The tilted posterior tooth.

Part II: Biomechanical

therapy
Adrian Becker, B.D.S., L.D.S., D.D.O.,* Maya Zalkind, D.M.D.,** and Noah Stern, D.M.D.,
M.S.D.***
Hebrew University-Hadassah Faculty of Dental Medicine, Jerusalem, Israel
w hen a tilted tooth borders on an edentulous
space, it is generally possible to provide a mechanical
solution to replacing the missing unit. As long as the
abutment remains tilted, however, the restoration
will generally be a compromise. The dentist should
consider the possibility of adjunctive orthodontic
therapy to return the malposed tooth to its former
position.. , The teeth of adults with normal invest-
ing tissues respond to orthodontic forces in much the
same way as do those of children, although the
response may be slower in adults.
The advantages of such preprosthetic groundwork
include (1) simplification of abutment preparation,
(2) transmission of occlusal forces through the long
axes of the teeth, (3) improved occlusal contour and
intercuspation. (4) alteration of the pontic area may
be achieved, (5) prevention of infrabony pockets
associated with tilting, and (6) elimination of extrac-
tion spaces in some instances.
ORTHODONTIC DEVICES
Both removable and fixed orthodontic devices are
suitable for the movement of teeth in the adult, and
each has its place in treating the many problems that
arise.
Removable devices are easier to construct, since a
designed cast, sent to the laboratory technician with
appropriate instructions, requires only minimal
chairside time. Such devices may be used to tip
individual teeth mesially, distally, buccally, and
palatally with great efficiency; however, they cannot
Supported in part by a grant from the Joint Research Fund of the
Hebrew University-Hadassah Faculty of Dental Medicine.
*Clinical Senior Lecturer, Department of Orthodontics.
**Lecturer, Department of Oral Rehabilitation.
***Associate Professor, Department of Oral Rehabilitation.
Of~22-3913/R2/OX0149 + 07$00.70/O IV 1982 The C. V Mosby Co.
move teeth bodily, nor can they produce root move-
ment. They can be used to temporarily increase the
occlusal vertical dimension, clearing the teeth to be
moved from occlusal interference. These removable
devices are often a problem to the patient because of
their size, their disturbance of normal function, and
perhaps because the patient can too easily remove
them (Fig. 1).
While the fixed devices are of more modest dimen-
sions, they generally require a greater degree of
technical skill in their construction and activation.
They may be designed to effect all forms of move-
ment of the teeth in all directions. They cannot be
used to separate the two dental arches when oc-
clusal interference occurs during tooth movement
and, therefore. they may require the addition of a
Hawley-type removable device to enhance their
efficiency.
When a mesially tilted tooth is tipped distally, it
meets with resistance from the occlusion of the
opposing teeth since distal tipping is accompanied
by elongation of the affected tooth. As uprighting
progresses, using a fixed device, the upper and lower
dental arches become further separated because a
premature occlusion develops between the tipped
tooth and its antagonist. This increase in the vertical
dimension of occlusion may result in transitory or
permanent injury caused by the abnormal occlusal
contact. In general, occlusal grinding of the affected
teeth is periodically necessary during the orthodontic
procedure. The insertion of a Hawley-type device
with a bite platform has the effect of separating the
teeth. This simplifies the desired movement of the
teeth by eliminating occlusal resisting forces. At the
same time, occlusal grinding may be delayed until
the end of treatment when the tooth is in its correct
axial relation. Often, however, a full reassessment of
the vertical dimension of occlusion is made when
THE JOURNAL OF PROSTHETIC DENTISTRY 149
BECKER, ZALKIND, AND STERN
Fig. 1. Right second maxillary molar has tilted mesially to partially obliterate first molar
extraction space. Adams clasps are placed on second premolar and canine on each side of
arch since molars of opposite side are missing. A, Simple finger spring is held in place by
palatal acrylic resin base. 8, Orthodontic device seated. C, Activation of spring may be
seen in this view in which orthodontic device is not fully seated.
Fig. 2. A, Diagrammatic representation of elements of simple fixed device with tube which
carries facility for inserting fine wire vertically between tube and pad. Wire is fashioned into
configuration suitable to its attachment to horizontal bar which has been bonded to both
premolars and canine of same side. B, Device in mouth. Third molar was extracted at time of
insertion. C, Initial placement radiograph. D, Posttreatment radiograph.
uprighting has been achieved; prosthetic occlusal on the side opposite the extraction site and dasps on
rehabilitation of the dentition, as a whole, will then both first premolars, while a simple finger spring
include the readjustment of the height of the clinical exerts light pressure (30 to 50 gm) on the potential
crown. abutment tooth in a distal direction (Fig. 1). The
DISTAL MOLAR TIPPING
addition of an acrylic resin platform anteriorly, acts
as a bite plane for the lower incisors, clears the
posterior teeth from occlusion, and facilitates the
desired movement.
With a removable device, adequate clasping may
be provided using Adams clasps on the first molar
150 AUGUST 1982 VOLUME 48 NUMBER 2
BIOMECHANICAL THERAPY
Fig. 3. A, Orthodontic device similar to that shown in Fig. 1, with Adams clasps on first
premolar and molar on unaffected side. B, Second molar of affected side has tilted and rotated
meslally, but some space of extracted first molar has been lost to distally drifted premolars.
Adams clasp is placed on canine on this side, and acrylic resin is judiciously cleared to allow
for mesial movement of premolars to be achieved with similar spring at same time as that
being used in opposite direction on molar. C, Activated springs with device partially seated.
D, Activated springs with device fully seated
Some years ago, orthodontic attachments welded
to orthodontic bands were used for all fixed devices.
Today, however, bands have largely been super-
ceded by directly attaching orthodontic brackets and
tubes to the enamel.. i
By using the acid-etch technique for bonding
composite resin directly to enamel, a round buccal
tube of 1 mm in diameter (0.040 inch) may be
welded to a small pad of stainless steel mesh. The
mesh acts as a mechanical retention for the tube,
which, through the medium of a composite resin
may be directly bonded to the buccal surface of the
tilted molar. The tube should be parallel to the
occlusal plane of the tilted tooth. A length of 0.5 mm
spring steel wire is inserted in the tube, with its
mesial end lying passively in the buccal vestibule
opposite the premolar teeth. This spring is raised to
hook over a simple wire bar which has been similarly
bonded to the premolar and canine teeth (Fig. 2).
Using either of the methods described, the move-
ment should be achieved rapidly and with no
ill effects on other teeth. provided there is no tooth
(erupted or unerupted) distal to the molar. The
space for the pontic will be increased as uprighting
proceeds.
DISTAL MOLAR AND MESIAL PREMOLAR
TIPPING
Distal drifting of premolars will often accompany
mesial tilting of the second molar when time has
lapsed since the extraction of the first molar. This
may be expeditiously treated with a removable
device similar to that described (Fig. Y,.
A second finger spring is used to move both
premolars mesially, applying force in the opposite
direction to the spring which tips the molar distally.
To accomplish this, good retention of the device is
necessary, which demands the use of Adams clasps
on two teeth of the opposite side. Since teeth that are
to be moved cannot be clasped, the canine on the
affected side becomes the most distal tooth to carry a
clasp; should this tooth fail to have a sufficiently
bulbous contour, it may become necessary to add a
clasp anteriorly. The addition of an anrerior biting
THE JOURNAL OF PROSTHETIC DENTISTRY 151
BECKER, ZALKIND. AiXL> STERN
Fig. 4. Flexed sectional rectangular archwire is tied into edgewise attachments on both
distally tilted second premolar and mesially tilted second molar. A, Diagrammatic represent-
ation of mechanism, with archwire shown above in its passive state and undistorted length (Lj.
Its new length (L) is dictated by distance between attachments, into which it is tied to produce
reciprocal mesial pressure on premolar and distal pressure on molar. B, Radiograph with
device in place at start of treatment. C, Radiograph with device in place at end of treatment.
Note change in shape of archwire. D, Position, deep in vestibule, of mesial end of archwire
when only distal end is engaged. E, Clinical view of device at start of treatment. F, Clinical
view of device at end of treatment.
platform, to free the posterior teeth from occlusion, is ments is smaller than the distance between the
also often advised, particularly where the tipping of corresponding bends of the archwire. Full engage-
the molar has been severe. ment of the wire dictates that it be sprung into the
Probably the simplest method of tipping a molar brackets, thereby exerting a force in both directions
distally and a premolar mesially is the use of an to move both teeth by a simple tilting movement and
edgewise bracket or tube placed on the molar (either increasing the pontic space.
welded to a band or directly bonded) and an
edgewise bracket on the premolar (Fig. 4). A section-
al rectangular archwire is fashioned so that when
placed in only one of the attachments, its other end
lies passively in the vestibule sulcus below the other
attachment. The distance between the two attach-
UPRIGHTING ABUTMENTS WITH
CONTROLLED LENGTH OF PONTIC SPACE
Movement of the roots of the teeth is required.
independent of any alteration in the distance
between their crowns. This is not possible with thr
152 AUGUST 1982 VOLUME 48 NUMBER 2
BIOMECHANICAL THERAPY
Fig. 5. A, Note similarity to mechanism used in Fig. 4. Important difference is unaltered
length of archwire between passivity and flexion. It is altered angulation of engaged ends of
wire which flexes wire and produces root movement only. B, Severe tilting of premolar and
molar. Corrective tipping alone would open pontic area equal to almost two premolar teeth. C,
Bands were placed on first and second molars, first premolar, and canine on the affected side.
Opposite side had bands placed on canine and first molar. Vertical slotted Begg brackets were
used on bands. Carrying uprighting auxiliary springs which were hooked over 0.018 Inch
round archwire. Elastic ligature was used to limit degree of tipping of intended abutments tu
limit space for pontic. D, Treated result.
removable devices but may be expeditiously per-
formed as described, using edgewise attachments
and the same type of sectional archwire. Here,
however, it is essential that the interattachment
distance be the same or slightly greater than the
distance between the corresponding bends on the
archwire (Fig. 5, A). This prevents the crowns from
further separation. Since each attachment is at right
angles to the long axis of each of the two teeth, the
engagement of the archwire (the two ends of which
are extensions of the same straight line) will bring
pressure to bear on the roots of the two teeth. This
pressure will only be relieved when the teeth become
parallel.
An alternative mechanism is presented to show a
different technique for achieving root movement,
using the Begg bracket and round cross-section
archwires (Fig. 5, B to D). Teeth must be banded on
both sides of the arch. Uprighting is achieved with
the use of auxiliary springs. The degree of alteration
of the pontic length is then controlled by
the ligation of the two teeth with a steel or elastic
ligature.
FULL CLOSURE OF EXTRACTION SPACE
The greatest advantages of full space closure are
that fixed restorations may be rendered entirely
unnecessary and that third molars may erupt and
become useful members of the masticatory appara-
tus. This approach is particularly pret&rable when
both lower, both upper, or all four lirst molars
require extraction (or have recently been extracted)
and where adequate alveolar bone is present in the
extraction spaces. Undoubtedly, the rnesial move-
ment of teeth is achieved only with its surrounding
alveolar bone; however, when thr first molar has
been missing for several years. the residual bone ma)
be thin. In this circumstance, ir SWIIIS likely that
mesial movement into such an area ma) result in
some loss of the buccal plate of boric 1 ovcrine the
THE JOURNAL OF PROSTHETIC DENTISTRY
153
BECKER, ZALKP-ID, AND STERN
bucc :a1 surfac e of the roots. Fenestration of the buccal
surfa ces of th te roots may thus occur.
In suitable instances, however, there is no reason
why
this trea tment should not be used to advantage
to e liminate an excessive horizontal overlap or
crow rding in the treatment of malocclusion. Full
mult i banded devices and a high degree of technical
Fig. 6. A, Lateral jaw radiographs of young adult showing missing left mandibular f$st molar
and remaining three first molars with questionable prognosis. B, Preorthodontic/orthodontic
conditions of left side. C, Postorthodontic condition of left side showing fully erupted and well
placed third molars in occlusion. D. View of latter stages of orthodontic treatment, showing
complex device used. E, Right and left views taken from panoramic radiograph made 2 years
after treatment was completed.
skill are essential, but the results are ml
ing (Fig. 6).
DISCUSSION
It is neither necessary nor desirable 1
tilted abutment teeth prior to prostheti
tion. Where minimal advantage is to I
ost encow
.o upright ail
.c reconstl cuc-
be gained
by
rag-
154 AUGUST 1982 VOLUME 48 NUMBER 2
BIOMECHANICAL THERAPY
adopting this procedure, it should be avoided. How-
ever, where periodontal problems exist, and the
solution may partially depend on improvement of
tooth position, or where the number of missing teeth
to be replaced may be reduced, orthodontic inter-
vention should be considered. Consideration should
be given to all factors which might benefit from such
treatment. Only then should the decision to alter the
position of the abutment teeth be made. If there is
value to be gained by this treatment, it will become
obvious almost solely in enhancing the long-term
prognosis of the results.
X word on the matter of prevention, as was
mentioned in an earlier communication, is in order.
It is not often that a posterior tooth is extracted in
circumstances other than the result of long-term
neglect. The most common occurrence is an episode
of acute dental pain. Either the seriousness of the
tooths condition or disinterest on the part of the
patient as to extended conservative treatment gener-
ally dictates extraction as the most likely form of
treatment. These patients are usually far from recep-
tive to the construction of devices aimed at prevent-
ing tipping movements of the adjacent teeth at this
point, as evidenced by their refusal of more conser-
vative initial measures which would not have
allowed their dental health to have deteriorated to
this level. However, many patients may be led to
greater awareness of the benefits that sound treat-
ment can provide if a little time and effort is spent
educating them in the nature of their potential
problem. Temporary space maintainers may be
simply constructed and successfully used for months
until repair has occurred or until the patient is
ready to accept construction of a fixed permanent
restoration.
SUMMARY
There are several reasons that may justify the use
of adjunctive orthodontic intervention prior to, or
instead of, the prosthetic replacement rlf missin,g
dental units. These have been outlined. Methods arr
described where the space for the pontic may be
altered in length while the abutment teetlr are made
parallel. Techniques which attempt to p~oduw root
movement or techniques in which full space closure
is planned are best performed by ;j i:ornpetent
orthodontist.
REFERENCES
1. Revah, A., Rehany, A., and Zalkind, M.: Ihr tilted posterior
tooth. Part III. An abutment for a fixed pan~ai denture. (To
be published.)
2. Marks, M. H.: Ioofh movement in prriodonial therapy. In
Goldman. H., and Cohen, I.). W.. editors. Periodontal
Therapy, ed 5. St. Louis, 1973, I% <:. 1 Vlosby Co.. pp
491-546.
3. Brown, S.: The effect of orthodontic therapy 011 terrain tvprs
of periodontal defects. I. Clinical iindinss ,i Pwioc-lonr
44~742. 1973.
4. Becker, A.: The median diastema. I)enr <al~rr North Am
22:685, 1978.
5. Way, D. C.: Direct bonding and its ~pplicx:ron to minor
rooth movements. Dent Clin North .Am 22:i)i. 19713.
6. Stern, N.. Revah. A., and Becker, :\: lhv !iltrd posterior
tooth. Part I: Etiology, syndrome, and p~ev<~~t~x~. ,] IKOS-
1HFl DlW 46:404. 1981.
Kqmt reyue.t1., to:
DR. ADRIAN BECKER
HEBREW U~~IVERSIT~-H.~DASSA~~
FACLI.TY OF DENTAI. MEDKXNE
P.O.B. 1172
JERUSALEM
IsR.411
THE JOURNAL OF PROSTHETIC DENTISTRY
155