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Original Article

The effectiveness of pendulum, K‑loop, and distal jet

distalization techniques in growing children and its
effects on anchor unit: A comparative study
Pravinkumar S Marure, Raju Umaji Patil1, Sumitra Reddy2, Amit Prakash3,
Nillachandra Kshetrimayum4, Rajeevkumar Shukla5
Department of Orthodontics, MIDSR Dental College and Hospital, Latur, 1Department of Pedodontics and Preventive Dentistry,
Sinhgad Dental College and Hospital, Pune, Maharashtra, 2Department of Orthodontics, KLE’S Institute of Dental Sciences, Bengaluru,
Karnataka, 3Department of Orthodontics, People’s College of Dental Sciences, Bhopal, Madhya Pradesh, 4Department of Orthodontics
Unit, SHIJA Hospital and Research Institute, Langol, Imphal, Manipur, 5Department of Orthodontics, Mithila Minority Dental College,
Laheriasarai, Darbhanga, Bihar, India

ABSTRACT Address for correspondence:

Dr. Raju Umaji Patil,
Background: A common strategy to correct Class
Department of Pedodontics and Preventive Dentistry,
II malocclusions using a nonextraction protocol in Sinhgad Dental College and Hospital, S. No. 44/1 Vadgaon
children is to move the maxillary molars distally Budruk, Off Sinhgad Road, Pune ‑ 411 041, Maharashtra, India.
using molar distalization appliances, which usually E‑mail: rupat13@yahoo.com
derive their anchorage from maxillary premolars,
causing mesialization of premolars and protrusion
of incisors. Objectives: To evaluate the skeletal, Access this article online
dental and soft tissue changes produced by three Quick response code Website:
different distalizing appliances, namely, pendulum, www.jisppd.com
K‑loop, and distal jet appliances. Materials and DOI:
Methods: Sixty‑six children of mean age 14.13 10.4103/0970-4388.191411
years requiring molar distalization were divided
PMID:
into three groups: Group I (pendulum appliance),
******
Group II (K‑loop), and Group III (distal jet). Lateral
cephalometric films were taken before and after
5 months of molar distalization and following
cephalometric parameters were used to assess the anchor unit. There was an increase in FMA angle,
effects of maxillary molar distalization, namely, significant bite opening, proclination of the maxillary
anteroposterior skeletal (SNA/SNB/ANB), vertical incisors and increase in the cant of the upper lip.
skeletal (face height ratio/Frankfort‑mandibular
plane [FMA]/angle formed between Maxillary KEYWORDS: Distal jet, K‑loop, molar distalization,
plane & Mandibular plane (MM)), interdental pendulum
(overjet/overbite), maxillary dentoalveolar, and
soft tissue parameters. Results: There was no
significant age difference between the three groups. This is an open access article distributed under the terms of the Creative
In overall treatment changes among the three Commons Attribution-NonCommercial-ShareAlike 3.0 License, which
groups, the Anteroposterior skeletal changes were allows others to remix, tweak, and build upon the work non-commercially,
not statistically significant, vertically FMA angle as long as the author is credited and the new creations are licensed under
increased by 1.79° ± 2.25° and overbite reduced by the identical terms.
2.38 ± 1.83 mm. The maxillary first molars were For reprints contact: reprints@medknow.com
distalized by an average of 4.70 ± 3.01 mm (Upper
6 [U6] to pterygoid vertical [PTV]). The maxillary How to cite this article: Marure PS, Patil RU, Reddy S,
central incisor labial tipping increased to an average Prakash A, Kshetrimayum N, Shukla R. The effectiveness of
of 1.61 ± 2.73 mm and cant of upper lip increased pendulum, K-loop, and distal jet distalization techniques in
by 3.40° ± 5.88° are statistically significant (P < 0.05).
growing children and its effects on anchor unit: A comparative
Conclusion: All three distalization techniques in
study. J Indian Soc Pedod Prev Dent 2016;34:331-40.
growing children produced significant effects on

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Marure, et al.: Distalization techniques in children…

Introduction Objectives
The aim of the study was to analyze the effects of molar
Treatment of Class II malocclusion is one of the most distalization appliances on the hard and soft tissues
interesting and controversial issues in contemporary cephalometrically:
pediatric orthodontics. There are various treatment 1. Amount and type of maxillary molar movement
strategies to address the different morphologic 2. Labial movement of incisors
characteristics of this malocclusion in children. The 3. Soft tissue changes.
therapeutic approaches for correcting it include
orthopedic appliances, extraoral or intraoral Materials and Methods
distalizing appliances and extractions of teeth.[1]
One of the primary concerns in treatment planning Sources of data
must be the final esthetic appearance of the Childs The present prospective clinical study was carried
facial profile. A Class II patient usually shows either out in the department of orthodontics. The sample
a protrusive upper jaw, retrusive lower jaw, or comprised 66 subjects (26 boys and 40 girls) and the
both. Correction of the molar relationship is often age range was 11–21 years with mean age of 14.13
required for the nonextraction treatment of Class II years [Table 1]. The patients who required molar
malocclusions.[2] distalization and satisfying inclusion criteria were
selected for the study.
Headgear is effective in maxillary molar distalization,
however, this method of Class II correction depends Inclusion criteria
greatly on child cooperation.[3] To avoid unpredictable 1. Skeletal‑Class I/II skeletal pattern
results because of patient noncompliance, the need Normal/short lower face height
for compliance and the esthetic drawbacks led the 2. Class II or end on molar relationship
clinicians to search for noncompliance alternatives. 3. Mixed or permanent dentition
These concerns have resulted in the development 4. Mild to moderate crowding/proclined in maxillary
of intraoral distal molar movement appliances that arch
offer noncompliance treatment and continuous forces. 5. Hypodivergent or average growth pattern
Among these are repelling magnets, active transpalatal 6. Well aligned teeth or mild crowding in mandibular
arches, nitinol coil springs, Jones jig, distal jet, arch
superelastic wires, K‑loop, and pendulum appliance.[2] 7. Straight profile or mild convex profile
These appliances usually derive their anchorage from 8. Patients with Normal TMJ function.
maxillary premolars and mesialization of premolars
and protrusion of incisors accompany maxillary molar Exclusion criteria
distalization. To maximize anchorage, these appliances 1. Hyperdivergent growth pattern patients.
can be used with implants.
Study groups
Recently, an ever‑increasing number of reports The sample consisted of three groups: Group I
regarding implant‑supported distalization systems (pendulum appliance), Group II (K‑loop), and Group
have been introduced in the literature. The studies III (distal jet) [Table 1].
have described the use of osseointegrated implants,
onplants, intraosseous screws, Miniscrew Implant Group I
Supported Distalization System and the bone‑anchored Group I comprised 22 subjects (14 boys, 8 girls) with
pendulum appliance in orthodontic patients requiring a mean age of 14.27 years, treated with the pendulum
distalization.[4,5] Nur, et al. designed an intraoral appliance [Figure 1]. The pendulum appliance consisted
appliance, named the zygoma‑gear appliance, for of a Nance button, bands on the first premolars, and
bilateral maxillary molar distalization using the pendulum springs as described by Hilgers.[8] The right
titanium anchor plates placed in the zygomatic process and left pendulum springs were formed from 0.032”
of the maxilla.[6] In recent years, many studies have beta‑titanium wire and consisted of a recurved molar
been published on intraoral distalization appliances. insertion wire, a small horizontal adjustment loop, a
In some of these studies, clinicians have tried to closed helix, and a loop for retention on the acrylic
prevent anchorage loss using uprighting bends, button. The springs were inserted in the lingual sheaths
occipital headgears, or utility arches.[7] However, there
are limited studies that have evaluated the skeletal,
dental, and soft tissue effects of distal jet, K‑loop, Table 1: Descriptive statistics of the sample
and pendulum appliances. Hence, the aim of this Groups n Mean age SD Minimum Maximum P
study was a cephalometric evaluation of the skeletal, Group I 22 14.27 2.687 12 21 0.656
dental, and soft tissue changes produced by the three Group II 24 13.33 2.066 11 17
distalizing appliances, pendulum, K‑loop, and distal Group III 20 14.80 3.347 12 20
jet appliances. SD: Standard deviation

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Marure, et al.: Distalization techniques in children…

Figure 1: Pendulum appliance (pre- and post-distalization) Figure 2: K-loop appliance (pre- and post-distalization)

on molar bands. The Nance button was held in place (°), and ANB angle (°)
with a soldered retaining wire to the bands on the first • Vertical skeletal: Face height ratio (%),
premolars. The molar bands were cemented. Before Frankfort‑mandibular plane (FMA) angle (°), and
placement of the appliance, the springs were bent MM angle (°)
parallel to the midline of the palate for activation and • Interdental: Overjet (mm), overbite (mm)
then inserted in the lingual sheaths on the molar bands. • Maxillary dentoalveolar: U6 to PTV horizontal
The force applied was 230 g. The patients were seen once (mm), U6 to palatal plane (°), U6 to Palatal plane
per month and the pressure exerted by the springs was vertical (mm), Upper 1 (U1) to palatal plane angle
checked. When the molars achieved a Class I occlusion, (°), and U1 to PTV (mm)
the appliance was replaced with a Nance button for • Soft tissue: Ls to “E” line (mm), Li to “E” line (mm),
retention. and Cant of upper lip angle (°).

Group II Method of statistical analysis

Group II comprised 24 subjects (4 boys, 20 girls) with a The following methods of statistical analysis have been
mean age of 13.33 years, treated with K‑loop appliance used in this study. Data were entered in Microsoft Excel
[Figure 2]. The K‑loop was constructed according and analyzed using Statistical Package for Social Science,
to the description by Kalra. The K‑loop was made
[9] Version 10.0.5 (IBM SPSS Inc. New York US) package.
from 0.017” × 0.025” TMA wire and located between 1. The results were averaged (mean ± standard
the upper first molar and the first premolar. The deviation) for each parameter for continuous
K‑loop was activated to produce 200 g of force. After data and numbers and percentage for categorical
placement of the appliances, patients were monitored data presented. The mean values were tested for
every 4 weeks, and the K‑loop was activated every 6 significant difference using a Student’s t‑test
weeks. When the molars achieved a Class I occlusion, x1 − x2
the appliance was replaced with a Nance button for=t t n1 + n2 − 2
retention. 1 1
s +
n1 n2

Group III (n1 − 1)s1 2 + (n2 − 1)s2 2
2
Group III sample consisted 20 subjects (8 boys, 12 girls) where S = ,
treated with distal jet appliance [Figure 3]. The mean (n1 + n2 − 2)
age of the patients was 14.80 years. The distal jet coil x1 and x2 are sample mean and s2 is a pooled
springs were activated every four to 6 weeks. 240 g variance.
of force generated by the nickel‑titanium coil spring
was used as recommended by Carano and Testa 2. Proportions were compared using Chi‑square test
(240 g).[10] Once a “super Class I” molar relationship of significance
was achieved, the distal jet was converted to a large Chi‑square test for (r × c tables)
Nance holding arch by removing the coil springs. a, b…h are the observed numbers
N is the grand total
Cephalometric evaluation
Lateral cephalometric films were taken before and  1 c a2 1 c b 2 1 c h2 
= χ 2 N  ∑ 1 + ∑ 1 + ................. + ∑ 1 − 1 
after 5 months of molar distalization of 66 patients  t1 1 ni t2 1 ni tr 1 ni 
[Figure 4]. The pretreatment and postdistalization
cephalograms were traced on a 75 µm lacquered DF = (r − 1) × (c − 1), where r = rows and
polyester acetate tracing papers using a 0.05” lead c = columns
pencil. A single operator performed the tracings in DF = Degrees of freedom (number of observation
a standardized manner to avoid errors due to any that is free to vary after certain restriction have
interoperator variations. The following cephalometric been placed on the data).
parameters were used to assess the effects of maxillary
molar distalization [Figure 5]. In all above test, P < 0.05 was taken to be statistically
• Anteroposterior skeletal: SNA angle (°), SNB angle significant.

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Marure, et al.: Distalization techniques in children…

Results
There was no significant age difference between the
three groups. Descriptive statistics, including mean and
standard deviation for observations of pretreatment
and posttreatment soft tissue, skeletal, and dental
changes measured from cephalometric radiographs
[Table 2].
Figure 3: Distal jet appliance (pre- and post-distalization)
Table 3, shows the overall treatment changes in the
three groups. The anteroposterior skeletal changes
were not statistically significant, vertically FMA
angle increased by 1.79° ± 2.25° and overbite reduced
by 2.38 ± 1.83 mm. The maxillary first molars were
distalized by an average of 4.70 ± 3.01 mm (U6 to PTV).
The maxillary central incisor labial tipping increased
to an average of 1.61 ± 2.73 mm and cant of upper lip
increased by 3.40° ± 5.88°, are statistically significant
(P < 0.05).

Discussion
A Class I molar relationship is an integral part of
precisely defined relationships; it has an overall impact
on the stomatognathic system, neuromusculature, and
facial esthetics. Because a balanced occlusion with
Figure 4: Lateral cephalogram (pre- and post-distalization) normal function requires an occlusal relationship in
which centric relation coincides with centric occlusion,
correcting the posterior occlusion into an ideal Class I
relationship, together with a Class I canine relationship
becomes an important goal. In conventional
orthodontic therapy for Class II malocclusion, it might
be necessary to use a distalizing appliance to correct
the molar relationship.[11]

A common strategy to correct Class II malocclusions

using a nonextraction protocol is to move the maxillary
molars distally during the initial stage of treatment
to convert the Class II molar relationship to a Class
I molar relationship. In conventional orthodontic
therapy for Class II malocclusion, it might be necessary
to use a distalizing appliance to correct the molar
relationship.[12] Although requiring minimal patient
compliance to produce molar distalization, several
Figure 5: Cephalometric measurements (postdistalization) studies have suggested that many intraoral devices
produce adverse treatment effects, such as maxillary
Method error test first molar tipping, anchorage loss (exhibited in the
A month after the measurements were made, twenty incisors as mesial movement), clockwise rotation of the
randomly selected traced radiographs were selected, mandibular plane, increased anterior face height and
retraced, and re‑measured to evaluate intraoperator lip protrusion.[9,7,13]
reliability and reproducibility of various parameters.
The mean, standard deviations and standard error were Skeletal changes
calculated for each parameter. The standard error of The present study showed that the changes in the SNA,
measurement was computed according to Dahlberg’s SNB, and ANB angles were insignificant in all the three
formula. There was no significant variability in groups [Table 3 and Figure 6]. de Almeida‑Pedrin
reproducing these measurements. et al.[1] reported that in the maxilla there were statistically

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Marure, et al.: Distalization techniques in children…

Table 2: Mean, standard deviation for Group I (pendulum), Group II (K‑loop), and Group III (distal jet)
appliances
Parameters Groups Treatment Mean SD Mean difference SD t P
SNA (°) Group I Pre 81 4.4328 1.0909 2.3645 1.53 0.157
Post 79.909 4.857
Group II Pre 80.667 4.9261 −2.1667 5.2409 −1.013 0.358
Post 82.833 4.4121
Group III Pre 80.3 7.3621 −0.6 0.6519 −2.058 0.109
Post 80.9 6.8593
SNB (°) Group I Pre 76.591 3.3972 0.9091 1.8278 1.65 0.13
Post 75.682 3.3636
Group II Pre 77.417 3.1689 0.6667 1.633 1 0.363
Post 76.75 1.6355
Group III Pre 76.6 6.3973 0 1.4577 0 1
Post 76.6 6.229
ANB (°) Group I Pre 4.409 2.0472 0.1818 1.2303 0.49 0.635
Post 4.227 2.1256
Group II Pre 3.25 3.5742 −0.3333 2.3381 −0.349 0.741
Post 3.583 3.04
Group III Pre 3.7 2.0187 −0.2 0.7583 −0.59 0.587
Post 3.9 2.4083
FH (%) Group I Pre 78.9 7.4674 1.0909 2.3746 1.524 0.159
Post 77.809 7.1124
Group II Pre 85.383 7.9547 0.1667 6.3582 0.064 0.951
Post 85.217 7.5316
Group III Pre 85.44 9.4002 1.4 5.52 0.567 0.601
Post 84.04 8.8999
FMA (°) Group I Pre 22.455 3.4961 −1.5909 1.6855 −3.13 0.011
Post 24.045 3.6977
Group II Pre 21.333 5.5737 −0.25 1.1726 −0.522 0.624
Post 21.583 5.2765
Group III Pre 20.2 6.4576 −4.1 2.7477 −3.337 0.029
Post 24.3 5.8907
M (°) Group I Pre 23.909 3.7869 −0.4545 1.9033 −0.792 0.447
Post 24.364 3.8281
Group II Pre 20.75 5.5835 −0.6667 1.7512 −0.933 0.394
Post 21.417 6.1678
Group III Pre 21.1 7.4867 −0.5 1.4142 −0.791 0.473
Post 21.6 7.0922
Overjet (mm) Group I Pre 5.818 2.9939 0 1.8841 0 1
Post 5.818 2.9178
Group II Pre 4.667 1.5055 −0.5833 2.2454 −0.636 0.553
Post 5.25 1.255
Group III Pre 5.9 3.1702 0.1 2.4597 0.091 0.932
Post 5.8 3.8341
Overbite (mm) Group I Pre 4.045 0.9606 2.3182 2.2391 3.434 0.006
Post 1.727 2.3597
Group II Pre 4.25 0.7583 2.1667 1.8074 2.936 0.032
Post 2.083 1.2007
Group III Pre 4.1 0.7416 2.8 0.9083 6.893 0.002
Post 1.3 0.6708
U6‑PTV (mm) Group I Pre 16.545 4.0587 6.4091 2.4982 8.509 0
Post 10.136 3.702
Group II Pre 14.167 1.9408 2.25 2.0917 2.635 0.046
Post 11.917 1.8552
Group III Pre 13.9 2.4597 3.9 2.9665 2.94 0.042
Post 10 3.937
Contd..

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Marure, et al.: Distalization techniques in children…

Table 2: Contd...
Parameters Groups Treatment Mean SD Mean difference SD t P
U6‑PP (°) Group I Pre 104.136 5.745 −7.3182 7.656 −3.17 0.01
Post 111.455 6.2668
Group II Pre 104.583 6.2483 −2.6667 9.9683 −0.655 0.541
Post 107.25 10.3235
Group III Pre 109.6 6.3875 2.9 3.0083 2.156 0.097
Post 106.7 8.5411
U6‑PP (mm) Group I Pre 23.909 3.9612 −0.6364 1.8986 −1.112 0.292
Post 24.545 2.6875
Group II Pre 21.75 2.4444 0.5 1.7889 0.685 0.524
Post 21.25 2.5642
Group III Pre 21.6 3.0496 1 1.2247 1.826 0.142
Post 20.6 2.4083
U1‑PP (°) Group I Pre 117.727 5.3449 −1.0909 3.1529 −1.148 0.278
Post 118.818 6.0261
Group II Pre 118 10.4259 −6.0833 8.0648 −1.848 0.124
Post 124.083 6.9023
Group III Pre 119 10.7935 −6.7 4.7381 −3.162 0.034
Post 125.7 7.2076
U1‑PTV (mm) Group I Pre 58.818 5.997 −0.9091 2.0835 −1.447 0.178
Post 59.727 5.9555
Group II Pre 55.5 4.3359 −4.1667 2.1134 −4.829 0.005
Post 59.667 5.7155
Group III Pre 55.3 4.7906 −0.1 2.9665 −0.075 0.944
Post 55.4 7.0922
Ls‑E (mm) Group I Pre 1.5 1.1832 0.6364 1.3246 1.593 0.142
Post 0.864 1.6139
Group II Pre 4.5 2.51 1 2.3452 1.044 0.344
Post 3.5 3.3764
Group III Pre 1.3 2.9917 0.3 1.0368 0.647 0.553
Post 1 2.8062
Li‑E (mm) Group I Pre −0.864 2.2482 1.1818 2.6483 1.48 0.17
Post −2.045 2.4845
Group II Pre 3 2.8983 1.1667 4.568 0.626 0.559
Post 1.833 4.2973
Group III Pre −0.4 4.3789 0.5 2.7839 0.402 0.709
Post −0.9 4.8913
Cant‑UL (°) Group I Pre 18.455 9.0925 −2.3636 4.4107 −1.777 0.106
Post 20.818 10.5576
Group II Pre 19.083 11.2801 −5 8.0808 −1.516 0.19
Post 24.083 11.5083
Group III Pre 16.043 6.0415 −3.8 6.6765 −1.273 0.272
Post 19.834 6.6212
SD: Standard deviation, Upper 1: U1, Upper 6: U6, PTV: Pterygoid vertical, FMA: Frankfort mandibular plane

Figure 6: Pre- and post-distalization overall measurement in the Group I (pendulum), Group II (K-loop), and Group III (distal jet) appliances

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Table 3: Pre‑ and post‑distalization overall measurement in the Group I (pendulum), Group II (K‑loop), and
Group III (distal jet) appliances
Parameter Treatment Mean SD Mean difference SD P
SNA (°) Pre 80.750 5.0539 −0.1818 3.3614 0.802
Post 80.932 5.1392
SNB (°) Pre 76.818 3.9778 0.6364 1.6632 0.087
Post 76.182 3.6986
ANB (°) Pre 3.932 2.4655 −0.0455 1.4793 0.887
Post 3.977 2.3527
FH (%) Pre 82.155 8.3395 0.9091 4.2833 0.331
Post 81.245 8.0767
FMA (°) Pre 21.636 4.6934 −1.7955 2.2555 0.001
Post 23.432 4.5937
MM (°) Pre 22.409 5.2250 −0.5227 1.6866 0.161
Post 22.932 5.2696
Overjet (mm) Pre 5.523 2.6479 −0.1364 2.0306 0.756
Post 5.659 2.7009
Overbite (mm) Pre 4.114 0.8300 2.3864 1.8383 0.000
Post 1.727 1.7777
U6‑PTV (mm) Pre 15.295 3.3970 4.7045 3.0145 0.000
Post 10.591 3.3153
U6‑PP (°) Pre 105.500 6.1644 −3.7273 8.4159 0.050
Post 109.227 7.9503
U6‑PP (mm) Pre 22.795 3.4595 0.0455 1.8121 0.907
Post 22.750 3.0890
U1‑PP (°) Pre 118.091 7.8704 −3.7273 5.6415 0.005
Post 121.818 6.9497
U1‑PTV (mm) Pre 57.114 5.3872 −1.6136 2.7340 0.012
Post 58.727 6.1368
Ls‑E (mm) Pre 2.273 2.4139 0.6591 1.5537 0.060
Post 1.614 2.6183
Li‑E (mm) Pre 0.295 3.3118 1.0227 3.1414 0.142
Post −0.727 3.8320
Cant‑UL (degree) Pre 18.068 8.8322 −3.4091 5.8851 0.013
Post 21.477 10.3619
SD: Standard deviation, Upper 1: U1, Upper 6: U6, PTV: Pterygoid vertical, FMA: Frankfort mandibular plane

significant reductions in the variables SNA and Nperp‑A the effect was reflected by dental anchorage loss.
in headgear group and extraction group and a mild Bussick and McNamara[17] reported that there was the
increase in pendulum group. There were no significant minimal sagittal skeletal effect of pendulum treatment
differences in the mandibular measurements (SNB and was reflected in the change in the ANB angle, which
Co‑Gn). For the maxillomandibular relationships, there increased 0.4°.
were reductions in the ANB angles in the headgear (–1.2
mm) and extraction (–1.7 mm) groups; no change was Angelieri et al.[18] reported that the maxilla and mandible
observed in the pendulum group (0.0 mm). Polat‑Ozsoy[2] showed similar behavior during orthodontic treatment
reported that the pendulum/K‑loop appliance showed with the pendulum and fixed orthodontic appliance.
insignificant changes in both the maxilla and the There was a statistically significant reduction in the
mandible. However, in the headgear group, the maxilla SNA and SNB angles of 1.1° and 1.5°, respectively.
moved backward by 1 mm, and the mandible rotated Alterations were kept constant during leveling and
posteriorly causing a decrease in SNB of 0.9 mm and an aligning. After retraction of the maxillary anterior
increase in GoGnSN of 0.9 mm. The overall change in teeth, there was a statistically significant increase in
treatment between the pendulum and headgear groups all variables: 1.6° for SNA and 1.5° for SNB returning
in SNA was statistically significant (P ˂ 0.05). to the initial values found at pretreatment, with no
statistical significance. Thus, the maxillomandibular
Byloff et al.[7] reported that the skeletal changes of relationship was not statistically significantly altered
the maxilla, the SNA angle showed no statistical during treatment, because there was reduction or
differences, confirming other studies.[14‑16] The author increase of both angles related to the maxilla and
suggested that A point was not affected by anteriorly mandible simultaneously and almost to the same
oriented forces within a relatively short period. Thus, extent.

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Marure, et al.: Distalization techniques in children…

In this study, mandibular plane (FMA) showed a and leveling with fixed appliances. Angelieri et al.[18]
small backward rotation of 1.79° with distalization also observed mild buccal tipping of these teeth during
[Table 3 and Figure 6], in Groups I and III, it was increased orthodontic treatment with pendulum and fixed
by 1.59° and 4.10° respectively (P ˂ 0.05). According to appliances. Sagittally, the retraction of the maxillary
most studies on the pendulum appliance,[7,19] significant incisors in the pendulum and headgear groups, was
increase in the vertical dimension must be expected. modest, and their magnitude was statistically different
These vertical changes comprise a slight opening compared with the extraction group.
of the mandibular plane angle (about 1°) and an
increase in lower anterior facial height (2.2–2.8 mm).[ 20] Maxillary dentoalveolar changes
Chaqués‑Asensi and Kalra[19] reported that Lower facial All groups showed a significantly larger amount
height (ANS‑Me) increased by 2.8 mm, while the of molar distalization with an average of 4.7 mm
mandibular plane angle increased by 1.3° with the [Table 3 and Figure 6]. In the present study, the distal
pendulum appliance. Bussick and McNamara[17] found movement of maxillary first molars in the Group I
no significant difference in lower anterior facial height
was 6.4 mm, with a distal tipping of 7.3°. Hilgers,[8]
increase among patients with high, neutral, or low
reported that 5 mm of distal molar movement in three
mandibular plane angles, whereas Ghosh and Nanda[21]
to 4 months. Ghosh and Nanda[21] showed that the
reported that the increase in lower anterior facial
maxillary first molar distalized by 3.37 mm and tipped
height was significantly greater in patients with higher
distally 11.99°. Byloff and Darendeliler[20] showed that
pretreatment mandibular plane angles. The increased
the pendulum appliance moved the molars distally
lower facial height and mandibular plane angle could
have resulted from driving the molars back into the with a mean of 3.39 mm, with a distal tipping of 14.5°.
“wedge.”[21] These results suggest that the pendulum Bussick and McNamara,[17] showed that the average
may be contraindicated in patients with excessive maxillary first molar distalization was 5.7 mm, with
lower facial height and/or minimal overbite.[19] In a distal tipping of 10.6°. Chaqués‑Asensi and Kalra[19]
Group III, greater increments in vertical dimensions reported that the maxillary first molars moved distally
were produced than those reported by other authors.[14] 5.3 mm, tipped distally 13.1°. Fuziy et al.[16] showed
that the mean distalization of the maxillary molars was
Chiu et al.[15] found that the effects of the pendulum and 4.6 mm, with a mean distal crown tipping of 18.5°.
distal jet appliances on vertical skeletal relationships
have had a slight opening of the mandibular plane In Group II, the mean molar distalization was
angle (about 1°) and an increase in lower anterior facial 2.25 mm [Table 3 and Figure 6]. Kalra[9] reported that
height (2.2–2.8 mm). 4 mm of molar distalization was achieved with K‑loop
appliance.
Interdental effects
In the present study, the interdental measurements In Group III, the average molar distalization was 3.9 mm
of all three groups demonstrated highly significant [Table 3 and Figure 6]. Ngantung et al.[14] showed that
changes from pre‑ to post‑treatment. The overall the maxillary first molars were distalized with the
overbite reduction was 2.38 mm. The overbite distal jet appliance by an average of 2.1 ± 1.8 mm. Bolla
decreased by 2.31, 2.16, and 2.80 mm in Groups I, II, et al.[22] demonstrated that the crowns of the maxillary
and III, respectively [Table 3 and Figure 6]. Ghosh and first molars were distalized an average of 3.2 mm. Chiu
Nanda[21] also showed that the overbite decreased by et al.[15] reported that the pendulum group showed a
1.39 mm in pendulum appliance groups. Bussick and significantly greater correction of molar relationship
McNamara[17] reported that the overbite decreased and a significantly larger amount of molar distalization
by 1.7 mm as a result of pendulum appliance. compared with the distal jet group (3.8 and 2.8 mm,
Chaqués‑Asensi and Kalra[19] reported that the overbite respectively).
reduced by 1.8 mm. Chiu et al.[15] reported that the
distal jet group had a significantly greater decrease in The overall results of a present study
overbite (2.9 mm) than the pendulum group (1.2 and [Table 3 and Figure 6] demonstrated labial tipping of
1.7 mm, respectively). upper incisor with a mean of 3.72° and 1.6 mm (U1 to
palatal plane and U1 to PTV respectively).
de Almeida‑Pedrin et al.[1] showed that the maxillary
incisors exhibited significant changes among groups In the present study, there was no incisor proclination
with regard to buccolingual tipping (1‑NA and noticed in the Group I. Ghosh and Nanda[21] found
1‑PP) and anteroposterior positioning (1‑NA). In an incisor proclination of 2.4° relative to the SN
the extraction group, the anterior teeth had greater line. Likewise, a mean of 1.71° of labial tipping was
incisor flaring and overjet than did the other two measured by Byloff and Darendeliler[20] and an average
groups (pendulum and headgear). The incisors in of 1.8 mm of anterior movement of the incisor edge.
the pendulum and headgear groups generally were In Group II, upper incisor to PTV distance increased
maintained in their initial orientation, with only mild showing the labial movement of upper incisor. In
buccal crown tipping, probably due to tooth alignment Group III, the position of the maxillary incisor to

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Marure, et al.: Distalization techniques in children…

palatal plane increased significantly from pretreatment inherent with the identification and recording of
to after distalization (6.7°). Ngantung et al.[14] reported the structures therein
that the maxillary incisor to the cranial base (SN) angle 2. The sample size was small and hence larger
increased an average of 12.2°. Bolla et al.[22] showed sample size would have been desirable to increase
that the maxillary incisors were proclined an average statistical power.
of 0.6°. Chiu et al.[15] reported that the pendulum
(U1‑FH = 3.1°) subjects showed significantly less Scope for the future study
anchorage loss at the maxillary incisors than the distal A study can be planned with a larger sample to study
jet subjects (U1‑FH = 13.7°). the changes with Temporary Anchorage Devices using
advanced diagnostic aids like cone beam computed
Soft tissue changes tomography can be a useful tool with minimal
Prediction of soft tissue changes is difficult because of identification error.
the vast number of variables to consider. Differences in
soft tissue thickness and tension between individuals
produce a complex variation in profiles as demonstrated
Conclusion
by hard tissue changes. However, changes in the
positions of the incisors do have a direct impact on the Pediatric orthodontists have been specifically
supporting soft tissues.[2] Most of the previous studies interested in facial growth and development.[24] To fight
on variations of the pendulum appliance have focused a borderline case, distalization is an important weapon
on soft tissue changes relative to the E‑plane.[23] in growing children and patient selection is of utmost
importance and should not be overlooked.[25] The
The present study showed statistically significant following conclusion can be drawn from the present
increase in the cant of the upper lip with a mean of 3.40° study with the pendulum, K‑loop, and distal jet
[Table 3 and Figure 6]. Ghosh and Nanda[21] evaluated appliances:
the soft tissue changes relative to the E‑plane and 1. No significant anteroposterior skeletal changes
reported a 0.31 mm protrusion in the upper lip and a (SNA, SNB, and ANB angles) were observed after
0.95 mm protrusion in the lower lip due to upper incisor distalization
protrusion. Bussick and McNamara[17] evaluated four 2. The Frankfort‑mandibular plane angle was slightly
soft‑tissue variables: Upper incisor and lower incisor opened after distalization and significant bite
position relative to the E‑plane, nasolabial angle, opening was noticed
and cant of the upper lip. Their results also showed 3. The significant amount of first molar distalization
protrusion in both the upper and lower lips and a 2.5° was achieved (4.7 mm)
decrease in the nasolabial angle and 2.0° decrease in 4. The maxillary incisors showed labial tipping
the cant of the upper lip, reflecting a slight protrusion 5. A statistically significant increase in the cant of the
of upper lip contour. Ngantung et al.[14] reported that upper lip with a mean of 3.4°
the upper lip to Rickett’s E‑plane increased an average
of 0.8 ± 2.2 mm in the distal jet appliance group. There Summary
exists only one study that showed a 0.4 mm retrusion
of the upper lip relative to the E‑plane, and the results The present study showed effective distalization of
of that study were found insignificant.[22] the molars with the pendulum, K‑loop, and distal
jet appliances. There was an increase in FMA angle,
Finally, although the results of this study indicate that significant bite opening, proclination of the maxillary
the pendulum, K‑loop, and distal jet appliances are incisors and increase in the cant of the upper lip.
effective in moving the maxillary molars distally, the Therefore, these appliances should be used with
clinical use of these appliances has some undesired caution. The conventional distalization appliances
effects, increase in mandibular plane angle, labial can be substituted by temporary anchorage devices to
movement of maxillary incisors and soft tissue profile prevent maxillary incisors proclination.
change. These should be considered by the clinician
and make sure that this treatment technique is
Financial support and sponsorship
appropriate for the specific patient. It is well known
Nil.
that Class II malocclusion can be due to a number of
differing causes.[17] This treatment protocol should be
used only in those patients who would benefit from Conflicts of interest
maxillary molar distalization. There are no conflicts of interest.

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Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2016 | Vol 34 | Issue 4 | 339
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340 Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2016 | Vol 34 | Issue 4 |