JCO-Online Copyright 2010

Uprighting of Lower Molars

VOLUME 30 : NUMBER 11 : PAGES (640-645) 1996
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 ( Figs. 1A , 1B ). 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" X .
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 cantilevers 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 direction 15 ( Figs. 3A , 3B ).
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
( Figs. 4B , 4C ). 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
( Figs. 5A-1 , 5A-2 , 5A-3 ). 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 ( Figs. 5B , 5C-1 , 5C-2 ).
On the right side, the force system was estimated with a computer program 15 under two different premises, with and
without the third molar ( Fig. 5D , 5E ). 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 ( Figs. 5F-1 , 5F-2 , 5G-1 , 5G-2 , 5H-1 , 5H-2 , 5H-
3 ).
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 ( Figs. 6A-1 , 6A-2 ). A two-cantilever system was designed for uprighting and intrusion ( Figs. 6B , 6C-1 , 6C-2 ), 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-loop 17 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 8 systems can be achieved with
statically indeterminate appliances. 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

Figures

Fig. 1A Two different lengths of cantilever used for uprighting. Long cantilever (See Fig. 1B) delivers moment-to-force
ratio of 25, compared to 15 for shorter cantilever.

Fig. 1B Two different lengths of cantilever used for uprighting. Long cantilever delivers moment-to-force ratio of 25,
compared to 15 for shorter cantilever (See Fig. 1A).
Fig. 2 Force systems produced by different positions of "V" bends.

Fig. 3A With point of force application buccal to center of resistance, molar is tipped lingually during uprighting.

Fig. 3B With long cantilever, point of force application is lingual to center of resistance, and molar is tipped buccally.
Fig. 4A Case 1. 26-year-old female with previous juvenile periodontitis, after extraction of lower right first molar.

Fig. 4B Case 1. Six months later, mesial tipping of second molar has worsened, and third molar is almost horizontal.

Fig. 4C Case 1. After treatment.

Fig. 4D Case 1. Two cantilevers, one for intrusion and uprighting of second molar and one for extrusion and
uprighting of third molar.

Fig. 4E Case 1. One year after treatment.

Fig. 5A1 Case 2. 17-year-old male with second molars tipped mesially.

Fig. 5A2 Case 2. 17-year-old male with second molars tipped mesially.

Fig. 5A3 Case 2. 17-year-old male with second molars tipped mesially.
Fig. 5B Case 2. Force system used on left side: two cantilevers, one extending from molar tube and one from vertical
tube welded to main arch, both delivering desirable moments to molar. Sum of forces produces slight intrusive force
against molar.

Fig. 5C1 Case 2. Appliance used on left side.

Fig. 5C2 Case 2. Appliance used on left side.

Fig. 5D Case 2. Computer simulation of second molar movement with third molar left in place.

Fig. 5E Case 2. Movement with center of resistance changed by extraction of third molar.
Fig. 5F1 Case 2. Force system used on right side. Labial: cantilever for delivery of extrusive force and large moment.

Fig. 5F2 Case 2. Force system used on right side. Lingual: open-coil spring for delivery of distal force against crown,
adding to uprighting moment.

Fig. 5G1 Case 2. Appliance used on right side.

Fig. 5G2 Case 2. Appliance used on right side.

Fig. 5H1 Case 2. After treatment.

Fig. 5H2 Case 2. After treatment.

Fig. 5H3 Case 2. After treatment.

Fig. 6A1 Case 3. 38-year-old male with lower right second molar tipped at 45° and slightly overerupted.

Fig. 6A2 Case 3. 38-year-old male with lower right second molar tipped at 45° and slightly overerupted.

Fig. 6B Case 3. Two cantilevers used for uprighting and intrusion.

Fig. 6C1 Case 3. After uprighting and intrusion of second molar.

Fig. 6C2 Case 3. After uprighting and intrusion of second molar.

Fig. 7A Case 4. 35-year-old male with extreme deep bite from Brodie syndrome and nearly horizontal lower third
molar.

Fig. 7B Case 4. After maxillary osteotomy and uprighting, intrusion, and mesial movement of third molar with two
statically indeterminate appliances.
References
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Footnotes
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