internal diameter.

Magnet Force System ™
This molar distalizer ties into the molar bracket
and bicuspid brackets to generate force. The
polarity of the magnets is reversed so they push
against each other with enough force to move
molars distally.
Using Repelling Magnets

Nickel-titanium Coil Springs and Repelling
Magnets: a Comparison of Two Different
Intra-oral Molar Distalization Techniques

Appliance design:
A modified Nance appliance soldered to the upper first
premolars was used, as described by Gianelly et al. (1988).
With this design, it was possible to observe any movement
of the second premolars. Prefabricated magnetic devices
(Medical Magnetics, Inc., Ramsey, N.J U.S.A.) were used on
the upper right quadrant These produced 225 g of
repelling force, when the magnets were in tight contact .
Nickel-titanium (Ortho. Organizer Inc. U.S.A.) open coil
springs size 0·014x 0·037-inch, were used on the left only.
In order to select the appropriate length of coil spring to
produce 225 g of force in each case, an intraoral gauge
was used. Coil springs were used (Ortho Organizer Inc.
U.S.A.) only on the right side of the patients .

For the activation procedure, the repelling surfaces of
the magnets were brought into contact by passing an
0·014 ligature wire through the loop on the auxiliary
wire then tying back a washer anterior to the magnets
(Fig. 1). Magnets were re-activated every week as
recommended by Gianelly et al. (1989) in order to
standardize the force level. Coil springs were activated
every month by adding a piece of a tubing (of equal
length to the amount of molar distalization) onto the
archwire at the end of the spring.

Frontal clinical view of midline discrepancy when magnet therapy began.
Right and left lateral views with repelling magnets in position.
American Journal of Orthodontics and Dentofacial Orthopedics November 1995

A and B, Upper and lower occlusal views 7 weeks after magnet distalization. Maxillary Nance now retains
distalized left molars and distal retraction of left second premolar was started. Lingual arch wire in
mandible will be extended distally to retain distalized lower right molar. Lower right magnets are still in
position. C, Anterior view, showing upper and lower midline correction, with Class II elastics on left and
Class Ill elastics on right.

Bondemark et al. , comparing repelling magnets
vs. superelastic Ni–Ti coil springs in the distalization
of maxillary molars, found, after 6 months of
treatment, that superelastic coils were more
ef?cient than repelling magnets. This can be
explained by the differential decrease of force in
the two systems. The open coils produce a more
constant force, while the magnet forces drop rather
quickly with increased distance between the poles
as a result of physical properties. These results
were confirmed by the work of Erverdi et al.

(a,b) Biomechanical force system produced by repelling magnets -sagittal and occlusal view .

Jones Jig
The Jones Jig is an open Ni–Ti coil spring
delivering 70–75 g of force, over a compression
range of 1–5 mm, to the molars (39). A modified
Nance appliance is attached to the upper first
or second premolars, or the second deciduous
molars. Because the line of force action lies
occlusally and buccally in respect to the centre
of resistance of the molar , we would expect
the molars to be distally tipped and rotated,
whereas the premolars to be mesially tipped.
The reports of other authors have
corroborated these side-effects

(a,b) Biomechanical force system produced by the Jones Jig –sagittal (a)
and occlusal view (b).
Jones Jig

The Lokar Distalizer
Dr. Bob Lokar designed an appliance with
one thing in mind – simplicity. His Distalizer
works with any common labial fixed
appliance; and it works very well for mixed
dentition cases. The Lokar Distalizer is tied
easily into position with ligature wire. It is
similar in functionality to other labial or
lingual non-compliant distalizing systems,
however the Lokar Distalizer is encompassed
in one convenient, streamlined unit

Details for use
In using the Lokar Distalizing Appliance, 1st molars are
usually banded, but they can also be bonded. Banding
molars allows for the use of an EZ lingual arch to control
the molars during distalization (ie: expansion, rotation and
translation).
ANCHORAGE: If used with full fixed appliances, a
banded or bonded Nance can be used from the 2nd
molars. In the case of mixed dentition a bonded Nance is
recommended. If full fixed appliances are used, another
anchorage option is to ligate a full-size wire from 2nd
bicuspid to 2nd bicuspid. Dr. Lokar prefers to bond the
entire lower arch, as well as ligate a full size wire and
instruct the patient to use class II elastics.

The Sliding Jig
It is more efficient to direct the distal force
generated by a Class III elastic directly against
the molar tooth using a sliding jig. This
auxiliary may be used either on the first or
second molar tooth.
ORTHODONTIC PEARLS 2004

The auxiliary should be constructed using a
relatively stiff wire, such as 0.457x0.635 mm
(0.018x0.025 inch) or round 0.508 mm (0.020
inch). The design will vary depending on the
molar buccal attachment.

Banded or bonded single buccal tube/
edgewise bracket
In cases where the buccal tube is less than
0.914 mm (0.036 inch) in diameter or where an
edgewise bracket is being used instead of a
buccal tube.

Construction (Figure a b)
• Bend an eyelet with a vertical post approximately 3 mm (0.12 inch) in
height.
• Bend the horizontal arm at right angles to the plane of the eyelet.
• Place the eyelet hard up against the mesial of the molar tube or
bracket with the horizontal arm extending mesially.
• Mark the horizontal arm at least 3 mm (0.12inch) mesial to the canine
bracket or as close to the distal of the lateral bracket as possible,
remove from the mouth.
• At this point, bend the wire up at right angles to the horizontal
section in the same direction (gingival) and plane as the vertical post of
the eyelet.
• At a height of 3 mm (0.12 inch) bend the wire (towards the dental
arch as opposed to the cheek) a full 180° to create a U-loop in the
same plane as the eyelet with the long arm now extending incisally.
• Measure approximately 4 mm (0.16 inch) on this descending arm
then bend a mesially facing hook.

Placement
• Slip the distal end of the main archwire out of the buccal tube.
• Thread the distal end of the archwire through the eyelet of the sliding jig.
• Replace the distal end of the archwire into the buccal tube.
• From the gingival, slip the anterior hook of the sliding jig over the archwire
in an incisal direction. In a few cases it may be necessary to
temporarily untie the lateral and canine brackets for this procedure.
• Once the anterior hook is in place, use a Howe or Weingart pliers to
squeeze closed the gingival U-loop. This should prevent the hook from
slipping up gingivally.
• The patient should now be able to attach a Class II elastic to the incisally
and anteriorly facing hook.
• Check that the hook does not impinge on the cheek or gingiva.

Banded or bonded double and/or
triple buccal tubes
Construction
• Bend a 3 mm (0.12 inch) vertical offset in an occlusal
direction.
• Place the distal end into one of the tubes not
holding the main arch.
• Slide the vertical offset up against the mesial of
the buccal tube.
• Mark and construct the anterior section as
described above.

Placement
With this design it is not necessary to disengage the
distal end of the main arch.
• Slide the distal end of the auxiliary into the free buccal
tube.
• Slip the anterior section into place as described
above.
• Make sure the distal extension of the jig is long
enough to prevent the jig from sliding out of the molar
tube.

Banded or bonded single round buccal
tube
The internal diameter of the buccal tube
is 0.914 mm (0.036 inch) or greater. The
design and fitting is the same as for the
double buccal tube (Figure 2). However, the
sliding jig wire size must not be greater
than 0.508 mm (0.020 inch) in order to fit
into the tube together with a 0.406 mm
(0.016 inch) main archwire. The combined
size of the sliding jig and the main archwire
cannot exceed 0.914 mm (0.036 inch).

Banded or bonded buccal tube with a
vertical slot
Construction
• The wire size of the jig must match the size of
the vertical slot of 0.457 mm (0.018 inch).
• Bend a 3 mm (0.12 inch) vertical post at right
angles to the main section.
• Slip the post into the vertical slot.
• Mark and construct the anterior section as
described above.

Placement
If the gingival margin of the band or tube is hard up
against the gingival soft tissues or if there is gingival
in?ammation or hypertrophy, this design is unsuitable.
However, provided there is adequate space
between the gingival edge of the buccal tube and the
soft tissue gingival margin, then from the occlusal
aspect insert the vertical post of the sliding jig into
the vertical slot of the buccal tube.
• With a ‘bird beak’ pliers grip the end of the post
protruding through the vertical slot of the buccal and
bend it horizontally.
• Slip the anterior section into place as described
above.

Advantages of the sliding jig
• It can be easily constructed at the chair-side.
• It can be added to the current fixed appliance
without having to remove or modify any
component of the existing appliance.
Disadvantage of the sliding jig
• It requires the use of Class II elastics,which
are in turn, dependent on patient compliance
and anchorage considerations.

K-Loop Molar Distalizing Appliance ™
Developed in Consultation with Dr . Varun Kalra
Used to distalize molars in a more bodily fashion as
the special V-bend in the K-Loop moves both the
crown and root distally. Made of CNA Beta III
Titanium, the K-Loop produces gentle continuous
forces for efficient and effective tooth movement.

Activation:
Step 1: Insert K-Loop into first molar tube and first
premolar bracket. Place a mark just mesial to the
molar tube and distal to the premolar bracket.
Step 2: Place 2.0mm high step bend 2.0mm distal to
the molar mark and 2.0mm mesial to the premolar
mark.
Step 3: Insert K-Loop in place and ligate into premolar
bracket. Place a cinch back bend mesial to the
premolar bracket as shown.

Interarch Maxillary Molar
Distalization Appliances
for Class II Correction
JCO/JANUARY 2008 Berkman, Haerian, and McNamara

A-The Herbst Appliance
The Herbst appliance, developed more than a
century ago, was designed to “jump the bite” of
Class II patients. Reintroduced by Pancherz in the
late 1970s, the modern Herbst appliance
incorporated thick bands on the maxillary first
molars, connected to bands on the mandibular
first premolars by a rigid plunger-in-tube system
that forced the lower jaw into a forward position
during closure. Subsequent banded designs have
incorporated bands on the lower first molars as
well.

Banded Herbst appliance Acrylic splint Herbst appliance

Stainless steel crown Herbst appliance.

in the maxillary posterior segments. The upper
molars may be distalized as much as 5-6mm if the
maxillary molars are connected directly and solely
to the Herbst without any intra-arch consolidation,
as would occur with a rapid palatal expander
or full edgewise appliances. When the appliance is
used during comprehensive edgewise orthodontic
treatment, maxillary molar movement generally is
much less, in the range of 1-3mm.

Pushing forces exerted by Herbst telescoping mechanism

B-The Jasper Jumper and
Related Appliances
In 1987, J.J. Jasper developed and patented the
Jasper Jumper , which featured a stainless steel
compression spring housed in a polyurethane
sheath.33 The Jasper Jumper was viewed by the
inventor as a modification of the Herbst “bite-
jumping” mechanism that would permit greater
freedom of mandibular movement . The
compression module, which is available in multiple
lengths, may be anchored to the main archwire,
attached directly to teeth, or connected with various
jig modifications

Jumper mechanism connected to a SS 0.017” x 0.025”sectional wire

The Jasper Jumper is flexible, and in fact
obtains its force-generating potential from its
flexibility. Because the appliance bends, it is
activated when the patient’s mandible is
elevated from an open position. This activation,
a build-up of internal stress, is released
continuously during periods of mandibular
closure or near-closure.The appliance is
designed to deliver approximately 60-250g of
force

Jasper Jumper and cross-section of force module.

Cope et al. described the orthopaedic and
orthodontic changes associated with the Jasper
Jumper therapy. They showed that the majority
of action was the result of dental, rather than
skeletal change, although the maxilla underwent
significant posterior displacement and the
mandible backward rotation. The maxillary
molars underwent significant distal tipping and
relative intrusion, of greater magnitude than
found with the Herbst. The mandibular incisors
underwent significant uncontrolled buccal tipping
and intrusion.

The Forsus Spring and Forsus Fatigue
Resistant Device (FRD), The Adjustable Bite
Corrector, The Eureka Spring, SUS ; appliances
that are conceptually similar to the Jasper
Jumper but hardier.
Forsus Fatigue Resistant Device

C-Mandibular Anterior
Repositioning Appliance
Another increasingly popular appliance for
correction of Class II malocclusion is the
Mandibular Anterior Repositioning Appliance
(MARA), a fixed device fabricated on stainless steel
crowns that commonly are placed over the
maxillary and mandibular first permanent molars .
Reintroduced in its present form in 1991 by Drs.
Douglas Toll (Germany) and James Eckhart (United
States), it is indicated for use throughout the late
mixed dentition and into adulthood.

The MARA’s extension arms prevent the patient
from closing in a natural Class II relationship,
requiring mandibular hyperpropulsion to achieve
intercuspation. The MARA is classified as a
functional appliance in part because it causes
forward repositioning of the lower jaw for the
duration of its use.
Mandibular Anterior Repositioning Appli ance

S
The MARA has been reported to have effects
generally similar to those of the Herbst
appliance, with a few exceptions. Whereas
maxillary molar intrusion is a characteristic
feature of the Herbst,this finding has not been
reported with the MARA.the dental changes
are due mainly to maxillary molar distalization,
which accounts for about 77% of the total
dental correction, with the remaining 23% due
to mesial mandibular molar movement.

Mandibular Molar Distalization

The most prevalent device used to distalize
lower molars was the lip bumper. Next most
popular were compressed nickel titanium coil
springs, which were usually used in conjunction
with some mechanism to control flaring of the
anterior teeth.To a much lesser extent, were tip-
back auxiliary springs, miniscrews, and Class III
elastics. Lower second molars were sometimes
extracted prior to distalization of the lower first
molars.
JOHN J. SHERIDAN 2007 JCO VOLUME XLI NUMBER 8

Removable appliances
Sagittal Appliance
This is a removable appliance with a screw
incorporated for the distalization of the first
permanent molars (Fig.). The anchorage is gained
by the remaining teeth anterior to the first
permanent molars. Retention clasps are used to
hold the appliance in place. The activation of the
screw causes the molars to be pushed distally.

Sagittal Appliance
The intraoral appliances take anchorage from
the palate and the anteriorly placed premolars.
By pitting more root surface area and/ or the
rugae region of the palate these appliances are
able to minimize the proclining effect of the
reciprocal forces generated while distalizing the
molars. Here also the efficiency of the
appliances is more before the eruption of the
second permanent molars.

Headgear Therapy to Distalize Molars
Four molar bands are placed, the upper molars
receive the KGR, and the lower molars via .045
buccal tubes provide attachment for an .022“arch
wire supporting sliding hooks via open coil springs.
The arch is ligated to the incisors and stopped at
the canine area. The coil springs are activated
periodically by extending them. ClassIII elastics are
worn only when the headgear is worn.
Andrew J. Haas Semin Orthod 2000;6: 79-90.)

The appliance for maintaining buccal teeth ,in space while the
corpus of the mandible advances growth.

The changes on a simulated wax set-up occurring in 14 months using growth to create
space in the anteroposterior and transverse dimensions

Lower Molar Distalization with
the Unilateral Frozat Appliance
This article describes an alternative treat-
ment, using an asymmetrically activated lingual
arch, that allows an intersegmental correction of
the malocclusion. A rigid and passive buccal wire
segment provides sufficient anchorage without
the need for special patient cooperation.
JCO/DECEMBER 2004

Fig. Passive unilateral Frozat appliance on patient’s cast. B. Lingual arch activated at anchor
molar band with three-prong plier. C. Antirotation bend placed in lingual arch at target molar
band. D. Appliance activated with about 200g of force.

Unilateral Frozat Appliance
A modification of the Frozat (fixed Crozat) appliance initially
developed by Mayes, the unilateral Frozat appliance consists
of two molar bands soldered to an .038" Blue Elgiloy* or
.040“ stainless steel wire (Fig. 1A). The wire is fabricated on
the patient’s setup cast with lingual steps bent mesial to the
molars and the distance from the alveolar process kept as
constant as possible in the anterior segment. On the anchor
side the lingual arch is bent into an occlusal U-loop distal to
the solder point on the molar band, then curved around to
form the lingual arm of the appliance. Care must be taken to
ensure that this arm is in contact with the lingual surfaces of
all the anchor teeth, and that the wire segment inserted
buccally on these teeth is as rigid and passive as possible. The
lingual arm and the segmental archwire combine to form one
large, multiroot anchor unit, as described by Bench with
regard to the Quad Helix.

The unilateral Frozat appliance is activated by using
an Aderer three-prong plier to make a 1st order
bend on the anchor side of the lingual arch, near
the molar band (Fig. 1B). An antirotation bend must
then be placed in the lingual arch in the region of
the molar to be distalized (Fig.1C). This activation
eliminates the risk of any contact between the
molar root and the lingual cortical bone, so that the
desired distalization takes place in the cancellous
bone. Before placing the appliance in the mouth, a
distalizing force of about 180-200g should be
verified on the cast(Fig. 1D).

The appliance must be inserted with caution to
preserve the activation and prevent distortion of
the bands. We recommend first inserting the molar
band on the anchor side and then extending the
appliance along the lingual surfaces of the teeth
until the molar band on the distalization side can
be cemented without difficulty. If necessary, the
unilateral Frozat appliance can be extraorally
reactivated and recemented at later appointments.

Modifications of Various Anchorage Approaches in
Unilateral Mandibular Molar Distalization Using a Fixed
Lingual Arch Appliance
Figure 1. Lingual arch appliance for unilateral
mandibular molar distalization with a lingual
arch and a lingual arm.
J Orofac Orthop 2004 · No. 2 © Urban& Vogel

Figures a and b. Example from patient group1. Occlusal views of the
lower dental arch before and after lingual arch appliance therapy.
Anchorage by means of the lingual arm alone.

Figures a to d. Example from patient group 2.Occlusal views of the lower dental arch
plus details from the panoramic radiographs (region: tooth 35) before and after
lingual arch appliance therapy. Anchorage by means of the lingual arm of the
appliance and a sectional archwire made of 0.016 0.022 stainless steel.

Figures a to d. Example from patient group 3.Occlusal views of the lower dental arch plus
de-tails from the panoramic radiographs (region:tooth 35) before and after lingual arch
appliance therapy. Anchorage by means of the lingual arm of the appliance, a sectional
archwire made of 0.016 0.022 stainless steel, and a lip bumper.

Mandibular Molar Distalization
with the Franzulum Appliance
This article presents a new device, based on the
Pendulum, that can distalize mandibular molars
without the drawbacks of other appliances.
Byloff, Darendeliler, and Stoff JCO/SEPTEMBER 2000

Appliance Design :
The Franzulum Appliance’s anterior anchorage
unit is an acrylic button, positioned lingually and
inferiorly to the mandibular anterior teeth, and
extending from the mandibular left canine to the
mandibular right canine (Fig. 1A). The acrylic
should be at least 5mm wide to avoid mucosal
trauma and to dissipate the reactive force
produced by the distalizing components. Rests
on the canines and first premolars are made
from .032" stainless steel wire. Tubes between
the second premolars and first molars receive the
active components.

Byloff, Darendeliler, and Stoff JCO/SEPTEMBER 2000

The posterior distalizing unit uses nickel
titanium coil springs,about 18mm in length, which
apply an initial force of 100-120g per side. A J-
shaped wire passing through each coil (Fig. 1B) is
inserted into the corresponding tube of the
anchorage unit (Fig. 1C); the recurved posterior
portion of the wire is engaged in the lingual sheath
of the mandibular first molar band (Fig. 1D). The
anchorage unit is bonded with composite resin to
the canines and first premolars. The J-shaped
distalizing unit is then ligated to the lingual sheaths
of the molar bands, compressing the coil springs.
Thus, the active part of the appliance runs lingually
at a level close to the center of resistance of the
molar, to produce an almost pure bodily movement.

Essix-based molar distalization
appliance
The laboratory technique The fabrication
sequence for the Essix-based molar distalization
appliance is described on a demonstration case as
follows: - A polyvinyl siloxane or an accurate
alginate impression must be taken to encompass
the complete dentition and one-third of the
alveolus. A working cast is obtained from quality
die stone. To increase the efficiency of
thermoforming, the long axis of the incisors should
be perpendicular to the base of the cast and
ideally, the cast should only be about 2 cm high.

-Vacuum a 0.040-inch (1 mm) sheet of Essix type
A plastic over the prepared model, remove
from the vacuum machine and allow it to cool.
Do not cut off the excess plastic around the
model (Figure 1).
- Place expansion screws (Dentaurum) just mesial
to the molars, while the Essix appliance is on
the model (Figure 2).
- To keep the orthodontic acrylic (to be added to
the Essix plastic) minimal in the buccal sections,
box out the vestibular aspects with baseplate
wax. Apply the orthodontic acrylic only to the
lingual side of the appliance (Figure 3).

- Cut away the plastic with a wheel saw and
remove the appliance from the model after
polymerization. Trim the lingual border of
appliance in the same manner as a conventional
removable appliance. However, the Essix plate
must be extended 3–4 mm onto the gingivae on
the buccal side. On the working cast, remove the
sections of the appliance covering the occlusal
surfaces of erupting teeth. Finalize the fabrication
by polishing (Figure 4a–c).

Effect of lip bumpers(LB) on
mandibular arch dimensions

In this systematic review, we discussed the effects
of LB treatment. The key question was “what are the
effects of the LB on mandibular arch dimensions in
adolescents compared with untreated patients?”
Our results showed increases in arch dimensions
that included an increase in arch length. This was
attributed to incisor proclination, distalization, and
distal tipping of the molars. There were also
increases in arch width and intercanine and
deciduous intermolar or premolar distances. The
long-term stability of the effects of the LB need to
be elucidated.
Hashish and Mostafa(Cairo) American Journal of Orthodontics and Dentofacial OrthopedicsJanuary 2009

CD Distalizer
C.D. Distalizer is a fixed orthodontic appliance
used to distalize molars on either the upper or
lower arch.Patients and doctors have had good
acceptance due to its easy wear and adjustability.
Developed by Dr. Peter Ching, this fixed
appliance can be used in either unilateral or
bilateral configurations and allow doctors to gain
up to 1 m of molar distalization per month.
Website: www.johnsdental.com

Contents:
The appliance consists of an anterior segment,
banding the first bicuspids, with a Nance button
and lingual arch wire to act as anchorage. Vertical
tubes are soldered to the buccal surface of the first
bicuspid bands. A .036 wire, with a 5 mm tube, is
placed on the molar band and then inserted into
the vertical tube on the bicuspid band. A small
bend is made in the .036 wire, at the gingival, to
hold the wire in place. The end is heat-treated for
ease of bending.

Adjustments:
At each patient visit, approximately every
three to four weeks, the Gurin lock is loosened
and pushed distally to compress the coil
spring. When the spring is compressed, the
lock is tightened to keep the coil spring
activated. Repeat this procedure at each
patient visit until the molars are in their
desired position.

Wilson Lingual Arch
3D Lingual Arch
Sophisticated Lingual Arch engineering. Vertical insertion, with a
friction lock provides maximum anchorage and permits multiple
auxiliary functions not possible with horizontal insertion. Twin vertical
posts provide molar control, torque and rotations that are
geometrically predictable.
The diamond loop design of the 3D Activator has dynamic three
dimensional force mechanics and multidirectional movement
possibilities with predictable forces. It has a lingual offset to avoid
mucosa compression. There are five angles in the activator that can
be adjusted slightly to give geometric predictable force vectors. Force
is dissipated 100%, resulting in a rapid controlled movement. The
resilience of the Activator produces the force.
Measurement is from mesial post to mesial post.

Wilson Lingual Arch
LOWER ARCH FUNCTIONS
-First molar distal uprighting
-Second molar distal uprighting
-Third molar distal uprighting
-Intrusion Anti-tipback Control

Jackscrew Regainer
Adjustable turn-nuts on threaded wire facilitates
bodily space opening.Bilateral design shown for
maximum cross-arch anchorage. Device may be
designed unilaterally.

Sliding Loop Regainer
Unilateral spacer with buccal adjustment loop.

Group Distal Movement of Teeth Using Microscrew
Implant Anchorage
Angle Orthodontist, Vol 75, No 4, 2005

CASE REPORT-1
Directional force treatment for an adult with
Class III malocclusion and open bite
Lima and Lima American Journal of Orthodontics and Dentofacial Orthopedics June 2006

TREATMENT PROGRESS
The proposed orthodontic treatment involved
fixed appliances in both arches, extraction of the
mandibular third molars, and the patient’s
cooperation using a J-hook headgear. A .022 .028-
in standard edgewise appliance was placed. The
main objective of the initial mechanics was to use
rectangular archwires for the distal movement of
the mand with the second molars. A loop in a
.019x .026-in archwire was bent flush against the
second molar tubes and activated with a high-pull
headgear with J-hooks, worn 10 to 12 hours per
day, and by hooks soldered mesial to the canines.
After alignment and leveling of the maxillary
teeth, a .019 .026-in archwire supported Class III
elastics and vertical anterior elastics at night.

Distal movement of mandibular second molars with loop mesial to
mandibular second molars and high-pull J-hook headgear in spurs
soldered at anterior region.

After distal movement of the mandibular
second molars, the J-hooks and high-pull
headgear were used to distalize the first molars .
The mandibular molars were tied together to
support the distal movement of the premolars
with elastomeric chains . The mandibular canines
were also distalized with the directional force of
the J-hook.

Distal position of mandibular second molars and jigs for distal movement of mandibular
first molars with high pull J-hook headgear.

Distal movement of mandibular second premolars with elastomeric chains and
canines with J-hooks, and retraction of mandibular incisors.

A new archwire, .019X .026-in with closing loops distal
to the lateral incisors, was used to retract the mandibular
incisors. The directional force mechanics were performed
in steps, and the overbite and crossbite were corrected
by the counterclockwise rotation of the mandible and
distal movement of the teeth. After Class I molar and
canine relationships were attained, .215X.275-in
coordinated archwires were placed, and vertical right and
left elastics were used to finish the occlusion . Active
treatment time was 28 months. The teeth were retained
with a maxillary removable Hawley appliance and a fixed
lingual arch from canine to canine. The 3-year
postretention records show the stability of the occlusion,
despite the need for continuous mandibular lingual
retention.

Case Report-2
C-Orthodontic Microimplant for Distalization of
Mandibular Dentition in Class III Correction
Angle Orthodontist, Vol 75, No 1, 2005

Treatment progress
Two C-implants were implanted in the interdental
spaces between the upper second premolars and
first molars. After incision of the mucosal area,
drilling was carried out at 1500 rpm of drill speed
and 15 Ncm of drill pressure with profuse irrigation
with isotonic saline solution. The 1.5-mm diameter
guide drill (Carl Martin, GmbH, Solingen, Germany)
was selected when drilling to depth in cortical bone.

The screw part was placed clockwise into the
prepared site using internal and external sterile
saline cooling .After an 8-week healing period,
the head part of C-implant was assembled into
the screw part by lightly tapping with a small
mallet 1 to 2 times. Immediate loading is
possible, mainly in areas where dense bone is
located and where primary stability can be
achieved .

Treatment was initiated with the leveling and
distalization of the lower posterior dentition.
Because of the patient’s dental and skeletal
problems, no bonds were placed on the maxillary
anterior and right posterior teeth. However ,
brackets were placed on the upper left posterior
teeth, followed by the placement of a segmented
0.022 0.028 inch preadjusted arch wire appliance
for intrusion of the upper left second molar . The
lower third molars were all

upper left second molar . The lower third molars
were all removed. The patient was instructed to
wear Class III elastics as long as possible to move the
lower dentition distally. The missing lower anterior
space was almost completely regained after 12
months of active tooth movement . The fixed
appliances were removed, and a tooth positioner
was used for 1 month for finishing. The retention
was provided by an upper fixed retainer and
removable lower Hawley retainer .

Molar distalization

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