case study

J. Stomat. Occ. Med. (2012) 5:134142

DOI 10.1007/s12548-012-0050-y

Posterior scissor bite and lateral open bite with

missing lower first molar and second premolar
TeresaPinho

Received: 28 January 2012 / Accepted: 15 May 2012 / Published online: 21 June 2012
Springer-Verlag 2012

Abstract This article presents an adult patient with scissor bite in the posterior region, lateral open bite with a
missing first molar and a second premolar on the lower
left side. The scissor bite was difficult to correct due to
severe occlusal difficulties in the lower left arch with a
highly titled and extruded third molar. After third molar
extractions (except left mandibular molar), the first step
was to upright the lower second molar with a helical
loop, replaced in a second step by a multiloop edgewise
archwire including the third molar in order to correct
the occlusal plane, uprighting and intruding the posterior teeth (second and third molar) and extruding the
lateral teeth (canine and first premolar). In a third step,
after the occlusal space was obtained on the teeth with
previous scissor bite, the upper second molar buccal inclination was also improved with a helical loop followed
by a multiloop edgewise archwire technique.
Keywords: Scissor-bite, Helical loop, Multiloop edgewise archwire, Orthodontics, corrective, Malocclusion,
therapy

Introduction
The primary problems of scissor bite correction are[1, 2]:
Buccal tipping with hyperextrusion of the maxillary
molar
Lingual tipping with overextrusion of the mandibular
molar
Molar 3-dimensional (3D) positioning
Lack of space to place appliances on the palatal side
of the maxillary molars and on the buccal side of the
mandibular molars
T.Pinho,Ph.D.()
Instituto Superior de Cincias da Sade-Norte, Centro de
Investigao Cincias da Sade (CICS), Rua Central de Gandra,
1317, 4585116 Gandra, PRD, Portugal
e-mail: terpinho@netcabo.pt; teresa.pinho@iscsn.cespu.pt

134

In addition, loss of one tooth can have significant effects,

mainly worsening the stability of the occlusion [3].
Several treatment procedures have been proposed to
treat scissor bite on molars:
Transpalatal arch appliance (TPA) with intramaxillary
elastics [4, 5]
Removable or fixed anterior maxillary bite plate [3, 6]
Bite turbos on the palatal surface of the maxillary incisors [2]
Lingual arch appliance with a bite plate at an early age
in conjunction with intramaxillary and intermaxillary
elastics [2]
Miniscrew anchorage [7, 8]
Surgical methods for true (skeletal) buccal crossbite
cases [9].
The first step of treatment for a scissor bite correction is
simultaneous intrusion and palatal tipping of the maxillary molar to allow mandibular molar movement without
resistance. The second step is to bring the mandibular
molar into the correct location. Subsequently, it is easier
to improve the maxillary molar adequate occlusion after
correction of the mandibular molar transverse relation
ship [1].
In this case the scissor bite was difficult to correct due
to severe occlusal difficulties on the lower left arch with
an extruded and highly titled third molar due to first
molar and second premolar previous extractions.

Case report
A 24-year-old woman reported a previous orthodontic
treatment with extraction of both upper and lower right
premolars without correcting the occlusion on the left
side when she was 16 years old and 8 years later a new
orthodontic treatment was suggested because chewing
on the left side was not possible. The patient was aware
and concerned about the scissor and open bite conditi-

Posterior scissor bite and lateral open bite with missing lower first molar and second premolar

case study
Fig. 1 Pretreatment smile
and intraoral photographs

ons and with the family incidence of gingival recession

and other periodontal problems.
The intraoral examination showed bilateral scissor
bite, at the right third molars level and on the left side,
between the third lower molar and the second maxillary
molar (Fig.1).
The mandibular left first molar and second premolar
had been extracted at an earlier age due to poor endodontic prognosis and for orthodontic reasons, resulting
in mesial tipping and drifting of the second and third
molars. This left side malocclusion was partially due
to labial tipping of the upper second molar and partially because of the loss of the second premolar and first
molar on the lower arch. The lower third molar implicated in the scissor bite was very extruded and the patient
also presented an open bite condition on the left side,
from the central incisor to the teeth that had scissor bite
allowing lingual interpositioning. A thin gingival biotype
with a tendency of generalized gingival recession was
present, seen more on the upper first molar, (Fig.1).
The patient presented a molar Class III and a canine
Class I on the right side, and a canine Class III on the

left side. The lower dental midline was deviated 1.5mm

towards the right with normal overjet and overbite
(Fig.1).
The patient complained of temporomandibular joint
symptoms on the left side and the extraoral examination
showed some movement limitation during jaw opening.
There was a right functional shift confirmed by the lower
dental midline deviation on the right and a crossbite tendency on the right side, due to interference of the implicated scissor bite teeth (Fig.1).
Mandibular closure in the centric relation exaggerated
the open bite obtained in the maximum intercuspidation
position by only having the posterior teeth in contact
(Fig.2).
The panoramic radiograph (Fig.3) showed severe tipping and mesial drifting of the second and third molars
into the lower second premolar and first molar missing
space.
Cephalometric analysis in maximum intercuspidation
(Fig.4 and Table1) indicated a skeletal Class II pattern
but with an alveolar Class III if the points A and B were
projected over the occlusal plane (Ao/Bo=0.9mm).

Posterior scissor bite and lateral open bite with missing lower first molar and second premolar

135

case study

Fig. 3 Pre-treatment panoramic x-ray of the patient dentition

Fixed prosthesis rehabilitation supported by a dental

implant on the lower left side to stabilize the posterior
occlusion

Treatment alternatives

Fig. 2 Dental casts before treatment in centric relationship

Treatment objectives
Occlusal plane reconstruction by eliminating the open
bite and scissor bite conditions, achieving an acceptable occlusion with a good functional occlusion

Several procedures have been suggested for the correction of a scissor bite.
Intermaxillary elastics alone or in combination with
a transpalatal arch or a maxillary arch appliance with
a bite plate in conjunction with intermaxillary elastics.
However, in the present case such treatment would cause
more molar extrusion and consequent augmentation in
posterior interferences with ineffectiveness on open bite
correction.
Miniscrews could be used to correct the scissor bite on
the upper left second molar with molar intrusion; however, this procedure would not allow for occlusal plane
reconstruction and the open bite would not be corrected.

Fig. 4 Pretreatment lateral

cephalometric rx and tracing

136

Posterior scissor bite and lateral open bite with missing lower first molar and second premolar

case study
Treatment plan
Third molar extraction with exception of the left mandibular molar.
The treatment plan consisted of improvement of the
lower left second molar tip-forward with a helical loop,
followed by a multiloop edgewise archwire on the lower
arch in order to correct the occlusal plane with uprighting and intrusion of the posterior teeth and lateral teeth
extrusion on the left side. After occlusal space resettlement on the teeth with scissor bite the wire on the upper
arch was extended to the second molar, first with a helical loop and then with a multiloop edgewise archwire.

Treatment details
In the first stage the fixed appliance (0.022 inch slot) was
applied both on the maxillary and mandibular arches,
excluding the teeth that were implicated in the scissor
bite (left upper second molar and lower third molar).
For maxillary teeth alignment and leveling, a sequence
of 0.014 inch and 0.018 inch nickel titanium arches
was used, later replaced by rectangular steel arches
(0.0160.022 inch and 0.0180.025 inch). In the lower
arch 0.014 inch and 0.016 inch nickel titanium arches
were used simultaneously with a 0.0160.022 inch and
then a 0.0180.025 inch stainless steel arch with a helical loop and an overlayed nickel titanium archwire (first
without the 34 ligature and then including this tooth);
monthly sequential tip-back activation in order to
improve the position of the second lower molar was done
(Fig.5a). Once this tooth was in a better position a multiloop edgewise archwire (constructed with a 0.0160.022
inch stainless steel wire), was used, including the third
molar (Fig.5b, c).
Due to correction of the lower occlusal plane with
uprighting and intrusion of posterior teeth and extrusion of the lateral teeth, an occlusal space was obtained
between the teeth implicated in the scissor bite (Fig.6a).
After that the wire was extended to the second molar, first
with a 0.0160.022 inch and then with a 0.0180.025
inch stainless steel wire with a helical loop, monthly and
sequentially activated with crown lingual activations, in
order to improve the labial torque of the second upper
molar (Fig. 6a, b), then replaced by a multiloop edgewise archwire (Fig. 6c). Class I and Class III elastics in
the anterior loops were applied on the right and left side
respectively, in order to obtain a synergetic effect during
the tip-back correction of the posterior teeth (Fig.6a). A
crossed elastic was also applied in order to maximize the
palatal movement of the molars and to improve lower
third molar lingual tipping and vestibular tipping of the
second upper molar, respectively (Fig.6b).
The active treatment took 24 months. Photographs,
dental casts, panoramic and cephalometric x-rays were
done at the end of the treatment and impressions were
taken to elaborate a maxillary wrap-around retainer

Fig. 5 a Tip forward measurement of the first lower left molar.

b Lower arch with a 0.0160.022 inch stainless steel with a
helical loop (no 34 ligature) overlay, a nickel titanium archwire
and upper arch with a 0.016 inch stainless steel and a vertical
elastic 1/4 (31/2oz). c Beginning of the use of a multiloop
edgewise archwire in the lower arch including the third molar
and a straight wire 0.0160.022 inch stainless steel in the
upper arch

(Figs.7 and 8). At the mandible a lingual bonded retainer

was placed on the lingual surfaces of the lower incisors
and canines, as well as a plastic retainer on the lower
teeth in order to maintain the space in the third quadrant
until the implant and crown rehabilitation had been
concluded.

Posterior scissor bite and lateral open bite with missing lower first molar and second premolar

137

case study

the temporomandibular joints was reported and the right

functional shift was corrected.
Cephalometric analysis (Figs. 8, 9 and Table 1) showed no skeletal changes in the maxilla or in the mandible, as expected in an adult. Nearly all cephalometric
measurements were maintained at pretreatment levels,
except the incisors that were slightly retroinclined and
the overbite that increased (within a normal range). Also
the uprighting and the intrusion of the molar could be
observed , which could be confirmed by the panoramic
x-ray, as well as an acceptable root parallelism (Fig.10).
The alveolar bone showed no significant alterations,
except for the teeth that were located mesial and distal
to the extraction space on the mandibular left area, to be
rehabilitated by an implant later on. No evidence of root
resorption was observed (Fig.10).
One year after the orthodontic treatment, the dental
occlusion and smile remained stable but the gingival
recession increased (Fig. 11). For this reason a connective tissue graft was done to improve gingival recession,
1 year and 6 months after the orthodontic treatment
(Fig.12).

Discussion

Fig. 6 a Three months after the beginning of the multiloop

edgewise archwire in the lower arch; fixed appliance in upper
arch extended to the second molar with a 0.0160.022 inch
stainless steel with a spiro. b Arch 0.0180.025 inch stainless
steel with a spiro; cross elastic applied daily from vestibular
face of 27 to lingual face of 38. c Multiloop edgewise arch wire
also in the upper arch

Treatment results
Posttreatment records (Figs.7 and 8) showed a well-aligned and intercuspidated dentition with a stable occlusion on the right side with a molar and canine Class I and
on the left side with a canine Class I and a molar Class
II. The scissor bite and the lateral open bite on the left
side were corrected. Mandibular left posterior teeth were
intruded and controlled successfully. No discomfort near

138

Some authors have reported that maxillary molars erupt

with buccal torque of the crown and then upright with
time, while mandibular molars erupt with lingual torque
of the crown and then upright with age [10].
In this case all of the third molars were in scissor bite
condition. This was corrected on the right side by the
extraction of right third molars before the beginning of
the second stage orthodontic treatment.
The problem worsened on the left side by mesial tipping of the second and third molars and the scissor bite
was due to a high labial torque of the upper second molar
and a high extrusion of the lower third molar. The other
teeth on this side were intruded leading to an open bite
from the central incisor to the scissor bite teeth. The patient stated that all of these problems were not corrected
by the inefficient technique that was used at the time of
the first orthodontic treatment.
The patient complained of temporomandibular joint
symptoms on the left side, the same side as the severe
malocclusion. Although a crossbite itself might not have
caused pathogenesis in a young patient [2], some authors
suggest that in the mixed dentition stage, adaptive remodeling in the temporomandibular joints may occur [11]
and this may promote asymmetric mandibular growth
[12, 13]. In this case there were no signs of an asymmetric face but a compromised mastication could possibly
lead to temporomandibular disfunction. Also, the severe
open bite in the centric position only with posterior contacts, the right functional shift due to the scissor bite teeth
interference as well as the mesial tipped distal cusps of
the second and third molars created excursive deflective
occlusal contacts that generated horizontal forces on the
ipsilateral molars [3].

Posterior scissor bite and lateral open bite with missing lower first molar and second premolar

case study
Fig. 7 Intraoral photos after
the orthodontic treatment

Fig. 8 Posttreatment lateral

a cephalometric radiograph
and b diagrammatic representation of ???

In this current case there were no width problems in

the mandibular base, as at most scissor bite cases [13, 5,
14] so orthodontic surgery treatment was not applicable

[9, 15] although in the present case the treatment options

were limited.

Posterior scissor bite and lateral open bite with missing lower first molar and second premolar

139

case study
Fig. 9 Diagrammatic representation of maxillary, mandibular
and perfil superpositions before and after the orthodontic
treatment (Bjork method)

Fig. 10 Panoramic x-ray after implant and crown rehabilitation in the third quadrant
Table 1 Cephalometric analysis before and after treatment
Cephalometric analysis

Normal

Before
Treatment

After
Treatment

FMIA

673

69.0

68.4

FMA

253

23.5

25.7

IMPA

883

87.5

85.9

SNA

822

83.1

82.4

SNB

802

78.5

77.5

ANB

15

4.6

4.9

Ao Bo

2mm2

0.9mm

1.9mm

Overjet

2.5mm2.5

3.2mm

3.0mm

Overbite

2.5mm2.5

2.4mm

3.8mm

Interincisal angle

12610

138.9

141.2

In spite of the lack of bone due to early extraction of

the teeth, some body teeth mesialization had occurred
on the mandibular left second and third molars and the

140

remaining extraction space resulted in the extraction of

two teeth that were rehabilitated only by one implant and
a molar Class II relationship was obtained at the end of
the treatment. Nevertheless, a stable occlusion and functional results were achieved. The horizontal bone defect
was improved during the implant surgery by alveolar
bone regeneration techniques.
When correcting a scissor bite, vertical space is needed for easy tooth movement [2, 6]. The critical procedures for scissor bite correction are intrusion and palatal or
buccal tipping of the involved teeth when they are both
extruded and buccally or lingually tilted [1]. Usually,
with the loss of a mandibular first molar, the mandibular
second and third molars tip mesially and the opposing
maxillary first molar supraerupts [3]. In this case in spite
of the second and third molars that were tipped mesially,
the upper second molar had high labial torque but presented no extrusion and only the lower third molar was
highly extruded. Therefore, first the occlusal plane had to
be improved on the lower arch by intrusion of the third
molar and only after a correct occlusal space was obtained between the scissor bite teeth, was the labial tipping
of the upper second molar ready to be corrected. For this
a wire with a helical loop, then replaced by a multiloop
technique, as well as a combined synergistic effect of
elastic forces were essential. Also, the open bite closure
was accomplished by intrusion of the posterior teeth and
extrusion of the lateral teeth due to different activation
of the loops and also due to the synergetic effect of the
elastics.
Mesial tipping of the mandibular second molar can
result in redundant edematous gingival accumulating
plaque at the tooth mesial surface, creating a defect

Posterior scissor bite and lateral open bite with missing lower first molar and second premolar

case study
Fig. 11 Smile and intraoral
photographs 1 year after the
orthodontic treatment

that cannot be properly cleaned with routine home care

procedures [3]. In this case the patient had excellent
oral hygiene throughout treatment but despite that a
generalized gingival recession tendency that was more
evident on the first upper left molar could be observed
in the intraoral photographs, probably due to a thin
gingival biotype as well as a family tendency for periodontal problems and gingival recession. This and the
total open bite in the centric relationship position could
justify some gingival recession before and at the end of
the orthodontic treatment, which worsened 1 year later.
Also, the correction of the mesial tipping of the second
lower molar and of the open bite at the lateral area to a
more uprighted and extruded position increased gingival
recession, in spite of all the treatment being done with
monthly and sequentially small activation, both during
the use of the helical loop and the multiloop edgewise
archwire technique.
In spite of this gingival condition a stable dental relationship was established and the orthodontic goals were
achieved. However, 1 year and 6 months after the orthodontic treatment a connective tissue graft was essential
for improving the gingival recession.

Conclusion

Fig. 12 Introral photographs during and 1 month after a connective tissue graft, 1 year and 6 months after the end of the
orthodontic treatment

In this case where bilateral scissor bite was present, third

molar extractions prior to orthodontic treatment (except
the left mandibular molar) were essential to eliminate
this condition on the right side. On the left side, in order
to correct the highly titled lower second and third molars
and also having this last tooth highly extruded, a helical
loop then replaced by a multiloop technique, combined

Posterior scissor bite and lateral open bite with missing lower first molar and second premolar

141

case study

with a synergetic effect of elastic forces, was essential to

improve the lower occlusal plane and to allow for correction of the labial tipping of the upper second molar.
A thin gingival biotype, a family tendency for generalized
gingival recession and the correction of the mesial tipping of the second lower molar and of the open bite in
the lateral dental area to a more uprighted and extruded
position, increased gingival recession in spite of monthly
and sequentially small activations.
Despite this gingival condition, a good dental relationship was established and all orthodontic goals were
achieved. However, a connective tissue graft was essential to improve the gingival recession 1 year and 6 months
after the end of the orthodontic treatment.
Conflict of interest
The authors declare that there is no actual or potential
conflict of interest in relation to this article.

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Posterior scissor bite and lateral open bite with missing lower first molar and second premolar