|Year : 2016 | Volume
| Issue : 4 | Page : 331-340
The effectiveness of pendulum, K-loop, and distal jet distalization techniques in growing children and its effects on anchor unit: A comparative study
Pravinkumar S Marure1, Raju Umaji Patil2, Sumitra Reddy3, Amit Prakash4, Nillachandra Kshetrimayum5, Rajeevkumar Shukla6
1 Department of Orthodontics, MIDSR Dental College and Hospital, Latur, India
2 Department of Pedodontics and Preventive Dentistry, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
3 Department of Orthodontics, KLE'S Institute of Dental Sciences, Bengaluru, Karnataka, India
4 Department of Orthodontics, People's College of Dental Sciences, Bhopal, Madhya Pradesh, India
5 Department of Orthodontics Unit, SHIJA Hospital and Research Institute, Langol, Imphal, Manipur, India
6 Department of Orthodontics, Mithila Minority Dental College, Laheriasarai, Darbhanga, Bihar, India
|Date of Web Publication||29-Sep-2016|
Raju Umaji Patil
Department of Pedodontics and Preventive Dentistry, Sinhgad Dental College and Hospital, S. No. 44/1 Vadgaon Budruk, Off Sinhgad Road, Pune - 411 041, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: A common strategy to correct Class II malocclusions using a nonextraction protocol in children is to move the maxillary molars distally using molar distalization appliances, which usually derive their anchorage from maxillary premolars, causing mesialization of premolars and protrusion of incisors. Objectives: To evaluate the skeletal, dental and soft tissue changes produced by three different distalizing appliances, namely, pendulum, K-loop, and distal jet appliances. Materials and Methods: Sixty-six children of mean age 14.13 years requiring molar distalization were divided into three groups: Group I (pendulum appliance), Group II (K-loop), and Group III (distal jet). Lateral cephalometric films were taken before and after 5 months of molar distalization and following cephalometric parameters were used to assess the effects of maxillary molar distalization, namely, anteroposterior skeletal (SNA/SNB/ANB), vertical skeletal (face height ratio/Frankfort-mandibular plane [FMA]/angle formed between Maxillary plane & Mandibular plane (MM)), interdental (overjet/overbite), maxillary dentoalveolar, and soft tissue parameters. Results: There was no significant age difference between the three groups. In overall treatment changes among the three groups, the Anteroposterior skeletal changes were not statistically significant, vertically FMA angle increased by 1.79° ± 2.25° and overbite reduced by 2.38 ± 1.83 mm. The maxillary first molars were distalized by an average of 4.70 ± 3.01 mm (Upper 6 [U6] to pterygoid vertical [PTV]). The maxillary central incisor labial tipping increased to an average of 1.61 ± 2.73 mm and cant of upper lip increased by 3.40° ± 5.88° are statistically significant (P < 0.05). Conclusion: All three distalization techniques in growing children produced significant effects on anchor unit. There was an increase in FMA angle, significant bite opening, proclination of the maxillary incisors and increase in the cant of the upper lip.
Keywords: Distal jet, K-loop, molar distalization, pendulum
|How to cite this article:|
Marure PS, Patil RU, Reddy S, Prakash A, Kshetrimayum N, Shukla R. The effectiveness of pendulum, K-loop, and distal jet distalization techniques in growing children and its effects on anchor unit: A comparative study. J Indian Soc Pedod Prev Dent 2016;34:331-40
|How to cite this URL:|
Marure PS, Patil RU, Reddy S, Prakash A, Kshetrimayum N, Shukla R. The effectiveness of pendulum, K-loop, and distal jet distalization techniques in growing children and its effects on anchor unit: A comparative study. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2020 Feb 18];34:331-40. Available from: http://www.jisppd.com/text.asp?2016/34/4/331/191411
| Introduction|| |
Treatment of Class II malocclusion is one of the most interesting and controversial issues in contemporary pediatric orthodontics. There are various treatment strategies to address the different morphologic characteristics of this malocclusion in children. The therapeutic approaches for correcting it include orthopedic appliances, extraoral or intraoral distalizing appliances and extractions of teeth.  One of the primary concerns in treatment planning must be the final esthetic appearance of the Childs facial profile. A Class II patient usually shows either a protrusive upper jaw, retrusive lower jaw, or both. Correction of the molar relationship is often required for the nonextraction treatment of Class II malocclusions. 
Headgear is effective in maxillary molar distalization, however, this method of Class II correction depends greatly on child cooperation.  To avoid unpredictable results because of patient noncompliance, the need for compliance and the esthetic drawbacks led the clinicians to search for noncompliance alternatives. These concerns have resulted in the development of intraoral distal molar movement appliances that offer noncompliance treatment and continuous forces. Among these are repelling magnets, active transpalatal arches, nitinol coil springs, Jones jig, distal jet, superelastic wires, K-loop, and pendulum appliance.  These appliances usually derive their anchorage from maxillary premolars and mesialization of premolars and protrusion of incisors accompany maxillary molar distalization. To maximize anchorage, these appliances can be used with implants.
Recently, an ever-increasing number of reports regarding implant-supported distalization systems have been introduced in the literature. The studies have described the use of osseointegrated implants, onplants, intraosseous screws, Miniscrew Implant Supported Distalization System and the bone-anchored pendulum appliance in orthodontic patients requiring distalization. , Nur, et al. designed an intraoral appliance, named the zygoma-gear appliance, for bilateral maxillary molar distalization using the titanium anchor plates placed in the zygomatic process of the maxilla.  In recent years, many studies have been published on intraoral distalization appliances. In some of these studies, clinicians have tried to prevent anchorage loss using uprighting bends, occipital headgears, or utility arches.  However, there are limited studies that have evaluated the skeletal, dental, and soft tissue effects of distal jet, K-loop, and pendulum appliances. Hence, the aim of this study was a cephalometric evaluation of the skeletal, dental, and soft tissue changes produced by the three distalizing appliances, pendulum, K-loop, and distal jet appliances.
The aim of the study was to analyze the effects of molar distalization appliances on the hard and soft tissues cephalometrically:
- Amount and type of maxillary molar movement
- Labial movement of incisors
- Soft tissue changes.
| Materials and Methods|| |
Sources of data
The present prospective clinical study was carried out in the department of orthodontics. The sample comprised 66 subjects (26 boys and 40 girls) and the age range was 11-21 years with mean age of 14.13 years [Table 1]. The patients who required molar distalization and satisfying inclusion criteria were selected for the study.
- Skeletal-Class I/II skeletal pattern
Normal/short lower face height
- Class II or end on molar relationship
- Mixed or permanent dentition
- Mild to moderate crowding/proclined in maxillary arch
- Hypodivergent or average growth pattern
- Well aligned teeth or mild crowding in mandibular arch
- Straight profile or mild convex profile
- Patients with Normal TMJ function.
- Hyperdivergent growth pattern patients.
The sample consisted of three groups: Group I (pendulum appliance), Group II (K-loop), and Group III (distal jet) [Table 1].
Group I comprised 22 subjects (14 boys, 8 girls) with a mean age of 14.27 years, treated with the pendulum appliance [Figure 1]. The pendulum appliance consisted of a Nance button, bands on the first premolars, and pendulum springs as described by Hilgers.  The right and left pendulum springs were formed from 0.032" beta-titanium wire and consisted of a recurved molar insertion wire, a small horizontal adjustment loop, a closed helix, and a loop for retention on the acrylic button. The springs were inserted in the lingual sheaths on molar bands. The Nance button was held in place with a soldered retaining wire to the bands on the first premolars. The molar bands were cemented. Before placement of the appliance, the springs were bent parallel to the midline of the palate for activation and then inserted in the lingual sheaths on the molar bands. The force applied was 230 g. The patients were seen once per month and the pressure exerted by the springs was checked. When the molars achieved a Class I occlusion, the appliance was replaced with a Nance button for retention.
Group II comprised 24 subjects (4 boys, 20 girls) with a mean age of 13.33 years, treated with K-loop appliance [Figure 2]. The K-loop was constructed according to the description by Kalra.  The K-loop was made from 0.017" Χ 0.025" TMA wire and located between the upper first molar and the first premolar. The K-loop was activated to produce 200 g of force. After placement of the appliances, patients were monitored every 4 weeks, and the K-loop was activated every 6 weeks. When the molars achieved a Class I occlusion, the appliance was replaced with a Nance button for retention.
Group III sample consisted 20 subjects (8 boys, 12 girls) treated with distal jet appliance [Figure 3]. The mean age of the patients was 14.80 years. The distal jet coil springs were activated every four to 6 weeks. 240 g of force generated by the nickel-titanium coil spring was used as recommended by Carano and Testa (240 g).  Once a "super Class I" molar relationship was achieved, the distal jet was converted to a large Nance holding arch by removing the coil springs.
Lateral cephalometric films were taken before and after 5 months of molar distalization of 66 patients [Figure 4]. The pretreatment and postdistalization cephalograms were traced on a 75 μm lacquered polyester acetate tracing papers using a 0.05" lead pencil. A single operator performed the tracings in a standardized manner to avoid errors due to any interoperator variations. The following cephalometric parameters were used to assess the effects of maxillary molar distalization [Figure 5].
- Anteroposterior skeletal: SNA angle (), SNB angle (), and ANB angle ()
- Vertical skeletal: Face height ratio (%), Frankfort-mandibular plane (FMA) angle (), and MM angle ()
- Interdental: Overjet (mm), overbite (mm)
- Maxillary dentoalveolar: U6 to PTV horizontal (mm), U6 to palatal plane (), U6 to Palatal plane vertical (mm), Upper 1 (U1) to palatal plane angle (), and U1 to PTV (mm)
- Soft tissue: Ls to "E" line (mm), Li to "E" line (mm), and Cant of upper lip angle ().
Method of statistical analysis
The following methods of statistical analysis have been used in this study. Data were entered in Microsoft Excel and analyzed using Statistical Package for Social Science, Version 10.0.5 (IBM SPSS Inc. New York US) package.
1. The results were averaged (mean standard deviation) for each parameter for continuous data and numbers and percentage for categorical data presented. The mean values were tested for significant difference using a Student's t-test
x 1 and x 2 are sample mean and s 2 is a pooled variance.
2. Proportions were compared using Chi-square test of significance
Chi-square test for (r Χ c tables)
a , b0…h are the observed numbers
N is the grand total
DF = (r − 1) Χ (c − 1), where r = rows and c = columns
DF = Degrees of freedom (number of observation that is free to vary after certain restriction have been placed on the data).
In all above test, P < 0.05 was taken to be statistically significant.
Method error test
A month after the measurements were made, twenty randomly selected traced radiographs were selected, retraced, and re-measured to evaluate intraoperator reliability and reproducibility of various parameters. The mean, standard deviations and standard error were calculated for each parameter. The standard error of measurement was computed according to Dahlberg's formula. There was no significant variability in reproducing these measurements.
| Results|| |
There was no significant age difference between the three groups. Descriptive statistics, including mean and standard deviation for observations of pretreatment and posttreatment soft tissue, skeletal, and dental changes measured from cephalometric radiographs [Table 2].
|Table 2: Mean, standard deviation for Group I (pendulum), Group II (K - loop), and Group III (distal jet) appliances|
Click here to view
[Table 3], shows the overall treatment changes in the three groups. The anteroposterior skeletal changes were not statistically significant, vertically FMA angle increased by 1.79 2.25 and overbite reduced by 2.38 1.83 mm. The maxillary first molars were distalized by an average of 4.70 3.01 mm (U6 to PTV). The maxillary central incisor labial tipping increased to an average of 1.61 2.73 mm and cant of upper lip increased by 3.40 5.88, are statistically significant (P < 0.05).
|Table 3: Pre - and post - distalization overall measurement in the Group I (pendulum), Group II (K - loop), and Group III (distal jet) appliances|
Click here to view
| Discussion|| |
A Class I molar relationship is an integral part of precisely defined relationships; it has an overall impact on the stomatognathic system, neuromusculature, and facial esthetics. Because a balanced occlusion with normal function requires an occlusal relationship in which centric relation coincides with centric occlusion, correcting the posterior occlusion into an ideal Class I relationship, together with a Class I canine relationship becomes an important goal. In conventional orthodontic therapy for Class II malocclusion, it might be necessary to use a distalizing appliance to correct the molar relationship. 
A common strategy to correct Class II malocclusions using a nonextraction protocol is to move the maxillary molars distally during the initial stage of treatment to convert the Class II molar relationship to a Class I molar relationship. In conventional orthodontic therapy for Class II malocclusion, it might be necessary to use a distalizing appliance to correct the molar relationship.  Although requiring minimal patient compliance to produce molar distalization, several studies have suggested that many intraoral devices produce adverse treatment effects, such as maxillary first molar tipping, anchorage loss (exhibited in the incisors as mesial movement), clockwise rotation of the mandibular plane, increased anterior face height and lip protrusion. ,,
The present study showed that the changes in the SNA, SNB, and ANB angles were insignificant in all the three groups [Table 3] and [Figure 6]. de Almeida-Pedrin et al.  reported that in the maxilla there were statistically significant reductions in the variables SNA and Nperp-A in headgear group and extraction group and a mild increase in pendulum group. There were no significant differences in the mandibular measurements (SNB and Co-Gn). For the maxillomandibular relationships, there were reductions in the ANB angles in the headgear (-1.2 mm) and extraction (-1.7 mm) groups; no change was observed in the pendulum group (0.0 mm). Polat-Ozsoy  reported that the pendulum/K-loop appliance showed insignificant changes in both the maxilla and the mandible. However, in the headgear group, the maxilla moved backward by 1 mm, and the mandible rotated posteriorly causing a decrease in SNB of 0.9 mm and an increase in GoGnSN of 0.9 mm. The overall change in treatment between the pendulum and headgear groups in SNA was statistically significant (P ˂ 0.05).
|Figure 6: Pre-and post-distalization overall measurement in the Group I (pendulum), Group II (K-loop), and Group III (distal jet) appliances|
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Byloff et al.  reported that the skeletal changes of the maxilla, the SNA angle showed no statistical differences, confirming other studies. ,, The author suggested that A point was not affected by anteriorly oriented forces within a relatively short period. Thus, the effect was reflected by dental anchorage loss. Bussick and McNamara  reported that there was the minimal sagittal skeletal effect of pendulum treatment was reflected in the change in the ANB angle, which increased 0.4.
Angelieri et al.  reported that the maxilla and mandible showed similar behavior during orthodontic treatment with the pendulum and fixed orthodontic appliance. There was a statistically significant reduction in the SNA and SNB angles of 1.1 and 1.5, respectively. Alterations were kept constant during leveling and aligning. After retraction of the maxillary anterior teeth, there was a statistically significant increase in all variables: 1.6 for SNA and 1.5 for SNB returning to the initial values found at pretreatment, with no statistical significance. Thus, the maxillomandibular relationship was not statistically significantly altered during treatment, because there was reduction or increase of both angles related to the maxilla and mandible simultaneously and almost to the same extent.
In this study, mandibular plane (FMA) showed a small backward rotation of 1.79 with distalization [Table 3] and [Figure 6], in Groups I and III, it was increased by 1.59 and 4.10 respectively (P ˂ 0.05). According to most studies on the pendulum appliance, , significant increase in the vertical dimension must be expected. These vertical changes comprise a slight opening of the mandibular plane angle (about 1) and an increase in lower anterior facial height (2.2-2.8 mm). [ 20] Chaquιs-Asensi and Kalra  reported that Lower facial height (ANS-Me) increased by 2.8 mm, while the mandibular plane angle increased by 1.3 with the pendulum appliance. Bussick and McNamara  found no significant difference in lower anterior facial height increase among patients with high, neutral, or low mandibular plane angles, whereas Ghosh and Nanda  reported that the increase in lower anterior facial height was significantly greater in patients with higher pretreatment mandibular plane angles. The increased lower facial height and mandibular plane angle could have resulted from driving the molars back into the "wedge."  These results suggest that the pendulum may be contraindicated in patients with excessive lower facial height and/or minimal overbite.  In Group III, greater increments in vertical dimensions were produced than those reported by other authors. 
Chiu et al.  found that the effects of the pendulum and distal jet appliances on vertical skeletal relationships have had a slight opening of the mandibular plane angle (about 1) and an increase in lower anterior facial height (2.2-2.8 mm).
In the present study, the interdental measurements of all three groups demonstrated highly significant changes from pre- to post-treatment. The overall overbite reduction was 2.38 mm. The overbite decreased by 2.31, 2.16, and 2.80 mm in Groups I, II, and III, respectively [Table 3] and [Figure 6]. Ghosh and Nanda  also showed that the overbite decreased by 1.39 mm in pendulum appliance groups. Bussick and McNamara  reported that the overbite decreased by 1.7 mm as a result of pendulum appliance. Chaquιs-Asensi and Kalra  reported that the overbite reduced by 1.8 mm. Chiu et al.  reported that the distal jet group had a significantly greater decrease in overbite (2.9 mm) than the pendulum group (1.2 and 1.7 mm, respectively).
de Almeida-Pedrin et al.  showed that the maxillary incisors exhibited significant changes among groups with regard to buccolingual tipping (1-NA and 1-PP) and anteroposterior positioning (1-NA). In the extraction group, the anterior teeth had greater incisor flaring and overjet than did the other two groups (pendulum and headgear). The incisors in the pendulum and headgear groups generally were maintained in their initial orientation, with only mild buccal crown tipping, probably due to tooth alignment and leveling with fixed appliances. Angelieri et al.  also observed mild buccal tipping of these teeth during orthodontic treatment with pendulum and fixed appliances. Sagittally, the retraction of the maxillary incisors in the pendulum and headgear groups, was modest, and their magnitude was statistically different compared with the extraction group.
Maxillary dentoalveolar changes
All groups showed a significantly larger amount of molar distalization with an average of 4.7 mm [Table 3] and [Figure 6]. In the present study, the distal movement of maxillary first molars in the Group I was 6.4 mm, with a distal tipping of 7.3. Hilgers,  reported that 5 mm of distal molar movement in three to 4 months. Ghosh and Nanda  showed that the maxillary first molar distalized by 3.37 mm and tipped distally 11.99. Byloff and Darendeliler  showed that the pendulum appliance moved the molars distally with a mean of 3.39 mm, with a distal tipping of 14.5. Bussick and McNamara,  showed that the average maxillary first molar distalization was 5.7 mm, with a distal tipping of 10.6. Chaquιs-Asensi and Kalra  reported that the maxillary first molars moved distally 5.3 mm, tipped distally 13.1. Fuziy et al.  showed that the mean distalization of the maxillary molars was 4.6 mm, with a mean distal crown tipping of 18.5.
In Group II, the mean molar distalization was 2.25 mm [Table 3] and [Figure 6]. Kalra  reported that 4 mm of molar distalization was achieved with K-loop appliance.
In Group III, the average molar distalization was 3.9 mm [Table 3] and [Figure 6]. Ngantung et al.  showed that the maxillary first molars were distalized with the distal jet appliance by an average of 2.1 1.8 mm. Bolla et al.  demonstrated that the crowns of the maxillary first molars were distalized an average of 3.2 mm. Chiu et al.  reported that the pendulum group showed a significantly greater correction of molar relationship and a significantly larger amount of molar distalization compared with the distal jet group (3.8 and 2.8 mm, respectively).
The overall results of a present study [Table 3] and [Figure 6] demonstrated labial tipping of upper incisor with a mean of 3.72 and 1.6 mm (U1 to palatal plane and U1 to PTV respectively).
In the present study, there was no incisor proclination noticed in the Group I. Ghosh and Nanda  found an incisor proclination of 2.4 relative to the SN line. Likewise, a mean of 1.71 of labial tipping was measured by Byloff and Darendeliler  and an average of 1.8 mm of anterior movement of the incisor edge. In Group II, upper incisor to PTV distance increased showing the labial movement of upper incisor. In Group III, the position of the maxillary incisor to palatal plane increased significantly from pretreatment to after distalization (6.7). Ngantung et al.  reported that the maxillary incisor to the cranial base (SN) angle increased an average of 12.2. Bolla et al.  showed that the maxillary incisors were proclined an average of 0.6. Chiu et al.  reported that the pendulum (U1-FH = 3.1) subjects showed significantly less anchorage loss at the maxillary incisors than the distal jet subjects (U1-FH = 13.7).
Soft tissue changes
Prediction of soft tissue changes is difficult because of the vast number of variables to consider. Differences in soft tissue thickness and tension between individuals produce a complex variation in profiles as demonstrated by hard tissue changes. However, changes in the positions of the incisors do have a direct impact on the supporting soft tissues.  Most of the previous studies on variations of the pendulum appliance have focused on soft tissue changes relative to the E-plane. 
The present study showed statistically significant increase in the cant of the upper lip with a mean of 3.40 [Table 3] and [Figure 6]. Ghosh and Nanda  evaluated the soft tissue changes relative to the E-plane and reported a 0.31 mm protrusion in the upper lip and a 0.95 mm protrusion in the lower lip due to upper incisor protrusion. Bussick and McNamara  evaluated four soft-tissue variables: Upper incisor and lower incisor position relative to the E-plane, nasolabial angle, and cant of the upper lip. Their results also showed protrusion in both the upper and lower lips and a 2.5 decrease in the nasolabial angle and 2.0 decrease in the cant of the upper lip, reflecting a slight protrusion of upper lip contour. Ngantung et al.  reported that the upper lip to Rickett's E-plane increased an average of 0.8 2.2 mm in the distal jet appliance group. There exists only one study that showed a 0.4 mm retrusion of the upper lip relative to the E-plane, and the results of that study were found insignificant. 
Finally, although the results of this study indicate that the pendulum, K-loop, and distal jet appliances are effective in moving the maxillary molars distally, the clinical use of these appliances has some undesired effects, increase in mandibular plane angle, labial movement of maxillary incisors and soft tissue profile change. These should be considered by the clinician and make sure that this treatment technique is appropriate for the specific patient. It is well known that Class II malocclusion can be due to a number of differing causes.  This treatment protocol should be used only in those patients who would benefit from maxillary molar distalization.
Limitations of the study
- Cephalograms are two-dimensional representations of three-dimensional objects. Hence, the exact representation of the landmarks was not possible. Perhaps the most important limitation of cephalometry relates to the errors inherent with the identification and recording of the structures therein
- The sample size was small and hence larger sample size would have been desirable to increase statistical power.
Scope for the future study
A study can be planned with a larger sample to study the changes with Temporary Anchorage Devices using advanced diagnostic aids like cone beam computed tomography can be a useful tool with minimal identification error.
| Conclusion|| |
Pediatric orthodontists have been specifically interested in facial growth and development.  To fight a borderline case, distalization is an important weapon in growing children and patient selection is of utmost importance and should not be overlooked.  The following conclusion can be drawn from the present study with the pendulum, K-loop, and distal jet appliances:
- No significant anteroposterior skeletal changes (SNA, SNB, and ANB angles) were observed after distalization
- The Frankfort-mandibular plane angle was slightly opened after distalization and significant bite opening was noticed
- The significant amount of first molar distalization was achieved (4.7 mm)
- The maxillary incisors showed labial tipping
- A statistically significant increase in the cant of the upper lip with a mean of 3.4
| Summary|| |
The present study showed effective distalization of the molars with the pendulum, K-loop, and distal jet appliances. There was an increase in FMA angle, significant bite opening, proclination of the maxillary incisors and increase in the cant of the upper lip. Therefore, these appliances should be used with caution. The conventional distalization appliances can be substituted by temporary anchorage devices to prevent maxillary incisors proclination.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]