progress in orthodontics 1 1 ( 2 0 1 0 ) 166–173

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Clinical contribution

Molar uprighting with mini screws: comparison among

different systems and relative biomechanical analysis

Marino Musilli a,c,∗ , Marco Marsico b,c , Annalisa Romanucci b,c , Francesco Grampone b,c
a DDS, Specialist in Orthodontics, Private practice in Naples/Salerno
b DDS, Private practice in Naples
c Private practitioners Biomech Study Group

a r t i c l e i n f o a b s t r a c t

Article history: Starting from a segmented approach, the Authors propose 3 different methods of using mini
Received 3 June 2009 screws during the process of molar uprighting. The first UPG is performed by placing a mini
Accepted 29 June 2010 screw in the retromolar area and by applying an elastic chain loaded between the screw and
the molar.The second UPG is made by placing a screw in the retro molar area and by using
Keywords: a small cantilever which is active during intrusion and uprighting.The third UPG is made
Biomechanics by using a miniscrew placed a few millimeters mesial to the molar to control the vertical
Cantilevers force produced by the uprighting with a long cantilever to the frontal teeth.To assist in the
Mini screws understanding of the different clinical indications, the biomechanical differences between
Molar uprighting these three systems are analyzed.
Segmented approach © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.

Dental implants have been used in extraction sites as

1. Introduction
Premature loss of the mandibular second premolars or first
molars, due to cavities or periodontal disease, can lead to
mesio-inclination of the second molars with reduction of the
mesial space, molar extrusion and a pseudo-pocket mesial to
the tooth.
Conventional prosthetic and implant rehabilitation are
both incapable of restoring correct function. Therefore, the
best solution is an interdisciplinary approach beginning with
orthodontic therapy.
To prepare and stabilize the dental anchorage, various
orthodontic treatments require a full arch bonding for sev-
eral months and adult patients are often not psychologically
prepared to undergo this therapy1,2 .
anchorage for molar uprighting, but now, with TADs (Tempo-
rary Anchorage Device), it’s possible to apply a different force
system and to immediately begin the therapy without waiting
on osseointegration time.
Miniscrews reduce the need for dental anchorage and make
it is possible to work exclusively on the molar, thus improving
the patients’ acceptability.
The Authors, starting from the segmented approach3,4,5 ,
describe how the mesially rotated molar can be eas-
ily forced upright without side effects through the use
of a miniscrew as direct or indirect anchorage 6,7,8 .Three
different molar uprighting systems are presented, and
for each one there are biomechanic and clinical evalua-
tions.

∗
Corresponding author: via Luigi Cacciatore 57 - 84124 Salerno, Italy.
E-mail address: marinomusilli@hotmail.com (M. Musilli).
1723-7785/$ – see front matter © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
doi:10.1016/j.pio.2010.08.002
 progress in orthodontics 1 1 ( 2 0 1 0 ) 166–173
Fig. 1 – Double cantilevers mechanic. The green cantilever,
from the molar to the anterior teeth, generates extrusion,
clockwise rotation on the molar and intrusion on the
anterior teeth, as indicated by the green arrows.
In order to control the vertical forces a second cantilever,
from a tube in the anterior, is required. This red cantilever
is placed distal to the molar and it produces molar intrusion
and a counter clockwise movement with extrusion on the
anterior teeth, as indicated by the red arrows.
If the vertical forces have the same magnitude, as resultant
we will only have two opposite moments, on the molar and
on the anterior teeth, because they delete themselves, see
the upper part of the picture. In case we need an intrusive
effect on the molar, red forces need to be a little bit higher
than the green ones. On the sagittal plane, we will have
a different force system with vertical forces, a small
clockwise moment, as indicated in pink, and different
magnitudes of red and green moments, see the lower part
of the picture. Of course, on the transversal plane, the
intrusive force on the molar will give labial proclination, if
the distal power arm (in dark green) is located at the same
level of the molar tube. Otherwise, the point of application
on the power arm needs to be more distal and closer (from
the occlusal point of view) to the Center of Resistance.
2. Materials and methods
When conventional orthodontic methods are employed to
the UPG mesio inclined molar, undesirable side effects occur,
including extrusion of the target molars and reciprocal forces
exerted on the anchorage unit. To avoid these side effects,
preparation and stabilization of the anchorage unit is required.
In a segmented approach, a typical example is the double
cantilevers mechanism (Fig. 1).
This method is chosen as a reference because the force
system on the sagittal plane is well described.
A first cantilever, placed from the molar to the anterior
teeth, generates a clockwise movement able to rotate the
molar. At the same time, this creates some unavoidable side
effects such as intrusion of the anterior teeth and molar
extrusion.
A second cantilever, from a tube in the anterior, is required
in order to control them. This cantilever, opposite to the first,
167
Fig. 2 – UPG is realized by using an elastomeric chain
loaded between the screw, distal to the tooth, and the
molar.
is distal to the molar and produces molar intrusion and extru-
sion with a counter clockwise movement on the anterior
teeth.
Two opposite moments, on the molar and on the anterior
teeth, occur and the vertical forces could be removed.
While the first moment is responsible to UPG the molar,
the second one is a side effect. To avoid this, it is possible to
extend the anchorage unit by adding more teeth.
Thanks to miniscrews and to the skeletal anchorage, it is
now possible to provide new therapy options with force sys-
tems that were previously inconceivable, while also reducing
side effects on the teeth. Beginning with these considerations
and according to biomechanic principles, introduced by C. J.
Burstone and B. Melsen4,5 , differences in molar uprighting are
evaluated by using the miniscrew as direct anchorage and also
as indirect anchorage.
The first system is executed by placing a mini screw in the
retro molar area and by using an elastomeric chain loaded
between the screw and the molar9,10,11 (Fig. 2). The elastic
chain works through a button or directly on the tooth, if
there aren’t occlusal interferences, with flowable light-cured
composite.
The second system is also executed by placing the minis-
crew in the retro molar area, but here a small cantilever
between the molar and the tooth provides the UPG (Fig. 3).
A small buccal tube, measuring .018 x .030 , is bonded to
the buccal surface of the molar.
The cantilever, a beta-titanium wire (.016 x .022 ), is placed
more occlusal than the screw when inserted in the tube. To
facilitate the insertion in the 0.75 mm holes on the head of
the screw, a 90◦ bend is placed.
The third system is closer to the double cantilevers mecha-
nism because it uses the same long cantilever, from the molar
to the anterior teeth, which generates extrusion, molar UPG
and intrusion of the anterior teeth. The intrusion, coherent
with the therapy, doesn’t allow the use of a second cantilever.
For this reason a miniscrew, used as indirect anchorage, con-
trols the vertical force on the molar.
Two strands of .010 legature wires are braided and tight-
ened between the screw, mesial to the tooth, and the molar
mesial crest (Fig. 4).
168 progress in orthodontics 1 1 ( 2 0 1 0 ) 166–173

Fig. 3 – UPG is realized by a miniscrew in the retro molar

area, and a small cantilever is inserted in a small buccal Fig. 5 – Initial Rx in the site of 37.
tube of .018 x .030 size, bonded to the labial surface of
the molar.
The cantilever is made of beta-titanium wire (.016 x .022 ),
inserted in the tube. It is placed more occlusal than the
screw and a 90◦ bend is made at the end to have an easier
insertion in the 0.75 mm holes in the head of the screw.
The yellow and green arrows show the system force
delivered on the tooth and TAD.

During the rotation, ligature controls the extrusive force

and the distal molar tipping in the same way that the UPG is
realized by mesial root tip instead of distal crown inclination.

3. Results
Fig. 6 – Final rx with 37 uprighted, distal miniscrew and an
In all three methods, the UPG was easily managed but there are implant in the site of 36.
significant biomechanical differences between them in terms
of effectiveness, type of movement and clinical indications.
The first movement (Figs. 5–7), an UPG of about 15◦ , is real-
ized in 5 weeks. The dental movement was made in a relatively
short time, because there was an uncontrolled tipping 12 real-
ized by using a single force on the crown.

Fig. 7 – Occluasal view of 37 uprighted by disto-inclination.

Because the line of force is distant from the center of

Fig. 4 – UPG is realized by a cantilever and a miniscrew
mesial to the molar.
Two strands of .010 legature wires are braided and
tightened between the screw, mesial to the tooth,
and the molar mesial crest.
resistence, the molar is loaded by a clockwise moment which
enables it to rotate with mesially open space.
In order to prevent lingual or labial proclination, it is impor-
tant to fix the elastic chain exactly on the distal crest, or, if
there are occlusal interferences, to divide the force system
with two chains, respectively on the disto-occlusal-vestibular
angle and on the disto-occlual-lingual angle.
 progress in orthodontics 1 1 ( 2 0 1 0 ) 166–173
Fig. 8 – Lateral view of 37 with a small cantilever from the
tooth to the screw, distal to the molar: at the beginning.
The second movement (Figs. 8–11), an UPG of 17◦ , is realized
in 7 weeks. This kind of dental movement was a combination
of a controlled crown tipping and a mesial root tip with light
intrusion.
It is very important to place the screw in the middle of the
labio-lingual width of the tooth in order to control the torque.
Fig. 9 – Occlusal view of 37 with a small cantilever from the
tooth to the screw, distal to the molar: at the beginning.
169
Fig. 10 – Lateral view of 37 with a small cantilever from the
tooth to the screw, distal to the molar: at the beginning.
Fig. 11 – Lateral view of 37 with a small cantilever from the
tooth to the screw, distal to the molar: at the end.
Fig. 12 – Frontal view of UPG of 37 and 46 with a long
cantilever, from the molar to the anterior teeth, and a screw
mesial to the molar: at the beginning.
In this way, even if the cantilever starts from the labial surface
of the molar, there are no vestibular or lingual proclinations.
The space opening is decreased in comparison to the previ-
ous mechanisms, but in both systems it is possible to perform
uprighting by using only one screw and a bracket on the molar,
without adding any other teeth.
The third movement (Figs. 12–21), an UPG of about 18◦ in
both molars, is realized in 9 weeks.
170 progress in orthodontics 1 1 ( 2 0 1 0 ) 166–173
Fig. 13 – Lateral view of UPG of 46 with a long cantilever,
from the molar to the anterior teeth, and a screw mesial
to the molar: at the beginning.
Fig. 14 – Lateral view of UPG of 37 with a long cantilever,
from the molar to the anterior teeth, and a screw mesial
to the molar: at the beginning.
It was a root tipping 12 with a light distal movement of the
crown and intrusion.
To control the torque it is sufficient that the cantilever is
attached to the anterior area in a point that coincides with
the middle of the labio-lingual molar width.
Fig. 16 – Lateral view from the Panoramic Radiograph of 36 and 47 at the beginning.
Fig. 15 – Occlusal view of UPG of 37 and 46 with a long
cantilever, from the molars to the anterior teeth, and a
screw mesial to the molar: at the beginning.
4. Discussion
The appliance and the relative force system described in the
first example (Figs. 2,7) is easier to understand. This is the
reason why it is used more often. The mini screw is placed
distal to the molar on the alveolar crest 6 and it works as a
direct anchorage.
The distalizing force produces a rototranslation which then
uprights the molar because the point of application and the
line of action of the force are far away from the Center of
Resistance.
The UPG movement is mostly due to the disto-inclination
of the crown and, in a small part, to mesial root tip. In con-
sequence, the system produces a space opening mesial to the
molar.
A correct screw positioning is required to control the ver-
tical position of the molar because if the screw is more apical
than the molar, we may also provide to add intrusion to the
UPG.
Clinical and radiographic examinations have revealed a
moderate mesial angulation of the second molar (Fig. 5). In
case of mild mesial angulation, the perpendicular distance
to the line of action at the crest level is great enough to
produce a moment which is capable of rotating the molar
but, in contrast, in cases of severe tipping, the moment, gen-
erated by a single force, is limited because of the reduced
 progress in orthodontics 1 1 ( 2 0 1 0 ) 166–173 171

Fig. 17 – Lateral view of UPG of 37 with a long cantilever,

Fig. 19 – Occlusal view of UPG of 37 and 46 with a long
from the molar to the anterior teeth, and a screw mesial
cantilever, from the molar to the anterior teeth, and a screw
to the molar: at the end.
mesial to the molar: at the end.

There should also be enough space for the disto-inclination

Fig. 18 – Lateral view of UPG of 46 with a long cantilever,
from the molar to the anterior teeth, and a screw mesial
to the molar: at the end.
distance from the line of force to the center of resistence4 .
The best indications for the use of this system are a disto-
inclination movement with good vertical control and a space
opening mesial to the molar. The screw insertion length is
limited because it is necessary that there not be any teeth
causing interference with the insertion distal to the molar.
movement of the crown. It is important, during the UPG with
intrusion, to insert the screw sufficiently apical with respect
to the molar.
The entire appliance consists of a screw and an elastic
chain. No more brackets on other teeth are required and no
dental anchorage is requested.
The second system is executed by placing a single minis-
crew in the retro molar area but a small cantilever, between
the molar and the screw, realizes the UPG (Figs. 3,9,10). From
a labial tube .018 x .030 begins a beta-titanium wire .016
x .022 .The cantilever, inserted in the tube, appears occlusal
in regard to the screw and a 90◦ bend is made at the end of
it to make its insertion in the 0.75 mm holes on the head of
the screw easier. The line of action of the cantilever produces
a moment and an intrusive force on the molar. The screw is
loaded by an extrusive force, a side effect easily supported by
the screw. The force system clinically produces a UPG by roto-
translation with light intrusion, different from single force or
from a couple of forces because in the first case, there will
be disto-inclination, like before, and in the second case, there
will be rotation around the center of resistance with consid-
erable space opening. Even here we generate space mesially,

Fig. 20 – Lateral view from the Panoramic Radiograph of 37 and 46, three months later the end. The movement on 37 and 46
is generated by the cantilever that from the auxiliary tube goes to the anterior teeth. From the basic tube of 46 starts a
connection wire for 47.
On both sides the screws are mesial and a legature wire is braided and tightened between the screws and the molar mesial
crest. At the end of the uprighting the 37 is stopped with a stainless steel sectional between 37, the screw and the 35.
172 progress in orthodontics 1 1 ( 2 0 1 0 ) 166–173

Fig. 21 – Lateral view tracing of UPG of 37 and 46 with superimposition. On both sides, the black line is the initial position
and the red line is the final position. The superimposition is applied on the Panoramic Radiograph and the mandibular
canal, the external oblique ridge and the lower border of the mandible are chosen as reference points.

but it is less when compared to both options. During rota- - clinical, surgical and anatomical consideration on the screw
tion, the friction between the wire and the molar tube brakes insertion;
the crown movement, reducing distal tipping. The indications - radicular molar resorption connected with individual fac-
for this system are molar UPG with less space opening and tors or forces applied.
considerable vertical control. As before, the entire appliance
consists of the screw and molar tube, and no other addi- Riassunto
tional appliances are required. Here the space necessary to
Gli autori propongono 3 differenti metodi per realizzare un movi-
the screw position is less because the distal molar rotation is
mento di uprighting (UPG) con miniscrew, usando come meccanica
less.
di riferimento quella a doppia leva, tipica della tecnica dell’arco seg-
The third system uses the same long cantilever, from
mentato. Nel primo UPG la minivite è posizionata in zona retromolare
the molar to the anterior teeth, as the double cantilevers
ed il movimento è generato da una catenella elastica posizionata tra
mechanisms that generate extrusion and molar rotation and
la vite stessa ed il molare.
intrusion of anterior teeth. Intrusion, coherent with the ther-
Nel secondo caso la minivite è sempre localizzata in zona retromolare,
apy, doesn’t permit use of a second cantilever. Therefore, a
ma lo spostamento è prodotto da una leva attiva in intrusione ed UPG
miniscrew, used by indirect anchorage, is required to control
molare.
the vertical force on the molar (Figs. 4,12,13,14).
Nel terzo caso l’UPG è realizzato grazie ad una lunga leva che dal
To prevent extrusion, we lock the molar with a double
molare si dirige ai denti anteriori, mentre la minivite, posizionata
metallic ligature wire .010 braided and tightened between the
pochi mm mesialmente al molare, viene utilizzata per il controllo
screw and the molar crest, with a vertical trajectory, but with-
della componente estrusiva.
out limiting the molar rotation. In this way the molars can
I tre sistemi di UPG sono state analizzati in dettaglio dal punto di
have a root movement. Sometime we can observe a crown
vista biomeccanico, al fine di evidenziare le differenze e le relative
movement around a chord of a circle, where the legature is the
indicazioni.
radius and the hole on top of the screw is the center of rotation.
Within these restraints, most of times the molar starts to
Résumé
distoinclinate with a light intrusion and then reaches the UPG
with radicular movement (Fig. 21). The third system is indi- Sur la base d’une approche segmentée les auteurs proposent 3 méth-
cated when there is no space distal to the molar for screw odes différentes d’utilisation de mini-vis pendant le processus de
insertion, a UPG without mesial space opening, when it is redressement de dents molaires. La première méthode se réalise à
necessary, and good vertical control. l’aide d’une mini-vis dans la région rétromolaire en appliquant une
chaînette élastique mise en charge entre la vis et la molaire.
La deuxième méthode porte sur la mise en place d’une vis dans la
5. Conclusions région rétromolaire et sur l’utilisation d’un petit cantilever activé
pendant l’intrusion et le redressement.
The appropriate method for molar UPG must be determined
La troisième méthode prévoit l’utilisation d’une mini-vis placée à
in each particular case but an appropriate force system using
quelques millimètres, côté mésial, par rapport à la dent molaire dans
miniscrews, as direct or as indirect anchorage, is a simple and
le but de contrôler la force verticale venant du redressement avec un
an effective method of UPG. All the systems are easy to apply
long cantilever jusqu’à la dent frontale.
and it is possible to significantly reduce treatment time and to
Les différences biomécaniques se dégageant des trois méthodes sont
minimize patient discomfort.
analysées pour mieux maîtriser les indications cliniques.
The possibility to unload the side effect on the screw per-
mit the elimination of dental anchorage and the possibility of
Resumen
unwanted movement of the anchorage unit.
As in any technique, even here there are some general lim- Fundamentándose en un enfoque segmentado los autores presentan
itations: 3 métodos diferentes de utilización de minitornillos en el proceso de
 progress in orthodontics 1 1 ( 2 0 1 0 ) 166–173
enderezamiento de dientes molares. El primer método consiste en
colocar un minitornillo en la región retromolar y aplicar una cadena
elástica cargada entre el tornillo y el molar.
El segundo método contempla la colocación de un tornillo en el área
retromolar, utilizando un pequeño cantilever que resulta activado
durante la intrusión y el enderezamiento.
El tercer método prevé la utilización de un minitornillo colocado a
unos milímetros, mesialmente, del molar para controlar la fuerza
vertical que se desprende del enderezamiento, con un largo cantilever
hasta el diente frontal.
Se analizan las diferencias biomecánicas de los tres sistemas para
un mejor manejo de las pautas clínicas.
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