CLINICIANS' CORNER
Molar uprighting with the piggyback buccal sectional arch wire technique Melvin Kogod, DDS, MS, and Harold S. Kogod, DDS Potomac, Md.
This article describes an orthodontic mechanical variation to unlock and upright mandibular impacted second permanent molars. This is 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. (AMJ ORTHODDENTOFACORTHOP1991; 99:276-80.)
I m p a c t i o n of the mandibular second molar occurs with sufficient frequency to necessitate the inclusion of creative mechanics within the orthodontist's armamentarium to disengage this important tooth. Characteristically, the mandibular second molar is observed to develop in the distal part of the dental arch. This tooth normally develops with a decided mesialaxial inclination within the mandibular corpus and in close proximity to the distoproximal surface of the first permanent molar. With continual favorable jaw growth as represented by adequate resorption of the anterior border of the ramus, the second permanent molar erupts after a succession of spontaneous adjustments in its axial inclination. Mesial movement of the first permanent molar subsequent to the exfoliation of the deciduous second molar may also result in an increase in space. Under these circumstances, normal eruption of the second permanent molar can occur without incidence. The second permanent molar can assume its proper position within the dental arch with roots more or less parallel to those of the first permanent molar and with the occlusal surface in harmony with those of the other posterior teeth. The adjustments in axial inclination of mandibular second permanent molars are thought to be associated with and are directly related to the natural increase in the posterior arch length. In many cases, however, where there is excessive mesial-axial inclination or where there is inadequate jaw growth producing a posterior arch length deficiency, the mandibular second molar becomes impacted against the distal contour of the first permanent molar. 811118266
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Several methods have been proposed for unlocking impacted permanent second molars. Separating wires and removable appliances have been used in some instances. Other clinicians have soldered helical loop springs to the distal end of a lingual arch ~ or formed partial loop springs from the distal end of the conventional labial arch wires. 2 To facilitate the manipulation of the impacted molar, other techniques have required that pins be screwed into the buccal surface of the second molar crown. 3 Black copper cement has been used previously to attach wire loops, 4's but today the newer direct bonding materials and polycarboxylate cements have facilitated the attachment of brass wire loops, 6 buccal tubes, 7 brackets, s or buttons 9 to the tooth structure. Surgical repositioning has been suggested as a rapid means of unlocking and uprighting impacted molars ~°~2 in various situations, including the post-orthodontic-treatment phase. Finally, extraction of mandibular second molars has been advocated to prevent impaction and to allow for eruption of mandibular third molars. ~'5"7 While it is recognized that any of the uprighting techniques previously mentioned might have application in a given situation, the technique of choice would be determined by such factors as the severity of the mandibular second molar impaction, the accessibility of the coronal surface of the impacted molar, the undesirable side effects, as well as the simplicity and expedience of the uprighting mechanics. SUBJECTS AND METHODS/CASE HISTORIES Over the past 2 years, the piggyback buccal sectional arch wire technique has been used efficiently and successfully in each of approximately 30 different cases in which it has been applied. The majority of cases
Volume 99 Number 3
Clhffcians' corner
d. a.
Fig. 1. Piggyback molar uprighting spring, a, Finishing loop; b, activating loop; c, vertical U loop; d, working end.
d
Fig. 2. Attachment of piggyback molar uprighting spring with wire ligature to base arch wire.
Fig. 3. Activation of piggyback molar uprighting spring. As the wire ligature draws the activating loop distally and compresses the vertical U loop, distal uprighting force is exerted on the impacted second molar.
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Fig. 4. A, Fixed appliances in place. B, PBBSAW in place 2 weeks after activation. C, Banding for leveling of mandibular second molar.
have required 2 to 4 weeks of uprighting mechanics, with only two cases requiring 6 to 10 weeks to disengage the impacted mandibular second molar. Patient discomfort and soft tissue irritation have been minimal with careful manipulation. The posttreatment radiographs show healthy dentoalveolar structures. A clear periapical radiograph should be taken of the impacted molar with the long-cone technique. The PBBSAW is made from 0.018-inch round orthodontic wire (Fig. 1) and can be designed with the working end determined by direct measurement of the periapical radiograph. The working end of the PBBSAW is positioned carefully beneath the gingiva and under the mesial contour of the impacted second molar. The sectional wire is held in position against the first molar buceal attachment by wire ligation without removing or altering in any way the base arch wire (Fig. 2). A periapical radiograph can be taken, verifying the sectional arch wire position. Activation of the uprighting spring is accomplished with the same wire ligature when it is drawn mesially through the sectional wire activating loop and is tightened (Fig. 3). The tightening, in turn, compresses the sectional wire vertical U loop. As the compressed U loop works toward restoring its original form, the working
end of the PBBSAW reciprocally places a distal upfighting force against the mesial surface of the impacted mandibular second molar. More than 2 to 4 weeks of activation (activated ovce per week) is rarely necessary to move the impacted mandibular second molar distally and to favorably alter its position so that the formerly impacted molar can be easily banded for further leveling and space closure. RESULTS
Three representative cases are illustrated. In Case I the mandibular fight second molar required 2 to 4 weeks of uprighting mechanics (Fig. 4). In Case 2 the mandibular right second molar required 8 weeks of uprighting mechanics (Fig. 5). In Case 3 the mandibular left second molar required 2 to 4 weeks of uprighting mechanics (Fig. 6). REFERENCES
1. Gottlieb EL. Uprighting lower 5's and 7's. J Clin Orthod 1971;5:12-9. 2. Canut JA. Clinical managementof the mandibularmolars. A.',I J OR'roOD1975;68:277-89. 3. BuchnerHJ. Correctionof impactedmandibularsecondmolars. Angle Orthod 1973;43:30. 4. Begg PR. Beggorthodontictheoryand technique. Philadelphia: W.B. Saunders, 1965:330-40.
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Clinicians" c o r n e r
Fig. 5. PBBSAW in place 2 weeks after activation (A) and 8 weeks after activation (B). (Photograph is reverse of radiograph). C, Mandibular second molar after leveling.
Fig. G. A, Fixed appliance in place. B, PBBSAW in place 4 weeks after activation. C, Mandibular second molar after leveling.
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5. Swain BF. Begg differential light forces technique. In: Graber TM, ed. Current orthodontic concepts and techniques. Vol. 11, 1969:585-816. 6. Rubenstein BM. Uprighting second molars with direct bonding. J Clin Orthod 1975;9:377-8. 7. Orton HS, Jones SP. Correction of mesially impacted lower second and third molars. J Clin Orthod 1987;21:176-81. 8. Safirstein GR. Unlocking impacted lower molars with direct bonding. J Clin Orthod 1974;8:205-12. 9. Lang R. Uprighting partially impacted molars. J Clin Orthod 1985;19:646-50.
10. PeskinS, Graber TM. Surgical repositioningof teeth. J Am Dent Assoc 1970;80:1320-6. ! 1. Laskin DM. Surgical aids in orthodontics. Dent Clin North Am, Jul 1968:509-24. 12. Laskin DM. Interceptive oral surgery. Clin Dent 1975;3:245-67.
Reprint requests to: Drs. Melvin Kogod and Harold S. Kogod 10320 Holly Hill PI. Potomac, MD 20854
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the AMERICAN JOURNAL OF ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS are available to subscribers (only) for the 1991 issues from the Publisher, at a cost o f $48.00 ($59.00 international) for Vol. 99 (January-June) and Vol. 100 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of'the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact M o s b y - Y e a r Book, Inc., Circulation Department, 11830 Westline Industrial Drive, St. Louis, M O 63146-3318, USA; telephone (800)325-4177, ext. 4351. S u b s c r i p t i o n s must b e in f o r c e to qualify. B o u n d v o l u m e s a r e not a v a i l a b l e in p l a c e o f a r e g u l a r J o u r n a l s u b s c r i p t i o n .
Molar uprighting with the piggyback buccal sectional arch wire technique Melvin Kogod, DDS, MS, and Harold S. Kogod, DDS Potomac, Md.
This article describes an orthodontic mechanical variation to unlock and upright mandibular impacted second permanent molars. This is 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. (AMJ ORTHODDENTOFACORTHOP1991; 99:276-80.)
I m p a c t i o n of the mandibular second molar occurs with sufficient frequency to necessitate the inclusion of creative mechanics within the orthodontist's armamentarium to disengage this important tooth. Characteristically, the mandibular second molar is observed to develop in the distal part of the dental arch. This tooth normally develops with a decided mesialaxial inclination within the mandibular corpus and in close proximity to the distoproximal surface of the first permanent molar. With continual favorable jaw growth as represented by adequate resorption of the anterior border of the ramus, the second permanent molar erupts after a succession of spontaneous adjustments in its axial inclination. Mesial movement of the first permanent molar subsequent to the exfoliation of the deciduous second molar may also result in an increase in space. Under these circumstances, normal eruption of the second permanent molar can occur without incidence. The second permanent molar can assume its proper position within the dental arch with roots more or less parallel to those of the first permanent molar and with the occlusal surface in harmony with those of the other posterior teeth. The adjustments in axial inclination of mandibular second permanent molars are thought to be associated with and are directly related to the natural increase in the posterior arch length. In many cases, however, where there is excessive mesial-axial inclination or where there is inadequate jaw growth producing a posterior arch length deficiency, the mandibular second molar becomes impacted against the distal contour of the first permanent molar. 811118266
276
Several methods have been proposed for unlocking impacted permanent second molars. Separating wires and removable appliances have been used in some instances. Other clinicians have soldered helical loop springs to the distal end of a lingual arch ~ or formed partial loop springs from the distal end of the conventional labial arch wires. 2 To facilitate the manipulation of the impacted molar, other techniques have required that pins be screwed into the buccal surface of the second molar crown. 3 Black copper cement has been used previously to attach wire loops, 4's but today the newer direct bonding materials and polycarboxylate cements have facilitated the attachment of brass wire loops, 6 buccal tubes, 7 brackets, s or buttons 9 to the tooth structure. Surgical repositioning has been suggested as a rapid means of unlocking and uprighting impacted molars ~°~2 in various situations, including the post-orthodontic-treatment phase. Finally, extraction of mandibular second molars has been advocated to prevent impaction and to allow for eruption of mandibular third molars. ~'5"7 While it is recognized that any of the uprighting techniques previously mentioned might have application in a given situation, the technique of choice would be determined by such factors as the severity of the mandibular second molar impaction, the accessibility of the coronal surface of the impacted molar, the undesirable side effects, as well as the simplicity and expedience of the uprighting mechanics. SUBJECTS AND METHODS/CASE HISTORIES Over the past 2 years, the piggyback buccal sectional arch wire technique has been used efficiently and successfully in each of approximately 30 different cases in which it has been applied. The majority of cases
Volume 99 Number 3
Clhffcians' corner
d. a.
Fig. 1. Piggyback molar uprighting spring, a, Finishing loop; b, activating loop; c, vertical U loop; d, working end.
d
Fig. 2. Attachment of piggyback molar uprighting spring with wire ligature to base arch wire.
Fig. 3. Activation of piggyback molar uprighting spring. As the wire ligature draws the activating loop distally and compresses the vertical U loop, distal uprighting force is exerted on the impacted second molar.
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Fig. 4. A, Fixed appliances in place. B, PBBSAW in place 2 weeks after activation. C, Banding for leveling of mandibular second molar.
have required 2 to 4 weeks of uprighting mechanics, with only two cases requiring 6 to 10 weeks to disengage the impacted mandibular second molar. Patient discomfort and soft tissue irritation have been minimal with careful manipulation. The posttreatment radiographs show healthy dentoalveolar structures. A clear periapical radiograph should be taken of the impacted molar with the long-cone technique. The PBBSAW is made from 0.018-inch round orthodontic wire (Fig. 1) and can be designed with the working end determined by direct measurement of the periapical radiograph. The working end of the PBBSAW is positioned carefully beneath the gingiva and under the mesial contour of the impacted second molar. The sectional wire is held in position against the first molar buceal attachment by wire ligation without removing or altering in any way the base arch wire (Fig. 2). A periapical radiograph can be taken, verifying the sectional arch wire position. Activation of the uprighting spring is accomplished with the same wire ligature when it is drawn mesially through the sectional wire activating loop and is tightened (Fig. 3). The tightening, in turn, compresses the sectional wire vertical U loop. As the compressed U loop works toward restoring its original form, the working
end of the PBBSAW reciprocally places a distal upfighting force against the mesial surface of the impacted mandibular second molar. More than 2 to 4 weeks of activation (activated ovce per week) is rarely necessary to move the impacted mandibular second molar distally and to favorably alter its position so that the formerly impacted molar can be easily banded for further leveling and space closure. RESULTS
Three representative cases are illustrated. In Case I the mandibular fight second molar required 2 to 4 weeks of uprighting mechanics (Fig. 4). In Case 2 the mandibular right second molar required 8 weeks of uprighting mechanics (Fig. 5). In Case 3 the mandibular left second molar required 2 to 4 weeks of uprighting mechanics (Fig. 6). REFERENCES
1. Gottlieb EL. Uprighting lower 5's and 7's. J Clin Orthod 1971;5:12-9. 2. Canut JA. Clinical managementof the mandibularmolars. A.',I J OR'roOD1975;68:277-89. 3. BuchnerHJ. Correctionof impactedmandibularsecondmolars. Angle Orthod 1973;43:30. 4. Begg PR. Beggorthodontictheoryand technique. Philadelphia: W.B. Saunders, 1965:330-40.
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Clinicians" c o r n e r
Fig. 5. PBBSAW in place 2 weeks after activation (A) and 8 weeks after activation (B). (Photograph is reverse of radiograph). C, Mandibular second molar after leveling.
Fig. G. A, Fixed appliance in place. B, PBBSAW in place 4 weeks after activation. C, Mandibular second molar after leveling.
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Am. J. Orthod. Dentofac. Orthop. March 1991
Kogod and Kogod
5. Swain BF. Begg differential light forces technique. In: Graber TM, ed. Current orthodontic concepts and techniques. Vol. 11, 1969:585-816. 6. Rubenstein BM. Uprighting second molars with direct bonding. J Clin Orthod 1975;9:377-8. 7. Orton HS, Jones SP. Correction of mesially impacted lower second and third molars. J Clin Orthod 1987;21:176-81. 8. Safirstein GR. Unlocking impacted lower molars with direct bonding. J Clin Orthod 1974;8:205-12. 9. Lang R. Uprighting partially impacted molars. J Clin Orthod 1985;19:646-50.
10. PeskinS, Graber TM. Surgical repositioningof teeth. J Am Dent Assoc 1970;80:1320-6. ! 1. Laskin DM. Surgical aids in orthodontics. Dent Clin North Am, Jul 1968:509-24. 12. Laskin DM. Interceptive oral surgery. Clin Dent 1975;3:245-67.
Reprint requests to: Drs. Melvin Kogod and Harold S. Kogod 10320 Holly Hill PI. Potomac, MD 20854
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the AMERICAN JOURNAL OF ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS are available to subscribers (only) for the 1991 issues from the Publisher, at a cost o f $48.00 ($59.00 international) for Vol. 99 (January-June) and Vol. 100 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of'the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact M o s b y - Y e a r Book, Inc., Circulation Department, 11830 Westline Industrial Drive, St. Louis, M O 63146-3318, USA; telephone (800)325-4177, ext. 4351. S u b s c r i p t i o n s must b e in f o r c e to qualify. B o u n d v o l u m e s a r e not a v a i l a b l e in p l a c e o f a r e g u l a r J o u r n a l s u b s c r i p t i o n .
