Biomechanical considerations for uprighting impacted mandibular molars 16/05/2023 21:59

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Case Report

Korean J Orthod 2020; 50(4): 268-277 https://doi.org/10.4041/kjod.2020.50.4.268

First Published Date July 25, 2020, Publication Date July 25, 2020
Copyright © The Korean Association of Orthodontists.

Biomechanical considerations for uprighting impacted

mandibular molars
Yukiko Morita , Yoshiyuki Koga , Tuan Anh Nguyen, Noriaki Yoshida

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Department of Orthodontics and Dentofacial Orthopedics, Nagasaki University

Graduate School of Biomedical Sciences, Nagasaki, Japan
Correspondence to:Yoshiyuki Koga.
Senior Lecturer, Department of Orthodontics and Dentofacial Orthopedics,
Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto,
Nagasaki 852-8588, Japan.
Tel +81-95-819-7669 e-mail koga@nagasaki-u.ac.jp

Received: January 16, 2019; Revised: March 3, 2019; Accepted: March 8, 2019

Abstract

This case report demonstrates two different uprighting mechanics separately

applied to mesially tipped mandibular first and second molars. The biomechanical
considerations for application of these mechanisms are also discussed. For
repositioning of the first molar, which was severely tipped and deeply impacted, a
novel cantilever mechanics was used. The molar tube was bonded in the
buccolingual direction to facilitate insertion of a cantilever from the buccal side. By
twisting the distal end of the cantilever, sufficient uprighting moment was
generated. The mesial end of the cantilever was hooked over the miniscrew placed
between the canine and first premolar, which could prevent exertion of an intrusive
force to the anterior portion of the dentition as a side effect. For repositioning of the
second molar, an uprighting mechanics using a compression force with two step
bends incorporated into a nickel-titanium archwire was employed. This generated
an uprighting moment as well as a distal force acting on the tipped second molar
to regain the lost space for the first molar and bring it into its normal position. This
epoch-making uprighting mechanics could also minimize the extrusion of the
molar, thereby preventing occlusal interference by increasing interocclusal
clearance between the inferiorly placed two step bends and the antagonist tooth.
Consequently, the two step bends could help prevent occlusal interference. After 2
years and 11 months of active treatment, a desirable Class I occlusion was
successfully achieved without permanent tooth extraction.
About the KJO
Article All Article For Authors Article in press
Keywords: Orthodontic treatment,
Category Orthodontic implant, Impacted molars, Mechanics

INTRODUCTION
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INTRODUCTION

Although the prevalence of third molar impaction is relatively high, first molar
1-3
impaction is extremely rare and has extremely complex treatment mechanisms.
Permanent tooth impaction frequently causes occlusal problems in which the
adjacent tooth tends to be inclined into the impacted tooth site, and the opposing
tooth tends to be over-erupted. In order to correct such a posterior bite collapse
orthodontically, an appropriate force system should be delivered to each tooth.
There are two general methods for uprighting molars. One involves a cantilever
mechanics, which is often used to effectively upright the molars, and it
4,5
simultaneously generates an extrusive force as well as a distal tipping moment.
Therefore, this mechanics is indicated for the correction of severely tipped and
deeply impacted molars. The other is a mechanics that uses a compression force
6
generated with an open-coil spring. This generates a distal force to the tipped
molar, which could regain the lost space, and a distal tipping moment due to a
distal force passing above the center of resistance (CR) of the molar.
Although many case reports have described the conventional orthodontic
7-15
treatment of mesially inclined impacted molars, there are few reports describing
the biomechanical considerations for delivering an optimal force system. When the
cantilever mechanics is used, the tipped molar is subjected to not only an
uprighting moment, but also an extrusive force, which could cause occlusal
interference with the opposing tooth. Additionally, an intrusive force is applied to
the teeth on which the mesial end of the cantilever is hooked as a side effect.
In order to minimize these adverse effects during molar uprighting, the use of
several types of orthodontic mechanics with temporary anchorage devices (TADs)
16-23
has been advocated. However, even with TADs, unwanted side effects cannot be
completely avoided, and the treatment mechanics required to produce an optimal
23
force system tend to be complicated.
This case report describes an effective treatment option with well-designed simple
mechanics including a novel cantilever system using TADs and uprighting
mechanics using a compression force with two step bends incorporated into a
nickel-titanium (NiTi) archwire.

DIAGNOSIS AND ETIOLOGY

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A 13-year-old Japanese girl with a slight Class II molar relationship visited the
Department of Orthodontics, Nagasaki University Hospital. Her chief complaints
were delayed eruption of the left mandibular first molar and occlusal pain in the
same region. Intraorally, all of the permanent teeth from the right first molar to the
left first molar were fully erupted, except the left mandibular first molar, and the
mandibular left second molar was partially erupted. A slight mid-line diasthema
was observed. The over-erupted maxillary left first molar was occluded with the
mandibular gingiva (Figures 1 and 2).

Figure 1. Pretreatment facial and intraoral photographs.

Figure 2. Pretreatment study model: over-erupted

maxillary left first molar occluding onto the mandibular
gingiva.

A panoramic radiograph obtained before treatment showed the presence of the

left mandibular first and second molars with severe mesial inclination and the four
developing third molar buds (Figure 3).

Figure 3. Pretreatment. A, Panoramic radiograph; B,

lateral cephalometric radiographs; C, cephalometric
superimposition.

TREATMENT OBJECTIVES

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The treatment objectives were to establish the left posterior occlusion, which
included the over-erupted maxillary first molar and the impacted mandibular
molars, and to also establish interdigitation of the maxillary and mandibular
dentition and a Class I molar relationship.
The treatment plan consisted of four stages. The first stage was intrusion of the left
maxillary first molar to acquire the lost interocclusal clearance for uprighting and
bringing the left mandibular first molar into occlusion. The second stage was
uprighting and distalization of the left mandibular second molar to gain the space
for the first molar. The third stage was uprighting of the left mandibular first molar
following surgical exposure. The last stage was alignment of the maxillary arch and
establishment of proper molar interdigitation and a Class I molar relationship.
The pretreatment panoramic radiograph and a schematic diagram indicating
treatment objectives and force systems acting on the molars are shown in Figure 4
A and 4B. Before uprighting of the impacted molars, the over-erupted maxillary first
molar, which was the opposed tooth on the opposite side, was to be intruded by 3
mm to the level of the maxillary occlusal plane (Figure 4B). The mandibular first
molar was to be uprighted by 60° and extruded by 6 mm at the location of its CR,
and the second molar was to be uprighted by 30° and extruded by 1 mm.

Figure 4. Treatment objectives. A, Treatment plan for

repositioning of the molars. B, Schematic diagram of
treatment objectives. The maxillary first molar is intruded
by 3 mm. The mandibular first and second molars are
uprighted by 60° and 30°, and extruded by 6 mm and 1
mm, respectively. U6, Upper first molar; L6, lower first molar; L7, lower second molar;
CR, center of resistance.

TREATMENT ALTERNATIVES

One treatment option could be extraction of the impacted first or second molar,
since the first molar was severely inclined mesially and deeply impacted, and the
second molar was also tipped mesially and disturbed the eruption of the first
molar. Extraction of the impacted molar could cause substantial bone loss in the
extraction area and result in a prolonged treatment time due to the need to wait for
the full eruption of the third molar. The other treatment option was non-extraction
and uprighting of both molars using TADs. The latter treatment option was selected,

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since it is less invasive and was a reversible approach unlike molar extraction. In
this case, there are two options for miniscrew placement sites for molar uprighting,
i.e., either anteriorly or posteriorly to the left mandibular molars. To extrude and
upright, a miniscrew was inserted anteriorly.

TREATMENT PROGRESS

For intrusion of the left maxillary first molar, one miniscrew (Dual-Top Anchor Screw;
Jeil Medical Co., Seoul, Korea) was inserted in the interradicular space between the
left second premolar and first molar on the palatal side. Another miniscrew was
placed between the left mandibular canine and first premolar on the buccal side. A
transpalatal arch (3D Palatal Appliance; Rocky Mountain Orthodontics, Denver, CO,
USA) was placed to minimize the undesirable buccolingual tipping of the molars
during intrusion. Intrusion of the over-erupted left maxillary first molar was started
by applying an elastomeric chain from the hook soldered to the transpalatal arch
to the miniscrew. After 6 months of molar intrusion, vertical clearance of 4 mm
between the left maxillary first molar cusp and the mandibular gingiva was
obtained (Figure 5A).

Figure 5. Progress and force system for uprighting the

mandibular second molar. A, Left mandibular second
molar uprighting using a 0.016 × 0.016-inch (in) square
nickel-titanium (NiTi) archwire with two step bends
whose distance was 2 mm wider than the inter-bracket
distance between the left second premolar and the
second molar. B, Force system acting on the second
molar when the uprighting mechanics using a compression force is employed. Two
step bends, whose distance is 2 mm wider than the inter-bracket distance between
the second premolar and second molar, are incorporated into a 0.016 × 0.016-in
square NiTi archwire. When the two step bends incorporated into the archwire are
squeezed and engaged into the brackets, a mesial force to the second premolar
and a distal force to the second molar are generated. Then, an uprighting moment
(M), whose magnitude is the product of the magnitude of the distal force (F) and
the perpendicular distance (d) from its line of force to the center of resistance (CR),
is produced. C, The length of the excess wire distal to the buccal tube on the right
first molar was used to shift the archwire to the left to reactivate the two step bends
without removing the archwire (circle). D, A crimpable stop placed on the archwire
just mesial to the anterior step bend (arrow).

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The left second molar was first uprighted to regain the space for eruption of the first
molar. In order to upright the second molar, a novel and unique mechanics was
used. In this mechanics, two step bends, whose distance was 2 mm wider than the
inter-bracket distance between the second premolar and second molar, were
incorporated into a 0.016 × 0.016-inch (in) NiTi archwire, and then squeezed and
engaged into the bracket and tube. Since a compression force was produced
between the two teeth, the second molar was subjected to a distal force (Figure 5A
and 5B).
The advantage of this archwire with two step bends is that its reactivation can be
performed without removing the archwire. The excess wire distal to the buccal tube
on the right first molar was left for the subsequent patient visits. On the next visit,
the archwire was shifted to the left, and the distal end of the archwire was slid
through a tube on the left second molar. The excess wire distance was used to
create the space for placing a crimpable stop onto the archwire just mesial to the
anterior step bend to reactivate the two step bends (Figure 5C and 5D). Three
months after the left second molar uprighting was started, the archwire was
changed to a heat-treated 0.017 × 0.022-in Elgiloy archwire. The second molar was
successfully uprighted into its normal position, and sufficient space for eruption of
the first molar was gained in 6 months.
In order to upright and extrude the first molar, surgical exposure of its crown was
performed by an open window procedure and a small molar tube (AP Terminal
tubes; TOMY International Inc., Tokyo, Japan) bonded in the buccolingual direction
on the distal surface of the exposed part, which facilitated insertion of an auxiliary
uprighting cantilever from the buccal side (Figure 6A and 6B). A moment for the
molar uprighting was efficiently produced by twisting the distal end of the
cantilever (Figure 6B and 6C). Since the cantilever should be kept stable in the oral
cavity without coming out of the tube, the middle part of the cantilever was passed
under the main archwire. Then, the mesial end of the cantilever was formed in a
semicircular shape and hooked over the head of the miniscrew that was inserted
between the canine and first premolar (Figure 6D).

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Figure 6. Treatment mechanics for uprighting of the left

mandibular first molar. A, B, A small molar tube bonded
buccolingually and an arrow indicates the insertion
direction of the cantilever. C, Force system acting on the
first molar and miniscrew when the cantilever mechanics
is employed. A dotted line indicates the cantilever in its
passive state, and a solid line in its active state. When the
cantilever is activated, a moment of couple (MC) to tip
the molar distally, an extrusive force on the molar tube,
and an intrusive force on the miniscrew are generated. The uprighting moment
acting on the molar is the sum of MC and the moment of force (MF). D, The
cantilever passes under the main archwire to avoid slipping buccally and the
mesial end of the cantilever hooked over the miniscrew (circle).

At 8 months (6 months with the auxiliary spring and 2 months with the main
archwire) from the beginning of correction of the impacted first molar, alignment of
the teeth of the left mandibular molar area was successfully completed (Figure 7),
after which the alignment of the maxillary dentition was started, thereby avoiding
the risk of undesired collision between the maxillary and mandibular molars during
their uprighting. To correct the molar relationship, the right maxillary quadrant was
moved distally with combined use of the transpalatal arch and the miniscrews. In
one year of additional treatment, proper overjet and overbite were obtained, and a
bilateral Class I canine and molar relationship was established. Anterior lingual
fixed retainers were placed in both jaws after appliance removal.

Figure 7. The treatment sequence for uprighting of the

left mandibular first molar (the blue arrow indicated)
(15M; 15 months after orthodontic treatment started).
Progress is shown at treatment times in months. The
archwire was 0.017 × 0.022-inch (in) Elgiloy and a 0.016 ×
0.022-in stainless steel cantilever was used for uprighting the left mandibular first
molar. At 21 months, a molar tube was bonded on the buccal surface of the first
molar and the 0.018-in nickel-titanium archwire was engaged for its alignment.

TREATMENT RESULTS

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The left mandibular first and second molars were successfully uprighted, and the
occlusion of the left posterior region was established (Figures 8 and 9). Overjet and
overbite were adequate, and occlusal interdigitation of the maxillary and
mandibular dentition and a Class I molar relationship were established (Figures 8
and 10). The posttreatment panoramic radiograph showed acceptable root
parallelism with no significant sign of bone or root resorption (Figure 10A). A
cephalometric superimposition demonstrated that the left maxillary first molar was
intruded by 3 mm (Figure 11B), and the left mandibular first molar was uprighted by
60° and extruded by 6 mm (Figure 11C). The total treatment period was 2 years 11
months. The patient maintained good occlusion for 2 years after the end of active
orthodontic treatment (Figure 12).

Figure 8. Posttreatment facial and intraoral photographs.

Figure 9. Posttreatment study

model: the left posterior
occlusion is normalized.

Figure 10. Posttreatment. A, Panoramic radiograph; B,

lateral cephalometric radiograph; C, tracing.

Figure 11. Superimposition of the pretreatment and

posttreatment lateral cephalometric radiographs. A, On
the sella-nasion plane at sella; B, on the palatal plane at
anterior nasal spine; C, on the mandibular plane at the
menton. Black line, Pretreatment; Red line, posttreatment.

Figure 12. Intraoral

photographs obtained 2 years
after orthodontic treatment.

DISCUSSION
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DISCUSSION

In the present case, the patient had three major dental problems associated with
collapse of the posterior occlusion on the left side: severely tipped and deeply
impacted mandibular left first molar, partially impacted and mesially tipped
second molar overhanging the adjacent first molar, and a maxillary first molar that
was elongated into the edentulous space occluding with the mandibular gingiva.
There are two options for the miniscrew placement site for molar uprighting. Molar
uprighting with a miniscrew inserted in the mandibular retromolar area could
simplify the mechanics by hooking an elastomeric chain between the miniscrew
16-19
head and an attachment on the molar crown. However, impacted molar teeth,
especially the first molar, might be subjected to a distal force depending on its
location using this mechanics. In the present case, a distal force could not be
applied to the first molar, since the first molar was deeply impacted and tipped
mesially, and its CR was located distally as compared to its ideal position (Figure
4B). Therefore, the placement of a miniscrew in the retromolar area was considered
to be unsuitable for the present case. Moreover, the soft tissue of the retromolar
area is movable and a miniscrew head might be more easily covered by mucosa,
potentially causing patient discomfort and gingival inflammation, which should be
24-27
prevented to ensure stability of the miniscrews.
On the other hand, when a miniscrew is placed anteriorly to the target molar, the
uprighting cantilever mechanics can be used. For uprighting and extruding the first
molar in this case, an uprighting cantilever was used, since the cantilever
mechanics will produce an uprighting moment and extrusive force simultaneously,
which is suitable for correction of the angulated and inferiorly positioned molar.
When a mesial end of the uprighting cantilever is directly hooked onto a main
archwire in a conventional method, an intrusive force is applied as a reaction force
at the point of force application on the wire, which could collapse the occlusal
interdigitation. To prevent this adverse effect, a miniscrew was inserted between
the canine and the first premolar, and the cantilever was hooked over the
miniscrew head (Figure 6B).
The most unique aspect of the molar uprighting mechanics used in the present
case was the attachment of a tube in the buccolingual direction instead of the
mesiodistal direction as is usually performed. If the molar is deeply impacted and
tipped mesially, it becomes quite difficult to attach a tube onto the buccal surface
in the mesiodistal direction due to the limited exposed area on the crown. On the

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other hand, placement of a tube in the buccolingual direction could facilitate the
bonding process and insertion of the right-angled distal end of the uprighting
cantilever from the buccal side (Figure 6A). An effective distal tipping moment can
20
be applied to the molar by twisting the distal end of the cantilever (Figure 6B).
Since the first molar was to be uprighted by 60°, an extremely large amount of root
movement was necessary; therefore, a substantial distal tipping moment had to be
applied. There are two options for the insertion site of the miniscrew, either between
the canine and premolar or between the first and second premolars. The length of
the cantilever varies depending on the location of the miniscrew. The more
anteriorly a miniscrew is placed, the longer the cantilever length, which produces a
larger uprighting moment acting on the molar. For this reason, a miniscrew was
inserted between the canine and first premolar to establish a longer cantilever
mechanics (Figure 4).
Figure 6C shows a force system acting on the first molar and miniscrew or the
activated cantilever in static equilibrium. To satisfy the conditions for equilibrium, a
pair of vertical forces (F) equal in magnitude and opposite in direction were
generated, making their sum with the moment of couple (MC) equal to zero. The
total amount of distal tipping moment (ΣM) acting on the molar can be calculated
as the sum of the moment of the couple and the moment of the force. The amount
of MC is expressed by the product of the amount of the vertical force (F: extrusive
force on the molar or intrusive force on the miniscrew) and the distance from the
miniscrew to the molar tube (d1), and the amount of the moment of force (MF) is
expressed by the product of the amount of the vertical force and the perpendicular
distance from a line of action of the force on the molar to its CR (d2). If an
uprighting cantilever is activated such that an extrusive force of 50 gm is produced,
the amount of distal tipping moment is calculated to be 1,250 gm-mm. If the
miniscrew is placed between the first and second premolars, the distance between
the miniscrew and the molar tube reduces, and the amount of uprighting moment
is decreased as a result. In other words, when a certain amount of uprighting
moment is required to be applied, a larger amount of extrusive force is generated,
which may cause occlusal interference with the maxillary molar. When the molar is
severely inclined, it is recommended to place the miniscrew more anteriorly and
secure a long cantilever length to produce an adequate uprighting moment.
Regarding the stability of miniscrews depending on their insertion sites, Chang et al.
28
suggested that the failure rate for miniscrews inserted in the interradicular space
is higher than that in the retromolar area. Nevertheless, we prioritized the use of the
cantilever mechanics considering its biomechanical advantage.

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In the present case, epoch-making mechanics were also applied for uprighting
and distalizing the second molar. First, two step bends, whose distance was 2 mm
longer than the distance between the second premolar bracket and the second
molar tube, were incorporated into an archwire. When the archwire with the
constricted two step bends was engaged, a compression force, namely, a distal
force to the second molar, was produced, which could yield the space for
positioning of the first molar. Since two step bends with archwires of a larger cross
section would produce an extremely heavy force, a 0.016 × 0.016-in square NiTi
archwire was used. By applying a distal force (F) to the second molar, a distal
tipping moment (M) based on the product of the distal force magnitude and the
perpendicular distance from a line of action of the force to its CR (h) was
simultaneously produced, as shown in Figure 5B.
The cantilever mechanics would generate not only an uprighting moment, but also
an extrusive force that could often cause occlusal interference with the maxillary
molar on the opposite side. On the other hand, the uprighting mechanics using a
compression force with two step bends or an open-coil spring could minimize the
magnitude of an extrusive force, which may be indicated for the second molar in
the present case since it was slightly inclined and did not require further eruption.
Since insertion of an open-coil spring into a straight archwire without step bends
could generate occlusal interference (Figure 5A), the two step-bend mechanics
was used. When the archwire with the constricted two step bends was engaged in
the brackets, the wire portion between the two step bends was deformed inferiorly
toward the gingiva. Consequently, vertical clearance between the maxillary and
mandibular molars could be obtained, which could also prevent the molar tube
from falling off.

CONCLUSION

Two different mechanics were used for uprighting the mandibular first and second
molars. The cantilever mechanics designed in this case report was found to be
effective for correction of a severely tipped and deeply impacted molar. Placement
of a miniscrew between the canine and first premolar with a long cantilever
mechanics allowed efficient uprighting of the molar by producing a large distal
tipping moment in relation to an extrusive force.
On the other hand, the mechanics using a compression force with two step bends
incorporated into a NiTi archwire was considered to be indicated for cases in which

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the molar was slightly tipped and extrusion and the resultant occlusal interference
should be prevented. Using the different designs of uprighting mechanics properly
depending on the stage of tipped molars would be the key to successful treatment.

How to cite this article:

Morita Y, Koga Y, Nguyen TA, Yoshida N. Biomechanical considerations for

uprighting impacted mandibular molars. Korean J Orthod 2020;50:268-277.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

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