CLINICIANS CORNER

Scissors-bite correction on second molar

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,
yschun@mm.ewha.ac.kr.
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.
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Yun et al 847