Molar Intrusion Techniques in Orthodontics: A Review Article (PDF Available) · February 2016

https://www.researchgate.net/publication/300853119_Molar_Intrusion_Techniques_in_Orthodontics_A_Review

Abstract

Molar intrusion has always been a complex and difficult treatment modality. It can be approached for treating open bite patients or over erupted molar tooth/teeth. Through the decades, various treatment strategies have been developed to intrude molar teeth, ranging from non-surgical to surgical approaches, and utilizing various appliances, some which rely on patient compliance. The aim of this article is to compile and summarize the existing molar intrusive techniques and appliances with respect to their advantages and disadvantages, and their possible clinical effectiveness.

ontributor:

Assistant Professor, Department of Preventive Dental Sciences,

Division of Orthodontics, College of Dentistry, Jazan University,

Jazan, Saudi Arabia.

Correspondence:

Hakami Z. Department of Preventive Dental Sciences,

Division of Orthodontics, College of Dentistry, Jazan

University, Jazan, Saudi Arabia. Tel: +(966)-507277543.

Email: Dr.zhakami@gmail.com

Howtocitethearticle:

Hakami Z. Molar intrusion techniques in orthodontics: A review.

J Int Oral Health 2016;8(2):302-306.

Abstract:

Molar intrusion has always been a complex and dicult treatment

modality. It can be approached for treating open bite patients or

over erupted molar tooth/teeth. Through the decades, various

treatment strategies have been developed to intrude molar teeth,

ranging from non-surgical to surgical approaches, and utilizing

various appliances, some which rely on patient compliance. The

aim of this article is to compile and summarize the existing molar

intrusive techniques and appliances with respect to their advantages

and disadvantages, and their possible clinical eectiveness.

KeyWords: Molar intrusion, open bite, supra-erupted molar

Introduction

Intrusion of teeth, particularly posterior teeth, has been a

difficult and complex treatment modality throughout the

20th century. The mechanics used in the majority of these

years relied heavily on patient compliance. The introduction

of temporary anchorage devices (TADs) over the more recent

years, has allowed for the intrusion of posterior teeth with

minimal need of patient compliance. Several cases reports

have been published using different intrusive mechanical

approaches. However, more organized clinical trials are still

needed to evaluate the amount of intrusion obtained from

using dierent techniques.1

Posterior teeth intrusion is one of the treatment strategies for

treating anterior open bites. Treatment approaches for open

bite patients dier when dealing with adults and growing

patients. In growing patients, the vertical forces applied against

the molars serve not only to intrude the molars but simply

to control their vertical eruption. In adults or non-growing

patients with the absence of vertical compensation of ramus

growth, the true intrusion of molar teeth is needed to let the

mandible to autorotate and subsequently close the open bite

anteriorly.2 According to jaw geometry, 1 mm of intrusion

posteriorly would result in about 2 mm of anterior open bite

closure.3

A molar can over erupt when its antagonist is lost, and there

is no replacement. To avoid excessive grinding of the over

erupted tooth which might end up with endodontic treatment,

the orthodontic intrusion is a possible solution. True intrusion

of an over erupted tooth is problematic, and careful mechanics

is needed to avoid the undesirable extrusion of adjacent teeth,

particularly with the use conventional fixed appliances.4

Furthermore, due to the diculty of molar intrusion, some

recent case reports have attempted incorporating some surgical

procedures to facilitate intruding the molars.5

Several molar intrusive treatment strategies have been

published, ranging from case reports to clinical trials. Ng

et al. have reviewed the techniques used to treat open bites.6

However, there was limited emphasis on molar intrusion,

as well as, more current techniques. Therefore, the primary

objective of this review article is to comprehensively compile

and update various molar intrusion techniques published in

the literature.

Excluding the orthognathic surgery, molar intrusion techniques

have been classied into non-surgical and surgical approaches

(Table 1). Furthermore, among the non-surgical approaches,

compliance and non-compliance appliances were separately

discussed in details.

Non-surgical Approach for Molar Intrusion

Complianceappliances

High pull headgear

It has been published that high pull headgear has been used

primarily for the purpose of producing an orthopedic force

to the maxilla for correction of class II as well as open bite

malocclusions.7-9 It has been suggested to apply a force

of 500 g to the upper first molar for a 6-month period.10

Moreover, it has been claimed to produce dental changes of

intrusion (0.96 ± 0.54 mm) in addition to the distal movement

Table 1: Molar intrusion techniques.

Non-surgical approach

Compliance appliances Non-compliance appliances

High pull headgear Temporary anchorage devices

High pull headgear to a splint Rapid molar intrusion device

Vertical pull chincup Vertical holding appliance

Posterior bite-block

Magnetic bite-block

Spring-loaded bite-block

Surgical approach

Corticotomy-enhanced molar intrusion

Osteotomy-assisted molar intrusion

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Journal of International Oral Health 2016; 8(2):302-306

Molar intrusion techniques … Hakami Z

(2.6 ± 0.6 mm).10 More intrusion has been shown with higher

force levels and headgear treatment over a longer time period.7

To create these eects, the force has to be directed carefully

through the center of resistance of the upper rst molar which

is located at the level of buccal trifurcation area. The direction

of the force above or below the center of resistance causes

undesirable extrusion by tipping the crown mesially or distally,

depending on the direction of the force which could result in

downward rotation of the mandible. The use of a transpalatal

arch (TPA) is necessary to maintain the arch width and to

prevent molar rotation.11

High pull headgear to a splint

This type of headgear is used for intrusion a group of teeth. It

works with similar principles of high pull headgear; however,

the force is applied to a splint covering the intended teeth.

A slight intrusion of maxillary dentition has been reported in a

study using headgear that attached to a full-coverage maxillary

occlusal splint in patients with the maxillary dentoalveolar

protrusion.12 However, there have been limited papers

published specically regarding this area.

Vertical pull chincap

The vertical chincap or high pull chincap has been used as a

functional orthopedic appliance for the treatment of skeletal

open bite. A force of 400 g is applied per side, and the force

vector passes through the anterior and inferior region of the

mandibular corpus approximately 3 cm from the outer canthus

of the eye.13,14 A study using vertical chincap for 6-12 months

in a growing group of subjects with open bites had observed

some intrusion of mandibular molars compared to the control

group.15

Posterior bite-block

The use of passive acrylic posterior bite-blocks has also been

used for the molar intrusion. These functional appliances hinge

the mandible open by approximately 3-4 mm beyond its resting

position, thereby maintaining pressure on the neuromuscular

system supporting the mandible.16 It has been found to be

eective in controlling vertical dimension which is of benet

for patients with skeletal open bite.16,17 When intrusion of the

posterior teeth is needed in adults with excess vertical face

height, bite-blocks have been unsuccessful in accomplishing

molar intrusion.18

Magnetic bite-block

This appliance was rst introduced by Dellinger, in 1986, under

the name active vertical corrector. The components of this

appliance consist of two posterior occlusal splints, one for the

upper, and one for the lower jaw. Samarium cobalt magnets are

incorporated into the acrylic splints, over the occlusal region of

the teeth that planned to be intruded. These magnetic modules

are expected to generate forces between 600 and 650 g per

module.19 It has been reported as an eective therapeutic tool

in reducing the open bite in growing patients by the intrusion

of molar teeth.17,20 Moreover, the magnetic repelling bite-block

has been reported to signicantly intrude the molars in adult

patients.21,22 Although magnetic posterior bite-blocks also

have shown to produce a quick response in the dental and

skeletal vertical relation, in can also help change posterior cross

bite relations compared to a passive bite block. Maintaining

arch width is sometimes dicult with magnetic bite-blocks.

Therefore, TPA is necessary.23

Spring-loaded bite-block

The design of spring-loaded bite-blocks was rst described, in

1986, by Woodside and Linder-Aronson. Upper and lower bite

block are connected with two helical springs that are activated

progressively to maintain the forces between 250 and 300 g.24

Few authors have reported that it has an orthopedic inuence in

treating open bite by intruding molars in growing patients.13,24-26

However, to this date, there is limited data regarding intrusion

in adults.

Non-complianceappliances

TADs

After Branemark introduced the concept of osseointegrated

pure titanium threaded implants in the clinical treatment of

the edentulous patient,27 the conventional implants replacing

missing teeth have been utilized as skeletal anchorage for the

correction of open bite by molars intrusion.28

Creekmore and Eklund introduced the vast possibilities of

skeletal anchorage and inserted surgical vitallium bone screws

just below the anterior nasal spine for deep bite patients.29

New sites for implant placement were then propositioned

such as endosseous implants in the retromolar pad area30 and

the midpalatal implant.31 Kanomi and Costa et al. introduced

the concept of miniscrew for orthodontic anchorage.32,33

Umemori et al. were the rst to use miniplates as temporary

skeletal anchorage for molar intrusion in managing the open

bite malocclusion.34 Since then, many publications involving

miniscrews as skeletal anchorage have been reported for molar

intrusion.35-37

Molars can be intruded approximately 2-4 mm using skeletal

anchorage, with better results in the maxilla than mandible.3,38-41

The mandible is composed of thicker cortices than the maxilla

which might suggest that it resists the intrusive force more

than the maxilla.38

The mechanics for molar intrusion in the buccally positioned

TADs comprises of a vertical intrusive force applied directly

to the molar or molars. A TPA is placed in the maxilla or a

lingual arch in the mandible to prevent distortion of the arch

form and buccal tipping of the posterior teeth during force

application. The use of a maxillary TPA has an added benet

because tongue pressure on the appliance may contribute to

molar intrusion. The TPA must be oset (relieved) from the

palatal mucosa, approximately the distance that the molars are

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Molarintrusiontechniques…HakamiZ Journal of International Oral Health 2016; 8(2):302-306

expected to be intruded.42 With TADs located in the palate, it

could be dicult to obtain a vector sum that passes through

the center of resistance due to the anatomy of the palatal and

buccal alveolar bone. Therefore, monitoring is important to

verify the torque and buccopalatal position of the molars being

intruded. Hence, a buccal force from another buccal screw is

combined to counteract the palatal moment.37 For intrusion of

single molar tooth, the force could be applied from a cantilever

attached directly to the miniscrew in combination with a TPA

to counteract 3rd-order side eects.43

Rapid molar intrusion device (RMI)

This appliance has been first proposed by Carano and

Machata.44 It has two elastic modules that are secured on the

rst molars with L-shaped pins. The straight terminal end

attaches into a maxillary molar tube and the angulated terminal

end attaches to a mandibular tube. When the patient closes

their mouth, the modules are exed and deliver an immediate

intrusive force of 800 g on each side. This force level decays

to 450 g by the end of the 1st week and 250 g by the end of

the second week. Because the intrusive forces on the labial

side of the molars generate moments that tip the crowns

buccally, the RMI appliance is always placed with TPA in

upper and a lingual arch in lower. The eect of this appliance

has been reported to intrude the upper and lower rst molars

signicantly in growing patients and adults. Furthermore, it

has been shown to intrude the rst and second molars if they

are attached together. However, it has the disadvantage that it

intrudes both the upper and lower molars simultaneously. So,

it cannot be used for the intrusion of molars in one arch.45,46 A

controlled, clinical trial study is needed to conrm its eciency

and ecacy.

Vertical holding appliance (VHA)

VHA is a TPA with an acrylic pad. Theoretically, pressure from

the tongue could reduce the eruption of maxillary permanent

rst molars during growth. However, it has not been clinically

proven.47,48 Nevertheless, during orthodontic treatment, VHA

is helpful in restricting further anterior bite opening resulting

from molar extrusion during leveling and alignment.48

Surgical-assisted Approach for Molar Intrusion

Corticotomy-enhancedmolarintrusion

Corticotomy-assisted orthodontics has been reported to limit

side eects of tooth movement and also enhance the rate of

tooth movement by increasing alveolar bone turnover and

reducing bone density.49,50 After raising a full mucoperiosteal

ap, corticotomy is performed selectively for intended molar or

molars to be moved. Vertical cuts were made on both mesial and

distal interproximal areas starting 2-3 mm above the alveolar

crest. It extends 2-3 mm past the estimated root apices, and

then a horizontal corticotomy was performed connecting the

interdental cuts. To apply an intrusive force, various methods

could be used. For example, an acrylic splint covering the teeth

except the tooth or teeth needed to be intruded can have an

intrusive force from a coil spring attached to the J-hooks in

the buccal and lingual shields which passes over the occlusal

surface.51 Furthermore, intrusive forces could be applied from

a magnetic - repelling acrylic splint,52 or skeletal anchorages,

such as zygoma anchors,53 miniplate, or miniscrew.5

Osteotomy-assistedmolarintrusion

An osteotomy followed by an orthodontic force has been

widely used as an option for movement of ankylosed teeth.54,55

It was published in a case report, where an osteotomy had been

performed, and intrusive force applied from miniplate on the

zygomatic buttress in a patient with an open bite.56 However,

more research is required to determine the limitations of this

procedure.

Stabilityofmolarintrusion

Maintaining the position of intruded molars is a challenging

step after orthodontic treatment of open bite malocclusion.

Different factors may contribute in the relapse of open

bites such as tongue size or posture, unfavorable growth

patterns, orofacial musculature, respiratory problems, and

dental movements.57 In general, the stability of open bite

treatment is greater than approximately 75%. Nevertheless,

in growing patients, long-term post-treatment stability is

unpredictable, particularly, in those having potential vertical

growth pattern.58

Some retention protocols have been suggested for preventing

the eruption of the posterior teeth. These methods could

incorporate the use of high pull headgear, vertical chincap, or

open bite activator.6 Other retention protocols have attempted

preventing relapses through controlling low tongue posture

or tongue-thrusting habit by means of orofacial myofuntional

therapy,59 tongue reduction,60 tongue crib, or tongue elevator

appliances.61,62

Several authors have reported tendency of relapse ranging

between 20% and 30% when using TADs for molar intrusion.38-40

The majority of the relapse occurs within the 1st year after

treatment. This would suggest eective retention protocols

must be introduced within this 1st year of retention.38,39 For

example, a retainer covering the occlusal surfaces of the molars

with elastics to the buccal TADs could be used and has shown

to be a successful method.3

Conclusion

This paper highlighted the molar intrusion techniques in the

literature. The mechanics for intruding the molar/molars are

usually accompanied with reciprocal eects on the anchorage

units. With the limitation of available strong evidence, utilizing

skeletal anchorage or, to a lesser extent, performing some

surgical procedures such as corticotomy, to the intended teeth

could be promising in ecient movements with limited side

eects. However, future clinical studies are needed to improve

our evidence in this regard.

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Molar intrusion techniques … Hakami Z

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• True molar intrusion attained during orthodontic treatment: A systematic review

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  Article · Jan 2007
  Julia NgPaul W MajorCarlos Flores-Mir
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