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Pendulum Therapy of Molar Distalization in Mixed Dentition

Article · January 2016

DOI: 10.5005/jp-journals-10005-1336

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IJCPD

Pendulum Therapy of10.5005/jp-journals-10005-1336

Molar Distalization in Mixed Dentition
CASE REPORT

Pendulum Therapy of Molar Distalization in

Mixed Dentition
1
Raju Umaji Patil, 2Amit Prakash, 3Anshu Agarwal

ABSTRACT by means of intraoral or extraoral forces.1 For cases with

minimal arch length discrepancy and mild class II molar
Early and timely pedo-orthodontic treatment is aimed at
relationship associated with a normal mandibular arch,
eliminating the disturbances of skeletal or dentoalveolar
development, to harmonize the stomatognathic system before molar distalization is of significant value. Conventional
the full eruption of all permanent teeth. The advantages of extraoral traction has been successful in correcting class II
pendulum appliance are its minimal dependence on patient’s malocclusion, either by restraining forward growth of
compliance (child cooperation), ease of fabrication, one- the maxilla or by distalizing maxillary molars. How-
time activation and adjustment of the springs if necessary
to correct minor transverse and vertical molar positions.
ever, these appliances rely partially or totally on patient
This article reports a successful treatment method of class II cooperation.
malocclusion with pendulum appliance in mixed dentition Numerous alternative intraoral noncompliant appli-
phase. Distalization of maxillary molar was done, followed by ances, such as pendulum,1 the distal jet,2 the K-loop molar
guidance of canine impaction orthodontically and other dental
distalizer,3 double loop NiTi4 and C space regainer5 have
correction using 0.022 MBT appliances. Posttreatment results
were stable and remarkable. been developed, and many well-documented studies
have substantiated their effects. These appliances have
Keywords: Class II malocclusion, Distalization, Mixed dentition,
drawbacks of anchor loss, proclination of the maxillary
Pendulum, Space regainer.
incisors, tipping of the maxillary molars and difficulty
How to cite this article: Patil RU, Prakash A, Agarwal A.
in keeping the molars in position following distal move-
Pendulum Therapy of Molar Distalization in Mixed Dentition.
Int J Clin Pediatr Dent 2016;9(1):67-73. ments. Space is easier to gain in the maxillary arch6,7 than
in the mandible because of increased trabecular structure
Source of support: Nil
of supporting bone and increased anchorage afforded
Conflict of interest: None by palatal vault. Table 11-3,8 shows the applications of
pendulum.
INTRODUCTION In this article, a case is presented, in which maxillary
Since all children do not cooperate for dental treatment, molar distalization was carried out using pendulum
it is difficult to manage problems of developing dentition distalization appliances. In this case, maxillary molar
in children with interceptive orthodontic appliances. distalization was effective and efficient in correcting the
Pendulum is unique and different as it is a child-friendly borderline class II malocclusion.
appliance. This is why clinicians often prefer intraoral
distalization appliances that minimize the need for Table 1: When to use pendulum
patient cooperation. Correction of class II malocclusion Indications of distalization
without extraction requires maxillary molar distalization   1. Class II or end-on molar relationship
  2. Mixed or permanent dentition
  3. Mild to moderate crowding in maxillary arch
1   4. Hypodivergent or average growth pattern
Professor and Head, 2,3Readers
  5. Well-aligned teeth or mild crowding in mandibular arch
1   6. Straight profile
Department of Pedodontics and Preventive Dentistry
Department of Pedodontics and Preventive Dentistry, STES   7. Functional – normal TMJ
Sinhgad Dental College and Hospital, Pune, Maharashtra, India   8. Skeletal class I pattern
2,3   9. Normal/short lower face height
Department of Orthodontics and Dentofacial Orthopedics
10. Loss of arch length due to premature loss of second
Rishiraj College of Dental Sciences and Research Centre
deciduous molar8
Bhopal, Madhya Pradesh, India
Contraindications
Corresponding Author: Raju Umaji Patil, Professor and 1. Temporomandibular joint disorder
Head, Department of Pedodontics and Preventive Dentistry 2. Class II skeletal jaw base
STES Sinhgad Dental College and Hospital, Pune-411041 3. Skeletal open bite and dental open bite/shallow bite
Maharashtra, India, phone: 08871963896, e-mail: rupat13@ 4. Excess lower face height
yahoo.com 5. Dental: Class I or III molar relation

International Journal of Clinical Pediatric Dentistry, January-March 2016;9(1):67-73 67

Raju Umaji Patil et al

CASE REPORT palatal button and anchoring teeth in the same dental
arch. The acrylic button fits tightly against the palatal
A 10-year-old girl presented with the chief complaint of
mucosa in the region of the palatal rugae and is linked to
crowded teeth. She was in mixed dentition stage, had
the teeth with occlusally bonded onlays. After placement
convex profile with average Frankfurt mandibular plane
angle, class II (end-on) molar relation, upper and lower of the preactivated pendulum springs, the anchorage
anterior crowding along with deviated midline (Fig. 1). unit is designed to counteract the reactive forces and
Pendulum appliance was used in this case to correct the moments. Maxillary molar distalization was completed
class II malocclusion (Fig. 2). Bonded pendulum appliance in 4 months (Fig. 3). Space gained in each side was 4 mm.
was designed to take support from deciduous molar for The rate of distalization was almost 1 mm per month.
anchorage. With pendulum appliances, as with almost Stabilization of class II molar relation with headgear and
all compliance-free appliances for molar distalization nance button was done to hold the gained space (Fig. 4).
described to date, the anchorage block consists of a nance Postdistalization headgear was also given for uprighting of

A B C

D E

Figs 1A to F: Pretreatment extraoral and intraoral photographs

68
IJCPD

Pendulum Therapy of Molar Distalization in Mixed Dentition

A B

C D

Figs 2A to D: Bonded pendulum appliance for distalization of maxillary molars

A B

C D

Figs 3A to E: Postdistalization showing space gain

International Journal of Clinical Pediatric Dentistry, January-March 2016;9(1):67-73 69

Raju Umaji Patil et al

Fig. 4: Postdistalization stabilization with headgear

molars. Bilaterally maxillary canine impaction was treated

after surgical exposure. Extrusion of canine was done on
0.018 stainless steel wire with E-chain as seen in Figure 5;
0.018 stainless steel wire with helices was made to apply
the force and sound biomechanics. After canine alignment
in the arch, 0.019 × 0025 stainless steel wire was used for
torque correction (Fig. 6). Finally, good dentoalveolar B
changes and occlusion were achieved (Fig. 7).

DISCUSSION
Distalization of maxillary molars is indicated for
correction of class II dental malocclusions and for space
gaining in cases of space deficiency. The ideal treatment
with an intraoral fixed appliance for molar distalization
should fulfill the following requirements: Patient
compliance, acceptable esthetics, comfort and minimum
anterior anchor loss (as evidenced by inclination of
incisors). There should be bodily movement of the molars
to avoid undesirable effects and unstable outcomes, and C

minimum time required during sessions for placement Figs 5A to C: Impacted canine correction on 0.018 stainless
and activations. To achieve this, many devices have been steel wire with E-chain
suggested. Ghosh and Nanda in 1996 reported that the
pendulum appliance is a reliable method for distalizing particular method of distalization is of utmost importance
maxillary molars at the expense of moderate anchorage and should not be overlooked.10
loss. Byloff and Darendeliler and Byloff showed that the It is not right to treat a condition without adequate
pendulum appliance moved molars distally without knowledge and understanding.11 When to treat and when
creating bite opening, but the molars did tend to tip. to refer to an orthodontist should be based on honest
Hilgers1 had shown that when the appliance is placed appraisal of skill levels and preferences of treatment.
before the eruption of the second molars, two-thirds of Pedodontist is accountable with the decision to treat or
the space gained is by molar distalization and one-third refer. Such decisions are aimed at patient benefit since
is experienced as forward shift of the anterior teeth. he/she should receive the correct treatment.
Pendulum appliances have several advantages which Using intraoral appliances, maxillary molars can
include cost-effectiveness and chair side activation.9 routinely be moved distally with little or no patient
It should be remembered that patient selection for a cooperation. A distal movement rate of approximately

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Pendulum Therapy of Molar Distalization in Mixed Dentition

A B

C D

Figs 6A to E: Torque correction with 0.019 × 0.025 stainless steel wire

1 mm per month of the first molar’s crowns has been the strain on the anchorage teeth will increase when the
reported, but there is marked individual variation.1-6 One first and second molars are moved simultaneously. Thus,
factor that influences the movement rate is the type of the anchorage loss (forward movement of the maxillary
movement and another factor is the timing of treatment. incisors) will be lower if the molars are moved before
Usually faster movement occurs when the molars are eruption of the second molars. Even if the anchorage loss
tipped, whereas bodily movement takes a longer time. can be corrected with modest intervention, the amount of
A favorable time to move molars distally appears to be lower anchorage loss will result in less time-consuming
in the mixed dentition before the eruption of the second correction.13
molars.12 The reason why it is more effective to move the
CONCLUSION
maxillary first molars distally before the second molars
have erupted is that there is one more tooth, and thus, a Hence, to conclude, in our day-to-day practice, we come
larger area of root surface to be moved when the second across many cases in which a class II div 1 malocclusion
molars have erupted. Conceivably, this also implies that is developing due to the mesial drifting of the maxillary
International Journal of Clinical Pediatric Dentistry, January-March 2016;9(1):67-73 71
Raju Umaji Patil et al

A B

C D

E F

Figs 7A to G: Posttreatment extraoral and intraoral photographs

72
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Pendulum Therapy of Molar Distalization in Mixed Dentition

permanent first molars. This mesial drift could be the 6. American Academy of Pediatric Dentistry. Clinical guideline
result of the loss of tooth material due to caries, the on management of the developing dentition in pediatric
dentistry. Pediatr Dent 2004;26(7 Suppl):128-131.
premature exfoliation/extraction of the deciduous molars
7. Hilgers KK, Redford-Badwal D, Reisine S, Mathieu GP. Or-
or the ectopic eruption of the maxillary permanent first thodontic treatment provided in pediatric dental residencies.
molars. Thus, the developing class II div 1 malocclusion J Dent Educ 2003 Jun;67(6):614-621.
can be successfully intercepted and corrected in the mixed 8. Survey of orthodontic services provided by pedodontists.
dentition period by molar distalization. Association of Pedodontic Diplomates. Pediatr Dent 1983
Sep;5(3):204-206.
9. McDonald, RE.; Avery, DR. Dentistry for the child and
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