Uprighting of Lower Molars

Taken from the JCO on CD-ROM (Copyright © 1997 JCO, Inc.), Volume 1996
Nov(640 - 645): Uprighting of Lower Molars BIRTE MELSEN, DDS, DO;
GIORGIO FIORELLI, DDS; ALBERTO BERGAMINI, D
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BIRTE MELSEN, DDS, DO
GIORGIO FIORELLI, DDS
ALBERTO BERGAMINI, DDS

The space available for eruption of the lower second and third molars depends
on several factors: resorption on the anterior border of the ramus, mesial
migration of the lower dentition in postnatal development, and migration of the
lower first molar after exfoliation of the second deciduous molar. Early
orthodontic treatment, such as sagittal expansion or lip-bumper therapy, may
prevent the mesial migration of the first molar and thus the uprighting of a
mesially inclined second molar.
Adult and elderly patients often present with molars that are overerupted as well
as mesially inclined. Tipping of the first molar can initiate a vicious cycle of
traumatic occlusion and of periodontal problems mesial to the tipped tooth.
Although a number of authors have presented simple appliances for molar
uprighting,1-6 their methods do not take individual patient variations into
account.7 Mesially inclined molars should be differentiated not only by degree
of impaction, but also by the types of tooth movement required for correction in
all three planes of space. For any particular tooth movement, there is only one
correct force system with respect to the center of resistance.8,9
In the sagittal plane, the appropriate combination of vertical movement and
uprighting must be determined. When the molar is to be extruded, the uprighting
is often performed with simple tipback mechanics.10 If significant extrusion is
needed, the force delivered to the bracket should be relatively large compared
to the moment (Fig. 1). If little or no extrusion is desired, the moment should be
larger and the cantilever as long as possible.
When molar intrusion is required, the biomechanics become more complex. The
law of equilibrium requires that the moment added to the molar be smaller than
the moment added to the anterior unit. This force system corresponds to what
Burstone and Koenig defined as a geometry V,11 and can be obtained by
proper activation of a root spring as described by Roberts and colleagues.12
An alternative would be to utilize a “V” or truncated “V” bend. Since all of these
appliances are statically indeterminate, even minor changes will alter the force
system. For example, with an interbracket distance of 21mm and an .017" ´
.025" TMA wire, a displacement of the “V” bend by 1mm from the center will
result in a vertical force of 55g and a change in the moment from 980gmm
bilaterally to 1,600gmm at the bracket closer to the “V” and 450gmm on the
other side (Fig. 2). With a displacement of 2mm, the vertical forces add up to
140g, the moment adjacent to the “V” becomes approximately 2,500gmm, and
the moment at the other unit decreases to only 340gmm.
An interbracket distance of 21mm is only possible with segmented arches.13
With conventional preadjusted edgewise appliances, the interbracket distance
will be much shorter, and the effect of small displacements will be even greater.
The force system may reverse into a geometry IV, where no moment is
generated with respect to one of the brackets.11 More displacement will reverse
the force system with respect to the farther bracket as well.
The force system developed by a “V” bend can also be generated by the
combination of two statically determinate systems, or cantilevers.14 If the point
of force application of the two canti levers is kept at or eccentric to the two
brackets, the system can only vary between geometry V and VI; with one
cantilever, it can be no less than geometry IV. Thus, with two cantilevers, the
force system is more constant and easier to monitor.
It is also important to consider the force system generated in the horizontal
plane. Whereas both the root spring and the “V” bend act parallel to the dental
arch, in close proximity to the center of resistance, the cantilevers may have
their point of force application on either side of the center of resistance, and
thus generate tipping in either the buccal or the lingual direction15 (Fig. 3).
In this article, we will focus on the force system parallel to the alveolar process.
The following case reports will show the importance of differential diagnosis,
selection of the force system, and appliance design in uprighting lower molars.
Case 1
A 26-year-old female had suffered from juvenile periodontitis and consequently
had lost the first permanent molars. In the absence of both the adjacent and
opposing first molars, the lower right second molar was tipped mesially and
overerupted (Fig. 4A). The third molar was tipped 60° mesially, but not yet fully
erupted.
The treatment plan involved uprighting and intrusion of the second molar and
uprighting and extrusion of the third molar. The biomechanics consisted of two
cantilevers, one for each molar (Fig. 4D). The force system resulted in a mesial
rotational moment with respect to the center of resistance of the anterior unit;
however, this was neutralized by the anchorage of the anterior occlusion. The
missing lower right first molar was not replaced prosthetically, since the existing
occlusion could stabilize the uprighted second and third molars (Fig. 4E).
Case 2
A 17-year-old male presented with slightly different degrees of impaction of the
lower second and third molars bilaterally (Fig. 5A). The left molars required
uprighting and intrusion, while the nearly horizontal right second molar needed
uprighting and extrusion.
On the left side, a cantilever extending from the molar tube delivered a large
moment, and another from a tube welded to the anterior segment generated an
intrusive force against the molar (Fig. 5B).
On the right side, the force system was estimated with a computer program15
under two different premises, with and without the third molar (Fig. 5D).
Extraction of the third molar would change the position of the second molar’s
center of resistance. Maintenance of the third molar would prevent distal
displacement of the second molar and thus keep space from opening anterior to
the second molar.16 Therefore, the third molar was not extracted. The force
system consisted of a buccal cantilever for uprighting and extrusion and a
lingual open-coil spring, which delivered a distal force against the molar crown
and aided in correction of the mesial rotation (Fig. 5F).
Case 3
Extraction of the lower right first molar in a 38-year-old male had caused mesial
tipping and overeruption of the second molar (Fig. 6A). A two-cantilever system
was designed for uprighting and intrusion (Fig. 6B), as in the previous cases.
Case 4
A 35-year-old male presented with an extreme deep bite due to a Brodie
syndrome (Fig. 7A). The lower left first and second molars had been extracted,
resulting in pronounced mesial tipping of the third molar. The Brodie syndrome
was corrected with a maxillary osteotomy, and the third molar was uprighted,
intruded, and moved mesially with two orthodontic appliances. The uprighting
and intrusion were achieved with a rectangular loop extending from the blocked
anterior segment, using a force system corresponding to a geometry V. A T-
loop17 was activated with a slightly larger moment to the anterior unit than to
the molar, thus moving the molar forward without mesial tipping. When the
mesial movement satisfied the requirements of the prosthodontist, the treatment
was terminated (Fig. 7B).
Discussion
Cantilevers are statically determinate appliances, but as shown in Case 4, the
same force systems can be achieved with statically indeterminate appliances.8
As with the “V” bend, a displacement of the T-loop to one side or the other
produces a significant change in the force system. With a cantilever system,
since the two forces acting on the molar both deliver an uprighting moment, the
moment cannot be changed to a geometry IV or lower. The relative moment-to-
force ratio can, however, be varied by the activation of the cantilevers, making
the system easy to control.13
References
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