ORIGINAL ARTICLE

Distal movement of mandibular molars in adult

patients with the skeletal anchorage system
Junji Sugawara, DDS, PhD,a Takayoshi Daimaruya, DDS, PhD,b Mikako Umemori, DDS, PhD,b Hiroshi
Nagasaka, DDS, PhD,c Ichiro Takahashi, DDS, PhD,b Hiroshi Kawamura, DDS, PhD,d and Hideo Mitani,
DDS, MS, PhDe
Sendai, Japan
The skeletal anchorage system (SAS) consists of titanium anchor plates and monocortical screws that are
temporarily placed in either the maxilla or the mandible, or in both, as absolute orthodontic anchorage units.
Distalization of the molars has been one of the most difficult biomechanical problems in traditional
orthodontics, particularly in adults and in the mandible. However, it has now become possible to move
molars distally with the SAS to correct anterior crossbites, maxillary dental protrusion, crowding, and dental
asymmetries without having to extract premolars. This study evaluated the treatment and posttreatment
changes during and after distalization of the mandibular molars. In 15 adult patients (12 women and 3 men),
a total of 29 mandibular molars were successfully distalized with SAS. The amount of distalization and
relapse and the type of tooth movement were analyzed with cephalometric radiographs and dental casts. The
average amount of distalization of the mandibular first molars was 3.5 mm at the crown level and 1.8 mm at
the root level. The average amount of relapse was 0.3 mm at both the crown and root apex levels. Of 29
mandibular molars, 9 were tipped back, and the others were translated distally in accordance with the
established treatment goals. SAS is a viable modality to move mandibular molars for distally correcting
anterior crossbites, malocclusions characterized by mandibular anterior crowding, and dental asymmetries.
(Am J Orthod Dentofacial Orthop 2004;125:130-38)

he distal movement of mandibular molars is

recognized as one of the most difficult-toachieve treatment objectives in clinical orthodontics; it is much more difficult than the distalization
of maxillary molars.1 Until now, several biomechanical
strategies have been proposed to move the mandibular
molars distally, eg, mandibular headgear,2 lip
bumper,3,4 distal extension lingual arch,5 Jones jig,6
Franzulum appliance,7 and multiloop edgewise archwire.8 However, most of these appliances have not been
widely used, especially in adult treatment, because the
amount of molar distalization achieved depends on
patient cooperation. Although a distal extension lingual
From the Graduate School of Dentistry, Tohoku University, Sendai, Japan.
a
Associate professor, Division of Orthodontics and Dentofacial Orthopedics.
b
Research associate, Division of Orthodontics and Dentofacial Orthopedics.
c
Research associate, Division of Maxillofacial Surgery.
d
Associate professor, Division of Maxillofacial Surgery.
e
Professor and chairman, Division of Orthodontics and Dentofacial Orthopedics.
This research was supported by grant-in-aid #12671985, Ministry of Education,
Culture, Sports, Science and Technology, Japan.
Reprint requests to: Dr Junji Sugawara, Tohoku University Graduate School of
Dentistry, Division of Orthodontics and Dentofacial Orthopedics, 4-1, Seiryomachi, Aoba-ku, Sendai 980-8575, Japan; e-mail, sugahara@mail.cc.
tohoku.ac.jp.
Submitted, September 2002; revised and accepted, February 2003.
0889-5406/$30.00
Copyright 2004 by the American Association of Orthodontists.
doi:10.1016/S0889-5406(03)00682-6

130

arch does not require patient cooperation, the type of

tooth movement is mostly that of tipping. In distalization with the Jones jig or Franzulum appliance, reciprocal forces cause anchorage loss and protrusion of the
anterior teeth. A multiloop edgewise archwire technique has also been used to distalize the mandibular
molars, but again by tipping rather than bodily movement. In addition, the patient must use short Class III
elastics so that the mandibular incisors do not become
flared.
Recently, a skeletal anchorage system (SAS) has
been developed that uses pure titanium anchor plates
and screws as absolute orthodontic anchorage units.9-12
The anchor plates are monocortically placed at the
piriform opening rim, the zygomatic buttresses, and any
regions of the mandibular cortical bone. Because the
anchor plates work as the onplant and the screws
function as the implant, SAS enables the rigid anchorage that results from the osseointegration effects in both
the anchor plates and screws. In addition, because all
portions of the anchor plates and screws are placed
outside the maxillary and mandibular dentition, the
SAS does not interfere with tooth movement. Therefore, it is possible to distalize the mandibular molars
with anchor plates placed at the anterior border of the
mandibular ramus or mandibular body. Distalization of

Sugawara et al 131

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 125, Number 2

Table I.

Sample characteristics

Patient no.

Sex

Age

Treatment
period
(mo)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

F
F
F
F
M
M
F
F
F
F
M
F
F
F
F

38 y 7 mo
21 y 7 mo
28 y 11 mo
36 y 5 mo
20 y 1 mo
24 y 6 mo
43 y 6 mo
27 y 9 mo
30 y 5 mo
16 y 10 mo
15 y 11 mo
22 y 10 mo
23 y 8 mo
16 y 1 mo
32 y 0 mo

30
35
36
25
39
24
33
19
27
31
30
29
27
21
27

Anteroposterior
jaw relationship
Class
Class
Class
Class
Class
Class
Class
Class
Class
Class
Class
Class
Class
Class
Class

III
III
I
II
II
III
III
III
III
III
III
III
III
III
I

Extraction of
lower third
molars

Chief
complaint

Procedure
for retention

Rs/Ls
Rs/Ls
Rs
CM
Rs/Ls
Rs
Rs/Ls
CM
CM
Rs/Ls
Rs/Ls
Rs/Ls
Rs/Ls
Rs
Rs/Ls

Crowding
Crowding
Crowding
Crowding
Crowding
Asymmetry
Crowding
Crossbite
Crossbite
Crowding
Crowding
Asymmetry
Crowding
Crossbite
Crowding

LBR
LBR
LBR
LBR
LA " LBR
LBR
LA " LBR
LBR

LBR
LBR
LBR
LBR
LBR
LBR

F, Female; M, male; Rs, right side; Ls, left side; CM, congenital missing; LBR, lingual bonded retainer; LA, lingual arch.

the mandibular molars enables the clinician to correct

anterior crossbites, mandibular incisor crowding, and
mandibular dental asymmetry without extracting premolars.
Until now, because there have been only a few
clinical studies involving the distalization of mandibular molars,2-8 little information has been available
regarding the type of tooth movement that occurs, the
limitations of distal movement, and posttreatment stability. Joondeph and Riedel13 believed that posttreatment stability is not a separate problem in orthodontics
but one to be considered in diagnosis and treatment
planning. Thus, it is as important to investigate the
posttreatment stability of distalized mandibular molars
as it is to demonstrate the overall effectiveness of this
procedure.
The aims of the present study were (1) to measure
the average amount of distalization of the mandibular
molars, (2) to evaluate the type of tooth movement that
occurs, and (3) to determine the stability of the distalized molars 1 year posttreatment.
MATERIAL AND METHODS

Fifteen adult patients (12 women and 3 men) who

had undergone orthodontic treatment in Tohoku University Dental Hospital, Sendai, Japan, were selected as
subjects in this study. All of them satisfied the following criteria for case selection: (1) diagnosed as having
no severe skeletal disharmonies, (2) sufficient space
behind the second molar for the application of mandibular molar distalization, (3) treated by distalization of 1
mandibular first molar, and (4) followed for at least 1
year posttreatment. The sample characteristics are

shown in Table I. The most common chief complaint of

these patients was mandibular incisor crowding. The
average age of the patients at the beginning of treatment
was 26.9 years and ranged from 16.1 to 43.5 years. The
average treatment period was 28.9 months, ranging
from 21 to 39 months.
The anchor plates (Leibinger, Muhlheim-Stelten,
Germany) (Fig 1, A), made of pure titanium, were
placed behind the second molars at the anterior border
of the mandibular ramus, as shown in Figure 1, B-D.
Implantation was performed under local anesthesia, and
the titanium plates were secured with pure titanium
screws10 (Leibinger) (Fig 1, B). The diameter and the
length of the monocortical screws were 2.0 and 5.0
mm, respectively (Fig 1, A).
The 2 fundamental methods of applying distalizing
forces to the subjects in this study are shown in Figure
2. One is for single molar distalization (Fig 2, A).
Extraction of the third molars is needed to create the
space for the molar distalization. After the buccal
segments are leveled and aligned, stiff archwires (.018
! .025-in or .019 ! .026-in stainless steel) are engaged, and the L-shaped anchor plates are placed at the
anterior border of the mandibular ramus. Then the
bands or brackets of the first molars are taken off, and
a retractive force is applied to the second molars with
an open coil spring. To avoid the side effects of the
reciprocal coil spring, the first premolars must be firmly
ligated with anchor plates. After the distalization of the
second molars, distalization of the first molars is done
with the same procedure.
The other method used is en masse distalization of
the entire buccal segments (Fig 2, B). The procedures

132 Sugawara et al

American Journal of Orthodontics and Dentofacial Orthopedics

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before distalization are the same as those for the single

molar distalization, but the mechanics are less complex.
Direct retractive force is applied from the anchor plates
to the first premolars to perform en masse distalization
of the buccal segments. Elastic modules or nickeltitanium closed coil springs usually provide the retractive orthodontic force.
After debonding, retention consisted of a lingual
bonded retainer with .0175-in multistranded flexible
wire on lingual surfaces of the mandibular anterior
teeth. The method for retention used in each subject is
indicated in Table I.
Lateral cephalometric radiographs, panoramic radiographs, photographs, and dental casts were taken
immediately before treatment, at debonding, and 1 year
after debonding. Cephalometric radiographs were
traced, and then mandibular tracings were carefully
superimposed on the detailed anatomic structures (ie,
inferior alveolar canals and fine structures in the symphysis).14,15 The left and right molars are distinguished
on the cephalograms by referring to the panoramic
radiographs.
The occlusal surfaces of the mandibular dental casts
were photocopied perpendicularly to the mandibular
occlusal plane, and occlusograms16 were produced by
tracing the outlines of all teeth. The occlusograms were
magnified by 1.06 to adjust to the magnification of the
cephalometric tracings. In aligning the edge of the
incisors and the midline of the mandibular occlusograms, the superimposed mandibular tracings and the
occlusograms were combined to analyze the type of
molar movement 3-dimensionally. Then the posterior
displacement of the medial surfaces of the first molars
was measured with calipers at a precision of 0.1 mm, as
shown in Figure 3. The amount of posterior displacement at the crown and root levels was measured on the
occlusograms and the cephalometric tracings, respectively. The type of tooth movement was evaluated by
the crown and root movement ratio. When the percentage ratio of the root movement to the crown movement
(the tipping ratio) was less than 25%, the type of tooth
movement was determined to be tipping. All cephalometric tracings and measurements were performed by a
single researcher (T.D.), and the intraindividual method
error did not exceed 0.2 mm.
The correlation between the amount of posterior
displacement at the crown level, the tipping ratio, and
Fig 1. Basic components of SAS and required surgical
procedures. A, Titanium anchor plates and monocortical bone screws; B, surgical procedure; C, intraoral
photograph of implanted anchor plate; D, panoramic
radiograph of implanted anchor plate.

American Journal of Orthodontics and Dentofacial Orthopedics

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Sugawara et al 133

Fig 2. Two fundamental mechanical modalities for mandibular molar distalization. A, Distalizing
force is applied to mandibular molars by ligating between stiff archwires (.019 ! .026-in stainless
steel) at premolar regions and first hook of miniplate, and open coil spring is placed between molars
and premolars; B, elastic modules are tied to first hook of miniplates and brackets to load distalizing
force on buccal segment with passively ligated stiff archwire (.019 ! .026-in stainless steel).

the amount of relapse was statistically analyzed. A

paired t test was applied for the statistical analysis for
comparison between the position of the mandibular first
molars at debonding and at 1 year posttreatment.
RESULTS

The results of this study are shown in Table II. The

average amount (# standard deviation) of distal movement was 3.5 # 1.4 mm at the crown level. The
maximum amount of distalization at the crown level
was 7.1 mm, and the minimum was 1.0 mm at the first

molar. The amount of root movement was 1.8 mm, on

average. In 2 of the 29 first molars, the roots moved
forward. The average tipping ratio was 46.3%. Although most of the first molars showed bodily movement, 9 of 29 molars showed tipping movement, in
which the tipping ratios were less than 25% (Table II).
The calculated correlation coefficient between the tipping ratio and the amount of distalization was 0.33,
which was not statistically significant (P $ .01).
The amount of relapse in the mandibular first
molars is shown in Table II. The average amount and

134 Sugawara et al

American Journal of Orthodontics and Dentofacial Orthopedics

February 2004

was to maintain the anteroposterior position of the

mandibular incisors by distalization of the molars and
lateral expansion of the buccal segments. To achieve
this treatment goal, 2 titanium anchor plates were
placed at the anterior border of the bilateral mandibular
ramus.
A multibracket system was applied, and the molars
were uprighted and distalized with SAS mechanics, as
shown in Figure 4, A. After 36 months of active
treatment, the appliances and the anchor plates were
removed. The patient was then given a wraparound
retainer for the maxillary dental arch and a lingual
bonded retainer for the mandibular anterior teeth. The
amount of distal movement of the mandibular first
molars was 7.1 mm on the left and 5.5 mm on the right.
The treatment goal was almost achieved, as shown in
Figure 4 B, D, and E. Both mandibular molars were
uprighted to the appropriate inclination, and a desirable
occlusion was obtained (Fig 4, D). Although the mandibular right first molar relapsed 1.0 mm by the 1-year
follow-up, the left molar, which showed the maximum
amount of distalization, was very stable, showing no
relapse.
DISCUSSION

Fig 3. Method to measure amount of mandibular molar

distalization. Superimposition of mandible on occlusogram. C, crown movement; R, root movement.

rate of relapse 1 year posttreatment were 0.3 mm and

9%, respectively. No statistically significant differences
were observed in the position of the first molars
between the time of debonding and 1 year posttreatment. Maximum relapse was 0.8 mm, and the maximum relapse rate was 40%. No statistically significant
correlation between the relapse rate and the amount of
posterior displacement or tipping ratio at the first
molars was observed.
Figure 4 shows the intraoral photographs and composite superimpositions of the occlusograms and tracings in patient 3, who had the maximum amount of
molar distalization among all subjects in this study.
This patient was a 36-year-old Japanese woman who
complained of a high maxillary left canine (Fig 4, A)
and bilateral linguoversion of the mandibular second
premolars (Fig 4, C). She had no skeletal but many
dental problems (crowding, a Class II molar relationship, a large overjet, a missing maxillary right canine, a
mesial rotation, and tipping of the mandibular first
molars). The treatment goal in the mandibular dentition

Numerous extraoral and intraoral mechanical modalities have been proposed for distalizing maxillary
molars,17-30 but only a few have been reported for
mandibular molars.2-8 Each previously reported mechanism has a disadvantagethe need for patient cooperation, tipping movement, anchorage loss, and flaring
of the incisors. In addition, it was more difficult to
distalize mandibular than maxillary molars.1
Therefore, clinical attention has been focused on
the use of endosseous implants to provide rigid, intraoral anchorage units for distalizing mandibular molars. However, neither the design of the implant itself
nor the position for implantation has been practical for
distalizing the mandibular molars, because the implant
disturbed tooth movement or became loose because of
the heavy force necessary for molar distalization in the
alveolar bone. Only Jenner and Fitzpatrick31 reported a
patient in whom skeletal anchorage was applied with
surgical bone plates to move a mandibular molar
distally.
Accordingly, we recently proposed the SAS, a safe
and useful system for skeletal anchorage that uses
titanium anchor plates and monocortical titanium
screws, which provide rigid anchorage units for distalizing the mandibular molars.9,12 The monocortical bone
screws in the SAS are fixed on the anterior border of the
mandibular ramus or the mandibular body beyond the
root apices or outside the alveolar region and never

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American Journal of Orthodontics and Dentofacial Orthopedics

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Table II. Tooth position at debonding and 1 year posttreatment and amount of relapse and mode of tooth
movement

Side

Crown

Root

Position of tooth
at 1 y
posttreatment
(mm)

R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
R
L
R
L
R
L
R
L
R
L
R
L

3.0
2.0
4.5
3.5
5.5
7.1
2.7
1.0
3.0
5.0
4.3
1.7
3.0
3.0
2.0
4.2
3.3
4.0
4.8
4.6
2.0
5.7
2.6
3.3
3.4
3.4
1.6
2.0
4.0
3.5
1.4

3.0
0.0
3.8
1.8
4.0
3.2
2.1
0.0
2.2
1.0
2.0
0.0
3.0
0.0
0.0
0.0
2.8
3.5
4.2
3.6
1.6
1.6
%0.7
1.8
1.5
2.4
%0.4
1.0
2.3
1.8
1.4

3.0
1.5
4.2
3.5
4.5
7.2
2.7
0.6
3.0
4.2
3.7
1.5
3.0
3.0
2.0
4.2
2.6
3.5
4.8
4.1
1.7
5.7
2.0
3.3
3.2
2.4
1.6
2.0
3.5
3.2
1.4

Tooth position at
debonding (mm)
Patient no.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Average
SD

Tipping
ratio
(%)
100.0
0.0
84.4
51.4
72.7
45.1
77.8
0.0
73.3
20.0
46.5
0.0
100.0
0.0
0.0
0.0
84.8
87.5
87.5
78.3
80.0
28.1
%26.9
54.5
44.1
70.6
%25.0
50.0
57.5
46.3
38.7

Relapse (mm)
Mode of tooth
movement
Translated
Tipping
Translated
Translated
Translated
Translated
Translated
Tipping
Translated
Tipping
Translated
Tipping
Translated
Tipping
Tipping
Tipping
Translated
Translated
Translated
Translated
Translated
Translated
Tipping
Translated
Translated
Translated
Tipping
Translated
Translated

Crown

Relapse
ratio (%)

0.0
%0.5
%0.3
0.0
%1.0
0.1
0.0
%0.4
0.0
%0.8
%0.6
%0.2
0.0
0.0
0.0
0.0
%0.7
%0.5
0.0
%0.5
%0.3
0.0
%0.6
0.0
%0.2
%1.0
0.0
0.0
%0.5
%0.3
0.3

0.0
25.0
6.7
0.0
18.2
%1.4
0.0
40.0
0.0
16.0
14.0
11.8
0.0
0.0
0.0
0.0
21.2
12.5
0.0
10.9
15.0
0.0
23.1
0.0
5.9
29.4
0.0
0.0
12.5
9.0
11.0

R, Right; L, left; SD, standard deviation.

Patient 9 showed asymmetric dentition; left molar was in exact position, so only right molar was distalized.

interfere with the root movement in orthodontic therapy. The SAS has 2 more outstanding advantages not
provided by the other mechanisms for distalizing the
mandibular molars. First, it is possible to intrude the
mandibular molars with the SAS. Therefore, the extrusion of the mandibular molars after the tipping of the
molar distalization can be corrected easily. Second, en
masse distalization of the mandibular buccal segments
or the entire dentition is also possible if the mandibular
dentition is fundamentally well aligned. These advantages simplify the orthodontic procedures and significantly reduce the orthodontic treatment period.
The previously reported mechanotherapies2-8 could
distalize the mandibular molars to some extent, but the
amount of molar distalization was quite limited, and the
mandibular molars could seldom be translated distally
with those mechanisms. As the results of this study

have shown, the SAS enables tooth movement to be

controlled 3-dimensionally, so that treatment goals can
be accomplished, even when the amount of tooth
movement required is more than the mesiodistal width
of the premolars. Consequently, with the SAS, it is not
always necessary to extract the mandibular first or
second premolars, even in patients with moderate to
severe crowding. Also, the molar relationship in patients with symmetric or asymmetric Class III molar
relationships can be corrected without having to extract
mandibular premolars.
The SAS might require dentists, especially orthodontists, to reconsider their thinking regarding arch
length discrepancy, space analysis, and tooth extraction criteria as they have been described in the
orthodontic literature.32,33 Traditionally, the arch
length deficiency has been calculated anterior to the

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American Journal of Orthodontics and Dentofacial Orthopedics

February 2004

Fig 4. Intraoral photographs (A-D) and superimposition of mandibles and occlusograms (E) of
patient treated with SAS. Intraoral photographs at initial treatment (A, C) and at debonding (B, D).
Note change in molar relationship shown in C and D. Arrowheads indicate lingual bonded retainer.
Solid line in E: at initial treatment in left panel and at debonding in right. Dotted line in E: at
debonding in left panel and 1 year posttreatment in right.

first molars because molar distalization was assumed

to be nearly impossible. However, by using the space
posterior to the second molars, 14 permanent teeth
can be well aligned in the alveolar bone, as demonstrated by the present study. Therefore, it will now

become necessary to find an indicator to determine

the posterior limits of the alveolar region from the
standpoints of orthodontics, anatomy, and periodontology. For example, the location of the mandibular
third molars should be a very useful indicator for

American Journal of Orthodontics and Dentofacial Orthopedics

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judging the posterior limit of the alveolar bone in the

mandibular dentition. But even in treatable cases, the
condition of oral hygiene around the distalized molars should be predicted before treatment.
The posttreatment stability of tooth movement
has also been an important issue in orthodontics. The
short-term relapse in the distalized mandibular molars in this study was minimal and was not correlated
with the amount of distalization. Previously, the
tendency has been that, the larger the amount of
tooth movement and the more the teeth are tipped,
the greater the relapse.13 However, no significant
correlation was found between the amount of relapse
and the tipping ratio and the amount of tooth movement in the present study. It was apparent that the
type of tooth movement could be well controlled
according to the treatment goal to achieve long-term
stability. It could well be that the achieved occlusion
is a contributing factor in maintaining the tooth
position. Another reason for the remarkable posttreatment stability might be that the shape of the
dental arch is not changed excessively and therefore
does not disrupt the balance to keep equivalence
between the perioral muscles and tongue function.
The SAS can be used to distalize the mandibular
molars; thus, it is not necessary to expand the
mandibular arch excessively. Because SAS treatment
is a symptomatic rather than a causal treatment,
further research is needed to verify its long-term
stability.
CONCLUSIONS

The SAS is a new and viable modality for distalizing mandibular molars. It enables en masse movement
of the mandibular buccal segments and even the entire
mandibular dentition with only minor surgery for placing the anchor plates at the anterior border of the
mandibular ramus or the mandibular body. Therefore,
this new technique is particularly effective for the
correcting Class III malocclusions, mandibular incisor
crowding, and dental asymmetries; it rarely requires the
extraction of the premolars.
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