CLINICIAN'S CORNER
Anchorage reinforcement with a fixed functional
appliance during protraction of the mandibular
second molars into the first molar extraction sites
Aditya Chhibbera and Madhur Upadhyayb
New York, NY, and Farmington, Conn
Protraction of posterior teeth into edentulous spaces is a challenge. This report describes the treatment of a
19-year-old woman with missing mandibular first molars owing to caries. A fixed functional appliance was
used for anchorage reinforcement during mandibular second molar protraction. Eight millimeters of bilateral pro-
traction was done with bodily mesial movement of the molars and no lingual tipping of the incisors. (Am J Orthod
Dentofacial Orthop 2015;148:165-73)
E
ffective space management of missing posterior
teeth is a great challenge in orthodontic treat-
ment. Edentulous posterior sites are commonly
seen in an adult population. The most commonly
observed missing teeth are first molars, often owing to
caries,1 and second premolars, which are the most com-
mon congenitally missing teeth.2 The sequel of missing
mandibular first molars is usually tipping and drifting of
adjacent teeth, supraeruption of unopposed teeth, poor
interproximal contacts, poor gingival contours, reduced
interradicular bone, and pseudopockets.3
Treatment options for missing posterior teeth
commonly include fixed prosthodontic bridges or endos-
seous implants. Although both are viable treatment
options, the use of fixed partial dentures may compro-
mise the longevity of adjacent prepared teeth with the
risk of secondary caries and mechanical failures,4
whereas endosseous implants can increase the finan-
cial burden for patients.5 Orthodontic space closure
of edentulous sites is an alternative treatment option.
However, attempts at space closure by protraction of
posterior teeth into the edentulous sites without
anchorage reinforcement bears the risk of anchorage
loss, thereby leading to a compromised occlusion.
a
Assistant professor, Division of Orthodontics, College of Dental Medicine,
Columbia University, New York, NY.
b
Assistant professor, Division of Orthodontics, Department of Craniofacial
Sciences, University of Connecticut Health Center, Farmington, Conn.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Aditya Chhibber, College of Dental Medicine,
Columbia University, 630 West 168th Street, New York, NY 10032; e-mail,
adityachhibber14@gmail.com.
Submitted, October 2014; revised and accepted, February 2015.
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.02.029
Historically, extraoral appliances such as chincup and
facemask have been used for protraction of posterior
teeth.6 However, use of extraoral devices depends on
patient compliance, and it has been reported that pa-
tient compliance is generally overestimated when
similar devices are used for orthopedic purposes.7
Hemisection of deciduous teeth has also been advo-
cated to encourage more mesial eruption of the
permanent teeth into the missing-tooth regions.8
Recently, there have been case reports in the literature
on the use of mini-implants for protraction of mandib-
ular posterior teeth into edentulous sites.9-12 However,
mini-implants placed in interradicular regions can
cause root damage because of improper placement
of the devices,13,14 which can subsequently lead to
implant failure.15,16
Thus, development of alternative methods capable of
providing absolute anchorage while protracting poste-
rior teeth into edentulous sites is desirable. Fixed func-
tional appliances have traditionally been used for Class
II correction. The use of such appliances results in a com-
bination of mild skeletal effects along with dentoalveo-
lar changes such as retroclination of the maxillary
incisors and proclination of the mandibular incisors,
and distalization of the maxillary molars and mesial
movement of the mandibular molars.17,18 The aim of
this report was to use a fixed functional appliance for
anchorage reinforcement during space closure by
protraction of the posterior teeth into the edentulous
spaces without Class II correction.
DIAGNOSIS AND ETIOLOGY
A 19-year-old woman came to the orthodontic
department at University of Connecticut Health Center
165
166 Chhibber and Upadhyay

Fig 1. Pretreatment photographs.

previously. She had a Class II malocclusion on an

Table. Cephalometric skeletal analysis before and af-
underlying Class II skeletal base with a normal sized
ter treatment
maxilla, a short mandible, and a vertical growth pattern
Pretreatment Posttreatment (Fig 1, Table). Dentally, the patient had proclined and
SNA (
) 77 77 forwardly placed maxillary incisors and normally
SNB (
) 71 71 inclined and forwardly placed mandibular incisors
ANB (
) 6 6
with U-shaped maxillary and mandibular dental arches,
SN-GoGn (
) 47 48
FMA (
) 41 42 missing mandibular right and left first molars with 8
U1-SN (
) 118 92 mm of extraction space bilaterally, mesially tipped
U1-NA (
) 42 19 mandibular second molars bilaterally (Fig 2), extruded
U1-NA (mm) 12 3 maxillary left and right first molars, an end-on canine
IMPA (
) 90 92
relationship, moderate crowding in both arches, an
L1-NB (
) 35 33
U1-NB (mm) 13 11 increased overjet, a 4-mm overbite, and a 3-mm curve
E-line–upper lip (mm) 1 5 of Spee in the mandibular arch. Facially, the patient
E-line–lower lip (mm) 5 2 had a leptoprosopic facial type with a convex soft tis-
sue profile, a right angled nasolabial angle, and 100%
with a chief complaint of “crooked teeth.” Her previous maxillary incisor and 70% mandibular incisor display
medical history was not significant, and no history of on smiling. The mandibular midline was coincident
habits was reported. Her dental history showed that with the facial midline, and the maxillary midline was
the mandibular left and right first molars were shifted 2 mm to the left, along with incompetent lips
extracted because of caries approximately 4 years (Fig 2) and lip strain on closure.

July 2015  Vol 148  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Chhibber and Upadhyay
Fig 2. Pretreatment radiographs.
TREATMENT OBJECTIVES
The treatment objectives for this patient were to
(1) improve the soft tissue profile and relieve the lip
incompetence with minimal changes to the skeletal
vertical dimensions, (2) manage the space of the
missing mandibular first molars by protraction of the
mandibular second molars into the first molar regions
bilaterally, (3) achieve simulated Class II molar and
Class I canine relationships by retraction of the maxil-
lary incisors and protraction of the mandibular molars,
(4) relieve the crowding in both arches, and (5) reduce
the increased overjet.
TREATMENT ALTERNATIVES
The alternative treatment plans that were considered
entailed extraction of only the maxillary premolars with
retraction of the incisors and endosseous implants, or
fixed partial dentures placed for the missing mandibular
first molars. Implants would increase the overall treat-
ment cost for the patient, and she was unwilling to
undergo this procedure. In addition, the use of fixed
partial dentures could compromise the longevity of the
prepared adjacent teeth in the long term. The use of
mini-implants or miniplates for protraction of the poste-
rior teeth into the edentulous sites could have been
considered as a treatment alternative.
TREATMENT PROGRESS
Treatment was initiated by bonding all teeth with a
0.022-in slot MBT (McLaughlin, Bennett, and Trevisi)
prescription, which had 6
of lingual crown torque on
American Journal of Orthodontics and Dentofacial Orthopedics
167
the mandibular anterior brackets. In the mandibular
arch, initial leveling and alignment was done with
0.16-in nickel-titanium archwires from the left second
premolar to the right second premolar without engaging
the tipped second molars. The archwire was gradually
increased to 0.021 3 0.025-in stainless steel. An up-
righting spring was fabricated and placed on the tipped
second molars to upright them (Fig 3, A). A seating
elastic was used in the anterior segment to prevent the
bite from opening during uprighting of the tipped molar.
The mechanics involved in using the uprighting spring
are shown more in Figure 3, B. An uprighting spring is
a 1-couple system. An intrusive component of force
exists in the anterior segment along with an extrusive
force on the molar with a counterclockwise moment
(moment of couple) to upright the tipped molar. In addi-
tion, the point of force application on the molar (buccal
tube) is usually ahead of the center of resistance of the
molar, thereby leading to an additional moment
(moment of force) in the counterclockwise direction
that can further help in uprighting the tipped molar.
In the maxillary arch, the patient was referred for
extraction of the maxillary first premolars. Initial leveling
and alignment were performed in the maxillary arch
using a 0.016-in nickel-titanium archwire. The archwires
were progressively increased to 0.021 3 0.025-in nickel-
titanium. Space closure was performed using loop
mechanics; a 0.019 3 0.025-in T-loop archwire was
fabricated for en-masse retraction of the maxillary ante-
rior teeth (Fig 4, A). After space closure, the archwire was
increased to a stiff 0.021 3 0.25-in steel archwire with
the wire cinched distal to the molars to prevent any
July 2015  Vol 148  Issue 1
168 Chhibber and Upadhyay

Fig 3. A, Placement of uprighting spring to upright mandibular second molars bilaterally; B,

biomechanics during the use of an uprighting spring. Green dot, Center of resistance of molar; a,
distance between the point of force application on the molar tube and the center of resistance of the
molar; d, distance between the point of force application and the molar tube; Mc, moment of the couple;
Mf, moment of the force; F, force applied by the uprighting spring; Fr, reciprocal force acting on the
molar tube.

spaces from opening up and to create the maxillary arch
as a single unit.
In the mandibular arch, after the tipped second
molars were uprighted, the archwires were built up
to a continuous stiff 0.021 3 0.025-in steel archwire
(Fig 4, B). Crimpable hooks were spot welded onto the
archwire distal to the canines bilaterally. A passive
Forsus appliance (size 25) was placed from the maxil-
lary molar to the distal aspect of the mandibular
canine. An elastic chain was placed from the second
molar to the crimpable hooks, applying approximately
200 to 250 cN of force (Fig 4, C). The patient was re-
called every 5 to 6 weeks until the space was closed by
protraction of the second molar; this took 9 months.
No breakage of any appliances or brackets during
the molar protraction phase was observed. After space
closure, a progress panoramic radiographic was
taken to evaluate root movement of the second
molars (Fig 5). No tipping of the second molars during
space closure was observed. Finishing and detailing of
the occlusion were performed as needed, and the
patient was debonded after 28 months of active treat-
ment. She was referred for extraction of the maxillary
third molars because there were no opposing teeth in
the mandibular arch. A maxillary Hawley retainer was
given. In the mandibular arch, a fixed lingual retainer
was placed on the anterior teeth. In addition, a
bonded buccal retainer was placed between the sec-
ond molar and the second premolar to minimize the
risk of space reopening after treatment.
TREATMENT RESULTS
After 28 months of active treatment, the patient was
debonded with simulated Class II molar and Class I
canine relationships bilaterally, along with ideal overjet

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Chhibber and Upadhyay
Fig 4. Progress records: A, placement of the 0.019 3 0.025-in T-loop for space closure in the maxillary
arch; B, continuous 0.021 3 0.025-in steel archwire in the mandibular arch after uprighting the tipped
second molars; C, placement of the Forsus appliance for anchorage reinforcement during mandibular
second molar protraction.
Fig 5. Progress panoramic radiograph after mandibular
molar protraction.
and overbite (Fig 6). The maxillary and mandibular
arches were well aligned, and the dental midlines were
coincident. The posttreatment facial photographs
showed a balanced profile. A slight gingival height
discrepancy was observed between the 2 maxillary
central incisors at the end of treatment; however, the
patient was not willing to have surgical recontouring
of the gingival margins. The radiographic records
showed root parallelism at the end of treatment, with
relief of the lip incompetence (Fig 7). A slight discrep-
ancy in the occlusal relationship of the molars was
American Journal of Orthodontics and Dentofacial Orthopedics
169
observed; it could be attributed to a posterior Bolton
discrepancy, since the maxillary first molar was
occluding with the mandibular second molar. In addi-
tion, a slight lateral open-bite tendency was also
observed at the maxillary left lateral incisor that could
be attributed to the torque control during space closure
with the T-loop.
Lateral cephalograms were taken at pretreatment and
posttreatment. The cephalometric evaluation showed
that the skeletal pattern was maintained with no change
of the SNA and SNB angles, along with maintenance of
the mandibular plane angle (Table). Reduction in the
proclination of the maxillary incisors and minimal
flaring of the mandibular incisors were observed. The
overall superimpositions with the best-fit method and
regional superimposition using the method of Bj€ ork
and Skieller19 showed a slight intrusion of the extruded
maxillary first molars (Fig 8). There was retraction of the
maxillary incisors into the extraction spaces. In the
mandibular arch, the incisors intruded with minimal flar-
ing of the anterior teeth. The mandibular second molar
underwent complete mesial movement into the missing
first molar space. The soft tissue evaluation showed
retraction of the maxillary lip, which led to a reduction
July 2015  Vol 148  Issue 1
170 Chhibber and Upadhyay

Fig 6. Posttreatment photographs.

Fig 7. Posttreatment radiographs.

July 2015  Vol 148  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Chhibber and Upadhyay
Fig 8. Overall and regional superimpositions: pretreatment (black) and posttreatment (red).
in lip incompetence and an improvement in the soft
tissue profile.
DISCUSSION
Protraction of posterior teeth, while being a treat-
ment option, is difficult to perform without anchorage
reinforcement. Traditionally, extraoral devices such as
chincup and facemask have been used for anchorage
reinforcement during protraction of posterior teeth.6
There have been a few reports in the literature on the
use of miniscrews for anchorage reinforcement during
molar protraction.9-12 However, there is a risk of
root contact when miniscrews are placed in the
interradicular regions13,14 leading to subsequent
implant failure.15,16 In addition, patients may not be
willing to have invasive procedures during orthodontic
treatment.20
Thus, there is a need to develop alternative methods
for anchorage augmentation to protract posterior teeth
into edentulous sites. A fixed functional appliance is
commonly used for Class II correction. These appliances
have a combination of skeletal and dental effects.17,18
Their use for simultaneous Class II correction and
protraction of posterior teeth has been reported in the
literature.21 However, we aimed to demonstrate the use-
fulness of a fixed functional appliance for anchorage
reinforcement during protraction of the second molars
into the missing mandibular first molar sites, with no
American Journal of Orthodontics and Dentofacial Orthopedics
171
skeletal or dental Class II correction being attempted.
The patient had a Class I canine relationship with
optimal overjet when molar protraction was initiated
(Fig 4, C). Adequate bone and gingival levels at the eden-
tulous site may be critical factors associated with suc-
cessfully protracting the second molars.22 Furthermore,
it has been reported that moving teeth into an edentu-
lous site increases the width and the height of the eden-
tulous alveolar ridge.23,24
Mechanically, placement of an elastic chain between
the second molar and the archwire hooks leads to a mesi-
ally directed force on the molar, but it also leads to a
reactionary force in the distal direction on the anterior
segment (Fig 9, A). We hypothesize that when the distal
force on the anterior segment leads to retraction of the
mandibular anterior teeth (anchorage loss), the Forsus
appliance that was placed passively becomes active,
thereby exerting a mesially directed force on the
mandibular anterior teeth offsetting the retractive force
and thereby preventing anchorage loss (Fig 9, A). In
addition, since the point of force application was
superior to the center of resistance of the second molar,
it leads to a moment of force to tip the molar into the
extraction space during protraction (Fig 9, A). However,
we did not observe any tipping of the second molars
after space closure in the progress panoramic radiograph
(Fig 5). This perhaps may be attributed to the use of a
stiff 0.021 3 0.025-in archwire during molar protraction
(Fig 9, B). It has been reported that the use of rigid
July 2015  Vol 148  Issue 1
172 Chhibber and Upadhyay

Fig 9. Biomechanics during the use of fixed functional appliance for molar protraction. A, Green dot,
Center of resistance of molar; d, vertical distance between the molar tube and the center of resistance
of the molar; F, force applied to the elastomeric chain on the molar; Fr, reciprocal force acting on the
mandibular anterior segment; Fr0 , force applied by the fixed functional appliance on the mandibular
anterior segment; a, length of the molar tube; Mc, moment of the couple; Mf, moment of the force. B,
Inside of a molar tube with a 0.021 3 0025-in steel archwire: a, Length of the molar tube; f, vertical
forces generated from tipping of the molar tube during protraction.

high-stiffness archwires leads to reduction of elastic
deflection of the archwire during tooth movement.25
Based on beam theory, elastic deflection is inversely pro-
portional to flexural rigidity of the archwire, EI, where E
is Young's modulus and I is the moment of inertia of the
cross-section. In the case of a rectangular cross-section
of width b and height h, I is calculated by the equation
I 5 bh3/12. Thus, the 0.021 3 0.025-in steel archwire
with high flexural rigidity may have minimized the
elastic deflection of the wire during molar protraction,
thereby preventing tipping of the molar during space
closure. It has also been reported that elastic deflection
of the archwire is proportional to the amount of
applied force.25 A decrease in the applied force associ-
ated with using elastomeric chains that have up to a
50% force decay26 may have led to a lesser reduction
in flexural rigidity of the archwire as opposed to methods
that apply a constant force such as nickel-titanium coil
springs.27
Play between the archwire and the bracket with un-
dersized archwires is often reported.28,29 Furthermore,
it has also been shown that a full-slot archwire provides
better root control during retraction of anterior teeth. It
has been suggested that torsion of the archwire
(moment of couple) may be completely transmitted to
the bracket with full-slot archwires during incisor retrac-
tion.30,31 Similarly, perhaps a full-slot archwire for molar
protraction would have led to better control of the roots
during protraction (Fig 8). However, further studies
would be necessary to substantiate this theory. It could
be argued that the point of force application could
have been lowered on the molar with power arms to
ensure that the point of force application was closer to
the molar's center of resistance and could be recommen-
ded for similar attempts in the future. In addition, it
could also be advisable to use the fixed functional appli-
ance during space closure in the maxillary dentition
because it might provide anchorage reinforcement
during anterior tooth retraction.
Some possible limitations reported with a Forsus
appliance are an increased risk for cheek irritation and
breakage of the appliance.32 Reports on breakages

July 2015  Vol 148  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Chhibber and Upadhyay
specifically with the Forsus appliance have been variable,
from as low as 1%33 to as high as 37%32; the breakages
have been attributed to varying levels of operator expe-
rience or other factors. However, we did not observe any
breakages during the space closure phase. This could be
attributed to operator experience or patient compliance,
or the fact that the fixed functional appliance was placed
passively. Another possible limitation with this approach
is that it may be suitable only for protraction of teeth in
the mandibular arch as opposed to protraction of maxil-
lary posterior teeth.
CONCLUSIONS
This case demonstrates the effectiveness of a fixed
functional appliance for anchorage reinforcement dur-
ing the protraction of the mandibular second molar
into the first molar extraction site.
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