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Strategic Molar Uprighting Using the
Biocreative Reverse-Curve Technique
HYO-WON AHN, DDS, MSD, PhD
MIN-KI NOH, DMD, MS, PhD
KYU-RHIM CHUNG, DMD, MSD, PhD
SEONG-HUN KIM, DMD, MSD, PhD
GERALD NELSON, DDS
M
esial molar tipping is a com-
mon occurrence caused by
factors such as lack of arch
length, an abnormal eruption path,
premature eruption of mandibular
third molars, early loss of mandib-
ular first molars, and iatrogenic is-
sues.1 Early treatment is recom-
mended, because mesial molar
impaction can lead to occlusal col-
lapse, periodontal problems, and
other concerns.2
Molar uprighting with conventional mechan-
ics may involve dental anchorage for an auxiliary
helix, compressed coil spring, or one of various
loop configurations. These tactics are typically
accompanied by undesirable movement of the an-
chor teeth, 3-5 however, and the target molars are
often extruded during the uprighting phase.
486
When a patient with well-aligned anterior
teeth needs molar uprighting, we prefer to employ
biomechanics using temporary anchorage devices
(TADs) so that the applied forces do not adversely
affect adjacent teeth.6-8 In addition, we often bond
brackets to the molars to control rotation.9
This article introduces the Biocreative
reverse-curve (BRC) technique, a major element
of the Biocreative orthodontic strategy, which uti-
lizes an anterior TAD and a reverse-curve nickel
titanium archwire.10
Technique
The BRC technique has five essential com-
ponents. The first is an I-type C-tube miniplate,*
which is placed in the mandibular symphysis be-
cause of the absence of vulnerable nerves and
blood vessels (Fig. 1). The second component is
an .032"-diameter brass wire connector that pro-
vides a lifting force from the C-tube miniplate to
the middle of the main archwire’s anterior section.
The length of the brass wire connector determines
the magnitude of force applied to the teeth. The
*Jin Biomed Co., Bucheon, Korea; www.dentalvitamin.com.
© 2020 JCO, Inc. JCO/august 2020
 Dr. Ahn Dr. Noh Dr. Chung Dr. Kim Dr. Nelson

Dr. Ahn is an Associate Professor, Dr. Noh is a Clinical Adjunct Assistant Professor, Dr. Chung is a Clinical Adjunct Professor, and Dr. Kim is Professor
and Chair, Department of Orthodontics, Graduate School, Kyung Hee University, Seoul, Korea. Dr. Nelson is a Clinical Professor, Department of Oro-
facial Science, Division of Orthodontics, University of California, San Francisco. Dr. Kim is also a Contributing Editor of the Journal of Clinical Ortho-
dontics; e-mail: bravortho@gmail.com.

Fig. 1 Biocreative reverse-curve (BRC) technique. A. C-tube miniplate inserted in mandibular symphysis. B. Brass
wire connector used to lift miniplate. C. Posterior teeth bonded with Tweemac prescription brackets. D. Reverse-curve
nickel titanium archwire. E. Bonded lingual arch.

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STRATEGIC MOLAR UPRIGHTING USING BIOCREATIVE REVERSE-CURVE TECHNIQUE

third components, Tweemac-prescription brack-
ets,11 are bonded only to the mesially tipped target
teeth in the posterior segments. Even with no
brackets on the anterior teeth, the lower anterior
teeth will move spontaneously in a lingual direc-
tion. The fourth component is an .017" × .025"
reverse-curve nickel titanium archwire.** The
fifth is a bonded lingual arch that maintains inter-
premolar width and increases the intrusive effect
on the molars.

Fig. 2 Four vertical control factors involved in BRC technique. A. More lift from brass wire connector produces more
molar intrusion. B. Bonding premolars produces more molar intrusion. C. Cinching distal end of archwire produces
molar root uprighting as opposed to distal crown tipping. D. Distal toe-in curve produces more molar uprighting.

a b

b c
Fig. 3 A. I-type C-tube miniplate* inserted between lower central incisors, with plate head positioned at muco­gingival
junction. B. Brass wire threaded through miniplate head and secured using Weingart plier. C. Reverse-curve nickel
titanium archwire** engaged in posterior brackets and passed through brass wire loop; .022" stop cinched on arch-
wire next to brass wire.

488 JCO/august 2020


The Tweemac bracket prescription is opti-
mized for the BRC technique to prevent unwanted
tooth movement. It combines the advantages of oth-
er clinically proven prescriptions: Roth (upper inci-
sors and canines and upper and lower molars),
MBT*** (lower incisors, canines, and premolars),
and Smile Arc Protection (upper premolars). The
preadjusted buccal crown torque incorporated in the
Tweemac prescription—similar to the −25° to −30°
torque of the Roth prescription—mitigates such side
effects as crossbite and transverse discrepancy.11
Four vertical control factors are important
in the BRC technique (Fig. 2). The first is the
amount of lift from the brass connector. The more
lift, the more intrusive force on the molars. The
second factor is the decision whether to bond the
premolars. Premolar bonding induces more intru-
sive force and tip-back moment on the molars;
excluding the premolars results in less intrusion.
The third factor involves cinching the distal end
of the archwire. The long lever arm extending to
the molars provides a light, continuous tip-back
force, but if molar root uprighting without distal
crown tipping is desired, the wire should be
cinched. The final control factor is a distal toe-in
curve in the archwire. The smaller the toe-in ad-
justment, the greater the buccal moment on the
molars; therefore, an adequate lingual toe-in bend
will prevent excessive buccoversion of the second
molar.
This technique is illustrated in a 23-year-old
female patient. First, a small vertical incision is
made in the alveolar mucosa between the lower
central incisors, and a flap is elevated. The head
Fig. 4 Case 1. 17-year-old female patient with Class III malocclusion, slight
anterior open bite, and congenitally missing lower left lateral incisor.
VOLUME LIV NUMBER 8
AHN, NOH, CHUNG, KIM, NELSON
of the I-type C-tube miniplate should be posi-
tioned to exit the tissue at the mucogingival junc-
tion (Fig. 3A). After the miniplate is adapted to fit
the symphyseal bone contour, it is anchored in
place with two 1.5mm × 4mm miniscrews and
bent to a neutral position between the gingiva and
lower lip using a Weingart plier.
The .032" brass wire connector is adjusted
intraorally using a Weingart plier and Tweed
loop-forming plier (Fig. 3B). It is usually positioned
at the incisal third of the incisor crown, but its length
will depend on the amount of uprighting force need-
ed. The wire is bent perpendicular to the incisor
edge, and a loop is formed to hold the archwire.
The .017" × .025" reverse-curve nickel tita-
nium archwire is engaged in the posterior brackets
and passed through the loop of the brass wire con-
nector, which is then closed to hold the wire se-
curely (Fig. 3C). For further stability, an .022" stop
is cinched on the archwire next to the brass wire.
Case 1
A 17-year-old female presented with a Class
III malocclusion, a slight anterior open bite, and
a congenitally missing lower left lateral incisor
(Fig. 4). We decided to apply the BRC technique
using an .017" × .025" reverse-curve nickel tita-
nium archwire with an uncinched distal end and
a toe-in curve.
*Jin Biomed Co., Bucheon, Korea; www.dentalvitamin.com.
**Titanol Spee, registered trademark of Forestadent GmbH,
Pforzheim, Germany; www.forestadent.com.
***Trademark of 3M, Monrovia, CA; www.3M.com.
489
STRATEGIC MOLAR UPRIGHTING USING BIOCREATIVE REVERSE-CURVE TECHNIQUE
Fig. 5 Case 1. After 12 months of
treatment.
After nine months of treatment, both lower
third molars were extracted. The second molars
were successfully intruded, distalized, and disclud-
ed over the next 10 months (Fig. 5). Full fixed ap-
pliances were then placed, and a standard treat-
ment protocol with Class III intermaxillary elastics
490
Fig. 6 Case 1. A. Patient after 28
months of treatment. B. Superimpo-
sition of pretreatment (black) and
post-treatment (red) cephalometric
tracings.
was followed for the remainder of treatment. Ad-
ditional distalization was applied to gain space for
a lower left lateral incisor implant, which was
placed before debonding.
After 28 months of treatment, Class I canine
and molar relationships were attained (Fig. 6).
JCO/august 2020
 AHN, NOH, CHUNG, KIM, NELSON

Case 2 ment objective was to upright the mandibular mo-

A 26-year-old female presented with the
chief complaint of a mesially tilted and rotated
lower left second molar after extraction of the low-
er left first molar several years earlier (Fig. 7). The
canine and premolars on the affected side were
distally inclined and spaced (Table 1). The treat-
lars without displacement of the anterior teeth by
using the BRC technique.
Before bonding, microperforation was per-
formed in the interproximal areas adjacent to the
lower left second molar to induce the regional
acceleratory phenomenon12 (Fig. 8). Initially,
brackets were bonded only to the severely tipped

TABLE 1
CASE 2 TWEEMAC ANALYSIS
Norm Pretreatment Post-Treatment

Skeletal
PA-PB 4.44mm ± 2.49mm 11.91mm 8.65mm
FH-PP 2.15° ± 2.32° 2.59° 3.05°
PP-MP 30.28° ± 4.27° 24.88° 26.19°
PP-OP 11.17° ± 2.48° 5.95° 6.52°
MP-OP 19.72° ± 3.53° 18.93° 19.67°
Dental
U1-PP 115.31° ± 4.85° 103.47° 109.35°
IMPA 93.67° ± 7.05° 90.60° 93.33°
Dentoalveolar
Esthetic angle 14.31° ± 5.65° 7.16° 4.44°
Soft tissue
Superior airway width 25.57mm ± 2.74mm 37.52mm 35.61mm
Inferior airway width 11.57mm ± 3.92mm 16.74mm 13.59mm

Fig. 7 Case 2. 26-year-old female patient with mesially tilted and rotated lower left second molar after extraction of
lower left first molar several years earlier.

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STRATEGIC MOLAR UPRIGHTING USING BIOCREATIVE REVERSE-CURVE TECHNIQUE

Fig. 8 Case 2. C-tube microplate inserted and brass wire connector placed. Microperforation performed in inter-
proximal areas adjacent to second molar to induce regional acceleratory phenomenon.

a b d
Fig. 9 Case 2. A. After three months of treatment. B. After five months of treatment, with plastic protective tubing
placed over archwire to prevent soft-tissue irritation. C. After seven months of treatment. D. After nine months of
treatment.

mandibular molars, and a lingual arch was bond-
ed between the premolars to stabilize the anterior
teeth. The force system was applied from the
C-tube miniplate and brass wire connector to an
.017" × .025" reverse-curve nickel titanium arch-
wire (Fig. 9). After nine months, the projected
molar movements had been achieved, and full
fixed appliances were placed to protract the low-
er right second molar and complete detailing.
Class I canine and molar relationships were
reached after 36 months of treatment (Fig. 10).
All spaces were closed, and ideal overbite and
overjet were obtained. The lower left second mo-
lar was successfully uprighted with favorable root

492 JCO/august 2020


a b
parallelism and no adverse effects on other teeth.
The Tweemac analysis and cephalometric super-
impositions confirmed uprighting of the lower
molars without extrusion (Table 1).
Discussion
A multiloop edgewise archwire (MEAW)
technique using conventional dental anchorage and
intermaxillary elastics can be effective in upright-
ing molars.4,5,9,13,14 Although this method has been
used widely for decades, however, it has undesir-
able consequences such as displacement of the
anchorage teeth and mandibular molar extru-
sion.15,16 Skeletal anchorage can facilitate molar
intrusion without these adverse effects, but simple
VOLUME LIV NUMBER 8
AHN, NOH, CHUNG, KIM, NELSON
Fig. 10 Case 2. A. Patient after 36
months of treatment. B. Superimpo-
sition of pre- and post-treatment
cephalometric tracings.
miniscrews are prone to failure, especially consid-
ering the heavier forces or moments needed for
molar control during uprighting. Our new method
combines the advantages of the modified MEAW
technique14 with the stability of a C-tube miniplate
for skeletal anchorage.
Following key Biocreative principles, the
BRC system has numerous advantages.10,17 If the
anterior teeth are in good position, they need not
be included in the appliance. Because only the tar-
get teeth are bonded, the technique is simplified,
reducing unwanted tooth movement and promoting
better oral hygiene.
The versatile C-tube miniplate can be in-
stalled on the labial aspect of the symphysis.18 Ad-
vantages over posterior TAD placement19 include
493
STRATEGIC MOLAR UPRIGHTING USING BIOCREATIVE REVERSE-CURVE TECHNIQUE
easier access and fewer obstructions.18 The long
lever arm from the anterior C-tube to the target
teeth produces a long, continuous range of action
with low forces.10
In the BRC technique, the extrusive or intru-
sive component of molar uprighting is determined
by the choice of posterior teeth to be bonded, the
magnitude of the activation force, and the distance
between the ascending ramus and the distal surface
of the terminal molar.10 Vertical control of the mo-
lars is therefore more reliable. In addition, as
shown in Case 2, both the second and third molars
can be uprighted simultaneously, shortening treat-
ment compared with sequential uprighting of each
tooth.
ACKNOWLEDGMENT: The authors wish to thank Dr. Tae-Gun
Kim, Clinical Assistant Professor, Department of Oral and
Maxillofacial Surgery, Catholic University of Korea, Seoul, Korea,
for manuscript editing.
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