Tip-back mechanics

David A. Romeo, D&D.,* and Charles J. Burrtone, D.D.S., MS.**

Westport and I/7arsningto?a, Conn.

0 rthodontists, during the course of treatment, are often faced with

the problem of moving posterior teeth further posteriorly. This is usually associ-
ated with a nonextraction approach to treatment in an effort to gain additional arch
length. However, skeletal asymmetries, perverted axial inclinations, or mesial
migration of posterior teeth may also be the rationale for such movement. In
some instances, this tooth movement is a bodily or translatory movement, which
is difficult to obtain if a large discrepancy exists. Fortunately, this movement
often is of a tipping nature which is more readily obtainable. A careful diagnosis
is required to determine whether tipping is indicated and, if so, the type of
tooth movement required.
Traditionally, tipping of teeth has been accomplished by a number of means,
including headgear, sliding yokes, and coil springs.l, e However, it is possible to
tip teeth posteriorly, both as a unit or individually, by means of a lever arm at-
tached to an anchor unit.3s 4 This type of mechanism has the advantage of not
requiring the active headgear cooperation from the patient. It also avoids flaring
of the anterior teeth, which may be an undesirable side effect with the use of
coil springs and sliding yokes with intermaxillary elastics.
When one is dealing with mechanics designed to tip teeth posteriorly, it is im-
portant to decide whether individual teeth need to be tipped or whether a unit of
teeth needs tipping. In this connection 45 degree head films are advantageous for
viewing the root dispersion of the teeth. A careful clinical examination, with
consideration of the depth of the curve of Spee, occlusal contacts in the pre-
molar area, and marginal ridge relationships, is also required. Fig. 1, A is repre-
sentative of what may exist in a patient who has a deep curve of Spee with no
occlusal contacts in the premolar area and good root dispersion. It is possible to

*Assistant Professor in Orthodontics, University of Connecticut School of Dental

Medicine.
“*Professor and Head, Department of Orthodontics, University of Connecticut School
of Dental Medicine.

414
 Tip-back mechanics 415

Treatment Occlusal Plane

Plane of Posterior Segment

Treatment Occlusal Plane

Plane of Posterior Segment

Fig. 1. A, Representation of a unit of teeth (posterior segment) which are mesially inclined
but with good root dispersion. B, Posterior segment of teeth after tip-back mechanics.

Treatment Occlusal Plane

Plane of Posterior Segment

Treatmsnt Occlusal Plane

Plane of Posterior Segment

Fig. 2. A, Representation of individually tipped teeth. B, Position of teeth after individual

tipping.

handle these teeth as a unit, rotating them about a point representing the centroid
(an estimate of the center of resistance) of the root mass.
The result is shown in Fig. 1, B, where the plane of the posterior segment
which was originally steeper than the treatment occlusal plane becomes parallel
to it. Fig. 2, A represents a patient in whom individual teeth are tipped in rela-
tion to one another. This requires separate movement of each tooth. Clinically,
marginal ridge discrepancies between the mesial and distal aspects of each tooth
416 Ko?)leo and Bursto?le Am. J. Orthod.
0ctdJw 1977

Fig. 3. Tip-back appliance; 0.018 by 0.025 (0.457 by 0.635 mm.) arch wire is placed into
the molar auxiliary and is hooked to an anterior anchor unit.
Fig. 4. Measurement, in grams, of vertical force with simple force gauge.

are found in these situations. In addition, the treatment plane of occlusion and
the plane of the posterior segment are parallel as compared to the case repre-
sented in Fig. 1. By individual tipping of each tooth, we obtain good root dis-
persion between all teeth, as shown in Fig. 2, B.
The tip-back mechanism is made of an 0.018 by 0.025 inch (0.457 by 0.635
mm.) arch wire with a helix to lower the load deflection rate and is hooked into
an anterior segment which acts as an anchor unit (Fig. 3). Activation is placed
in the helix so that the anterior part of the lever lies gingivally. The force applied
is measured in grams (Fig. 4). The anterior hook is placed at a point which
approximates the center of resistance of the anterior segment (Fig. 5). In a
patient in whom teeth must be tipped back as a unit, the posterior teeth are held
together by a rigid wire segment with the tip-back spring acting on the entire
posterior segment (Fig. 6). When all teeth of a segment need to be individually
tipped, the spring acts against the last molar only. No rigid wire segment is
used; however, a rope tie is placed between the last molar and the other teeth of
the posterior segment (Fig. 7). As the molar tips back, it produces a force through
the rope tie, tipping the more anterior teeth posteriorly.
The force system from this mechanism produces a rotational tendency or
Volume 72 Tip-back mschanics 417
Number 4

CR - CENTER OF RESISTANCE

Fig. 5. Force system resulting from application of tip-back mechanics with approximate
centers of resistance.

fig. 6. A rigid wire segment holding the posterior teeth together as a unit and a tip-back
appliance acting on the entire segment.
Fig. 7. Individual tipping of teeth utilizing a rope tie with tip-back appliance to the molar
only.
418 Romeo and Burstone Am. J. Ortfwxl.
October 1977

Table I

Moment required Vertical force

Teeth (Gm./mm.) L (Gm.1
1 molar 800-1,200 30 2-l-40
2 molars 1,600-2,400 30 53-80
I molar and 1 premolar 1,200- 1,800 30 40-60
2 molars and I premolar 2,400-3,600 30 80-120

moment on the posterior tooth or segment, tending to tip crowns posteriorly. In

addition, there is an extrusive component of force on the posterior teeth and an
intrusive component on the anterior anchor unit (Fig. 5).
In order to tip two molars and a premolar efficiently, it is necessary to produce
a moment in the magnitude of 2500 Gm./mm. (Table I). Considering an average
lever-arm length of 15 mm., a force of approximately 165 Gm. is required at the
hook. This intrusive force to the anterior anchor unit of at least six teeth will
usually produce the tip-back of the posterior teeth before anterior intrusion is
obtained. Although 165 Gm. of extrusive force posteriorly is sufficient to cause
eruption, occlusal forces tend to help minimize this effect. However, this should
be carefully considered in any patient in whom an increase in vertical dimension
is not desirable. With this size of spring, we find that for every degree of tip-back,
the moment decreases approximately 100 Gm./mm. This means that the spring
acts over a fairly long range of activation and usually allows the tip-back to be
completed with one activation. Only in patients with severe mesial inclinations
is it necessary to reactivate the spring.
Patient P. N. had a Class II, Division 1 malocclusion with a 2 mm. overjet
and minimal overbite. The mandibular second and third molars were congenitally
missing bilaterally. The facial profile was excellent, and no retraction of the lower
incisors was indicated. There was, however, 4 mm. of lower anterior crowding.
Both lower buccal segments appeared mesially inclined with good root dispersion.
It was decided that, by tipping back the mandibular posterior segments, enough
space could be gained to align the anterior teeth without flaring. This, in con-
junction with the extraction of two maxillary first premolars, would create a full
Class II occlusion with normal overjet and overbite, providing occlusion for the
upper maxillary second molars and preventing their overeruption. Fig. 8 shows
the posterior segments prior to treatment, with occlusal contacts present in the
premolar area. However, it was thought that, with the large intermaxillary
growth space, hinging would be minimal. After completion of tip-back mechanics
(Fig. 9)) a space of 2 mm. is seen distal to the canines on both right and left sides.
This space can be used to align the lower anterior teeth without the need to
Aare, which was contraindicated in this patient.
In some orthodontic eats there are skeletal asymmetries which are not severe
enough to require surgical intervention. In these cases it is necessary to compro-
mise the axial inclinations of individual teeth. One should make a careful diag-
nosis to be certain that surgical correction is not indicated. A side effect associ-
 Tip-back mechanics 419

Fig. 8. Left and right buccal segments tipped mesially prior to therapy.

ated with compromising the axial inclination is marginal ridge discrepancy (Fig.
10).
In Patient J. W. a combined surgical-orthodontic approach was required. Be-
cause of the premature loss of a maxillary right premolar, the right maxillary
posterior segment had tipped mesially. Individual tipping of the teeth was in-
dicated to correct the asymmetry prior to surgical intervention. Fig. 11, A shows
this segment at the initiation of tip-back mechanics. Three weeks later (Fig. 11,
8) a space is evident mesial to the first molar.
Use of this type of tip-back mechanism is an efficient way to move teeth pos-
teriorly. It has the advantage over headgear of not requiring active cooperation
of the patient anci produces more rapid movement since the moment is greater
in magnitude than that of a typical headgear because the applied force is farther
from the center of resistance. The side effect associated with this type of mecha-
nism is intrusion. Flaring of the anterior teeth can bc avoided if the center of re-
sistance of the anterior teeth is closely approximated. Normally, the teeth will
tip back before any intrusion is observed.
 Am. J. Orthod.
420 Komeo wad Bwstone October 1977

Fig. 9. Lei ‘t and right segments after tip-back with 2 mm. of space mesial to the lo wer
sect lnd ve !molar to allow alignment of anterior teeth without flaring.

Fig. 10. , A! symmetric axial inclinations resulting from tipping of individual teeth il n a par Cent
witt 1 a sk :eletal asymmetry not requiring surgical correction. Note marginal ridge dis-
crer )anc :ies
Fig. 11. A, Posterior segment prior to tip-back in a patient with early loss of a premolar
and tipping of posterior teeth. 8, Posterior segment 3 weeks later with a space of ap-
proximately 1.5 mm. mesial to the molar.

It is possible, with a simple mechanism, to tip back teeth, both individually

and as a group, without the disadvantages associated with other more commonly
used methods. In addition, this mechanism offers the advantage of a long range
of activation and constancy of moment application. However, as in all orthodontic
movements, it is essential that a careful diagnosis he made prior to initiat,ion of
any appliance therapy.
REFERENCES
1. Tweed, Charles : Clinical orthodontics, St. Louis, 1966, The C. V. Moshy Company.
2. Thurow, Raymond: Edgewise orthodontics, St. Louis, 1966, The C. V. Mosby Company.
3. Burstone, Charles J. : Segmented arch syllabus, Indianapolis, 7 959, Indiana University,
4. Burstone, Charles J.: The mechanics of the segmented arch techniques, Angle Orthod. 36:
99-120, 1966.

Health Center (0603’9)