MOLAR DISTALIZATION

PRESENTER
R.HARSHITHA
II year PG
 CONTENTS

● INTRODUCTION
● HISTORY
● INDICATIONS
● CONTRA INDICATIONS
● DIAGNOSIS
● CLASSIFICATION
● TYPES OF APPLIANCES
● CONCLUSION
● REFERENCES
 INTRODUCTION

● Molar distalization is considered as one of the conservative ways

to treat malocclusion.
● This procedure has gained popularity due to the fact that by
distalization of molars, many Class II molar cases can be treated
without extraction.
● An estimated 25-30% of Class II orthodontic patients can be benefited
from maxillary expansion, and 95% can be improved by distalization
& expansion (Corbet, 1997).
 HISTORY

1892 WILLIAM First person to move maxillary teeth back using headgear
KINGSLEY

1944 OPPENHEIM Used occipital anchorage to move maxillary molar distally

without disturbing mandibular teeth

1956 RENFROE Reported that lip bumper primarily devised to hold

hypertonic lower lip caused distal movement of lower
molars (sufficient to change Class II to Class I)

1957 GOULD Unilateral distalization of molars with extra oral force

1961 KLOEHN Described effects of cervical pull headgear

1969 GRABER T.M. Extracted maxillary 2nd molar and distalized first molar to
correct Class II division 1
 INDICATIONS

In a growing child:
● To relieve mild crowding
(Causes permanent increase in arch length of about 2mm on each side)
Late mixed dentition:
● Mild anterior crowding.
● When lower E space is utilized for relief of anterior crowding.
● Lack of space for eruption of premolars due to mesial migration of 1st
molars.
 INDICATIONS

Late mixed dentition:

● Mild to moderate Class II where extraction is not indicated.
● Borderline cases.
● Mesially angulated upper molar.
● Mild to moderate discrepancy when missing 3rd molars or 2nd
molars not yet erupted.
 INDICATIONS

Others:
● Direct distal movement of upper or lower molars to correct dental class
II or class III.
● Labially placed/impacted canines.
● Good soft tissue profile.
● Brachycephalic / mesocephalic pattern.
● Short lower facial height.
● Class II division 1 with low mandibular plane angle.
 INDICATIONS

Second Molar:
1) 1969 Graber - Suggested that 2nd molar extraction to facilitate
distalization of the maxillary molars in selected class II division I
malocclusion cases.
2) 1971 Armstrong - Molar movement will complete, before the eruption of
2nd permanent molar.
3) 1973 Worms et al - Noted that erupted 2nd molar contacted with 1st
molar, created a resistance for distalization.

Chandra P, Agarwal S, Singh D, Agarwal S. Intra Oral Molar Distalization - A Review.

2012; 1(1): 15-18
 CONTRAINDICATIONS

Profile :
● Retrognathic
Functional :
● Signs & symptoms of TMJ disorders.
● Posteriorly & superiorly displaced condyles.
 CONTRAINDICATIONS

Skeletal
● Open bite
● Excessive lower facial height
● Constricted maxillary arch
● Dolico cephalic growth pattern
● High mandibular plane
 CONTRAINDICATIONS

Dental :
● Class I molar relationship.
● Fully grown patients, where anterior anchorage loss occurs due to
forces required to distalize including 3rd molars.
● Severe arch length and tooth size discrepancy.

Vinay Umale et al.Molar distalization – A review.Indian J Orthod Dentofac Research.

2018 July-Sept;4(3):146-150
 CONTRAINDICATIONS

Dental :
According to William Wilson (1978):
Molar distalization should not be done before 11 years of age because
maxillary tuberosity enters its rapid growth phase and also leads to
2nd or 3rd molar impaction.
 DIAGNOSIS

First step is to confirm the diagnosis of a forward maxillary molar

position.

1. Check the TMJ status.

● Before considering the molar relationship in terms of dental or
skeletal malocclusion, it is desirable to check TMJ status.
● All records must be correlated, ie., cephalometrics, functional
analysis, radiographs ( CT, MRI).
 DIAGNOSIS

2. Ricketts criterion:
Upper molar to Ptv
In growing : Age+3mm
In Non growing : 18mm
If the patient value is greater, the possibility for
distalization is high.
 DIAGNOSIS

3. IOPA \ OPG Assessment:

● Absence of upper 3rd molars offer better prognosis.

● Posterior crowding as indicated by distal angulation of the
molars make distalization unsuitable.
CLASSIFICATION
 TYPES OF APPLIANCES

1. BILATERAL DISTALIZATION – HEADGEARS

EXTRA ORAL
2. UNILATERAL – POWER ARM FACE BOW
SOLDERED OFFSET FACE BOW
SWIVEL FACE BOW
SPRING ATTACHMENT FACE BOW

1. INTER ARCH
INTRA ORAL
2. INTRA ARCH
INTER ARCH APPLIANCES

1. ATKINSON BUCCAL BAR

2. TANDEM YOKE
3. 3D BIMETRIC DISTALIZING ARCH
4. HERBST APPLIANCE
5. JASPER JUMPER
6. SLIDING JIG
7. CRICKETT APPLIANCE
8. KLAPPER SUPER SPRING
INTRA ARCH APPLIANCES
REMOVABLE

MAXILLARY FIXED
INTRA ARCH
● LIP BUMPER
MANDIBULAR ● FRANZULUM
APPLIANCE
● MODIFICATION OF
DISTAL JET APPLIANCE
● UNILATERAL FROZAT
● IMPLANT ASSISTED
DISTALIZATION
MAXILLARY INTRA ARCH
APPLIANCES
EXTRA ORAL
APPLIANCES
Headgear components

Delivering
J Hook, facebow
Force unit
Generating
Springs /
unit
elastics

Location depends upon

Anchor unit direction of force (neck or head
straps)

Outerbow
(.072”; short, medium ,long)
Attachments Facebow
Innerbow .045- .052”
 HEADGEAR

To cause bilateral molar distalization

● High pull headgear

● Straight pull headgear
● Cervical or low pull headgear

To cause unilateral molar distalization

● Power arm face-bow

● Swivel- offset face bow
● Soldered offset face bow
● Spring attached face bow
 CERVICAL HEADGEAR

● Short face Class II maxillary protrusive

cases with low MPA & deep bite.
● Extrusive & distalizing effect.
● Outer bow is longer than inner bow.
● Outer bow lies above inner bow so that line
of force lie above upper molar center of
resistance.
 OCCIPITAL HEADGEAR

● Posterior direction of pull.

● Force through center of resistance cause intrusion &
distal movement of molar.
● Outer bow is same length of inner bow.
● Outer bow lies above inner bow so that line of force lie
above upper molar center of resistance.
● Long face class II patients with high MPA
COMBINATION PULL HEADGEAR
UNILATERAL - POWER ARM FACEBOW
INTER ARCH APPLIANCES
 ATKINSON BUCCAL BAR

● Guerrero James
● When it is used with minimum amount of
elastic force, i.e., 2 ounces measured with a
Richmond or a postal scale, this appliance will
move the buccal segments posteriorly,
whether second molars are present or not.
● Cervical anchorage was used to position the
anterior teeth.

Guerrero J. J. Posterior movement of buccal segments. Am J Orthod 1959; 45(2): 125–130.

 BIMETRIC DISTALIZING ARCH

● Wilson and Wilson, 1978

● Maxillary molar and buccal segments are
distalized bilaterally or unilaterally without
headgear.
● 3D Bimetric distalizing Arch & 3D
mandibular Lingual Arch with Class II
elastics.
● Open coil spring is placed between omega
loop and buccal tubes for activation.
● Distal tipping of the molars,premolars and
 ● An .010 × .045 coil spring (5mm in length), is inserted
between the Omega loop and molar tube.
● Compressed to 3mm - 2mm to distalize maxillary
molar.
● Supported by an intermaxillary elastic system.
● Sequential use of elastics with decreasing force
values:

5/16” 6-oz in first week, similar size 4-oz in second and

similar size 2-oz in third and subsequent weeks of
treatment.
 HERBST APPLIANCE

● Emil Herbst 1905 later it was popularized by

Pancherz 1985.
● The appliance can be compared to an artificial joint
● working between maxilla & mandible.
● A bilateral telescope mechanism attached to
orthodontic bands keeps the mandible mechanically
in a continuous anterior jumped position.

Pancherz, H. The Herbst appliance—Its biologic effects and clinical use. American
Journal of Orthodontics 1985; 87(1):1–20.
 HERBST APPLIANCE

● It has the ability to inhibit maxillary

anteroposterior growth and to produce an
increase in mandibular length and lower facial
height.
● The intrusive and distal movements of
maxillary molars including tipping of crowns
distally and mesial drift of the mandibular
anterior and posterior teeth is observed.
 JASPER JUMPER

● Jasper & James Namara.

● Flexible force module.
● Due to restriction of lateral movements of mandible in
Herbst appliance, modification of Herbst was
developed.
● The modules are available in seven lengths, ranging
from 26mm to 38 mm in 2mm increments.
● This interarch flexible force module allows the patient
greater freedom of mandibular movement.

Jasper, J. J., & McNamara, J. A. The correction of interarch malocclusions using a

fixed force module. Am J Orthod Dentofac Orthop 1995;108(6):641–650.
KLAPPER SUPER SPRING

● Lewis Klapper, 1998

● Resembles Jasper Jumper with the substitution of
a cable for the coil spring.
● The appliance consists multiflex NiTi spring
Upper 1st molar tube : Bending back on itself
Lower arch wire : Helical loop
● Two sizes:
Extraction cases = 27mm
Non-extraction cases = 40mm
 SLIDING JIG

● Auxillary sectional arch wires (round .022 inch or

rectangular wire) used to tip or move one/group of
teeth in buccal segments distally without disturbing
anteriors.
● Bent in eyelets on each side.
● To move maxillary molars distally,
Distal eyelet - against molar tube
Mesial eyelet - located between canine & 1st premolar
(atleast 2mm anterior to premolar bracket).

Alfred rechter. Sliding Jig. J Clin Orthod 1968; 2(5):239-45.

 MAXILLARY
INTRA ARCH
REMOVABLE APPLIANCES
 CETLIN APPLIANCE

● Norman M. Cetlin & Ane Ten Hoeve

● Combination of extraoral force (headgear)
& intraoral force in the form of a removable
appliance.
● Tips the crowns distally and then an
extraoral force to upright the roots.
● Appliance worn = 24hrs/day
● Springs activation = 1-1.5mm (50gms)
● Headgear = 12-14hrs/day (150gm/side)

Cetlin N.N and Tenhoeve A. Nonextraction.J Clin Orthod 1983;17:396-413.

 ACCO

● ACrylic Cervical Occipital Anchorage

● Dr. Herbert Margolis
● Devised to harness growth ie., entire maxilla
is restrained while mandible is allowed to
express its growth potential.
● Later added various finger spring auxiliaries
for distal tooth movement.
● Finger spring activation :½ the width a
bicuspid tooth for a 3 week period.

Leonard B. The ACCO Appliance. J Clin Orthod. 1969;3:461-8.

 MODIFIED ACCO

Giuliano Manio. A Modified ACCO for Class II Nonextraction Treatment J Clin

Orthod. 2006;10:605-12.
 C SPACE REGAINER

Ikyu-Rhim Chung, Young-Guk Park, Su-Jin Ko - C-Space Regainer For Molar Distalization. J Clin
Orthod 2000;1: 32-39
● When compressed, coil spring exerts
200g of force and move the molars
distally about 1-1.5mm/month.
● Vertical control is maintained by
adjusting the wire framework occlusally
or gingivally
 MAXILLARY
INTRA ARCH
FIXED APPLIANCES
 K LOOP
● Kalra - 1995
● Wire - .017x .025” TMA
● Anchorage - Nance button
● Each loop = 8mm long. 1.5mm wide
● Legs bent 20 deg (counteract tipping moments)
● Stops bent 1mm distal , 1mm mesial
● Stops- 1.5mm long
● For additional molar movement, the appliance is
reactivated 2mm after six to eight weeks
 Reactivation sequence:

Open loop 1mm at (1)

Open loop 1mm at (2)
Open at (3) to regain 20° bend of mesial & distal legs.
Produces = 2mm reactivation
➔ In most cases, one reactivation, producing a total of
as much as 4mm of distal molar movement.

Varun Kalra. The K-Loop Molar Distalizing Appliance. J Clin Orthod. 1995;29(5):298-305
 PENDULUM APPLIANCE

● In 1992, Hilgers
● 0.032 TMA
● Broad, swinging arc or pendulum of force from the
midline to lingual sheaths.
● Consists:
1. Recurved molar insertion wire
2. Small horizontal adjustment loop
3. Closed helix

Hilgers JJ. The pendulum appliance for Class II non-compliance therapy. J Clin Orthod 1992;26:706-14.
Preactivation

Parallel to mid sagittal plane (90 deg).

About a third of the bend is lost in the insertion,resulting in a
60° activation / 250g of distalizing force.

● Produces 5mm of distal movement in 3-4 months.

● Loss of anchorage is minimal: 1.5mm in the premolar
area and about 1-2° of proclination of the maxillary
incisors.
Reactivation

● Patient seen about every three weeks

● If reactivation is needed, center of the helix is
then held with a bird-beak plier, and the
spring is reactivated by pushing it distally
toward the midline.
MODIFIED PENDULUM

● Giuseppe Scuzzo
● Inverted loop
● Activation - 40-450
● Springs deliver approximately 125 gms/side.
● Springs have adjustment loop.
 PENDEX

Hilgers JJ. The pendulum appliance for Class II non-compliance therapy. J Clin Orthod 1992;26:706-14.
 MINI DISTALIZING APPLIANCE
HILGERS PhD APPLIANCE Hilgers and Traceyin, 2003
 T- REX

● Fixed rapid palatal expander.

● Metal framework
● Expansion screw, occlusal rests, and two .032" TMA
springs.
● Screw and springs are embedded in acrylic.
 PENDULUM K

● Kinzinger et al., 2005

● Due to disadvantages of pendulum appliances ie.,
palatal movement of the molars & tipping of
crowns.
● The present modification, the Pendulum K was
developed to negative side effects by:
1. Incorporating a distal screw into the base of the
appliance.
2. Application of uprighting activation & a toe-in bend
in the region of the springs.

Kinzinger, G. S. M., & Diedrich, P. R. Biomechanics of a modified Pendulum appliance--theoretical

considerations and in vitro analysis of the force systems.The Eur J Orthod 2006; 29(1):1–7.
 JONES JIG

● Richard D. Jones & Michel, 1992

● Intra oral non compliance distalization appliance.
● Consists of
1. Open coil NiTi spring (slides over .036 main frame)
2. Attachments to head hear tube and archwire slot.
3. Hook.
4. Eyelet tube.
● 0.014” ligature wire -buccal tube & mainframe hook
(very lightly).
● 0.012” ligature wire is wound twice - premolar
bracket & mesial end passed through the eyelet
tube.
● The ligature wire is then tightened until 'light' through
the middle of the open coil is barely seen.
● NiTi coil spring= 70-75g of force, over a compression
range of 1-5mm.
 DISTAL JET

● Carano Aldo and Testa Mauro,1996

● Consists of a wire emerging from acrylic Nance
button and passes through tube of 0.036 inch
internal diameter.
● A NiTi coil spring and a screw clamp are slide over
each tube.
● The wire extending from the acrylic through each
tube ends in a bayonet bends that is inserted into
the lingual sheath of the 1st molar band.

Aldo Carano, Mauro T. The Distal Jet for Upper Molar Distalization.J Clin Orthod 1996;30(7):378-92.
SUPER ELASTIC NITI WIRES

● Gianelly,1998
● 100gm (Neosentalloy) super elastic Niti Wire
with regular arch form is placed over the
maxillary arch.
● 3 points are marked as follows on each side at:
1. Distal wing of 1st premolar bracket.
2. 5-7mm distal to the anterior opening of the
molar tube.
3. Between the lateral incisors and canines

Locatelli R, Bednar J, Dietz VS, Gianelly AA. Molar distalization with superelastic Ni–Ti wire.
 MAGNETS

● Gienally et al., in 1988 used a repelling type of

magnetic force for distal tooth.
1. Repelling Magnets
2. Sectional wire
3. Sliding yoke
4. Headgear tube on first molar
● Activation: By tightening the 0.014” ligature wire to
bring the magnets into contact.
● 80% of the space created was due to molar
distalization and only 20% of space was attributed to
anchor loss (Gianelly, 1989).
 FIRST CLASS APPLIANCE FOR MOLAR DISTALIZATION

Fortini Lupoli M and Parri M, 1999

2 components
Vestibular Palatal

10mm long screws (welded ● Palatal button &

to deciduous 2nd molars or butterfly shape wire
2nd premolars) (0.045”) assembly.
● NiTi coil spring is
compressed between
bicuspid soldered
joints.

Arturo Fortini et al., The First Class Appliance for Rapid Molar Distalization. J Clin Orthod. 1999; Jun:
322–28.
 ASYMMETRIC TPA

● Maldurino and Balducci, 2001.

● TPA is constructed using an 0.032” TMA
bars.
● The direction of insertion of the TPA into
the occlusal molar tubes is different.
● The arch is inserted from distal into anchor
molar and mesially into the molar which has
to be distalized.
● When activated, the arch applies a mesio-buccal rotation
to the anchor molar and distally directed force on the
opposite molar.
● Central omega loop is not needed as TMA is not used for
palatal expansion.
● TMA is activated monthly by bending the end inserted
from the distal by about 30°.
● One possible disadvantage of this method is that only
one molar can be distalized at a time.
 DISTALEX

● Originally borrowed from quad helix which

borrows the four helices and from the
Hilgers distalization pendulum spring.
● Blue elgiloy round wire and can be welded
on premolar or molar bands.
● Forces = 250-300gms in growing patient.
● Distatization= 8-9mm in 4-6 months.
 KELES SLIDER

Ahmet Keles, 2002

Components:

A. Acrylic anterior bite plane

B. Retaining wire for maxillary first premolar
C. 0.036-inch diameter wire rod for distal sliding of
maxillary first molar
D. Adjustable screw for activation of the coil spring
E. 0.036-inch heavy Ni-Ti open coil spring.
F. Special tube soldered to the first molar band.
● Distalization - heavy Ni-Ti coil spring (2-cm
long, 0.9-mm diameter, and 0.016” thick)
● Activattion : full compression (amount of
force generated of the 2-cm open coil -
about 200 g)
● Force system allows consistent application
of force at the level of the center of
resistance of the first molars.
 CARRIÈRE DISTALIZER

● Luis Carriere, 2004

● Carrière Distalizer is a simple and efficient fixed
functional appliance for Class II treatment.
● The Distalizer is made of mold-injected, nickel-free
stainless steel.
● Ball and socket joint provides torque (3D) control of
both the canine and molar

Luis Carriere. A New Class II Distalizer. J Clin Orthod. 2004;38(4);26:224–31.

 Appliance design

It is bonded to the canine and first molar as follows:

Canine pad - Distal movement of the canine along the

alveolar ridge without tipping & provides a hook for the
attachment of Class II elastics.

Slight curve - runs over two upper premolars

The posterior end of the arm is a permanently attached

ball that articulates in a socket on the molar pad.
● Patient is instructed to wear heavy 6 ½ oz , ¼ “
Class II elastics 24 hours a day, except during
meals.
● The posterior portion of the Distalizer accomplishes
three types of molar movement:
1. Uprighting of the crown, if it is mesially in­clined.
Once the molar has been upright­ed; the joint
prevents distal tipping.
2. Distal rotation around the palatal root.
3. Distal displacement without distal tipping of the
crown
 FROG APPLIANCE

Forestadent, Pforzheim, Germany)

 ● 1 complete rotation of screw opens the appliance 0.4
mm.
● 3 rotations are recommended : 4-5 week intervals & 5
rotations are recommended for 8 week intervals.
● If 2nd molars are erupted,

3 rotations for 5-6 week intervals are recommended.

>3 rotations are not recommended when second molars

are erupted.
 ZYGOMATIC ANCHORAGE SYSTEM

● IZC - Regular size of a micro-implant ranges

between 12-14mm length, 2mm diameter.
● Placement : in between 1st and 2nd molar ,
close to MB root of first molar.
● Immediate loading is possible and a force of up
to 300–350 g can be taken up by a single bone
screw.

Ghosh A. Infra-zygomatic crest and buccal shelf - Orthodontic bone screws: A leap ahead of
 MANDIBULAR
INTRA ARCH
FIXED APPLIANCES
 LIP BUMPER

● To distalize lower mandibular molars and

increases space in mandibular arch.
● Made of 0.045” SS that spans the facial
structures of mandibular arch without contacting
teeth and inserted into molar tubes.
● Anteriorly wire is covered by plastic tubing or
acrylic shield to hold lip away from incisors.
 FRANZULUM

● Friedrich Byloff, 2000.

● Anterior anchorage unit is an acrylic
button, (positioned lingually & inferiorly to
mandibular anterior teeth ie., 33 to 43)
● Rests on canines & first premolars are
made from .032" stainless steel wire.
● Tubes between the second premolars
and first molars receive the active
components.
 ● NiTi coil spring = 18mm in length applies
initial force of 100-120g/side.
● A J-shaped wire passing through each coil is
inserted into the corresponding tube of the
anchorage unit

Distalization phase = 4.5-5mm, tipped 4° distally

Incisors = 1mm anteriorly, tipped 1° labially.
Anchorage loss of incisor = 1mm and 1°.

Friedrich Byloff. Mandibular Molar Distalization with the Franzulum Appliance J Clin Orthod.
MODIFIED DISTAL JET
 SKELETAL ANCHORAGE SYSTEM

● Buccal shelf screws = 10-12mm length, 2mm

diameter.
● For placement of bone screws in the BS area of
mandible (2nd molar region).
● Initial point of insertion is inter-dentally between
the 1st & 2nd molar and 2mm below the
mucogingival junction.
● The self-drilling screw is directed at 90° to the
occlusal plane at this point & direction is changed
60°– 75° towards the tooth.
 CONCLUSION

● There are many advantages and disadvantages of both the intra-

oral and extra-oral methods.
● It should be remembered that patient selection for a particular
method of distalization is of utmost importance and should not be
overlooked .
● Right appliance should be selected for the right patient and one
should not select the patient for the appliance rather the appliance
should be for the patient.
 REFERENCES
● Phulari. History of Orthodontics
● Chandra P, Agarwal S, Singh D, Agarwal S. Intra Oral Molar Distalization - A
Review. 2012; 1(1): 15-18
● Vinay Umale et al.Molar distalization – A review.Indian J Orthod Dentofac
Research. 2018 July-Sept;4(3):146-150
● Guerrero J. J. Posterior movement of buccal segments. Am J Orthod 1959;
45(2): 125–130.
● Jasper, J. J., & McNamara, J. A. The correction of interarch malocclusions
using a fixed force module. Am J Orthod Dentofac Orthop 1995;108(6):641–
650.
● Pancherz, H. The Herbst appliance—Its biologic effects and clinical use.
American Journal of Orthodontics 1985; 87(1):1–20.
● Alfred rechter. Sliding Jig. J Clin Orthod 1968; 2(5):239-45.
● Cetlin N.N and Tenhoeve A. Nonextraction.J Clin Orthod 1983;17:396-413.
● Leonard B. The ACCO Appliance. J Clin Orthod. 1969;3:461-8.
● Giuliano Manio. A Modified ACCO for Class II Nonextraction Treatment J Clin
Orthod. 2006;10:605-12.
● Ikyu-Rhim Chung, Young-Guk Park, Su-Jin Ko - C-Space Regainer For Molar
Distalization. J Clin Orthod 2000;1: 32-39
● Varun Kalra. The K-Loop Molar Distalizing Appliance. J Clin Orthod.
1995;29(5):298-305
● Hilgers JJ. The pendulum appliance for Class II non-compliance therapy. J
Clin Orthod 1992;26:706-14.
● Kinzinger, G. S. M., & Diedrich, P. R. Biomechanics of a modified Pendulum
appliance--theoretical considerations and in vitro analysis of the force
systems.The Eur J Orthod 2006; 29(1):1–7.
● Aldo Carano, Mauro T. The Distal Jet for Upper Molar Distalization.J Clin
Orthod 1996;30(7):378-92.
● Locatelli R, Bednar J, Dietz VS, Gianelly AA. Molar distalization with
superelastic Ni–Ti wire. J Clin Orthod. 1992;26:277–9.
● Arturo Fortini et al., The First Class Appliance for Rapid Molar Distalization. J
Clin Orthod. 1999; Jun: 322–28.
● Luis Carriere. A New Class II Distalizer. J Clin Orthod. 2004;38(4);26:224–31.
● Ghosh A. Infra-zygomatic crest and buccal shelf - Orthodontic bone screws: A
leap ahead of micro-implants – Clinical perspectives. J Indian Orthod Soc
2018;52:S127-41
● Friedrich Byloff. Mandibular Molar Distalization with the Franzulum Appliance
J Clin Orthod. 200;Sept:518–523.