DENTAL TECHNIQUE

Uprighting a mesially tilted mandibular left second molar with

anchorage from a dental implant
Jie Zhou, MS,a Xueqi Gan, PhD,b Xianglong Han, PhD,c Michael E. Razzoog, DDS, MS, MPH,d and
Zhuoli Zhu, PhDe

Mesial tilting of adjacent teeth ABSTRACT

may appear after the removal
Mesial tilting of adjacent teeth may appear after the removal of a tooth, leading to a lack of
of a tooth, leading to a lack of restorative space. This dental technique presents a method of uprighting a mesially tilted adjacent
restorative space. Minor tooth tooth by using a dental implant as anchorage. (J Prosthet Dent 2019;-:---)
movement (MTM) will regain
the space needed for the restoration. Implant anchorage first molar (Fig. 1). The residual root of the mandibular
is a rapid, efficient, straightforward, and convenient tool left first molar had been extracted 1 year previously. A
for MTM. Since the 1980s, when Brånemark et al1 and cone beam computed tomography (CBCT) image showed
Roberts et al2 published articles on the use of titanium that the minimum mesiodistal dimension between the
implants for orthodontic anchorage, miniscrew implants mandibular left second premolar and the mandibular left
(MSIs) have been extensively used.3-6 Generally, the MSI second molar was 6.2 mm (Fig. 2). The 3-dimensional
has been used for enhancing vertical and sagittal space was deemed inadequate for a normal-sized
anchorage during orthodontic treatment. It is also a restoration.
useful tool for MTM such as uprighting or intruding a
molar tooth before restoration.
A conventional dental implant, which will be used for Timeline
the eventual restoration of the missing tooth, provides 1. Insertion 2. Extraction 3. Start of 4. Finish 5. Delivery
alternative anchorage for MTM after osseointegration, of implant of 28/38 MTM of MTM of crown
avoiding additional implant surgery. This dental tech-
nique presents a new method of uprighting a mesially
tilted adjacent tooth by using a dental implant for
anchorage. 6 months for 2 months of MTM
osseointegration

TECHNIQUE Figure 1. Timeline of treatment included 6 months for osseointegration

and 2 months of MTM. Time nodes included insertion of implant,
A 24-year-old woman presented to the Department of extraction of maxillary left third molar and mandibular left third molar,
Prosthodontics, West China Hospital of Stomatology, start of MTM, finish of MTM, and delivery of implant-supported crown.
Sichuan University, with the loss of her mandibular left Time for each segment, 1 month.

J.Z. and X.G. contributed equally to this article.

a
Postgraduate student, State Key Laboratory of Oral Disease, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University,
Chengdu, PR China.
b
Associate Professor, State Key Laboratory of Oral Disease, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University,
Chengdu, PR China.
c
Professor, Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, PR China.
d
Professor, Department of Biologic and Materials Sciences, Division of Prosthodontics, School of Dentistry, The University of Michigan, Ann Arbor, Mich.
e
Associate Professor, State Key Laboratory of Oral Disease, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University,
Chengdu, PR China.

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Figure 2. Cone beam computed tomography image of mandibular left
second premolar to mandibular left second molar before insertion of
implant. A, Sagittal view. B, Coronal view. C, Transverse view.
The procedure was as follows:
1. Place an implant (Nobel Active, diameter 4.3 mm,
length 10.0 mm; Noble Biocare) and assess stabil-
ity. In this patient, 6 months was allowed for
osseointegration. At that time, because of addi-
tional tilting, the minimum mesiodistal dimension
between the mandibular left second premolar and
the mandibular left second molar was 5.6 mm
(Fig. 3).
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Figure 3. Mesially moved and tipped mandibular left second molar. A,
Buccal image. B, Radiograph.
2. Connect an implant abutment (diameter 3.5 mm,
height 5.5 mm, 0 ; Noble Biocare) to the implant.
3. Bond a buccal tube (Shinyle) to the buccal surface of
the mandibular left second molar.
4. Insert the distal part of a stainless-steel wire (Ortho
Organizers Inc) segmental arch with an open ver-
tical helical loop and tip back bend (Fig. 4) into the
buccal tube. Clasp the mesial portion of the wire on
the distal portion of the implant abutment. Activate
the open vertical helical loop and increase the tilt
angle of tip back bend each month.
5. After 2 months, the mandibular left second molar had
been uprighted, allowing sufficient space for a resto-
ration of normal size (Figs. 5, 6). Complete an implant-
supporting prosthetic crown of the normal size.
6. After 6 months, assess the relationship of the
implant-supporting prosthetic crown with the
adjacent teeth and the gingival tissues. It was stable
in this study (Fig. 7).
DISCUSSION
After a tooth has been missing for a long time, the
adjacent tooth is likely to be mesially tilted, leading to a
Zhou et al
- 2019
Figure 4. Minor tooth movement included implant abutment connected
to implant, buccal tube bonded on buccal surface of mandibular left
second molar, stainless-steel wire segmental arch with open vertical
helical loop, and tip back bend. A, Buccal view. B, Occlusal view. C, Buccal
view of cast.
Figure 5. Images at different time nodes. A-C, Buccal views. D-F, Occlusal
views. Time points: before MTM, after MTM, after placement of implant-
supported crown. MTM, minor tooth movement.
lack of restorative space. If the mesially tilted tooth is
uprighted by MTM and the restoration space regained,
Zhou et al
3
Figure 6. Panoramic radiographs. A, Before MTM. B, After MTM. C, 6
months after placement of implant-supported crown. MTM, minor tooth
movement.
an implant-supported crown with an appropriate rela-
tionship with the adjacent tooth can be provided.
Furthermore, the occlusal forces are directed along the
long axis of the dental implant. A dental technique to
upright a mesially tilted adjacent tooth by using a dental
implant as anchorage is presented.
Implants can provide sufficient anchorage for MTM,
which is typically provided by MSIs. MSIs can support
light continuous force as they are based on relatively
low bone-to-implant contact (BIC).7,8 However, dental
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Figure 7. Six months after restoration. A, Occlusal view. B, Buccal view.
implants of greater diameter and length, as well as
those with modified surface characteristics, have greater
BIC supporting occlusal loads and therefore the much
lower orthodontic forces. MSIs have been used as
direct9,10 and indirect anchorage10 for uprighting
mesially tilted mandibular molars. In a direct anchorage
system, force is applied directly from the MSI to the
mesially tilted mandibular molar. However, the force is
only unidirectional, and it is hard for the system to
provide 3-dimensional control of the tooth position.
With indirect anchorage, the MSI is connected to an
anchor tooth or teeth, and force is applied to the
mesially tilted mandibular molar. However, these ap-
pliances are rather complex and make oral hygiene
difficult.
In the treatment described, the dental implant pro-
vided the force to the mesially tilted mandibular molar
via an orthodontic segmental arch, which included an
open vertical helical loop and a tip back bend. The open
vertical helical loop could provide the force to upright the
mesially tilted mandibular molar, and the tip back bend
could offer the force to intrude the molar. The appliance
is straightforward, and 3-dimensional control was ach-
ieved. After 2 months of MTM, the mandibular left
second molar was uprighted, and the space was suffi-
cient for an implant-supported restoration of the
mandibular left first molar. This technique achieved
sufficient restorative apace efficiently and rapidly and
avoided the additional insertion of an MSI for anchorage.
The relationship with adjacent teeth and gingival tissues
was also recovered accurately. In addition, the maxillary
left third molar and the mandibular left third molar had
both been extracted before the MTM, which can accel-
erate the bone remodeling for the MTM. That was why
the maxillary left third molar and the mandibular left
third molar were extracted at the end of the osseointe-
gration stage. Further design of the connecting device
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between the segmental arch and the implant should be
considered.
SUMMARY
Dental implants may be used as orthodontic anchorage
to upright mesially tilted adjacent teeth. This patient’s
treatment achieved sufficient space for a normally sized
implant-supported restoration.
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Corresponding author:
Dr Zhuoli Zhu
14 S Renmin Rd 3rd Sec.
Chengdu 610041
Sichuan
PR CHINA
Email: zzl7507@126.com
Copyright © 2019 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2019.03.015
Zhou et al