A newly designed spring, the dragon helix appliance, is used with an indirect skeletal anchorage system to correct scissors-bite. Scissors-bite on several molars resulting from transverse skeletal deficiency is termed Brodie bite. A mandibular second molar tends to erupt lingually, producing a posterior crossbite, or a scissors bite.
A newly designed spring, the dragon helix appliance, is used with an indirect skeletal anchorage system to correct scissors-bite. Scissors-bite on several molars resulting from transverse skeletal deficiency is termed Brodie bite. A mandibular second molar tends to erupt lingually, producing a posterior crossbite, or a scissors bite.
A newly designed spring, the dragon helix appliance, is used with an indirect skeletal anchorage system to correct scissors-bite. Scissors-bite on several molars resulting from transverse skeletal deficiency is termed Brodie bite. A mandibular second molar tends to erupt lingually, producing a posterior crossbite, or a scissors bite.
A newly designed spring, the dragon helix appliance, is used with an indirect skeletal anchorage system to correct scissors-bite. Scissors-bite on several molars resulting from transverse skeletal deficiency is termed Brodie bite. A mandibular second molar tends to erupt lingually, producing a posterior crossbite, or a scissors bite.
with a dragon helix appliance Sung Won Yun, a Won Hee Lim, b Deuck Ryong Chong, c and Youn Sic Chun d Seoul, Korea Many efforts have been made to correct scissors-bite and establish proper molar interdigitation for prosthetic or orthodontic treatment. The critical procedures for scissors-bite correction are intruding and palatally tipping the involved tooth when it is both extruded and buccally ared. Conventional approaches give rise to problems such as repetitive bonding failure and loss of anchorage. A newly designed spring, the dragon helix appliance, is used with an indirect skeletal anchorage system to correct scissors-bite. This spring provides effective tooth movement and the convenience of a simple and small design. We report a successful treatment with the dragon helix. (Am J Orthod Dentofacial Orthop 2007;132:842-7) C rossbite is a condition in which 1 tooth or several are abnormally positioned buccally or lingually with reference to the opposing tooth or teeth. Scissors-bite applies to total maxillary buccal (or mandibular lingual) crossbite, with the mandibular dentition completely contained in the maxillary denti- tion in habitual occlusion. Scissors-bite on several molars resulting from transverse skeletal deciency is termed Brodie bite. A transverse mandibular deciency might manifest itself in unilateral or bilateral buccal crossbite, or Brodie bite. Brodie bite occurs in 1.0% to 1.5% of the population. 1-3 Although there is no arch-length discrepancy in the posterior segments, the mandibular second molars tend to erupt lingually, producing a posterior crossbite, or a scissors-bite. 4-6 The primary problems in correcting a scissors-bite are (1) buccal tipping with overextrusion of the maxil- lary molar, (2) lingual tipping with overextrusion of the mandibular molar, (3) molar position that is resistant to correction, and (4) lack of space to place appliances on the palatal side of the maxillary molar and the buccal side of the mandibular molar (Fig 1, A). The rst step in correcting a scissors-bite is the simultaneous intrusion and the palatal tipping of the maxillary molar to let the mandibular molar move without resistance (Fig 1, B). The second step is to bring the mandibular molar into proper position (Fig 1, C). Then it is easy to settle down the maxillary molar for proper occlusion after correction of the mandibular molar (Fig 1, D). Therefore, the main key to successful treatment is the intrusion of the maxillary molar without loss of anchorage. Efforts have been made to obtain strong anchorage that does not alter the previous occlusion and to develop an appliance that is small enough not to injure soft tissues yet can produce effective correction. For- tunately, various appliances have been developed since the micro-implant (screw) was used in orthodontic treatment. 7 Dragon helix appliance combined with indirect skeletal anchorage Strong anchorage is required for molar intrusion. It was reported that intraoral titanium screws used for orthodontic anchorage are both stable and safe. 8-10 Shouichi and Isao 11 and Bae et al 12 reported on direct skeletal anchorage in which teeth were pulled directly by elastics or springs tied to a miniscrew. A disadvantage of direct skeletal anchorage is that at least 2 screws are needed, not only to control torque but also to prevent rotation. Therefore, an indirect skeletal anchorage system with only 1 screw was developed to overcome the shortcomings of direct skeletal anchorage. A screw is usually placed between premolars because of good accessibility at these sites. The location for the screw is exible, depending on spaces between roots. The screw is connected to the adjacent tooth by a 0.019 0.025-in stainless steel wire with conventional com- posite resin after sandblast etching. The tooth con- nected with the screw provides strong and stable anchor- From the Division of Orthodontics, Department of Dentistry, Ewha Womans University, Seoul, Korea. a Former resident. b Assistant professor. c Former resident. d Professor. Reprint requests to: Youn Sic Chun, Division of Orthodontics, Department of Dentistry, 911-1 Mokdong YangCheon-Gu, Seoul, Korea, 158-710; e-mail, [email protected]. Submitted, October 2005; revised and accepted, March 2006. 0889-5406/$32.00 Copyright 2007 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2006.03.029 842 age similar to an ankylosed tooth; this technique is indirect skeletal anchorage (Fig 2). The dragon helix was developed by the Division of Orthodontics, Ewha Mokdong Hospital, Seoul, Korea, to achieve intrusion and palatal tipping simul- taneously under absolute anchorage. It consists of 2 arms and helixes made of 0.016 0.022-in stainless steel wire. One arm is at an angle of about 110 to the other arm. The length of each arm is about 5.0 mm, and the helix diameter is about 2.0 mm (Fig 3, A). The number of helixes is not important because almost the same force is applied if more than 5 helixes are used. The total length from the buccal groove to the mesial marginal ridge of second molar consists of 8 to 10 helixes. In indirect skeletal anchor- age, 1 arm is bonded on the occlusal surface of the target tooth, and the other is on the buccal surface of the anchorage tooth (Fig 3, B). It can apply 200 to 250 mg of force on activation (Fig 3, C). CASE REPORT A girl, aged 16, was referred from a local clinic to the Division of Orthodontics of Ewha Womans Uni- versity Mokdong Hospital in Seoul, Korea, with the chief complaint of crowding. She had a convex facial prole with lip protrusion and moderate crowding on both the maxillary and mandibular anterior teeth. She also had a severe scissors-bite on the left maxillary and mandibular second molar with a Class II molar rela- tionship. She had no signicant deviation of the trans- verse skeletal pattern, but she had a history of delayed eruption of the left mandibular second molar, which was involved in the scissors-bite. She was diagnosed as having a Class II Division 1 malocclusion with scis- sors-bite on the left second molars. The objectives of treatment were to relieve crowd- ing and lip protrusion and to correct the left posterior scissors-bite; these corrections could provide both a balanced prole and occlusal interdigitation. Extraction of the maxillary rst premolars was performed to relieve crowding and reduce lip protrusion. The rst option was to extract the second molar if the third molar was properly developed and well positioned; however, that was not the case for this patient. The second option involved intrusion of the extruded molars with magnets, followed by corti- cotomy. In this case, the sinus wall was close to the root of the maxillary second molar, and the patient and her parents declined surgical procedures. The third option was to use intermaxillary crossbite elastics. This ap- proach might be suitable in mild cases, but not for this patient, because the amount of extrusion of both molars was severe, and bonding on the palatal side of the maxillary molar and the buccal side of the mandibular molar was impossible because of lack of space. The fourth option was to use the newly designed spring, the dragon helix, combined with indirect skeletal anchor- age. The patient and her parents chose the fourth option after the advantages and disadvantages of each option were explained in detail. One screw (1.6 8.0 mm, no. 1D16109, OSAS self-drilling screw; EPOCH Medical, Seoul, Korea) was placed between the maxillary left second premolar and the rst permanent molar under local anesthesia. The screw was connected to the mesiobuccal surface of the maxillary rst permanent molar by a 0.019 0.025-in stainless steel wire, and a dragon helix was bonded to the maxillary molars (Fig 4, A and B). Five Fig 1. The principle of scissors bite correction. A, An illustration of scissors bite at the distal aspect (black line normal occlusion). Intrusion and palatal tipping are necessary for correction of scissors bite. B, After intru- sion and palatal tipping of the maxillary molar to allow the mandibular molar to move without resistance, the mandibular molar can easily be uprighted. C, The max- illary molar descended for settling after correction of the mandibular molar into the proper position. D, An illus- tration of the post-treatment appearance. Fig 2. A photograph of indirect skeletal anchorage. American Journal of Orthodontics and Dentofacial Orthopedics Volume 132, Number 6 Yun et al 843 months after bonding the dragon helix, remarkable intrusion was seen on the maxillary left second perma- nent molar (Fig 4, C and D). Enough space was created for uprighting the mandibular left second permanent molar 7 months after intrusion of the maxillary left second permanent molar (Fig 4, E and F). The second screw (OSAS, 1.6 8.0 mm) was placed between the mandibular left second premolar and the mandibular rst permanent molar, and con- nected to the mesiobuccal surface of the mandibular left rst permanent molar by a 0.019 0.025-in stainless steel wire. The bonded button on the lingual surface of the mandibular second molar was tied by elastics to the wire arm (Fig 5, A and B). The elastics Fig 3. The procedure for bonding Dragon Helix to the maxillary molar. A, One arm is bonded to the occlusal surface of the second molar (target tooth involved in scissors bite) by composite resin. B, The second arm is brought to the rst molar (anchorage tooth) connected with a screw. C, The second arm is bonded to the buccal surface of the rst molar (anchorage tooth) by composite resin with the application of 200-250 mg force upon activation. Fig 4. A, B, After activation by elastics; C, D, after 2 months bracket bonding to control mandibular molar; E, F, after 3 months, notice the level of mandibular molars. American Journal of Orthodontics and Dentofacial Orthopedics December 2007 844 Yun et al passed through the occlusal surface of the mandibu- lar molar, which contributed to more intrusion. 13 A bracket was bonded on the second molar for detail movement after uprighting (Fig 5, C and D). Three months were needed to upright the molar success- fully (Fig 5, E and F). The extruded and buccally inclined maxillary right second permanent molar was both intruded and pala- tally tipped without a problem, and the extruded and lingually inclined mandibular second molar was up- righted also. The scissors-bite on the left second molars was corrected in about 10 months during orthodontic treatment (Fig 6, A and B). There was no sign of pulp necrosis or sensitivity. DISCUSSION Great efforts have been made to treat scissors- bite successfully. It has been reported that scissors- bite patients treated with extraction of scissor-bite teeth and use of third molars. 14-17 There are, how- ever, some limitations for this approach, such as the necessity for a sound third molar in a good position. Another approach to treat scissors-bite involves a surgical procedure. 18,19 The intrusion of su- pererupted molars was also performed with magnets combined with corticotomy 20 and by parasymphyseal osteotomy. 21 This procedure might result in surgery- related complaints and also requires good patient health. The third option, reported by Gerhard and Weiland, 22 is to use a modied transpalatal arch to intrude the maxillary second molar, in which loss of anchorage can occur, and application might be lim- ited to mild cases. The fourth approach was to use the molar intrusion arch. 23 Limitations involved use of several teeth for enforcement of anchorage and change of occlusion in spite of all efforts. The fth was to use cross-arch elastics in patients with asym- metry. 24 Finally, intrusion of the maxillary second molar with the miniscrews 25 has been performed since the miniscrew for orthodontic treatment be- came available. Two screws were used, on the buccal and lingual sides, and no opposing teeth were present in these cases. There are advantages to using indirect skeletal anchorage. 26 Only 1 miniscrew is required; this makes it possible to place a miniscrew at any place that is easily accessible and to also avoid anatomical structures. The strength of the dragon helix is that it results in no interruption during mastication because it is bonded only on the buccal side, and less injury results to oral tissues relative to traditional appliances because of its small size and simple design. The dragon helix combined with indirect skeletal anchorage allows other orthodontic treat- ment to continue with no loss of anchorage. There are some clinical ndings in patients treated with the dragon helix combined with indirect skeletal anchorage. First, the mechanics related to this system rely on absolute anchorage. If a micro- screw becomes loosened in indirect skeletal anchor- age, there is a chance of displacement of the an- chored tooth. However, continuously checking the mobility of the microscrew can reduce this risk. Second, the helix part of the dragon helix should be placed so that it is just at the buccal gingival margin of the involved tooth or a little coronally; if the helix part is located too close to the gingiva, it might cause inammation because of pressure, and a helix part located too coronally might not be effective because of a short active arm. Third, regular checkups for periodontal pockets should be performed with cau- tion because deepening of the sulcus depth has been found in some patients at the end of treatment. It is not clear whether this phenomenon is temporary. Fig 5. A, B, After bonding the Dragon Helix; C, D, after the 5 months that Dragon Helix was bonded, remark- able maxillary molar intrusion was seen; E, F, after 7 months, notice the space to upright mandibular molar that was created by maxillary molar intrusion. American Journal of Orthodontics and Dentofacial Orthopedics Volume 132, Number 6 Yun et al 845 Melsen et al 27 demonstrated that the combination of periodontal treatment with orthodontic intrusion seems to be a method for improving the periodontal condition, if both the biomechanical force system and oral hygiene are kept under control. The impor- tance of oral hygiene care should be emphasized to reduce any risk factors that can aggravate a periodon- tal problem. CONCLUSIONS A newly designed spring, the dragon helix, com- bined with indirect skeletal anchorage was used to treat a scissors-bite successfully. An advantage of this method is the binding of only 2 teeth, including the target tooth in most cases; this allows other orthodontic treatment to continue without loss of anchorage or change of occlusion. REFERENCES 1. Harper DL. A case report of a Brodie bite. Am J Orthod Dentofacial Orthop 1995;108:201-6. 2. Emrich RE, Brodie AG, Blayney JR. Prevalence of Class I, Class II and Class III (Angle) malocclusions in an urban population: an epidemiological study. J Dent Res 1965;44:947-53. 3. Grewe JM, Hagan DV. Malocclusion indices: a comparative evaluation. Am J Orthod 1972;61:286-94. 4. Tollaro I, Defraia E, Marinelli A, Alarashi M. Tooth abrasion in unilateral posterior crossbite in the deciduous dentition. Angle Orthod 2002;72:426-30. 5. Pinto AS, Buschang PH, Throckmorton GS, Chen P. 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