Molar uprighting

GOOD MORNING
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

MOLAR UPRIGHTING
SEMINAR BY
Dr. P. PREMANAND

INTRODUCTION

Introduction
 When a posterior tooth( usually first
permanent molars) is lost the adjacent teeth
usually drift and rotate and gingival tissue
becomes folded and distorted . Forms
pseudopocket that is impossible to clean
 The elimination of potentially pathologic
conditions associated with tipped molars is
probably the most important procedure and has
the added advantage of simplifying the
ultimate restorative procedures.

VARIABLES THAT CAN
INFLUENCE THE UPRIGHTING OF
A MOLAR TIPPED INTO AN
EXTRACTED SITE

Extraction timing
 If first molar is lost while the second molar is
still unerupted, the second molar may erupt
forward in the arch and eventually takes a
position either near or in contact with the
second premolar.
 The angulation of this second molar may or
may not be desirable, and the opposing upper
molar may have supraerupted into the area
occupied by the lost molar.

 If the first molar is lost after the second molar has
erupted fully, the second molar will usually tip
forward into the extraction site of the first molar.
Later,third molar erupts and it makes contact with the
tipped second molar.
 When an adult with good occlusion loses a first
molar, the second molar may remain in a reasonably
good position because of the good interdigitation of
the opposing teeth.
 Most adults who lose first molars, the second molars
tip forward to varying degrees depending on the time
elapsed since the first molar was lost.

Periodontal condition
 Patients have difficulty cleaning the partially
submerged mesial surface of the tipped molar
and plaque gets formed
 Eventually periodontal disease including loss
of alveolar bone results
 Uprighting the molar helps stop the
periodontal disease process on its mesial
surface.

Vertical dimension
 The position of teeth in the opposite arch occluding
with the tipped molar should be carefully observed.
 The teeth in the opposing arch have overerupted into
the area of the tipped tooth and sometimes teeth are
no longer present to occlude with the tipped molar.
 Repositioning the tipped molar in a distal direction
extrudes it occlusally and opens the bite.

 An already overerupted opposing tooth exaggerates
the open bite and can be intruded by an orthodontic
appliance
 Its crown can be shortened by occlusal equilibration
to control bite opening.
 Absence of opposing teeth allows the tipped molar to
extrude too far occlusally when repositioned. The
choice of appliance and occlusal equilibration can
help control the vertical position of the repositioned
molar.
 The distal movement and uprighting of a molar
usually creates an open bite and informed consent
should be obtained for this procedure.

Number of missing teeth
 The number of teeth missing mesial to the tipped
molar must be considered as fixed appliances cannot
effectively control the movement of a tipped second
or third molar that is isolated at the distal end of an
edentulous ridge with only a first premolar or canine
available forward of the molar.
 When the patient is missing several teeth, removable
appliance can be used to upright a molar
 Removable appliances derive their anchorage from
both the teeth and the alveolar ridge.

Position of third molar
 When a tipped lower second molar to be
repositioned distally for a prosthetic appliance
is in close contact with a lower third molar, the
lower third molar is often extracted at the
beginning of treatment to make room for the
repositioning of the second molar.
 This approach to treatment is appropriate
when the opposing upper third molar is absent
or impacted.

Resorbed alveolar ridge
 When permanent tooth is lost, the extraction site of
the alveolar ridge resorbs. The resorbed ridge is short
and narrow.
 Molars cannot be easily moved through an hourglass
ridge, and if they are forced to do so, the molar roots
may partially resorb.
 A first molar space is more easily closed
mechanically by retracting the premolars into the
narrower hourglass ridge. This movement is not
desirable for most patients.

 The resorption of an alveolar plate of bone is
removed with the extracted tooth. Moving
teeth into resorbed ridges can result in a
compromised periodontal attachment.
 When a lower second molar is tipped mesially
into the extraction site of a first molar and the
alveolar ridge has resorbed to an hourglass
shape, the most common orthodontic treatment
involves tipping the second molar distally to
an upright position to prepare for a prosthetic
replacement.

Impacted mandibular second molars
 When the mandibular second molars is partially
erupted and tipped forward its mesial surface is
locked beneath the distal surface of the first molar.
 If an impacted third molar should be extracted when
it lies behind and over the distal surface of the
impacted second molar to make room in the alveolus
for uprighting the second molar.
 When impacted second molars are usually only
partially erupted, bonding a rectangular tube on the
exposed buccal surfaces is easier than fitting on the
exposed. A tube or bracket can be bonded to a small
part of the occlusal surface

 These tipped molars must be moved distally and
occlusally so that the molar occludes at a normal axial
angulations with the upper teeth.
 In adolescent patients the opposing upper molars are
usually present but not over erupted. In adult patients
the opposing upper molars are likely to be over
erupted.
 The primary difficulty encountered is that the
uprighted molar moves upward too much and opens
the bite.
 Occlusal surfaces of the crowns of both the upper and
lower molars at the site of uprighting may need to be
mechanically reduced to reestablish a healthy
overbite.

The effects of space closure (AJO Volume 1984) of
mandihular first molar area in adults
 Fourteen adult patients were selected to determine the
dental and periodontal changes that occur .
 Using Pre- and post-treatment study models the
mesiodistal length of the edentulous space and the
buccolingual width of the alveolar ridge was
calculated.
 The amount of crown and root movement of the
second molar and premolar was measured
 The anatomic changes of the second molar and
adjacent periodontium was measured using
radiographs

 All cases showed significant space closure (x = 6.2 mm)
ranging from 2.7 to 11.5 mm.
 There was crestal bone loss (x = 1.3 mm) mesial to the second
molar in all but five cases. These latter cases showed bone
addition.
 As the molar moved mesially, the alveolar ridge increased in
width an average of 1.2 mm.
 The adult patient who showed the greatest amount of space
closure and the least amount of molar bone loss had (1)
mesiodistal space of 6.0 mm, (2) buccolingual ridge width of
7.0 mm, and (3) mesial molar bone level 1.0 mm apical to the
cementoenamel junction.
 The results of this study indicate that space closure should be
considered as a potential solution to the absence of mandibular
first permanent molars.

Appliances for Molar Uprighting

Principles
 Each appliance can be separated into an active and a
reactive (stabilizing or anchor) unit.
 To provide appropriate anchorage, the canine in the
treatment quadrant and in most cases, the canine on
the contralateral side also should be linked to the
anchor teeth by the use of a heavy stabilizing lingual
arch.
 Advisable in the maxillary arch, particularly if a
premolar is also missing.
 canine-to-canine stabilizing arch increases the
anterior anchorage and resists buccal displacement of
the anchor teeth.

 Directly bonded brackets generally are
preferred over bands for the premolars and
canine teeth in the anchorage unit.
 The decision as to a band or bonded
attachment for the molar(s) depends on the
individual circumstances.
 Bonded attachments for molars are more likely
to fail than for premolars due to the difficulty
in moisture control in the molar region and
heavy occlusal forces against attachment

 Gingival irritation is greater with bands than bonded
attachments.
 Molar bands are best when the periodontal condition
allows (younger and healthier patients).
 Greater the degree of periodontal breakdown around
the molar to be uprighted, the more a bonded
attachment
 Bonding to metal or porcelain surfaces is less
successful than bonding to enamel, so teeth with large
restorations on the buccal surface usually are better
banded than bonded.

 Whether it is banded or bonded, the molar to be
uprighted should carry a combination attachment
consisting of a wide twin bracket with a convertible
cap and a gingivally placed auxiliary tube.
 If second and third molars are being uprighted
simultaneously, the convertible cap should be
removed before the second molar band is cemented
 The third molar should carry a single tube .If
rotations or crossbites are to be corrected, lingual
buttons or cleats are to be used . These lingual
attachments should be welded to bands, not bonded
individually to the lingual surfaces

 Where premolar and canine brackets should be placed
it depends on the intended tooth movement.
 If these teeth are to be repositioned, the brackets
should be placed in the ideal position at the center of
the facial surface of each tooth
 If the teeth are merely serving as anchor units and no
repositioning is planned, then the brackets should be
placed in the position of maximum convenience
where minimum wire bending will be required to
engage a passive archwire

Uprighting a Single Molar
Distal Crown Tipping with Occlusal Antagonist.
 If the molar is only moderately tipped, treatment
often can be accomplished with a flexible rectangular
wire such as 17 X 25 braided stainless steel or 17 X
25 NiTi.
 If the anchor teeth require extensive alignment, the
best choice is 17x25 A-NiTi that delivers
approximately 100 gm of force
 If the anchor teeth are reasonably well aligned, 17 X
25 braided steel wire usually is satisfactory

 If the molar is severely tipped, a continuous
wire used that uprights the molar will also tip
the second premolar distally,
 Bulk of the uprighting using a sectional
uprighting spring can be carried out
 A stiff rectangular wire (19 X 25 steel)
maintains the relationship of the teeth .
 The uprighting spring is formed from either 17
X 25 beta-Ti wire without a helical loop, or 17
X 25 steel wire with a loop added to reduce the
force level

 Because uprighting a tipped molar as described
above causes considerable occlusal as well as
distal crown movement, this method should be
used only when the terminal molar has an
occlusal antagonist.
 Frequent occlusal adjustments are necessary to
reduce developing interferences, but even
so, the occlusal contacts control the amount of
extrusion.

 A slight lingual
bend is placed
in the
uprighting
spring as it is
needed to
counteract the
forces that tend
to tip the anchor
teeth buccally
and the molar
lingually

Uprighting with Minimal Extrusion
 If the molar to be uprighted has no occlusal
antagonist, if extrusion is undesirable, or if the crown
is to be maintained in position while the roots are
brought mesially, an alternative uprighting approach
should be used.
 After initial alignment of the anchor teeth with a
light flexible wire, a single "T-loop" sectional
archwire of 17 X 25 stainless steel or 19 X 25 beta-Ti
wire is adapted to fit passively into the brackets on
the anchor teeth and gabled at the T to exert an
uprighting force on the molar

 When engaged in the molar bracket, this wire will
thrust the roots mesially while the crown tips
distally.
 Since the extrusive forces generated with the
appliance are small, it is ideally suited for patients
in whom the opposing tooth has been lost.
 Severely rotated teeth may be treated using this
appliance, but in this case, the design of the T-
loop is modified so that the end of the archwire is
inserted from the posterior aspect of the molar
tube

An alternative method
 to stabilize the anchor segment as described
initially using a modified design of the
auxiliary uprighting spring with helical loops
mesially and distally.
 Compared to the T-loop, this gives more
precise control of the force system against the
molar, but less control of its mesiodistal or
rotational position.

Final Positioning of Molar and
Premolars.
 Once molar uprighting has been accomplished, it is
desirable to increase the available pontic space and
close open contacts in the anterior segment.
 This is done best using a relatively stiff base wire
with a compressed coil spring threaded over the wire
to produce the required force system.
 With 22-slot brackets, the base wire should be round
or 17 X 25 rectangular steel wire, which should
engage the anchor teeth and the uprighted molar more
or less passively.

 The wire should extend through the molar
tube, projecting about 1 mm beyond the distal. An
open coil spring over the base wire, when compressed
between the molar and distal premolar, should exert a
force of approximately 150 gm to move the premolars
mesially while continuing to tip the molar distally
 The coil spring can be either steel or A-NiTi. A steel
spring may need to be reactivated by compressing it
and adding a split tube spacer over the wire between
the coil and the bracket;
 The very large range of A-NiTi means that
adjustments seldom will be necessary.

 Continued use of a compressed coil spring
once the premolar spaces are closed may result
in anterior displacement of the anchor teeth
and incisors.
 The occlusion should be checked carefully
against the original study casts at each visit
and the spring removed when the desired
movement has been accomplished.
 Due to the long range of action of A-NiTi
springs

 The appliances for uprighting a single molar
described earlier may be used in the maxilla or the
mandible unilaterally or bilaterally
 During bilateral molar uprighting, the strain on the
anterior anchorage is increased
 Very light forces .should be used and the anterior
occlusion must be monitored carefully.
 If it appears that the anchor teeth are moving, then it
is advisable to deactivate one segment, complete
molar uprighting in one quadrant, stabilize those
teeth, and then upright the contralateral quadrant.

Uprighting Two Molars in the Same
Quadrant
 The resistance offered when uprighting two molars is
considerable, only small amounts of space closure
should be attempted.
 The goal of treatment is to upright the molars with a
combination of mesial root movement and distal
crown tipping, opening the space slightly.
 Trying to upright both the second and third molars
bilaterally at the same time is not a good idea—
significant movement of the anchor teeth is
inevitable.

 When both the second and third molars are to be
uprighted, the third molar should carry a single
rectangular tube and the cap should be removed from
the convertible bracket on the second molar
 The second molar is usually more severely tipped
than the third molar, increased flexibility of the wire
mesial and distal to the second molar is required.
 The best approach is to use a modern highly flexible
wire initially, and 17 x 25 A-NiTi
 Excessive mobility of the teeth being uprighted can
result from either too much force or failure to reduce
the occlusal interferences.

 The treatment time will vary with the type and extent
of the tooth movement required.
 Uprighting a tooth by distal crown tipping proceeds
more rapidly than mesial root movement.
 Failure to eliminate occlusal interferences will
prolong treatment.
 The simplest cases should be completed in 8 to 10
weeks, but uprighting two molars with mesial root
movement could take 20 to 24 weeks, and the
complexity of doing this puts it at the margin of
adjunctive treatment.

Retention
 After molar uprighting, the teeth are in an unstable
position until the prosthesis that provides the long-
term retention is placed.
 A fixed bridge should be placed within 6 weeks after
uprighting is completed. If an implant is
planned, there may be a considerable delay while the
bone graft heals and the implant becomes integrated.
 For a short time, the orthodontic retainer can be a 19
X 2 5 steel or 21 X 25 beta-Ti wire designed to fit the
brackets passively

 If retention is needed for more than a few
weeks, the preferred approach to intermediate
splinting is an intracoronal wire splint (19 X
25 or heavier steel wire), bonded into shallow
preparations in the abutment teeth
 This type of splint causes little gingival
irritation and can be left in place for a
considerable period, but it would have to be
removed and rebonded to allow bone grafting
and implant surgery.

 A Segmented Approach to mandibular molar uprighting
(AJO Volume 1982).
TREATMENT OBJECTIVES
 Ideal tooth positioning in molar uprighting is coincidental with
obtaining an optimal periodontal environment. This, in
turn, provides the following:
I. Protection against inflammatory periodontal disease.
 A. Elimination of the pathologic periodontal environment
which may exist in the presence of tipped molar(s) and angular
osseous crests.
 B. Correction of vertical osseous defects, if present, through
forced eruption.

II. Protection against occlusal traumatism.
 Alignment of roots perpendicular to the occlusal
plane so that they may optimally withstand the forces
of occlusion.
 Improvement of crown/root ratios of periodontally
involved molars.
 Provision of the shortest possible edentulous span
allows the necessary occlusal support of maxillary
posterior teeth and an interarch cusp-fossa
relationship,
 Reduces flexing of bridgework in the pontic area and
minimizes the related undesirable forces transmitted
to the abutment teeth

 Markedly inclined molar(s) requiring distal crown tipping, or
mesial root movement and/or forced eruption is indicated,
 a modification of the root spring described by Burstone allows
to provide the desired combinations of moments and forces.
The anterior stabilizing segment consists of the following:
(1) A lingual arch wire (approximately 0.032 inch) bonded, or
soldered to bands, from canine to canine.
(2) Bonding the mandibular incisors to the lingual arch wire adds
stability to these periodontally involved teeth.

Anterior stabilizing segment recommended
when the
 mandibular second premolar is missing from
the quadrant containing the inclined molar
 second and third molars are being uprighted
 when the second molar is considerably tipped,
 when there is well-aligned incisors

Alternatives to stabilizing the anterior segment
as suggested previously
 (1) The lingual arch wire may be replaced by
bracketing of the incisors labially and
continuing the labial stabilizing wire from the
premolar area on the side of the uprighting to
the canine or beyond on the opposite side
 (2) The lingual arch may extend to the
premolars and molars, if desired, and lingually
bonded to each tooth in the anchorage segment

 The alpha (anterior) portion of the uprighting spring
inserts into the gingival slot of the canine bracket.
The beta (posterior) attachment, a rectangular buccal
tube, bonded so that gingival irritation is minimized
and placed far gingivally in order to facilitate
occlusal adjustment of the molar.
 Prior to correction of inclination of the molar, the
canine and premolar(s) should be consolidated and
aligned. Ideally, molar rotations and cross-bite
should also be corrected with a light continuous
wire, offset to the angulation of the inclined molar.

 The three steps which prepare the uprighting
spring for insertion are
Fabrication, preactivation, and compensation
compose
 The spring is composed of approximately 0.018
by 0.025 inch wire for insertion into a 0.022 by
0.028 inch bracket. A 0.018 by 0.025 inch
bracket would require a corresponding wire size.

 The uprighting spring is constructed to fit passively
(in all three planes of space) into alpha and beta
positions.
 After the spring has been contoured
buccolingually, one leg is engaged into its
respective bracket and adjusted so that the
opposite leg lies passively (occlusogingivally and
buccolingually) at the level of the opposite
bracket, without engaging the bracket.
 The reverse procedure is then followed, making the
spring completely passive if inserted into the alpha
and beta attachments

 The alpha and beta helices are then preactivated the
designated degrees, depending upon the desired
forces and moments
 It is important to measure the degree of preactivation
from the inclination of the bracket and not from the
level of the occlusal plane.
 Preactivation bends should be tested during
fabrication, at insertion, and during treatment, since
tooth movement alters the force system.
 Typical activations (in the case where there is no loss
of attachment apparatus) for equal and opposite
moments are 45 degrees to the attachments in the
alpha and beta positions.

 It is recommended that the movement generated
should not exceed 3,000 Gm. Mm
 The degree of uprighting spring preactivation vary
greatly, depending not only upon the magnitude of
the desired moment but also upon the size and
chemical composition of the wire used for uprighting
and the interattachment distance.
 Symmetric alpha and beta activations are indicated
for correction of inclination

 If eruption is indicated, either to attempt correction
of a vertical defect or to level the osseous crests and
marginal ridges between second and third molars, the
spring can be preactivated to produce pure molar
eruption.
 Compensation for bending in the span of wire
between alpha and beta loops occurs upon trial
activation and alters the desired force level by
bending in a mild reverse curve, equal and opposite to
the curve observed upon trial activation.
 After final placement of the uprighting spring, the
span of wire between alpha and beta helices should
then be straight

 The soft tissues of the cheek and tongue
habitually rest in this long edentulous span
 it is important to minimize the patient's
discomfort by lingually offsetting the
uprighting spring so that it lies over the
edentulous ridge.

 When there is a short edentulous span, tightly
common-tying from canine to molar brackets
will inhibit distal molar crown movement.
 In the long edentulous span, this kind of
ligature tie will loosen during normal function.
 Buccolingual compensation for rotation of the
molar should also be incorporated in the wire
design when mesial root movement is
attempted.

Advantages of the uprighting spring recommended
 Symmetrical preactivation is an extraoral procedure.
Force levels are easy to determine and to check
periodically.
 Few adjustments are necessary during treatment
because of load/deflection considerations in spring
design.
 In the edentulous span wire is not disturbed by
normal function as it is positioned at the level of the
gingiva.
 Patient discomfort is minimized by offsetting the
spring over the edentulous ridge

A SIMPLE TECHNIQUE FOR MOLAR UPRIGHTING
Elie capelluto, LSD, Isabelle lauweryns, LTH, PHD
Appliance Designs
 In the MUST 1 an .018‖- .025‖ tube is soldered cervically to
the molar tube, parallel to the occlusal plane (with a double
molar tube, the gingival auxiliary tube can be used). A shorter
.018‖ - .025 tube is soldered horizontally to the distocervical
wing of the premolar bracket. The tubes should have 0 torque
to avoid gingival interference.
 The active component of the uprighting spring is a superelastic
.016‖ - .022‖ Niti wire. which produces light and continuous
force throughout treatment. This wire extends form the mesial
of the premolar tube to the distal of the molar tube.

Once inserted in the tubes,
 the wire is activated by pulling it mesially out of the molar
tube any excess wire is then cut off
 the ends are bent back and coated with glass ionomer cement
to prevent irritation.
 This activation augments the internal tension in the wire, thus
increasing forces, couples, and moments and generates a
horizontal distalizing force against the molar as a reaction to
the mesial pull of the wire.
 The premolar can be anchored by fixed appliances on the
entire mandibular arch, a lingual bar, or any other suitable
means. In addition, lingual buttons may be bonded to the
molar and premolar and connected by a passive elastic chain to
help prevent unwanted distal movement or rotation.

Uprighting of lower molar (JCO volume 1996)
Brite melsenGiorgio Fiorelli, Alberto Bergamini
When the molar is to be extruded, the uprighting is
often performed with simple tipback mechanics.
If significant extrusion is needed, the force delivered to
the bracket should be relatively large compared to the
movement.
If little or no extrusion is desired, the moment should
be larger and the cantilever as long as possible

 The distal jet for uprighting lower molars
(JCO volume 1996)
 0.036‖ tube to the premolar band is
soldered, parallel to the occlusal plane below
the level of the edentulous ridge
 Orient the tube so that a wire with a bayonet
bend can be slid into the tube from the distal.
 A circle is bent into the distal end of this
wire, and attached to the molar band with a
screw.

 An adjustable screw-clamp and a 150g nickel
titanium open-coil spring is placed over the tube.
 Two premolars are connected with a soldered lingual
wire to form the anchorage unit.
 As the clamp is moved distally, the coil spring is
compressed and a distalizing force is applied.
 The connection of the molar band to the wire is not
rigid, the line of action of this force is at the level of
the molar crown, and the point of force application is
at the screw and the molar crown will therefore be
tipped distally.

Lower distal Jet.
 A. Wire with bayonet
bent, attached with
screw to molar
band, slides through
0.036‖ tube soldered
to premolar bond.

 .Distal tipping force is
applied to molar crown
by compression of
nickel titanium open-
coil spring with screw-
clamp on tube.

 MOLAR UPRIGHTING WITH CROSSED
TIPBACK SPRINGS (JCO volume 1992)
Frank J. Weiland, Hans-peter Bantleon,Helmut Droschl
 The simple tipback – uprighting method has the
undesirable side effect of extruding the molar. This
article presents an easy way to upright a molar using
tipback mechanics but without extrusion

 Tipback mechanics use
a spring made of 0.016‖
x 0.022‖ stainless steel
with two and one – half
helices, or of 0.017‖ x
0.025‖ TMA

 This method generates
vertical forces in addition to
the uprighting movement.
The molar is thus
extruded, which is
generally an undesirable
side effect.
 To prevent extrusion, a
counteracting intrusive
force is needed and can be
achieved simple by using a
second tipback spring.

Appliance design
 The passive part of appliance includes a
lingual canine-to-canine or premolar-to-
premolar bonded retainer made of 0.0215‖
multistranded wire.
 Labial edgewise brackets are attached to the
cuspids, the premolars, and the molar to be
uprighted.
 The molar bracket contains two horizontal
tubes, and the burstone cuspid bracket has an
additional vertical slot.

 A rectangular wire segment is tied to fit snugly in the cuspid
and premolar bracket slots (0.018‖ X 0.025‖ in an 0.018‖
slot, 0.025‖ in an 0.022‖ slot). A stabilizing distal
extension, about 10mm long, is inserted into one of the two
horizontal molar tubes.
 The active portion of the appliance consists of two tipback
springs: one from the second molar tube, and the other from
the vertical slot of the cuspid bracket,are ligated to the
stabilizing wire at the first premolar.
 As long as the two springs are activated equally, the vertical
forces will cancel each other out. The applied forces can be
measured with a force gauge. The moments should be about
2,000g/mm, but no more than 3,000g/mm.

 Tipping the molar without intrusion (―neutral‖
uprighting) will result in an extruded position
of the molar as it erupts.
 The molar can be intruded during uprighting
by activating the mesial spring so that it
delivers 20g more force than the distal spring.
 This also generates an extrusive force and
movement in the anterior segment.
 An upper gnathological splint can be added to
the lingual retainer for extra stability

 Uprighting impacted second molars with segmented
springs (JCO volume 1995 March)
Aurelie Majourau, and Louis A. Norton
 Severe impaction of lower second molars often leads
to the extraction
 To avoid potential damage to the first molar root. a
case of simple biomechanical principles allows us to
upright bilaterally impacted lower second molars into
the desired location in a fairly short time

 Stainless steel buttons are bonded to
distal occlusal surface of second
molars.
 0.017 x 0.025 TMA wire is bent into
finger spring configuration
associated with active 0.030 steel
open coil is inserted from distal of
first molar auxiliary tubes.
 Open coil acts as stiff compressible
stop for distally activated finger
spring.
 Continuous 0.019 x 0.025 stainless
steel wire first molar to first molar is
used as anchorage unit. Applied
result forces are distal force on the
second molars and mesial force on
anchorage unit.

 Correction of mesially impacted lower second and
third molars ((JCO volume 1987)
H.S. ORTON, OBE. DORTH, FDSRCS S.P. JONES
DORTH,
 The LTM uprighting whip
a simple whip spring that is fairly fast-acting, with a
treatment time of four to 12 months.
It is used for disimpacting mild to severe mesially
impacted LTMs that do not have associated rotations
or buccolingual malpositions.
Rotations and buccolingual tipping would have to be
corrected with more comprehensive mechanics in a
second stage.

 The whip spring is
fabricated at chairside with
0.018‖ x 0.025‖ or wire for
an 0.022‖ slot, or 0.017‖ x
0.022‖ wire for an 0.018‖
slot.
 A circular loop is placed
mesial to the tube to prevent
posterior displacement of
the wire and
 provides attachment for an
elastic module that anchors
the wire in the tube
anteriorly.

 The wire extends mesially
from the loop, and a vertical
bend is placed occlusally
next to the midbuccal
fissure of the anchor molar.
 The wire is curved lingually
to pass through the
midbuccal groove and onto
the occlusal surface.
 It is then contoured distally
to run along the occlusal
surface.

 Moving the whip to the occlusal surface of the anchor
molar activities the appliance.
 The whip’s shape insures that it remains in place on
the anchor molar, and the elastic keeps it locked in
the tube on the LTM.
 The whip spring can be reactived in the mouth by
lifting the wire away from the occlusal surface with a
Briault probe and gently squeezing the arm of the
spring, between the loop and the vertical bend, with
Tweed loopforming pliers.
 After the initial adjustment at three to four
weeks, adjustments every six weeks seem to be
adequate. Overcorrection is advised.

 Unlocking Impacted Lower Molars With
Direct Bonding (JCO 1974)
G. RICHARD SAFIRSTEIN
 The operator should plan on bonding an
attachment on the basis of available tooth
surface. If there is enough room on the
buccal, bond a buccal tube.
 If only the distal half of the buccal surface is
available, a bracket will be easier to bond.

Bonded buccal tube.
 If tooth and tube alignment permit, placement of an .014" or
.016" wire through the buccal tubes of the first and second
molars with a mildly active compressed coil spring strung on
the wire between them is most effective. Compressing the coil
and sliding the wire through may require digital dexterity, but
it can be done.
 , the first molar can be bypassed and the wire ligated to it for a
few visits.
 A variation of this is to end the base is to modify an uprighting
spring, insert what is normally its vertical post into the second
molar buccal tube, and activate the spring by engaging it on
the archwire mesial to the first molar

Bonded bracket. There are occasions when the buccal
surface of the tooth is not accessible
 A bracket can be bonded to the tip of the distobuccal
cusp, and this will afford adequate purchase to begin
unlocking the tooth.
 The bracket is exchanged for a bonded buccal tube
when an adequate amount of buccal surface is
exposed.
Bonded spring. When neither a bracket or tube can be
bonded, the uprighting of impacted molars by
forming a spring of .016" wire and bonding it directly
to the surface of the locked molar, engaging the other
end on the base archwire.

 This spring has been made
more effective by
incorporating a helix.
 This is most easily made by
again modifying an
uprighting spring, this time
by bending a loop in the
distal end of the vertical
post at right angles to the
helix and bonding the loop
directly to the surface of the
locked molar.

 Use of Nickel Titanium
Coil Springs for Partially
Impacted Second Molars
 JCO Volume 1998.
 a nonsurgical technique to
erupt a partially
impacted, obliquely tilted
second molar, using a
modified lingual arch and a
nickel titanium coil spring.

Australian uprighting spring
JCO July 1999
 In this article a simple way to upright partially
impacted second molars was done using a
molar band, a lingual button, and an uprighting
spring bent from Australian wire
 Uprighting spring bent from .014" Australian
wire-Left loop is molar stop; right loop is
actual uprighting spring.

Hook on right end engages
lingual button.
 A. Occlusal view.
 B. Buccai view

 Spring activated by
attaching hook to
lingual button on
impacted molar

 Uprighting fully impacted
mandibular second molars
(JCO volume 1995 May )
 an archwire with a nickel
titanium compressed-coil spring
extending from the buccal first
molar tube to a bracket bonded
to the occlusal surface of the
impacted molar is used
 This simple technique may
prevent the soft-tissue irritation
 The light continuous force of
the nickel titanium spring
efficiently disengages the
impacted tooth.

Technique clinical correction of impacted
mandibular second molars
(JCO 2003, Volume 33)
 An impacted mandibular second molar can be
brought into the arch rapidly and efficiently by
raising a soldered .036" lingual arch with occlusal
rests on the bicuspids and an .036" distal extension
ending in an eyelet.

The technique is as follows:
 Seat mandibular first molar bands with double buccal tubes.
 maxillary and mandibular alginate impressions are made
 Fabricate the lingual arch with distal extension .
 Fit a lip bumper to the cast.
 If necessary, the impacted second molar surgically exposed.
 Cement the lingual arch in place.
 Bond a plastic button to any exposed area on the second
molar, using plastic powder and liquid bonding adhesive
(applied with a brush)..

 Tie elastic thread between
the button and the eyelet
for traction . Begin lip-
bumper therapy 12 hours
a day for anchorage.
 When the second molar
has sufficiently erupted
bond a buccal tube to it
and align it, using the
archwire slot of the first
molars buccal tube

 UPRIGHTING PARTIALLY IMPACTED
MOLRS
 RANDY LANG(JCO volume 1985)
 Halterman described a techniques in which an elastic
is stretched between a long hook soldered to the
lingual surface of a second primary molar bond and a
button bonded to the first permanent molar.
 This article presents a modification of Halterman’s
technique that can be used equally effectively on
impacted second permanent molars and on
ectopically erupting first permanent molars

The following advantages:
 Simple to construct
 Requires no patient
cooperation
 Activates easily
 Requires no bending of
springs
 Treats rapidly
 Does not rotate molars
because the elastic
chain pulls straight
back.

CLINICAL EXPERIENCE WIHT THIRD MOLAR
ORTHODONTICS (AJO Volume 1989 December)
Appliance construction and management
 The wire portion of the appliance is fabricated from 0.032-
inch stainless stainless steel wire and adapted closely to
the mucosa.
 The mesial hook is placed 3 mm distal to the distal contact
point of the third molar.
 Standard soldering techniques are used to attach the wire
to the buccal or lingual surface of the band.
 This appliance may be easily modified to incorporate a
hook or additional tube for security in retaining the device
or so that the appliance may be incorporated into the fixed
appliance therapy at a later date.

 By manipulation of the distal arm of the appliance
either buccally or lingually, depending on the desired
movement, teeth can be¸ directed or rotated
 variation can also be accomplished by alteration of
the bond position of the cleat.
 Exaggerated occlusal movement can also be
accomplished as desired.
 Following activation, rapid uprighting and
distalizaiton will occur in 3 to 6 months in most
cases. Grinding of occlusal surfaces of the teeth
during uprighting is usually not necessary.
 When the third molars are upright, the appliances are
removed and the third molars are
banded, leveled, and aligned with the rest of the teeth.

This technique used to upright first and second molars and may
be used successfully in preparation for prosthodontic
procedures.
 The main contraindication to this technique is a severely
impacted maxillary third molar.
 The advantages of the appliance, (Lang and others), include
 ease of fabrication and manipulation,
 rapid treatment, little discomfort,
 and no demands for patient co-operation.
 is biomechanically simple.
 With this appliance, forces are usually applied so that they do
not pass through the center of resistance, thereby producing a
combination of rotation and translation.

 A mesially impacted mandibular second molar.
Treatment considerations and outcome: A case
report (JCO volume 1993)
 The uprighting of an impacted mandibular second
molar presents special problems that requires
auxiliary appliances and the implementation of
―therapeutic diagnosis‖. The presence of an
ectopically positioned third molar required
modification of the original plan.
 The procedure may become difficult if the tooth
position is deep and horizontal, and other factors
complicate the problem.

 Active treatment started with maxillary partial
banding to intrude the overerupted second molar.
 After surgical exposeure of the impacted molar, an
attachment was bonded to the exposed occlusal third
of the distal surface and vertical elastics initiated.
 Five weeks later, it was possible to bond an additional
brackets to the buccal surface of the impacted
tooth, and combined intraarch and interarch eruption
mechanics was started.
 the vertical elastics were discontinued, and eruption
was guided solely by mandibular arch wire
mechanics.

 Placement and use of
intermaxillary mechanics
(vertical elastics) for initial
eruption.
 B. combined interarch and
intraarch mechanics (0.016
x 0.022-inch Blue Elgiloy)
for continued uprighting.
 The arch wire was designed
to transmit a posterior
superior force vector.

 Molar uprighting with piggyback buccal sectional
arch wire technique (JCO volume 1991 March )
 an orthodontic mechanical variation to unlock and
upright mandibular impacted second permanent
molars. Was accomplished with a small sectional arch
wire that is ligated in a piggyback fashion to the
existing arch wire and first molar band attachment.
 The piggyback buccal sectional arch wire (PBBSAW)
technique provides a simple, expedient, and effective
mechanical approach to the impacted second molar
problem.

 Uprighting molars with twisted superelastic nickel
titanium wires (JCO 2001 February)
 Superelastic nickel titanium wires was used to torque
and upright buccally or lingually tipped molars.
 Nickel titanium alloys exhibit excellent spring
back, shape memory and flexibility, producing
light, continuous forces for optimal physiologic tooth
movement.
 Patient discomfort is minimized, chair time for arch
wire placement is reduced, and the appointment
interval can be lengthened, improving treatment
efficiency and control.

 The mere engagement of a super elastic nickel
titanium wire into the molar tube produces molar root
torque because of he shape memory of the wire.
 Torsional force can be amplified by twisting the long
axis of the wire 180 .
 An interbracket span of 25-40mm from the canine
bracket to the molar tube optimizes the activation at
the molar and avoids depending of premolar brackets.
 The advantages of super elastic nickel titanium wires
can be used early in treatment to upright buccally or
lingually tipped molars,

 The forces measured in the laboratory and the results
produced in clinical trials demonstrate that the 180
torsional force genreated by Neo Sentalloy wires is
suitable for correction of the following common
problems:
 Buccal crossbite or buccal tipping of maxillary
molars due to either ectopic eruption or orthodontic
palatal expansion.
 Lingual tipping of mandibular molars due to
transverse constricting mechanizes.Severe lingual
tipping of mandibular molars due to ectopic eruption
and/or malocclusion.

Uprighting lower 5s 7s
(JCO Volume 1971)
 A mesially tipped lower
second molar locked
beneath the distal curve of
the first molar can be
uprighted efficiently with a
helical loop of round wire
soldered to the distal end of
a lingual arch.

 A typical mesially tipped lower second molar is shown. The
technique begins as with any removable lingual arch.
 Bands are fitted to lower first molars, seated in a compound
impression and a work model is poured in stone. The
lingual tubes are soldered and a normal removable lingual
arch is made.
 To the end of the lingual arch, a length of .028 round wire
is soldered and this is formed into a helical loop spring.
 A downward bend on the distal leg of this spring assures
that the end will remain engaged when the spring is
activated mesial to the tipped second molar.

 This arch was placed in the mouth and the helical
spring engaged mesial to the second molar.
 In two weeks, visible uprighting had occurred.
 In less than five weeks, with just two
adjustments, the tooth was in an upright position.

Clinical Management of Unilaterally Impacted
Mandibular First and Second Molars (JCO
2003, Vol. 37.)
 The present article shows a fixed ―eruption-
assisting‖ appliance that can efficiently extrude
impacted molars while ruling out ankylosis and
limiting adverse effects on the adjacent teeth.

 The appliance consists of a lower lingual arch
with acrylic added for support and to allow
extension distal to the second premolar.
 This distal extension includes two .020" round
TMA wires embedded into the acrylic and
activated by attaching them to the gold chains
on the molars with elastic thread.
 Due to the mesial angulation of the molars, the
TMA loops were placed slightly distal and
occlusal to the impacted molars, thus directing
the forces in a disto-occlusal direction.

Modified Removable
Transpalatal Bar for Rapid
Uprighting of impacted second
molars (JCO 2002)
 A Preformed transpalatal bar
connected to lingual attachment
on first molar adjacent to
impacted second molarwas cut
and modified according to
clinical needs and patient's
anatomy.
 B. Power chain from distal
extension to bonded button on
crown of impacted molar
provides uprighting force with
horizontal and distal vectors.

Case report: implants as anchorage for molar
uprighting and intrusion (JCO volume 1996 No. 3).
 The most common sequel to molar uprighting is
elevation of the molar.
 Controlling the elevation was critical when the patient
has deficient overbite, a long lower face height, and
/or excessive lip incompetency.
 Allowing the molar to elevate would make their other
problems worse.

 When an objective of treatment is to increase the over
bite, it would be ideal to actually intrude the molar as it is
being uprighted. An intrusive force on the molar can only
occur when an extrusive force is placed elsewhere, usually
on the premolars.
 Ankylosed teeth and dental implants could provided ideal
anchorage for tooth movement because they are incapable
of movement within the bone. Ankylosed teeth occur
infrequently, and they are rarely prescribed by the
orthodontist, thus dental implants are more commonly used
for anchorage.

 Miniscrew treatment of
ectopic mandibular
molars (JCO - 2003)
 The miniscrews used for
orthodontic anchorage are
made of pure medical
titanium. They are 7mm
long, with a maximum
diameter of 2.3 mm, and
have a partial thread with a
2mm diameter on the
external side.
 The first model had a
stress capability of
550N/mm2, but perhaps
due to fractures, the
breaking load was raised to
869 N/mm2.

 The miniscrew kit includes a drill and screwdriver.
 Miniscrews are always placed under local
anesthesia, using one of two surgical procedures. The
direct method consists of raising a sub-periosteal flap and
then suturing the incision.
 If the marginal gingiva is thick enough, the indirect or
transmucosal technique is indicated, without a surgical flap.
Once the surgical site has been prepared with the
appropriate drill, the miniscrew is inserted with the
screwdriver provided.

 Orthodontic traction was applied by means of elastic
threads, each exerting about 150g of force, attached
from the miniscrews to hooks bonded to the ectopic
molars.
 The single force applied to the ectopic molar
generates an extrusive moment and allows distal
tipping of the crown.
 The elastic thread was replaced throughout
treatment, so that a continuous force was maintained
24 hours a day until the screws were removed. The
hooks bonded to the molar crowns were moved
mesially whenever feasible.

A simple method of molar uprighting with micro-
impact anchorage (JCO – 2002).
 This article describes how upper and lower second
molars can easily be uprighted with Micro-Implant
Anchorage.
Surgical Procedure
 After an injection of local anesthesia, make a 3-4mm
incision with a No. 15 blade, and reflect the flaps
with a periosteal elevator .Drill a hole with a .9mm
pilot drill under coolant irrigation. Place the micro-
implant with a special screwdriver.

 CT scans show considerable space for micro-implant
placement buccal and distal to the lower second molar
 Positioning the head of the microscrew in the occlusogingival
dimension, as well as in the buccolingual and mesiodistal
dimensions, is critical to controlling tooth movement.
 If the head of the microscrew is lower than the occlusal surface
of the molar, the molar will tend to intrude during uprighling
 Gingival inflammation is sometimes seen distal to the second
molar. This can be reduced by proper oral hygiene and topical
medication or, if necessary, by periodontal surgery.
 The microscrew is removed simply by unscrewing it in the
opposite direction after exposure.

 After two weeks of healing, we bonded a lingual
button to the mesiolingual surface of the second
molar and applied 70g of force with elastomcric
thread. To prevent bucco lingual movement of the
elastomeric thread, the occlusal surface of the crown
can be grooved if a prosthetic replacement is planned
 With Micro-Implant Anchorage, upper and lower
second molars can easily be uprighted without side
effects on the anterior teeth and without using
orthodontic brackets.
 Molar intrusion can be performed, eliminating the
need for occlusal reduction.

 New microimplants for
orthodontic
anchorage, with the
heads, necks, and
threads of the screws
modified to improve
their efficiency have
been found.

The surgical uprighting of mandibular second
molars (JCO volume 1995 Aug).
 The mandibular second molars can become
impacted beneath the crown of the first molars and
fail to erupt normally.
 A study of 22 cases with follow-up periods of at
least 18 months shows the results obtained by
surgical uprighting of these teeth.

 Of 22 teeth, one has been lost but none of the
remaining 21 has developed infection or required root
treatment, and all are in good occlusion.
 Six teeth give a normal response to electrical pulp
testing.
 With judicious bone removal, the second molar is firm
and stable after uprighting and requires no
splinting, but in some cases temporary stabilization is
required.
 The bone defect normally seen mesially after
uprighting reossifies both clinically and
radiographically. www.indiandentalacademy.com

Early Surgical Management of Impacted
Mandibular Second Molars (JCO 2003 Vol. 35)
 Surgical uprighting with extraction of the third
molar, but without an autogenous bone implant.
 This technique is the most efficient for both the
patient and the clinician.

Concept of surgical uprighting
procedure.
A. Mesially impacted mandibular
second molar and third molar
bud.
B. After extaction of third molar
bud, bone level mesial to
secondmolar slants downward
(arrow).
C. After surgical uprighting, bone
level is still angled and deficient
mesial to second molar, which
is held in place with brass wire
(arrow).
D, Long-term result: second molar
roots have fully developed, and
alveolar bone height is level.

CONCLUSION

 Emphasis is placed on early diagnosis and initiation of
corrective orthodontic therapy.
For the best clinical results,
 uprighting of mesially impacted mandibular second molars
should begin in early adolescence.
 With early diagnosis and recognition of the potentially
developing impaction, practitioners are alerted to initiate
adequate corrective measures.
 Although surgical uprighting of impacted mandibular second
molars appears to be a quick and easy procedure, orthodontic
uprighting techniques are more advantageous and offer a better
long-term prognosis with no adverse pulpal or periodontal risks
to the tooth or supporting structures (ANGLE 1998)

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