Molar uprighting /certified fixed orthodontic courses by Indian dental academy


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Molar uprighting /certified fixed orthodontic courses by Indian dental academy

  1. 1. GOOD MORNING INDIAN DENTAL ACADEMY Leader in continuing dental education
  4. 4. 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.
  6. 6. 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.
  7. 7.
  8. 8.    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.
  9. 9. 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.
  10. 10. 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.
  11. 11.     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.
  12. 12.
  13. 13. 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.
  14. 14. 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.
  15. 15. 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.
  16. 16.   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.
  17. 17. 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
  18. 18.     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.
  19. 19. 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
  20. 20.      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.
  21. 21. Appliances for Molar Uprighting
  22. 22. 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.
  23. 23.
  24. 24.    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
  25. 25.     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.
  26. 26.    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
  27. 27.
  28. 28.    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
  29. 29. 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
  30. 30.     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
  31. 31.
  32. 32.   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.
  33. 33.  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
  34. 34. 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
  35. 35.
  36. 36.    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 Tloop is modified so that the end of the archwire is inserted from the posterior aspect of the molar tube
  37. 37.
  38. 38. 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.
  39. 39. 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.
  40. 40.    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.
  41. 41.
  42. 42.    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
  43. 43.     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.
  44. 44. 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.
  45. 45.     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.
  46. 46.     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.
  47. 47. Retention    After molar uprighting, the teeth are in an unstable position until the prosthesis that provides the longterm 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
  48. 48.
  49. 49.   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.
  50. 50.
  51. 51. 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. 
  52. 52. 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
  53. 53.   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.
  54. 54. 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
  55. 55. 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
  56. 56.   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.
  57. 57.  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.
  58. 58.    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
  59. 59.
  60. 60.     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.
  61. 61.
  62. 62.    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
  63. 63.    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
  64. 64.   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.
  65. 65.    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.
  66. 66. 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
  67. 67. 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.
  68. 68.
  69. 69. 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.
  70. 70.
  71. 71. 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
  72. 72.
  73. 73.     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.
  74. 74.     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.
  75. 75. Lower distal Jet.  A. Wire with bayonet bent, attached with screw to molar band, slides through 0.036” tube soldered to premolar bond.
  76. 76.  .Distal tipping force is applied to molar crown by compression of nickel titanium opencoil spring with screwclamp on tube.
  77. 77.  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
  78. 78.  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
  79. 79.   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.
  80. 80. Appliance design  The passive part of appliance includes a lingual canine-to-canine or premolar-topremolar 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.
  81. 81.    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.
  82. 82.
  83. 83.     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
  84. 84. 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 
  85. 85.     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.
  86. 86. 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. 
  87. 87.    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.
  88. 88.    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.
  89. 89.     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.
  90. 90. 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. 
  91. 91. 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
  92. 92. 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.
  93. 93.   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.
  94. 94.    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.
  95. 95.
  96. 96. 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.
  97. 97. Hook on right end engages lingual button.  A. Occlusal view.  B. Buccai view
  98. 98.  Spring activated by attaching hook to lingual button on impacted molar
  99. 99.     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.
  100. 100. 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.
  101. 101. 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)..
  102. 102.   Tie elastic thread between the button and the eyelet for traction . Begin lipbumper 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
  103. 103.     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
  104. 104. 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.
  105. 105. CLINICAL EXPERIENCE WIHT THIRD MOLAR ORTHODONTICS (AJO Volume 1989 December) Appliance construction and management     The wire portion of the appliance is fabricated from 0.032inch 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.
  106. 106.
  107. 107.      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.
  108. 108. 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.
  109. 109.    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.
  110. 110.     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.
  111. 111.    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.
  112. 112.    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.
  113. 113.
  114. 114.
  115. 115.     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.
  116. 116.     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,
  117. 117.
  118. 118.    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.
  119. 119. 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.
  120. 120.     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.
  121. 121.
  122. 122.    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.
  123. 123. Clinical Management of Unilaterally Impacted Mandibular First and Second Molars (JCO 2003, Vol. 37.)  The present article shows a fixed “eruptionassisting” appliance that can efficiently extrude impacted molars while ruling out ankylosis and limiting adverse effects on the adjacent teeth.
  124. 124.    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.
  125. 125.
  126. 126.   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.
  127. 127. 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.
  128. 128.   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.
  129. 129.    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.
  130. 130.    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.
  131. 131.    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.
  132. 132. A simple method of molar uprighting with microimpact 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 microimplant with a special screwdriver.
  133. 133.      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.
  134. 134.    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.
  135. 135.  New microimplants for orthodontic anchorage, with the heads, necks, and threads of the screws modified to improve their efficiency have been found.
  136. 136. 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.
  137. 137.     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.
  138. 138. 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.
  139. 139. 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.
  140. 140. CONCLUSION
  141. 141. 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) 
  142. 142. THANK U