CLINICIAN'S CORNER

Uprighting mesially impacted mandibular molars

with 2 miniscrews
Su-Jung Mah,a Pil-Jun Won,b Jong-Hyun Nam,b Eun-Cheol Kim,c and Yoon-Goo Kangd
Seoul, Korea

Mesially tilted or impacted mandibular molars cause occlusal disharmony and periodontal problems. For proper
restoration of the occlusion and to prevent further periodontal damage, uprighting of tilted molars is the recom-
mended treatment option. Although several orthodontic methods including miniscrews have been proposed,
most of them have innate limitations and problems such as the possibility of unwanted tooth movement. In
this case series, we introduce a new system that uses 2 miniscrews with slots that can accommodate rectangular
orthodontic wires to 3 dimensionally control the tilted molar in 3 patients. We also discuss the advantages and
possible disadvantages of this new system. (Am J Orthod Dentofacial Orthop 2015;148:849-61)

M
andibular second molar impaction occurs in 3
of every 1000 people in the general population
and in 2 or 3 of every 100 orthodontic pa-
tients.1,2 It is more common in male patients and most
typically occurs unilaterally on the right side in the
mandible rather than in the maxilla.2 Mandibular
second molar impactions occur in several patterns: uni-
lateral or bilateral, with or without loss of the mandib-
ular first molar, and with or without mandibular third
molar impaction. Many causative factors contribute to
the abnormal eruption of the mandibular
second molar: lack of arch length, abnormal erupting
angulation, premature eruption of the mandibular third
molar, early loss of the mandibular first molar, alteration
of the dental follicle or the periodontal ligament, and
other iatrogenic factors.3-5
To obtain proper occlusion and prevent further peri-
odontal problems, uprighting of mesially tilted molars is
a
Clinical instructor, Department of Orthodontics, Dental Hospital, Kyung Hee
University Hospital at Gangdong, Seoul, Korea.
b
Private practice, Seoul, Korea.
c
Professor, Department of Oral and Maxillofacial Pathology, School of Dentistry
and Research Center for Tooth & Periodontal Regeneration, Kyung Hee Univer-
sity, Seoul, Korea.
d
Assistant professor, Department of Orthodontics, Dental College, Kyung Hee
University, Seoul, Korea.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Supported by the National Research Foundation of Korea grant funded by the
Korean government (number 2012R1A5A2051384).
Address correspondence to: Yoon-Goo Kang, Department of Orthodontics,
Kyung Hee University Dental College, Hoegi-dong 1, Dongdaemun-gu, Seoul,
Korea; e-mail, deodor94@khu.ac.kr.
Submitted, October 2014; revised and accepted, July 2015.
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.07.027
the recommended treatment and should be done as soon
as possible. If not properly corrected, mesially impacted
molars may lead to adverse events such as elongation of
opposing teeth, periodontal problems on the mesial side
of the affected teeth, caries in the unerupted molars, and
poor oral hygiene.6-8 Many clinical procedures have
been reported to upright mesially tilted mandibular
molars, but biomechanical shortcomings have been
observed. A disadvantage of uprighting mandibular
molars with conventional dental anchorage is the
unintended displacement of the anchorage tooth or
teeth.8,9 To minimize dental anchorage displacement,
it was necessary to include multiple teeth in the
anchorage unit, which resulted in the placement of
heavy orthodontic appliances.
During the last decade, the use of skeletal anchorage
has been widely accepted in clinical orthodontics. Skel-
etal anchorage reduces the side effects that occur with
dental anchorage and simplifies the orthodontic appli-
ances and the treatment biomechanics. In this article,
we introduce a biomechanical system for uprighting
mandibular molars with 2 miniscrews and a connecting
wire, and present 3 patients whose mesially tilted
mandibular second molars were corrected with the sys-
tem. This system was designed to provide a simple and
efficient molar uprighting technique that will minimize
the orthodontic appliances and be more comfortable
for patients.
The technique uses 2 miniscrews with a slot that can
accommodate an orthodontic wire (0.0215 3 0.0250 in)
(Fig 1). Machined-surface miniscrews (Dual Top Anchor
System, JD type; Jeil Medical, Seoul, Korea) were 6 mm
in length and 1.6 mm in diameter. The miniscrews were
implanted in the attached gingiva between the
849
850 Mah et al

Fig 1. Two miniscrews and a connecting wire system for uprighting molars.

Fig 2. Initial intraoral photographs of patient 1: 11-year-old girl with impacted mandibular right and left
second molars.

mandibular first and second premolars, and between the
second premolar and the first molar. A standard implan-
tation method was used. Briefly, the surgical site was
scrubbed with povidone-iodine, and local anesthesia
was induced by infiltration with 2% lidocaine plus
epinephrine (1:100,000). Then a miniscrew was im-
planted at 90 to the cortical surface using a manual
driver under saline solution irrigation. A rectangular
wire was used to connect the 2 miniscrews and move
the target tooth. Connecting the 2 miniscrews provides
effective resistance against orthodontic forces and mo-
ments that act to loosen the miniscrew (ie, loosening
the moment force of one miniscrew acts to tighten the
moment force of the other miniscrew, thereby neutral-
izing the forces). By placing a connecting wire in the 2
miniscrew slots, it is possible to create a 3-dimensional
vector control force on the target tooth. The slots as-
sume a role similar to that of orthodontic brackets that
use conventional orthodontic mechanics to upright
molars. The wire was placed immediately after miniscrew
implantation.
PATIENT 1
An 11-year-old girl presented with mesially tilted
mandibular second molars on both sides. The clinical ex-
amination showed a Class I molar and canine relation-
ship without notable arch length discrepancies (Fig 2).
Developing mandibular third molars were observed
bilaterally on the panoramic radiographic view.
A treatment plan was established to upright both
mesially tilted second molars using the 2-miniscrews
system and to extract the mandibular left and right
third molars to aid in uprighting the second molars.
The occlusion and the alignment of the patient's other
teeth were fairly acceptable, and we did not plan to
bond or band orthodontic appliances to keep their
positions.

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Mah et al 851

Fig 3. Intraoral photographs of patient 1 showing treatment progress: first row, treatment initiated with
0.016 3 0.022-in stainless wire and a nickel-titanium open-coil spring; second row, 0.017 3 0.025-in
beta-titanium alloy wire with loops engaged with miniscrews; third row, uprighting completed after
9 months; fourth row, cast photographs to show the relationships between the mandibular
second molars and their opposing teeth.

Two miniscrews on each side were implanted be-
tween the first molar, the second premolar, and the first
premolar. An orthodontic tube was bonded on the mesi-
ally tilted second molars at the proper position. Initially,
a passively bent 0.016 3 0.022-in stainless steel con-
necting wire was inserted into the 2 miniscrew slots
and the second molar tube. A nickel-titanium open-coil
spring was used for the distalization of the mandibular
second molars (Fig 3). After a month, both mandibular
second molars were unlocked from the first molars,
and a 0.017 3 0.025-in beta-titanium alloy wire with
a loop was placed to upright the molars (Fig 3). The
miniscrew implanted between the left second premolar
and the first molar fell out before application of the
initial force; therefore, we decided to use 1 miniscrew
on the left side instead of implanting another (Fig 3).
This 1 miniscrew withstood the orthodontic forces
throughout the treatment.
After 9 months of treatment, the mesially tilted
second molars were successfully uprighted, and the or-
thodontic tubes and miniscrews were removed (Fig 3).
The patient's occlusion and dental alignment were

American Journal of Orthodontics and Dentofacial Orthopedics November 2015  Vol 148  Issue 5
852
Fig 4. Panoramic radiographs of patient 1: top, before
treatment; middle, at 5 months; bottom, at 9 months,
with the appliances removed.
maintained. After a year, the retention records showed
that the alignment continued to be maintained (Figs 3
and 4).
PATIENT 2
This patient was a 13-year-old girl with a malpositioned
mandibular right second molar. The intraoral examination
showed a Class I molar and canine relationship with good
alignment of the maxillary and mandibular dentitions. Her
mandibular right second molar was horizontally impacted
with supragingival exposure of the distal part of the crown
(Fig 5). A panoramic radiograph showed horizontal impac-
tion of the mandibular right second molar and absence of
the third molars.
A treatment plan was established to upright the hor-
izontally impacted mandibular right second molar using
the 2-miniscrew system. One miniscrew was inserted be-
tween the first molar and the second premolar, and the
November 2015  Vol 148  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Mah et al
other between the first and second premolars. An ortho-
dontic half tube was bonded on the impacted
second molar. A 0.016 3 0.022-in beta-titanium alloy
looped spring was inserted to provide a distalization
force to the impacted tooth (Fig 6). An additional mini-
screw was implanted on the distal side of the impacted
tooth to aid the distalizing movement (Fig 6). Two mini-
screws and a connecting wire system were expected to be
sufficient to normalize the position of the impacted
tooth, but to enhance the efficiency of the applied force
vector and thereby shorten the treatment time, an addi-
tional miniscrew was used. The third miniscrew was
considered necessary to correct a severely horizontal
impacted second molar. The more horizontally impacted
the molar, the smaller the moment generated by the
appliance.10 To increase the moment, it was decided to
use both a pushing force from the buccal 2-miniscrew
system and a pulling force from the ramal miniscrew
(Fig 7). However, experience with a series of similar cases
had demonstrated that this additional miniscrew in the
ramus is not necessary. The buccal 2-miniscrew system
generates a couple moment in the molar tube, whereas
the crown distal force generates a moment that uprights
the second molar (Fig 8). These moments were enough
to upright a severely horizontal impacted second molar
without a third ramal miniscrew (see patient 3, below).
If the pulling force from a ramal miniscrew is desired,
a modified design of the wire can be used (Fig 9).
After 6 months, the half tube was replaced by a full-
sized tube, and a 0.017 3 0.025-in beta-titanium alloy
wire with loops was inserted to control the second molar
(Fig 6). After 8 months of treatment, a 0.016 3 0.022-in
stainless steel wire was used for fine alignment of the
second molar.
After treatment, the horizontally impacted
second molar was uprighted successfully without inter-
rupting the initial occlusion or the alignment of the
other teeth (Fig 6). The total duration of treatment
was 13 months.
The retention records after 1 year showed that the
treatment results were well maintained (Figs 6 and 10).
PATIENT 3
A 13-year-old boy came with a chief complaint of
malpositioned mandibular second molars. The intraoral
examination showed a Class II dental relationship with
mild crowding, horizontal impaction of the mandibular
right second molar, and a mesially tipped mandibular
left second molar (Fig 11). Examination of the facial pro-
file showed lip protrusion with a retrognathic mandible.
The patient and his parents were interested only in
normal eruption and positioning of the impacted
Mah et al
Fig 5. Initial intraoral photographs of patient 2: 13-year-old girl with impacted mandibular right
second molar.
mandibular second molar and did not want full ortho-
dontic treatment to resolve the Class II relationship or
the crowding and lip protrusion. A panoramic radio-
graph showed a horizontally impacted mandibular right
second molar and a mesially tipped left second molar.
A treatment plan was established to upright both
mandibular second molars using the 2-miniscrew sys-
tem. After extraction of the mandibular right third
molar, miniscrews were inserted between the mandib-
ular first and second premolars, and between the second
premolars and first molars. A half-size tube was bonded
on both sides of the second molars. A 0.0215 3 0.0250-
in cobalt-chromium alloy wire was formed to passively
fit the miniscrew slots, and vertical loops were added
to provide distal force to the right second molar, while
horizontal loops were formed to vertically control the
left second molar (Fig 12). After a year of treatment,
the left second molar was corrected, and the appliances
on the left side were removed. At that time, uprighting of
the right second molar was almost complete, and a hor-
izontal looped 0.0215 3 0.0250-in stainless steel wire
was inserted for final correction of the tooth position.
The appliances on the right side were removed 24 months
after the start of treatment. The treatment duration was
prolonged because the patient did not appear for
7 months before removal of the appliances on the left
side, and afterward did not appear for 9 months before
removal of right-side appliances. The total number of
visits was 8, including visits for placement and removal
of the appliances. Panoramic views of treatment prog-
ress are presented in Figure 13.
American Journal of Orthodontics and Dentofacial Orthopedics
853
DISCUSSION
The treatment of mandibular second molar impac-
tion has prompted many creative ideas by orthodontists
and maxillofacial surgeons. Treatment options can be
chosen based on the severity of the impaction, the acces-
sibility to the impacted molar, the simplicity of treat-
ment, or the possible side effects.11 Surgical and
orthodontic methods are the 2 major treatment options.
Surgical methods include repositioning, transplantation,
and extraction of the impacted second molar. These sur-
gical approaches are a rapid and relatively easy solution
when the mandibular second molar is impacted.12 How-
ever, they involve the risk of pulp necrosis, ankylosis, and
root resorption; therefore, the prognosis is rather poor,
and the predictability is low.13,14
The orthodontic method may have a better prognosis
because the risk level is lower than that of the surgical
method. Various conventional methods have been
used. Among them, the predominant method is the
tip-back cantilever spring or the uprighting spring. How-
ever, orthodontic methods that use conventional biome-
chanics have problems in acquiring anchorage.8,9
To overcome such problems, molar uprighting
methods using an orthodontic miniscrew have recently
been reported.15,16 In most reports, miniscrews were
used as anchorage, in addition to conventional
orthodontic appliances. Unlike in these previous
reports, the system described here uses miniscrews as
the main, and not a supportive, appliance.
There are 2 ways to use miniscrews to upright a
molar: indirect and direct anchorages. Using a miniscrew
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854 Mah et al

Fig 6. Intraoral photographs of patient 2 showing treatment progress: first row, 0.016 3 0.022-in beta-
titanium alloy looped spring engaged with 2 miniscrews; second row, 6 months later, 0.017 3 0.025-in
beta-titanium alloy wire with loops was inserted; third row, the appliance was removed after 13 months
of treatment; fourth row, 1 year retention after debonding; fifth row, cast photograph to show the rela-
tionship between the treated mandibular second molar and its opposing tooth.

as indirect anchorage is achieved by connecting the possible to adopt conventional orthodontic methods,
miniscrew to the anchor tooth (or teeth) using a resin- including tip-back springs. However, the appliance is
wire splinting method.16 This method permits absolute rather complex and makes oral hygiene difficult. In addi-
anchorage of the splinted tooth (or teeth) and makes it tion, clinicians might not notice miniscrew failure.

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Mah et al
Fig 7. Biomechanical illustration of pulling force from the
ramal miniscrew shown in patient 2. Rotation of the molar
around its center of rotation may cause eruption of the
tooth.
Loosening of the miniscrew, which could result in move-
ment of the anchor tooth (or teeth), might not be
apparent because of the connection to the tooth
(or teeth). There is also the possibility that indirect
miniscrew anchorage does not provide a totally rigid
anchorage system, thereby allowing the orthodontic
force to push the indirectly anchored tooth even when
miniscrew stability is good.17 The direct use of mini-
screws to upright the molars is accomplished by placing
the miniscrews distal to the molar and applying a distal
uprighting force to the molar.18 However, the miniscrew
can provide only a 1-way directed force and cannot pro-
vide 3-dimensional control of the tooth position. There-
fore, it is necessary to place orthodontic brackets and
tubes on the other teeth to fine-tune the positioning
of the impacted molar, which in turn causes unwanted
movement of the teeth. It is more problematic if the
impacted molar is 3-dimensionally malpositioned
(lingually tipped or rotated).10 In such cases, 1 miniscrew
for direct anchorage is not sufficient to fully control the
target molar without bonding or banding brackets on
the other teeth because it usually results in unwanted
tooth movement.10
The method described here uses 2 miniscrews as or-
thodontic brackets and can control the impacted molar
position 3-dimensionally by placing a rectangular con-
necting wire. This method combines the advantages of
direct and indirect anchorage with miniscrews. There is
no need for additional orthodontic brackets or tubes
on the other teeth; therefore, there are no side effects
from unwanted tooth movement. Without multiple
brackets on teeth, it is still possible to use various crea-
tive wire designs (loops or helices) to upright and control
American Journal of Orthodontics and Dentofacial Orthopedics
855
the molar position. The appliance system is simpler and
allows better oral hygiene with no risk of decalcification
or gingival problems. Unlike conventional orthodontic
treatment, which requires an orthodontic bracket or
tube bonded on the first molar to acquire proper
anchorage, the wire span between the anchor unit (the
miniscrew) and the target tooth is rather long. This en-
ables a longer range of action that results in effective
tooth movement.
Similar strategies of miniscrews as orthodontic
brackets to upright mesially tilted second molars have
been reported. Nienkemper et al19 and Melo et al20 im-
planted miniscrews in the alveolar crests of missing first
molars in the vertical direction. This direction is perpen-
dicular to the force vector generated from uprighting
the second molar. Therefore, it reduces the possibility
of miniscrew loosening, even when only 1 miniscrew
is used. However, vertical implantation is possible
only when the first molar is missing—a situation not
found in any of our patients. Nienkemper et al stated
that an uprighting spring exerts an axial moment on
a single buccal miniscrew, thus increasing the risk
of miniscrew failure. This is one reason that
Nienkemper et al used 2 miniscrews. We also showed
a 3-dimensional force being applied on the tooth
through the wire connected to an 0.018-in bracket
with a special orthodontic abutment attached to a
mini-implant with a special inner thread design on its
head. Our system uses the built-in rectangular slot
that connects the 2 miniscrews. Notwithstanding the
differences in implant position and design, the authors
of all studies used miniscrews as orthodontic brackets.
In patient 1, 1 of 2 miniscrews on the left side fell out
before the process of uprighting the molar was started,
so only 1 miniscrew was used. Fortunately, the left
miniscrew could withstand the uprighting force: the
moment produced from uprighting the molar was in
the clockwise direction, which contributed to tightening
the miniscrew into the bone. However, there were some
problems, including the minor distal rotation of the
mandibular left second molar (Fig 3), which could not
be controlled by only 1 miniscrew. One miniscrew slot
is too short to hold the wire firmly to give sufficient con-
trol to the molar. Two miniscrew slots with a proper in-
terval distance are needed to firmly hold the wire.
Nonetheless, the patient was satisfied with the outcome;
there were no functional or food impaction problems.
The important findings of this case were twofold: (1) if
the miniscrew's thread direction can resist the moment
generated from the uprighting force (ie, a right mini-
screw with a counterclockwise thread direction, or a
left miniscrew with a clockwise thread direction), the
miniscrew may survive; and (2) if the slot length of the
November 2015  Vol 148  Issue 5
856 Mah et al

Fig 8. Biomechanical illustration of the vertical looped wire for uprighting a mesially impacted
second molar. Vertical loops can be opened for distal activation of the second molar. Left, Before inser-
tion of the activated wire into the molar tube; right, insertion of the wire into the molar tube exerts an
uprighting moment by 2 mechanisms (couple moment generated in the tube and distalizing force).

are more effective than coil springs. This force uprights

Fig 9. Miniscrew connecting wire can be attached to the
button bonded on the occlusal table of the molar to give a
similar force system as the Halterman appliance or the
ramal miniscrew.
miniscrew head is long enough to hold the wire firmly,
the molar position may be controlled properly. As a sum-
mary, the manufacture of miniscrews with appropriate
directions of the threads and sufficiently long slot
head designs could contribute to successful uprighting
and precise control of the molar position using the
biomechanics presented here without having to place
additional multibrackets on other teeth.
Two types of wire loops were used in the 3 patients:
vertical and horizontal. Initially, a multiple vertical
looped wire was used to apply distalizing force to the
crown of the impacted or mesially tipped molar. Instead
of vertical loops, an open-coil spring can be used to pro-
vide the distalizing force, as shown in the photographs
of patient 1. Our experiences have shown that loops
the molar by a combination of crown distal tipping
and root mesial tipping. By opening up the loops of
the vertical looped wire, one can adjust (increase) the
distalizing force and the insertion angle of the wire
into the tube (Fig 8). After uprighting the molar, vertical
control is usually needed to fully contact the opposing
tooth and also to ensure that the marginal ridge level co-
incides with the first molar. A horizontal looped wire is
used to provide vertical and rotational control to the
molar. By opening the horizontal looped wire, one
can adjust the couple moment generated in the tube,
thereby controlling the angulation (second order) of
the tooth. If the mesial loop is opened, extrusion of
the tooth will occur; if both the mesial and distal
loops of the horizontal wire are opened, extrusion with
distal tipping will occur (Fig 14). If mesial angulation
of the second molar is not severe (as with the left
second molar of patient 3), a horizontal looped wire
with widened mesial and distal loops will solve the prob-
lem. From the occlusal view, when buccal or lingual
positioning of the second molar is needed, the wire
can be adjusted as shown in Figure 15. A passively fitting
wire can be buccally (or lingually) bent to move the tooth
buccally (or lingually) in a parallel or nonparallel direc-
tion, as described by Burstone.21 Parallel activation
may result in buccal (or lingual) movement of the tooth
with rotation, whereas nonparallel activation results in
buccal (or lingual) movement without rotation. Buccal
or lingual movement can alter the buccolingual inclina-
tion of the tooth.

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Mah et al 857

Fig 10. Panoramic radiographs of patient 2: top left, before treatment; top right, at 6 months; bottom
left, 13 months later, with uprighting complete; bottom right, 1 year retention after debonding.

Fig 11. Initial intraoral photographs of patient 3: 13-year-old boy with bilateral impacted mandibular
second molars.

In patient 1, a passively bent stainless steel wire with
a nickel-titanium open-coil spring was initially used to
apply the uprighting force. This rigid wire is good for
rotational control of the molar during application of
the uprighting force, but rigidity can limit the uprighting
movement: binding of the wire occurs, and further
uprighting is prohibited. To overcome this problem,
frequent fine wire adjustments are required; these can
become tiresome. Therefore, we turned to a multiple ver-
tical looped wire. This wire is flexible, and since tooth
movement is not halted, the uprighting process evolves
faster. This is why we considered the multiple looped

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858 Mah et al

Fig 12. Intraoral photographs of patient 3 showing treatment progress: first row, 0.0215 3 0.0250-in
cobalt-chromium alloy wire with loops engaged; second row, after 12 months of treatment, a
0.0215 3 0.025-in stainless steel wire with loops was inserted at the right second molar, and the left
second molar appliances were removed; third row, appliances were removed after 24 months of treat-
ment; fourth row, cast photographs to show the relationships between the treated mandibular
second molars and their opposing teeth.

wire to be more effective than the open-coil spring.
However, flexibility resulted in loss of control and distal
rotation of the molar. This distal rotation can be cor-
rected by inserting a straight rigid wire (a horizontally
looped wire or a no-looped wire) into the molar tube af-
ter uprighting the molar. These 2 types of uprighting
methods have advantages and disadvantages. In our
opinion, there is no one method that is superior to other
methods.
A buccal 2-miniscrew system is basically a 2-couple
moment system in which the center of rotation is
changed by altering the couple moment generated in
the molar tube. Lee et al10 showed the limitation of their
single-force system in patients with lingually tipped or
rotated molars and patients with molar extrusion. In
our patients 2 and 3, the second molar showed severe
mesial impaction with its center of rotation (bifurcation
area) located close to the occlusal plane. Distal rotation

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Mah et al
Fig 13. Panoramic radiographs of patient 3: top left, before treatment; top right, at 12 months, upright-
ing of the mandibular left second molar was complete; bottom left, at 15 months; bottom right, after
24 months of treatment, the mandibular right molar appliances were removed.
of the tooth around the center of rotation located near
the bifurcation area would cause extrusion of the tooth
(Fig 14). In such cases, more complex biomechanics
should be provided using our 2-miniscrew system, for
example.
In the 3 patients presented, various metal alloys and
wire sizes were used. When the moment exerted from the
wire during uprighting of the second molar is expected
to be high, the wire should be rigid enough to neutralize
the loosening moment between the miniscrews. On the
other hand, force to the tooth should be light enough
to provide biologically proper tooth movement: loops
between the miniscrew and the molar tube are needed
to lighten the force. This is particularly needed in the
initial phase of molar uprighting: a more angulated
tube on the molar exerts more moment on the miniscrew.
In the final stage of fine-tuning the molar position, the
moment generated from molar uprighting becomes
negligible, and the wire no longer needs to be rigid. How-
ever, and because the distance between the miniscrew
and the molar tube is long, a strong wire without loops
should be used for fine-tuning the molar position. There-
fore, nickel-titanium wires and round wires are not rec-
ommended in treatments with this system. The wire
between the miniscrews should be rigid enough to over-
come the loosening moment exerted by the molar tube.
American Journal of Orthodontics and Dentofacial Orthopedics
859
The disadvantage of this system is the use of 2
miniscrews. Most of the previous biomechanical options
for uprighting the molars used 1 miniscrew; the addition
of a second miniscrew might be a burden to both the pa-
tient and the orthodontist. However, based on our expe-
rience with this system, we have concluded that the
benefit from eliminating the need for multiple bracket-
ing is preferable to the risk or burden of using 1 more
miniscrew. Another disadvantage is the inconvenience
of the looped wire for both the patient and the operator.
The looped wire is custom-bent; this can become tire-
some to the operator. However, once the wire is formed,
only minor adjustments are required, and little technical
skill is needed. The patient may feel uncomfortable with
the bulky wire design, but it is tolerable.
It has been advocated that if the third molars inter-
fere with the distal uprighting of the second molars,
they may need to be extracted. However, according to
the spatial relationship between the second and third
molars, the third molar may help the second molar's up-
righting.22 The third molar may provide changes in the
position of the center of rotation for a mesially impacted
second molar, thereby preventing space opening ante-
rior to the second molar. In patient 3, third molar extrac-
tion was not helpful in uprighting the second molar
and therefore not needed; in patient 1, the value of
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860
Fig 14. Activation mode of the horizontally looped wire:
top, the wire is bent passively initially; middle, molar erup-
tion with distal rotation will occur after both mesial and
distal loops are opened; bottom: molar eruption without
axial rotation will occur when only the mesial loop is
opened.
extraction was doubtful: the panoramic view does not
give precise information and does not provide full
evidence for third molar extraction. To avoid uncer-
tainty, we routinely order third molar extractions when
second molar uprighting is needed.
CONCLUSIONS
Our system, using 2 miniscrews and a connecting
wire, offers a good biomechanical option for treating
impacted or mesially tilted mandibular molars. The sys-
tem is simple, uses few orthodontic appliances, provides
effective forces, has the advantage of nondental
anchorage, and prevents unwanted movement of the
teeth.
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Mah et al
Fig 15. Biomechanical illustration for molar expansion or
molar buccal tilting: left, nonparallel activation of the wire
causes molar expansion without rotation; right, parallel
activation of the wire causes molar expansion with distal
rotation.
REFERENCES
1. Grover PS, Lorton L. The incidence of unerupted permanent teeth
and related clinical cases. Oral Surg Oral Med Oral Pathol 1985;59:
420-5.
2. Wellfelt B, Varpio M. Disturbed eruption of the permanent lower
second molar: treatment and results. ASDC J Dent Child 1988;
55:183-9.
3. Eckhart JE. Orthodontic uprighting of horizontally
impacted mandibular second molars. J Clin Orthod 1998;
32:621-4.
4. Oliver RG, Richmond S, Hunter B. Submerged permanent molars:
four case reports. Br Dent J 1986;160:128-30.
5. Valmaseda-Castellon E, De-la-Rosa-Gay C, Gay-Escoda C. Erup-
tion disturbances of the first and second permanent molars: results
of treatment in 43 cases. Am J Orthod Dentofacial Orthop 1999;
116:651-8.
6. Stern N, Revah A, Becker A. The tilted posterior tooth. Part I:
etiology, syndrome, and prevention. J Prosthet Dent 1981;46:
404-7.
7. Norton LA. Periodontal considerations in orthodontic treatment.
Dent Clin North Am 1981;25:117-30.
8. Sawicka M, Racka-Pilszak B, Rosnowska-Mazurkiewicz A. Up-
righting partially impacted permanent second molars. Angle Or-
thod 2007;77:148-54.
9. Shellhart WC, Oesterle LJ. Uprighting molars without extrusion. J
Am Dent Assoc 1999;130:381-5.
10. Lee KJ, Park YC, Hwang WS, Seong EH. Uprighting mandibular
second molars with direct miniscrew anchorage. J Clin Orthod
2007;41:627-35.
11. Kogod M, Kogod HS. Molar uprighting with the piggyback buccal
sectional arch wire technique. Am J Orthod Dentofacial Orthop
1991;99:276-80.
12. Pogrel MA. The surgical uprighting of mandibular second molars.
Am J Orthod Dentofacial Orthop 1995;108:180-3.
Mah et al
13. Johnson JV, Quirk GP. Surgical repositioning of impacted mandib-
ular second molar teeth. Am J Orthod Dentofacial Orthop 1987;91:
242-51.
14. Shapira Y, Borell G, Nahlieli O, Kuftinec MM. Uprighting mesially
impacted mandibular permanent second molars. Angle Orthod
1998;68:173-8.
15. Giancotti A, Arcuri C, Barlattani A. Treatment of ectopic mandib-
ular second molar with titanium miniscrews. Am J Orthod Dento-
facial Orthop 2004;126:113-7.
16. Sohn BW, Choi JH, Jung SN, Lim KS. Uprighting mesially impacted
second molars with miniscrew anchorage. J Clin Orthod 2007;41:
94-7.
17. Holberg C, Winterhalder P, Holberg N, Wichelhaus A, Rudzki-
Janson I. Indirect miniscrew anchorage: biomechanical loading
American Journal of Orthodontics and Dentofacial Orthopedics
861
of the dental anchorage during mandibular molar protraction—
an FEM analysis. J Orofac Orthop 2014;75:16-24.
18. Park HS, Kyung HM, Sung JH. A simple method of molar upright-
ing with micro-implant anchorage. J Clin Orthod 2002;36:592-6.
19. Nienkemper M, Pauls A, Ludwig B, Wilmes B, Drescher D. Prepros-
thetic molar uprighting using skeletal anchorage. J Clin Orthod
2013;47:433-7.
20. Melo AC, Duarte da Silva R, Shimizu RH, Campos D, Andrighetto AR.
Lower molar uprighting with miniscrew anchorage: direct and indi-
rect anchorage. Int J Orthod Milwaukee 2013;24:9-14.
21. Burstone CJ. Precision lingual arches. Active applications. J Clin
Orthod 1989;23:101-9.
22. Melsen B, Fiorelli G, Bergamini A. Uprighting of lower molars. J
Clin Orthod 1996;30:640-5.
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