Improved facial profile with non-

extraction treatment of severe

protrusion using TSADs
Jae Hyun Park, Yoon-Ah Kook, Yoonji Kim, Lyun Kwang Ham, and Nam-Ki Lee

Extraction has traditionally been necessary to correct bimaxillary and lip pro-
trusion with proclined maxillary and mandibular incisors. However, non-
extraction treatment using temporary skeletal anchorage devices (TSADs) is
now an option for severe overjet or full-step Class II malocclusions. It is pos-
sible to treat bimaxillary protrusion with non-extraction, but for successful
non-extraction treatment in bimaxillary patients, the amount of total arch
distalization of the mandibular dentition is crucial.
For maximum total mandibular arch distalization in protrusion patients, it is
recommended to extrude and distalize the molars simultaneously, which
results in more posterior movement of the mandibular dentition without gin-
gival impingement. Therefore, this paper presents efficient biomechanics, a
strategy, and the anatomy of the retromolar area for total arch distalization
using TSADs to improve facial profile without extracting premolars in Class
II maxillary and bimaxillary protrusion patients. (Semin Orthod 2022; 28:157–
163) © 2022 Elsevier Inc. All rights reserved.

Introduction the modified C-palatal plate (MCPP) for maxil-

lary molar distalization. Some studies reported
raditionally, patients with bimaxillary pro-
T trusion were treated with premolar extrac-
tion. Non-extraction treatment may occasionally
skeletal and dental effects of maxillary total arch
distalization and its long-term results in both ado-
lescent and adult patients using MCPP.4 7
cause labioversion of the maxillary and mandibu-
In a patient with severe bimaxillary protru-
lar incisors, increase lip protrusion, and degrade
sion, Kook et al.8 also reported a case with a
the facial profile.
prominent profile change by extracting four first
Conventionally, Schacter et al.1 reported a
premolars and total arch distalization. In addi-
bimaxillary case of extreme protrusion treated
tion, non-extraction treatment has been used to
with atypical extraction of a molar and two pre-
treat full-step Class II or severe overjet cases with
molars from one quadrant. However, with the
palatal TSADs for total arch distalization in
recent application of temporary skeletal anchor-
adolescents.9 11
age devices (TSADs), Kook et al.2,3 introduced
This paper presents efficient biomechanics for
total arch distalization using TSADs to improve
Postgraduate Orthodontic Program, Arizona School of Dentistry
the facial profile without extraction of premolars
& Oral Health, A.T. Still University, Mesa, AZ and International
Scholar, Graduate School of Dentistry, Kyung Hee University, Seoul, in Class II maxillary protrusion. The strategy for
South Korea; Department of Orthodontics, Seoul St. Mary’s Hospital, total arch distalization of the lower dentition in a
College of Medicine, Catholic University of Korea, Seoul, South severe bimaxillary protrusion patient will also be
Korea; Department of Orthodontics, Section of Dentistry, Seoul discussed.
National University Bundang Hospital, Seongnam, Gyeonggi Prov-
ince, South Korea.
Corresponding author at: Department of Orthodontics, Section of Biomechanics for total arch distalization in Class
Dentistry, Seoul National University Bundang Hospital, 82, Gumi-
ro 173Beon-gil, Bundang-gu, Seongnam, Gyeonggi Province, South
II maxillary protrusion
Korea. E-mail: nklee@snubh.org In protrusion cases without crowding, the first
© 2022 Elsevier Inc. All rights reserved. step after bonding a 0.022-in slot bracket to the
1073-8746/12/1801-$30.00/0
maxillary second molar is to ligate the bracket
https://doi.org/10.1053/j.sodo.2022.10.015

Seminars in Orthodontics, Vol 28, No 3, 2022: pp 157 163 157

158 Park et al

in a figure eight form from the first molar to the mandibular first and second molars (Fig. 1E). If
first premolar with 0.009-in stainless steel (SS) the maxillary and mandibular incisors are
wire. This preemptively prevents space from extruded during total arch distalization, place an
developing due to molar distalization between exaggerated curve of Spee and a reverse curve of
the first molar and second premolar. Next, place Spee wires to address the issue.
an 0.016-in nickel-titanium (NiTi) wire as the ini- After the finishing stage, a Class I molar rela-
tial wire and progress to an 0.018-in NiTi wire. In tionship and normal overbite and overjet will be
addition, place an MCPP and banded palatal achieved (Fig. 1F).
retraction arch (PRA) to induce molar distaliza-
tion during leveling and alignment (Figs. 1 A, B).
A strategy for total arch distalization in
Then, to maintain space consolidation when
bimaxillary protrusion
changing the wire from 0.016 £ 0.022-in NiTi to
0.019 £ 0.025-in SS, place hooks between the Successful non-extraction treatment in bimaxil-
maxillary lateral incisor and canine and connect lary protrusion patients is determined by the
the first molar with a 0.010-in ligature wire. At amount of total arch distalization of the mandib-
the same time, bond the brackets in the mandib- ular dentition. Therefore, it is crucial for clini-
ular dentition, align and level by moving from cians to understand the biomechanics of
the initial round wire to the full-sized efficient total lower arch distalization.
0.019 £ 0.025-in SS wire (Fig. 1C).
During the maxillary molar distalization,
intrusion of the molars and extrusion of the inci-
Total arch distalization of the mandibular
sors will cause a disocclusion of the posterior
dentition
teeth. Then, insert screws (1.6 mm in diameter, Efficient total arch distalization of the lower den-
8 mm in length) between the mandibular first tition can be considered in two modalities: mild
and second molars and apply elastomeric chains crowding or moderate-to-severe crowding. In
from the screws to the hook between the lateral mild crowding, total arch distalization uses
incisor and canine on the 0.019 £ 0.025-in SS 0.019 £ 0.025-in SS archwire after leveling and
wire (300 g per side) to achieve total arch distali- alignment.
zation (Fig. 1D). To prevent impingement of the However, in moderate-to-severe anterior
mandibular second molar as a result of the distal- crowding, total arch distalization is achieved by
ization, apply box elastics on both sides with 1/4- the following steps: Step 1, the alignment and
in, 4.5 oz size elastics between the maxillary and leveling of teeth except for four incisors

Fig. 1. A. Class II malocclusion, B. A modified C-palatal plate and banded palatal retraction arch, C. Total arch
distalization of the maxillary dentition, D. Insertion of screws between the mandibular first and second molars
and placement of elastomeric chains from screws to the hook between the lateral incisor and the canine, E. Appli-
cation of box elastics between the maxillary and mandibular first and second molars, F, achievement of the Class I
molar and canine relationship, normal overjet, and overbite.
 Improved facial profile with non-extraction treatment of severe protrusion using TSADs 159

Fig. 2. Schematic drawing for total mandibular arch distalization in moderate to severe anterior crowding. A.
Alignment and leveling of teeth except for four incisors, B. Distalization of posterior teeth for incisor space, C.
Leveling and alignment of incisors and distalization of posterior teeth, D. Total arch distalization of the mandibu-
lar dentition.

(Fig. 2A). Step 2, after inserting screws between Total arch distalization of the maxillary
the mandibular first and second molars, the pos- dentition
terior teeth are distalized using elastomeric
After achieving sufficient overjet by total mandib-
chains from the screws to the anterior hook on
ular arch distalization, the treatment process in
the 0.019 £ 0.025-in SS archwire to create space
the maxillary dentition is similar to that of Class
for incisor alignment (Fig. 2B). Step 3, after suffi-
II maxillary protrusion, as shown in Fig. 1.
cient space between the anterior teeth has been
In bimaxillary protrusion, total arch distaliza-
obtained, the four incisors are bonded. Leveling
tion of the maxillary and mandibular dentition is
and alignment of the incisors and distalization of
performed using MCPPs and screws. The overjet
the posterior teeth are accomplished simulta-
is increased by total arch distalization in the man-
neously (Fig. 2C). In Step 4, the mandibular den-
dibular dentition. The placement of a reverse
tition, including the four incisors, is distalized
curve of Spee wire in the mandibular dentition is
with 0.019 £ 0.025-in SS archwire (Fig. 2D).

Fig. 3. A. Class I bimaxillary protrusion, B. Total arch distalization of the maxillary and mandibular dentition, C.
Sufficient overjet after total arch distalization in mandibular dentition, D. Placement of reverse curve wire in man-
dibular dentition; E. Achievement of the Class I molar and canine relationship, normal overjet, and overbite.
160 Park et al

Fig. 4. Initial: intraoral and facial photographs, panoramic radiograph, and lateral cephalogram.

required to avoid deep bite during total arch dis- Class II pattern (ANB=8.5°), a hyperdivergent
talization. After the finishing stage, the Class I pattern (PFH/AFH = 53.0, FMA = 36.5°), and a
molar and canine relationship, normal overjet, Class I molar relationship. Also, the arch length
and overbite are achieved (Fig. 3). discrepancy of her mandibular dentition was
The strategy for treating bimaxillary protru- 6.8 mm (Fig. 4). The treatment time was 3 years
sion illustrated in Fig. 3 was applied in the case of and 6 months. According to the lateral cephalo-
a 15-year-old female patient with lip protrusion metric measurements, her maxillary incisor to
and mandibular anterior crowding as her chief FH decreased by 16°, while IMPA decreased
complaints. Neither the patient nor her parents from 105° to 87.5° and her nasolabial angle
wanted extraction. The patient had a skeletal increased by 7° (Figs. 5 and 6).

Fig. 5. Treatment progress in 28 months.

 Improved facial profile with non-extraction treatment of severe protrusion using TSADs 161

Fig. 6. Debonding: intraoral and facial photographs, panoramic radiograph, lateral cephalogram, and superim-
position.

Discussion
Anatomy of retromolar area for molar
distalization
Traditionally, clinicians have evaluated the dis-
tance between the second molar and anterior
border of the ramus on a lateral cephalogram for
molar distalization. Several studies12,13 reported
that the available space of retromolar area
ranged from 3.5 to 3.9 mm when measured by
cone-beam computed tomography (CBCT).
Yeon et al.14 showed 1.8 mm movement during
mandibular total arch distalization using minis-
crews.
Regarding the application of various TSADs
for the mandibular total arch distalization, a
finite element study demonstrated a greater dis-
tal displacement of the posterior teeth with ramal
plates than with miniscrews. Moreover, ramal
plates produced an extrusive movement due to
the force vector parallel to the line of occlusion
(Fig. 7).15 Fig. 7. Displacement of mandibular dentition during
Additionally, in a clinical comparison total arch distalization according to locations and types
of TSADs. Dotted line, line of occlusion; green arrow,
between ramal plates and miniscrews, the screw between second premolar and first molar; yellow
ramal plates showed 0.2 mm of extrusion of arrow, screw between first and second molars; red
the mandibular first molar, while the arrow, ramal plate.
162 Park et al

Fig. 8. Gingival impingement. A. occlusal view, B. buccal view.

miniscrews showed 1.3 mm of intrusion.14 Due apply force parallel to the line of occlusion as
to the intrusive force vector with miniscrews, it shown in Fig. 7. She demonstrated that there was
could possibly have been some gingival approximately 10 mm of available space for distal
impingement of the mandibular second molar movement in the retromolar area in Class I
during distalization (Fig. 8). group (Fig. 9B).
Kook et al.16 reported 5 mm of movement of
the mandibular first molar during distalization
using ramal plates in full Class III patients. Kim Conclusion
et al.17 also showed 5 mm of distal movement of For successful non-extraction treatment of
the mandibular first and second molars with severe protrusion, clinicians must understand
microimplants. On the other hand, when mea- efficient biomechanics for total arch distaliza-
suring the buccolingual width between buccal tion using TSADs. Therefore, for maximum
and lingual cortices to accommodate the second total mandibular arch distalization in patients
molar (Fig. 9A), Seol18 reported that when ramal with protrusion, it is recommended that the
plates are placed in the retromolar area, they molars be extruded and distalized

Fig. 9. Retromolar area space. A. CBCT view: a. Lingual cortex line, b. Buccolingual width of the second molar
distal root, c. Posterior limit which has buccolingual root width of second molar distal root, d. Available retromolar
area space for distalization, B. Bar graph of the retromolar area in Class I malocclusion with and without third
molars: Horizontal axis (2-, 4-, 6-, and 8-mm) means the distance from the cementoenamel junction to the apical
direction; Vertical axis means available retromolar area space for distalization.
 Improved facial profile with non-extraction treatment of severe protrusion using TSADs 163

simultaneously, which results in a more poste- anchorage plate in adolescents. Angle Orthod. 2015;
rior movement of the mandibular dentition 85:657–664.
without gingival impingement. 5. Kook YA, Bayome M, Trang VT, et al. Treatment effects
of a modified palatal anchorage plate for distalization
evaluated with cone-beam computed tomography. Am J
Orthod Dentofacial Orthop. 2014;146:47–54.
Acknowledgment 6. Kook YA, Lim HJ, Park JH, et al. 3D digital applications of
the modified C-palatal plate for molar distalization. J Clin
The authors thank Tiffany H. Park, dental stu-
Orthod. 2021;55:773–781.
dent at The University of Pennsylvania School of 7. Chou AHK, Park JH, Shoaib AM, et al. Total maxillary arch
Dental Medicine for her help with the prepara- distalization with modified C-palatal plates in adolescents:
tion of the manuscript. A long-term study using cone-beam computed tomogra-
phy. Am J Orthod Dentofacial Orthop. 2021;159:470–479.
8. Kook YA, Park JH, Bayome M, et al. Correction of severe
Patient consent bimaxillary protrusion with first premolar extractions
and total arch distalization with palatal anchorage plates.
Consent to publish the case report was obtained. Am J Orthod Dentofacial Orthop. 2015;148:310–320.
9. Han SH, Park JH, Jung CY, et al. Full-step Class II correc-
tion using a modified C-palatal plate for total arch distali-
Funding zation in an adolescent. J Clin Pediatr Dent. 2018;42:307–
313.
No funding or grant support. 10. Kook YA, Park JH, Bayome M, et al. Application of palatal
plate for nonextraction treatment in an adolescent boy
with severe overjet. Am J Orthod Dentofacial Orthop.
Author contributions 2017;152:859–869.
11. Alfawaz F, Park JH, Lee NK, et al. Comparison of treat-
Jae Hyun Park: Conceptualization, data curation, ment effects from total arch distalization using modified
writing. Yoon-Ah Kook: Writing review & editing. C-palatal plates versus maxillary premolar extraction in
Yoonji Kim: Methodology. Lyun Kwang Ham: Visu- Class II patients with severe overjet. Orthod Craniofac Res.
2022;25:119–127.
alization. Nam-Ki Lee: Data curation, Writing
12. Kim SJ, Choi TH, Baik HS, et al. Mandibular posterior
original draft, Writing review & editing. anatomic limit for molar distalization. Am J Orthod Dentofa-
cial Orthop. 2014;146:190–197.
13. Kim SH, Cha KS, Lee JW, et al. Mandibular skeletal poste-
Declaration of competing interest rior anatomic limit for molar distalization in patients with
Class III malocclusion with different vertical facial pat-
The authors reported no competing financial terns. Korean J Orthod. 2021;51:250–259.
interests or personal relationships that could 14. Yeon BM, Lee NK, Park JH, et al. Comparison of treat-
appear to influence the work reported in this ment effects after total mandibular arch distalization
paper. with miniscrews vs ramal plates in patients with Class III
malocclusion. Am J Orthod Dentofacial Orthop. 2022;
161:529–536.
15. Kim YB, Bayome M, Park JH, et al. Displacement of man-
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