CASE REPORT

Patrice Bergeyron

Molar distalization 2 by 2

Patrice Bergeyron

Key words DOLJQHUWUHDWPHQWFDQLQHLPSDFWLRQ&ODVVΖΖWUHDWPHQWLQWUDRUDOGLVWDOL]LQJ

appliance, molar distalization in the maxillary arch, tooth movement

7he clinical cases oI tZo yoXnJ Iemale patients presentinJ Invisalign Summit in 2005, Bergeyron Sresented the ȴrst
Zith a &lass ΖΖ dental malocclXsion treated Zith the ΖnvisaliJn case of complete distalization, which was started in 2003.
techniTXe in comEination Zith &lass ΖΖ elastics are presented At this time, precision cuts did not exist; it was necessary to
in this article 7he ȴrst case shoZed a IXll dental &lass ΖΖ rela- bond aesthetic buttons on the aligners. These procedures
tionship, severe overjet, strong incisor proclination and an were time-consuming and because the treatment required
impacted maxillary canine 7he second case displayed an up to 70bpairs of aligners it meant bonding 280bbuttons for
asymmetric &lass ΖΖ canine and molar relationship %oth pa- one single case. The treatment time was also longer, requir-
tients reIXsed ȴxed appliances and chose aesthetic treatment ing at least 35b months when changing the aligners every
options. Maxillary molar distalization was prescribed in the 14bdays.
&lin&hecN Iollowing a new protocol oI  by  distalization. 7he Since that time, Align Technology (Santa Clara, CA, USA)
new protocol proposed shortened treatment time and was has developed the sequential maxillary molar distalization
e΍ective to correct dental &lass ΖΖ malocclXsion. protocol (MMDP) and the precision cuts. The distalization
starts with the maxillary second molars. Once the second
molars are two-thirds of the way, the maxillary ȴrst molars
Introduction move back, then the premolars, and so on, until the en masse
retraction of the four incisors completes the treatment
Distalization of ma[illary molars to correct dental &lassbII plan1,2.
malocclusions or anterior crowding without the need for In order to shorten treatment time and reduce the
extraction has been a treatment alternative sought for number of aligners, in 2005 Bergeyron decided to test a
many years by many authors. During the ȴrst EuroSean new MMDP, distalizing two molars at the same time bilat-
erally from the ȴrst aligner. If we were able to bodily dis-
talize a molar using plastic aligners, why not attempt to
distalize two molars at the same time to reduce the treat-
ment time?
The aim of this article is to describe the evolution of the
Patrice Bergeyron, Dr. 2bbyb2bdistalization protocol adopted in two clinical cases
Quai des Bergues 27, 1201 Genève, Suisse
treated only with the Invisalign technique and Class IIbelas-
Correspondence to: Dr. Patrice Bergeyron
E-Mail: [email protected] tics.

Journal of Aligner Orthodontics 2018;2(3):215–224 215

BERGEYRON

Case 1 Treatment progression

The treatment was planned with the Invisalign technique,
Diagnosis including Class II elastics for anchorage on the mandibular
The 14-year-old female patientȇs chief complaint was impac- second molars and maxillary ȴrst premolars. Once the
tion of tooth 13, an increased overjet, proclination of the space for the canine was created, the patient was asked to
maxillary incisors, spacing in the maxillary arch and a desire wear an elastic from the exposed canine to a button bonded
to improve the aesthetics of her smile. Her skeletal relation- on the aligner. The treatment consisted of a ȴrst phase with
ship was characterised by a short lower facial third. The 55baligners in the maxillary arch and 20bactive aligners in
aesthetic analysis of the soft tissues displayed a convex the mandibular arch, and another 10baligners added in the
proȴle with a reduced labiomental angle, retrusive chin and reȴnement phase.
lower lip. The nasolabial angle was increased. In the ȴrst ClinCheck suggested by Align Technology, the
Intraorally, the patient presented with a canine and mo- usual sequential MMDP required 75baligners. This ClinCheck
lar ClassbIIbrelationship on the left side and a Class IIbmolar was rejected. The new ClinCheck, using our new distaliza-
relationship on the right. She also had spacing in the max- tion protocol, only required 55baligners. The second and ȴrst
illary arch and a severe rotation of toothb14, with restricted maxillary molars were distalized together on both sides. The
maxillary arch form. Her smile was constricted, displaying maxillary incisors were levelled and aligned and, during
black corridors. The maxillary and mandibular midline was canine traction, once the molars were in a ClassbI relation-
centred to the facial midline. Results of cephalometric anal- ship, the second and ȴrst premolars started distalizing to-
ysis showed a skeletal Class II relationship with coun- gether, with space closure and retrusion en masse of canines
ter-clockwise rotation of the mandible. With regard to inci- and maxillary incisors.
sor tooth axes, both maxillary and mandibular incisors were
proclined. Overjet and overbite were severely increased. Treatment results
Through orthodontic treatment with the Invisalign appli-
Treatment goals ance in combination with Class II elastics, it was possible to
The patient was concerned about aesthetics and wanted an place tooth 13 in the arch with an adequate tooth axis incli-
invisible treatment. The orthodontic treatment plan in- nation and good periodontal support. A Class Ibcanine and
cluded the following treatment objectives. 1) Space opening molar relationship with physiological overjet and overbite
for the impacted canine, through distalization of the maxil- was obtained. The results of the cephalometric analysis
lary molars and premolars; 2)bAlignment, levelling and co- showed no modiȴcation of the skeletal ClassbII relationship,
ordination of the arches to achieve a molar and canine Class but an improvement of the divergence, with a clockwise
I relationship with physiological overjet and overbite; 3) rotation of the mandible. With regard to incisor tooth axes,
Expansion of the maxillary arch; 4) Correction of the incli- both the maxillary and mandibular incisor proclination were
nation of both the maxillary and mandibular incisors. greatly improved, as well as the interincisal angle.

Treatment alternatives
There are many ways to distalize maxillary molars. Intraoral Case 2
appliances like the pendulum or the Carriere motion fol-
lowed by multibracket treatment are often utilised to cor- Diagnosis
rect dental Classb II. Nowadays, the use of temporary an- The 15-year-old female patientȇs chief complaint was an-
chorage devices (TADs) simpliȴes the orthodontistȇs life in terior crowding and a desire to improve the aesthetics of her
many clinical situations. In this clinical case, Bergeyron de- smile. Her facial conȴguration was characterised by a good
cided, together with the patient and her family, to use balance between facial thirds and slight deviation of the chin
aligner therapy to treat the ClassbII malocclusion while also to the right. The aesthetic analysis of her proȴle displayed a
performing space opening and traction of the impacted retrusive chin and lower lip. Intraorally, she presented with
canine. canine and molar ClassbII on the right and Class Ibcanine and

216 Journal of Aligner Orthodontics 2018;2(3):215–224

 MOLAR DISTALIZATION 2 BY 2

a b c

)LJDWRHbbExtra- and intraoral situation

at the start of treatment. d e

)LJDDQGEbbPretreat-
ment panoramic
radiograph and lateral
cephalogram. a b

a b c

)LJDWRHbbMolar distalization during

treatment using Invisalign aligners canine
traction. d e

Journal of Aligner Orthodontics 2018;2(3):215–224 217

BERGEYRON

a b

)LJDDQGEbbSequential distalization protocol of Align Technology compared with the ȴrst ȊDistalization 2 by 2 protocolȋ.

a b

)LJDWRGbbEnd of
treatment
intraoral photo-
c d graphs.

218 Journal of Aligner Orthodontics 2018;2(3):215–224

 MOLAR DISTALIZATION 2 BY 2

)LJDDQGEbbEnd of
treatment panoramic
radiograph and lateral
cephalogram. a b

7DEOHbbSummary of cephalometric analysis.

Measurement Normal ISD Pretreatment Post-treatment

Maxillomandibular relationships
SNA (degrees) 83.1 2.8 81degrees 81degrees
SNB (degrees) 79.5 2.7 76 degrees 76 degrees
ANB (degrees) 3.6 2.7 5 degrees 5 degrees
FMA (degrees) 29.0 3.6 24 degrees 30 degrees

Measurement Normal ISD Pretreatment Post-treatment

Dental relationships
UI to FH (degrees) 112.3 5.1 117 degrees 98 degrees
FMIA (degrees) 60.3 5.4 43 degrees 50 degrees
IMPA (degrees) 90.7 5.6 113 degrees 100 degrees
Incisal angle (degrees) 128.0 8.0 119 degrees 128 degrees

molar relationship on the left. She also had crowding in the anteriors to create a physiological overjet and overbite, as
maxillary and mandibular arches, with a restricted maxillary well as a maxillary midline correction. The maxillary arch
arch form. Her smile was constricted, displaying black corri- needed expansion and the maxillary incisors needed a
dors. The maxillary midline was shifted to the left while the torque correction.
mandibular midline was centred to the facial midline. Results
of the cephalometric analysis showed a skeletal ClassbI rela- Treatment alternatives
tionship with counter-clockwise rotation of the mandible. In this case of a monolateral Class II relationship and the
With regard to incisor tooth axes, both maxillary and man- patientȇs wish for an aesthetic treatment, several treatment
dibular incisors displayed vestibular inclination. options were possible; for example, lingual multi-bracket
treatment with the use of Class II elastics, a noncompliance
Treatment goals intraoral device to perform unilateral distalization (Pendu-
The patient was concerned about aesthetics and wanted an lum on mini-screws, DistalJet, Top-jet, etc) or the Invisalign
invisible treatment. The orthodontic treatment plan in- system with ClassbII elastics to support monolateral distali-
cluded alignment of the arches, distalization of the right zation.
maxillary molars, premolars and canines to a Class I rela- In this clinical case, Bergeyron, the patient and her fam-
tionship and the creation of space for the alignment of the ily decided to use aligner therapy to treat her malocclusion.

Journal of Aligner Orthodontics 2018;2(3):215–224 219

BERGEYRON

Treatment planning eɝciency of tooth movement with aligner therapy. Aligner

Treatment was planned with the Invisalign technique, in- treatment is particularly e΍ective for molar distalization.
cluding Class II elastics for anchorage on the mandibular Aligner therapy in association with composite attach-
ȴrst molars and maxillary canines worn full time on the right ments and Class II elastics can distalize maxillary ȴrst molars
and only at night on both sides. In the ȴrst ClinCheck sug- by 2.25bmm without signiȴcant tipping and vertical move-
gested by Align Technology the usual sequential MMDP ments of the crown2. In an attempt to reduce the number
required 57baligners. This ClinCheck was rejected. The sec- of aligners and also the treatment time, Bergeyron changed
ond ClinCheck with the ȴrst 2b byb 2 distalization protocol Invisalignȇs MMDP when treating the ȴrst case presented in
required 63 aligners. The last ClinCheck with the revised this article and started distalizing two maxillary molars at
2bbyb2 distalization protocol simultaneous to the movement the same time, in order to promptly create the space for
of the canines and incisors required only 47baligners and canine traction and repositioning while at the same time
was accepted. The second and ȴrst maxillary molars were correcting the dental ClassbII malocclusion.
distalized together on both sides and the maxillary central In both the cases presented here, the treatment goals
incisors and maxillary canines were aligned simultaneously. were achieved with success. In the ȴrst case the canineb13
Once the molars were in a ClassbI relationship, the second was in a good position and there was a good Class I rela-
and ȴrst premolars started distalizing, followed by an en tionship. The overjet and overbite were corrected, as was
masse retrusion of the canines and maxillary incisors. The the incisor inclination.
patient chose to use an intraoral acceleration device in or- In the second case, the 2 by 2 distalization protocol was
der to be able to change the aligners every 7bdays. performed only on the right side to correct the monolateral
ClassbII relationship, as well as the maxillary midline devia-
Treatment results tion. The precision of this technique made it possible to
After 47baligners, the patient had a ClassbI molar and canine move only the desired teeth, using the rest of the teeth as
relationship on both sides with correct overjet and overbite. a single anchorage unit, together with the use of Class II
Both arches were aligned and levelled and the patient was elastics to avoid loss of anchorage. Treatment was almost
already very satisȴed with the aesthetic result of her smile. completed, but a reȴnement was necessary to perfect the
The lateral cephalogram showed no changes of the ANB posterior occlusion, therefore the patient still has bonded
angle. There was a clockwise rotation of the mandible and composite attachments.
an important reduction in the proclination of the maxillary
incisors. There was some proclination of the mandibular
incisors, as shown by the IMPA angle. A new set of 14balign- Conclusion
ers will be necessary to reȴne the occlusion.
As is shown in these case reports, it is possible today to
shorten the treatment time of patients displaying dental
Discussion bilateral or monolateral Class II relationships by using 2bbyb2
the maxillary molar distalization protocols described in this
Every day, patients request orthodontic treatment using article. The patientȇs compliance in wearing the aligners and
clear aligners, which are now used by orthodontists world- using Class II elastics as prescribed by the orthodontist is
wide. Nowadays, the clear option is an important treatment essential.
tool to correct a wider range of malocclusions and is used It is the orthodontistȇs role to choose the best treatment
in conjunction with auxiliaries such as inter-maxillary elas- option and treatment tools for each individual patient. The
tics, power arms, TADs, etc4. The precision of the ClinCheck Invisalign technique has great potential and further studies
software treatment plan, the simpliȴed oral hygiene and on a larger scale is necessary to assess the advantages and
comfort for the patient together with a reduced chair time limitations of orthodontic treatments using clear aligners.
are just some of the numerous advantages of aligner treat-
ments. Numerous studies have proved the eɝcacy and

220 Journal of Aligner Orthodontics 2018;2(3):215–224

 MOLAR DISTALIZATION 2 BY 2

a b c

d e f

g h

i j k
)LJDWRNbbExtra- and intraoral situation at the start of treatment.

Journal of Aligner Orthodontics 2018;2(3):215–224 221

BERGEYRON

)LJDDQGEbbPretreatment and lateral

a b cephalogram and proȴle superimposition.

)LJbb2 by 2 distalization protocol with simultaneous movement of incisors and canines during distalization and staging of the reȴne-
ment.

222 Journal of Aligner Orthodontics 2018;2(3):215–224

 MOLAR DISTALIZATION 2 BY 2

a b
)LJDDQGEbbMolar distalization using Invisalign aligners and Class II elastics.

)LJDDQGEbbProgress
of treatment panoramic
and lateral radiographs. a b

7DEOHbbSummary of cephalometric analysis.

Measurement Normal ISD Pretreatment Post-treatment

Maxillomandibular relationships
SNA (degrees) 83.1 2.8 89 degrees 89 degrees
SNB (degrees) 79.5 2.7 86 degrees 86 degrees
ANB (degrees) 3.6 2.7 3 degrees 3 degrees
FMA (degrees) 29.0 3.6 17 degrees 20 degrees

Measurement Normal ISD Pretreatment Post-treatment

Dental relationships
UI to FH (degrees) 112.3 5.1 127 degrees 101 degrees
FMIA (degrees) 60.3 5.4 67 degrees 58 degrees
IMPA (degrees) 90.7 5.6 96 degrees 102 degrees
Incisal angle (degrees) 128.0 8.0 120 degrees 135 degrees

Journal of Aligner Orthodontics 2018;2(3):215–224 223

BERGEYRON

a b c d

e f g

h i

j k l
)LJDWRObbExtra- and intraoral photographs showing treatment.

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224 Journal of Aligner Orthodontics 2018;2(3):215–224

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