Received: 21 November 2020 | Revised: 9 January 2021 | Accepted: 9 January 2021

DOI: 10.1111/ocr.12470

REVIEW ARTICLE

Distalization of maxillary molars using temporary skeletal

anchorage devices: A systematic review and meta-­analysis

Mohamed Bayome1,2 | Jae Hyun Park3,4 | Curt Bay5 | Yoon-­Ah Kook6

1
Department of Preventive Dental Sciences,
College of Dentistry, King Faisal University, Abstract
Al Hofuf, Saudi Arabia Objectives: The aim of this systematic review is to assess the treatment effects
2
Department of Postgraduate Studies,
(amount of distalization, distal tipping and vertical movement) of buccally versus pal-
Universidad Autónoma del Paraguay,
Asunción, Paraguay atally placed temporary skeletal anchorage devices (TSADs) on maxillary first molars
3
Postgraduate Orthodontic Program, during distalization.
Arizona School of Dentistry & Oral Health,
A.T. Still University, Mesa, AZ, USA
Materials and methods: Medline and Scopus databases were searched up to
4
Graduate School of Dentistry, Kyung Hee September 2020 for randomized controlled trials (RCTs) and non-­randomized pro-
University, Seoul, Korea spective cohort studies on maxillary molar distalization using TSADs in patients with
5
Department of Interdisciplinary Health
Class II malocclusion. After study selection, data extraction and risk of bias assess-
Sciences, Arizona School of Health Sciences,
A.T. Still University, Mesa, AZ, USA ment, meta-­analyses were performed for the amount of distalization, distal tipping
6
Department of Orthodontics, Seoul St. and intrusion of first molars.
Mary’s Hospital, The Catholic University of
Korea, Seoul, Korea Results: Nine studies (2 RCTs and 7 prospective studies) were included. The risk of
bias of the RCTs was low to unclear. The non-­randomized studies were of moderate
Correspondence
Jae Hyun Park, Arizona School of Dentistry quality. In five studies, the TSADs were placed in the infrazygomatic process while in
& Oral Health, A.T. Still University, Mesa, two studies, they were placed in the buccal inter-­radicular spaces, and in two studies,
AZ, USA.
Email: [email protected] they were placed in the midpalatal region. The first molar distalization was 2.75 mm
when buccal inter-­radicular TSADs were used, but 4.07 and 4.17 mm with palatal and
infrazgomatic TSADs. The palatal appliances were associated with 11.17° of distal
tipping of the first molar while infrazygomatic and buccal inter-­radicular TSADs re-
sulted in 3.99° and 1.70° of tipping, respectively.
Conclusions: Inter-­radicular TSADs resulted in less distal tipping but also in less dis-
talization. Palatal TSAD-­supported appliances showed the greatest amount of dis-
tal tipping. Further RCTs or prospective studies on the effect of various designs of
TSAD-­supported distalization are warranted.

KEYWORDS

distalization, maxillary molars, temporary skeletal anchorage devices

1 | I NTRO D U C TI O N Extraoral anchorage and non-­c ompliance intraoral appli-

ances such as the pendulum and distal jet have been used for
Distalization of maxillary dentition is an efficient option, espe- maxillary molar distalization. 2,3 However, they often yield
extraction treatment modalities.1
cially for patients seeking non-­ undesirable tooth movement such as distal tipping and ex-
Nevertheless, the fundamental quandary is finding the appropriate trusion of molars and protrusion of incisors due to loss of
anchorage that will not produce unwanted side effects. anchorage. 4,5

© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Orthod Craniofac Res. 2021;24(Suppl. 1):103–112.  wileyonlinelibrary.com/journal/ocr | 103

104 | BAYOME et al.

To overcome the loss of anchorage, intraoral distalization ap- 5. Study design: RCTs and non-­randomized prospective clinical
pliances have been supported by temporary skeletal anchorage trials.
devices (TSADs) placed in the palate.6-­8 However, there have been
disadvantages related to the associated force vector.9
Recently, several studies have reported the placement of TSADs 2.1.2 | Exclusion criteria
buccally, either in the inter-­radicular spaces or in the infrazygomatic
region for molar distalization.10-­13 However, TSADs placed in the Studies were excluded if demographic data (age and gender) of
inter-­radicular spaces may have a limited range of action and high the samples were not reported adequately, if the anchorage ap-
risk of root injury. Also, placing TSADs in the narrow inter-­radicular plied was indirect or hybrid, if TSADs and/or forces were applied
spaces may be difficult, especially in adolescents. Miniscrews may on both sides, if the description of the distalization appliance was
interfere with the distalization process and require relocation if a deficient, or if they included the effects on the temporomandibu-
large amount of distalization is needed.14 Placement of TSADs in the lar joint, surgical procedures or enrolled patients with craniofacial
infrazygomatic region as well as their removal at the end of the treat- syndromes.
ment requires surgical procedures on each side, increasing the cost
of the procedure.
Since the palate has sufficient bone quality and quantity to 2.2 | Information sources, search strategy and
support TSADs with no anatomical structures that might be com- study selection
promised during TSAD placement,15-­18 several researchers have
applied palatal plates such as a modified C-­p alatal plate (MCPP) The search strategy included terms related to maxillary molar dis-
supported by miniscrews in the median and paramedian palatal talization and skeletal anchorage devices: (‘maxilla’[MeSH Terms]
regions.19-­21 With these appliances, forces are directed in favour- OR ‘maxilla’[All Fields] OR ‘maxillary’[All Fields]) AND (‘molar’[MeSH
able vectors to avoid the side effects of the other extraoral and Terms] OR ‘molar’[All Fields]) AND distalization[All Fields] AND
intraoral appliances. 22,23 skeletal[All Fields] AND anchorage[All Fields] AND Class[All Fields]
Several review articles have evaluated maxillary molar distal- AND II[All Fields]. Comprehensive searches, without date restric-
ization, comparing headgear, conventional intraoral appliances and tions or any other limits such as language, were conducted using
24-­27
TSAD-­supported appliances. However, no systematic review has Medline (via PubMed) and Scopus on 2 September 2020. Manual
assessed the treatment effects of TSAD-­supported maxillary molar searching was performed using the reference lists in the full-­text
distalization relative to the location of TSAD placement. Therefore, articles considered eligible for inclusion and other relevant system-
the aim of this systematic review is to assess the treatment effects atic reviews. Assessment of studies for inclusion in the review was
(amount of distalization, distal tipping and vertical movement) of performed independently by two authors, and differences were re-
buccally or palatally placed TSADs on maxillary first molars during solved by consensus.
distalization in patients with Class II molar relationship, that were
reported in randomized controlled trials (RCTs) and non-­randomized
prospective clinical trials. 2.3 | Risk of bias and quality assessment in
individual studies

2 | M ATE R I A L A N D M E TH O DS The risk of bias regarding the selected studies was evaluated by two
authors independently, and disagreements were resolved by con-
2.1 | Eligibility criteria sensus. RCTs were assessed using the Cochrane Collaboration's risk
of bias tool. The following six domains were considered: random se-
2.1.1 | Inclusion criteria quence generation, concealment of allocation, blinding of outcome
assessment, incomplete outcome data, selective reporting and other
Following Population, Intervention, Comparison, Outcome, Study biases. A modified version of the Newcastle-­Ottawa scale was used
design (PICOS) format: to evaluate the quality of the non-­randomized studies. A modifica-
tion was implemented to accommodate a comparison between the
1. Population: Patients with Class II molar relationship who un- pre-­and posttreatment position of the teeth instead of comparing
derwent the process of maxillary first molars distalization. two different groups. Studies ranked as high-­quality were those
2. Intervention: First molar distalization via buccally or palatally achieving a maximum score of 9 stars. Moderate-­quality studies
placed TSADs. were those scoring between 6 and 8 stars, and low-­quality studies
3. Comparison: Not required. scored 5 stars or less. RCTs with low or unclear risk of bias and non-­
4. Outcomes: Amount of (1) distalization, (2) distal tipping, and (3) randomized studies with high to medium quality were included in
vertical displacement. the results.
BAYOME et al. | 105

2.4 | Data items and collection balanced study weights. Estimates of distalization time are also
provided for each index and overall. Heterogeneity was assessed
Study design, sample size, age, gender, severity of Class II malocclu- using an I2 statistic, the percentage of variability due to study het-
sion, appliance type, location of TSAD placement, duration of distali- erogeneity. An alpha of 0.05 was used as the criterion for statistical
zation and type of records used for measurements were recorded. significance.
Means and standard deviations of distalization, distal tipping and
vertical displacement of the maxillary first molars were extracted.
All data were extracted by one author (MB) into an excel sheet 3 | R E S U LT S
(Microsoft Office Professional Plus 2013, Microsoft Corporation,
Redmond, Washington) and reviewed by another author to confirm 3.1 | Study selection and characteristics of included
accuracy. studies

Two hundred and ten studies were initially identified in MEDLINE (via
2.5 | Meta-­analysis PubMed), and 74 articles were obtained through Scopus. After removal
of any duplicates, 278 studies remained. By screening the titles and
A meta-­analysis on each outcome was partitioned according to abstracts, 34 studies were deemed to be eligible for inclusion. An ad-
the location of the TSADs. Meta-­analyses were conducted using ditional 10 studies were identified via manual searching from the ref-
Comprehensive Meta-­Analysis software (V.3.3.070; Biostat Inc). erence lists. By applying the inclusion and exclusion criteria to the 44
Mixed, random-­effects models were used, and mean differences eligible studies, two RCTs and seven non-­randomized prospective clin-
were reported, with 95% confidence intervals for distalization, dis- ical studies were selected (Figure 1). Thus, nine studies were included
tal tipping and vertical displacement. Since the studies included in in the qualitative and quantitative synthesis.9-­11,28-­33 Two studies re-
our analysis were quite variable with regard to severity of the maloc- ported palatal placement of TSAD using two appliances,9,33 and seven
clusions and amount of the applied forces among other factors, the studies assessed the effects of using buccally placed TSADs10,11,28-­32;
random-­effects model was selected as it would be a more plausi- five studies placed TSADS in the infrazygomatic process11,28-­31 and
ble and conservative option compared to the fixed-­effect model. It two in the inter-­radicular spaces.10,32 One of these two studies was an
estimates the mean of a distribution of effects and results in more RCT comparing two designs of miniscrew placement.10

F I G U R E 1 Flow chart showing

screening and selection process
106 | BAYOME et al.

FIGURE 2 Risk of bias summary using Cochrane Collaboration's risk of bias tool

TA B L E 1 Newcastle-­Ottawa Scale (NOS) for assessing the The two studies in which TSADs were placed in the inter-­
quality of non-­randomized studies
radicular spaces used two types of placements: a single miniscrew
Selection Comparability Outcome between the second premolar and first molar on each side, and
(4*) (2*) (3*) two miniscrews, one as described and the other placed between
Abdelhady, 2020 *** * ** the first and second premolars.10,32 The two studies assigned 36
Cambiano, 2017 *** * ** patients (3 males and 33 females) to three groups; one group of

Duran, 2016 *** * ** adolescents and two groups of adults with mild to moderate se-
verity of Class II malocclusions. The mean duration of distalization
Kilkis, 2016 *** ** **
ranged from 4.9 to 11.3 months. The average amount of distaliza-
Nur, 2012 *** ** **
tion in the three groups ranged between 1.29 mm and 4.09 mm.
Kaya, 2009 *** * **
The average distal tipping was 1.55° for the two miniscrews de-
Cornelis, 2007 *** ** **
sign, and 2.48° and 3.19° for the other two groups. The two minis-
crews design resulted in an intrusion of 1.40 mm, while the single
3.2 | Risk of bias within studies miniscrew groups showed 0.11 mm of extrusion and 0.84 mm of
intrusion.
The risk of bias of the included RCTs was low to unclear (Figure 2). The two studies with palatally placed TSADs used a bone-­
All the non-­randomized studies were of moderate quality (Table 1). anchored pendulum appliance (BAPA), and a miniscrew-­s upported
hyrax screw with arms similar to those of the pendulum appliance
for force delivery.9,33 The two studies incorporated 39 adoles-
3.3 | Results of individual studies (quantitative cent patients (16 males and 23 females) with moderate severity
analysis) of Class II malocclusions. The mean duration of distalization was
4.8 and 5.3 months. The average amount of distalization was
Table 2 provides the data extracted from the included studies. The 3.45 mm and 4.10 mm. The average distal tipping was 11.02° and
five studies in which the TSADs were placed in the infrazygomatic 11.24°; and the authors reported average intrusions of 0.59 mm
process included 78 patients (23 males and 55 females), four studies and 0.74 mm.
used adolescent subjects and one used adults. The mean duration
of distalization ranged between 5.4 and 9.0 months. The severity of
malocclusions was reported in different formats; hence, it was not 3.4 | Meta-­analysis
possible to aggregate the data and the severity was not reported
in one study.11 Cornelis et al11 only reported the molar distaliza- Figures 3-­5 provide graphical representations of the aggregated
tion. The average amount of distalization in the five studies ranged data for maxillary first molar distalization, distal tipping and in-
between 2.93 mm and 5.31 mm. The average distal tipping in the trusion. Within each figure, measurements are grouped by loca-
four studies ranged between 1.21° and 6.39° with average intrusion tion of TSAD placement. The figures provide a weighted average
ranging between 0.13 mm and 1.57 mm. estimate (last row within each group) and the aggregate P-­v alue
 BAYOME et al.
TA B L E 2 Extracted data from the included studies

Max. 1st Max. 1st

Duration of molar Max. 1st molar vertical
distalization Distalization molar distal movement
Gender Age (mo) (mm) tipping (°) (mm)
Study Measuring Severity of Sample
name Study type material Appliance design malocclusion size M F Mean SD Mean SD Mean SD Mean SD Mean SD

Cornelis Prospective 3D model Infrazygomatic plate N/A 17 2 15 27.3 N/A 7 2 3.3 1.8 N/A N/A N/A N/A
et al,
2007
Kaya et al, Prospective Ceph Zygoma at least half cusp 15 5 10 14.74 N/A 9.03 0.62 5.03 0.3 5.43 1.36 −0.13 0.27
2009 anchorage system
Nur et al, Prospective Ceph Zygoma gear at least half cusp 15 7 8 15.87 1.09 5.21 0.96 4.36 2.15 3.3 2.31 −0.5 0.46
2012
El-­Dawlatly RCT CBCT Zygoma mini-­implant anteroposterior and 10 0 10 10-­12 N/A 6.0 N/A 2.93 0.7 1.21 0.89 −1.57 1.18
et al, vertical maxillary (range)
2014 excess
Kilkis et al, Prospective Ceph Zygoma gear need for molar 21 9 12 15.68 2.18 5.4 1.4 5.31 2.46 6.39 5.39 −0.76 2.85
2016 distalization of at least
3 mm
Bechtold RCT Ceph Miniscrew between moderate Class II, 12 1 11 23.58 6.92 9.08 4.89 1.29 0.66 3.19 4.61 −0.84 1.09
et al, 2nd premolar and 1st minimal crowding
2013 molar at each side
2 miniscrew between moderate Class II, 13 2 11 22.92 7.1 11.27 5.71 2.91 0.96 1.55 1.32 −1.4 0.99
1st and 2nd premolars minimal crowding
& between 2nd
premolar and 1st
molar on each side
Abdelhady Prospective Ceph Miniscrew between mild to moderate arch 11 0 11 12.4 N/A 4.9 1.5 4.09 0.92 2.48 6.16 0.11 0.63
et al, 2nd premolar and 1st length discrepancy
2020 molar on each side
Duran et al, Prospective 3D model Miniscrew-­supported moderate crowding 21 12 9 13.6 N/A 5.3 1.46 4.1 1.57 11.02 5.32 −0.59 0.5
2016 hyrex screw (≤5 mm)
Cambiano Prospective Ceph BAPA at least half cusp 18 4 14 14 1.08 4.8 N/A 3.45 1.54 11.24 3.44 −0.74 0.68
et al,
2017

Abbreviations: CBCT, Cone-­Beam Computerized Tomography; Ceph, Cephalometric radiograph; F, Female; M, Male; Max., Maxillary; N/A, not available; RCT, Randomized Controlled Trial; BAPA, bone-­
anchored pendulum appliance.

|
107
108 | BAYOME et al.

FIGURE 3 Forest plot of maxillary first molar distalization. Heterogeneity for distalization = 61.95%

FIGURE 4 Forest plot of maxillary first molar distal tipping. Heterogeneity for distalization = 52.00%

for each location category. Weighted means, 95% confidence in- 4 | D I S CU S S I O N

tervals and P-­v alues are displayed for each group; however, no
comparisons across groups were performed due to the sparsity Temporary skeletal anchorage devices-­supported maxillary molar
of the data. The I2 for distalization was 61.95%, and the over- distalization has become a viable treatment option for the cor-
all effect was significant, Z = 14.44, P < .001. For distal tipping rection of Class II malocclusions. A wide variety of appliances and
2
(I = 52.00%), the difference was significant, Z = 12.50, P < .001. designs have been introduced to avoid the shortcoming of the tra-
Likewise, for intrusion (I2 = 15.47%), Z = 7.62, P < .001. Figure 6 ditional methods including headgear and non-­compliance intraoral
provides estimates of duration of distalization by group, and the appliances. TSADs were placed in several locations to support max-
associated statistics. illary molar distalization such as in the infrazygomatic process, the
BAYOME et al. | 109

FIGURE 5 Forest plot of maxillary first molar intrusion. Heterogeneity for distalization = 15.47%

FIGURE 6 Forest plot of duration (months) of maxillary first molar distalization

paramedian palatal region and the inter-­radicular spaces. This sys- is about 8.3 months, irrelevant of the anchorage type whether con-
tematic review was conducted to assess the effect of the location of ventional or skeletal.34 In our study, the duration of distalization of
the TSADs on the distalization of the maxillary first molars. the first molar was 8.2 months with buccal inter-­radicular TSADs,
A previous systematic review showed that the time required for 6.7 months with infrazygomatic TSADs and 5.3 months with pala-
the distalization of the maxillary molar by around half to a full cusp tal TSADs. However, these data should be interpreted with caution
110 | BAYOME et al.

due to the variability in reported severity of the malocclusions and meta-­analysis would be conducted using studies of the same sever-
amount of the applied forces. ity, studies of heterogenous malocclusion severity were pooled in this
Our analysis suggested that the palatally placed TSADs support- study.
ing appliances with pendulum-­like arms produced a large amount of Only two RCTs were eligible for inclusion into our systematic
distal tipping (11.17°) compared to the buccally placed TSADs. This review. Therefore, prospective cohort studies were also included to
could be attributed to the design of the appliance in the included allow greater insight into the effect of TSAD placement locations on
studies, since both of them had pendulum-­like arms extending from the distalization process. However, meta-­analysis on studies with sin-
a TSAD-­supported appliance. However, several studies on palatally gle arms might be questioned due to the potential bias and diversity
placed TSADs with different appliance designs such as MCPPs re- in study designs.39 These issues rendered the estimation of effects
19,35-­37
ported minimal distal tipping. Even though these findings were challenging, and therefore the findings should be interpreted with
explained by several studies using 3D finite element analysis, 22,23 caution.
no RCTs or prospective cohort studies have been conducted with The assessment methods in the included studies varied; mea-
these appliances, and therefore such studies might be warranted to surements were taken on lateral cephalographs in most of them, on
validate our knowledge regarding the MCPP. In future systematic CBCT images in one of them, and on 3D dental models using differ-
review studies on treatment effects, it might be recommended that ent landmarks in two of them. However, all these methods have been
the groups be aggregated based on the direction of the force vector validated and reported accurate in assessing treatment effects.40,41
as well as on the location of the anchorage used in the studies. In addition, these studies were assessing the difference in the po-
The buccal inter-­radicular TSADs were associated with a small sition of the first molars, so it was not necessary that they all used
amount of first molar distal tipping (1.70°). However, they also re- the same landmarks to aggregate and evaluate the amount of these
sulted in the smallest amount of distalization (2.75 mm). This might changes.
be due to the proximity of the anchorage unit to the first molar which Moreover, not all factors used in the typical decision process
decrease the range of action. In addition, the duration to achieve this for selecting the appropriate TSADs for distalization were included
distalization was 8.2 months. Moreover, this design might interfere in this study. Other potential factors include the level of clinician
with total arch distalization due to the limited space available for experience required, the need for a surgical flap for placement and
premolar distalization. removal of the TSADs, and the cost of the appliance.
Our meta-­analysis showed a small amount of intrusion of first
molars associated with the three locations of the TSADs. The pal-
atally placed TSADs resulted in 0.64 mm of intrusion of the maxil- 5 | CO N C LU S I O N S
lary first molars. The amount of intrusion ranged between 0.1 and
1.6 mm depending on the appliance design and the force vector. On 1. The first molar distalization was 2.75 mm when buccal inter-­
the other hand, a previous review on BAPAs reported an extrusion radicular TSADs were used, but 4.07 and 4.17 mm with palatal
of the first molar ranging between 0.1 and 1.75 mm.38 This discrep- and infrazgomatic TSADs, respectively.
ancy could be due to the inclusion of studies on different age groups 2. Palatal bone-­anchored pendulum-­like appliances were associated
or due to selective reporting that might have been associated with with a large amount of distal tipping of the first molars (11.17°),
some studies. while the infrazygomatic and buccal inter-­radicular TSADs
Only two studies reported the rotation of the maxillary first mo- showed 3.99° and 1.70°, respectively.
lars after distalization.32,33 When the TSADs were placed buccally, 3. The three subgroups of TSAD-­supported distalization produced
there was a mesiobuccal rotation of 11.89° ± 5.86°; while the pala- in a small amount of first molar intrusion (0.60-­0.69 mm).
tally placed TSADs resulted in distobuccal rotation of 4.92° ± 3.09°. 4. First molar distalization to reach Class I molar relationship can
In addition, three studies showed the treatment effects on the max- be achieved in 8.2 months using buccal inter-­radicular TSADs,
illary second molars; one on Zygomatic TSADs and two on palatally 6.7 months using infrazygomatic TSADs and 5.3 months using
placed TSADs.9,30,33 Therefore, it was not practical to include those palatal TSADs.
variables as outcomes in our analysis. 5. Further well-­designed, high-­quality RCT or prospective studies
are required to determine the effect that various TSAD designs
have on distalization.
4.1 | Limitations
C O N FL I C T O F I N T E R E S T
The severity of the malocclusion is related to the amount of molar All authors report no financial or non-­financial interest in the subject
distalization required to achieve Class I molar relationship. Among the matter or materials discussed in this manuscript.
studies included in this systematic review, only one had no informa-
tion regarding the severity of the malocclusions. Since the reporting AU T H O R C O N T R I B U T I O N S
systems were not homogenous, it was not possible to group the stud- Bayome M, Park JH, Kook YA: Conception and design of study.
ies according to the severity of the malocclusion. Although the ideal Bayome M, Park JH: Acquisition of data. Bay C, Bayome M: Data
BAYOME et al. | 111

analysis and/or interpretation. All authors: Drafting of manuscript 17. Ryu JH, Park JH, Vu Thi Thu T, Bayome M, Kim Y, Kook YA. Palatal
bone thickness compared with cone-­beam computed tomography
and/or critical revision and approval of final version of manuscript.
in adolescents and adults for mini-­implant placement. Am J Orthod
Dentofacial Orthop. 2012;142:207-­212.
DATA AVA I L A B I L I T Y S TAT E M E N T 18. Vu T, Bayome M, Kook YA, Han SH. Evaluation of the palatal soft
Data available on request from the authors. tissue thickness by cone-­beam computed tomography. Korean J
Orthod. 2012;42:291-­296.
19. Kook YA, Bayome M, Trang VT, et al. Treatment effects of a modified
ORCID
palatal anchorage plate for distalization evaluated with cone-­beam com-
Mohamed Bayome https://orcid.org/0000-0001-7314-1419 puted tomography. Am J Orthod Dentofacial Orthop. 2014;146:47-­54.
Jae Hyun Park https://orcid.org/0000-0002-3134-6878 20. Kook YA, Kim SH, Chung KR. A modified palatal anchorage plate for
Yoon-­Ah Kook https://orcid.org/0000-0001-9969-8645 simple and efficient distalization. J Clin Orthod. 2010;44:719-­730.
21. Kook YA, Lee DH, Kim SH, Chung KR. Design improvements in
the modified C-­palatal plate for molar distalization. J Clin Orthod.
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