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ARTICLE 3

UPRIGHTING MOLARS WITHOUT EXTRUSION

W. CRAIG SHELLHART, D.D.S., M.S.; LARRY J. OESTERLE, D.D.S., M.S.

Uprighting A B S T R A C T mesially tipped

tipped second mo- molar include elimi-
lars can benefit Background. Orthodontic molar uprighting often re- nation of the pseu-
patients function- sults in extrusion of the molar, which is not always beneficial. dopocket that often
ally, periodontally The authors present a strategy for accomplishing molar upright- forms on the mesial
and prosthodonti- ing without extrusion. aspect of these
cally. The specific Description of the Procedure. The au- teeth.3 Eliminating
benefits to be thors review and compare the benefits of molar uprighting with this pseudopocket
gained depend on and without extrusion. The helical uprighting spring is probably may improve the
the directions in the most popular appliance used for molar uprighting. It exerts patient’s ability to
which the molar an extrusive force on the molar during uprighting. The authors control plaque accu-
moves, both in the explain why this appliance produces an extrusive force and pre- mulation in that
vertical and sent a strategy to modify the appliance so that it can be used to area. The prostho-
mesiodistal planes upright without extrusion. dontic advantages
of space. Clinical Implications. The information presented of molar uprighting
in this article should help the dental practitioner select a suitable via distal tipping
MESIODISTAL
AND VERTICAL appliance, understand how it works and use it appropriately so include an im-
PLANES OF that molar uprighting can be achieved without extrusion of the proved line-of-draw
MOVEMENT
molar. if a bridge is being
Mesiodistal constructed, or im-
plane. In the mesiodistal plane, the molar can be proved space and marginal ridge relations if an
tipped to the distal aspect or the root of the molar implant-borne prosthesis is planned. The func-
can be moved to the mesial aspect. Since a tipped tional advantages of uprighting a tipped molar by
second molar is most commonly found when a repositioning the crown distally include the provi-
first molar is missing, mesial movement of the sion of an occlusal contact for each tooth in the
root of the second molar is often followed by opposing arch. Leaving teeth unopposed can allow
movement of the entire tooth to close the space. excessive eruption to occur.4
Distal tipping is the more common solution in Vertical plane. In the vertical plane of space,
this situation because of the problems that can be the molar can be extruded or intruded or its ver-
encountered with mesial movement if the alveolar tical position can be maintained (that is, the cen-
ridge has narrowed in the area of the missing ter of resistance of the tooth does not move oc-
first molar. These problems can include root re- clusally or apically).2 It is important to note that
sorption, bone dehiscence and a decreased rate of there is some variability in patients’ responses to
movement.1,2 Therefore, we will focus on molar up- orthodontic forces. For example, two patients
righting via distal crown tipping. could have extrusive forces of the same magni-
The periodontal advantages of uprighting a tude placed on their molars, and one might expe-

JADA, Vol. 130, March 1999 381

Copyright ©1998-2001 American Dental Association. All rights reserved.
CLINICAL PRACTICE

in the same direction that it

Figure 1. Forces on the wire resulting in elastic deformation of the wire
are shown. An occlusally directed force acting on the mesial aspect of
the wire is the most obvious force (A). A gingivally directed force is ex-
erted on the wire by the molar bracket (B, C1 and C2). The molar brack-
et also exerts two forces that keep the wire from spinning in a counter-
clockwise direction.
rience significant extrusion
while the other experiences al-
most no extrusion. This variabil-
ity may be caused by the magni-
tude and duration of forces
exerted by the patient that op-
pose the extrusive force (that is,
biting, chewing and parafunc-
tional forces). Since the re-
sponse to these forces is some-
what unpredictable, it is usually
wise for the dentist to determine
the direction in which he or she
would like the tooth to move
(and sometimes more impor-
tantly, the direction in which
the dentist does not want the
tooth to move) and plan force
directions accordingly.
When a molar is extruded in
the presence of opposing teeth,
one of two things happens.
Either the teeth come into con-
tact earlier in the closure path
of the mandible, thus opening
the anterior overbite, or the oc-
clusal surface of one or both op-
posing teeth must be reduced.
Opening the anterior overbite
could be advantageous, but
often can be disastrous, espe-
cially if comprehensive or-
thodontic treatment is not
planned.
Reducing the occlusal surface
of a tooth can have beneficial ef-
fects, including a reduction of
the crown-to-root ratio (particu-
larly beneficial for patients who
have experienced periodontal
disease in the form of attach-
ment loss). Significant reduc-
tion of the tooth also could have
negative effects, such as pulpal
sensitivity, pulpal exposure and
a reduced crown height for
bridge construction. Another po-
tential advantage of extrusion,
particularly for patients who
have had periodontal disease in
the form of attachment loss, is a
reduction of pocket depth, not
only on the mesial aspect, but
also for the rest of the tooth.
Vertical position. Main-
taining the vertical position of
the tooth as it is being upright-
ed does not mean that the verti-
cal position of the crown will be
maintained. Even if the tooth
merely rotates around its center
of resistance, and the center of
resistance does not move oc-
clusally, the crown of a tipped
tooth will move occlusally as it
is uprighted,2 although not as
much as if the tooth actually ex-
truded. Since the crown moves
would have had the tooth actu-
ally extruded, although to a
smaller degree, the advantages
and disadvantages of maintain-
ing the vertical position of the
tooth are the same, although to
a lesser extent.
Intrusion. Intruding a
molar as it is being uprighted
can be advantageous if the den-
tist wishes to avoid opening the
anterior occlusion, and if the
molar is not to be reshaped oc-
clusally.5 This is particularly
applicable if an implant is to be
used for prosthetic replacement
of the missing tooth. In this sit-
uation, the second molar will
not need to be prepared as a
bridge abutment and enamel
reduction can be minimized.
The risks of intruding a
molar include the possibility of
creating an infrabony perio-
dontal pocket, since the
supragingival plaque can be
shifted to a subgingival loca-
tion,6 and occlusal movement
of the anterior teeth if these
teeth are used as anchors for
the molar movement. Ob-
viously, occlusal movement of
the anterior teeth could reduce
the depth of the overbite or re-
quire occlusal reduction of
these teeth if the depth of the
overbite is not to be changed.
The helical uprighting spring
is the most commonly used ap-
pliance for molar uprighting
(Figure 1). This appliance up-
rights the molar with distal
crown tipping and molar extru-
sion.7
If a patient would benefit
from molar uprighting without
extrusion, a clear understand-
ing of why and how the helical
uprighting spring produces ex-
trusion will help dentists select
an appliance that will not ex-
trude the molar.

382 JADA, Vol. 130, March 1999

Copyright ©1998-2001 American Dental Association. All rights reserved.

MOLAR UPRIGHTING
WITH THE HELICAL
UPRIGHTING SPRING
The helical uprighting spring
(Figure 1), like many orthodon-
tic appliances, uses an elastical-
ly deformed wire to exert forces
on the teeth. With this appli-
ance, the active wire is inserted
into the bracket that is affixed
to the tipped molar. Usually,
this active wire is relatively
large and rectangular so there
is not a lot of room for the wire
to rotate or otherwise move
within the bracket slot. Of
course, if the wire were small
enough to rotate within the
bracket, the wire could revolve
to a position from which it
would produce altered direc-
tions of force, and undesirable
tooth movement could occur.
Choice of wire. If the
bracket slot size is 18 mil (.018
inch), a good choice for the wire
is 16- × 22-mil stainless steel. A
large wire like this is not inher-
ently springy, and springiness
is desirable when teeth are to
be moved. A springy wire is eas-
ier to activate with the precise
amount of force, and the force it
exerts is of longer duration than
that of a stiff wire (tooth move-
ment does not change the level
of force nearly as much for a
springy wire as it does for a stiff
wire).8 To make the wire
springier, the dentist increases
the length of the wire that will
deform elastically (that is, the
length between brackets), both
by skipping a couple of teeth
and by incorporating a helical
coil (Figure 1).
An alternative to the 16- ×
22-mil stainless steel wire with
a helix is a 17- × 25-mil titani-
um-molybdenum alloy, or TMA,
wire. Because it is inherently
more springy than stainless
steel, this wire often can be
Copyright ©1998-2001 American Dental Association. All rights reserved.
Figure 2. Forces on the teeth from the elastically deformed wire are
shown.
used without a helix. A hook is
formed at one end of the
springy wire (either the stain-
less steel wire or the TMA
wire), and the hook attaches the
mesial end of the spring to a
large, stiff wire that is rigidly
attached to a number of anteri-
or teeth. The purpose of this
Opening the anterior
overbite could be
advantageous, but
often can be disas-
trous, especially if
comprehensive or-
thodontic treatment
is not planned.
large, stiff wire is to anchor
these anterior teeth together so
that none of them can move
much without all of the teeth
moving. A good choice of wire
size and material for this an-
choring wire is 17- × 25-mil
stainless steel (for an 18-
mil–sized slot). The strategy of
attaching a stiff wire to a num-
ber of teeth is usually effective
in reducing the movement of
these teeth.9
Determining forces. One of
CLINICAL PRACTICE
the easiest and most reliable
ways to determine all of the
forces that an appliance will
exert on the teeth is to deter-
mine all of the forces that are
needed to activate or elastically
deform the appliance. To de-
form the spring, a balanced set
of forces must be placed on it. If
the forces are not balanced, the
wire will not deform, but will
move to a new position. To
demonstrate the balanced na-
ture of the forces that are need-
ed to deform this spring, we will
describe the forces that act on
the wire, starting with the most
obvious and moving to the least
obvious.
The most obvious force that
acts on this wire after it has
been placed in the molar brack-
et is the occlusally directed
force that lifts the hook so that
it can be placed over the stiff
anterior wire (Figure 1, force
A). However, if this were the
only force acting on the wire,
the wire would not deform. It
would simply move in an oc-
clusal direction. The molar
bracket holds the wire and
keeps it from moving occlusally
by exerting an apically directed
force on it (Figure 1, force B).
Yet, if these two forces were the
JADA, Vol. 130, March 1999 383
CLINICAL PRACTICE
Figure 3. Two helical uprighting springs oriented to produce molar up-
righting without extrusion.
only ones that acted on the
wire, it would still not deform
elastically, but would simply ro-
tate (this rotation would be
counterclockwise in Figure 1).
Once again, the molar brack-
et holds the wire, and keeps it
from spinning by placing a set
of forces on it. As the wire be-
gins to rotate in a counterclock-
wise direction, as described
above, it encounters the mesial
and distal aspects of the molar
bracket slot. The mesial aspect
of the bracket slot exerts an api-
cally directed force on the wire,
and the distal aspect of the slot
exerts a coronally directed force
on the wire (Figure 1, forces C1
and C2).
The combined forces identi-
fied thus far will deform the
spring. The reason why the wire
now deforms is because an op-
posing (or balancing) force or
set of forces blocks every move-
ment of the wire. Because this
wire is sufficiently springy, the
deformation is elastic. Once this
spring is elastically deformed, it
will exert forces on whatever
keeps it from returning to its
nondeformed shape. When the
wire is connected to the teeth, it
will exert forces on these teeth.
These forces are opposite in di-
384 JADA, Vol. 130, March 1999
Copyright ©1998-2001 American Dental Association. All rights reserved.
rection to the forces that acted
on the wire to deform it. An in-
trusive force acts on the anteri-
or teeth; an extrusive force acts
on the molar; and two forces
that are parallel, but not colin-
ear, act on the molar bracket to
rotate it (and the molar) to the
distal aspect (Figure 2).
The dentist should
monitor the appliance
closely because the
molar tooth and the
anterior segment of
teeth will likely re-
spond differently to
the forces exerted.
MOLAR UPRIGHTING
WITHOUT EXTRUSION
If the dentist chooses molar up-
righting without extrusion, one
strategy is to use a helical up-
righting spring and place an in-
trusive force on the molar to
block its extrusion. A second
helical uprighting spring orient-
ed as if it were a mirror image
of the first spring (Figure 3) can
accomplish this. One way to at-
tach a second helical uprighting
spring is to use two tubes that
have been welded together, and
slide or crimp one tube over the
anterior anchoring wire. The
dentist then places the second
helical spring into the second
tube of this double-tube device.10
By placing another wire that
extends to the distal aspect of
the molar bracket, the dentist
can hook the second spring over
this extra wire (Figure 3).
The forces from this second
spring are similar to the forces
from the first spring. These in-
clude an intrusive force on the
molar, an extrusive force on the
anterior teeth and two forces
that cause a crown-to-mesial ro-
tation on the anterior segment
of the teeth. If the wires require
the same degree of force to acti-
vate them, the extrusive and in-
trusive forces from the two
springs will cancel each other;
thus, neither the molar nor the
anterior teeth will extrude. The
forces that act on the teeth
(that is, those that have not
been canceled out) include a set
of forces on the molar that
cause a crown-to-distal rotation
(thus uprighting this tooth) and
a set of forces on the anterior
segment that cause a crown-to-
mesial rotation of the anterior
segment.
The dentist should monitor
the appliance closely because
the molar tooth and the anteri-
or segment of teeth will likely
respond differently to the forces
exerted. As discussed above, the
anterior segment includes a
number of teeth attached to-
gether in a rigid manner, with
the objective of reducing tooth
movement. The molar is not
rigidly attached to any other
teeth because the dentist’s ob-
jective is to produce significant
movement of this tooth. With
significant movement of the
 CLINICAL PRACTICE

fits for patients. The appliance molar uprighting. Am J Orthod

1982;81(3):177-84.
most often used for molar up- 3. Diedrich PR. Orthodontic procedures im-
righting, the helical uprighting proving periodontal prognosis. Dent Clin
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distal crown tipping and extru- Orthodontics and orthognathic surgery: ad-
juncts to restorative and periodontal therapy.
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Dr. Shellhart is an as- Dr. Oesterle is an 5. Shellhart WC, Moawad M, Lake P. Case
sociate professor and
geous for many patients; howev-
associate professor report: implants as anchorage for molar up-
chair of the Division and chair of the er, in some situations, righting and intrusion. Angle Orthod
of Orthodontics, Department of uprighting without extrusion is 1996;66(5):324.
University of Growth and Develop- 6. Zachrisson BU. Clinical implication of re-
Colorado School of ment, University of the best objective. This can be cent orthodontic-periodontic research find-
Dentistry, C-284, Colorado School of accomplished fairly simply with ings. Semin Orthod 1996;2(1):4-12.
4200 E. Ninth Ave., Dentistry, Denver. 7. Drescher D, Bourauel C, Thier M.
Denver, Colo. 80262.
a modification of the helical up- Application of the orthodontic measurement
Address reprint re-molar and in- righting spring. It is important and simulation system (OMSS) in orthodon-
quests to Dr.
tics. Eur J Orthod 1991;13(3):169-78.
Shellhart.
significant for dentists to monitor tooth 8. Shellhart WC, Oesterle LJ, Cailleteau
movement of movement closely and be pre- JG. Effective orthodontics: achieving objec-
tives, avoiding misadventures. JADA
the anterior segment, the de- pared to adjust the appliance 1997;128(1):97-104.
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intrusion. Am J Orthod 1997;72(1):1-22.
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1. Roberts WE, Marshall KJ, Mozsary PG. Variable modulus orthodontics advanced
rather quickly, and the intru- Rigid endosseous implant utilized as anchor- through an auxiliary archwire attachment.
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extraction site. Angle Orthod 1990;60(2):135-
longer be balanced. 52.
2. Roberts WW 3d, Chacker FM, Burstone
CONCLUSION CJ. A segmental approach to mandibular

Uprighting mesially tipped mo-

lars can have significant bene-

JADA, Vol. 130, March 1999 385

Copyright ©1998-2001 American Dental Association. All rights reserved.