Original Article

Extraoral vs Intraoral Appliance for Distal Movement of

Maxillary First Molars:
A Randomized Controlled Trial
Lars Bondemarka; Ingela Karlssonb

Abstract: Using randomized controlled trial methodology, the aim of this study was to evaluate
and compare the treatment effects of an extraoral appliance (EOA) and an intraoral appliance
(IOA) for distal movement of maxillary first molars. A total of 40 patients (mean 11.5 years, SD
1.29) at the Orthodontic Clinic, National Health Service, Skane County Council, Malmö, Sweden,
were randomized to receive treatment with either extraoral traction (cervical headgear) or an IOA
using superelastic coils for distal movement of maxillary first molars. The inclusion criteria were
a nonextraction treatment plan, a Class II molar relationship and maxillary first molars in occlusion
with no erupted maxillary second molars. The outcome measures to be assessed in the trial were
treatment time, cephalometric analysis of distal molar movement, anterior movement of maxillary
central incisors, ie, anchorage loss and sagittal and vertical skeletal positional changes of the
maxilla and mandible. In the IOA group, the molars were distalized during an average time of 5.2
months, whereas in the EOA group the corresponding time was 6.4 months (P , .01). The mean
amount of distal molar movement was significantly higher in the IOA than in the EOA group, three
mm vs 1.7 mm (P , .001). Moderate anchorage loss was produced with the IOA implying in-
creased overjet (0.9 mm) whereas the EOA created decreased overjet (0.9 mm). It can be con-
cluded that the IOA was more effective than the EOA to create distal movement of the maxillary
first molars. (Angle Orthod 2005;75:699–706.)
Key Words: RCT; Distal molar movement; Extraoral traction; Intraoral appliance

INTRODUCTION movement, these treatments are highly dependent on

patient cooperation. Therefore, various intraoral devic-
To correct a Class II dental malocclusion or to cre-
es that have almost eliminated the reliance on the pa-
ate space in the maxillary arch by a nonextraction pro-
tient have been introduced. These techniques include
tocol, maxillary molars can be moved distally and
Wilson arches,4 Hilgers pendulum appliances,5–7 re-
thereby gain space and convert the Class II molar re-
pelling magnets, and superelastic coils.8–15 However,
lationship to a Class I. Then, the molars are held in
in a literature review, it was reported that the quality
place whereas the premolars, canines, and incisors
of evidence for any method of moving maxillary molars
usually are retracted by conventional multibracket
distally was not high.16
techniques. A variety of modes of distal molar move-
So far, there is no randomized controlled trial (RCT)
ment have been suggested including extraoral trac-
comparing the effectiveness of extraoral appliance
tion1,2 and extraoral traction in combination with re-
(EOA) and intraoral appliance (IOA) as methods of dis-
movable appliances.3 Despite their efficacy in tooth
talizing maxillary first permanent molars as part of a
course of orthodontic treatment. Thus, using RCT
a
Head and Associate Professor, Department of Orthodontics, methodology, the aim of this study was to evaluate
Faculty of Orthodontics, Malmö University, Malmö, Sweden.
b
Consultant, Specialist in Orthodontics, Orthodontic Clinic, Na- and compare the treatment effects of extraoral traction
tional Health Service, Skane County Council, Malmö, Sweden. (cervical headgear) and an IOA using superelastic
Corresponding author: Lars Bondemark, DDS, Odont Dr, Faculty coils for distal movement of maxillary first molars.
of Odontology, Malmö University, SE-205 06 Malmö, Sweden
(e-mail: lars.bondemark@od.mah.se)
MATERIALS AND METHODS
Accepted: August 2004. Submitted: August 2004.
Q 2005 by The EH Angle Education and Research Foundation, The sample size for each group was calculated
Inc. based on an alpha significance level of 0.05 and a

699 Angle Orthodontist, Vol 75, No 5, 2005

700 BONDEMARK, KARLSSON

beta of 0.1 to achieve 90% power to detect a clinically was tilted upward 158. A force of 400 g was used for
meaningful difference of two mm (61.5 mm) distal mo- the first two weeks, after which it was increased to 500
lar movement between the EOA and the IOA groups. g. This force was checked at each visit (every five
The power analysis showed that 13 patients in each weeks) at the clinic and reactivation was carried out
group were needed, and to compensate for conceiv- when necessary. All patients were instructed to use
able withdrawal or dropouts during the trial, it was the appliance at least 12 h/d. At each visit to the clinic,
judged to enroll at least 20 patients in each group. the patient submitted a form where he or she had re-
The patients were recruited from one orthodontic corded how many hours per day the appliance had
clinic at the National Health Service, County Council been used.
Skane, Malmö, Sweden. Two experienced orthodontic
specialists treated all the patients. In the system of the Design of the IOA
National Health Service, the specialists are salaried
The appliance consisted of bands placed bilaterally
and the treatment provided at no cost to the patient
on the maxillary first molars and on either the second
and parents. The patient inclusion criteria for this study
deciduous molars or first or second permanent pre-
were:
molars. A tube, 1.1 mm in diameter and approximately
• No orthodontic treatment before molar distalization; 10 mm in length, was soldered on the lingual side of
• A nonextraction treatment plan; the molar band. A 0.9-mm lingual archwire that united
• Maxillary first permanent molars in occlusion and no a Nance acrylic button was soldered on to the lingual
erupted maxillary second permanent molars; of the second deciduous molar or to the first or second
• Class II molar relationship, defined by at least end- permanent premolar band (Figure 1). The lingual ar-
to-end molar relationship. chwire also provided two distal pistons that passed bi-
The ethic committee of Lund/Malmö University, laterally through the palatal tubes of the maxillary mo-
Sweden, which follows the guidelines of the Declara- lar bands. The tubes and pistons were required to be
tion of Helsinki, approved the protocol and the in- parallel in both the occlusal and sagittal views.
formed consent form. A Ni-Ti coil (GAC Int Inc, Central Inslip, NY), 0.012
When a patient who satisfied the inclusion criteria inches in diameter, with a lumen of 0.045 inches and
attended the orthodontic clinic, he or she was invited cut to 10 to 14 mm in length, was inserted on the distal
to enter the trial, and the orthodontist supplied the pa- piston and compressed to half of its length when the
tient and parent both oral and written information of molar band with its lingual tube was adapted to the
details to the study. After written consent was obtained distal piston of the lingual arch wire (Figure 1).13 When
from the patient and parent, the patient was random- the coil was compressed, two forces were produced,
ized to receive treatment with either the EOA or IOA. one distally directed to move the molars distally and a
A restricted randomization method was used in blocks reciprocal mesially directed force against which the
of 10 to ensure that equal numbers of patients were Nance button provided anchorage. Ni-Ti coils dem-
allocated to each of the two treatment groups. During onstrate a wide range of superelastic activity with a
the molar distalization time, no other appliances were small fluctuation of load despite a large deflection and
placed. exhibit small increments of deactivation with time, and
Outcome measures to be assessed in the trial were: therefore the number of reactivation appointments can
• Treatment time, ie, the time in months to achieve a be reduced.17 Because the compression of the Ni-Ti
normal molar relation; coil to half its length provided about 200 g of maximal
• Distal movement and distal tipping of maxillary first force and because of the small fluctuation of load de-
permanent molars; spite a large deflection of the coil, the force fell from
• Anterior movement and inclination of maxillary cen- approximately 200 to 180 g as the molars moved dis-
tral incisors, ie, anchorage loss; tally. Thus, after the appliance was inserted with the
• Movement of mandibular first permanent molars; compressed Ni-Ti coils, there was no need for further
• Movement and inclination of mandibular central in- activation of the coils during the molar distalization pe-
cisors; riod.13
• Skeletal sagittal position changes of the maxilla and
mandible; Data collection
• Bite-opening effect. The time in months to achieve a normal molar re-
lation by distal molar movement was registered. Lat-
Design of the EOA eral head radiographs in centric occlusion were ob-
A Kloehn cervical headgear with bands on maxillary tained at the start and after completion of the molar
first permanent molars was used and the outer bow distalization. The measuring points, reference lines,

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DISTAL MOVEMENT OF MAXILLARY MOLARS 701

FIGURE 1. Occlusal view (A) of the intraoral appliance. In this case, the second premolars have erupted, and thus are these teeth engaged
in the appliance. The occlusal detail (B) shows the inactivated Ni-Ti coil inserted on the distal piston and the steel tubing lingually on the
maxillary molar band allowing the molar to slide distally. (C) The lingually inserted Ni-Ti coil is compressed to approximately half of its length.

Angle Orthodontist, Vol 75, No 5, 2005

702 BONDEMARK, KARLSSON

and measurements used were based on those defined

and described by Björk18 and Pancherz.19 Dental and
skeletal changes as well as dental changes within the
maxilla and mandible were obtained by the Pancherz
analysis.19 Measurements were made to the nearest
0.5 mm or 0.58. Images of bilateral structures were
bisected. No correction was made for linear enlarge-
ment (10%). Changes in the different measuring points
during the treatment were calculated as the difference
in the after-minus-before position.
The cephalograms were scored and coded by an
independent person, and the examiner conducting the
measurement analysis of the cephalograms was un-
aware of the group to which the patient had been al-
located. An intention-to-treat approach was performed,
and the results of all patients were analyzed regard-
less of the outcome of treatment.

Statistical analysis
The arithmetic mean and standard deviation were
calculated for each variable. Differences in means
within samples/groups were tested by paired t-tests
and between samples and groups by unpaired t-tests
after F tests for equal and unequal variances. Asso-
ciation between time of use and distal molar move-
FIGURE 2. The flow chart of the patients in this study. IOA indicates
ment in the EOA group was assessed with Pearson’s intraoral appliance; EOA, extraoral appliance.
product moment correlation coefficient (r). Differences
with probabilities of less than 5% (P , .05) were con-
sidered statistically significant. were in good accordance with each other because no
significant between-group difference was found for the
Error of the method variables measured.
Twenty randomly selected cephalograms were All patients in the EOA group submitted the form
traced on two separate occasions. No significant mean showing how many hours per day the appliance had
differences between the two series of records were been used during the treatment period. It was found
found by using paired t-tests. The method error20 that the appliance had been used for an average time
ranged from 0.5 to 1.08 and 0.5 to 0.8 mm, corre- of 10.8 h/d (SD 0.72).
sponding to coefficients of reliability21 from 0.92 to 0.97 The average molar distalization time for the IOA
and from 0.94 to 0.98, respectively. group was 5.2 months (SD 1.00) whereas in the EOA
group the corresponding time was 6.4 months (SD
0.97). Thus, the treatment time for the distal molar
RESULTS
movement was significantly shorter for the IOA than
A total of 44 patients were enrolled, and four of the EOA group (P , .01). The mean amount of distal
these refused to enter the study. Thus, 40 patients molar movement within the maxilla was significantly
were randomized, 20 (10 girls and 10 boys) were al- greater in the IOA than in the EOA group (P , .001),
located to receive treatment with the IOA, and 20 (12 three mm (SD 0.64) vs 1.7 mm (SD 0.91) (Table 2).
girls and eight boys) with the EOA. All 40 patients In the EOA group, no interdependence was found be-
completed the trial (Figure 2). The mean age was 11.4 tween the time of use of the appliance per day and
(SD 1.37) and 11.5 (SD 1.25) years for the IOA and distal molar movement (r 5 0.23). The amount of distal
EOA groups, respectively. No significant difference in molar tipping was small in both groups and no signif-
any of the variables used in the study was found be- icant difference existed between the groups (Table 2).
tween girls and boys, and consequently, the data for The total molar relation correction was 3.3 mm in
girls and boys were pooled and analyzed together. the IOA group and 2.4 mm in the EOA group (Figure
Pretreatment cephalometric records are summa- 3). The molar relation was corrected mainly by distal
rized in Table 1. Cephalometrically the two groups movement of the maxillary first molars in the IOA

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DISTAL MOVEMENT OF MAXILLARY MOLARS 703

TABLE 1. Pretreatment Cephalometric Records for the IOA Group and the EOA Groupa
IOA (N 5 20) EOA (N 5 20)
Group Difference
Mean SD Mean SD P Value
Sagittal variables (mm)
Maxillary base, A-OLp 79.0 4.06 79.1 3.79 NS
Mandibular base, Pg-OLp 82.8 5.88 81.6 5.42 NS
Maxillary incisor, Is-OLp 85.9 4.78 87.0 3.61 NS
Mandibular incisor, Ii-OLp 82.0 5.32 82.3 4.19 NS
Maxillary molar, Ms-OLp 41.6 3.91 42.4 3.53 NS
Mandibular molar, Mi-OLp 41.6 4.03 42.0 4.32 NS
Molar relationship, Ms-OLp minus Mi-OLp 20.1 1.27 0.4 1.30 NS
Overjet, Is-OLp minus Ii-OLp 3.9 1.59 4.7 1.85 NS
Sagittal variables (8)
Maxillary incisor inclination, ILs/NSL 100.1 6.36 100.6 7.68 NS
Mandibular incisor inclination, ILi/ML 91.4 4.01 93.5 6.46 NS
Maxillary first molar inclination, Mls/NSL 68.6 3.59 68.7 5.28 NS
Vertical variables (mm)
Overbite, Is-NSL minus Ii-NSL 3.1 1.87 3.8 1.95 NS
Vertical variables (8)
Mandibular inclination, NSL/ML 33.3 3.63 32.2 6.32 NS
Occlusal plane inclination, OL/NSL 19.0 4.06 19.5 4.31 NS
a
IOA indicates intraoral appliance; EOA, extraoral appliance, NS, not significant; * P , .05; ** P , .01; *** P , .001.

TABLE 2. Changes in Cephalometric Variables Within and Between the Two Groups After Distal Movement of Maxillary Molars. Changes
were Calculated as the Difference After-Minus-Before Positiona
IOA (N 5 20) EOA (N 5 20)
Group Difference
Mean SD Mean SD P Value
Skeletal sagittal variables (mm)
Maxillary base, A-OLp 0.8*** 0.47 0.7*** 0.65 NS
Mandibular base, Pg-OLp 0.8** 0.70 0.9** 1.48 NS
Skeletal 1 dental sagittal variables (mm)
Maxillary molar position, Ms-OLp 22.2*** 0.78 21.0** 1.32 **
Mandibular molar position, Mi-OLp 1.1*** 0.87 1.2*** 1.43 NS
Maxillary incisor position, Is-OLp 1.6*** 0.99 20.3 1.23 **
Mandibular incisor position, Ii-OLp 0.7*** 0.75 0.4 1.24 NS
Dental sagittal variables within the maxilla and mandible
Maxillary molar, Ms-OLp (d) minus A-OLp (d) 23.0*** 0.64 21.7*** 0.91 ***
Mandibular molar, Mi-OLp (d) minus Pg-OLp 0.3** 0.49 0.3 0.91 NS
Maxillary incisor, Is-OLp (d) minus A-OLp (d) 0.8** 0.88 21.0*** 0.99 ***
Mandibular incisor, Ii-OLp (d) minus Pg-OLp (d) 20.1 0.41 20.5* 0.96 *
Molar relationship, Ms-OLp (d) minus Mi-OLp (d) 23.3*** 0.89 22.0*** 0.77 ***
Overjet, Is-OLp (d) minus Ii-OLp (d) 0.9*** 0.88 20.9*** 0.63 ***
Sagittal variables (8)
Maxillary incisor inclination, ILs/NSL 2.0** 2.66 20.6 1.94 **
Mandibular incisor inclination, ILi/ML 0.1 0.81 0.4 1.13 NS
Maxillary first molar inclination, M1s/NSL 22.9*** 1.92 23.0*** 2.85 NS
Vertical variables (mm)
Overbite, Is-NSL minus Ii-NSL 20.8*** 0.80 20.7*** 0.72 NS
Vertical variables (8)
Mandibular inclination, NSL/ML 0.5** 0.74 0.2* 0.38 NS
Occlusal plane inclination, OL/NSL 20.1 0.60 0.1 0.74 NS
a
IOA indicates intraoral appliance; EOA, extraoral appliance; NS, not significant; * P , .05; ** P , .01; *** P , .001.

Angle Orthodontist, Vol 75, No 5, 2005

704 BONDEMARK, KARLSSON

group corrected, whereas in the EOA group the molar

relation was corrected by an equal amount of distal
movement of the maxillary molars and mesial move-
ment of mandibular first molars (Figure 3).
Because of anchorage loss, the maxillary incisors in
the IOA group proclined and moved forward 0.8 mm
(SD 0.88) and the overjet was increased by an aver-
age of 0.9 mm (SD 0.88) (Figure 3; Table 2). However,
in the EOA group, the maxillary incisors retroclined
and moved distally one mm (SD 0.99) and the overjet
decreased by a mean of 0.9 mm (SD 0.63) (Figure 3;
Table 2).
In both groups, the overbite was significantly re-
duced, 0.8 mm (SD 0.80) in the IOA group and 0.7
mm (SD 0.72) in the EOA group (Table 2). During the
trial period, the maxilla and mandible in both groups
both moved forward small amounts and the mandib-
ular plane angle increased (Table 2).

DISCUSSION

In any scientific study, it is important that the power

is high and the characteristics of any withdrawal sub-
jects are known. The power analysis revealed that a
sample size of 13 patients per group was sufficient.
Because 20 patients per group were enrolled in this
study and the number of withdrawals after randomi-
zation was zero, no loss of information biased the
data. Moreover, because the measurement analysis of
the cephalograms was performed in a blinded manner,
ie, the examiner was unaware of the group to which
the patient had been allocated, and the risk of mea-
surements being affected by the researcher was low.
The most important finding of this study was that the
amount of distal movement of the maxillary first molars
was significantly higher and more rapid with the IOA
than the EOA. It is not possible to make comparisons
with previous studies because of a lack of RCTs be-
tween IOA and EOA for molar distalization. Neverthe-
less, a RCT regarding two IOAs, a Jones Jig and an
upper removable appliance, has recently reported that
the amount of distal movement was small (one to two
mm) and that both appliances were equally effective.22
Furthermore, a systematic review has revealed that
the amount of distal molar movement that may be
achieved is approximately two mm.16 In this study, the
amount of distal molar movement produced by the
EOA was comparable with the Jones Jig and the up-
per removable appliance,22 whereas the amount of dis-
tal molar movement produced with the IOA was higher
FIGURE 3. Skeletal and dental mean changes (in mm) and standard (three mm). The distal molar tipping was small in both
deviations contributing to alterations in sagittal molar relationship
and overjet. N 5 20 in each group. *P , .05; **P , .01; ***P ,
groups, and thus, the molar distalization consisted of
.001. mainly bodily movement.
In the IOA group, the molar correction consisted of
66% distal movement of maxillary molars and 34% of

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DISTAL MOVEMENT OF MAXILLARY MOLARS 705

mesial movement of mandibular molars. This is con- such as restricted forward growth of the maxilla can
tradictory to the findings by Paul et al,22 who reported be produced by the EOA, but then much higher forces
that significant correction of the molar relation was by than 500 g have to be used.
mesial movement of mandibular molars. However, in Even if cost effectiveness as well as the patients’
the EOA group, the correction in molar relation was in perceptions of pain and discomfort of the appliances
accordance with Paul et al,22 ie, 45% distal movement were not evaluated in this investigation, it seems nat-
of maxillary molars and 55% mesial movement of ural to claim that the IOA is a more favorable method
mandibular molars. than the EOA to create distal molar movement. To ac-
The likelihood of patient cooperation is one of the complish a complete comparison, studies regarding
most important factors influencing the effectiveness of cost effectiveness and patients’ perceptions of the two
a treatment. The patients in the EOA group used the appliances have been commenced and will be pre-
cervical headgear for an average time of 10.8 h/d. This sented later.
time of use was judged as acceptable or good and
quite normal for orthodontic patients in Scandinavian CONCLUSIONS
countries where treatment is provided at no cost to the
patient and parents. Because the duration of the force • It was clearly demonstrated that the IOA was more
per day on the molars of course was greater in the effective than the EOA to create distal movement of
IOA than in the EOA group, this was the major expla- maxillary first molars.
nation for the higher effectiveness of the IOA in distal • Moderate and acceptable anchorage loss was pro-
molar movement. Another advantage of the IOA lies duced with the IOA implying increased overjet
in its single activation because the Ni-Ti coils dem- whereas the EOA created decreased overjet.
onstrate a wide range of superelastic activity with a • For the clinician, the IOA is a more favorable method
small fluctuation of load despite a large deflection.17 than the EOA to create distal molar movement.
Furthermore, the Ni-Ti coils exhibit small increments • The two appliances did not have any considerable
of deactivation with time, thus reducing the number of corrective effect on Class II skeletal relationships
reactivation appointments during the molar distaliza- and these appliances shall therefore only be used in
tion period. cases of moderate dental sagittal discrepancies and
An advantage with the EOA (cervical headgear) is arch-length deficiencies.
that during molar distalization this appliance also cre-
ates distal movement of the maxillary incisors implying
decreased overjet, and this decrease in overjet is of ACKNOWLEDGMENTS
course desired when Class II division 1 occlusions are The Swedish Dental Society and Skane County Council,
treated. However, when maxillary molars are moved Sweden, supported the research.
distally by an intraoral appliance, an anchorage loss
or forward movement of one to two mm of the anterior
REFERENCES
teeth occurs.6,7,9,13–15 In this study, a similar amount of
forward movement of maxillary incisors was observed 1. Graber TM. Extraoral force—facts and fallacies. Am J Or-
for the IOA. In most instances, the problem of forward thod. 1955;41:490–505.
movement of the incisors can be controlled with mod- 2. Wieslander L. Early or late cervical traction therapy of Class
est intervention. It has been shown that forward move- II malocclusion in the mixed dentition. Am J Orthod. 1975;
67:432–439.
ment of the maxillary incisors associated with distal 3. Cetlin NM, TenHoeve A. Nonextraction treatment. J Clin Or-
molar movement was totally reversed and eliminated thod. 1983;17:396–413.
by the subsequent multibracket appliances and inter- 4. Wilson RC. Modular orthodontic systems. Part 1. J Clin Or-
maxillary Class II elastics.23 On the other hand, in cas- thod. 1978;12:259–278.
es with retroclined maxillary incisors, for example in 5. Hilgers JJ. The pendulum appliance for Class II non-com-
subjects with a Class II division 2 occlusion, the recip- pliance therapy. J Clin Orthod. 1992;26:706–714.
6. Ghosh J, Nanda RS. Evaluation of an intraoral maxillary
rocal effect of forces can be used for proclination of molar distalization technique. Am J Orthod Dentofacial Or-
the incisors. thop. 1996;110:639–646.
In both groups, only small skeletal changes were 7. Byloff FK, Darendeliler MA. Distal molar movement using
shown and these changes were mainly assigned to the pendulum appliance. Part 1: clinical and radiological
normal growth changes. Because the two appliances evaluation. Angle Orthod. 1997;67:249–260.
8. Jones R, White J. Rapid Class II molar correction with an
had a small or negligible corrective effect on the Class
open coil jig. J Clin Orthod. 1992;26:661–664.
II skeletal relationships, these appliances should only 9. Bondemark L, Kurol J. Distalization of maxillary first and
be used in cases of moderate dental discrepancies second molars simultaneously with repelling magnets. Eur
and arch-length deficiencies. Of course skeletal effects J Orthod. 1992;14:264–272.

Angle Orthodontist, Vol 75, No 5, 2005

706 BONDEMARK, KARLSSON

10. Carano A, Testa M. The distal jet for upper molar distali- literature on methods described to effect distal movement
zation. J Clin Orthod. 1996;30:374–380. of maxillary molars. J Orthod. 2002;29:211–216.
11. Gianelly AA. Distal movement of the maxillary molars. Am 17. Miura F, Mogi M, Ohura Y, Karibe M. The superelastic Jap-
J Orthod Dentofacial Orthop. 1998;114:66–72. anese NiTi alloy wire for use in orthodontics. Part III. Studies
12. Gulati S, Kharbanda OP, Parkash H. Dental and skeletal on the Japanese NiTI alloy coil springs. Am J Orthod Den-
changes after intraoral molar distalization with sectional jig tofacial Orthop. 1988;94:89–96.
assembly. Am J Orthod Dentofacial Orthop. 1998;114:319– 18. Björk A. The relationship of the jaws to the cranium. In:
327. Lundström A, ed. Introduction to orthodontics. New York,
13. Bondemark L. A comparative analysis of distal maxillary NY: McGraw-Hill; 1960:104–140.
molar movement produced by a new lingual intra-arch Ni-Ti 19. Pancherz H. The mechanism of Class II correction in Herbst
coil appliance and a magnetic appliance. Eur J Orthod. appliance treatment. A cephalometric investigation. Am J
2000;22:683–695. Orthod. 1982;82:104–113.
14. Papadopoulos MA, Mavropoulos A, Karamouzos A. Ceph- 20. Dahlberg G. Statistical Methods for Medical and Biological
alometric changes following simultaneous first and second Students. London: Allen and Unwin; 1940:122–132.
maxillary molar distalization using a non-compliance intra- 21. Houston WBJ. The analysis of errors in orthodontic mea-
oral appliance. J Orofac Orthop. 2004;65:123–136. surements. Am J Orthod. 1983;83:382–390.
15. Fortini A, Lupoli M, Giuntoli F, Franchi L. Dentoskeletal ef- 22. Paul LD, O’Brien KD, Mandall NA. Upper removable appli-
fects induced by rapid molar distalization with the first class ance or Jones jig for distalizing first molars? A randomized
appliance. Am J Orthod Dentofacial Orthop. 2004;125:697– clinical trial. Orthod Craniofacial Res. 2002;5:238–242.
705. 23. Bondemark L, Kurol J. Class II correction with magnets and
16. Atherton GJ, Glenny AM, O’Brien KD. Development and superelastic coils followed by straight-wire mechanothera-
use of a taxonomy to carry out a systematic review of the py. J Orofac Orthop. 1998;59:127–138.

Angle Orthodontist, Vol 75, No 5, 2005