Rev. Med. Chir. Soc. Med. Nat., Iaşi – 2015 – vol. 119, no. 2

DENTAL MEDICINE CASE REPORTS

572

SECOND MOLAR UPRIGHTING AFTER PREMATURE LOSS

OF MANDIBULAR FIRST PERMANENT MOLAR- CASE REPORT

E. R. Cernei1, R. B. Mavru2, Irina Nicoleta Zetu1*

University of Medicine and Pharmacy, “Grigore T. Popa”-Iaşi

Faculty of Dental Medicine

1. Department of Orthodontics

2. Department of Pedodontics

*Corresponding author. E-mail: irinazetu@yahoo.com

SECOND MOLAR UPRIGHTING AFTER PREMATURE LOSS OF MANDIBULAR

FIRST PERMANENT MOLAR- CASE REPORT (Abstract): Introduction: Uprighting a

tipped molar by using an uprighting spring is a fundamental orthodontic treatment technique.

Following a weak anchorage done only by the anterior teeth the permanent lower second mo-

lar will rotate around its center of resistance, and besides the distalizing movement will oc-

cur its extrusion. Following the reaction, the mandibular anterior teeth will have a movement

of intrusion. All these elements will lead to anterior open bite. Correction of vertical prob-

lems has become easier with the advent of mini-implants. Case presentation: U.I patient

aged 24 years presenting for aesthetic and functional disorders. Clinical examination reveals

intraoral Class I molar malocclusion on the right sight, upper narrowing arch with a slight

overbite, and the both permanent first molars on the left side lost prematurely. The tooth 37

is inclined at 600 degrees to the plane of occlusion. To avoid front opening occlusion we

used an orthodontic miniscrew inserted between the canine and the first premolar on the

same side to achieve the second molar up righting. Lower second molar uprighting was

achieved without unwanted movements in anterior mandibular region and without molar ex-

trusion. Conclusions: Using mini implants in uprighting a tipped molar will achieve the de-

sired tooth movement and will reduce the number of unwanted side effects and eventually to

improve patient’s esthetics. Keywords: SECOND MOLAR UPRIGHTING, PREMATURE

LOSS, MANDIBULAR FIRST MOLAR, ORTHODONTIC MINISCREW

The first permanent molar has been re-

ported to be the most caries prone tooth in

the permanent dentition. More than 50% of

children over the age of 11 years have

some caries experience in this tooth (1, 2,

3). The early loss of permanent first molars

is a routine problem in the orthodontic

clinic and results in mesial inclination of

the second molars. Especially the early loss

of the lower first permanent molar should

be immediately addressed by prosthetic

replacement or orthodontic space closure as

it may lead to functional and anatomical

disturbances. The sequelae of events in-

clude distal migration of premolars, extru-

sion of the antagonist molar, premature

contacts in centric relation, occlusal inter-

ferences during lateral and protrusive

movements. In addition there is a difficulty

in prosthetic adaptation when the inclina-

Second molar uprighting after premature loss of mandibular first permanent molar - case report

573

tion is excessive. Mesial inclination favors

the appearance of vertical bone defects and

infra-osseous pockets in the mesial region

of molars (4, 5).

Molar uprighting into its correct posi-

tion leads to the normalization of function-

al and periodontal occlusion situation, ena-

bling the roots to be positioned perpendicu-

lar to the occlusal plane so that they are

better able to resist to occlusal forces, in

addition to facilitating the plane of inser-

tion of the prosthesis parallel to the long

axis of the tooth (6). Various conventional

orthodontic approaches were used to

achieve such a movement, but all have

been plagued to a greater or lesser extent

by the following issues: extrusion of the

molar to be up righted, unwanted move-

ment of the anchorage unit, the need for

bulky appliances, the frequent need of

accessories to strengthen anchorage, and

long treatment time (7).

With the advent of the use of minis-

crews as orthodontic anchorage, molar

uprighting procedures have become sim-

pler, with more predictable results, and

since there is no need to use other teeth as

anchorage, there is better control of unde-

sirable effects (6).

The aim of this study is to describe a

method for molar uprighting with the use

of a titanol spring supported on a messially

placed miniscrew.

CASE REPORT

Therefore we want to present a case that

presented in the clinic of Orthodontics and

dento-facial orthopedics in the Ambulatory

Pediatric Dentistry from Iasi, Romania. U.

I. patient aged 24 years presenting for func-

tional disorders. The extra-oral examination

(fig. 1) revealed an oval shape of the face, a

mesocephalic head shape, a mesoprosopic

face, and a mild convex profile. Facial

changes occur hyperdivergent profile and an

acute naso-labial angle. The patient showed

a good range of mandibular movements and

no temporomandibular-joint symptoms.

Fig. 1. Extraoral aspect-before treatment

Clinical examination revealed intraoral

Class I molar malocclusion on the right

sight, upper narrowing arch with a slight

overbite, and the both permanent first mo-

lars on the left side lost prematurely. The

space for 26 and 36 decreased due to mesi-

al inclination and migration of the second

molars. Tooth 16 was covered by a metal-

ceramic crown (fig. 2).

Orthopantomogram (OPG) examination

revealed good root canal treatment on tooth

16. All wisdom teeth were present.

The OPG was processed by tracking the

following structures (fig. 3):

-the occlusion plane – line tangent to

the vestibular cusps tips of premolars and

the canine tip on the same side;

-the axis of lower second permanent

E. R. Cernei et al.

574

molar – the line passing through the center

of the crown and the center of radicular

bifurcation.

The tooth 37 was tipped at approximate

600 degrees to the plane of occlusion (fig.

3). Second permanent molar from the four

quadrants had an inclination of 78 ° to the

plane of occlusion.

Cephalometric analysis using Onyx

CephR software revealed a Class I skeletal

(∠ ANB=2.20) with a hyperdivergent pro-

file ∠GoGn/SN=350

.

Fig. 2. Intraoral aspect-before treatment

Fig. 3. OPG and Cephalometry - before treatment

The patient’s chief concern was the dif-

ficulty of achieving chewing on the left

side. There were two treatment alternatives

for this case:

(1) Opening the space, uprighting and

distalization of upper and lower left molars

and implant/prosthetic replacement of the

left first permanent molars or (2) orthodon-

tic space closure by uprighting the second

and third molars and translating them into

mesial space.

Because the patient did not want a pros-

thetic/implant replacement he accepted an

orthodontic treatment. The treatment plan

included a surgical palatal expansion

(fig.4), extraction of 18 and 48, uprighting

the second permanent molar and a full

fixed appliance therapy with space closure.

We use a prefabricated superlastic Sand-

er spring (Memory-Titanol-Fefer; Forestadent,

Second molar uprighting after premature loss of mandibular first permanent molar - case report

575

Bernard Förster GmBH, Pforzheim, Germany) to

achieve the second molar uprighting. Be-

cause the patient had a slightly hiper-

divergent profile (∠GoGn/SN=350) and to

avoid front opening occlusion we used a

titan orthodontic miniscrew (8 mm, Ortho-

Easy®Pin Forestadent®) inserted between

the canine and the first premolar on the

lower left side as for anterior anchorage

(fig. 5).

Fig. 4. After surgical palatal

expansion

Fig. 5. Achieving uprighting of 37: superlastic Sander spring and mini implant insertion

E. R. Cernei et al.

576

Fig. 6. Achieving uprighting

of 37: final situation

DISCUSSION

Permanent first molars are the first

permanent teeth to erupt into the oral cavi-

ty. They have been quoted as the most

caries-prone tooth in the permanent denti-

tion leading to their early loss, probably as

a result of their early exposure to the oral

environment (1, 2). Loss of a first perma-

nent molar should be immediately ad-

dressed by prosthetic replacement or ortho-

dontic space closure as it may lead to func-

tional and anatomical disturbances (4). The

second and third molars from that side will

incline and rotate, canine and premolars

will move distally into the molar space, and

the opposing first molar will extrude. Cor-

rection of these problems is the biggest

challenge to the orthodontist (5).

The ideal solution of six years molar

syndrome is protraction of the second and

the third molars and toothless gap closure

without biological sacrifice. The procedure

is not simple, as these strong roots and a

significant path that follows the apex, if we

take into account initial second molar in-

clination. In a second molar inclination of

300-40

0 correspond to 11 mm travel only

apical-uprighting recovery (8) (fig. 7).

The optimal molar uprighting technique

for most situations in adults should thus

apply an intrusive force to the molar

crown, within an inflammatory- free envi-

ronment. A safe and simple method to

achieve such conditions is to use the pre-

fabricated superlastic Sander spring

(Memory-Titanol-Fefer; Forestadent, Ber-

Second molar uprighting after premature loss of mandibular first permanent molar - case report

577

nard Förster GmBH, Pforzheim, Germany).

Although the prefabricated Sander spring is

a simple and effective method for mandibu-

lar molar up righting, the method can in-

volve unwanted movements in anterior

mandibular region (9) (fig. 8).

Lee et al. have promoted the use of

miniscrew as direct anchorage changing the

mini implant position in order to obtain two

different types of force. The miniscrew can

be positioned in the retromolar area, where

it acts as a fulcrum for the traction by pull-

ing distally to the second molar (10). This

position of the miniimplant can be used in

mild tipped molars cases with mesial incli-

nation of the crown, because it generates a

sufficient effective uprighting moment to

allow the complete straightening of the

molar. Instead in moderate to severe tipped

cases, the generated moment is too small to

produce a sufficient straightening of the

tooth (11). For this reason it is essential to

consider the possibility of placing the mini

implant mesially to the tipped tooth so as a

thrusting action force from mesial to distal

in generated (12). To avoid front opening

occlusion we used in this case an orthodon-

tic miniscrew inserted between the canine

and the first premolar on the same side to

achieve the second molar uprighting.

Achieving uprighting of 37 the slightly

hiperdivergent profile remained constant

(∠GoGn/SN=350).

Fig. 7. Closing gaps steps left by the

absence of a first lower molar

Fig. 8. Consequences of molar uprighting with poor anterior anchorage

and molar extrusion

CONCLUSIONS

In this article we used a miniimplant in

uprighting a tipped molar to achieve a de-

sired tooth movement and to reduce the

number of unwanted side effects and even-

tually to improve patient’s esthetics. It is

necessary a proper clinical, radiological, and

biomechanical evaluation and a thoughtful

selection of the best orthodontic devices to

grant successful treatment results.

E. R. Cernei et al.

578

ACKNOWLEDGMENTS

This work received financial support

through the "Program of Excellence in

multidisciplinary doctoral and postdoctoral

research in chronic diseases", contract no.

POSDRU / 159 / 1.5 / S / 133377 benefi-

ciary U.M.F "Gr. T. Popa" Iasi, financed

from the European Social Fund through the

Sectoral Operational Programme Human

Resources Development 2007-2013.

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