Original Article

Maxillary Molar Distalization with a

Bone-Anchored Pendulum Appliance
Beyza Hancıoğlu Kircellia; Zafer Özgür Pektaşb; Cem Kircellic

ABSTRACT
To obtain an effective and compliance-free molar distalization without an anchorage loss, we
designed the bone-anchored pendulum appliance (BAPA). The aim of this study was to evaluate
the stability of the anchoring screw, distalization of the maxillary molars, and the movement of
teeth anterior to maxillary first molars. The study group comprised 10 patients (mean age 13.5 6
1.8 years) with Class II molar relationship. A conventional pendulum appliance was modified to
obtain anchorage from an intraosseous screw instead of the premolars. The screw was placed in
the anterior paramedian region of the median palatal suture. Skeletal and dental changes were
measured on cephalograms, and dental casts were obtained before and after distalization. A super
Class I molar relationship was achieved in a mean period of 7.0 6 1.8 months. The maxillary first
molars distalized an average of 6.4 6 1.3 mm in the region of the dental crown by tipping distally
an average of 10.98 6 2.88. Also, the maxillary second premolar and first premolar moved distally
an average of 5.4 6 1.3 mm and 3.8 6 1.1 mm, respectively. The premolars tipped significantly
distally. No anterior incisor movement was detected. The BAPA was found to be an effective,
minimally invasive, and compliance-free intraoral distalization appliance for achieving both molar
and premolar distalization without any anchorage loss.
KEY WORDS: Molar distalization; Pendulum appliance; Intraosseous screw; Anchorage

INTRODUCTION maxillary first molars. Any action to move molars dis-

Nonextraction treatment of Angle Class II malocclu- tally produces a mesial reaction force on the anchoring
sion usually requires distalization of maxillary molars. teeth.6 As a consequence, if the premolars or incisors
Beginning in the 1980s, intraoral appliances, such as (or both) are the anchoring teeth, they move mesially,
repelling magnets,1 superelastic NiTi coil springs,2 the incisors protrude, and overjet increases.1–5,7–14
pendulum,3 Jones-jig,4 and distal-jet,5 have been intro- However, this effect is in contradiction with the main
duced to distalize molars with minimal patient compli- objective of Class II treatment. Furthermore, distalized
ance. molars are questionable anchors for the retraction of
Intraoral distalization appliances have been de- premolars and incisors, despite attempts (headgears,
signed to deliver a continuous reciprocal force on the Nance appliance etc) that have been made to maintain
them in their new positions.7,8
a
Assistant Professor, Department of Orthodontics, Adana Recently, researchers have tried to overcome this
Medical Research and Teaching Center, Baskent University, major problem by designing new intraoral systems in-
Adana, Turkey volving rigid skeletal anchorage. Byloff et al15 designed
b
Assistant Professor, Oral and Maxillofacial Surgery, Adana the Graz implant-supported pendulum appliance. The
Medical Research and Teaching Center, Baskent University,
Adana, Turkey.
anchorage part of this appliance consisted of a surgi-
c
Instructor, Department of Prosthodontics, Adana Medical Re- cal plate (15 3 10 mm) fixed with four titanium min-
search and Teaching Center, Baskent University, Adana, Turkey. iscrews to the palatal bone. The acrylic part of the pen-
Corresponding author: Beyza Hancıoğlu Kircelli, DDS, PhD, dulum appliance was fitted to the cylinders, soldered
Department of Orthodontics, Adana Medical Research and to the center of the surgical plate, on the basis of a
Teaching Center, Baskent University, Dadaloğlu mah, 39. sok.
No. 6 Yuregır, Adana 01250, Turkey telescopic principle. They used this appliance in adult
(e-mail: beyzakircelli@hotmail.com) patients.16
Accepted: July 2005. Submitted: April 2005.
Keleş et al17 used an osseointegrated palatal im-
Q 2006 by The EH Angle Education and Research Foundation, plant instead of a Nance button in the Keles slider ap-
Inc. pliance. Carano et al18 introduced the distal-jet in con-

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BONE-ANCHORED PENDULUM APPLIANCE 651

FIGURE 2. Intraoral view of screw in place.

FIGURE 1. The intraosseous screw.

junction with a miniscrew anchorage system. Karaman

et al19 and Gelgör et al20 used an intraosseous screw
with their distalization mechanics containing com-
pressed coil springs. Both the authors used this screw
as an indirect rigid anchorage; the first premolars were
connected to the intraoral neck of the screw via a
heavy archwire, using light-cured composite resin.
To obtain an effective and compliance-free molar
distalization without anchorage loss, we designed the
bone-anchored pendulum appliance (BAPA). The aim FIGURE 3. Lateral cephalometric radiograph showing screw posi-
of this study was to evaluate the stability of the an- tion.
choring screw, distalization of the maxillary molars,
and the movement of the anchoring teeth anterior to TABLE 1. Screw Inclination Relative to Palatal Plane (Angle Be-
the maxillary first molars. tween the Long Axis of the Screw and the Palatal Plane)
N Min Max Mean SD
MATERIALS AND METHODS
Screw-PP (8) 10 50 76 65 77,655
The study group comprised 10 patients (nine female
and one male; mean age 13.5 6 1.8 years) requiring
intraoral molar distalization. The selection criteria for lateral to the median line (Figure 2). A 1.3-mm-diam-
patients included good oral hygiene, permanent den- eter drill was used to maintain primary stability of the
tition, Class II molar relationship with a moderate screw. In two patients, the screws were inserted bilat-
space deficiency in the maxillary dental arch, and min- erally to the median palatal suture. The screw position
imal or no crowding in the mandibular arch. No other was checked on a lateral cephalometric radiograph
appliance was used other than BAPA during the dis- (Figure 3). Minimum, maximum, and mean values for
talization phase. All patients and parents were in- the screw angulation relative to the palatal plane are
formed about the surgical procedure and signed a shown in Table 1.
consent form.
Construction of the BAPA
Intraosseous screw and surgical procedure
After soft tissue healing, impressions and stone
A titanium intraosseous screw (2.0 mm diameter 3 casts were obtained with the IMF screws in place. On
8 mm length) (IMF intermaxillary fixation screw, Stry- the stone model, the screw head was blocked out with
ker, Leibinger, Germany) was used as a rigid bone wax, and the pendulum appliance was constructed ac-
anchor (Figure 1). The screw was inserted in the an- cording to Hilgers3 descriptions, excluding the auxiliary
terior paramedian region of the median palatal suture, wires that extend to the occlusal surface of the first
7–8 mm posterior to the incisive foramen and 3–4 mm and second premolars.

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652 B. H. KIRCELLI, PEKTAŞ, C. KIRCELLI

FIGURE 4. Intraoral application of bone-anchored pendulum appli-

ance.

The appliance adaptation was checked clinically,

FIGURE 5. Skeletal and soft tissue measurements. (1) SNA. (2)
and the springs were activated parallel to the median
SNB. (3) ANB. (4) FMA. (5) GoGnSn. (6) PTV-A point. (7) Palatal
palatal suture. The acrylic plate was connected to the plane angle. (8) Upper lip to E-plane. (9) Lower lip to E-plane. PTV
screw head using cold-curing, methyl methacrylate- indicates pterygoid vertical plane.
free acrylic resin (Ufi Gel hard, Voco GmbH, Cuxha-
ven, Germany). Finally, activated 0.032-inch titanium
molybdenum alloy (TMA) springs (Ormco Corp, Glen-
dora, Calif) were inserted into the lingual sheaths on
the first molar bands (Figure 4).
Patients were specially educated to maintain their
oral hygiene and were asked to use a mouthwash reg-
ularly. At every appointment, the soft tissue around the
acrylic plate was checked. Also, the springs were re-
activated if necessary.

Cephalometric and dental cast analysis

After achieving a super Class I molar relationship, a
lateral cephalometric radiograph was obtained to as-
sess dentoalveolar, skeletal, and soft tissue changes.
The pterygoid vertical plane and the Frankfort horizon-
tal plane were used as reference planes for measuring
the cephalometric changes (Figures 5 and 6).
The degree of rotation of the maxillary first molars
and the amount of expansion between the maxillary
right and left first molars were measured on photocop- FIGURE 6. Dental linear measurements. (1) U6-PTV. (2) U5-PTV.
ies21 of the maxillary plaster casts. On the photocop- (3) U4-PTV. (4) U1-PTV. (5) L6-PTV. (6) U6-FH. (7) U5-FH. (8) U4-
ies, movements of the maxillary first molars were as- FH. (9) U1-FH. Dental angular measurements. (10) U6-FH. (11) U5-
sessed according to the median palatal plane22 (Figure FH. (12) U4-FH. (13) U1-FH. PTV indicates pterygoid vertical plane;
FH, Frankfort horizontal plane.
7).
Acquired arch lengths were also calculated from
cast photocopies. The total arch length was measured
of occlusion and straightened out for the measure-
as the arch perimeter from one upper first molar to the
ment.
other. This measurement was over the contact points
of the posterior teeth and the incisal edges of the in-
Statistical analysis
cisors, both before treatment and after distalization. In
addition, the acquired arch length in the anterior seg- The initial measurements were repeated after 1
ment was calculated by measuring the arch perimeter week. Spearman’s rho coefficients were calculated to
between the mesial contact points of the first premo- analyze repeatability. Coefficients were found to be
lars. A piece of ligature wire was contoured to the line close to 1.00. Nonparametric Wilcoxon sign rank test

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BONE-ANCHORED PENDULUM APPLIANCE 653

was used for comparison of paired values of the mea-

surements. A probability of .05 was accepted as criti-
cal significance.

RESULTS
A super Class I molar relationship was achieved in
a mean period of 7.0 6 1.8 months. In the region of
the dental crown, the maxillary first molars distalized
an average of 6.4 6 1.3 mm tipping distally, an aver-
age of 10.98 6 2.88. Also, the maxillary second pre-
molar and first premolar moved distally an average of
5.4 6 1.3 mm and 3.8 6 1.1 mm, respectively. No
anterior movement of the incisors was detected.
The mean, standard deviation, and statistical signif-
icance of the skeletal, dental, and soft tissue cepha-
lometric changes from pretreatment to after achieving
a super Class I molar relationship with BAPA are sum-
FIGURE 7. Maxillary model photocopy measurements. 1. Intermolar marized in Table 2. The dental cast measurements are
distance. 2. Length of total arch perimeter. 3. Length of anterior arch shown in Table 3. Figures 8 through 13 demonstrate
perimeter. 4. Maxillary first molar-Median palatal plane (8). a sample case treated with BAPA.

TABLE 2. Changes in Cephalometric Skeletal, Soft Tissue, and Dental Measurements From Pretreatment to After Distalizationa
Pretreatment After Distalization
Measurements Mean 6 SD Mean 6 SD Difference Mean 6 SD Significance
Skeletal
SNA (8) 78.3 6 3.7 79.0 6 3.9 0.7 6 0.8* .03
SNB (8) 74.8 6 2.3 74.8 6 2.3 0 6 0.6 NS
ANB (8) 3.6 6 2.1 4.2 6 2.9 0.6 6 0.9 NS
FMA (8) 29.9 6 2.8 30.8 6 2.5 0.9 6 1.1* .03
GoGnSn (8) 38.5 6 3.1 39.4 6 2.9 0.9 6 1.1* .03
PTV-A point (mm) 51.4 6 2.9 52.0 6 3.0 0.6 6 0.6* .03
PTV-B point (mm) 42.8 6 3.8 42.6 6 3.6 20.2 6 1.3 NS
PTV-palatal plane (8) 1.1 6 2.7 1.1 6 2.4 0 6 1.4 NS
Soft tissue
Upper lip to E-plane (mm) 22.7 6 2.3 22.4 6 2.4 0.3 6 1.1 NS
Lower lip to E-plane (mm) 21.5 6 1.4 21.2 6 1.1 0.3 6 1.0 NS
Dental-linear sagital (mm)
Maxillary first molar-PTV 26.7 6 2.9 20.3 6 2.6 26.4 6 1.3** .005
Maxillary second premolar-PTV 30.1 6 3.6 24.7 6 3.5 25.4 6 1.3** .005
Maxillary first premolar-PTV 37.6 6 3.7 33.8 6 3.8 23.8 6 1.1** .005
Maxillary incisor-PTV 54.9 6 4.0 54.7 6 4.1 20.2 6 0.7 NS
Mandibular first molar-PTV 24.0 6 2.6 24.3 6 2.5 0.3 6 0.6 NS
Overjet 4.1 6 1.1 4.4 6 1.3 0.3 6 0.6 NS
Dental-linear vertical (mm)
Maxillary first molar-FH 46.5 6 4.0 46.6 6 4.1 0.1 6 0.5 NS
Maxillary second premolar-FH 49.0 6 3.0 49.1 6 1 0.1 6 0.6 NS
Maxillary first premolar-FH 50.2 6 3.3 50.6 6 3.1 0.4 6 0.7 NS
Maxillary incisor-FH 54.5 6 3.7 54.5 6 3.8 0 6 0.6 NS
Overbite 4.0 6 2.0 3.45 6 2.0 20.5 6 0.5* .03
Dental-angular (8)
Maxillary first molar-FH 73.0 6 4.3 62.1 6 5.1 210.9 6 2.8** .005
Maxillary second premolar-FH 83.1 6 5.1 66.8 6 5.5 216.3 6 6.5** .005
Maxillary first premolar-FH 91.2 6 4.8 80.2 6 4.4 23.8 6 1.1** .005
Maxillary incisor-FH 106.6 6 7.6 106.0 6 8.6 20.6 6 1.8 NS
a
PTV indicates pterygoid vertical plane; FH, Frankfort horizontal plane; and NS, non significant.
* P , .05.
** P , .01.

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654 B. H. KIRCELLI, PEKTAŞ, C. KIRCELLI

TABLE 3. Changes in Dental Cast Measurements From Pretreatment to After Distalization

Pretreatment After Distalization Difference
Measurements Mean 6 SD Mean 6 SD Mean 6 SD Significancea
Intermolar distance (mm) 46.6 6 2.0 49.6 6 2.7 3.0 6 3.0** .01
Length of total arch perimeter (mm) 74.9 6 2.8 88.8 6 5.1 13.9 6 4.1** .008
Length of anterior arch perimeter (mm) 46.1 6 3.5 52.3 6 3.8 6.2 6 3.2*** .000
Maxillary first molar-MPP (8) 28.3 6 6.5 32.4 6 10.8 4.1 6 9.0 NS
a
NS indicates non significant.
** P , .01.
*** P , .001.

In all the patients, the 2 3 8–mm intraosseous On the other hand, Fritz et al29 investigated the clin-
screw remained stable during the distalization period. ical suitability of the titanium miniscrews for orthodon-
However, we observed a minimal rotational movement tic anchorage purposes (predominantly used for pre-
of the acrylic plate during spring reactivation, espe- molar distalization, molar uprighting, and mesial move-
cially in patients presenting a shallow palatal vault. Af- ment of the molar) and reported a failure rate of 30%.
ter experiencing this effect, we placed two screws bi- In our study, a suitable area to insert the screw was
laterally to mid-palatal suture in two patients. localized with respect to a computerized tomographic
After removing the acrylic plate, mild to moderate study in which Bernhart et al32 indicated the area for
soft tissue irritation was detected on the palatal mu- implant placement was 6 to 9 mm posterior to the in-
cosa, but this was resolved in a few days (Figure 12). cisive foramen and 3 to 6 mm lateral to the mid-palatal
Relatively less irritation was observed in patients suture. Moreover, Costa et al33 reported a mean 10.57-
whose pendulums were supported with bilateral mm bone depth in the paramedian area in the pre-
screws. maxilla region of the palate.
At first sight, one can assume that severe mucosal
DISCUSSION irritation might occur with the BAPA; however, the
screw head in the palatal acrylic acts as a stop so that
The pendulum appliance has experienced wide-
the palatal mucosa cannot be compressed. In this
spread clinical use,23 and various studies have dem-
onstrated its skeletal and dentoalveolar effects.8–12 In- study, unilateral screws were applied in eight and bi-
variably, the pendulum was found to be an effective lateral screws in two patients. Although none of the
appliance for distalizing maxillary molars. However, unilateral screws had failed to withstand reciprocal
associated anterior anchorage loss, which represent- forces during the distalization period, we suggest bi-
ed 30–43% of the space created between molars and lateral screws for eliminating both rotational move-
premolars, was a constant finding of these studies. ments during spring activations and diminishing soft
Today, rigid bone anchors including osseointegrated tissue irritations. Also, bilateral screws might present
implants,17,24–26 titanium miniscrews,18–20,27–30 and mini- more predictable results for the clinicians when using
plates15,16 are powerful candidates to solve the an- this system.
chorage concern. Elimination of the osseointegration Despite the fact that all patients were strictly en-
period (2–6 months), wider range of application sites, couraged to maintain their oral hygiene, some plaque
simple surgical procedures during the insertion and re- accumulation was evident under the acrylic plate.
moval processes, and decreased cost make intraos- However, this condition did not affect the screw sta-
seous screws preferable rigid bone anchors. bility. This might be attributed to the dense, thick, and
Screws are attached to the bone by mechanical re- keratinized structure of the attached palatal mucosa.
tention. Osseointegration is not a goal when screws The only difficulty experienced with the BAPA was
are placed. However, primary stability is a prerequisite detaching the acrylic plate from the screw head when
for future stability.30,31 removing the appliance. We used a carbide bur with
In a recent study, Deguchi et al28 placed 96 small an aerator under copious irrigation. As a suggestion,
titanium screws in eight dogs and demonstrated a suc- if the acrylic plate is made no thicker than 2 mm over
cessful rigid osseous fixation (97%). Huga et al30 the screw head and the grooves at the top of the screw
claimed that the bone supporting monocortical screws are filled with a thin layer of wax, it will facilitate de-
would most likely withstand immediate loading and taching the acrylic plate.
support tooth-moving forces; they tested the pull-out When the BAPA is compared with other systems,
strength of monocortical miniscrews with mechanical the Graz implant-supported pendulum appliance15,16
testing. seems convenient regarding its removable property,

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BONE-ANCHORED PENDULUM APPLIANCE 655

FIGURE 8. Pretreatment photographs of a 13-year-old patient.

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656 B. H. KIRCELLI, PEKTAŞ, C. KIRCELLI

FIGURE 9. Postdistalization intraoral photographs. Note maxillary molar and premolar distalization providing adequate space for maxillary
canines spontaneously.

FIGURE 11. BAPA can be held in place during the full fixed therapy;
thus minor activation of the springs supports the molar anchorage.
BAPA indicates bone-anchored pendulum appliance.
FIGURE 10. Lateral cephalometric radiograph after distalization.

lary molars moved distally a mean of 6.4 mm and the

thereby enabling activations extraorally. The pendu- second and first premolars drifted distally a mean of
lum appliance fixed to an osseointegrated implant26 5.4 and 3.8 mm, respectively. Because reactive forces
could present a more reliable anchorage when an arising from the pendulum springs were directly re-
uprighting bend is added to the springs. However, both sisted by an intraosseous screw, the premolars were
systems are more invasive than applying a screw. free from any attachment, and they drifted distally via
transeptal fibers during the distalization period. As a
Maxillary molar and premolar distalization
result, in the study group, a Class I relationship was
In all patients, a super Class I molar relationship simultaneously achieved in the second premolars.
was achieved in approximately 7 months. The maxil- The mesial movement of the premolars with the con-

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BONE-ANCHORED PENDULUM APPLIANCE 657

sition when a continuous archwire is applied to upright

the molars. Also, the molar position is maintained
when leveling and retracting first premolars and ca-
nines. In the present study, this so-called active an-
chorage concept, defined by Byloff et al,15 coped with
the anchorage concern of the distalized molars.
On the other hand, overcorrection of the molar re-
lationship is another goal that taxes molar anchorage20
during full fixed therapy, especially if distal tipping ex-
ists. Again, a problem appears for the conventional in-
traoral distalization appliances because the amount of
distal movement correlates with the amount of an-
FIGURE 12. Soft tissue status immediately after the removal of chorage loss.8 In this context, one can use the BAPA
BAPA. BAPA indicates bone-anchored pendulum appliance. to freely move the molars to a super Class I relation-
ship without considering anchorage loss.
ventional pendulum or other intraoral distalizing appli-
ances is a well-established finding in the literature.1– Skeletal and soft tissue effects
5,7–14
However, this can also occur when distalizing mo-
lars using indirect skeletal anchorage in which reactive • In this study, the cant of the palatal plane remained
forces are initially resisted by premolars stabilized by unchanged and the mandibular plane rotated by 0.98
a rigid anchor. Gelgör et al20 demonstrated a slight an- in a clockwise direction. This agrees with the results
chorage loss in the anterior segment and attributed demonstrated by other studies with the conventional
this effect to mesial tipping of first premolars during pendulum.8,10 This clockwise rotation can be attri-
molar distalization. In the same manner, a 4.1 mm an- buted to the maxillary molars moving distally into the
terior incisor movement was reported in a study34 wedge of occlusion and to the cusp interferences.
where premolars were indirectly anchored to an os- Although it is clinically negligible, point A moved an-
seointegrated palatal implant with a special abutment. teriorly by 0.6 mm. This effect might be remodeling
The most beneficial finding of BAPA is the simulta- because of reciprocal forces affecting the anterior
neous distal movement of premolars with molars. This palate. No significant difference was observed re-
is advantageous in several aspects. The new molar garding the upper and lower lip positions relative to
position has not been jeopardized because there is no the esthetic line. Conversely, protrusion is a result of
need to retract the anterior teeth. An unnecessary an- the action of a conventional pendulum.8,10 However,
terior movement has been avoided at the premolars future studies with greater sample size would permit
and incisors. Moreover, anterior crowding has been more reliable statements to be made regarding the
spontaneously solved out because of the stretched clinical success of the BAPA.
transeptal fibers. As a consequence, the total treat-
ment time is shortened. In this study, after molar dis-
CONCLUSIONS
talization, an average of 13.9 and 6.2 mm of space
was gained in the total maxillary arch and in the an- • Molar distalization, as well as premolar distalization,
terior segment, respectively. was achieved with BAPA without any anchorage
loss.
Distal tipping
• Besides the space gained in the posterior segment,
A significant distal tipping was observed with both a quantity of space was also gained in anterior seg-
premolar and molar distalization. Mean tipping values ment, and spontaneous alignment of anterior crowd-
for the crowns of the maxillary first molars, second pre- ing was achieved during molar distalization.
molars, and first premolars were 10.98, 16.38, and 3.88, • In this study, the BAPA presented an effective and
respectively. minimally invasive, compliance-free alternative for
Distalization with a tipping movement can be ques- intraoral molar distalization in nonextraction Class II
tioned because a quantity of space can be lost with treatment.
molar uprighting when full fixed therapy is initiated.8,14
However, in this system, there is no need to remove
ACKNOWLEDGEMENT
the appliance immediately after distalization. Thus, mi-
nor activation of the pendulum springs (terminal dou- Special thanks to Mrs. Fahrunnisa Dınkcıoğlu and Mr. Mus-
ble back bend is eliminated) helps maintain molar po- tafa Obaz for their contributions.

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658 B. H. KIRCELLI, PEKTAŞ, C. KIRCELLI

FIGURE 13. Posttreatment photographs.

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Angle Orthodontist, Vol 76, No 4, 2006