ORIGINAL ARTICLE

Treatment effects of a modified palatal anchorage

plate for distalization evaluated with cone-beam
computed tomography
Yoon-Ah Kook,a Mohamed Bayome,b Vu Thi Thu Trang,c Hye-Jin Kim,d Jae Hyun Park,e Ki Beom Kim,f
and Rolf G. Behrentsg
Seoul, Korea, Asuncion, Paraguay, Hanoi, Vietnam, Mesa, Ariz, and St Louis, Mo

Introduction: The purpose of this study was to evaluate the treatment effects of maxillary posterior tooth distal-
ization performed by a modified palatal anchorage plate appliance with cephalograms derived from cone-beam
computed tomography. Methods: The sample consisted of 40 lateral cephalograms obtained from the cone-
beam computed tomography images of 20 Class II patients (7 men, 13 women; average age, 22.9 years)
who underwent bilateral distalization of their maxillary dentition. The lateral cephalograms were derived from
the cone-beam computed tomography images taken immediately before placement of a modified palatal
anchorage plate appliance and at the end of distalization. Paired t tests were used for comparisons of the
changes. Results: The distal movement of the maxillary first molar was 3.3 6 1.8 mm, with distal tipping of
3.4
6 5.8
and intrusion of 1.8 6 1.4 mm. Moreover, the maxillary incisors moved 3.0 6 2.7 mm lingually,
with lingual tipping of 6.2
6 7.6
and insignificant extrusion (1.1 mm; P 5 0.06). The occlusal plane angle
was increased significantly (P 5 0.0001). Conclusions: The maxillary first molar was distalized by 3.3 mm at
the crown and 2.2 mm at root levels, with distal tipping of 3.4
. It is recommended that clinicians should consider
using the modified palatal anchorage plate appliance in treatment planning for patients who require maxillary to-
tal arch distalization. (Am J Orthod Dentofacial Orthop 2014;146:47-54)

E
xtraoral appliances have been prescribed for
maxillary molar distalization in nonextraction
treatment of Class II malocclusion patients. How-
ever, these devices require patient cooperation.1 To
effectively overcome this problem, intraoral
a
Professor, Department of Orthodontics, Seoul St. Mary's Hospital, Catholic Uni-
versity of Korea, Seoul, Korea.
b
Research assistant professor, Graduate School, Catholic University of Korea,
Seoul, Korea; visiting professor, Department of Postgraduate Studies, Universi-
dad Auton oma del Paraguay, Asunci on, Paraguay.
c
Lecturer, Department of Orthodontics, Hanoi Medical University, Hanoi,
Vietnam.
d
Private practitioner, Yonseijin Dental Clinic, Seoul, Korea.
e
Associate professor and chair, Postgraduate Orthodontic Program, Arizona
School of Dentistry & Oral Health, A. T. Still University, Mesa, Ariz; adjunct pro-
fessor, Graduate School of Dentistry, Kyung Hee University, Seoul, Korea.
f
Associate professor, Department of Orthodontics, Center for Advanced Dental
Education, Saint Louis University, St Louis, Mo.
g
Professor, Department of Orthodontics, Center for Advanced Dental Education,
Saint Louis University, St Louis, Mo.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Yoon-Ah Kook, Department of Orthodontics, Seoul
St. Mary's Hospital, Catholic University of Korea, 505 Banpo-Dong, Seocho-Gu,
Seoul, 137-701, Korea; e-mail, kook190036@yahoo.com.
Submitted, July 2013; revised and accepted, March 2014.
0889-5406/$36.00
Copyright Ó 2014 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.03.023
noncompliance appliances have been developed.2-6
Nevertheless, the negative side effects of these
appliances include anchorage loss at the reactive part,
distal tipping, and extrusion of molars.7,8
To reduce the drawbacks of noncompliance appli-
ances, temporary skeletal anchorage devices (TSADs)
have been applied to the buccal plate of the bone to
achieve molar distalization.9-13 However, the buccal
approach poses an increased risk of contacting the
roots of adjacent teeth, and the range of action might
be limited by the interradicular space. Sugawara et al14
placed plates at the zygomatic buttresses for distaliza-
tion of the maxillary dental arch. However, their method
involved surgical procedures and a latency time between
the surgery and force application.
Recently, palatal bone thickness and density as well
as palatal soft-tissue thickness have been evaluated in
adults and adolescents.15-18 These studies have
provided detailed information for the placement of the
TSADs in the palate. In addition, the placement of the
TSADs in the palate eliminates the need for
reimplanting miniscrews as in the buccal approach.19,20
Several appliances with TSADs have been reported to
distalize the maxillary posterior teeth, but some were
47
48
Fig 1. The palatal plate is connected to the hooks of the palatal wire via power elastics or nickel-
titanium closed-coil springs. The direction of force can be changed according to the notches on the
arms of the palatal plate (A, B, and C).
bulky and others contributed to distal crown
tipping.21,22 Kinzinger et al23 proposed a distal jet appli-
ance supported by dental and skeletal anchorages.
Although it reduced the anchorage loss, it prevented
movement of the premolars during the distalization
period. Kircelli et al24 used a bone-anchored pendulum
appliance. A large amount of distal tipping of the first
molar (10.9
) was reported with this appliance; this
could have been due to a force vector similar to the con-
ventional appliance. On the other hand, the modified
palatal anchorage plate (MPAP) appliance has been re-
ported to effectively distalize the posterior teeth in
adults and adolescents.25,26 Finite element analysis
suggested that distalization with a palatal plate rather
than buccally placed mini-implants provides bodily
molar movement without tipping or extrusion.27 How-
ever, no clinical evaluation has been performed with
the MPAP.
So far, most distalization studies have used 2-
dimensional lateral cephalograms. The disadvantages
of this approach include confounded images caused by
superimposed anatomic structures, vertical and horizon-
tal magnifications, and a lack of right and left side infor-
mation.28,29 Although cone-beam computed
tomography (CBCT) has disadvantages that include
higher doses of radiation, higher cost, and limited avail-
ability, these limitations are overcome by the huge
amount of data that is provided without distortion or su-
perimposition.30
The degree of difficulty and the prognosis of distali-
zation are affected by the patient's dental and chrono-
logic ages. A high success rate with fewer
complications occurs when the maxillary molars are
distalized in the mixed dentition stage.31 Hence, most
distalization studies have focused on adolescents, and
there have been no studies, to the best of our knowledge,
July 2014  Vol 146  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Kook et al
investigating the distalization effect in adults who have
full eruption of their maxillary second molars.
Therefore, the purpose of this study was to evaluate
the treatment effects of posterior tooth distalization in
adults with an MPAP appliance using lateral cephalo-
grams derived from CBCT images.
MATERIAL AND METHODS
Forty lateral cephalograms were obtained from CBCT
images of 20 consecutively treated Class II adult patients
(7 men, 13 women; average age, 22.9 years; range, 17.4-
33 years) who underwent bilateral distalization of their
maxillary dentition at the Department of Orthodontics
at Seoul St. Mary's Hospital, Catholic University of Ko-
rea. Of the 40 lateral cephalograms, 15 sides had one
quarter cusp, 12 had one half cusp, 7 had three quarters
cusp, and 6 had full cusp Class II molar relationships.
The inclusion criteria for this retrospective study were
(1) dental Class II relationship, (2) 3-dimensional CBCT
images taken immediately before and after distalization,
(3) exclusive use of the MPAP appliance for distalization,
and (4) age over 17 years. The exclusion criteria were (1)
extraction treatment (except for third molars) and (2)
unilateral distalization. Approval was obtained from
the institutional review board of the Catholic University
of Korea (KC11RASI0790), and informed consent was
provided according to the Declaration of Helsinki.
The MPAP appliance (Fig 1) and its installation
method have been described in previous articles.25,26
The MPAP was fitted on the dental cast to the shape
of the palate, extending its arms to the area between
the first molar and the second premolar and leaving
enough space between the arms and the palatal slopes.
The transfer from the cast to the patient's mouth was
made with a jig by the same operator (Y.-A.K.) using 3
Kook et al
miniscrews (length, 8 mm; diameter, 2 mm: Jeil, Seoul,
Korea). Then a palatal bar with 2 hooks extending
along the gingival margins of the teeth was banded to
the right and left maxillary first molars. Immediately
after placement, distalization can be initiated by
engaging elastics or nickel-titanium closed-coil springs
between the MPAP arm notches and the hooks on the
palatal bar, applying approximately 300 g of force per
side.
Along with the MPAP appliance, 0.022-in slot
brackets and bands (Tomy, Tokyo, Japan) were placed
on the maxillary and mandibular teeth including the
second molars. The interval between appointments
was 3 to 4 weeks. The distalization periods were calcu-
lated from the patients' records.
CBCT images (before and after distalization) were
taken with an iCAT scanner (Imaging Science Interna-
tional, Hatfield, Pa). The scanning parameters were
120 kV, 47.7 mAs, 20 seconds per revolution,
170 3 130 mm field of view, and voxel size of
0.4 mm. Each seated subject's head position was ori-
ented so that the Frankfort plane was parallel to the
floor, and the images were taken at the intercuspal po-
sition.
The CBCT data were exported in a digital imaging
and communications in medicine (DICOM) multifile
format and imported into InVivo software (version 5.2;
Anatomage, San Jose, Calif) for 3-dimensional volume
rendering. Reorientation of the head position of each
scan was performed as follows. The horizontal plane
(x) was defined through the right and left orbitales and
the left porion, and the midsagittal plane (y) was defined
as the perpendicular plane passing through nasion and
anterior nasal spine. The vertical plane (z) was perpen-
dicular to both x and y. Then, using the super-ceph
module in the InVivo software, a lateral cephalometric
image was created for each right and left side indepen-
dently and saved in JPG format. Each image was then
traced and superimposed using V-Ceph software
(version 5.5; Cybermed, Seoul, South Korea) with the
manual geometric method.32,33 The horizontal
reference line was the Frankfort horizontal plane, and
the vertical reference line was the perpendicular at
pterygoid. All tracings and digitizations were made by
1 examiner (V.T.T.T.) to minimize operator-generated
variation in the measurements.
The software calculated the linear and angular di-
mensions between certain landmarks according to the
definitions given in Figures 2 through 4.
The maxillary third molar was present in 31 sides and
extracted or missing from 9 sides during treatment.
Ten randomly selected subjects were reprocessed
4 weeks later to evaluate intraoperator reliability. The
American Journal of Orthodontics and Dentofacial Orthopedics
49
Fig 2. Cephalometric landmarks and maxillary dental
sagittal, vertical, and angular measurements. Land-
marks: Or, Orbitale; Po, porion; Pt, pterygoid; ANS, ante-
rior nasal spine; PNS, posterior nasal spine; FH, Frankfort
horizontal; VRL, vertical reference line; U1, incisal tip of
the maxillary central incisor; U1r, root tip of the maxillary
central incisor; U5, cusp tip of the maxillary second pre-
molar; U5r, root tip of the maxillary second premolar;
U6, distobuccal cusp of the maxillary first molar; U6r, dis-
tobuccal root tip of the maxillary first molar. Measure-
ments: 1, U6-VRL; 2, U6r-VRL; 3, U6-FH; 4, U6r-FH; 5,
angle between U6-U6r and FH; 6, U5-VRL; 7, U5r-VRL;
8, U5-FH; 9, U5r-FH; 10, angle between U5-U5r and
FH; 11, U1-VRL; 12, U1r-VRL; 13, U1-FH; 14, U1r-FH;
15, angle between U1-U1r and FH.
intraclass correlation coefficient showed that the mea-
surements were reliable (.0.997).
Statistical analysis
Statistical evaluation was performed using SPSS soft-
ware (version 16.0; SPSS, Chicago, Ill). Normal distribu-
tion of the parameters was assessed with the
Kolmogorov-Smirnov test. The paired t test was used
to evaluate the skeletal, dental, and soft-tissue changes
from before to after distalization. The comparison be-
tween subjects who had third molars during distalization
and those with missing or extracted ones was performed
by an independent sample t test. The statistical signifi-
cance was determined at a 5 0.05.
RESULTS
Clinically successful distalization was achieved using
the MPAP appliance for an average of 12.5 months.
There were significant changes in the sagittal and ver-
tical positions (P \0.0001) and angulations (P 5 0.001)
of the maxillary first molars after distalization. The mean
amount of first molar distalization was 3.30 6 1.80 mm,
July 2014  Vol 146  Issue 1
50
Fig 3. Cephalometric landmarks and mandibular dental
sagittal, vertical, and angular measurements. Land-
marks: Or, Orbitale; Po, porion; Pt, pterygoid; FH,
Frankfort horizontal; VRL, vertical reference line; L1,
incisal tip of the mandibular central incisor; L1r, root
tip of the mandibular central incisor; L5, cusp tip of
the mandibular second premolar; L5r, root tip of the
mandibular second premolar; L6, distobuccal cusp of
the mandibular first molar; L6r, distal root tip of the
mandibular first molar. Measurements: 1, L6-VRL; 2,
L6r-VRL; 3, L6-FH; 4, L6r-FH; 5, angle between L6-
L6r and FH; 6, L5-VRL; 7, L5r-VRL; 8, L5-FH; 9, L5r-
FH; 10, angle between L5-L5r and FH; 11, L1-VRL;
12, L1r-VRL; 13, L1-FH; 14, L1r-FH; 15, angle between
L1-L1r and FH.
Fig 4. Cephalometric midsagittal measurements. Land-
marks: S, Sella turcica; N, nasion; Or, orbitale; Po, porion;
Pt, pterygoid; FH, Frankfort horizontal; ANS, anterior
nasal spine; A, A-point; Ls, labrale superior; Li, labrale
inferior; B, B-point; Pog’, soft-tissue pogonion; Me, men-
ton; VRL, vertical reference line. Measurements: 1,
SNA; 2, ANB; 3, palatal plane angle; 4, occlusal plane
angle; 5, mandibular plane angle; 6, ANS-Me; 7, nasola-
bial angle; 8, mentolabial fold; 9, Ls-VRL; 10, Li-VRL; 11,
Pog'-VRL.
July 2014  Vol 146  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Kook et al
with distal tipping of 3.42
6 5.79
and intrusion of
1.75 6 1.35 mm. The maxillary second molar showed
2.66 6 1.90 mm of distalization, 1.28 6 1.61 mm of
intrusion, and 2.03
6 7.49
of distal tipping. The maxil-
lary second premolars moved distally 3.05 6 2.14 mm
and tipped distally 8.38
6 6.80
, with no significant
change in the crown vertical position. The maxillary cen-
tral incisors were retracted by 2.99 6 2.73 mm, with a ret-
roclination angle of 6.21
6 7.64
and no significant
change in the vertical position (Table I, Fig 5).
The occlusal plane angle was significantly
(P 5 0.001) increased by 2.81
. However, the palatal
plane angle was not changed. The upper and lower
lips showed about 1.5 mm of retraction (P 5 0.016
and 0.008, respectively). The nasolabial angle was
significantly (P 5 0.008) increased to 101.9
(Table II).
There were no significant differences in the amount
of the change in position or angulation of teeth between
the maxillary third molar extraction (n 5 31) and nonex-
traction (n 5 9) groups (Table III).
DISCUSSION
The aim of this study was to evaluate a newly
developed palatal plate appliance designed for molar
and total arch distalization using cephalograms
derived from CBCT images. A lateral cephalogram of
each side was created independently to eliminate the
superimposition of anatomic structures. This allowed
for accurate root position and evaluation of each
side separately. These reconstructed images are accu-
rate and reliable when compared with conventional
radiographs.34,35
With the pendulum appliance, Ghosh and Nanda5
had distal tipping of the maxillary first and
second molars of 8.4
and 12.0
, respectively, at the
end of the distalization period. They stated that the
molar relationship could be corrected by a tipping
movement, but retention would be doubtful during
retraction of the incisors. Other studies showed 8.8

and 10.9
of distal tipping of the maxillary first molars
after distalization via miniscrews.24,36 Meanwhile, the
bone-anchored pendulum appliance showed 9
of distal
tipping.22 In our study, the maxillary first and
second molars tipped distally by 3.4
and 2.0
, respec-
tively. This decreased tipping in our study might be
due to the ability to adjust the force vector by selecting
the most appropriate plate notch that is estimated to
result in bodily movement.
Although the distal tipping was limited (3.4
), the
standard deviation was 5.8
, which represented wide
variability. This might be attributed to the individual
Kook et al 51

Table I. Comparisons of predistalization and postdistalization positions of the maxillary dentition (n 5 40)
Predistalization Postdistalization Change

Variable Mean SD Mean SD Mean SD P value

Central incisor crown horizontal distance (mm) 55.22 5.32 52.23 5.52 2.99 2.73 \0.001
Central incisor root horizontal distance (mm) 47.21 3.77 46.89 3.97 0.33 2.08 0.327
Central incisor crown vertical distance (mm) 54.52 4.57 55.61 4.20 1.09 3.51 0.056
Central incisor root vertical distance (mm) 35.17 3.46 35.72 3.43 0.55 1.92 0.077
Central incisor inclination (
) 68.15 10.47 74.36 10.34 6.21 7.64 \0.001
Second premolar crown horizontal distance (mm) 33.14 5.21 30.09 4.94 3.05 2.14 \0.001
Second premolar root horizontal distance (mm) 33.61 3.87 33.26 4.03 0.34 2.21 0.332
Second premolar crown vertical distance (mm) 49.88 4.69 50.04 4.13 0.16 3.91 0.798
Second premolar root vertical distance (mm) 33.26 5.20 32.75 3.63 0.51 3.61 0.381
Second premolar angulation (
) 92.11 7.22 100.49 8.66 8.38 6.80 \0.001
First molar crown horizontal distance (mm) 18.43 4.42 15.13 4.17 3.30 1.80 \0.001
First molar root horizontal distance (mm) 22.99 3.48 20.82 3.53 2.17 1.85 \0.001
First molar crown vertical distance (mm) 45.51 4.08 43.76 4.63 1.75 1.35 \0.001
First molar root vertical distance (mm) 31.53 3.74 29.98 3.78 1.55 1.96 \0.001
First molar angulation (
) 109.30 6.05 112.72 7.83 3.42 5.79 0.001
Second molar crown horizontal distance (mm) 9.23 3.93 6.57 3.74 2.66 1.90 \0.001
Second molar root horizontal distance (mm) 16.00 3.13 13.88 3.19 2.12 1.90 \0.001
Second molar crown vertical distance (mm) 42.56 4.75 41.28 5.15 1.28 1.61 \0.001
Second molar root vertical distance (mm) 30.97 3.91 29.67 4.03 1.30 1.45 \0.001
Second molar angulation (
) 120.67 10.05 122.71 9.36 2.03 7.49 0.118
Positive values indicate distal movement, retraction, intrusion, and mesial tipping. P values were obtained by paired t test.

Fig 5. Summary of mean maxillary dental changes after distalization by the MPAP appliance.

variations in the shape and extension of the maxillary
sinus and the alveolar arch, which might have affected
the distalization, and to the differences in the required
amount of distalization in each patient.
Recently, a finite element study has suggested that
application of force through the most apical notch in
the MPAP resulted in bodily movement of the first
molar.27 Therefore, in our study, this minimal amount
of distal tipping might have resulted from using the
occlusal or the middle plate notches in some patients
according to their estimated treatment needs (Fig 1).
In addition, a recent modification of this appliance
had a fourth notch to provide a better range to control
the distal tipping and vertical dimension.26 Since
palatal morphology varies widely in its degree of con-
cavity, anteriority, and sharpness, these 4 notches of
the MPAP allow for adjusting the force vector accord-
ing to the estimated center of resistance of the denti-
tion; this might be difficult to achieve in some
patients.37 Moreover, these notches might also facili-
tate the application of various forces on at least 1
tooth according to the required tooth movement. It

American Journal of Orthodontics and Dentofacial Orthopedics July 2014  Vol 146  Issue 1
52 Kook et al

Table II. Skeletal and soft-tissue cephalometric measurements before and after distalization (n 5 20)
Predistalization Postdistalization Change

Variable Mean SD Mean SD Mean SD P value

SNA (
) 81.18 3.35 80.42 3.22 0.76 1.95 0.097
ANB (
) 4.38 2.11 3.36 1.80 1.01 1.46 0.006
Palatal plane angle (
) 5.96 17.50 9.31 3.08 3.35 16.81 0.384
Occlusal plane to SN (
) 18.78 6.33 21.60 5.94 2.81 3.37 0.001
Mandibular plane angle (
) 23.90 8.96 24.46 9.00 0.55 2.58 0.351
ANS-Me (mm) 67.43 6.01 68.62 6.44 1.19 3.26 0.120
Overjet (mm) 4.71 1.67 3.54 0.90 1.17 1.90 0.013
Overbite (mm) 3.28 1.44 3.16 1.15 0.13 1.64 0.735
Nasolabial angle (
) 98.64 7.69 101.90 8.38 3.26 4.87 0.008
Mentolabial fold (
) 135.53 9.74 133.36 9.02 2.17 6.39 0.145
LS-VRL (mm) 67.22 5.04 66.04 5.01 1.18 1.99 0.016
LI-VRL (mm) 63.70 5.86 62.16 5.87 1.54 2.33 0.008
Pog0 -VRL (mm) 42.38 9.77 41.82 9.92 0.56 2.91 0.398

P values were obtained by paired t test.

Table III. Comparison of amounts of distalization in the maxillary dentition between the third molar extraction and
nonextraction groups
Extraction (n 5 31) Nonextraction (n 5 9)

Variable Mean SD Mean SD P value

Central incisor crown horizontal distance (mm) 3.12 2.86 2.55 2.34 0.594
Central incisor root horizontal distance (mm) 0.08 2.05 1.18 2.08 0.167
Central incisor crown vertical distance (mm) 0.22 1.86 0.73 0.90 0.488
Central incisor root vertical distance (mm) 0.32 1.21 1.34 3.41 0.401
Central incisor inclination (
) 6.37 8.01 5.67 6.60 0.812
Second premolar crown horizontal distance (mm) 3.01 2.22 3.19 1.94 0.824
Second premolar root horizontal distance (mm) 0.19 2.33 0.87 1.73 0.423
Second premolar crown vertical distance (mm) 0.36 3.59 0.34 1.07 0.990
Second premolar root vertical distance (mm) 1.04 3.62 0.09 1.39 0.503
Second premolar angulation (
) 8.69 7.14 7.31 5.71 0.598
First molar crown horizontal distance (mm) 3.23 1.89 3.55 1.54 0.643
First molar root horizontal distance (mm) 2.20 1.87 2.18 1.88 0.976
First molar crown vertical distance (mm) 1.75 1.36 1.73 1.43 0.972
First molar root vertical distance (mm) 1.45 2.11 2.00 1.14 0.512
First molar angulation (
) 3.27 5.78 3.94 6.16 0.765
Second molar crown horizontal distance (mm) 2.52 2.00 3.05 1.60 0.478
Second molar root horizontal distance (mm) 2.22 1.98 1.83 1.74 0.597
Second molar crown vertical distance (mm) 1.14 1.70 1.78 1.21 0.357
Second molar root vertical distance (mm) 1.44 1.59 0.79 0.49 0.085
Second molar angulation (
) 0.58 7.51 4.74 4.10 0.146
Positive values indicate distal movement, retraction, intrusion, and mesial tipping. P values were obtained by independent sample t test.

might be important to conduct further studies to eval-
uate the effect of palatal shape on the force system
used for distalization.
Previous studies showed 3.8 and 3.9 mm of distal
movement of the maxillary first molars using
TSADs.24,36 However, because of a small amount of
distal tipping in our study, the amount of root
movement might be more than that in other studies.
The maxillary molars were also intruded by 1.8 mm,
and the maxillary incisors were extruded by 1.1 mm;
therefore, the occlusal plane angle was increased by
2.8
. The intrusion of the molars during distal
movement could help maintain the anterior facial
height; the ANS-Me difference was 1.19 mm
(P 5 0.12). This is especially important if the patient
has a hyperdivergent growth pattern.
The maxillary incisors were retroclined by 6.2
and
retracted by 3 mm. In agreement, previous studies
showed incisor retroclination in their implant-
supported pendulum appliance groups.38,39 The

July 2014  Vol 146  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Kook et al
mechanics of retracting the entire dentition with
miniscrews might prevent the round tripping
movement of the anterior teeth.
Several authors have suggested that the erupted
second molars create resistance to distalization.40 Gia-
nelly et al41 recommended that the maxillary third mo-
lars should be extracted before distalization of the
posterior teeth. However, in our study, the maxillary
third molars were sometimes left in position during dis-
talization because the patients did not want extractions.
Several studies reported greater distal tipping and higher
movement rates of the maxillary first molars when the
second molars were at the apical third of the first molars
than when the second molars were erupted.2,42,43 In
contrast, several authors reported minimal or no
significant effect of the second and third molars'
eruption status on first-molar movement.3,5,44
However, in these studies, the second or third molars
were either erupted or unerupted, but not extracted.
Therefore, their effect might have been based on their
position inside the alveolar ridge as a fulcrum
opposing the movement of the first molar.
Our results showed no noticeable difference in the
amounts of distalization and tipping between the sub-
jects who had third molars and subjects in whom they
had been extracted. However, these results should be ap-
proached with caution because of the small sample size
of the nonextraction group. Further study evaluating the
effect of the presence of the third molar on total arch
distalization might be recommended.
In this study, the total distalization period was an
average of 12.5 months. Sar et al22 reported that the
average distalization durations were 8.2 months in the
miniscrew-supported distalization system group and
10.2 months in the bone-anchored pendulum appliance
group. Chiu et al4 reported 10 months for distalization of
the molars. The longer distalization time in our study
might have been because the MPAP appliance was
placed for total arch distalization, not just Class II dental
correction.
The MPAP appliance allows for molar distalization
simultaneously with leveling and alignment of the
maxillary dentition. Therefore, the plate should be
installed early in the treatment so that distalization
can start with the molars and then expand to include
the whole dentition via buccal archwires as soon as the
leveling and alignment stage is finished. Moreover, it is
advisable to include the second molars in bonding to
the archwire to prevent any unwanted tooth movement,
such as tip-back caused by distal movement of the first
molar, and to provide efficient movement of the
second molar during full arch distalization. In our study,
the similar degrees of distal tipping of both first and
American Journal of Orthodontics and Dentofacial Orthopedics
53
second molars confirmed this. The MPAP was left in
place after the end of distalization to serve as skeletal
anchorage whenever needed and then was removed at
debonding.
In our study, some of the early subjects, treated when
the MPAP had no screw tubes, showed inflammation
and overgrowth of palatal soft tissues. However, it
resolved soon after removal of the MPAP. In the recent
subjects, the screw tubes decreased the micromovements
of the MPAP; this reduced the irritation to the soft tis-
sues. Hence, no signs of inflammation were noticed. In
addition, the installation of the MPAP resulted in alter-
ation of the pronunciation of some letters in some pa-
tients, but this resolved within 2 weeks without any
intervention.
Further study to evaluate the effect of this appliance
in adolescent patients is also recommended. In addition,
assessment of long-term stability after the retention
period should be considered.
CONCLUSIONS
The maxillary first molar was distalized 3.3 mm at the
crown and 2.2 mm at the root level, with distal tipping of
3.4
and 1.8 mm of intrusion. The MPAP appliance is
effective in minimizing distal tipping and preventing
molar extrusion during distalization. Therefore, it is rec-
ommended that clinicians consider using the MPAP
appliance in treatment planning for patients who require
maxillary total arch distalization.
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