Spring 2000 New Member Forum

In this issue, Dr. Michael Sales asks, "What are your criteria for banding/bonding second molars?"

Dr. Gary Stafford

As a resident, I asked this very same question. One faculty member said he rarely, if ever, banded second molars. Another said he always, without exception, banded second molars. The rest had differing answers that fell between those two extremes. The range of responses surprised me at the time. I guess I expected a consensus, a "right" answer. But instead, this survey just added confusion to an already confused student. However, the experience made me determine for myself when and why I would band/bond second molars.

Mandibular second molars are routinely banded/bonded in my practice. In some cases, the second molars themselves need alignment, correction of a marginal ridge discrepancy, uprighting from a mesially or lingually inclined position or crossbite correction. In other cases, while their position may be good, banding/bonding mandibular second molars helps level the arch more efficiently and gives a more favorable force vector for Class II elastics. While I routinely "get on" mandibular second molars, if I cannot think of a reason to do so in a given case, then I do not. Also, in the large majority of cases, I bond a buccal tube, as opposed to placing a band.

I do not routinely band/bond maxillary second molars. In my limited experience, I have found that they erupt into a relatively good position if the other teeth, including the mandibular second molars, are in a good position. I do bond maxillary second molars to correct rotations, crossbites, marginal ridge discrepancies and to increase anchorage where needed. Also, I band upper second molars when needed to coordinate the arches. One of the few absolutes in my practice is that when I do "get on" maxillary second molars, I always bond them and never band them.

Dr. John Trotter

I base my decision to bond second molars on a number of factors including, but not limited to, vertical and horizontal skeletal relationships, dental alignment and the dental age of the patient. A patient presenting with an exceedingly high vertical/mandibular plane angle or open-bite tendency may necessitate not bonding the second molars for fear of opening the bite further (the "scissor effect"). If the alignment of the erupting second molars is exceptionally poor in a high-angle patient, then I’ll wait until the last possible moment to bond the second molars; or I may choose to attempt to correct the malalignment with an extension from a Hawley retainer after debanding. Given a low vertical/mandibular plane angle or deep-bite tendency, bonding the second molars as early as possible can often give a significant mechanical advantage in opening and maintaining the proper overbite and overjet. The earlier the better in a "low-angle" malocclusion.

I believe that placing bonds on the second molars can also aid in correcting the patient’s sagittal relationship. By extending Class II elastics an additional tooth distally, a stronger and more efficient force can be realized while using the same-sized elastic. When the erupted or erupting second molar is in poor alignment, my choice is to bond as early as is practical to effect the necessary movement. I believe that extreme care should be taken in gaining the proper buccal-lingual root-torque, mesial/distal tip and marginal ridge alignment so as to prevent any non-working interference from occurring during a patient’s excursive movements. An examination should also be made to determine if bonding the second molar will have a positive or negative effect on the position and alignment of the first molar.

Dr. Paul Kasrovi

Second molars, to band or not to band? Like many other questions and dilemmas in orthodontics, there is no one answer that fits all. In some cases the answer is a resounding yes and in some, one has to do a little bit of risk/benefit analysis prior to formulating an answer. The criteria that I consider in my decision making include, but are not limited to, the amount of overbite, occlusal plane and the curve of Spee, vertical jaw relationship, transverse discrepancies, marginal ridge discrepancies and the TMJ status. I strongly believe that the second molars like any other teeth in the mouth should be in their most optimal position at the end of comprehensive orthodontic treatment. I routinely band or bond second molars unless they are already in a favorable position in all three dimensions of space, or if I feel that the potential risks of engaging them would far outweigh the benefits.

Brachyfacial patients with excessive overbite benefit from early banding/bonding of second molars. This will help level the curve of Spee and open the bite. Patients with a normal mandibular plane angle and normal overbite can also benefit from banding second molars that may have mild transverse or marginal ridge discrepancies. Care must be taken, however, not to inadvertently extrude the second molars (in particular the palatal cusp of the upper second molars) by placing the slot too gingivally. Light anterior box elastics during the initial leveling of the second molars in these cases may be helpful in preventing the development of an anterior open bite. Transpalatal arches with adequate buccal root torque can also be used to provide proper vertical control. Dolichofacial patients, presenting with minimal overbite or an anterior open bite, are poor candidates for banding second molars. In some cases, only lower second molars may be banded and a slight curve of Spee may be maintained in the upper arch with the second molars kept elevated off the occlusal plane. Patients with minimal overbite who present with second molars in crossbite also require careful attention. In some cases, the crossbite may best be left uncorrected, or occlusal equilibration may be required as the crossbite is being corrected to prevent iatrogenic bite opening.

In extraction cases, in particular second premolar extraction cases, banding second molars will reinforce posterior anchorage and minimize unwanted tipping of the first molars into the extraction site. The second molars in orthognathic patients should be banded prior to surgery even if the archwire is not going to be engaged prior to surgery. Many surgical patients may have limited range of opening as well as reduced bite force for months after surgery, which will make it difficult to band second molars after surgery. If the second molars are being leveled prior to surgery, special attention must be paid to preventing any extrusion of these teeth. Premature contact of second molar cusps in pre-surgical set-ups is a frequent culprit for poor arch coordination and tooth interference prior to orthognathic surgery. Impacted second molars should be brought into the arch. Many times early extraction of third molars, followed by mechanics that promote distal eruption of second molars, may be required.

In summary, banding/bonding second molars must be evaluated on a case-by-case basis. I find myself banding second molars in an overwhelming majority of my cases, unless I feel that this would not be in the best interest of the patient.

Dr. Adrian Vogt

I generally band all 1st and 2nd molars with few exceptions. There are times, however, when I do bond brackets. It is not possible to slip a band past the mesial contact of an ectopic mandibular 2nd molar that is mesially impacted. When a partially erupted molar is erupting into lingual crossbite it is easier to correct the inclination prior to its maxillary counterpart erupting. Occasionally, I will completely bond all the teeth. In such cases, I would start by placing the 2nd molar brackets first. This improves access and makes placement easier. I do not band or bond 2nd molars at all during the treatment of cases in which the 2nd molars are already well aligned and inclined. Similarly, I do not band or bond maxillary 2nd molars in anterior open bite cases or in cases with an open bite tendency.

Editor's Comment - Michael A. Sales, DMD

Perfection is found in the details. While we don’t want to burden ourselves with the obsessive compulsions of a perfectionist, Orthodontics is a health care specialty that deals with functional and esthetic issues that are significant at measurements of 1mm or less. Interproximal food traps, improper contacts with their resultant manifestations and unhappy cosmetic situations commonly arise from a deviation of less than 1mm. How often are we critical of a result that is left in end on CL II relation? Long face, short face, gingival display, overbite, overjet, the list goes on. All aspects of orthodontic treatment are affected by relatively small dimensional changes. Ignoring the 2nd molars is a similar, albeit more subtle and hidden, abdication of our responsibility to provide the highest standard of orthodontic care.

When analyzing a finished case for the quality of result, we consider occlusion related matters such as overbite, overjet, marginal ridge relation, root alignment, intercuspation, rotation and contact points. These criteria apply to all teeth not just to the most visible or most convenient to treat. With this in mind, it seems reasonable to determine for each case a plan for assuring that the 2nd molars will be in their optimal positions upon completion of treatment. For some cases, this may require an alteration in treatment timing. In other cases, a variation in our usual mechanics will be required. The mechanics of treatment can be greatly enhanced for many cases by including the 2nd molars into the setup. This applies to both antero-posterior and vertical movements.

A choice not to routinely band/bond 2nd molars is either a statement that the occlusion and position of these teeth are exempt from the ramifications that affect other improperly positioned teeth or an expression of belief that the second molars have figured out how to find their way to ideal occlusion without any help. I would prefer it if the later were the case, but based upon my years of observation, I am forced to conclude that the 2nd molars are not blessed with any special powers. Further, such a choice ignores the bio-mechanical treatment differential that must result from ending the appliance at the first molars. This is not to say that we should ignore reason and common sense in handling the 2nd molars. Rather, I am suggesting that a plan be in place to deal with and utilize them to our best advantage. This will reduce the number of unanticipated and unwanted obstacles that can prevent the attainment of a truly well finished case. In the words of Benjamin Franklin, "By failing to prepare you are preparing to fail."

The American Board of Orthodontics points out the disproportionately large percentage of cases that are downgraded because of inattention to the positioning of 2nd molars. I refer the reader to the November 1998 issue of the AJO/DO for a discussion of the grading system currently in use by the Board.

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