Pacific Coast Society of Orthodontists Bulletin Summer 2020 - 61

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of distalized molars during the anterior retraction
phase, and distal tipping and extrusion of molars
(Figure 4). As a result, the mandibular plane angle
and lower facial height increased. Also, Class
II elastics were widely used for dentoalveolar
correction of Class II patients in orthodontics,
but they exhibited some very similar untoward
effects as the other fixed maxillary distalizing
appliances. Class II elastics can cause lingual
tipping and extrusion of the maxillary incisors,
labial tipping and intrusion of the mandibular
incisors, and mesialization and extrusion of the
mandibular molars.4 In terms of the long-term
effectiveness, both the maxillary molar distalizing
fixed appliances and Class II elastics are similar to
all other functional appliances.
How can temporary skeletal anchorage devices
(TSADs) change these treatment options for Class
II patients?
When TSADs or miniscrews were used in the
palate in combination with molar distalizers,
some of the above-mentioned limitations were
effectively resolved.5 The incisor anchorage was
stabilized; therefore, the incisors did not flare,
and there was no posterior anchorage loss during
the retraction phase when the same TSADs
were used as absolute anchorage for retraction.
However, distal tipping and extrusion of the
maxillary molars, which caused unfavorable
clockwise rotation of the mandible, were still not
resolved. Therefore, some clinicians started to
apply TSADs in different anatomical sites in the
maxilla in conjunction with traditional types of
fixed molar distalizers or simultaneously with
fixed appliances alone for retraction of posterior segments or entire arches for nonextraction
Class II patients. Depending on how carefully the
force vector is designed concerning the center of
resistance (CR) and the biomechanical principles
are incorporated, some orthodontists have been
able to achieve intrusive retraction of the molars
using TSADs in the buccal interradicular bone,6
zygomatic buttresses, or palate,7,8 thus eliminating the extrusive side effects on the maxillary
molars. However, there are still some limitations

Summer 2020    PCSO Bulletin	

Figure 4. (A) Side effects of conventional molar
distalizing appliances, (B) side effects of conventional molar distalizing appliances
to these techniques. For instance, the buccal
interradicular approach could potentially cause
root perforations, and because of the limited
space between the roots, more than 3 mm of
distalization is not possible without distal repositioning of the TSADs. Especially where the cortex
is thin, the stability of the TSADs is likely to be
compromised because of the low density of the
trabecular bone in the maxillary buccal area. The
zygomatic buttress or zygomatic crest approach
provides the freedom to distalize molars beyond
3 mm without repositioning the TSADs but still
exposes patients to risks of sinus perforations,
even more so than with the buccal interradicular
approach, and it involves surgical procedures.
Often, the zygomatic approach also makes TSADs

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Pacific Coast Society of Orthodontists Bulletin Summer 2020

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