Diagnostic Criteria for Maxillary Molar Distalization A Review

Anurag Rai*, Shweta Rai**, Mukesh Kumar***

Abstract
In Non-Entraction cases alternatives to extraction are considered for space gain such as proximal stripping, arch-expansion molar distalization. Uprighting of teeth etcetra. The maxillary molar distalization has made a great impact in Non-Extraction treatment. Timely distalization of the 1st molars prior to the eruption of additional molar teeth is an effective method of space gain which is described is this article. Key Word : Molar distalization, Space gaining methods

INTRODUCTION

rofitt 1 discusses several methods of space gain especially in the teratment of Cl II malocclusion. These include Differential growth, Extraction and Orthodontic, Camouflage, Class II intermaxillary elastics with sliding jigs for distalization etc. The tooth than can most after cause loss of space is the 6 year molar. It accomplishes this by drifting mesially and encroaching the territory needed for the eruption of second bicuspid. The mesial drift of the 6 year Molar is only the final act in a series of events that may initiate space loss. Headgears are quite successful in maxillary first molar distalization to gain space in the arch. Except for its patient compliance. Hilgers2 introduced the term Non-Compliance to orthodontics, where patient co-operation is minimally needed. Orthodontists have well encashed this term and the proof lies in various intraoral maxillary first molar distalization techniques. Introduced in recent years. There are many schools of thought related to this technique though. Many have criticized it as a procedure of mere transferring the locale of the discrepancy form front to back.

Iatrogenic mesial drift because of too early extraction of primary molars by dentist without placing a space maintainer. The 21-23 rule3 On the average, 21 mm is required in each lower quadrant to allow unhindered eruption of permanent cuspids and bicuspids: Whereas 23 mm is needed in the upper quadrant. This helps to determine whether there is adequate space to allow eruption of the cuspids and bicuspids or there is a need for molar distalization. The discrepancy anterior to the first molars does not exceed 2-3mm on either side and when there is no evidence of developing posterior crowding. Incisors are retroclined or when the profile can afford some proclination. Patients have normal to near normal mandibular arch with upright or slight retroclined incisors, no crowding with flat curve of Spee. Upper molars placed normally buccopalatally in the cancellous bone. An end-on or full class II molar relationship due to maxillary protrusion. An end-on or full class II molar relationships due to maxillary cuspids being either impacted, unrequited or erupted labially and high in the vestibule. An end-on full class II molar relationship due to the ectopic eruption of either the first or second bicuspid.

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2.

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INDICATIONS
1. There is mesial tipping or migration of maxillary first molars. The maxillary first molar often cause space loss by drifting mesially and encroaching on the territory needed for the eruption of the second bicuspid. There are three factors which permit mesial drift of maxillary first molar. a. Caries b. Ectopic eruption of maxillary first molar

8.

CONTRA INDICATIONS
1. 2. 3. Excessive proclination of anterior teeth Posterior crowding An end-on or full class II molar relationship due to retrognathic mandible 4. TMJ problem 5. Unfavourable growth pattern. James J. Hiligers (1992)4 stated that with maxillary molar distalization, there is a tendency for anterior bite
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*Professor (Orthodontics); **Reader (OMFS); ***Professor, Dr. B.R. Ambedkar Institue of Dental Science & Hospital, Hari Om Nagar, New Bailey Road, Patna- 801503 JIDA, Vol. 5, No. 2, February 2011

to open. This open bite generally corrects by itself in brachyfacial patients but can be a problem in dolichofacials with tongue thrust habits. He recommends treating vertical growth patterns conservatively with extractions, directional headgears and transpalatal bars. David J.Snodgrass (1996) 5 suggested that any expansional and distalization appliance tends to extrude the molars and therefore molar distalization should be done with caution in patient with vertical growth pattern. John W. Witzing and Terrance J. Spahl (1987) 6 suggested that distalization of the maxillary first molars aids in increase in vertical height. As the first molar is distalized, they move closure to the hinge axis of rotation of the TMJ and came into occlusal contact sooner with the opposing teeth during the act o closure, thereby increasing the vertical dimension of occlusion. This is the reason for contraindication of maxillary molar distalization in unfavorable growth pattern where lower anterior facial height is already increased.

also shown us that distalization of first and second molars together with recent efficient intraoral methods is possible without any problem.

UPPER MOLAR POSITION

Cephalometrically, according to Ricketts Analysis, Upper molar position is the horizontal distance from Ptyrygoid Vertical Line or PTV Line ( a vertical line drawn through the distal radiographic outline of Pterygomaxillary Fissure and perpendicular to the Frankfort Horizontal) to the distal surface of the maxillary first permanent molar. On the average, this measurement should equal the age of the patient + 3.00 mm (eg. A patient 11 years of age has a norm of 11 + 3= 14 mm: one mm is added per year for age adjustment ). This measurement assists in determining whether the malocclusion is due to the postion of upper or lower molar and also is useful in deciding whether extractions are necessary. It suggests whether sufficient space is present or not for the second and third molars. This measurement indicates or contraindicates maxillary molar distaliztion. Jedlickova (1990)9 attributed the failure of therapeutic method of upper first molar distalization by extraoral traction due to the lack of space. He elaborated a method

TIMING OF DISTALIZATION
Different views have been expressed by different authors. Joseph M. Sims (1977)7 suggested that the patient should be treated before the age of 9 years as the root of the molar to be moved has not completed its growth and the orthodontic distal tipping or distal bodily movement is easier. If the treatment is delayed too long and the second molar begins to erupt then it requires vastly increased anchorage and a very efficient appliance approach in moving first and second molars distally. Many clinicians suggest that molar distalization is very efficient, if carried out when the second molar crown is at the apical third of the molar. S.R. Langford and M.R. Sims (1981)8 illustrated that the distal movement of upper molar roots against adiacent unerupted teeth could cause resorption. Ottolenguri (1914) suggested that the first molars should be moved backward against unerupted second molars during orthodontic treatment with caution as such movement could result in root resorption of the first molar. David J. Snodgrass (1996)5 stated that in the mixed dentition molar distalization should not be carried out until full development of the maxillary first molar roots. In the permanent dentitions, molar distalization is most effective before the full eruption of the second molar. James J. Hilgers (1992)4 suggested that the distal movement of the first molars is most efficient before the eruption of upper second molars. But from our clinical experience, we feel that it is better to do molar distalization as early as possible before second molar eruption but with caution. Experience has
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which helped to assess the future spatial possibilities in the molar region.

MAXILLARY SECOND MOLAR EXTRACTION IN MAXILLARY FIRST MOLAR DISTALIZATION

Hilgers (1992)4 suggested that when a great deal of distal movement is needed and it is preferable not to extract the upper first bicuspids, it is always beneficial to remove the upper second molars and let the third molars drift into place. Chipman10 believes that maxillary second molar extraction is indicated when:a. The second molars are severely carious, ectopically erupted or severely rotated. b. Mild to moderate arch length deficiencies exist with good facial profile. c. There is crowding in the tuberosity area with a need to facilitate first molar distal movement. The optimal time for extracting second molar is when the third molars have migrated sufficiently in the maxillary alveolar bone. Strang and Thompson also recommended the extraction of maxillary second molars to move first molars distally with either extraoral appliances or class II mechanics. According to Graber11 the indications for second molar extraction are: a. There should be excessive inclination of maxillary incisors with no spacing. b. Overbite must be minimial or negative c. Third molars should be present and in a good position to erupt. And, the contraindications are: a. Vertically inclined maxillary incisors b. No spacing c. Marked overbite According to Samir E. Bishara,12 Various advantages and disadvantages of second molar extraction are as follows: Advantages 1. Facilitation of first molar distal movement. 2. Distal movement of the dentition only as needed to correct the overjet. 3. Reduction in the amount and duration of appliance therapy. 4. Facilitation of treatment using removable appliances. 5. Disimpaction of third molars. 6. Faster eruption of third molars. 7. Prevention of dished in appearance of the face at the end of facial growth
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8. Less likelihood of relapse. 9. Good functional occlusion. Disadvantages 1. Too much tooth substance is removed in class I malocclusions with mild crowding. 2. Extraction site location far from area of concern in moderate-to -server anterior crowding 3. Extraction sites of no help in the correction of anterior posterior discrepancies without patient cooperation in wearing appliances copable of moving the dentition to the distal en mass 4. Possible impaction of third molars even with second molar extraction.

SUMMARY
Maxillary molar distalization is supposed to be one of the pillarstone of the Non-Extraction Theapy. Its popularity shows its importance. Every other day, a new maxillary molar distalizer is introduced to the orthodontic field and most of the Maxillary Molar Distalizing systems used to-date have been discussed. With the use recent intraoral methods achieving approximately 5-6 mm of molar distalization within 4-5 months is a long cherished dream coming true. Few questions remain and their answer lies in yet to be developed a unique Maxillary Molar Distalizing System offering a pure distal translatory movement without anchorage loss. The perfect indication of the Maxillary First Molar Distalization is a Class II molar relationship on a Class I skeletal base where the second molar are yet to erupt.

BIBLIOGRAPHY
Profit WR. Contemporary orthodontics. Second edition, Mosby year book 1993: 225-64. 2. Hilgers JJ. The Pendulum Appliance for class II noncompliance therapy. J Clin Orthod 1992; 26(11) : 706-14. 3. Steger ER, Blechman AM. Case reports molar distalization with static repelling mgnets part II. Am J Orthod Dentofac Orthop 1995; 108 : 547-55. 4. Hilgers JJ. The Pendulum Appliance for class II noncompliance therapy. J Clin Orthod 1992; 26(11) : 706-14. 5. Scodgrass DJ. A Fixed appliance for maxillary expansion, molar rotation and molar distalization. J Clin Orthod 1996; 30 : 156-59. 6. Witzing JW, Spahl TJ.The clinical management of basic maxillofacial orthopedic appliances. Vol-I: PSG Publishing company. The great second molar debae. 155-216; The sagittal appliance, 217-278. 7. Sim JM. Minor tooth movement in children. Second edition. The C.V.Mosby company: 1977: 302-21. 8. Langford SR., Sims MR. Upper molar root resorption because of distal movement report of a case. Am J Orthod 1981; 79: 669-79. 9. Jeckal N, Rakoshi T. Molar distalization by intra oral force application. Eur J Orthod 1991; 13(1) : 43-46. 10. Chipman MB. Second and third molar Their role in Orthodontic therapy. Am J Orthod 1961; 47 : 498-520. 11. Grabber TM. Maxillary second molar extraction in Class II malocclusion. Am J Orthod 1969; 56 : 331-53. 12. Bishara SE., Burkey PS. Second molar extraction A review. Am J Orthod 1986; 89: 415-24. 281 1.