CASE REPORT

Molar Uprighting simplified

Prashanth C.S I, Dharma R.M II, Akshai Shetty K.R III Case Report
The patient is a 15 year old male who presented with the chief complaint of crowding of upper front teeth. Extraoral examination revealed convex profile , acute nasolabial angle, recessive chin and a steep mandibular plane angle. Intraorally patient presented with class II molar relation on the right, and an end-on on left side with an overjet of 5mm. There was posterior crossbite in relation to 15, 16 & 45; 46& 35,36 and an anterior crossbite with respect to 12 &42;22&32.

ABSTRACT
Impaction of the lower second molar is a common problem, and a very challenging one for the orthodontist . Here is a case report of uprighting of a mesioangular impacted mandibular right permanent second molar. Though various treatment options were available, uprighting with traction from RME in the opposite arch was chosen. This method assumes significance, because cases which require RME usually present with a need for uprighting of lower molars, where this technique can be employed simultaneously to upright the impacted or tilted lower molar and decrease the treatment time considerably. Since anchorage is derived from the RME appliance,the usual untoward reciprocal effects on the adjacent teeth associated with cases of molar uprighting are avoided.
Key Words: Rapid maxillary expansion, Uprighting, impacted molar

Cephalometrically, patient was found to have skeletal class II jaw bases with vertical growth pattern, proclined upper and normally inclined lower incisors and an acute nasolabial angle with an upper lip strain of 2 mm. OPG revealed impacted mandibular second molar below the CEJ of mandibular first molar.

Introduction
Impacted or lingually tilted molars require uprighting . There are several approaches by which molar uprighting can be accomplished, like Australian uprighting spring, cantilever spring, push spring appliance, NiTi coil spring, Mini implant, forced eruption by elastics ,traction from removable appliances, surgical uprighting etc1-7,10. Rapid maxillary expansion (RME) is usually carried out for one month and kept in place for retention for 3 months.11-12The ideal procedure employed should allow the establishment of normal functional occlusal relationship without causing periapical or periodontal pathology13. The present article is an attempt to focus on a very simple yet efficient and effective way of disimpacting or uprighting a lower molar which can be easily employed in conjunction with routine orthodontic treatment procedures. The treatment plan chosen constituted of 2 phase therapy, Phase 1 constituted of bonded type of rapid maxillary expansion(RME) and lower molar uprighting while Phase 2 constituted of fixed mechanotherapy with MBT prescription. A bonded RME was used to correct posterior crossbite. To simultaneously upright impacted mandibular second molar , a hook fabricated from round stainless steel wire was incorporated on to the posterior aspect of upper right side of the RME appliance(Fig 1). Surgical exposure of mandibular second molar was done and two attachments were placed on the buccal aspect of mandibular second molar, which was the only accessible surface of the tooth.(fig 2)8,9,15-16 RME and uprighting of molar using blue vertical elastics were carried out simultaneously. RME was carried out for one month and kept in place for retention for 3 months.11-12

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Fig 1: Bonded RME appliance with hook

Fig 2: Surgical exposure of mandibular second molar

with bonded orthodontic attachment

Initially blue elastics were given from attachments on buccal surface of mandibular second molar to hook in the right side of RME(Fig 3). Later one more attachment was bonded on the buccal surface and red elastics were given from same attachment for a duration of 2 months(Fig 4). During the same period the vertical elastics for disimpacting mandibular second molar caused lingual rolling, so new attachments were bonded on occlusal surface of mandibular second molar and blue elastics were given in order to correct the angulation of the teeth being disimpacted which was continued for 2 more months(Fig 5)15-16. At this point RME was removed and posterior fixed bite plane was given to retain the expansion achieved . Later, red elastics were given for a duration of another 2 months from the hook incorporated in the posterior aspect of the fixed posterior bite plane(Fig 6).The comparison of pretreatment and posttreatment O.P.G.s reveal the uprighting of lower second molar. (Fig. 7) Phase 2 was carried out with all first premolar extraction using an .022 MBT prescription.

Fig 3: Vertical traction from hook in RME to the

orthodontic attachment

Discussion
This case report describes a new method of uprighting molars which is simple, efficient and less time consuming. Molar uprighting usually presents difficulty in managing the unwanted reactionary force vectors associated, which if not taken care can produce deleterious effects on areas of dentition employed for anchorage17. Uprighting tipped molars can benefit patients functionally, periodontally and for prosthodontic rehabilitation of mutilated cases. The specific benefits to be gained depend on the directions in which the molar moves, both in the vertical and mesio-distal planes of space18-19. The periodontal advantages of uprighting a mesially Fig 5: Changed vector of vertical force by applying elastic tipped molar include elimination of the pseudopocket force to the new attachment on occlusal surface that often forms on the mesial aspect of these teeth eliminating this pseudopocket may improve the IJCD NOVEMBER, 2010 1(2) 44 patients ability to control plaque accumulation in that 2010 Int. Journal of Contemporary Dentistry 18-19 area .
Fig 4: Vertical traction from hook in RME to the

orthodontic attachment with increased force

CASE REPORT

Fig 6: Final uprighting using traction from bonded

posterior bite plane eliminating this pseudopocket may improve the patients ability to control plaque accumulation in that area18-19. The present simple technique has a few advantages over other molar uprighting/disimpaction techniques 1)Time saved as this method is employed in conjunction with regular orthodontic treatment mechanics. 2)Since anchorage is derived from RME no additional anchorage preparation required and reciprocal effects seen in other molar uprighting techniques are not seen. 3) Since the force vector is vertical, it can be considered more physiologic as it is in the direction of normal eruptive path.
Fig 7: Pre and post OPG revealed achieved uprighting

of mandibular second molar 3. Tuncay, O.C.; Biggerstaff, R.H.; Cutcliffe, J.C.; and Berkowitz, J.B.: Molar uprighting with T-loop springs, J. Am. Dent. Assoc. 100:863-866, 1980. 4. Roberts, W.W.; Chacker, F.M.; and Burstone, C.J.: A segmental approach to mandibular molar uprighting, Am. J. Orthod. 81:177-184, 1982. 5. Weiland, F.J.; Bantleon, H.P.; and Droschl, H.: Molar uprighting with crossed tipback springs, J. Clin. Orthod. 26:335-337, 1992. 6. Capelluto, E. and Lauweryns, I.: A simple technique for molar uprighting, J. Clin. Orthod. 31:119-125, 1997. 7. Shellhart, W.C. and Oesterle, L.J.: Uprighting molars without extrusion, J. Am. Dent. Assoc. 130:381-385, 1999. 8. M.Anthony Pogrel: Surgical Uprighting of Mandibular Second Molar AJODO 1995 Aug 180-183 9. Mc aboy CP et al:Surgical Uprighting and repositioning of severely impacted mandibular 2nd Molar JADA, Vol. 134, November 2003, 1459-1462 10. Varpio M, Wellfelt B. Disturbed eruption of the lower second molar: clinical appearance, prevalence and etiology. ASDC J Dent Child. 1988;55:114118. 11. Mge Sandikioglu ,Skeletal and dental changes after maxillary expansion in the mixed dentition , AJODO Mar 321 - 327: 1997

Conclusion
After considering the biomechanical aspects as demanded by the clinical situation, employing the best of the various treatment options available for molar uprighting can give desired treatments results. Simple method of uprighting like the one described in this article are quite effective and also take up less of treatment time as it can be used along with regular treatment mechanics. Since the anchorage is derived from the bonded RME appliance, any further need for any anchorage preparation is eliminated.

References
1. Kraal, J.H.; Digiancinto, J.J.; Dail, R.A.; Lemmerman, K.; and Peden, J.W.: Periodontal conditions in patients after molar uprighting, J. Prosth. Dent. 43:156-162, 1980. 2. Lubow, R.M.; Cooley, R.L.; and Kaiser, D.: Periodontal and restorative aspects of molar uprighting, J. Prosth. Dent. 47:373376, 1982.

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12. Robin A. Sandstrom et al.Expansion of the lower arch concurrent with rapid maxillary expansion, AJO- About the Authors: DO, Volume 1988 Oct 296 - 302 I ) Prashanth C.S MDS, 13. W. Craig Shellhart et al : Uprighting Molar Without Extrusion, JADA Vol 130, Mar 1999. 14. Frank C. Treatment option for impacted teeth J Am Dent Assoc 2000; 131: 623-32 15. Hassan A. El-Abdin et al.Surgical exposure and orthodontic traction of unerrupted teeth: A preliminary study. The Saudi Dental Journal, Volume 7, Number 1, January 1995 16. 18. Hunt NP. Direct traction applied to the unerupted teeth using acid-etch technique. Br J Orthod 1977;4:211-12. 17. HYO-SANG PARK et al. A Simple Method of Molar Uprighting with Micro-Implant Anchorage , JCO Oct 2002 : 592-96

Professor Department Of Orthodontics and Dentofacial Orthopedics, DAPM R V Dental College, Bangalore. II ) Dharma R.M MDS, Professor Department Of Orthodontics and Dentofacial Orthopedics, DAPM R V Dental College, Bangalore. III) Akshai Shetty K.R MDS M Orth R.C.S.E.d, Professor Department Of Orthodontics and Dentofacial Orthopedics, DAPM R V Dental College, Bangalore.

18. Monika Sawicka et al Uprighting Partially Impacted Permanent Second Molars, Angle Orthodontist, Vol 77, Correspondence Address: No 1, 2007 Email: toprashanthcs@gmail.com 19.Kraal, J.H.; Digiancinto, J.J.; Dail, R.A.; Lemmerman, K.; and Peden, J.W.: Periodontal conditions in patients after molar uprighting, J. Prosth. Dent. 43:156-162, 1980.

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