Thursday, November 24, 2011

Diagnosis and treatment of mesially rotated upper 1st molars

Often, a Class II molar relationship develops because the upper 1st molars are mesially rotated. Recent studies show that mesial molar rotation exists in over 80% of Class II malocclusions (1). The importance of molar rotation in the development of Class II occlusion has been recognized for well over a century. In 1906 Angle wrote that the upper 1st molar is the key to development of good occlusion (2). Strang, the author of the 1950 edition of the Textbook of Orthodontics, writes, “Rotation of teeth often appears in the maxillary arch…and the mesio-lingual cusp of the maxillary molar resists displacement so strongly that the crown often rotates bodily around this …root" (3). In the June, 2003 issue of the Angle Orthodontist, authors Gunduz et al. described the etiology of upper molar rotation:
“The space between the buccal and lingual cortical plates becomes narrow anterior to the first-molar roots. When the upper first molar drifts mesially, the large lingual root contacts the lingual plate and allows the two buccal roots to rotate mesio-lingually. The occlusal surface of the first permanent molar is trapezoidal in shape, with the long diagonal from distolingual to mesiobuccal. Therefore, more mesio-distal space is used in the dental arch when this tooth rotates mesially with the lingual root as the axis. By correction of these rotations, one to two mm of arch length per side and partial Class II correction can be achieved. These corrections also are needed to provide good intercuspation."(4)

Ricketts (5) proposed a method of diagnosing mesial rotation of the upper first molar. This method has been widely used for the last 30 years. To determine if mesial rotation exists, view the upper arch from the occlusal and draw a line from the distal buccal through the palatal cusp of the upper molar. That line should pass through the opposite canine.

The figure above shows a correctly rotated molar. The line as described by Ricketts passes through the canine on the opposite side of the arch. Compare that picture to the one below, which shows mesially rotated molars.

Ricketts’ line passes through the opposite bicuspids. The molars are mesially rotated. This results in a Class II molar relationship.

The same patient after molar distal rotation has been accomplished. Ricketts’ line passes through the opposite canine. The molar relationship is Class I.

Why this is important

In normal occlusion, the palatal cusp of the upper 1st molar occludes with the central pit of the lower 1st molar. When the upper molar is mesially rotated, the palatal cusp is in a posterior position. This forces the mandible into a posterior (Class II) position. By distally rotating the molars the palatal cusp is positioned anteriorly. Upper palatal cusp/lower central fossa occlusion encourages forward positioning of the entire mandibular dentition. This results in a more anterior (Class I) mandibular position. Therefore, proper molar rotation results in correction of many Class II malocclusions.
Many clinicians further encourage forward mandibular positioning by expanding the upper arch. The rationale for this is the wider maxilla will accept the mandible in a more forward (Class I) position. Expansion and distal rotation of upper 1st molars has been used to correct Class II malocclusions for over a century. Many appliances can be used to make this correction. Proper manipulation of the inner bow of a headgear has been one of the most often used methodologies. Today, since the use of headgear is declining in most treatment systems, many clinicians simply use arch wires.
There are other advantages to proper upper molar positioning. Correctly rotated molars occupy less space than do molars that are incorrectly rotated. Up to 2 mm of space per side can be gained by correctly rotating the upper molars.

Correct molar rotation (left) and incorrect rotation (right). Notice the amount of space required in each situation.

Bracket position and its effect on molar rotation

Bracket position is critical in the effort to achieve proper upper molar rotation. Whether a band or direct bond bracket is used, the position of the bracket is evaluated by viewing the bracket from the occlusal. If the most anterior portion of the bracket bisects the mesio-buccal cusp, the bracket is placed correctly. When the upper molar band fits well, the bracket is automatically placed in the correct position. Problems arise when a band that is too large is used. The most common reason for using too large a band is insufficient space for band seating. Lack of space is almost always caused by incorrect use of spacers. When the contacts are tight, the clinician is forced to “wiggle” the band through the contacts to seat it. This is impossible to do with a band that is the correct size. Only a band that is too large may be wiggled into place. Bands that are too large result in poor position of the attachment. Poor bracket positioning means that sufficient distal rotation cannot be accomplished with a straight arch wire. To insure sufficient distal rotation, fit the bands correctly. If a bracket is bonded, carefully evaluate the bracket position from the occlusal view. If the bracket is not in the correct position, reposition the band or bonded bracket immediately.

The pictures below show an incorrectly placed band (top) and a correctly placed band (bottom).

Incorrect band size leads to incorrect bracket position. Proper molar position is impossible to attain with a straight wire.

Correct band position leads to correct bracket position. A straight wire results in good molar position.

Archwire bends to achieve distal molar rotation

When a patient presents with severely mesially rotated molars, good bracket position may not be enough to gain proper rotation. Toe-in bends are routinely used to correct severely mesially rotated molars. A 2X4 set-up with 45 degree bends mesial to the molars is an effective molar rotator. This also promotes upper arch expansion, as a toe-in close to the molar not only distally rotates the molar but also expands it by moving the crown buccally. Remember, for these mechanics to be effective, the bend must be an off-center bend. This means that the lateral segments must be bypassed (either left unbracketed or bypassed with a utility arch type bend).

Note: the shaded molar in the picture shows the movement that the 1st molar will experience.

An additional benefit of lateral segment bypass is arch development. This is due to the “Frankel effect”. Frankel appliances, which were developed in East Germany immediately after World War II, correct malocclusions by upsetting muscle balance. They consist of flanges that push muscles away from the arches in an effort to develop the arches(6). For instance a Frankel appliance to correct a Class III occlusion has flanges in the anterior vestibule on the upper arch. These flanges push the upper lip away from the teeth. The created muscular imbalance encourages the arches to develop into the void. The “Frankel effect” has proven to be reliable, especially in young patients. When using an arch wire that bypasses the lateral segments, the wire pushes the cheeks away from the arch. This allows lateral development of the arches into the void created by the wire.

Here is an example of how distal molar rotation is used to achieve a Class I molar relationship:

Pretreatment diagnosis: 4mm Class II as a result of mesially rotated molars

Treatment description:
The phase 1 treatment consisted of a 2X 4 set up in both arches. After leveling and aligning, expansion (using an expanded arch wire) and distal rotation (using bilateral toe-in bends) of the upper molars was accomplished. This corrected the ClassII molar relationship. These arch wires were kept in until the canines and bicuspids erupted. At this point the patient is ready for phase 2, which will consist of simply leveling and aligning, then using Class II elastics if necessary to correct any lingering ClassII relationship.

Because the lateral segments must be bypassed for toe-ins to be effective, this set-up is ideally suited for early treatment. Establishing the correct distal rotation of the upper molars is one of the most important benefits of early treatment. Proper rotation of the upper molars is an essential aspect of a Class I relationship. By establishing the correct molar relationship in the mixed dentition, a child’s growth and development can proceed normally.

In conclusion, proper distal rotation of the upper 1st molar is critical in the development and maintenance of a Class I molar relationship. Mild mesial rotation can be corrected by proper bracket positioning. Severe rotations call for more aggressive intervention. Bypassing the lateral segments and using toe-in bends mesial to the molars aid in the correction of even the most severe rotations. Without proper upper molar position, ideal occlusion is difficult to obtain.

1) Mesial rotation of upper first molars in Class II division 1 malocclusion in the mixed dentition: a controlled blind study. Progress in Orthodontics Vol12 issue 2 pp107-113 Nov, 2011.
2) Angle, Edward H.: “The Upper First Molar as a Basis of Diagnosis in Orthodontics.” Items of Interest, Vol. 28, June, 1906.
3) Strang, R.H. : Textbook of Orthodontics, Third Edition, 1950.
4) Gündüz, A. G. Crismani, H. P. Bantleon, Klaus D. Hönigl, and Bjorn U. Zachrisson (2003) An Improved Transpalatal Bar Design. Part II. Clinical Upper Molar Derotation—Case Report. The Angle Orthodontist: June 2003, Vol. 73, No. 3, pp. 244-248.
5) Ricketts RM. Occlusion-the medium of dentistry. J Prosthet Dent 1969; 21:39-60.
6) Prabhu, N. Interception of class II div.1 malocclusion by phase 1 treatment with Frankel appliance. JIADS: Vol 2 Issue 2. April 2011, p62.

Sunday, November 20, 2011

Anterior labial root torque

When upper anterior teeth, particularly lateral incisors, are in cross bite, they often need labial root torque. Normally positioned lateral incisor brackets, due to the torque built into those brackets, encourage the expression of lingual root torque. In cases where labial root torque is desired, the laterals never look quite right when normal torque expression occurs. My answer to this problem is to place the lateral incisor brackets on upside down. Flipping the brackets changes the torque expression from predominately lingual root torque to predominately labial root torque when rectangular wire is used.

Flipped upper lateral incisor bracket (top)
Normally positioned upper lateral incisor bracket (bottom)

The procedure to encourage labial root torque is as follows:

1) Create space in the arch form for the blocked out lateral incisor. This can be done on the initial arch wire by packing open coil spring between the central and canine in non-extraction cases, or by using a combination of coils and/or lacebacks in extraction cases. Remember not to pack too much coil on the initial arch wire (my coil springs are usually about 2mm longer than the space between the brackets on the adjacent teeth). This helps prevent distortion of the arch form. Be patient; use a slightly larger (about 2mm) piece of coil each month until enough space in the arch form is created to accommodate the blocked out tooth.

Blocked out upper right lateral.
Labial root torque will be needed.

Creating space with lacebacks and coil spring.

2) Once sufficient space is created, bracket the blocked out tooth (in our example, the upper lateral incisor). Place the bracket on upside down and engage the tooth. A light flexible arch wire must be used because that wire must be deflected a significant amount to engage the tooth. Often, as in the case shown here, a tandem arch wire set up is used. Additionally, in patients with deep bites, the bracket on the blocked out tooth may cause severe occlusal interferences. If this is the case, temporarily prop the bite open by bonding composite to the occlusal surface of both lower 1st molars. Remove the composite after the crossbite is corrected.

The lateral can be moved into the arch form after space is created. Note how composite is used to temporarily eliminate the occlusal interferences.

3) This set-up will result in labial movement of the crown. Because round wire is being used, no torque expression occurs as a result of torque in the bracket slot. At this stage of treatment it doesn't matter what the torque in the bracket slot is. Once the crossbite is corrected, remove the composite from the occlusal surface of the lower molars. The overbite will help retain the labial crown movement.

Crown is now in place. Note the need for labial root torque.

4)Once initial aligning is complete, begin torque expression by using a low load deflection rectangular arch wire. I often use 019x025 heat activated nickel titanium (HANT) followed by 021x025 HANT. Filling the slot encourages the expression of torque. The upside down bracket means the torque in the bracket slot encourages labial root/lingual crown torque. Because of anterior overbite, occlusion helps the crown retain its position while labial root torque occurs. Usually about 10 weeks of 021x025 HANT is necessary to achieve full torque expression. Leave the bracket on upside down for the whole treatment. That way correct torque expression is encouraged throughout the whole treatment.

Rectangular wire (021x025HANT) fills the slot. Note expression of labial root torque.

The treatment photos below (courtesy of Dr. Gerald Samson) demonstrate how much improvement in root position is possible with this technique.

Thursday, May 5, 2011

More questions and answers

Question: Why are Class III cases with open bite tendencies so difficult for beginners to treat?

Class III open bites are difficult for anyone, not just beginners. In these cases you have two problems that are tough to control. With Class III’s, you are at the mercy of mandibular growth. This growth accelerates during the growth spurt which means the Class III often worsens. In other words growth works against your treatment. Often Class III elastics are effective in correcting mild to moderate Class III problems. However, any inter-arch mechanics (in high angled patients, because muscle strength in these patients is usually not strong enough to resist the vertical component of force resulting from these mechanics) can make the high angled problem worse. Since virtually every published study involving facial aesthetics show that excessive face height leads to the most unattractive faces, it is important to minimize increases in face height in patients who already have long faces.
In these cases, extractions are sometimes effective. Extractions and space closure are effective in limiting increases in the vertical dimension and in many cases can actually reduce the anterior facial height. However, as this happens, the mandible rotates into a more closed position and, because the mandible opens and closes on an arc, it also moves forward, which worsens the Class III. So you see, most of what you can do in these cases have consequences that worsen other aspects of the malocclusion. There are no easy answers. This is why they are so difficult.

Question: One of my patients has a deep bite and bad oral hygiene. Every month he comes in, brackets are missing. Is it the bracket positioning that is responsible for the bonding failures? What do you suggest?

The bracket positioning is the least of your worries. Orthodontic bonding failures occur more in poor cooperators than in good cooperators. Poor cooperation is the major problem. My advice: either the patient improves his oral hygiene or you remove the braces. Don't tolerate this stuff. The patient and family are not upholding their end of the contract. The worst thing that can happen in an orthodontic case is decalcification due to bad hygiene. This problem will make any malocclusion look mild in comparison. Don't allow the possibility of decalcification to rear its ugly head. It's either clean teeth or no braces. It is just that simple. Do not compromise.

Question: I am a little confused about the shaping of arch wires. Is the upper wire 3mm longer than lower? What arch wire shape do you usually buy? There are so many sizes (for example wide, narrow, natural) that I am not sure which ones should I buy. Should I use the same arch form for nitinol wires as I do for stainless steel wires?

When coordinating arch wires, it is the width of the wire we are altering. The length simply depends on the total amount of wire needed to engage all the brackets. We have no control over this as it just depends on the total arch length. When buying wire, buy upper and lower broad arch forms for both stainless steel and nitinol. The original arch form of the stainless steel wire is less important than nitinol, because you will be shaping all stainless steel wires based on the pre-treatment arch form. Since the more flimsy (scientific term: low load-deflection rate) nitinol wire does not, due to its lack of stiffness, affect arch width as much as stiffer (high load deflection rate) wires like stainless steel, we do not routinely reshape nitinol wire (because of its flexibility it is hard to do anyway) and simply use the broad arch form in both the upper and lower arches.

Question: Do you prefer to use standard size brackets or minis?

I actually like the standard size brackets. Larger (wider) brackets result in better rotation control. Additionally, standard brackets have more surface area on the bonding pad which results in greater bond strength. Many doctors prefer the mini brackets because they are more aesthetic, but I don’t think the aesthetics of mini stainless steel brackets are that much different than the standard sized brackets.

Question: In extraction cases, what teeth do you usually extract?

If there is minimal lower arch crowding with a Class II tendency, I tend to extract upper 4’s and lower 5's. In this situation, reciprocal space closure results in more forward lower molar movement than forward upper molar movement. This moves the molars closer to a Class I relationship. In cases that are close to a full cusp Class II with minimal lower arch crowding, I often extract only upper 1st bicuspids and finish the case with Class II molars. If the case is Class I and extractions are necessary, four 1st bicuspid extractions is usually my treatment of choice.

Question: I am starting a case that has anterior spacing in both the upper and lower arches. How are these cases best started? Should I use 6-6 chain right from the start in 016 Niti wire? Or do I wait until later in the wire sequence?

For a case with spacing, it is usually prudent to progress into stiffer wires before initiating space closure. Always get the bite open to the desired level before initiating space closure. Additionally, you want the teeth to be sliding on a rigid arch wire so side effects of space closure are minimal. If the wire is too flimsy the chain can collapse the lateral segments, which results in a lot of tipping that you may not want. So wait to begin space closure. When you finally start space closure, if you want to reduce anterior torque, use round wire (020ss is my choice) when you close the spaces. If maintaining torque is a concern, wait until you are in 019X025 stainless steel (rectangular wire) before initiating space closure. The advantage of space closure on rectangular wire is the amount of control it provides but, because of the friction created due to the relatively full slot (there is not a lot of “slop” with 019X025 wire in an 022 slot), space closure may be inhibited. This is frustrating. Frictional forces are much less when closing space on 020 stainless steel, but this advantage is offset by the disadvantage of lack of control that is a result of the wire not filling the slot to a significant degree.
Many practitioners prefer to close space on round wire due to ease of space closure. For me, it depends on the torque of the anterior teeth. If torque is excessive, round is OK. If not, be careful. It is not easy to regain lost torque. Also, de-torqued anterior teeth (as the teeth de-torque the incisal edges rotate lingually) are often esthetically and functionally inferior to properly torqued teeth.

Question: I am treating a 10 year old boy with a 2x4 set-up on both upper and lower arches. His pretreatment overbite was 8mm. I'm intruding lower anterior teeth with a tip back set-up. Should I also intrude the upper anteriors?

It depends. My decision to intrude the upper anterior teeth is based on the amount of gingival display. If he has a smile that is too gummy, use tip back bends to intrude the upper anteriors. If his smile line is OK, just intrude the lowers.