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Treatment Planning and Sequence Phase Sequences Phase I: Space-Gaining Phase Upper Arch Lower Arch

Evolution of the Technique

Comparison of Two Distalization Methods: Pendulum versus Palatal Bar Plus Pendulum Molar Uprighting and Vertical Control after Distalization with the Pendulum Segmental Alveolar Corticotomy to Enhance Upper Molar Distalization Phase II: Space Utilization


Extractionists and nonextractionists still debate the best way of

treating an orthodontic malocclusion with crowding, but clinical

research has thus far failed to demonstrate that one treatment is better than the other.

No difference in terms of the final dental and facial aesthetic result,

functional result and stability, because of the great variability and unpredictability from patient to patient.

Nonextraction approach that is divided into two phases:

Space-gaining phase
Space-utilization phase

Treatment Planning and Sequence

The objectives of the first phase are:

To increase space and change the original malocclusion into a

super Class I malocclusion. Molar rotation, inclination, and crossbite are corrected, and the curve of Spee is leveled.

The objectives of the second phase are:

To achieve Andrews six keys to normal occlusion . Overbite, overjet, and all dental malpositions are corrected. The final objective is a mutually protected occlusion with canine and incisal guidance.

This approach is most suitable for treating Class I and II

malocclusions with upper and lower crowding.

The best patients are those who are growing and who are in the late mixed dentition stage because this stage offers several advantages:

The leeway or E space is still available.

Facial growth is at its peak. Tissues respond better to mechanical deformation and remodel

more quickly.

Patient compliance is usually good.


The Cetlin approach were used to gain space and, in a growing

patient, allow growth to reach its potential.

Gaining space in the upper and lower arch is the key phase of any nonextraction treatment.

The objectives of this initial part

Correction of molar inclination, rotation, and crossbite Overcorrection of molar relationship Generalized spacing in both the upper and lower arch.

10 ways to create space in an arch via orthodontics

Distolateral rotation of mesially rotated and constricted upper

molars (found in most of Class I and II malocclusions with crowding)

Distalization of upper molars (in both Class I and II malocclusions)

Distal and buccal uprighting of lower molars (as leveling of the curve of Spee occurs)

Distal rotation of ovoid premolars

Maintenance of the leeway space

Modification of the arch width (orthopedic/ orthodontic transverse

increase in the maxilla)

Modification of the archform (an initial constricted, tapered archform needs to be changed)

Selective stripping on trapezoid teeth or teeth with interproximal

fillings or teeth with abnormal anatomy.

Incisor repositioning (depending on periodontal, aesthetic, skeletal,

and dental features of the patient)

Extraction of teeth (the last option)

Phase I: Space-Gaining Phase

Space was gained in the upper arch through the use of three


The Palatal Bar (PB): helped to correct maxillary constriction, rotation, distalization, and torque of both first and second upper molars; it also controlled them vertically.

The Extraoral Forces were used to control the roots and the vertical dimension of the upper molars.

The removable Cetlin Plate, with two distalizing springs against the first molars, tipped the crowns distally while maintaining a good control of anterior anchorage.

Palatal Bar
The PB was introduced by R. H. Goshgarian as an anchorage

appliance. Cetlin modified it as removable tooth-moving appliance.

The PB is made of a 0.036-inch SS wire, doubled back at the ends to be inserted in a 0.036- 0.072-inch horizontal lingual sheath.

lingual sheaths have an 8-degree mesial offset that facilitates

insertion and removal of the PB

A gingival hook help to tie back the PB and aid in insertion of intraarch or interarch elastics.

The U-shaped coffin loop is positioned generally toward the mesial

for two reasons:

To make the PB more comfortable and To incline molar roots distally because of forces exerted by tongue during speech and swallowing anterior to the center of resistance (CR) of molars.

The loop is left distal if intrusive force is desired posterior to the center of resistance to tip molar crowns distally.

Uses of PB


Expansion or constriction Vertical control Torque Anchorage reinforcement


Distalization is done with only unilateral activation of the PB. It can

be used in two clinical situations:

Class II molar relation on one side When both upper molars must be distalized and the patient does not want to wear headgear

In unilaterally Class II cases, rotation on the Class I side is controlled with a headgear with an inner bow that has a toe-out or an edgewise wire extended at least to the controlateral premolar.


Distal rotation of upper molars may gain as much as 3 mm of space

per side

If the palatal cusps still seat in the central fossa, the faulty molar relationship is easier to correct; however, if occlusion occurs mesial

to the central fossa, the Class II molar relationship is more difficult

to solve.

Rotation of Upper 2nd molars should be corrected because it

facilitates distalization of the first molars.

Expansion or Constriction

Transverse corrections should be made before rotating or distalizing

the molars.

Activation should be in the range of 1.0 to 1.5 mm of expansion or constriction per side and per activation until the problem has been


Lateral movement of upper molars can be either coronal tipping or bodily movement. If bodily movement is required, buccal-root torque

(when expanding) or lingual-root torque (when constricting) must be


Vertical Control: Intrusion

The PB, alone or with a high-pull headgear, can be used to take

advantage of the intrusive force exerted by the tongue during

chewing, swallowing, and speech.

The PB is kept low in the oral cavity, 4 or 5 mm away from the

palatal vault.

To increase the surface on which the tongue will be acting, two extra loops or an acrylic button can be added to the Coffin loop.


The PB allows an excellent control of upper molar torque. Buccal

root torque is more often required because it helps keep palatal

cusps high and away from occlusal interference.

If control of the extrusive component is needed, the PB should be

kept low and/or a high-pull headgear could be added to upper



After space has been created, control of the upper molars is crucial.

In this biomechanical sequence, three-dimensional control is

achieved with the BP alone or with the use of extraoral forces.

Extra-oral Forces
During the space-gaining phase, headgear was applied with the

PBs and eventually with the removable plate to distalize upper

molars in a bodily fashion.

During the second phase, when the spaces were used to finish up

the case, extraoral forces helped to maintain posterior anchorage.

Occipital Force

High-pull (occipital force) headgear traction force was exerted from

above the occlusal plane and thus had both distalizing and intrusive

The high pull was applied to upper first molars by means of a

facebow with the outer bow of the same length of the inner bow.
The inner bow was passive to the molar tubes; the outer bow was bent upward so that the point of force application and the line of

force lay above the upper molar center of resistance.

Cervical force

The cervical gear traction force was exerted from below the occlusal

plane and had extrusive as well as distalizing effects.

The appliance consisted of a facebow in which the outer bow was longer than the inner bow and was bent upward so that both the

point of force application and the line of force lay above the upper
molar center of resistance.

When this appliance was combined to the removable plate, the

molars were moved bodily backward and downward.

Clinical Management of Headgear

Extraoral forces were applied to upper first permanent molars as

soon as the molars had been rotated with PBs, when facebows
could be easily inserted into molar tubes.

When headgear was used together with a PB, the inner bows had

to be passive to molar tubes.

When the headgear was used alone, the inner bows of high-pull device should have been slightly constricted, whereas those of low

pull should have been expanded to prevent the upper molars from
rolling out or in.

Facebows had to lie on lower lip. This confirmed that desired

moment was being applied to the molars.

If the facebow had two canine hooks on their inner bows, a light elastic (L10) could be applied to fit on the labial screen of

the Cetlin plate to increase anterior anchorage.

Extraoral forces had to be about 150 g per side to exert orthodontic and not orthopedic effects. The devices had to be

worn at least 12 to 14 hours a day.

The Removable Distalizing Plate

The removable distalizing plate was used to continue distalization of

the upper molars when a super Class I relationship could not be

obtained using only PBs and headgear.

This plate was designed to apply a gentle, constant force of

approximately 30 g to the upper first permanent molars with minimal

reaction on the upper front teeth.

However, its forces might tend to incline molar crowns distally and

extrude the molars. For this reason, it always had to be used in

conjunction with an extraoral force to control molar roots, ensure vertical control, and thus obtain the desired distal bodily movement

of the molars.

Components of active plate

The active part: Two 0.028-inch SS distalizing springs with arms

that lay against the mesial surface at the gingival level of the U6s.

The retention part: An anterior 0.017- 0.025-inch arch covered by a labial screen and having two Adams clasps on the first premolars

or the first deciduous molars.

The anterior bite plane: Disclusion aids in the distal movement of the upper molars and in the leveling of the curve of Spee by the lip


Clinical Management of the Distalizing Plate

The distalizing plate had to be worn 24 hours a day except for

meals and hygiene. It always had to be used with the extraoral force
to control molar roots and obtain a distal bodily movement.

An activation of 2.0 to 2.5 mm per side gave approximately 30 g of

distal force either bilaterally or adjusted on alternate sides, as it was

done with the PB.

After the first permanent molars have been brought to a super Class

I relationship, the Adams clasps and the acrylic palatal to the

canines and first premolars was trimmed to allow spontaneous distal movement of these teeth through the action of the transeptal

fibers, with no strain on the anchorage.

Retention was then provided by the labial shield, which was relined with cold-cure acrylic.


Lower arch

Space gaining in the lower arch was gained with the lip bumper.

Dentoalveolar widening occurred through a combination of

uprighting and lateral growth of the dental arches and alveolar bone.

Lip bumper could change the neuromuscular factors that determine

the form and the dimension of the lower arch, create space by lateral dentoalveolar growth, and allow spontaneous reduction of

the lower crowding and of the curve of Spee.

Lip bumper gave support to the lower lip, improving lip competence,

which was an important factor in mandibular growth.

The lip bumper transmitted lower lip force to the lower molars, allowing achievement of upright positioning and rotation.

The objectives of the first phase of Cetlins nonextraction approach

in the lower arch were

Rotations correction and upright positioning of the lower molars Leveling of the curve of Spee Encouraging lateral growth of the arch and Creating space to align all the teeth.

The lip bumper is a fixed functional orthodontic appliance. It works

by altering the equilibrium between cheeks, lips and tongue and by

transmitting forces from perioral muscles to the molars.

The lip bumper has been used for various purposes:

Molar anchorage
Therapy of habits Space gaining in the lower arch

Characteristics of the Lip Bumper

Two molars bands cemented to first or second molars with 0.045-

inch tubes.

4-degree mesial offset to facilitate insertion and a step-out to prevent gingival impingement.

Removable part: composed by of 0.045- inch SS wire.

Loops: two at the molar level and two at the canine level in modified form. The two additional loops give a better shielding effect in the canine region and allow the use of Class III elastics in more severe cases.

Fitting the Lip Bumper

The lip bumper must keep cheeks and lip away from the lower

dentoalveolar area.

It should be wider buccally and flatter anteriorly the natural archform is desired..

The lip bumper should not exert any expansion or contraction on the molars.

Guidelines for obtaining an optimal adaptation of the appliance:

Transverse position: The wire must be 2.0 mm from the lower

canines and 3.0 to 4.0 mm from the premolars. Protection of the canine area is crucial.

Sagittal position: The lip bumper should not be more than 1.0 to 2.0 mm away from the labial surface of lower incisors.

Vertical position: In the lateral segments, the wire must be positioned generally at the middle third of premolar and canine crowns. If good vertical control is necessary, the bumper can be adapted to rest deeper in the vestibule.

The bumper can be positioned at three different levels with respect

to the incisor crowns, depending of overbite.

Incisal edge: this position usually is used during the initial phase of

treatment. It helps to upright mesially inclined molars.

Middle third: this is the position to use when a shielding effect on

incisors is desired. The lower lip is kept away from the teeth,
altering the equilibrium in favor of the tongue.

Gingival level: this level is used when the orthodontist does not

want to alter the equilibrium forces. Because the incisors are still
under the lower lip action, they maintain their position. The lip bumper must be kept very close to the incisors.

Activating the Lip Bumper

Lip bumper can be activated to correct the rotation of the lower


A slight lingual bend is placed in one terminal (or both, if necessary), adding approximately 1.0 mm of expansion to

counteract the lower molar tendency to tip lingually.

To prevent any change in the activation, the bumper is tied in with an elastic chain.

In a few circumstances, the appliance can be expanded if the lower

molars are lingually inclined.

Clinical Management of the Lip Bumper

The appliance must be worn 24 hours a day and should be

removed only for meals and hygiene.

If cooperation is a problem, the appliance can be tied to molar hooks with an elastic chain.

If the appliance has been well fitted, a red line can be seen on the
inside of the cheeks and the lower lip where the wire runs.

If the lip bumper is too distant from the teeth, ulcers may appear. In

such cases, the appliance is removed for a day or two, lesions heal,
and treatment is restarted with an appliance that runs closer to the teeth.

The patient may be given a card showing the positions of the two
terminals and should be advised always to check these positions before inserting the appliance..

Class III Mechanics

If the upper arch has been overcorrected and the upper molars are

in super Class I relationship but space is still needed in the lower

arch, the lip bumpers action can be enhanced by the use of light (2 to 3 ounces per side) Class III elastics that are driven from upper

first molars to the bumpers hooks at the canine level.

Anchorage on the upper molar can be controlled with a PB, an extraoral force, or both.

Evaluation of the Technique

Limitations of Cetlin mechanics.

The distalizing plate: Need full-time wear to obtain a bodily

movement of the upper permanent molars.

Continuous disclusion between the two arches is necessary to achieve mandibular growth, leveling of the lower curve of Spee, and lateral dentoalveolar growth in both the upper and lower molar/premolar area, and

The headgear has often been a difficult-to-accept appliance.

Various modifications have been done to overcome these problems

of compliance.

The Pendulum Appliance presented by Dr. Hilgers has replaced the Cetlin Distalizing Plate and, partly, the headgear.

Comparison of Two Distalization Methods: Pendulum Versus Palatal Bar Plus Pendulum
A clinical study has been carried out at the University of Ferrara

Aim was to find out whether the combination of the two appliances,
first the PB to rotate distolaterally and then the pendulum to distalize the upper first molars, could lead to more bodily movement

and therefore minor loss of anterior anchorage , and

To verify whether the use of a PB prior to the application of a pendulum would result in less extrusion and better vertical control of

the permanent molars.

The study group consisted of 20 consecutively treated patients

whose nonextraction therapy was started with a PB and continued

with a pendulum to attempt a bodily distal movement of the same teeth. The pendulum used in this group had bonded occlusal rests

only on the upper first premolars.

The control group consisted of patients treated with the Hilgers

pendulum alone. Lateral cephalograms were taken before (T1) and

immediately after (T2) distalization.

The T test of the cephalometric data revealed that only the

measurement of inclination of the molar axis was significantly

altered during distalization in both patient groups.

The use of the PB to initiate molar movement reduced the anterior

anchorage needed since the modified pendulum bonded only on the

first premolars and produced the same anchorage loss of the classically pendulum designed on all four upper premolars.

Moreover, the combined use of PB and modified pendulum gave a

better molar vertical control and a faster distalization of the lateral upper segment (molars plus premolars).

Molar Uprighting and Vertical Control After Distalization with the Pendulum
The distalization of the upper molars with the intraoral distalizing

appliances may produce molar distal tipping and extrusion.

These undesirable effects are corrected with a PB with a large biscuit-like acrylic button around the Coffin loop .

The appliance is kept in place until molars are uprighted, the

marginal ridges discrepancy is corrected, and vertical molar control is recovered.

In another study conducted at the University of Ferrara, growing

patients (mean age, 9.5 to 13.8 years) with Class II malocclusions

treated with an initial palatal bar, a pendulum, and a PB with this large acrylic button to control molars were analyzed on


Results have shown that ANB and Sn-GoGn decreased on average, respectively, 3.32 and 1.3 degrees.

Segmental Alveolar Corticotomy to Enhance Upper Molar Distalization

Corticotomy has long been used in orthodontic treatment to

accelerate dental movement and improve its efficacy, and to reduce

the appearance of undesired phenomena such as root resorption, loss of vitality and relapse of the corrections carried out.

Suya suggested that most of the therapeutic procedures be carried

out in the first 3 to 4 months, before fusion of the tooth-bone units.

In 2001, Wilcko et al published a case report in which corticotomy

was used in conjunction with resorbable alloplastic grafts of

demineralized freeze-dried bone.

They found that the fast orthodontic tooth movement was due to a

cascade of physiological events (area of transitory secondary

osteoporosis and greatly reduced bone density) described by Frost as regional accelerated phenomena (RAP).

The protocol consisted of an initial phase of leveling and aligning

(straight-wire appliance with 0.022 slot) up to a 0.018- 0.025-inch

SS wire.

At this moment, the segmental corticotomy was arranged.

Local anesthesia: Lidocaine 2% with epinephrine 1 : 100,000

Buccal and palatal (lingual) sulcular incisions were made,Fullthickness flaps were reflected.

Decortication was then produced using a rounded bur under

irrigation. Vertical cuts were produced between the roots of the

teeth (first and second permanent molars) to be moved orthodontically and were then connected by horizontal cuts beyond

the apices. The cuts ended 1 to 2 mm before the alveolar crest

Scraping of the cortex was then produced both buccally and

palatally to create a bleeding bed for the graft.

Bio-Oss was then placed only buccally to cover the decorticated areas .

In more recent protocols, new piezoelectric blades are being used

instead of burs on surgical handpiece. Grafting is being modified by adding VEGF (Vascular Growth Factors).

The flaps were sutured with nonresorbable silk 4-0.

After 1 week, on removal of the sutures, two 200 g nickel-titanium

springs (Sentalloy red, GAC) were positioned bilaterally between the permanent first upper molars and the second upper premolars

on the 0.018 0.025-inch steel wire to distalize the molars.

Following molar distalization, the retraction of the upper anterior

group was carried out in 4 weeks by use of Class II elastics on an

0.018-inch Australian Special Plus Begg-Type upper archwire with two helices between lateral incisors and canines.

The necessary distalization of the permanent first and second

molars was achieved generally in 8 weeks, without needing any anterior anchorage accessories (Class II elastics, Nance buttons,


The results of these clinical studies showed that corticotomy helped

accelerate distalization of the upper molars and promoted a more

bodily movement with less need for anterior anchorage.

The use of a sliding mechanic, however, requires optimal alignment

and leveling of both arches to minimize the friction generated as the

molar tubes slide along the wire used (0.018- 0.025-inch stainless steel) and the occlusal interference created by the lower molars.

These mechanics may be difficult to apply in cases in which

alignment and leveling of the entire arches cannot be carried out

before distalization of the molars.

In these situations, segmental corticotomy may be associated with

appliances to distalize the upper molars before applying brackets

and wires on the premolars, canines, and incisors.

Space Utilization
Once maxillary molars had been distalized, a generally long period

followed to wait for spontaneous drift of premolars and canines.

No apparent active treatment was carried out. Bonding of the arch was contraindicated because friction of brackets and archwires and ligatures would have compromised the spontaneous movement of teeth in an improved position and would have caused anchorage


The new self-ligating brackets combined with the light small wires

seem to overcome these problems and allow bonding of the arches

earlier without compromising spontaneous changes.

At present, the self-ligating brackets are the best way to standardize

force application, wire seating and decrease friction.

The light forces also seem promising in reducing the need for intrusion mechanics.

Nonextraction treatment mechanics as described by Cetlin has

been proved to be a successful way of treating Class I and II

malocclusions with crowding.

The original mechanics needed to be updated to overcome

problems related to patient cooperation and to take advantage of

the new appliances and methods.

Clinical research will continue to improve the efficacy of this unique

therapeutic approach.