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Treatment Planning Considerations for Molar Uprighting By Harsimrat Kaur, MDS; Pavithra US, MDS; Shabeer N. N, MDS; Reji Abraham, MDS
Abstract: Molar uprighting cases require individualized treatment planning depending upon condition of ridge, growth pattern of patient, periodontal condition, lower facial height, position of third molar and anchorage. Uprighting of molar was done in two cases effectively using simple tip back spring in one case and implant in another. Keywords: First molar; second molar; molar uprighting; mini-screw; uprighting springs
ntroduction Due to the early exposure of the first molar to the oral environment, its survival is at risk.1 Prevalence of first molar caries varies from one region to another depending on the preventive measures. Its prevalence is 30% for American Indian/Alaska native second grade children2 whereas for Saudi Arabian children is 87%,3 resulting in its early loss. This early loss can lead to many consequences as shown in (Figure 1). Mesial tipping of the second molar is a frequent outcome, because it can act as a plaque harboring area, which ultimately leads to periodontal destruction. Repositioning of the second molar eliminates pathologic condition and further facilitates path of insertion of prosthesis.4 An added advantage is that the alignment of roots perpendicular to the occlusal plane allow the tooth to withstand the forces of occlusion. The reason is that vertical forces are best tolerated by periodontium, with maximum in number of oblique fibers (Figure 2). To remedy this, surgical uprighting of the second molar can be done.5 Without doubt, this gives quick results, but requires removal of bone distal to second molar and causes trauma to apical vessels which can lead to devitalisation of uprighted tooth. There are possibilities of post-surgical infection and pulpal calcification, which reflects on possible drawbacks of this procedure. However, such an invasive approach is generally not required, as excellent results can be obtained by using numerous uprighting springs.6,7,8,9,10 Case Report 1: A 28-year-old post pubescent female patient presented with bi-maxillary dento-alveolar protrusion, class I skeletal and horizontal skeletal pattern. The patient desired correction of her procumbent anterior teeth and she was conscious of the space in lower left posterior region. The patient presented with missing 36(19) and mesially tipped 37(18) (Figure 3, 4). She had proper bucco-lingual width of the alveolar ridge favouring space closure of 36(19), by either retraction of the anterior teeth, or by protraction of the molar. Extraction was planned for her in first, second and fourth quadrant utilizing 36(19) space in third quadrant for retraction IJO
of the anterior teeth. Uprighting of 37(18) was performed by distal crown movement that will further provide space for anterior retraction. After initial leveling and aligning space, closure was performed on 0.017 x 0.025 S.S. in 0.018 Roth slot. After partial space closure, molar Helical uprighting spring was placed (Figure 5).
Figure 1: Mesial tipping of second molar, distal tipping of second premolar and supraeruption of antagonist tooth.
Figure 2: Oblique fibres are maximum in number in PDL. They are responsible for tolerating vertical forces.