Review

Distalization Methods for Maxillary Molars Utilizing Temporary

Anchorage Devices (TADs): A Narrative Review
Fırat Oğuz 1 , Samet Özden 1 and Orhan Cicek 2, *

1 Department of Orthodontics, Faculty of Dentistry, İnönü University, Malatya 44280, Türkiye;

[email protected] (F.O.); [email protected] (S.Ö.)
2 Department of Orthodontics, Faculty of Dentistry, Zonguldak Bulent Ecevit University,
Zonguldak 67600, Türkiye
* Correspondence: [email protected]

Abstract: Class II malocclusions, characterized by the mesial positioning of the maxillary molars
relative to the mandibular molars, are among the most frequently encountered orthodontic issues.
One of the widely adopted non-extraction approaches for addressing this malocclusion is maxillary
molar distalization, which has been utilized for decades to create space within the dental arch. Histor-
ically, extraoral appliances such as headgear were commonly employed. However, with technological
advancements, intraoral distalization devices, particularly those incorporating temporary anchorage
devices (TADs), have gained prominence due to their compact size, not being visible externally,
and improved patient acceptance. These appliances offer significant advantages, including being
less invasive compared with extraction-based camouflage treatments, being more readily accepted
by patients due to the absence of extraction spaces, and not requiring the complex biomechanical
principles involved in extraction-based methods. TADs have revolutionized distalization techniques
by providing superior anchorage control, reducing treatment duration, and offering a straightfor-
ward, patient-friendly application. The purpose of this comprehensive narrative review is to focus
specifically on intraoral distalization techniques utilizing TADs, summarizing their efficacy and
outcomes in the management of Class II malocclusions as reported in clinical studies over the past
three decades.

Citation: Oğuz, F.; Özden, S.; Cicek, O. Keywords: Class II malocclusion; intraoral molar distalization; skeletal anchorage; TADs; camouflage
Distalization Methods for Maxillary treatment
Molars Utilizing Temporary
Anchorage Devices (TADs): A
Narrative Review. Appl. Sci. 2024, 14,
11333. https://doi.org/10.3390/ 1. Introduction
app142311333
According to Angle [1], normal occlusion is characterized by the arrangement of
Academic Editor: Jong-Moon Chae the upper and lower teeth in a smooth curve that is in harmonious alignment. Angle
identified the first molars as the most reliable reference points for classification, basing
Received: 30 September 2024
sagittal relationships on their positions. Class II malocclusion is defined as the condition
Revised: 1 November 2024
where the lower first molar is positioned more distally relative to the upper first molar [1].
Accepted: 9 November 2024
In Graber’s approach [2], the treatment of Class II malocclusions is guided by fundamental
Published: 5 December 2024
principles: the severity of the malocclusion, the patient’s growth stage, and the etiology of
the condition. Treatment options include growth modification, orthognathic surgery, and
camouflage therapy.
Copyright: © 2024 by the authors. Contemporary orthodontic treatment approaches for sagittal discrepancies in the den-
Licensee MDPI, Basel, Switzerland. tal arches, particularly Class II malocclusions, prioritize noninvasive orthodontic methods
This article is an open access article that can be executed without the necessity for permanent tooth extractions [3]. In this
distributed under the terms and regard, the utilization of various orthodontic appliances through different methods that
conditions of the Creative Commons diminish or even eliminate the need for tooth extractions is a noteworthy phenomenon [4].
Attribution (CC BY) license (https:// Camouflage treatment is a therapeutic approach aimed at achieving acceptable occlusion
creativecommons.org/licenses/by/ and aesthetic appearance without inducing skeletal changes in the patient. This treatment
4.0/).

Appl. Sci. 2024, 14, 11333. https://doi.org/10.3390/app142311333 https://www.mdpi.com/journal/applsci

Appl. Sci. 2024, 14, 11333 2 of 20

can be performed with or without tooth extraction [5]. In non-extraction camouflage

treatments, distalization of the molars can be employed to create the necessary space [5].
Maxillary molar distalization (MMD) has been recognized as an alternative non-
extraction treatment option in cases of mild to moderate sagittal discrepancies [6,7]. Al-
though the intraoral appliances traditionally used for MMD eliminate the need for patient
compliance, they may also lead to undesirable effects such as distal tipping, crown rotation,
and anchorage loss, resulting in mesial movement of the premolars, flaring of the maxillary
incisors, and increased overjet [8]. It has been reported that the use of skeletal temporary
anchorage devices (TADs) during MMD provides resistance to reactive forces [9] and
that achieving direct anchorage with these devices eliminates the adverse effects, such
as mesial tipping and anterior tooth proclination, caused by the loss of anchorage due to
the reactive forces generated during MMD [6,10]. Miniscrews, when used as TADs, have
gained widespread acceptance due to their ease of placement and removal, their ability to
be loaded immediately, and their cost-effectiveness [11].
Although numerous studies have reported the efficacy of TADs, which can be placed in
interradicular alveolar areas such as buccal or palatal regions or in extra-radicular areas such
as the infrazygomatic region, providing three-dimensional tooth movement with minimal
anchorage loss, clinical evidence regarding the treatment effects of these mechanics remains
unclear [12,13]. Consequently, conventional intraoral molar distalization appliances such as
the Distal Jet [14] and pendulum [15], which provide effective distalization while replacing
headgear that requires patient compliance, raise aesthetic concerns, and have been used for
many years [13,16], continue to be utilized for the purpose of distalizing maxillary molars.
A review of the literature reveals that, in response to increasing aesthetic demands
and the necessity for effective and stable outcomes, various intraoral molar distalization
appliances have evolved over time [17,18], while technological advancements have further
introduced the use of clear aligners produced through three-dimensional printing for
distalization [19], thereby providing orthodontists with a wide array of treatment options
for achieving molar distalization. To the best of our knowledge, there is no study in the
literature that comprehensively addresses the numerous MMD appliances that have been
developed with various biomechanical design approaches and reported using different
application methods.
We believe that the complexities arising from this versatility in MMD may be the
reason for the unresolved issues mentioned. In light of the above, this study provides a
comprehensive overview of all reported appliances used in MMD, along with an analysis
of their various methods of application. Thus, this narrative review aims to provide
orthodontists with valuable clinical insights to guide their selection of the appropriate
method and appliance when planning for MMD.

2. Materials and Methods

2.1. Literature Search
A literature review was conducted to prepare this study, utilizing databases such as
PubMed, Scopus, and Google Scholar. Searches were performed using specific keywords,
including “Class II malocclusion”, “extraoral molar distalization”, “intraoral molar distal-
ization”, “skeletal anchorage”, “TADs”, “camouflage treatment”, “distalization appliances”,
and “tooth-tissue-supported”. To illustrate the development of distalization techniques
over time, appliances were organized and discussed under appropriate headings in accor-
dance with our classification.

2.2. Study Selection

Articles not meeting inclusion and exclusion criteria were excluded from the review.
Of the articles initially screened, a total of 24 articles met the inclusion criteria and were
incorporated into the study.
Inclusion criteria were as follows: (1) prospective cohort studies, randomized con-
trolled trials, and non-randomized controlled trials conducted within the last 20 years and
 trolled trials, and non-randomized controlled trials conducted within the last 20 years and
(2) studies reporting clinically significant outcomes. Exclusion criteria were as follows: (1)
non-clinical studies; (2) retrospective studies; (3) case reports; and (4) articles lacking in-
formation on parameters such as the distalization pattern in molar teeth, treatment dura-
Appl. Sci. 2024, 14, 11333 tion, applied force, and anchorage loss. 3 of 20
Maxillary molar distalization methods are generally divided into two categories: ex-
traoral and intraoral mechanics. In this narrative review, extraoral appliances are briefly
(2)discussed, while the
studies reporting primarysignificant
clinically focus is onoutcomes.
intraoral distalization methods.
Exclusion criteria wereThese intraoral
as follows:
approaches are categorized into two main types: tooth tissue-supported appliances
(1) non-clinical studies; (2) retrospective studies; (3) case reports; and (4) articles lacking and
skeletal anchorage-supported appliances, each reviewed in detail under specific
information on parameters such as the distalization pattern in molar teeth, treatment headings
and subheadings.
duration, applied force, and anchorage loss.
Maxillary molar distalization methods are generally divided into two categories:
3. Extraoral
extraoral Molar Distalization
and intraoral mechanics. In Methods
this narrative review, extraoral appliances are briefly
discussed, while the primary focus isappliances
In the United States, headgear on intraoral were commonlymethods.
distalization used in the mid-1940s.
These intraoralThe
effects of headgear
approaches on theinto
are categorized craniofacial
two maincomplex weretissue-supported
types: tooth intended to both appliances
inhibit maxillary
and
growth
skeletal and distalize upper appliances,
anchorage-supported molars [20].each reviewed in detail under specific headings
Headgear is categorized into three groups: occipital, cervical, or a combination of
and subheadings.
both based on their points of support (Figure 1). The cervical headgear, also known as the
3. Kloehn
Extraoral Molar
type Distalization
headgear, after itsMethods
developer, is the most commonly used type. The molar
In the United States, headgear appliances
distalization achieved with this appliance were in
results commonly
extrusionused in the mid-1940s.
and posterior rotationThe
of the
effects of headgear
mandible. on the craniofacial
This extraoral appliance iscomplex weresuitable
particularly intendedfortocases
bothofinhibit maxillary
skeletal deep bite
growth and
[21]. In distalize
patients withupper molars
a vertical [20]. pattern and posterior mandibular rotation, occipital
growth
Headgear
headgear is categorized[22].
is recommended into three groups: occipital, cervical, or a combination of
both based on their
Occipital points is
headgear ofassociated
support (Figure 1). The cervical
with distalization andheadgear,
intrusion also known
of the molars,as cervi-
the
Kloehn type headgear, after its developer, is the most commonly used type.
cal headgear with distalization and extrusion of the molars, and combined headgear with The molar
distalization
distalization achieved
withoutwith thismovement
vertical appliance ofresults in extrusion
the molars [22]. and posterior rotation of
the mandible. This extraoral appliance is particularly
Headgear has been an effective treatment for the correctionsuitable for of
cases
Angleof skeletal
Class II deep
maloc-
bite [21]. InThe
clusions. patients with a of
cooperation vertical growth
children pattern andplays
and adolescents posterior
a majormandibular rotation,
role in achieving the
occipital
desiredheadgear is recommended
results, but cooperation is[22].
often difficult to verify [23].

Figure
Figure 1. Different
1. Different types
types of headgear:
of headgear: (A);
(A); Cervical
Cervical headgear,
headgear, (B);(B); Occipital
Occipital headgear,
headgear, (C);(C); Combi-
Combina-
nation headgear.
tion headgear.

4. Intraoral Molar Distalization

Occipital headgear is associatedMethods
with distalization and intrusion of the molars, cervical
headgearIntraoral distalization methods wereofdeveloped
with distalization and extrusion the molars, to and combined
overcome headgear with of
the disadvantages
distalization without
extraoral molar vertical movement
distalization techniques.of the
Themolars
primary[22].
advantages of these appliances are
Headgear
that hasrely
they do not beenonanpatient
effective treatmentand
compliance for they
the correction
minimize of Angle Class
aesthetic II maloc-
concerns [24].
clusions.
Intraoral distalization methods are divided into two main groups, tooth tissuethe
The cooperation of children and adolescents plays a major role in achieving sup-
desired
portedresults, but cooperation
and skeletal supported,isaccording
often difficult to anchorage
to the verify [23].area.

4. Intraoral Molar Distalization Methods

Intraoral distalization methods were developed to overcome the disadvantages of
extraoral molar distalization techniques. The primary advantages of these appliances are
that they do not rely on patient compliance and they minimize aesthetic concerns [24].
Intraoral distalization methods are divided into two main groups, tooth tissue sup-
ported and skeletal supported, according to the anchorage area.

4.1. Tooth Tissue-Supported Intraoral Molar Distalization Methods

In tooth tissue-assisted intraoral distalization methods, the posterior teeth are typically
distalized using the support of the premolar teeth and an acrylic Nance button positioned
on the anterior palate.
 Appl. Sci. 2024, 14, x FOR PEER REVIEW 4 of 21

Appl. Sci. 2024, 14, 11333 4 of 20

4.1. Tooth Tissue-Supported Intraoral Molar Distalization Methods
In tooth tissue-assisted intraoral distalization methods, the posterior teeth are typi-
cally distalized using the support of the premolar teeth and an acrylic Nance button posi-
4.1.1.
tionedAcrylic Cervical
on the anterior Occipital (ACCO) Appliance
palate.
The ACCO appliance, designed by Bernstein [25], is a removable molar distalization
4.1.1. Acrylic
device. Cervical Occipital
It is supported (ACCO)
by Adams Appliance
clasps attached to an acrylic plate for retention, along
The ACCO appliance, designed by Bernstein
with a labial arch. Two spring systems, known as [25], is a removable
finger molar
springs, are bentdistalization
around the molars
device. It is supported by Adams
and activated to apply a force [26].clasps attached to an acrylic plate for retention, along
with a labial arch. Two spring systems, known as finger springs, are bent around the mo-
lars and
4.1.2. activated to apply
Super-Elastic a force [26]. (Ni-Ti) Open Coil Springs
Nickel–Titanium
Ni-Ti open coil springs have gained large popularity for distalization purposes due
4.1.2. Super-Elastic Nickel–Titanium (Ni-Ti) Open Coil Springs
to their good spring-back action and light continuous force delivery. They produce about
Ni-Ti open coil springs have gained large popularity for distalization purposes due
100 gm of force when they are compressed by 10 mm between the first premolars and
to their good spring-back action and light continuous force delivery. They produce about
first molars
100 gm on when
of force a 0.016 × are
they 0.022 inch stainless
compressed steelbetween
by 10 mm wire [27].
the first premolars and first
Öztürk et al. [28] showed that compressed
molars on a 0.016 × 0.022 inch stainless steel wire [27]. Ni-Ti coil springs were effective in moving
maxillary
Öztürkfirst molars
et al. distally,
[28] showed particularly
that compressedinNi-Ti
the treatment
coil springsof noncooperative
were patients with
effective in moving
Class II molars malocclusion. However, molar distalization occurred at
maxillary first molars distally, particularly in the treatment of noncooperative patients the expense of
increased crown tipping and anchorage loss at the anterior dental region
with Class II molars malocclusion. However, molar distalization occurred at the expense [28].
of increased crown tipping and anchorage loss at the anterior dental region [28].
4.1.3. Transpalatal Arch
4.1.3.The
Transpalatal Archarch (TPA) is a widely used appliance in orthodontic treatments and,
transpalatal
The transpalatal
in addition to several arch (TPA)
other is a widely
functions, used appliance
including in orthodontic
stabilization treatments correction
and anchorage, and, of
in addition
molar to several
rotation, other
vertical functions,
molar including
control, stabilization
and treatment and anchorage,
of unilateral molarcorrection
crossbites, of it is also
molar
an rotation, to
alternative vertical molartreatment
the other control, and treatment
regimen for of
theunilateral
correctionmolar crossbites,
of the it is
molar relationship
also an alternative to the other treatment regimen for the correction of the molar relation-
when the maxillary molars present a slight unilateral Class II discrepancy [29].
ship when the maxillary molars present a slight unilateral Class II discrepancy [29].
An intraoral occlusal view of the transpalatal arch is shown in Figure 2.
An intraoral occlusal view of the transpalatal arch is shown in Figure 2.

Figure 2.
Figure 2. Transpalatal
Transpalatalarch.
arch.

4.1.4. Jones
4.1.4. JonesJig
JigAppliance
Appliance
The Jones
The JonesJig
Jigappliance
applianceis inserted buccally
is inserted and acts
buccally andthrough a nickel–titanium
acts through spring spring
a nickel–titanium
anchored in the second premolars. Patel et al. [30] compared the dentoalveolar
anchored in the second premolars. Patel et al. [30] compared the dentoalveolar changes in changes
Class II patients treated with Jones Jig and pendulum appliances. In conclusion, the Jones
in Class II patients treated with Jones Jig and pendulum appliances. In conclusion, the
Jig group showed greater mesial inclination and extrusion of the maxillary second premo-
Jones Jig group showed greater mesial inclination and extrusion of the maxillary second
lars. The mean amounts and monthly rates of first molar distalization were similar in both
premolars.
groups [30].The mean amounts and monthly rates of first molar distalization were similar
in both groups [30].
4.1.5. Distal Jet Appliance
4.1.5. Distal Jet Appliance
The Distal Jet appliance was developed to prevent the rotational and tipping move-
The
ments Distal
often Jet appliance
observed in molars was developed
during to prevent the
intraoral distalization rotational
methods. and tipping
The Nance appli- move-
ments oftenasobserved
ance serves in molars
the anchorage during intraoral
unit. Distalization distalization
is achieved methods.
through Ni-Ti springsThe Nance appli-
attached
ance serves as the anchorage unit. Distalization is achieved through Ni-Ti springs attached
to a thick wire, which is embedded on one side in the Nance acrylic and on the other side
in the palatal tube of the molar band. Activation is performed by compressing the Ni-Ti
springs toward the first molar. Pereira et al. [31] compared the maxillary dentoalveolar
changes in patients treated with three distalization force systems (Jones Jig, Distal Jet and
First Class appliances) using digitized models. The Distal Jet appliance promoted smaller
mesial displacement of the premolars and greater expansion of the posterior teeth [31].
An intraoral occlusal view of the Distal Jet appliance is shown in Figure 3.
 to a thick wire, which is embedded on one side in the Nance acrylic and on the other side
in the palatal tube of the molar band. Activation is performed by compressing the Ni-Ti
springs toward the first molar. Pereira et al. [31] compared the maxillary dentoalveolar
changes in patients treated with three distalization force systems (Jones Jig, Distal Jet and
Appl. Sci. 2024, 14, 11333 First Class appliances) using digitized models. The Distal Jet appliance promoted smaller
5 of 20
mesial displacement of the premolars and greater expansion of the posterior teeth [31].
An intraoral occlusal view of the Distal Jet appliance is shown in Figure 3.

Figure 3.
Figure 3. Distal
DistalJet
Jetappliance.
appliance.

4.1.6. First
4.1.6. FirstClass
ClassAppliance
Appliance
The First
The FirstClass appliance
Class was developed
appliance was developedby Fortini
by etFortini
al. [32] et
to address
al. [32] the
to issue of the is-
address
anchorage loss associated with the Distal Jet appliance. This device comprises
sue of anchorage loss associated with the Distal Jet appliance. This device comprises two com-
ponents, palatal and buccal, which are connected by Ni-Ti springs positioned between the
two components, palatal and buccal, which are connected by Ni-Ti springs positioned
premolars and molars. Pereira et al. [31] compared the maxillary dentoalveolar changes
between the premolars and molars. Pereira et al. [31] compared the maxillary dentoalveolar
in patients treated with three distalization force systems (Jones Jig, Distal Jet, and First
changes in patients
Class appliances) treated
using withmodels.
digitized three distalization
In conclusion,force systems
similar amounts (Jones Jig, Distal Jet, and
of distalization
First
wereClass appliances)
promoted, using
with some digitized
degree models. In
of undesirable conclusion,
effects. The Firstsimilar amounts of
Class promoted thedistaliza-
tion wererotation
smallest promoted, with some
of maxillary degree
molars of undesirable
and had effects. The
the shortest treatment First Class promoted the
time.
smallest rotation of maxillary molars and had the shortest treatment time.
4.1.7. K-Loop Appliance
4.1.7.The
K-Loop
K-LoopAppliance
was constructed according to the description by Kalra [33] for upper
molarThe K-Loop was
distalization. Theconstructed according
K-Loop is made to the ×description
from 0.017” 0.025” TMAbywire Kalra
and[33] for upper
located be- molar
tween the upper
distalization. Thefirst molarisand
K-Loop the from
made first premolar.
0.017” ×Marure
0.025” TMAet al. [34]
wireused
andK-Loop,
locatedpen-
between the
dulum,first
upper and molar
Distal Jet
andappliances to evaluate Marure
the first premolar. the skeletal, dental,
et al. and soft-tissue
[34] used changes
K-Loop, pendulum, and
produced. The K-Loop was activated to produce 200 g of force. After placement
Distal Jet appliances to evaluate the skeletal, dental, and soft-tissue changes produced. of the The
appliances,
K-Loop waspatients were
activated to monitored
produce 200 every
g of4 force.
weeks,After
and the K-Loop was
placement activated
of the every patients
appliances,
6 weeks. When the molars achieved a Class I occlusion, the appliance was replaced with
were monitored every 4 weeks, and the K-Loop was activated every 6 weeks. When the
a Nance button for retention. In conclusion, all three distalization techniques in growing
molars achieved a Class I occlusion, the appliance was replaced with a Nance button for
children produced significant effects on the anchor unit. There was a significant bite open-
retention. In conclusion,
ing, proclination all three
of the maxillary distalization
incisors, techniques
and increase in growing
in the cant children
of the upper produced
lip [32].
significant effects on the anchor unit. There was a significant bite
To prevent anchorage loss, the use of cervical or occipital headgear was recommended. opening, proclination of
the
Themaxillary incisors,offers
K-Loop appliance and advantages
increase insuch the cant of of
as ease thefabrication,
upper liphygienic
[32]. To design,
preventand anchorage
loss, thecomfort
patient use of [32].
cervical or occipital headgear was recommended. The K-Loop appliance
offersAn
Appl. Sci. 2024, 14, x FOR PEER REVIEW advantages such as
illustrated model ofease of fabrication,
the K-Loop appliancehygienic
is showndesign,
in Figure and
4. patient comfort
6 of 21 [32].
An illustrated model of the K-Loop appliance is shown in Figure 4.

Figure 4.
Figure 4. K-Loop
K-Loopappliance.
appliance.

4.1.8. Wilson
4.1.8. Wilson3D
3DBimetric
BimetricMolar
MolarDistalization ArchArch
Distalization
Wilson [35]
Wilson [35]introduced
introduced thethe
3D3D bimetric molar
bimetric distalization
molar arch, which
distalization arch, combines a
which combines a
3D lingual arch with Class II elastics. The maxillary arch wire, measuring 0.022
3D lingual arch with Class II elastics. The maxillary arch wire, measuring 0.022 inches inches in
thickness, is passively inserted into the bracket slot. Hooks are positioned posteriorly for
in thickness, is passively inserted into the bracket slot. Hooks are positioned posteriorly
attaching the elastics, and omega bends are located at the entrance of the molar tube. An
for attaching the elastics, and omega bends are located at the entrance of the molar tube.
opening spring is placed between the omega bends and the molar tube to facilitate molar
distalization. Class II elastics are employed to prevent the protrusion of the anterior teeth.
Altug-Atac et al. [36]compared the dentofacial effects of an intraoral technique, the three-
dimensional bimetric maxillary distalizing arch, with an extraoral technique, cervical
headgear, in subjects requiring maxillary molar distalization. The result showed that
while the techniques are both effective in distalizing the maxillary molar teeth, the distali-
zation time was significantly shorter with the 3D bimetric molar distalization arch [36].
Appl. Sci. 2024, 14, 11333 6 of 20

An opening spring is placed between the omega bends and the molar tube to facilitate
molar distalization. Class II elastics are employed to prevent the protrusion of the anterior
teeth. Altug-Atac et al. [36] compared the dentofacial effects of an intraoral technique, the
three-dimensional bimetric maxillary distalizing arch, with an extraoral technique, cervical
headgear, in subjects requiring maxillary molar distalization. The result showed that while
the techniques are both effective in distalizing the maxillary molar teeth, the distalization
time was significantly shorter with the 3D bimetric molar distalization arch [36].

4.1.9. Veltri Appliance

The Veltri appliance was first introduced by Veltri [37] in 1999. This appliance uses an
expansion screw placed in the palatal region to exert an active distalization force. The screw
arms are soldered to the bands on the molars and first premolars. To enhance anchorage,
acrylic is added in the palatal region between the palatal bar and the premolar bands. Screw
activation is recommended at a rate of two half-turns per week. Oruç et al. [38] examined
the clinical efficacy of Veltri and First Class appliances. In conclusion, although Veltri and
First Class appliances provided a similar amount of distalization in a similar amount of
time, recurrence was observed in the Veltri group during the reinforcement period. In
addition, a loss of anchorage was observed more in the Veltri group [38].

4.1.10. Frog Appliance

The Frog appliance was designed by Walde [39] in 2003. In this appliance, the anterior
arms of an expansion screw placed in the palatal region are soldered to the bands on
the first premolars, while the acrylic Nance appliance provides anchorage support. The
posterior arms of the screw consist of two springs that exert an active force and are inserted
into the molar tubes. Burhan et al. [40] evaluated the efficiency of the Frog appliance (FA)
alone or in combination with headgear for distalizing the maxillary molars. In conclusions,
the Frog appliance can effectively distalize the maxillary molars, but this distalization is
associated with some unfavorable changes. Nighttime use of high-pull headgear combined
with the Frog appliance can reduce these unfavorable changes and improve treatment
outcomes [40].

4.1.11. Carriere Distalizer

Luis Carriere [41] introduced the Carriere Distalizer in 2004, later renaming it the
Carriere Motion 3D. The appliance consists of two rigid rods attached bilaterally to the
Appl. Sci. 2024, 14, x FOR PEER REVIEW 7 of 21
maxillary canine and first molar teeth. Its primary objective is to establish a Class I molar
relationship in highly cooperative patients who initially present with a Class II molar
relationship, prior to beginning leveling and alignment with fixed appliances [41].
relationship in highly cooperative patients who initially present with a Class II molar re-
Yin et al. [42] evaluated the treatment effectiveness of the Carriere Distalizer in compar-
lationship, prior to beginning leveling and alignment with fixed appliances [41].
ison Yin
withet Class
al. [42]II intermaxillary
evaluated elastics
the treatment and Forsus.
effectiveness of theIn conclusion,
Carriere there
Distalizer was no clinically
in com-
significant
parison with Class II intermaxillary elastics and Forsus. In conclusion, there was no clini-patients. The
skeletal correction induced by the Carriere Distalizer in growing
Carriere Distalizer
cally significant can
skeletal be applied
correction to treatment
induced of mild
by the Carriere to moderate
Distalizer in growingClass II dental maloc-
patients.
The Carriere Distalizer can be applied to treatment of mild to moderate Class
clusion over 6 months on average, although the total treatment time may be prolonged due II dental
malocclusion
to various side overeffects
6 months
[42].on average, although the total treatment time may be pro-
longed due to various side effects [42].
An intraoral view of the Carriere Distalizer is shown in Figure 5.
An intraoral view of the Carriere Distalizer is shown in Figure 5.

Figure 5.5.Carriere
Figure CarriereDistalizer.
Distalizer.
4.1.12. Intraoral Bodily Molar Distalizer
The intraoral bodily molar distalizer appliance was introduced in 2000 by Keleş and
Sayinsu [43]. The anchorage unit was provided by a Nance appliance, while the distaliza-
tion unit consisted of springs made from 0.032 × 0.032-inch TMA wire. One of the loops in
the springs generated the force required for distalization, while the other loop applied a
Appl. Sci. 2024, 14, 11333 7 of 20

4.1.12. Intraoral Bodily Molar Distalizer

The intraoral bodily molar distalizer appliance was introduced in 2000 by Keleş
and Sayinsu [43]. The anchorage unit was provided by a Nance appliance, while the
distalization unit consisted of springs made from 0.032 × 0.032-inch TMA wire. One of
the loops in the springs generated the force required for distalization, while the other loop
applied a counterforce to prevent distal tipping of the tooth.
Ijaz et al. [26] compared the clinical dental effects of two different molar distalization
devices (the intraoral bodily molar distalizer and the ACCO), involving 29 patients having
Class II malocclusion with low angle or normal angle. The appliances were used for the
mean period of 11 months and 7.2 months respectively. Measurements were made from the
lateral cephalogram tracings before and after molar distalization. The results showed that
with I.B.M.D maxillary first molar distalized bodily on an average of 4.5 mm and the mean
anchorage loss was 4.75 mm. In I.B.M.D the distalization spring being composed of square
sectioned TMA wire distalized the maxillary first molar bodily without any rotation. With
A.C.C.O mean distal movement of the maxillary first molar was 4.38 mm with mesial tip of
3.03 degree. However, anchorage loss with A.C.C.0 appliance was less being 2.11 mm on
an average due to the use of the headgear [26].

4.1.13. Pendulum Appliance

The pendulum appliance is used for the treatment of Class II malocclusions, utilizing
the Nance button for anchorage. The pendulum employs two hoops made from 0.032-inch
diameter round TMA wire capable of applying a continuous, light force. The pendulum
springs are used parallel to the palatal midline, with a mean force of about 250 g. Patel
et al. [30] compared the dentoalveolar changes in Class II patients treated with pendulum
and Jones Jig appliances. As a result, the maxillary first molars showed distal tipping, distal
movement, and a slight intrusion in both groups. The mean amount of distalization and
Appl. Sci. 2024, 14, x FOR PEER REVIEW
the monthly rate of distal molar movement were statistically similar in the two groups8 [30].
of 21
An intraoral occlusal view of the Pendulum appliance is shown in Figure 6.

Figure6.6.Pendulum
Figure Pendulumappliance.
appliance.

4.1.14.
4.1.14.Keles
KelesSlider
SliderAppliance
Appliance
Keles
Keles [43] introduced
introduced the theKeles
KelesSlider,
Slider, a parallel
a parallel molar
molar distalization
distalization appliance,
appliance, in a
in a study.
study. To ensure
To ensure force application
force application close toclose to theofcenter
the center of resistance,
resistance, tubes weretubes were soldered
soldered over
over the molar
the molar
bands andbands
alignedand aligned
parallel to parallel to the
the occlusal occlusal
plane. Openplane.
Ni-TiOpen Ni-Ti
springs springs
placed placed
on the wire onex-
the wire extending between the acrylic part and the tube generated a distalization
tending between the acrylic part and the tube generated a distalization force in the molars. force in
the molars. Sayınsu et al. [44] utilized the Keles Slider in 17 patients to achieve
Sayınsu et al. [44] utilized the Keles Slider in 17 patients to achieve unilateral molar distaliza-unilateral
molar distalization,
tion, observing observing
an average an average
distalization ratedistalization ratemonth,
of 0.48 mm per of 0.48totaling
mm per2.85month,
mm.totaling
The first
2.85 mm. The
premolars first premolars
exhibited 2 mm ofexhibited 2 mm of mesial
mesial movement movement
and 2.03 and 2.03 while
mm of extrusion, mm oftheextrusion,
anterior
while
teeth showed 1.32 mm of protrusion and 1.12 mm of extrusion. The mandibular incisorsThe
the anterior teeth showed 1.32 mm of protrusion and 1.12 mm of extrusion. and
mandibular
mandibular incisors and mandibular
molars erupted molars
0.83 and 0.95 mm, erupted 0.83 The
respectively. andKeles
0.95 mm,
Sliderrespectively. The
distalized molars
Keles Slider distalized
successfully to a Class Imolars successfully[44].
molar relationship to a Class I molar relationship [44].

4.2. Skeletal Anchorage-Assisted Distalization Methods

Anchorage loss is a common issue in intraoral molar distalization studies [45]. To
address this, the use of miniscrews for anchorage support has gained prominence [46].
Miniscrews can be placed in various anatomical regions of the buccal and palatal areas to
facilitate distalization.
Appl. Sci. 2024, 14, 11333 8 of 20

4.2. Skeletal Anchorage-Assisted Distalization Methods

Anchorage loss is a common issue in intraoral molar distalization studies [45]. To
address this, the use of miniscrews for anchorage support has gained prominence [46].
Miniscrews can be placed in various anatomical regions of the buccal and palatal areas to
facilitate distalization.

4.2.1. Palatinal Miniscrew-Assisted Distalization Applications

The palatal region offers several advantages over other anatomical sites for miniscrew
placement in the maxilla. These include the keratinized surface of the palate, the absence
of frenulum attachments and mobile tissues, and a reduced risk of root contact [47]. To
prevent anchorage loss during molar distalization, miniscrews have been incorporated
into distalization appliances, either by modifying existing devices or by being included in
original appliance designs.

Beneslider Appliance
Wilmes et al. [48] introduced the ‘Beneslider’ appliance for molar distalization, de-
scribing it as a modification of the miniscrew Keles Slider and Distal Jet appliances. In
this appliance, anchorage is achieved using miniscrews placed in the palatal region in
either an anteroposterior or right-left orientation. Stainless steel (SS) wire ‘Beneplates’ are
passed through the grooves of the ‘Benetubes’, which are attached to the molar bands,
allowing the applied force to pass through the molars’ centers of resistance. The appliance
can apply a force ranging from 200 to 500 g, generated by compressing Ni-Ti springs using
activation locks.
Appl. Sci. 2024, 14, x FOR PEER REVIEW 9 of 21
An intraoral occlusal view of the Beneslider appliance is shown in Figure 7.

Figure7.7.Beneslider
Figure Benesliderappliance.
appliance.

Modified
ModifiedLokar
LokarAppliance
Appliance
Kaan
Kaan[49]
[49]used
usedaamodified
modifiedmini-implant-anchored
mini-implant-anchoredLokar Lokarappliance
applianceon on2020patients
patientstoto
evaluate its effectiveness. An activator tube soldered to the Lokar was positioned
evaluate its effectiveness. An activator tube soldered to the Lokar was positioned on the on the
buccal
buccalside
sideand
andattached
attachedtotothe
themolar
molarband
bandtotoensure
ensurethetheforce
forcepassed
passedas asclose
closeas
aspossible
possible
to
to the center of resistance. Mini-implants were placed between the first molar andsecond
the center of resistance. Mini-implants were placed between the first molar and second
premolar,
premolar,serving
servingas asanchors,
anchors, while
while the
the Ni-Ti
Ni-Ticoil
coilsprings
springson onthe
theLokar
Lokarappliance
appliancewere
were
activated
activated toto generate
generate the
thedistalization
distalization force.
force. After
After 10.8
10.8 months
months ofof treatment,
treatment, the
the results
results
indicated ◦
indicatedaa3.28
3.28mmmmdistal
distalmovement
movementand andaa5.48
5.48°distal
distaltipping
tippingofofthe
themolars.
molars.TheTheauthor
author
also
also noted that the distal movement ◦of the upper incisors was insignificant andthat
noted that the distal movement of the upper incisors was insignificant and thatthe
the
overjet
overjetvalues
valuesdecreased
decreaseddueduetotoaa0.93
0.93°distal
distaltipping.
tipping.
Miniscrew-AssistedFrog
Miniscrew-Assisted FrogAppliance
Appliance
Ludwig et
Ludwig et al.
al. [50]
[50] redesigned
redesignedthe
themodified
modifiedNance
Nanceappliance,
appliance,which serves
which as the
serves an-
as the
chorage unit in the Frog appliance, by incorporating miniscrews, and introduced
anchorage unit in the Frog appliance, by incorporating miniscrews, and introduced this this
modificationinin2011.
modification 2011.Anchorage
Anchoragewaswas achieved
achieved using
using twotwo screws
screws placed
placed on either
on either sideside of
of the
the median
median palatal
palatal suture,suture, posterior
posterior to the to the intersection
intersection of the
of the line line connecting
connecting the
the distal distal
contact
contact points of the canine crowns in the rugae region with the midline. Aside from the
modified anchorage unit, the rest of the appliance was constructed similarly to the con-
ventional Frog appliance. It can be activated with a force of 200 g, and it has been reported
that turning the Frog screw 3–5 times over a 4–5-week period results in an average distali-
zation of 1–2 mm per month.
Appl. Sci. 2024, 14, 11333 9 of 20

points of the canine crowns in the rugae region with the midline. Aside from the modified
anchorage unit, the rest of the appliance was constructed similarly to the conventional Frog
appliance. It can be activated with a force of 200 g, and it has been reported that turning the
Frog screw 3–5 times over a 4–5-week period results in an average distalization of 1–2 mm
per month.

Modified Distal Jet Appliance

Cozzani et al. [17] investigated and compared the efficiency of two appliances for
molar distalization, the modified Distal Jet and the traditional tooth-supported Distal Jet,
for molar distalization and anchorage loss. In conclusion, the modified distal is an adequate
compliance-free distalizing appliance that can be used safely for the correction of Class II
malocclusions. In comparison with the traditional Distal Jet, the modified distal enables
not only a good rate of molar distalization, but also a spontaneous distalization of the
first premolars [17].

Modified Pendulum Appliance

Kircelli et al. [51] used a bone-supported modified pendulum appliance for molar
distalization in 10 patients, placing an osseointegrated implant 7–8 mm posterior to the
foramen incisivum for skeletal anchorage. After 7 months of treatment, the upper first mo-
lars exhibited 6.4 mm of distal movement and 10.9◦ of distal tipping, with distal movement
also observed in the premolars, while no forward movement was noted in the incisors.
Appl. Sci. 2024, 14, x FOR PEER REVIEW Similarly, Escobar et al. [52] applied a modified pendulum appliance supported 10 ofby
21
two miniscrews in the palatal region in 15 patients. After 7–8 months of distalization, they
reported that the first molars demonstrated 6 mm of distal movement and 11.3◦ of distal
tipping, ◦
tipping,the
thesecond
secondpremolars
premolarsshowed
showed4.85
4.85 mm
mm ofof distalization
distalization and
and 8.6
8.6° of
of distal
distal tipping,
tipping,
and the upper incisors exhibited 0.5 mm of retrusion and 1.27 ◦ of palatal tipping.
and the upper incisors exhibited 0.5 mm of retrusion and 1.27° of palatal tipping.
The
Themodified
modifiedpendulum
pendulumappliance
applianceisisshown
shownininFigure
Figure8.8.

Figure8.8. Modified
Figure Modifiedpendulum
pendulumappliance.
appliance.

Modified
ModifiedPalatal
PalatalAnchorage
Anchorage Plate
Plate
The modified palatal anchorage
The modified palatal anchorage plate platewas
was introduced
introduced to the
to the literature
literature by Kook
by Kook et al.
et al. [53] in 2010. The modified palatal anchorage plate appliance was
[53] in 2010. The modified palatal anchorage plate appliance was introduced to effectively introduced to
effectively distalize maxillary
distalize maxillary molars inmolars in adolescents
adolescents [53]. It functions
[53]. It functions by rigidlyby attaching
rigidly attaching
a palatal a
palatal plate adapted to the curve of the palatal region in the transverse direction
plate adapted to the curve of the palatal region in the transverse direction to the palatinal to the
palatinal
process of process of the with
the maxilla, maxilla,
onewith one minivail
minivail on one
on one side side
of the of the palatal
median mediansuture
palataland
suture
two
and two minivails on the other side. With three notches on the palatal plate,
minivails on the other side. With three notches on the palatal plate, the direction of the the direction
of the vector
vector that creates
that creates the distalization
the distalization force force can
can be be adjusted
adjusted differently.
differently. In this
In this way,way, the
the dis-
distalization pattern can be modified according to the desired movement.
talization pattern can be modified according to the desired movement. Kook et al. [53] Kook et al. [53]
evaluated the treatment effects of maxillary posterior tooth distalization performed by a
evaluated the treatment effects of maxillary posterior tooth distalization performed by a
modified palatal anchorage plate appliance with cephalograms derived from cone-beam
modified palatal anchorage plate appliance with cephalograms derived from cone-beam
computed tomography. In conclusion, the maxillary first molar was distalized by 3.3 mm
computed tomography. In conclusion, the maxillary first molar was distalized by 3.3 mm
at the crown and 2.2 mm at the root level, with distal tipping of 3.4◦ [53].
at the crown and 2.2 mm at the root level, with distal tipping of 3.4° [53].

Modified Keles Slider

The Keles Slider appliance was employed by Keles et al. [43] bilaterally with support
from a palatal implant. An 8 mm long and 4.5 mm diameter osseointegrable titanium im-
plant was placed in the palatal region for anchorage. Özdemir et al. [54] performed three-
 Appl. Sci. 2024, 14, 11333 10 of 20

Modified Keles Slider

The Keles Slider appliance was employed by Keles et al. [43] bilaterally with support
from a palatal implant. An 8 mm long and 4.5 mm diameter osseointegrable titanium
implant was placed in the palatal region for anchorage. Özdemir et al. [54] performed
three-dimensional comparisons of changes occurring after maxillary first molar distaliza-
tion with modified and tooth tissue-supported Keles Slider appliances. They reported that
Appl. Sci. 2024, 14, x FOR PEER REVIEW only dentoalveolar changes and maxillary first molar distalization were obtained in both 1
appliance groups. Maxillary first molars moved more parallelly with the bone-supported
Keles Slider appliance. Retraction of upper incisors and distalization of the upper canine
and premolar teeth was observed in the skeletal anchorage group while distalization of the
upper second premolars, protrusion of the upper incisors, and mesialization of the canine
and first premolars were seen in the Keles Slider group. Significant increases in vertical
Appl. Sci. 2024, 14, x FOR PEER REVIEW
dimension were observed in both groups. 11 of 21
The occlusal view of the modified Keles Slider appliance is shown in Figure 9.

Figure 9. Modified Keles Slider.

4.2.2. Buccal
Figure
Figure
Miniscrew-Assisted
9.9. Modified
Modified KelesSlider.
Keles Slider. Distalization Applications
Distalization methods using miniscrews placed in the buccal interradicular are
4.2.2.
4.2.2. Buccal
Buccal Miniscrew-Assisted
Miniscrew-AssistedDistalization
DistalizationApplications
Applications
ure 10) result in less soft tissue irritation and greater patient comfort compared wi
Distalization methods using miniscrews
Distalization methods using miniscrews placed placedin in
thethe buccal
buccal interradicular
interradicular area area
(Fig-
plications
(Figure inresult
10) the palatal
in less region
soft tissue [55]. However,
irritation and placing
greater miniscrews
patient comfort between
compared withthe tooth
ure 10) result in less soft tissue irritation and greater patient comfort compared with ap-
introduces
plications inthe
applications in risk
thethe of region
palatal
palatal root contact
region [55].
[55]. during
However,
However, distalization
placing
placing inbetween
miniscrews
miniscrews thebetween
sagittal thedirection,
the tooth tooth
roots po
potential
roots
introduces disadvantage
introduces the risk
the risk of of
of root rootthe
contact buccal
contact position
during
during [56].
distalization
distalization To
in in minimize
thethe sagittal
sagittal this risk,
direction,
direction, it has
posing
posing a bee
a potential
potential disadvantage
disadvantage of of
the the
gested that miniscrews be placed at a 30°–40° buccal
buccal position
position [56].
[56]. To To minimize this risk, it has been
angle to the long axis of the tooth [50
minimize this risk, it has been sug-
suggested
gested thatthat miniscrews
miniscrews be be placed
placed at aat a 30◦ –40
30°–40°
◦ angle to the long axis of the tooth [50].
angle to the long axisbuccally
of the tooth [50]. Ad-
ditionally,
Additionally,
duedue
to this concern, molar distalization with applied miniscr
ditionally, due totothis
thisconcern,
concern,molar
molardistalization
distalizationwith
with buccally
buccally applied
applied miniscrews
miniscrews isis
recommended
recommended for Class II molar relationships requiring less distalization, typically
recommendedfor forClass
ClassIIIImolar
molarrelationships
relationshipsrequiring
requiringless
lessdistalization,
distalization,typically
typicallyupuptoto
3 3mm
mm [57].
[57].
3 mm [57].

Figure 10. Buccal miniscrew-assisted distalization applications.

Figure
Figure10.
10. Buccal
Bechtold et miniscrew-assisted
Buccal miniscrew-assisted distalization
distalization
al. [58] studied to determine applications.
applications.
the effects of linear force vector(s) from in-
terradicular
Bechtoldminiscrews
et al. [58] on the distalization
studied to determinepattern of the maxillary
the effects arch in
of linear force adult Class
vector(s) fromII
Bechtold
patients. Either
interradicular et al. [58]
single or on
miniscrews studied
dual to
theminiscrewsdetermine
were
distalization the
inserted
pattern effects of
of theinmaxillarylinear
the posterior
arch in force vector(s)
interradicular
adult Class fro
IIarea to deliver
terradicular
patients. a distalizing
miniscrews
Either single or onforce
dualthe todistalization
the mainwere
miniscrews archwire. The
pattern
inserted displacement
inof the
the patterns
maxillary
posterior archof in
interradiculartheadult C
maxillary incisors and molars were measured and compared. As a result, significant dis-
patients. Either single or dual miniscrews were inserted in the posterior interrad
talization in the molars and incisors was shown in both groups. Significantly greater dis-
area to deliver a distalizing force to the main archwire. The displacement patterns
talization and intrusion of the first molar and intrusive displacement of the incisor, to-
maxillary
gether withincisors andreduction
significant molars in were measured plane,
the mandibular and compared.
were noted inAsthea dual
result,
screwsignifican
talization
group, in in the molars
contrast with theand incisors
rotation of thewas shown
occlusal planeininboth groups.
the single screwSignificantly
group [58]. great
talization and intrusion of the first molar and intrusive displacement of the incis
Appl. Sci. 2024, 14, 11333 11 of 20

area to deliver a distalizing force to the main archwire. The displacement patterns of
the maxillary incisors and molars were measured and compared. As a result, significant
distalization in the molars and incisors was shown in both groups. Significantly greater
distalization and intrusion of the first molar and intrusive displacement of the incisor,
together with significant reduction in the mandibular plane, were noted in the dual screw
group, in contrast with the rotation of the occlusal plane in the single screw group [58].
Appl. Sci. 2024, 14, x FOR PEER REVIEW
4.2.3. Infrazygomatic Miniscrew-Assisted Distalization Applications
The infrazygomatic crest region (IZC) is a suitable anatomical site for the placement
of miniscrews and mini-plates in the maxilla. It features the thickest cortical bone in the
maxilla, second
side only and
effects to theachieves
mandible. distalization
Clinically, the IZC is palpable
without between loss
anchorage the alveolar
[60]. Howev
bone ofanatomical
the maxilla and the zygomatic process. In young individuals, it is
location of the zygomatic region, the surgical procedure for min typically located
at the level of the second premolars and first molars, while in adults, it is generally found
ment is more complex
at the level of the first molars [59]. than that for other skeletal anchorage devices and s
formedmolar
Maxillary by an experienced
distalization usingsurgeon.
the zygomatic plate as an anchorage unit provides
The IZC
a stable and effective screw
method for was first introduced
the simultaneous in 2003
distalization and
of both the was applied
first and second using
molars.method
The literature
to the attached gingiva and the mobile mucosa border effects
suggests that this approach minimizes undesirable dental side between the
and achieves distalization without anchorage loss [60]. However, due to the anatomical
ond maxillary molars. Since then, numerous researchers have proposed mo
location of the zygomatic region, the surgical procedure for mini-plate placement is more
complex this technique
than that for other[61].skeletal anchorage devices and should be performed by an
Wu
experienced surgeon. et al. [59] placed stainless steel IZC screws (Bioray, Taiwan) with a
Themm IZCandscrew was first
a length ofintroduced
10 mm ininthe 2003 and was appliedregion
infrazygomatic using aof self-drilling
20 patients (16
method to the attached gingiva and the mobile mucosa border between the first and second
male) with a mean age of 12 ± 5 years. They used 0.019 × 0.025-inch stainle
maxillary molars. Since then, numerous researchers have proposed modifications to this
wires
technique [61].between the lateral incisors and canines, with 4 mm high retraction
Wu tioned in the
et al. [59] same
placed region.
stainless steelAIZCforce of 300
screws g was
(Bioray, applied
Taiwan) withusing Ni-Ti
a diameter of spring
2 mm andthe IZC screws. This method enabled the distalization of the entire maxill
a length of 10 mm in the infrazygomatic region of 20 patients (16 female and
with a mean age of 12 ± 5 years. They used 0.019 × 0.025-inch stainless steel arch-
4 male)[58,59].
wires between the lateral incisors and canines, with 4 mm high retraction hooks positioned
Chang et al. [62] assessed the 6-month success rate of infrazygomat
in the same region. A force of 300 g was applied using Ni-Ti springs anchored to the IZC
screws.screws
This methodrelative
enabledto patient age, insertion
the distalization angle,
of the entire sinusdentition
maxillary penetration,
[58,59]. and term
torque.
Chang et al.In
[62]conclusion, both sinus
assessed the 6-month penetration
success and IZCcrest
rate of infrazygomatic bone bone quality
screws increa
relativeSinus
to patient age, insertion angle, sinus penetration, and terminal
penetration did not significantly affect the 6-month survival rate of t insertion torque.
In conclusion, both sinus penetration and IZC bone quality increased with age. Sinus
because the loss of bone quantity at the interface was offset by the age-relate
penetration did not significantly affect the 6-month survival rate of the IZC TADs because
the lossbone quality
of bone at the
quantity IZC
at the site. was offset by the age-related increase in bone
interface
An infrazygomatic
quality at the IZC site. mini-screw-assisted distalization applications are
AnFigure 11. mini-screw-assisted distalization applications are illustrated in Figure 11.
infrazygomatic

Figure
Figure 11. 11. Infrazygomatic
Infrazygomatic miniscrew-assisted
miniscrew-assisted distalization
distalization applications: (A); Aapplications: (A); A powe
power arm-assisted
distalization,
distalization, (B); Distalization
(B); Distalization with
with direct force direct force
application to theapplication
teeth. to the teeth.
4.2.4. Maxillary Tuber Miniscrew-Assisted Distalization Applications
4.2.4. Maxillary
Maintaining anchorageTuber Miniscrew-Assisted
in orthodontic Distalization
treatments has always beenApplications
a challenging
objective. ToMaintaining anchorage
address this, miniscrews areinplaced
orthodontic
in varioustreatments has always
a ch
anatomical locations been
within
jective. To address this, miniscrews are placed in various anatomical locatio
jawbones, one of which is the maxillary tuberosity (MT) [63]. The MT is the
tension of the maxillary bone, bordered mesially by the last molar tooth and
sinus and distally by the pterygopalatine fissure and the pyramidal process o
 Appl. Sci. 2024, 14, 11333 12 of 20

the jawbones, one of which is the maxillary tuberosity (MT) [63]. The MT is the posterior
extension of the maxillary bone, bordered mesially by the last molar tooth and the maxillary
sinus and distally by the pterygopalatine fissure and the pyramidal process of the palatine
bone [64]. While the cortical bone in this region is thinner and bone density is lower
compared with other maxillary sites, it offers advantages such as a minimal risk of damage
to the molar roots, a wide range of orthodontic tooth movements, and the possibility of en
masse retraction of the upper teeth [65,66].
A sufficient number of prospective and randomized controlled clinical studies on
distalization methods using maxillary tuberosity screws is lacking in the existing literature.
Appl. Sci. 2024, 14, x FOR PEER REVIEW
4.3. Distalization with Clear Aligner Systems
In recent years, aesthetics has become a significant requirement in orthodontic treat-
ments due to the increasing number of adult orthodontic patients. Clear aligner technology
clear
was aligner to
developed systems.
meet thisSimon
demand etand
al. has
[67]become
reported an popular.
highly 87% successToday,rate
therefor
aremaxilla
distalization
numerous with clear
clear aligner aligners,Effective
manufacturers. while Rossini et al. [68]can
molar distalization also noted that
be achieved withmaxilla
clear aligner systems.
distalization with Simon et al. [67] reported
clear aligners is among anthe
87%most
success rate formovements,
reliable maxillary molar with an
distalization with clear aligners, while Rossini et al. [68] also noted that maxillary molar
cess rate. When greater distalization is needed beyond the movement capacity of
distalization with clear aligners is among the most reliable movements, with an 88% suc-
alone,
cess rate.auxiliary
When greater elements should
distalization be added,
is needed beyond asthe
aligners
movement may not suffice
capacity independe
of aligners
tachments,
alone, auxiliaryClass II elastics,
elements should and TAD as
be added, support
alignersare
mayexamples
not sufficeofindependently.
such auxiliaries.
Ravera
Attachments, et al.
Class [69] conducted
II elastics, and TAD supporta retrospective
are examplesstudy
of suchevaluating
auxiliaries. the effects of
Ravera et al. [69] conducted a retrospective study
maxillary molar distalization with Class II elastics and attachmentevaluating the effects of bilateral
support in
maxillary molar distalization with Class II elastics and attachment support in 20 adult
patients. The average treatment duration was found to be 24.3 ± 4.2 months, with
patients. The average treatment duration was found to be 24.3 ± 4.2 months, with the
molars
first molarsdistalized
distalized by byan anaverage
average of 2.25
of 2.25 mm mm without
without tippingtipping ormovement.
or vertical vertical movemen
Figure
Figure 12 illustrates
12 illustrates the use the use of
of Class Class IIwith
II elastics elastics with
skeletal skeletal
anchorage anchorage
support for sup
distalization with clear aligners.
distalization with clear aligners.

Figure
Figure 12.12. Distalization
Distalization withaligners.
with clear clear aligners.

5. Results
5. Results
For intraoral MMD appliances, the type of anchorage used, the name of the appliance,
For intraoral
the applied MMD and
force, the duration appliances,
amount of the type of the
distalization, anchorage
amount ofused, the loss,
anchorage name of th
ance,
and the applied force,
recommendations the duration
are summarized and1 amount
in Table based on ofthedistalization, the amount of an
available literature.
loss, and recommendations are summarized in Table 1 based on the available lite
Appl. Sci. 2024, 14, 11333 13 of 20

Table 1. Intraoral distalization applications.

Anchorage Loss
(Measured as the Amount
Treatment of Mesialization in the
Movement Type of First Force (g)
Study Anchorage Type Appliance Name Duration of Molar Upper Premolars Authors’ Recommendations
Molars and Anterior Teeth (Unilateral)
Distalization Corresponding to Each
1 mm of Distalization in
the First Molar)
4.38 mm distal movement
The face bow can also be bent to reduce
Ijaz et al. (2004) [26] Tooth tissue-supported ACCO appliance of first molars and 2.2 mm 300 g 11 months 0.5 mm of premolars
extrusion in the molar tooth.
protrusion of anterior teeth
4.59 mm distal movement The use of Class II elastics is
Super-elastic Ni-Ti
Öztürk et al. (2005) [28] Tooth tissue-supported of first molars and 2.22 mm 250 g 6.95 months 0.62 mm of premolars recommended to support
open coil springs
protrusion of anterior teeth anchorage anteriorly.
2.06 mm distal movement
TPA can be used in the unilateral
Eyüboğlu et al. (2004) [29] Tooth tissue-supported Transpalatal arch of first molars and 2.22 mm 150 g 5 months 0.36 mm of premolars
distalization of maxillary molars.
protrusion of anterior teeth
3.12 mm distal movement
Caution should be exercised as the
Patel et al. (2009) [30] Tooth tissue-supported Jones Jig appliance of first molars and 1.11 mm 100 g 10.9 months 0.81 mm of premolars
appliance is prone to anchorage loss.
protrusion of anterior teeth
3.32 mm distal movement
Care should be taken to ensure that it
Pereira et al. (2021) [31] Tooth tissue-supported Distal Jet appliance of first molars and 0.56 mm 240 g 11.4 months 0.47 mm of premolars
expands the posterior teeth.
protrusion of anterior teeth
Orthodontic mechanics should be
2.98 mm distal movement
applied to correct the undesirable
Pereira et al. (2021) [31] Tooth tissue-supported First Class appliance of first molars and 0.51 mm 240 g 8.2 months 0.55 mm of premolars
effects inherent in the use of
protrusion of anterior teeth
conventional anchorage.
2.2 mm distal movement of The conventional distalization
1.8 mm of premolars and
first molars and 4.1 mm appliances can be substituted
Marure et al. (2016) [34] Tooth tissue-supported K-Loop appliance 200 g 5 months protrusion of upper
protrusion of upper by TAD to prevent maxillary
anterior teeth
anterior teeth incisors proclination.
3.55 mm distal movement
To achieve successful results, the
of first molars, 0.06 mm 0.79 mm of premolars and
effects of treatment modality on
Wilson 3D bimetric protrusion of upper anchorage loss in the
Altug-Atac et al. (2007) [36] Tooth tissue-supported 180 g 3.4 months dentofacial structures need to be
molar distalization arch anterior teeth, and 2.82 mm mandibular dental arch due
taken into consideration for each
protrusion of mandibular to Class II elastics
individual patient.
anterior teeth
Distalization of the first
2.16 mm distal movement
molar by 0.5 mm per week Anchorage loss should be considered in
Oruç et al. (2024) [38] Tooth tissue-supported Veltri appliance of first molars and 4.39 mm 4.2 months 2.28 mm of premolars
was achieved by turning the clinical application.
protrusion of anterior teeth
the screw twice per week.
Distalization of the first
5.51 mm distal movement Nighttime use of high-pull
molar by 0.5 mm per week
Burhan et al. (2013) [40] Tooth tissue-supported Frog appliance of first molars and 1.78 mm 7.4 months 0.49 mm of premolars headgear should be combined with the
was achieved by turning
protrusion of anterior teeth Frog appliance.
the screw twice per week.
Appl. Sci. 2024, 14, 11333 14 of 20

Table 1. Cont.

Anchorage Loss
(Measured as the Amount
Treatment of Mesialization in the
Movement Type of First Force (g)
Study Anchorage Type Appliance Name Duration of Molar Upper Premolars Authors’ Recommendations
Molars and Anterior Teeth (Unilateral)
Distalization Corresponding to Each
1 mm of Distalization in
the First Molar)
3.5 mm distal movement of 0.62 mm of premolars and
There is no clinically significant skeletal
first molars and 3 mm 150–200 g from the anchorage loss in the
Yin et al. (2019) [42] Tooth tissue-supported Carriere distalizer 6.3 months correction caused by the Carriere
protrusion of upper Class II elastics mandibular dental arch due
distalizer in growing patients.
anterior teeth to Class II elastics
4.5 mm distal movement of
Intraoral bodily molar
Ijaz et al. (2004) [26] Tooth tissue-supported first molars and 3.85 mm 230 g 7.5 months 1.05 mm of premolars Demands anchorage reinforcement.
distalizer
protrusion of anterior teeth
3.51 mm distal movement
Caution should be exercised as the
Patel et al. (2009) [30] Tooth tissue-supported Pendulum appliance of first molars and 1.47 mm 250 g 14.1 months 0.63 mm of premolars
appliance is prone to anchorage loss.
protrusion of anterior teeth
2.85 mm distal movement Patients with palatally inclined
Sayinsu et al. (2006) [44] Tooth tissue-supported Keles Slider appliance of first molars and 1.32 mm 150 g 6 months 0.70 mm of premolars maxillary incisors should be selected
protrusion of anterior teeth for treatment with distalization devices.
The benefit system is more secure and
Skeletal 4.6 mm distal movement of
Wilmes et al. (2010) [48] Beneslider appliance 240 g 8 months No anchorage loss more comfortable for the clinician than
supported (palatinal) first molars
the spider screw system.
3.28 mm distal movement Transverse evaluation showed
No anchorage loss
Skeletal Modified Lokar of first molars and significant distopalatal rotation of
Kaan (2007) [49] 240 g 10.8 months (1.83 mm distalization of
supported (palatinal) appliance 0.23 mm retrusion of the upper first molar. Caution should
upper second premolar)
anterior teeth be exercised.
The Frog appliance is an effective,
Skeletal Miniscrew-assisted 3 mm distal movement of noninvasive, and compliance-free
Shah et al. (2016) [70] 200 g 5 months No anchorage loss
supported (palatinal) Frog appliance first molars intraoral distalization appliance for
achieving maxillary molar distalization.
The modified Distal Jet is a
No anchorage loss (2.1 mm
Skeletal Modified Distal 4.7 mm distal movement of compliance-free distalizing appliance
Cozzani et al. (2014) [17] 240 g 9.1 months distalization of upper
supported (palatinal) Jet appliance first molars that can be used safely for the
second premolar)
correction of Class II malocclusions.
The modified pendulum appliance is
an effective, minimally invasive, and
No anchorage loss (5.4 mm
Skeletal Modified pendulum 6.4 mm distal movement of compliance-free intraoral distalization
Kircelli et al. (2006) [51] 250 g 7 months distalization of upper
supported (palatinal) appliance first molars appliance for achieving both molar and
second premolar)
premolar distalization without any
anchorage loss.
It is recommended that clinicians should
3.3 mm distal movement of No anchorage loss consider using the modified palatal
Skeletal Modified palatal
Kook et al. (2014) [53] first molars and 3.0 mm 300 g 12.5 months (3.05 mm distalization of anchorage plate appliance in treatment
supported (palatinal) anchorage plate
retrusion of anterior teeth upper second premolar) planning for patients who require
maxillary total arch distalization.
Appl. Sci. 2024, 14, 11333 15 of 20

Table 1. Cont.

Anchorage Loss
(Measured as the Amount
Treatment of Mesialization in the
Movement Type of First Force (g)
Study Anchorage Type Appliance Name Duration of Molar Upper Premolars Authors’ Recommendations
Molars and Anterior Teeth (Unilateral)
Distalization Corresponding to Each
1 mm of Distalization in
the First Molar)
The maxillary first molars can be
3.58 mm distal movement No anchorage loss
Skeletal moved in parallel without any
Özdemir (2013) [54] Modified Keles Slider of first molars and 0.53 mm 300 g 10.5 months (3.42 mm distalization of
supported (palatinal) anchorage loss using the
retrusion of anterior teeth upper second premolar)
bone-supported appliances.
The dual-screw group demonstrated
2.91 mm distal movement significantly greater molar distalization
Skeletal
Bechtold et al. (2013) [58] Buccal miniscrew of first molars and 2.41 mm 200 g 10.1 months No anchorage loss and intrusion, as well as incisor
supported (buccal)
retrusion of anterior teeth retraction, compared with the
single-screw group.
The anchorage of miniscrews
implanted in the IZ crest is an efficient
device for maxillary dentition
Skeletal 3.15 mm distal movement
distalization. Therefore, it is
Wu et al. (2018) [59] supported IZC screw of first molars and 4.3 mm 300 g 8 months No anchorage loss
recommended that clinicians consider
(infrazygomatic) retrusion of anterior teeth
using the method in treatment
planning for adult patients who require
maxillary total dentition distalization.
Clinicians may consider incorporating
2.25 mm distal movement
130 from the 24.3 months of total Invisalign aligners into treatment plans
Ravera et al. (2016) [69] Clear aligner technique Clear aligner technique of first molars and 2.23 mm No anchorage loss
Class II elastics orthodontic treatment for adult patients requiring 2 to 3 mm
retrusion of anterior teeth
of maxillary molar distalization.
Appl. Sci. 2024, 14, 11333 16 of 20

6. Discussion
Class II malocclusions can be subdivided into skeletal and dental subtypes. In skele-
tal Class II malocclusion, orthopedic and orthodontic corrections are typically pursued
before growth and development are complete, while surgical approaches or camouflage
treatments may be considered, depending on the severity of the malocclusion after growth
has ceased [71,72]. In cases of dental Class II malocclusion, where no skeletal discrepancy
is present, orthodontic correction is required to address the malocclusion. One of these
corrective methods involves the distalization of the upper molars.
In orthodontics, the distalization of the upper molars is primarily achieved through
extraoral and intraoral methods. Extraoral appliances such as headgear have been utilized
in orthodontic practice for many years and have demonstrated effective results. However,
in contemporary settings, the acceptability of extraoral appliances has declined due to
aesthetic concerns [24]. One study reported complications associated with headgear use,
including skin irritation, abnormal tension in neck muscles, and injuries to the face and
eyes [73]. Beyond aesthetic concerns, these appliances rely on patient compliance, which
can negatively impact treatment effectiveness from a clinician’s perspective. Consequently,
challenges such as patient cooperation, associated complications, and difficulty in achieving
a Class I molar relationship as patients age have led researchers to develop intraoral
distalization methods [74]. Unlike headgear, these systems do not require extraoral support
for distalization; rather, they apply continuous force while relying on adjacent teeth and
tissues for support. As a result, anchorage loss in premolars and incisors is common.
Furthermore, when the mesially shifted premolars and incisors are subsequently distalized,
additional disadvantages, such as anchorage loss and time inefficiency, may arise [75].
To ensure the permanence of results and prevent relapse after molar distalization, it is
recommended that molars not be used as support for any orthodontic movement for at least
4–5 months following the completion of distalization. Given these requirements, intraoral
molar distalization methods, which allow for rapid distalization, may actually prolong the
overall treatment duration when the necessary retention period is considered [75]. Conse-
quently, when tooth tissue-supported appliances are used, treatment duration may increase,
and anchorage loss may develop in the supporting teeth. To address this anchorage loss,
researchers have sought to utilize direct bone support. Initially, osseointegrated implants
were employed [76], but their primary drawbacks include the need for surgical placement
and removal, an average postoperative healing period of three months, and relatively large
size [77]. Another technique for providing direct skeletal anchorage is the use of titanium
mini-plates, which, despite requiring surgical placement and having limited application
sites, offer the significant advantages of eliminating the need for osseointegration and
allowing the application of heavy forces [78]. In recent years, miniscrews have become
increasingly popular, as they help overcome the disadvantages of surgical stages and
osseointegration requirements [79]. In addition to their small size, which enables their use
for distalization in the oral cavity, skeletal anchorage distalization mechanics are frequently
noted in the literature to have minimal complications [48,51].
Due to these advantages, the use of orthodontic miniscrews has become widespread,
and miniscrew-supported molar distalization methods have gained popularity as a means
of minimizing anchorage loss. The primary advantage of miniscrew-supported molar
distalization is that it does not require other dental structures to serve as anchorage units.
Consequently, reciprocal forces are avoided, and unwanted movements in the premolar
and incisor regions are minimized, which not only shortens the treatment duration but also
provides the clinician with a more predictable treatment outcome [55,80].
With the increasing use of miniscrew-supported molar distalization systems, these
screws have started to be used in modified forms alongside traditional distalization appli-
ances [81]. However, these appliances still require laboratory procedures, occupy space in
the oral cavity that may cause patient discomfort, and impose additional financial costs for
clinicians. For these reasons, distalization methods that utilize screws independently of
appliances—such as those placed in the buccal, infrazygomatic crest, and maxillary tuberos-
Appl. Sci. 2024, 14, 11333 17 of 20

ity regions—are gaining prominence. Among these, the use of extra-alveolar screws, which
has gained popularity in recent years, offers clinicians a new perspective. Extra-alveolar
screws are less limited by anatomical constraints, resulting in a lower risk of root damage
and a safer working environment. Compared with intra-alveolar screws, extra-alveolar
screws can be used with larger diameters and lengths. Additionally, since they do not
require surgical procedures, they can be placed by orthodontists in the clinic with local
anesthesia. Using an infrazygomatic crest screw, a variety of malocclusions can be corrected
in the sagittal, vertical, and horizontal planes. If distalization with an infrazygomatic screw
proves as effective as anticipated, it could replace hybrid distalization devices that require
extensive laboratory procedures.
In this narrative review, the effectiveness of appliances used for maxillary molar distal-
ization over the past two decades has been examined, with an emphasis on identifying the
most effective methods for current clinical practice. The primary limitation of this study is
the lack of comprehensive research in the existing literature directly comparing all appli-
ances, which restricts the objective evaluation of their relative effectiveness. Nevertheless,
through an extensive literature review, the clinical advantages and limitations of tooth
tissue-supported and skeletal anchorage distalization methods have been systematically
analyzed. This review aims to serve as a valuable resource for clinicians in selecting the
most appropriate distalization method on a patient-specific basis and to lay the groundwork
for future comparative studies.

7. Conclusions
Intraoral MMD methods generally offer several advantages over extraoral methods,
including greater comfort and ease of use, improved aesthetics and patient acceptance,
and shorter treatment times due to the continuous force application that does not rely on
patient compliance. However, these methods also present drawbacks such as undesirable
tooth movements resulting from anchorage loss, including distal tipping and rotation of
the molars, mesialization of the premolars, and proclination of the incisors. To address
these issues, miniscrew applications have been incorporated into distalization mechanics in
orthodontic treatments in recent years. When applied in a controlled manner, these minis-
crews can help achieve treatment goals more effectively by mitigating the disadvantages of
intraoral molar distalization.
In distalization methods that utilize miniscrews in regions such as the buccal area,
infrazygomatic crest (IZC), and maxillary tuberosity, these approaches are considered
preferable due to the absence of anchorage loss, lack of laboratory requirements, reduced
intraoral bulk compared with other methods, and improved patient comfort. However,
more comprehensive studies are needed to further elucidate the advantages and disadvan-
tages of these distalization techniques in clinical case selection and to effectively compare
them with one another.

Author Contributions: Conceptualization, S.Ö., O.C. and F.O.; methodology, S.Ö. and F.O.; software,
F.O. and S.Ö.; validation, F.O., S.Ö. and O.C.; formal analysis, F.O., S.Ö. and O.C.; investigation,
F.O. and S.Ö.; resources, F.O., S.Ö. and O.C.; data curation, F.O. and S.Ö.; writing—original draft
preparation, F.O. and S.Ö.; writing—review and editing, S.Ö. and O.C.; visualization, S.Ö., F.O. and
O.C.; supervision, S.Ö. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: The original contributions presented in the study are included in the
article, further inquiries can be directed to the corresponding author.
Conflicts of Interest: The authors declare no conflicts of interest.
Appl. Sci. 2024, 14, 11333 18 of 20

References
1. Bishara, S. Textbook of Orthodontics; Saunders Company: Philadelphia, PA, USA, 2001; pp. 83–85.
2. Huang, G.J.; Graber, L.W.; Vanarsdall, R.L.; Vig, K.W. Orthodontics-E-Book: Current Principles and Techniques; Elsevier Health
Sciences: Amsterdam, The Netherlands, 2016.
3. Quinzi, V.; Marchetti, E.; Guerriero, L.; Bosco, F.; Marzo, G.; Mummolo, S. Dentoskeletal class II malocclusion: Maxillary molar
distalization with no-compliance fixed orthodontic equipment. Dent. J. 2020, 8, 26. [CrossRef] [PubMed]
4. Mummolo, S.; Nota, A.; De Felice, M.E.; Marcattili, D.; Tecco, S.; Marzo, G. Periodontal status of buccally and palatally impacted
maxillary canines after surgical-orthodontic treatment with open technique. J. Oral Sci. 2018, 60, 552–556. [CrossRef]
5. Bowman, S.J.; Johnston, L.E., Jr. The esthetic impact of extraction and nonextraction treatments on Caucasian patients. Angle
Orthod. 2000, 70, 3–10. [PubMed]
6. Abdelhady, N.A.; Tawfik, M.A.; Hammad, S.M. Maxillary molar distalization in treatment of angle class II malocclusion growing
patients: Uncontrolled clinical trial. Int. Orthod. 2020, 18, 96–104. [CrossRef] [PubMed]
7. Soheilifar, S.; Mohebi, S.; Ameli, N. Maxillary molar distalization using conventional versus skeletal anchorage devices: A
systematic review and meta-analysis. Int. Orthod. 2019, 17, 415–424. [CrossRef]
8. da Costa Grec, R.H.; Janson, G.; Branco, N.C.; Moura-Grec, P.G.; Patel, M.P.; Henriques, J.F.C. Intraoral distalizer effects with
conventional and skeletal anchorage: A meta-analysis. Am. J. Orthod. Dentofac. Orthop. 2013, 143, 602–615. [CrossRef]
9. Kırcalı, M.; Yüksel, A.S. Evaluation of dentoalveolar and dentofacial effects of a mini-screw-anchored pendulum appliance in
maxillary molar distalization. Turk. J. Orthod. 2018, 31, 103–109. [CrossRef]
10. Cozzani, M.; Fontana, M.; Maino, G.; Maino, G.; Palpacelli, L.; Caprioglio, A. Comparison between direct vs indirect anchorage in
two miniscrew-supported distalizing devices. Angle Orthod. 2016, 86, 399–406. [CrossRef]
11. Kinzinger, G.S.; Gülden, N.; Yildizhan, F.; Diedrich, P.R. Efficiency of a skeletonized distal jet appliance supported by miniscrew
anchorage for noncompliance maxillary molar distalization. Am. J. Orthod. Dentofac. Orthop. 2009, 136, 578–586. [CrossRef]
12. Cornelis, M.A.; De Clerck, H.J. Maxillary molar distalization with miniplates assessed on digital models: A prospective clinical
trial. Am. J. Orthod. Dentofac. Orthop. 2007, 132, 373–377. [CrossRef]
13. Raghis, T.R.; Alsulaiman, T.M.A.; Mahmoud, G.; Youssef, M. Efficiency of maxillary total arch distalization using temporary
anchorage devices (TADs) for treatment of Class II-malocclusions: A systematic review and meta-analysis. Int. Orthod. 2022, 20,
100666. [CrossRef] [PubMed]
14. Chiu, P.P.; McNamara, J.A., Jr.; Franchi, L. A comparison of two intraoral molar distalization appliances: Distal jet versus
pendulum. Am. J. Orthod. Dentofac. Orthop. 2005, 128, 353–365. [CrossRef] [PubMed]
15. Fuziy, A.; de Almeida, R.R.; Janson, G.; Angelieri, F.; Pinzan, A. Sagittal, vertical, and transverse changes consequent to maxillary
molar distalization with the pendulum appliance. Am. J. Orthod. Dentofac. Orthop. 2006, 130, 502–510. [CrossRef] [PubMed]
16. Greenspan, R.A. Reference charts for controlled extraoral force application to maxillary molars. Am. J. Orthod. 1970, 58, 486–491.
[CrossRef]
17. Cozzani, M.; Pasini, M.; Zallio, F.; Ritucci, R.; Mutinelli, S.; Mazzotta, L.; Giuca, M.R.; Piras, V. Comparison of maxillary molar
distalization with an implant-supported distal jet and a traditional tooth-supported distal jet appliance. Int. J. Dent. 2014, 2014,
937059. [CrossRef] [PubMed]
18. Sfondrini, M.F.; Cacciafesta, V.; Sfondrini, G. Upper molar distalization: A critical analysis. Orthod. Craniofacial Res. 2002, 5,
114–126. [CrossRef]
19. Wu, D.; Zhao, Y.; Ma, M.; Zhang, Q.; Lei, H.; Wang, Y.; Li, Y.; Chen, X. Efficacy of mandibular molar distalization by clear aligner
treatment. J. Cent. South Univ. Med. Sci. 2021, 46, 1114–1121.
20. Nucera, R.; Militi, A.; Giudice, A.L.; Longo, V.; Fastuca, R.; Caprioglio, A.; Cordasco, G.; Papadopoulos, M.A. Skeletal and dental
effectiveness of treatment of class II malocclusion with headgear: A systematic review and meta-analysis. J. Evid. Based Dent.
Pract. 2018, 18, 41–58. [CrossRef]
21. Kucukkeles, N.; Cakirer, B.; Mowafi, M. Cephalometric evaluation of molar distalization by hyrax screw used in conjunction with
a lip bumper. World J. Orthod. 2006, 7, 261–268.
22. Nanda, R.S.; Dandajena, T.C. The role of the headgear in growth modification. Semin. Orthod. 2006, 12, 25–33. [CrossRef]
23. Brandão, M.; Pinho, H.S.; Urias, D. Clinical and quantitative assessment of headgear compliance: A pilot study. Am. J. Orthod.
Dentofac. Orthop. 2006, 129, 239–244. [CrossRef] [PubMed]
24. Bolla, E.; Muratore, F.; Carano, A.; Bowman, S.J. Evaluation of maxillary molar distalization with the distal jet: A comparison
with other contemporary methods. Angle Orthod. 2002, 72, 481–494.
25. Bernstein, L. Treatment of Class II, Division 1 maximum anchorage cases with the ACCO appliance. J. Clin. Orthod. 1970, 4,
374–383.
26. Ijaz, A.; MCPS, M. A comparative study between two molar distalization appliances. Pak. Oral Dent. 2004, 24, 157–164.
27. ElBady Mahmoud El-Ashry, K.; Fouda, A.E.-S.M.; Mohammad Hafez, A. Maxillary molars distalization: A review. Mansoura J.
Dent. 2020, 7, 63–65. [CrossRef]
28. Öztürk, Y.; Firatli, S.; Almaç, L. An evaluation of intraoral molar distalization with nickel-titanium coil springs. Quintessence Int.
2005, 36, 731–765. [PubMed]
29. Eyüboğlu, S.; Bengİ, A.O.; Gürton, A.Ü.; Akin, E. Asymmetric maxillary first molar distalization with the transpalatal arch. Turk.
J. Med. Sci. 2004, 34, 59–66.
Appl. Sci. 2024, 14, 11333 19 of 20

30. Patel, M.P.; Janson, G.; Henriques, J.F.C.; de Almeida, R.R.; de Freitas, M.R.; Pinzan, A.; de Freitas, K.M.S. Comparative
distalization effects of Jones jig and pendulum appliances. Am. J. Orthod. Dentofac. Orthop. 2009, 135, 336–342. [CrossRef]
31. Bellini-Pereira, S.-A.; Aliaga-Del Castillo, A.; Vilanova, L.; Patel, M.-P.; Reis, R.-S.; Janson, G. Sagittal, rotational and transverse
changes with three intraoral distalization force systems: Jones jig, distal jet and first class. J. Clin. Exp. Dent. 2021, 13, e455.
[CrossRef]
32. Fortini, A.; Lupoli, M.; Parri, M. The First Class Appliance for rapid molar distalization. J. Clin. Orthod. 1999, 33, 322–328.
33. Kalra, V. The K-loop molar distalizing appliance. J. Clin. Orthod. 1995, 29, 298–301. [PubMed]
34. Marure, P.S.; Patil, R.U.; Reddy, S.; Prakash, A.; Kshetrimayum, N.; Shukla, R. The effectiveness of pendulum, K-loop, and distal
jet distalization techniques in growing children and its effects on anchor unit: A comparative study. J. Indian Soc. Pedod. Prev.
Dent. 2016, 34, 331–340. [PubMed]
35. Wilson William, L.; Wilson Robert, C. Multi directional 3D functional class 2 treatment. J. Clin. Orthod. 1987, 21, 186–189.
36. Altug-Atac, A.T.; Erdem, D. Effects of three-dimensional bimetric maxillary distalizing arches and cervical headgear on dentofacial
structures. Eur. J. Orthod. 2007, 29, 52–59. [CrossRef]
37. Veltri, N. Espansione mascellare a 360 gradi. Sistematica dell’utilizzo di apparecchi fissi con vite per la correzione delle anomalie
del mascellare superiore. Boll di Inf Ortod Leone. 1999, 63, 25–28.
38. Oruç, K.; Kama, J.D.; Özer, T. Comparison of two different types of molar distalization appliance. Dicle Dent. J. 2024, 25, 46–57.
39. Walde, K.C. The simplified molar distalizer. J. Clin. Orthod. 2003, 37, 616–619.
40. Burhan, A.S. Combined treatment with headgear and the Frog appliance for maxillary molar distalization: A randomized
controlled trial. Korean J. Orthod. 2013, 43, 101–109. [CrossRef]
41. Carrière, L. A new Class II distalizer. J. Clin. Orthod. JCO 2004, 38, 224–231.
42. Yin, K.; Han, E.; Guo, J.; Yasumura, T.; Grauer, D.; Sameshima, G. Evaluating the treatment effectiveness and efficiency of Carriere
Distalizer: A cephalometric and study model comparison of Class II appliances. Prog. Orthod. 2019, 20, 24. [CrossRef]
43. Keles., A.; Sayinsu, K. A new approach in maxillary molar distalization: Intraoral bodily molar distalizer. Am. J. Orthod. Dentofacial
Orthop. 2000, 117, 39–48.
44. Sayinsu, K.; Isik, F.; Allaf, F.; Arun, T. Unilateral molar distalization with a modified slider. Eur. J. Orthod. 2006, 28, 361–365.
[CrossRef] [PubMed]
45. Ghosh, J.; Nanda, R.S. Evaluation of an intraoral maxillary molar distalization technique. Am. J. Orthod. Dentofac. Orthop. 1996,
110, 639–646. [CrossRef] [PubMed]
46. Karaman, A.I.; Başçiftçi, F.; Polat, O. Unilateral distal molar movement with an implant-supported distal jet appliance. Angle
Orthod. 2002, 72, 167–174.
47. Nienkemper, M.; Wilmes, B.; Pauls, A.; Yamaguchi, S.; Ludwig, B.; Drescher, D. Treatment efficiency of mini-implant-borne
distalization depending on age and second-molar eruption Effizienz miniimplantatgestützter Molarendistalisierung abhängig
vom Patientenalter und dem Durchbruch der zweiten Molaren. J. Orofac. Orthop. 2014, 75, 118–132. [CrossRef] [PubMed]
48. Wilmes, B.; Drescher, D. Application and effectiveness of the Beneslider: A device to move molars distally. World J. Orthod. 2010,
11, 331–340.
49. Kaan, E. Mikro-Implant Destekli Modifiye Lokar Apareyinin Ortodontik Bölgeye Etkisi. Ph.D. Thesis, Gazi Üniversitesi, Ankara,
Turkey, 2007.
50. Ludwig, B.; Glasl, B.; Kinzinger, G.S.M.; Walde, K.C.; A Lisson, J. The skeletal frog appliance for maxillary molar distalization. J.
Clin. Orthod. JCO 2011, 45, 77–84.
51. Kircelli, B.H.; Pektaş, Z.O.; Kircelli, C. Maxillary molar distalization with a bone-anchored pendulum appliance. Angle Orthod.
2006, 76, 650–659.
52. Escobar, S.A.; Tellez, P.A.; Moncada, C.A.; Villegas, C.A.; Latorre, C.M.; Oberti, G. Distalization of maxillary molars with the
bone-supported pendulum: A clinical study. Am. J. Orthod. Dentofac. Orthop. 2007, 131, 545–549. [CrossRef]
53. Kook, Y.-A.; Bayome, M.; Trang, V.T.T.; Kim, H.-J.; Park, J.H.; Kim, K.B.; Behrents, R.G. Treatment effects of a modified palatal
anchorage plate for distalization evaluated with cone-beam computed tomography. Am. J. Orthod. Dentofac. Orthop. 2014, 146,
47–54. [CrossRef]
54. Özdemir, G. Kemik ve Diş-Doku Destekli Keleş Slider Apareylerinin Etkilerinin 3 Boyutlu Görüntüleme Yöntemiyle Karşılaştırıl-
ması. Ph.D. Thesis, Atatürk Üniversitesi, Erzurum, Turkey, 2013. Available online: https://www.atauni.edu.tr/yuklemeler/1507
18cf3e1e6234ca764507c5dcde0b.pdf (accessed on 30 September 2024).
55. Park, H.-S.; Kwon, T.-G.; Sung, J.-H. Nonextraction treatment with microscrew implants. Angle Orthod. 2004, 74, 539–549.
56. Jeon, J.M.; Yu, H.S.; Baik, H.S.; Lee, J.S. En-masse distalization with miniscrew anchorage in Class II nonextraction treatment. J.
Clin. Orthod. 2006, 40, 472–476. [PubMed]
57. Bechtold, T.E.; Park, Y.-C.; Kim, K.-H.; Jung, H.; Kang, J.-Y.; Choi, Y.J. Long-term stability of miniscrew anchored maxillary molar
distalization in Class II treatment. Angle Orthod. 2020, 90, 362–368. [CrossRef] [PubMed]
58. Bechtold, T.E.; Kim, J.-W.; Choi, T.-H.; Park, Y.-C.; Lee, K.-J. Distalization pattern of the maxillary arch depending on the number
of orthodontic miniscrews. Angle Orthod. 2013, 83, 266–273. [CrossRef]
59. Wu, X.; Liu, H.; Luo, C.M.; Li, Y.M.; Ding, Y.M. Three-dimensional evaluation on the effect of maxillary dentition distalization
with miniscrews implanted in the infrazygomatic crest. Implant Dent. 2018, 27, 22–27. [CrossRef] [PubMed]
Appl. Sci. 2024, 14, 11333 20 of 20

60. Nur, M.; Bayram, M.; Pampu, A. Zygoma-gear appliance for intraoral upper molar distalization. Korean J. Orthod. 2010, 40,
195–206. [CrossRef]
61. Chang, C.; Huang, C.; Roberts, W. 3D cortical bone anatomy of the mandibular buccal shelf: A CBCT study to define sites for
extra-alveolar bone screws to treat Class III malocclusion. Int. J. Orthod. Implant. 2016, 41, 74–82.
62. Chang, C.H.; Lin, J.-H.; Roberts, W.E. Success of infrazygomatic crest bone screws: Patient age, insertion angle, sinus penetration,
and terminal insertion torque. Am. J. Orthod. Dentofac. Orthop. 2022, 161, 783–790. [CrossRef] [PubMed]
63. VJ, S.G. Simultaneous Intrusion and Distalization Using Miniscrews in the Maxillary Tuberosity. J. Clin. Orthod. JCO 2016, 50,
605–612.
64. Apinhasmit, W.; Chompoopong, S.; Methathrathip, D.; Sangvichien, S.; Karuwanarint, S. Clinical anatomy of the posterior maxilla
pertaining to Le Fort I osteotomy in Thais. Clin. Anat. Off. J. Am. Assoc. Clin. Anat. Br. Assoc. Clin. Anat. 2005, 18, 323–329.
[CrossRef]
65. Venkateswaran, S.; Rao, V.; Krishnaswamy, N.R. En-masse retraction using skeletal anchorage in the tuberosity and retromolar
region. J. Clin. Orthod. JCO 2011, 45, 268–288.
66. Azeem, M.; Haq, A.U.; Awaisi, Z.H.; Saleem, M.M.; Tahir, M.W.; Liaquat, A. Failure rates of miniscrews inserted in the maxillary
tuberosity. Dent. Press J. Orthod. 2019, 24, 46–51. [CrossRef] [PubMed]
67. Simon, M.; Keilig, L.; Schwarze, J.; Jung, B.A.; Bourauel, C. Treatment outcome and efficacy of an aligner technique–regarding
incisor torque, premolar derotation and molar distalization. BMC Oral Health 2014, 14, 68. [CrossRef] [PubMed]
68. Rossini, G.; Parrini, S.; Castroflorio, T.; Deregibus, A.; Debernardi, C.L. Efficacy of clear aligners in controlling orthodontic tooth
movement: A systematic review. Angle Orthod. 2015, 85, 881–889. [CrossRef]
69. Ravera, S.; Castroflorio, T.; Garino, F.; Daher, S.; Cugliari, G.; Deregibus, A. Maxillary molar distalization with aligners in adult
patients: A multicenter retrospective study. Prog. Orthod. 2016, 17, 12. [CrossRef]
70. Shah, A.H.; Shah, D.H. Miniscrew implant-supported Frog® appliance for maxillary molar distalization. J. World Fed. Orthod.
2016, 5, 35–43. [CrossRef]
71. Arvystas, M.G. Nonextraction treatment of severe Class II, division 2 malocclusions: Part 2. Am. J. Orthod. Dentofac. Orthop. 1991,
99, 74–84. [CrossRef]
72. Epker, B.N.; Fish, L.C. The surgical-orthodontic correction of mandibular deficiency. Part I. Am. J. Orthod. 1983, 84, 408–421.
[CrossRef]
73. Samuels, R.H.A.; Jones, M.L. Orthodontic facebow injuries and safety equipment. Eur. J. Orthod. 1994, 16, 385–394. [CrossRef]
[PubMed]
74. Arman, A.; Gökçelik, A. Ağız içi molar distalizasyon yöntemleri. Cumhur. Üniversitesi Diş Hekim. Fakültesi Derg. 2005, 8, 48–55.
75. Bondemark, L.; Karlsson, I. Extraoral vs intraoral appliance for distal movement of maxillary first molars: A randomized
controlled trial. Angle Orthod. 2005, 75, 699–706.
76. Shapiro, P.A.; Kokich, V.G. Uses of implants in orthodontics. Dent. Clin. N. Am. 1988, 32, 539–550. [CrossRef] [PubMed]
77. Wehrbein, H.; Feifel, H.; Diedrich, P. Palatal implant anchorage reinforcement of posterior teeth: A prospective study. Am. J.
Orthod. Dentofac. Orthop. 1999, 116, 678–686. [CrossRef] [PubMed]
78. El-Dawlatly, M.; Abou-El-Ezz, A.; El-Sharaby, F.; Mostafa, Y. Zygomatic mini-implant for Class II correction in growing patients. J.
Orofac. Orthop. 2014, 75, 213–225. [CrossRef]
79. Duran, G.S.; Görgülü, S.; Dindaroğlu, F. Three-dimensional analysis of tooth movements after palatal miniscrew-supported molar
distalization. Am. J. Orthod. Dentofac. Orthop. 2016, 150, 188–197. [CrossRef] [PubMed]
80. Sugawara, J.; Kanzaki, R.; Takahashi, I.; Nagasaka, H.; Nanda, R. Distal movement of maxillary molars in nongrowing patients
with the skeletal anchorage system. Am. J. Orthod. Dentofac. Orthop. 2006, 129, 723–733. [CrossRef]
81. Kaya, B.; Şar, Ç.; Arman-Özçırpıcı, A.; Polat-Özsoy, Ö. Palatal implant versus zygoma plate anchorage for distalization of
maxillary posterior teeth. Eur. J. Orthod. 2013, 35, 507–514. [CrossRef]

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