# Sandibular Molar Distalization in Class III Malocclusion: A Systematic Review
## 4 Discussion
### MMD with Skeletal Anchorage
#### 4.2.1 TADs  
TADs are widely used as stable anchorage in orthodontic treatments in which significant tooth movement is required. TADs in various applications have been demonstrated to optimize orthodontic mechanics, they need very little cooperation from the patient, and they reduce adverse side effects such as mesialization of the anterior anchorage teeth, premolar tipping, molar extrusion, and protrusion of anterior teeth. Advantages of TADsinclude a decreased treatment period, simple surgical insertion and removal, and a lower risk of potential morbidity [39; 40]. Correction of an open bite in a TCM is more challenging when approached nonsurgically, but it is made possible through orthodontic methods with skeletal anchorage [41; 42]. Several studies have reported that the total distalization of the mandibular dentition was successful when using skeletal anchorage, and maximizing the distalization of the mandibular arch was seen to reduce the effect of the increased concave profile; this is characteristic of a TCM, given the counterclockwise rotation of the mandible [34; 43]. The results of [PERSON] et al. in 2013 also suggest that the application of TADs in the posterior area of the mandible is an effective systematic for nonsurgical TCM treatment [41] (Figure 4A,B). The application methods of TADs are varied. A study by [PERSON] in 2013 showed that the direct use of mini-screws in the retromolar area required less time and more body movements to retract the mandibular arch without patient cooperation, and this was a better choice for patients with the potential for TJM disorders [34]. [PERSON] at al. evaluated cases in which TADs were used for MMD as a function of different force angulations to the mandibular occlusal plane, and for the camouflage treatment of various types of skeletal TCMs. The use of TADs between the roots of premolar and molar, coupled with a thorough knowledge of biomechanics and anatomic limitations, can successfully produce a correct and controlled MMD treatment [44; 45]. Generally, two TADs were inserted into the mandibular arch after leveling the plane; one was inserted into the interradicular bone between the mandibular right second premolar and first molar, and the other was inserted between the mandibular left second premolar and first molar. The TADs were placed in different interradicular areas, such as the mandibular left first and second molars, to prevent root damage during installation [46]. [PERSON] et al. used two TADs that were 1.5 mm in diameter in the buccal alveolar bone, one between the mandibular left second premolar and the first molar, and the other between the maxillary right second premolar and the first molar, to provide anchorage in order to correct of a case of TCM subdivision left [47]. TCM treated nonsurgically, with the help of Class III elastics, led to an increase in the angle of the mandibular plane, as compared with the use of TADs which decreased the angle [48]. Class III elastics were preferred for patients with a low angle and short face, whereas TADs were preferred for patients with a high angle and long face [29]. As the direction of the retraction force given to the mini-screws is above the center of resistance of the mandibular arch, the occlusal plane flattens, and the mandibular arch rotates counterclockwise during the distalization movement [49] (Figure 5). As the mini-screws' retraction force is delivered in a direction that is above the mandibular arch's center of resistance, the mandibular arch can be turned counterclockwise when distalized, creating an occlusal plane that is flat [50; 51]  
Figure 4: (**A,B**) TADss application sites for MMD. The goal of a study sponsored by [PERSON] and colleagues in 2018 was to compare the effectiveness of a TCM treatment with the removal of two mandibular premolars and the MMD technique. However, regarding the treatment of MMD with skeletal anchorage, it has been seen that the effectiveness of the two treatments when compared is similar in terms of greater patient comfort and less stress [31].