CLINICIAN'S CORNER

Expanding torque possibilities: A

skeletally anchored torqued cantilever for
uprighting “kissing molars”

rgio Estelita Barros,a Guilherme Janson,b Kelly Chiqueto,a Eduardo Ferreira,a and Cassiano Ro
Se € singc
Porto Alegre, Rio Grande do Sul, and Bauru, S~ao Paulo, Brazil

Several uprighting mechanics and devices have been used for repositioning tipped molars. “Kissing molars”
(KMs) are an uncommon tooth impaction involving 2 severely tipped mandibular molars with their occlusal sur-
faces positioned crown to crown, with the roots pointing in opposite directions. Orthodontic uprighting of KMs has
not been a usual treatment protocol, and it can be a challenging task due to the severe tipping and double impac-
tion, requiring efficient and well-controlled uprighting mechanics. An innovative skeletally anchored cantilever,
which uses the torque principle for uprighting tipped molars, is suggested. This torqued cantilever is easy to
manufacture, install, and activate; it is a well-known torque that is effective for producing root movement. A suc-
cessful treatment of symptomatic KMs, involving the first and second molars, was achieved with this cantilever.
Thus, clinicians should consider the suggested uprighting mechanics and orthodontic device as a more conser-
vative alternative to extraction of KMs, depending on the patient's age, involved teeth in KMs, tipping severity,
and impaction positions. (Am J Orthod Dentofacial Orthop 2018;153:588-98)

M
olar uprighting mechanics are frequently
required to reposition mesially tipped and
impacted molars or when the erupted molars
tip toward an edentulous space because of loss or agen-
esis of an adjacent tooth.1,2 However, “kissing molars”
(KMs) describe an unusual type of tooth impaction in
which 2 mandibular molars are severely tipped and
impacted with their occlusal surfaces positioned
crown-to-crown and the roots pointing in opposite di-
rections.3-8 Gulses et al9 proposed a radiographic classi-
fication of KMs into Class I, Class II, or Class III categories
depending on the location of the teeth involved. If the
impactions are between the first and second molars,
they are classified as Class I KMs; between the second
and third molars, Class II KMs; and between the third
a
Department of Orthodontics, Faculty of Dentistry, Federal University of Rio
Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
b
Department of Orthodontics, Bauru Dental School, University of S~ao Paulo,
Bauru, S~ao Paulo, Brazil.
c
Department of Periodontics, Faculty of Dentistry, Federal University of Rio
Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: S
ergio Estelita Barros, Department of Orthodontics,
Faculty of Dentistry, Federal University of Rio Grande do Sul, Rua Ramiro Barce-
los, 2492, Bairro Santana, Porto Alegre, RS 90035-003, Brazil; e-mail,
sergioestelita@yahoo.com.br.
Submitted, March 2017; revised and accepted, December 2017.
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2017.12.006
588
and fourth mandibular molars, Class III KMs.4,9,10
However, this classification does not set treatment
guidelines.
KMs should be treated if they cause adverse symp-
toms, are associated with cystic pathology, or because
they have a high risk of caries, periodontal complica-
tions, or progressive bone loss.5,9 Orthodontic
mechanics for uprighting KMs have not been reported.
Surgical treatment involving extraction of 1 or both
KMs is the most common protocol.4,7,11-13 The reason
for this includes the high severity of the ectopic
positions inherent to KMs. When molar tipping is
extremely severe, showing a vertically inverted position
in a panoramic radiograph (ie, root apex positioned
more occlusally than the tooth crown), and the
exposure level of the molar crown does not allow
placement of uprighting mechanics on its buccal
surface, molar uprighting may be a challenging task.
This report shows an orthodontic treatment option for
Class I KMs, presents an innovative skeletally anchored
cantilever to aid in uprighting severely tipped KMs,
and discusses reasons and guidelines for orthodontic
treatment of this anomaly.
DIAGNOSIS AND ETIOLOGY
A girl, aged 10 years 9 months, sought treatment at
the dental school at the Federal University of Rio Grande
do Sul in Porto Alegre, Brazil, with a clinical history of
Barros et al
Fig 1. Pretreatment facial and intraoral photographs.
recurrent pericoronitis involving the mandibular right
molar region. The clinical examination was not enough
to provide an accurate diagnosis (Fig 1). Radiographi-
cally, the right first and second molars were severely tip-
ped toward each other so that their occlusal surfaces
were contacting crown to crown, whereas the roots
pointed in opposite directions, in a typical KM impaction
position (Fig 2).4-7 The second molar was the most
severely tipped, with a vertically inverted position and
over 90 of long axis rotation in relation to the
adjacent unaffected teeth (Fig 2). The unerupted sur-
faces of the KMs presented an enlarged pericoronal
space that communicated with the oral cavity, allowing
food debris impaction, bacterial contamination, and
chronic infection with acute episodes, leading to bone
loss (Figs 1 and 2). This difficult access for dental
cleaning probably led to the development of a deep
carious lesion in the first molar (Fig 2).5 The patient's
parents reported a history of a cystic lesion related to
the KMs, which had been surgically treated 3 years
American Journal of Orthodontics and Dentofacial Orthopedics
589
previously. Since the patient had no history of metabolic
diseases, trauma, or fracture involving the KM area, the
cystic formation may have contributed to the displace-
ment of the adjacent teeth to the KM
position.4,5,7,9,11,13-15
The premolar relationships showed a half cusp Class II
malocclusion (Fig 1). Distal tipping of the first molar,
associated with mesial tipping of the second molar,
caused arch-length shortening in the KM area. The pre-
treatment dentoskeletal and soft tissue cephalometric
features are shown in the Table.
TREATMENT OBJECTIVES
The primary treatment objectives were to normalize
the posterior occlusion on the KM side and the periodontal
health and dental cleaning access, preventing progress of
the side effects associated with this developmental anom-
aly, such as occlusal collapse and bone loss.6,9 Additional
objectives included Class II malocclusion correction and
establishment of a functional occlusion.
April 2018  Vol 153  Issue 4
590 Barros et al

Fig 2. Pretreatment, panoramic, and periapical radiographs. The second molar was the most severely
tipped KM with a vertically inverted position (root apex positioned more occlusally than the tooth crown)
and over 90 of long-axis rotation in relation to the long axis of adjacent unaffected teeth. Note that the
distalization force vector is close to the center of resistance of the severely tipped second molar.

uncertainties regarding the third molar's anatomic char-

Table. Cephalometric data before and after ortho-
acteristics, including its shape, structure, and dimen-
dontic treatment
sions.17 Treatment time would also be greatly
Variable Pretreatment Posttreatment Difference increased waiting for the eruption of the third molar,
SNA ( ) 87.8 88 0.2 to adequately position this molar and close residual
SNB ( ) 84.1 85.3 1.2 spaces. Finally, replacement of the second molar with
ANB ( ) 3.7 2.7 1
a dental implant instead of the third molar could also
Wits (mm) 2.3 0 2.3
SN.GoGn ( ) 24.9 26 1.1 be disadvantageous because the patient has a long
FMA ( ) 17.6 18.1 0.5 growth period ahead, which contraindicates implant
LAFH (mm) 54 59.2 5.2 placement in the short term while risking bone loss in
Mx1-NA ( ) 26.3 20 6.3 the extraction area.
Mx1-NA (mm) 3.6 2.7 0.9
An alternative and conservative approach would be
Md1-NB ( ) 19.8 31.2 11.4
Md1-NB (mm) 1.6 4.4 2.8 to extract the damaged first molar, but this option
Overjet (mm) 5 2 3 must take into account that treatment success would
Overbite (mm) 3.5 2.2 1.2 depend on the less predictable results of uprighting an
Nasolabial angle ( ) 113.7 112.4 1.3 extremely tipped second molar. The previously
Upper lip to E-plane (mm) 0.9 1.2 0.3
mentioned drawbacks, such as developmental uncer-
Lower lip to E-plane (mm) 1.5 0.2 1.3
Inter-KMs angle ( ) 138.5 5 133.5 tainties regarding the third molar, increased treatment
time, and need for closing the residual spaces also
applied to this protocol, as well as to bone loss in case
TREATMENT ALTERNATIVES of an implant rehabilitation choice. Lastly, it must be
Based on the primary objectives, some treatment al- considered that, unlike second molar extraction, first
ternatives were considered. Extraction of both KMs is the molar removal would require the difficult task of mesial-
most usual treatment reported.4-7,9,11-16 However, in izing 2 molars.
this young patient, having Class I KMs, extraction of The factors that influenced the decision to treat this
first and second molars would produce an extensive Class I KM patient using a nonextraction protocol were
occlusal sequel and early need for rehabilitation. the following: the patient's young age, the need for im-
Extracting only the second molar could be a more mediate clinical intervention, the early development
conservative and reasonable alternative, taking into stage of the third molar, the moderate preservation of
account its considerable tip (Fig 2). However, the first the dental structure of the KMs, and the parental reluc-
molar had a deep carious lesion and some root short- tance to accept an extraction treatment plan. Thus, any
ening compared with the contralateral tooth (Fig 2). of the previously discussed extraction protocols
Furthermore, the potential replacement of the involving late third molar handling would still be avail-
second molar with the third molar, which was in the early able if for some reason the repositioning of the KMs
stage of cusp calcification, raised treatment success proved to be unsuccessful.

April 2018  Vol 153  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Barros et al
Fig 3. An innovative skeletally anchored cantilever: A and B, radiographic and clinical view of the
molar tube buccolingually positioned on the occlusal surface of the KM; C and D, a torqued cantilever
was inserted into the molar tube to obtain mesiodistal root movement and KM uprighting. Skeletal
anchorage was used to prevent the cantilever vertical side effects on the dental arch.
TREATMENT PROGRESS
The orthodontic treatment began with a focused
intervention on KMs because of the urgent patient
need and because not all permanent teeth were erupted
at this time. Due to the arch-space deficiency for first
molar repositioning, KM correction was started with up-
righting of the second molar. However, the position and
exposure degree of the second molar crown was not
favorable for conventional buccal uprighting mechanics
(Fig 1).1,2,18 In addition, uprighting mechanics that are
based on distalization force vectors cannot produce an
effective uprighting moment when the molar is
extremely tipped because the line of force action lies
close to the center of resistance of the tipped molar
(Fig 2).19-21 Consequently, some distal movement of
the second molar roots could occur; this would be
undesirable (Fig 2). Thus, an innovative skeletally
anchored cantilever made of stainless steel rectangular
wire (0.019 3 0.025 in) was proposed. This cantilever
was created to satisfy the clinical conditions and the me-
chanical objectives of this patient (Fig 3). A mini-implant
was inserted between the canine and the first premolar
to prevent the undesirable side effects from cantilever
intrusion force. Unlike the usual cantilever mechanics,
this new uprighting device uses the torque principle to
move the roots in a mesiodistal direction (Fig 4). Torque
is a twisting force traditionally used to produce tooth
movement in a buccolingual direction. To achieve this
new torque effect, an orthodontic tube was bonded
with its slot buccolingually positioned on the erupted
part of the occlusal surface of the impacted tooth (Figs
3, A and B, and 4, B). Thus, when this torqued cantilever
is actively inserted into the molar tube, a mesiodistal
moment of force is applied on the molar roots, produc-
ing an uprighting effect (Figs 3, C and D, and 4).
American Journal of Orthodontics and Dentofacial Orthopedics
591
After 5 months of uprighting mechanics with this skel-
etally anchored torqued cantilever, the second molar posi-
tion was significantly corrected, and its buccal surface was
clinically accessible, allowing orthodontic tube reposition-
ing (Fig 5, A and B). A temporary bite raising was performed
by adding light-curing composite resin on the occlusal sur-
face of the maxillary premolars, allowing initial mandibular
arch leveling. An open-coil spring was used to open space
for the first molar repositioning and to aid in the
second molar uprighting since the distalization force vector
was away from the molar resistance center in this advanced
uprighting stage, producing an efficient moment of force
for uprighting (Figs 5, B and C, and 6). After space opening,
a closed-coil spring was used to maintain the space, and
first molar alignment was started with an auxiliary nickel-
titanium wire inserted into the orthodontic tube bonded
on its occlusal surface because the buccal surface was not
accessible (Fig 5, D). At this stage, the KMs underwent peri-
odontal surgery by means of an apically repositioned full-
thickness flap to expose a greater amount of their clinical
crowns, allowing repositioning of orthodontic accessories
on the buccal surfaces (Fig 5, E). After 1 year, the
second molar was uprighted, and the first molar correction
was in progress (Fig 5, F). Positioning of the KMs progres-
sively improved until total correction (Figs 5, G and H).
Accentuated and reverse curves of Spee were used to
correct the overbite. A Class I molar relationship was ob-
tained with Class II elastics. However, the treatment fin-
ishing phase had to be postponed because the
restorative treatment of the first molar's carious lesion
was not successful and required endodontic treatment.
Orthodontic treatment was discontinued for 2 months
while the patient was endodontically treated, after which
the finishing phase began. Although the root canal
filling lengths and homogeneities were not ideal, there
April 2018  Vol 153  Issue 4
592
Fig 4. Torqued cantilever mechanics: A, this cantilever is activated by torquing the end of the rectan-
gular wire that is inserted into the molar tube; B, since the molar tube is bonded buccolingually on the
occlusal surface of the KM, the torque action of this cantilever will produce an uprighting movement of
the impacted molar.
was no periapical pathology or patient symptom after-
ward. Orthodontic treatment was completed in 3.2 years
(Figs 7 and 8).
TREATMENT RESULTS
Adequate positioning of the KMs was achieved (Figs
8 and 9). The first and second molars were uprighted by
133 until satisfactory root parallelism (5 ) was reached
between them (Table; Figs 9 and 10). The external apical
root resorption of the KMs was not excessive,
maintaining the initial root shortening of the first
molar (Figs 2 and 9). The lost alveolar bone height
between the KMs progressively recuperated as they
were uprighted (Figs 2 and 5). The mesial surface of
the second molar and the distal surface of the first
molar were significantly extruded during the
uprighting process, allowing recovery of the bone crest
level (Fig 9). Clinically, the patient was completely
asymptomatic, the pseudopocket was eliminated, the
KMs were periodontally healthy, and pericoronitis recur-
rence was eliminated (Figs 8 and 9).
In addition, molar relationship, overjet, and overbite
were normalized; this contributed to a well-finished static
and functional occlusion (Figs 7 and 8). The dentoskeletal
and soft tissue changes are shown in the Table and
Figure 10. The final smile esthetics were pleasant because
midlines, smile arc, and buccal corridors were adequate
(Fig 8).22,23 Correction of the KMs was stable 10 months
after orthodontic treatment (Fig 11).
DISCUSSION
Extraction of the most distal Class II KM and both
Class III KMs may be a less controversial decision because
in both cases the extractions do not involve the first and
April 2018  Vol 153  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Barros et al
second molars, and bone availability in the retromolar
area is often critical to accommodate the third molars
and certainly insufficient for a fourth molar if all other
teeth are present. However, nonextraction treatment
should be considered for patients in the late mixed
dentition and with symptomatic Class I KMs because
first or second molar extraction may be disadvanta-
geous. Nevertheless, it would require using unique or-
thodontic mechanics because of the severe ectopic
positioning inherent to KMs.
Based on a recent literature search and as far as we
know, there has been no reported case of orthodonti-
cally treated KMs.13 Several orthodontic mechanics
and devices have been proposed to verticalize and dis-
impact the mesially tipped mandibular molars. Remov-
able and fixed appliances and, more recently, skeletal
anchorage have been used with push springs,24,25
open-coil and closed-coil springs,1,21,26,27 tip-back
cantilevers,1,2,18,28 looped springs,19 and several other
types and designs of uprighting springs29-32 to
perform the challenging task of uprighting tipped
molars. However, this is the first time that a moment
of force used for molar uprighting has been obtained
by an actively torqued rectangular archwire. This new
use of archwire torque seemed to be as effective in
accomplishing mesiodistal root movement as its
traditional use to move the roots buccolingually. In
this patient, second molar uprighting occurred
mainly at the expense of torque movement, which is
associated with extensive root repositioning and
minor crown displacement in the opposite
direction.33 This mechanical characteristic can be a
clinical advantage when root movement is prioritized
during the uprighting process.
Barros et al 593

Fig 5. Progress of KM uprighting: A and B, second molar uprighting and space opening for the first
molar, using a torqued cantilever and an open-coil spring; C, second molar uprighting after 5 months;
D and E, first molar uprighting and leveling; F, KMs uprighted after 1 year; G, clinical position of KMs
after 2 years; H, uprighting of KMs completed.

American Journal of Orthodontics and Dentofacial Orthopedics April 2018  Vol 153  Issue 4
594 Barros et al

Fig 6. Moment of force produced by distalization forces depending on the degree of molar tipping: A,
extreme molar tipping can reduce the distance (d) between the center of resistance (CR) of the molar
and the distalization force vector (F), compromising the moment of force (M5Fxd) for molar uprighting;
B, when the molar tipping degree is not extreme, distalization forces (F) can be indicated to produce an
efficient moment of force (M) for molar uprighting and recovery of the arch space reduced by molar
tipping.

Fig 7. Finishing phase: KMs and the Class II malocclusion were satisfactorily corrected. Treatment fin-
ishing was performed with vertical elastics and wire bends to improve tooth positioning and achieve
satisfactory tooth interdigitation.

A clinical advantage of the skeletally anchored torqued
cantilever is that it does not depend on exposure of the
buccal surface of the tooth, as generally required by con-
ventional cantilevers, because this area is frequently un-
available in patients with extremely tipped and partially
erupted mandibular molars.2,18,29 Another mechanical
advantage is that the moment of force produced by the
skeletally anchored torqued cantilever, unlike some
uprighting mechanics, does not depend on any distal
force. Extremely tipped mandibular molars frequently
have the center of resistance close to the line of action
of the distal forces, generating reduced moments of
force and tending to produce distal bodily movement of
the tipped molar, which can reduce molar uprighting
efficiency (Figs 2 and 6).
Mini-implant insertion between the first premolar
and the canine allowed use of a longer cantilever arm,
which contributed to preventing excessive molar extru-
sion during uprighting (Figs 3 and 4).18 Furthermore, a
longer cantilever arm can deliver a relatively low load-
deflection rate, providing the force system with a high
degree of constancy, which can benefit the extensive

April 2018  Vol 153  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Barros et al
Fig 8. Posttreatment facial and intraoral photographs.
root movement required for uprighting.18 Lastly, activa-
tion of a conventional cantilever produces a well-known
vertical deflection of this device, while with the skeletally
anchored torqued cantilever a torsional deflection of the
rectangular wire occurs simultaneously with the vertical
deflection (Figs 3 and 4). This dual deflection system of
the skeletally anchored torqued cantilever with a longer
cantilever arm further reduces the load-deflection rate
and ensures uniformity of the cantilever force, making
the use of helical loops and flexible metal alloys, such
as titanium-molybdenum alloy, unnecessary.
In this patient with KMs, the first molar buccal
enamel defect could not be clinically or radiographically
diagnosed at the beginning of treatment, and endodon-
tic treatment need was not a certainty at that time (Figs 1
and 2). However, the survival of endodontically treated
teeth has been shown to be about 93% after 10 years,
suggesting a good prognosis.34 Despite the low root-
American Journal of Orthodontics and Dentofacial Orthopedics
595
crown ratio of the mandibular right first molar (1.1), it
was not so below the molar norm, and the 1:1 prosthetic
parameter for minimal root-crown ratio was satis-
factorily maintained.35 The radiolucency involving the
mesial root of the second molar at the end of treatment
was not indicative for endodontic treatment because the
pulp vitality test did not suggest necrosis; the patient
was asymptomatic; the carious lesions were inactive
and restricted to fissures, and bone reorganization
around the roots was in progress after extensive KM
movement. Radiographic follow-up showed that this
was the right clinical decision (Fig 11). The second and
third molars' overlapping on the right side did not
seem to be due to uncontrolled KMs uprighting me-
chanics because an even greater overlapping was seen
on the opposite side, where no distal movement was per-
formed. Arch-length discrepancy in this area seems to be
the most determinant factor for that. Despite the
April 2018  Vol 153  Issue 4
596
Fig 9. Posttreatment, panoramic, and periapical radiographs.
Fig 10. Overall superimposed tracings. Black, pretreat-
ment; red, posttreatment.
potential impaction, if the third molar is asymptomatic
and has no associated pathology or detrimental condi-
tion, prophylactic extraction has not been supported in
the scientific literature, and professional monitoring
seems to be a reasonable decision.36,37 In this patient,
third molar follow-up can be further advantageous
because it remains as an orthodontic option to replace
April 2018  Vol 153  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Barros et al
the second molar if first molar extraction is eventually
required in the long term. If the first molar has unfavor-
able changes over time, it should be considered for
extraction because of its less preserved dental structure.
First molar extraction would allow suitable third molar
positioning, but the cost-benefit rate of this hypothetic
treatment should be carefully considered with the pa-
tient. She has a well-established Class I molar relation-
ship, and mesialization of 2 molars through a molar
width is always a hard and time-consuming task, even
when skeletal anchorage is used. If this option is not
accepted by the patient, first molar extraction and
implant-restorative treatment should be proposed. In
this situation, no previous orthodontic treatment would
be needed because the second molar has already been
uprighted, and implant bone availability would be guar-
anteed by the opportune presence of the first molar.
Finally, the radiographic follow-up of the third molar
did not show molar overlapping, reinforcing third molar
follow-up indication (Fig 11). This molar overlapping
improvement may have been due to the continuous
mandibular growth and posterior relocation of the
ramus, in addition to the progress of third molar devel-
opment into a favorable eruption axis.38
Despite the complexity and adversities, this treatment
could be considered successful because it reached its
main objectives, and the results were stable, suggesting
that when the KMs have an angular positioning about
Barros et al
Fig 11. Follow-up records: intraoral photographs 10 months postorthodontic treatment. Periapical
radiograph of KMs 14 months postendodontic treatment and 10 months postorthodontic treatment.
140 between each other, with an impaction depth at the
level of the alveolar ridge, orthodontic treatment using
similar uprighting mechanics could be a reasonable op-
tion to solve this problem. This is especially true if the
KMs are symptomatic, the first and second molars are
implicated (Class I KMs), the patient is young (mixed
or early permanent dentition), normal third molar devel-
opment cannot be predicted or the third molar is
missing, risks of caries and periodontal damage are pre-
sent, and the patient or his or her parents do not agree to
have extractions performed.
CONCLUSIONS
Early treatment of Class I KMs can prevent progres-
sion of periodontal disease, bone loss, and carious le-
sions, allowing preservation of the mandibular first
and second molars. However, the severity and
complexity of the positions of the KMs require efficient
and proper molar uprighting mechanics for successful
nonextraction treatment. This can be achieved with
the aid of a skeletally anchored torqued cantilever, which
can perform an extensive root uprighting movement
with minimal side effects, allowing easier clinical
handling of extremely tipped and partially erupted KMs.
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