European Journal of Orthodontics 22 (2000) 293–298  2000 European Orthodontic Society

Effects of a three-dimensional bimetric maxillary

distalizing arch
T. T. Üçem, S. Yüksel, C. Okay and A. Gülşen
Department of Orthodontics, Gazi University, Ankara, Turkey

SUMMARY This study aimed to investigate the dental effects of a three-dimensional (3D)
bimetric maxillary distalizing arch. The Wilson rapid molar distalization appliance for Class
II molar correction was used in 14 patients (10 girls and four boys with a mean age of 12.18
years). The open coil springs were activated with bent Omega stops and Class II inter-
maxillary elastics. The mandibular anchorage was gained by a 0.016 × 0.016 utility arch
with a 3D lingual arch or a lip bumper with a standard lingual arch. The lateral
cephalograms taken before and after treatment formed the material of the research. A
Wilcoxon test was used to statistically evaluate the treatment effects.
The results showed that the distal tipping of the maxillary first and second molars, and
first and second premolars and canines were statistically significant. Significant distal
movement occurred in all posterior and canine teeth. The maxillary first molar distalization
was found to be 3.5 mm. The maxillary incisor showed significant proclination and protru-
sion. The decrease in overbite was found to be statistically significant. The mandibular
plane angle significantly increased by a mean of 0.5 mm. In addition, significant soft tissue
changes were observed.

Introduction
Class II malocclusions may be corrected by (Hilgers, 1992), distal-jet (Carano and Testa, 1996),
combinations of restriction or redirection of and Jones jig appliances (Jones and White, 1992).
maxillary growth, distal movement of the max- Wilson (1978) introduced the concept of
illary dentition, mesial movement of the ‘modular orthodontics’ and the method of rapid
mandibular dentition, and enhancement or molar distalization which is one aspect of
redirection of mandibular growth. To establish modular orthodontics. This treatment approach
a Class I molar relationship and create space in to distalizing maxillary molars has been designed
the lateral segments for the canines or pre- using a 3D bimetric distalizing arch and a 3D
molars, in non-extraction treatment modalities, mandibular lingual arch with Class II elastics
distalization of the maxillary first molars is the (Wilson, 1978a,b; Wilson and Wilson, 1980a,b).
aim. Commonly used mechanics include extra- Until now, limited research has been con-
oral forces such as headgear. ducted to analyse the effects of this appliance.
Orthodontists have long sought methods of The aim of this study was to evaluate the effects
correcting Class II malocclusions without the of the 3D bimetric rapid molar distalization arch
need for strict patient compliance. In the 1990s, on maxillary dentoalveolar structures.
non-compliance therapies in various forms
became more widely used. These systems include
Subjects and methods
repelling magnets (Gianelly et al., 1988, 1989),
nickel titanium coil springs (Gianelly et al., The subjects were 14 non-extraction patients
1991), the K-loop (Kalra, 1995), super-elastic (10 girls, four boys) with a full Class II molar
wires (Locatelli et al., 1992), and the Pendulum relationship in the late mixed dentition. At the
294 T. T. Ü Ç E M E T A L .

beginning of treatment, the average chrono-

logical age was 12.20 years.
The upper molars were banded and the upper
incisors were bonded with 0.22-inch Roth
brackets (Rocky Mountain Orthodontics, Denver
Colorado, USA). To establish a Class I molar
relationship all patients received appropriately
sized 3D maxillary bimetric distalizing arches.
The anterior arch (0.022-inch Truchrome; Rocky
Mountain Orthodontics) was adjusted to insert
passively into incisor brackets. The posterior
0.040-inch end section with inter-maxillary hooks
had Omega adjustable stops attached. Elgiloy
open coil springs (0.010 × 0.045 inches; Rocky
Mountain Orthodontics) 5 mm in length, were
inserted between the Omega adjustable stops
and buccal tube. The coil springs were com-
pressed to 3 mm to produce a 2-mm activation
and movement. This was supported by an inter-
maxillary elastic system (Wilson and Wilson,
1980a,b,c; Figures 1 and 2a,b). Those authors
recommended using three 2-oz elastics during
the first 5 days, two during the second 5 days and
one during the final 11 days of treatment. In this
study, the elastic load reduction principle was
modified from its original version. The elastic
force was adjusted until the arch inserted into Figure 2 (a,b) Intra-oral view of 3D bimetric distalizing
the brackets slots and weekly arrangements were arch.
made to maintain this force. Fresh elastics were
applied daily.
Mandibular anchorage was gained by a 0.016 × Lateral cephalometric radiographs were
0.016-inch utility arch, with a 3D lingual arch in taken at the beginning of treatment and after a
six patients. Eight patients had a lip bumper Class I molar relationship was obtained. All
(which was in contact with the labial surface of radiographs were taken at the same laboratory
the lower incisors) with a standard lingual arch with the patient orientated in a cephalostat. The
for anchorage. enlargement was 8.3 per cent. No corrections
were made for the enlargement.
The approximate treatment time (from the
start of active treatment to the second radio-
graph) was 1.5 months. Treatment time for each
subject is shown in Table l.
To evaluate the effects of the appliance, the
tracings of the lateral cephalograms obtained
pre- and post-treatment were superimposed on
the best fit of palatal structures. The ANS–PNS
plane of the pre-treatment radiograph was
used as the horizontal reference plane. A line
Figure 1 The components of the 3D bimetric distalizing perpendicular to the ANS–PNS plane at point T
arch (Wilson and Wilson, 1980b). (the most superior point of the anterior wall
3 D B I M E T R I C M A X I L L A RY D I S TA L I Z I N G A R C H 295

Table 1 Treatment times for each subject. of the sella turcica at the junction with the
tuberculum sella) on the pre-treatment radio-
Case no. Treatment time (days) graph was used as the vertical reference plane
(RD1). Twenty-three parameters were measured
1 63 as shown in Figure 3. When the right and left
2 42
3 49 tooth images were not coincident on the lateral
4 42 cephalometric radiographs, the mid-point of the
5 63 cusp tip images were traced.
6 42
7 35
All of the lateral cephalometric radiographs
8 56 were retraced and recalculated, including super-
9 42 impositions, after 15 days. The method error
10 63
coefficients ranged from 0.97 to 0.99 and were
11 42
12 42 found to be within acceptable limits (Winner, 1971).
13 56 A Wilcoxon test was used to determine the
14 42 differences in mean changes during treatment.

Figure 3 Skeletal measurements: (1) SNA; (2) SNB; (3) ANB; (4) SN/MP. Dental measurements: (5) RD1–U7; (6)
RD1–U6; (7) RD1–U5; (8) RD1–U4; (9) RD1–U3; (10) RD1–U1; (11) ANS–PNS–U6; (12) ANS–PNS–U1; (13)
U7/ANS–PNS; (14) U6/ANS–PNS; (15) U5/ANS–PNS; (16) U4/ANS–PNS; (17) U3/ANS–PNS; (18) U1/ANS–PNS. (19)
Molar relationship (the distance between the distal curvature of upper and lower first molar). (20) Overjet. (21) Overbite
soft tissue measurements. (22) Nasolabial angle. (23) Aesthetic plane-upper lip.
296 T. T. Ü Ç E M E T A L .

Table 2 Descriptive statistics, mean changes and P values for 3D maxillary bimetric distalizing arches.

Pre-treatment Post-treatment Mean changes

x SE x SE D SE P

1. SNA 77.0 1.00 77.0 1.01 0.0 0.23 1.000

2. SNB 73.3 1.01 73.1 0.99 –0.2 0.33 0.174
3. ANB 3.7 0.38 3.9 0.39 0.2 0.25 0.136
4. SN/MP 38.0 1.30 38.5 1.40 0.5 0.30 0.037*
5. RD1U7 15.8 1.40 13.6 1.53 –2.2 0.33 0.001**
6. RD1U6 22.7 1.63 19.2 1.74 –3.5 0.36 0.001**
7. RD1U5 38.5 1.81 36.4 1.85 –2.1 0.23 0.001**
8. RD1U4 46.3 2.00 44.6 2.05 –1.7 0.21 0.001**
9. RD1U3 56.0 1.87 54.4 1.98 –1.6 0.33 0.002**
10. RD1U1 62.3 1.88 63.3 1.95 1.0 0.24 0.006**
11. U6–ANS–PNS 20.7 0.66 20.7 0.68 0.0 0.25 0.600
12. U1–ANS–PNS 30.0 0.51 30.5 0.59 0.5 0.30 0.168
13. U7/ANS–PNS 63.7 2.02 62.4 2.05 –1.3 0.47 0.008**
14. U6/ANS–PNS 71.3 1.49 69.5 1.13 –1.8 0.63 0.044*
15. U5/ANS–PNS 82.9 0.98 81.5 1.03 –1.4 0.37 0.048*
16. U4/ANS–PNS 91.4 1.36 89.6 1.10 –1.8 0.62 0.006**
17. U3/ANS–PNS 106.0 1.81 101.4 1.55 –4.6 0.89 0.002**
18. U1/ANS–PNS 106.2 1.74 109.8 1.68 3.6 1.14 0.015**
19. Molar relationship –0.7 0.47 2.9 0.44 3.6 0.49 0.001**
20. Overjet 2.6 0.35 2.5 0.24 –0.1 0.39 0.844
21. Overbite 3.3 0.38 2.6 0.29 –0.7 0.31 0.044*
22. Nasolabial angle 118.2 1.58 114.7 2.10 –3.5 0.36 0.032*
23. Aesthetic plane
—upper lip –3.3 0.52 –2.5 0.61 0.8 0.49 0.019*

*P < 0.05; **P < 0.01.

x = Pre- and post-treatment mean values. SE = standard error of the mean pre- and post-treatment values. D = the
difference between pre-and post-treatment mean values. SE = the standard error of the mean differences.

Results
Soft tissue evaluation demonstrated that there
The means, standard deviations and the sig- was a significant decrease in the nasolabial angle
nificance of the treatment changes are shown in (P < 0.05). The labial movement of the upper lip
Table 2. according to the aesthetic plane was statistically
The increase in SN/MP angle was found to be significant (P < 0.05).
statistically significant (P < 0.05).
The upper molars, premolars and canines
Discussion
distance to RD1 showed a significant decrease
(P < 0.01). Upper incisor labial movement accord- The early loss of the maxillary second decid-
ing to RD1 was found to be statistically significant uous molar is generally followed by mesial
(P < 0.01). The upper molars, premolars, and movements of the maxillary first molar
canines showed statistically significant distal (Northway et al., 1984). Several treatment
tipping according to ANS–PNS plane (P < 0.05, methods are available to distalize the maxillary
P < 0.01) The upper incisor/ANS–PNS angle molars effectively. After Wilson (1978a,b)
demonstrated a significant increase (P < 0.05) introduced the 3D bimetric distalizing arch as a
and the increase in molar relationship was found part of ‘modular orthodontics’, a few studies
to be statistically significant (P < 0.01). Overbite were undertaken to evaluate the effects of
showed a significant decrease (P < 0.05). the appliance. In this investigation, the effects
3 D B I M E T R I C M A X I L L A RY D I S TA L I Z I N G A R C H 297

of the appliance on the maxillary buccal teeth to move molars distally. Other types of intra-oral
were evaluated in addition to the dentoalveolar molar distalization appliance such as nickel
effects. titanium coil springs (Gianelly et al., 1991) and
The maxillary first molar moved distally the K-loop (Kalra, 1995) showed 1-mm anchorage
3.5 mm in relation to the vertical reference line loss in premolars during 4-mm molar distalization.
(RD1). The molar relationship change was With the use of a Pendulum appliance mesial
3.6 mm resulting in a Class I molar relationship movement occurred in the upper second premolars
obtained by molar distalization. Muse et al. (Byloff and Darendeliler, 1997). This was an
(1993) reported that 50.7 per cent of Class II inevitable result of the design of those appliances.
correction was obtained by upper molar distal- The upper second molar showed a significant
ization (2.16 mm) and 39.8 per cent by lower mean distalization of 2.2 mm. Bondemark et al.
molar mesialization (1.38 mm) using the 3D (1994) found that super-elastic nickel-titanium
bimetric distalizing arch. Wilson (1995) and open coils were more effective than repelling
Yüksel et al. (1996) highlighted the preservation magnets for the simultaneous distal movement
of anchorage of mandibular molars in their of second molars.
studies. The upper canine, first and second premolars,
In this investigation, the upper first molar and second molar showed significant distal
showed a significant 1.8 degree of distal tipping, tipping similar to the upper first molar. The
while Muse et al. (1993) found 7.8 degrees of greatest degree of tipping 4.6 degrees was
distal tipping. Wilson (1995) suggested that observed in the canine teeth. The reason for this
utilizing the elastic load reduction principle with could be as a result of the eruption path and time
adequate 3D anchorage would ensure no molar of eruption of the canine teeth, and the vestibulo
extrusion or tipping. Yüksel et al. (1996) position of the canine teeth due to the pre-
reported maxillary molar distalization with treatment crowding.
mostly bodily movement in four subjects. Itoh Aras (1993) showed a posterior rotation of the
et al. (1991) found a 7.4-degree distal tipping of mandible and suggested this was an effect of
the molars with repelling magnets and suggested mandibular molar extrusion and maxillary molar
this represented slight tipping. Byloff and distalization. This finding is in agreement with
Darendeliler (1997) suggested that the signifi- the increase in SN/MP angle found in this study.
cant molar tipping should be taken into con- The soft tissue changes were parallel to the
sideration when using the Pendulum appliance. upper incisor changes. The mean forward
The forward movement of the upper incisors is movement of the upper lip was 0.75 mm and the
in agreement with Muse et al. (1993). Itoh et al. nasolabial angle showed significant decrease.
(1991) reported 1.2-mm labial movement of the The 3D bimetric distalization system had no
anterior teeth with a 2.1-mm molar distalization physical disturbance or hygienic disadvantage
with repelling magnets. than any fixed appliance. However, in other
The most significant findings of this study were intra-oral molar distalization systems patients
the distalization of the upper premolars and reported difficulty in brushing and some dis-
canines. These results were as statistically sig- comfort of the buccal mucosa due to the size of
nificant as the upper first molar distalization. It the magnets and slight inflammation of the palatal
should be pointed out that, clinically, no mucosa. This resolved a week after appliance
diastemas were observed between the first removal and was due to the Nance appliance
molar–second premolar and first premolar– (Byloff and Darendeliler, 1997).
second premolar. In the local evaluation the This investigation focused only on upper arch
mean distalization for first and second premolar changes as research evaluating the effects of
(RD1U4, RD1U5) was 1.7 and 2.1 mm, different anchorage systems using the 3D
respectively. Distal movement of the canine was bimetric maxillary distalizing arch on lower arch
1.6 mm. Gianelly et al. (1989) reported mesial changes performed on a large sample is currently
movement in premolars with the use of magnets being undertaken.
298 T. T. Ü Ç E M E T A L .

Conclusion Gianelly A A, Bednar J, Dietz V S 1991 Japanese NiTi

coils used to move molars distally. American Journal
1. Class I molar relationship was effectively of Orthodontics and Dentofacial Orthopedics 99:
established in approximately 1.5 months by 564–566
upper molar distalization. Hilgers J J 1992 The Pendulum appliance for Class II non-
compliance therapy. Journal of Clinical Orthodontics 26:
2. A significant distalization of the upper 706–714
premolars and canines was obtained with the
Itoh T, Tokuda T, Kiyosue S, Hirose T, Matsumoto M,
3D bimetric arch system compared with other Chaconas S J 1991 Molar distalization with repelling
intra-oral mechanics. magnets. Journal of Clinical Orthodontics 25: 611–617
3. The upper incisor labial movement and Jones R D, White J M 1992 Rapid Class II molar correction
decrease in overbite should be considered with an open-coil jig. Journal of Clinical Orthodontics 26:
661–664
before treatment.
Kalra V 1995 The K-loop molar distalizing appliance.
Journal of Clinical Orthodontics 24: 298–301
Address for correspondence Locatelli R, Bednar J, Dietz V S, Gianelly A A 1992 Molar
distalization with superelastic NiTi wire. Journal of
Tuba Tortop Üçem Clinical Orthodontics 26: 277–279
Gazi Üniversitesi Muse D S, Fillman M J, Emmerson W J, Mitchell R D 1993
Diş Hekimliği Fakültesi Molar and incisor changes with Wilson rapid molar
Ortodonti Anabilim Dalı distalization. American Journal of Orthodontics and
Dentofacial Orthopedics 104: 556–565
06510 Emek-Ankara
Northway W M, Wainright R L, Demirjian A 1984 Effects
Turkey of premature loss of deciduous molars Part ll. Angle
Orthodontist 54: 295–329
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