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 the recommended treatment and should be done as soon
of every 1000 people in the general population as possible. If not properly corrected, mesially impacted
and in 2 or 3 of every 100 orthodontic pa- molars may lead to adverse events such as elongation of
tients.1,2 It is more common in male patients and most opposing teeth, periodontal problems on the mesial side
typically occurs unilaterally on the right side in the of the affected teeth, caries in the unerupted molars, and
mandible rather than in the maxilla.2 Mandibular poor oral hygiene.6-8 Many clinical procedures have
second molar impactions occur in several patterns: uni- been reported to upright mesially tilted mandibular
lateral or bilateral, with or without loss of the mandib- molars, but biomechanical shortcomings have been
ular first molar, and with or without mandibular third observed. A disadvantage of uprighting mandibular
molar impaction. Many causative factors contribute to molars with conventional dental anchorage is the
the abnormal eruption of the mandibular unintended displacement of the anchorage tooth or
second molar: lack of arch length, abnormal erupting teeth.8,9 To minimize dental anchorage displacement,
angulation, premature eruption of the mandibular third it was necessary to include multiple teeth in the
molar, early loss of the mandibular first molar, alteration anchorage unit, which resulted in the placement of
of the dental follicle or the periodontal ligament, and heavy orthodontic appliances.
other iatrogenic factors.3-5 During the last decade, the use of skeletal anchorage
To obtain proper occlusion and prevent further peri- has been widely accepted in clinical orthodontics. Skel-
odontal problems, uprighting of mesially tilted molars is etal anchorage reduces the side effects that occur with
dental anchorage and simplifies the orthodontic appli-
a
ances and the treatment biomechanics. In this article,
Clinical instructor, Department of Orthodontics, Dental Hospital, Kyung Hee
University Hospital at Gangdong, Seoul, Korea. we introduce a biomechanical system for uprighting
b
Private practice, Seoul, Korea. mandibular molars with 2 miniscrews and a connecting
c
Professor, Department of Oral and Maxillofacial Pathology, School of Dentistry wire, and present 3 patients whose mesially tilted
and Research Center for Tooth & Periodontal Regeneration, Kyung Hee Univer-
sity, Seoul, Korea. mandibular second molars were corrected with the sys-
d
Assistant professor, Department of Orthodontics, Dental College, Kyung Hee tem. This system was designed to provide a simple and
University, Seoul, Korea. efficient molar uprighting technique that will minimize
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported. the orthodontic appliances and be more comfortable
Supported by the National Research Foundation of Korea grant funded by the for patients.
Korean government (number 2012R1A5A2051384). The technique uses 2 miniscrews with a slot that can
Address correspondence to: Yoon-Goo Kang, Department of Orthodontics,
Kyung Hee University Dental College, Hoegi-dong 1, Dongdaemun-gu, Seoul, accommodate an orthodontic wire (0.0215 3 0.0250 in)
Korea; e-mail, deodor94@khu.ac.kr. (Fig 1). Machined-surface miniscrews (Dual Top Anchor
Submitted, October 2014; revised and accepted, July 2015. System, JD type; Jeil Medical, Seoul, Korea) were 6 mm
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists. in length and 1.6 mm in diameter. The miniscrews were
http://dx.doi.org/10.1016/j.ajodo.2015.07.027 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 molars. The wire was placed immediately after miniscrew
second premolar and the first molar. A standard implan- implantation.
tation method was used. Briefly, the surgical site was
scrubbed with povidone-iodine, and local anesthesia
was induced by infiltration with 2% lidocaine plus PATIENT 1
epinephrine (1:100,000). Then a miniscrew was im- An 11-year-old girl presented with mesially tilted
planted at 90 to the cortical surface using a manual mandibular second molars on both sides. The clinical ex-
driver under saline solution irrigation. A rectangular amination showed a Class I molar and canine relation-
wire was used to connect the 2 miniscrews and move ship without notable arch length discrepancies (Fig 2).
the target tooth. Connecting the 2 miniscrews provides Developing mandibular third molars were observed
effective resistance against orthodontic forces and mo- bilaterally on the panoramic radiographic view.
ments that act to loosen the miniscrew (ie, loosening A treatment plan was established to upright both
the moment force of one miniscrew acts to tighten the mesially tilted second molars using the 2-miniscrews
moment force of the other miniscrew, thereby neutral- system and to extract the mandibular left and right
izing the forces). By placing a connecting wire in the 2 third molars to aid in uprighting the second molars.
miniscrew slots, it is possible to create a 3-dimensional The occlusion and the alignment of the patient's other
vector control force on the target tooth. The slots as- teeth were fairly acceptable, and we did not plan to
sume a role similar to that of orthodontic brackets that bond or band orthodontic appliances to keep their
use conventional orthodontic mechanics to upright 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- a loop was placed to upright the molars (Fig 3). The
tween the first molar, the second premolar, and the first miniscrew implanted between the left second premolar
premolar. An orthodontic tube was bonded on the mesi- and the first molar fell out before application of the
ally tilted second molars at the proper position. Initially, initial force; therefore, we decided to use 1 miniscrew
a passively bent 0.016 3 0.022-in stainless steel con- on the left side instead of implanting another (Fig 3).
necting wire was inserted into the 2 miniscrew slots This 1 miniscrew withstood the orthodontic forces
and the second molar tube. A nickel-titanium open-coil throughout the treatment.
spring was used for the distalization of the mandibular After 9 months of treatment, the mesially tilted
second molars (Fig 3). After a month, both mandibular second molars were successfully uprighted, and the or-
second molars were unlocked from the first molars, thodontic tubes and miniscrews were removed (Fig 3).
and a 0.017 3 0.025-in beta-titanium alloy wire with The patient's occlusion and dental alignment were

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852 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
Fig 4. Panoramic radiographs of patient 1: top, before wire with loops was inserted to control the second molar
treatment; middle, at 5 months; bottom, at 9 months, (Fig 6). After 8 months of treatment, a 0.016 3 0.022-in
with the appliances removed. stainless steel wire was used for fine alignment of the
second molar.
After treatment, the horizontally impacted
maintained. After a year, the retention records showed second molar was uprighted successfully without inter-
that the alignment continued to be maintained (Figs 3 rupting the initial occlusion or the alignment of the
and 4). other teeth (Fig 6). The total duration of treatment
was 13 months.
PATIENT 2 The retention records after 1 year showed that the
This patient was a 13-year-old girl with a malpositioned treatment results were well maintained (Figs 6 and 10).
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 PATIENT 3
mandibular right second molar was horizontally impacted A 13-year-old boy came with a chief complaint of
with supragingival exposure of the distal part of the crown malpositioned mandibular second molars. The intraoral
(Fig 5). A panoramic radiograph showed horizontal impac- examination showed a Class II dental relationship with
tion of the mandibular right second molar and absence of mild crowding, horizontal impaction of the mandibular
the third molars. right second molar, and a mesially tipped mandibular
A treatment plan was established to upright the hor- left second molar (Fig 11). Examination of the facial pro-
izontally impacted mandibular right second molar using file showed lip protrusion with a retrognathic mandible.
the 2-miniscrew system. One miniscrew was inserted be- The patient and his parents were interested only in
tween the first molar and the second premolar, and the normal eruption and positioning of the impacted

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Mah et al 853

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- DISCUSSION
dontic treatment to resolve the Class II relationship or The treatment of mandibular second molar impac-
the crowding and lip protrusion. A panoramic radio- tion has prompted many creative ideas by orthodontists
graph showed a horizontally impacted mandibular right and maxillofacial surgeons. Treatment options can be
second molar and a mesially tipped left second molar. chosen based on the severity of the impaction, the acces-
A treatment plan was established to upright both sibility to the impacted molar, the simplicity of treat-
mandibular second molars using the 2-miniscrew sys- ment, or the possible side effects.11 Surgical and
tem. After extraction of the mandibular right third orthodontic methods are the 2 major treatment options.
molar, miniscrews were inserted between the mandib- Surgical methods include repositioning, transplantation,
ular first and second premolars, and between the second and extraction of the impacted second molar. These sur-
premolars and first molars. A half-size tube was bonded gical approaches are a rapid and relatively easy solution
on both sides of the second molars. A 0.0215 3 0.0250- when the mandibular second molar is impacted.12 How-
in cobalt-chromium alloy wire was formed to passively ever, they involve the risk of pulp necrosis, ankylosis, and
fit the miniscrew slots, and vertical loops were added root resorption; therefore, the prognosis is rather poor,
to provide distal force to the right second molar, while and the predictability is low.13,14
horizontal loops were formed to vertically control the The orthodontic method may have a better prognosis
left second molar (Fig 12). After a year of treatment, because the risk level is lower than that of the surgical
the left second molar was corrected, and the appliances method. Various conventional methods have been
on the left side were removed. At that time, uprighting of used. Among them, the predominant method is the
the right second molar was almost complete, and a hor- tip-back cantilever spring or the uprighting spring. How-
izontal looped 0.0215 3 0.0250-in stainless steel wire ever, orthodontic methods that use conventional biome-
was inserted for final correction of the tooth position. chanics have problems in acquiring anchorage.8,9
The appliances on the right side were removed 24 months To overcome such problems, molar uprighting
after the start of treatment. The treatment duration was methods using an orthodontic miniscrew have recently
prolonged because the patient did not appear for been reported.15,16 In most reports, miniscrews were
7 months before removal of the appliances on the left used as anchorage, in addition to conventional
side, and afterward did not appear for 9 months before orthodontic appliances. Unlike in these previous
removal of right-side appliances. The total number of reports, the system described here uses miniscrews as
visits was 8, including visits for placement and removal the main, and not a supportive, appliance.
of the appliances. Panoramic views of treatment prog- There are 2 ways to use miniscrews to upright a
ress are presented in Figure 13. 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 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
Fig 7. Biomechanical illustration of pulling force from the
the second molar. Therefore, it reduces the possibility
ramal miniscrew shown in patient 2. Rotation of the molar
around its center of rotation may cause eruption of the of miniscrew loosening, even when only 1 miniscrew
tooth. 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
Loosening of the miniscrew, which could result in move- that an uprighting spring exerts an axial moment on
ment of the anchor tooth (or teeth), might not be a single buccal miniscrew, thus increasing the risk
apparent because of the connection to the tooth of miniscrew failure. This is one reason that
(or teeth). There is also the possibility that indirect Nienkemper et al used 2 miniscrews. We also showed
miniscrew anchorage does not provide a totally rigid a 3-dimensional force being applied on the tooth
anchorage system, thereby allowing the orthodontic through the wire connected to an 0.018-in bracket
force to push the indirectly anchored tooth even when with a special orthodontic abutment attached to a
miniscrew stability is good.17 The direct use of mini- mini-implant with a special inner thread design on its
screws to upright the molars is accomplished by placing head. Our system uses the built-in rectangular slot
the miniscrews distal to the molar and applying a distal that connects the 2 miniscrews. Notwithstanding the
uprighting force to the molar.18 However, the miniscrew differences in implant position and design, the authors
can provide only a 1-way directed force and cannot pro- of all studies used miniscrews as orthodontic brackets.
vide 3-dimensional control of the tooth position. There- In patient 1, 1 of 2 miniscrews on the left side fell out
fore, it is necessary to place orthodontic brackets and before the process of uprighting the molar was started,
tubes on the other teeth to fine-tune the positioning so only 1 miniscrew was used. Fortunately, the left
of the impacted molar, which in turn causes unwanted miniscrew could withstand the uprighting force: the
movement of the teeth. It is more problematic if the moment produced from uprighting the molar was in
impacted molar is 3-dimensionally malpositioned the clockwise direction, which contributed to tightening
(lingually tipped or rotated).10 In such cases, 1 miniscrew the miniscrew into the bone. However, there were some
for direct anchorage is not sufficient to fully control the problems, including the minor distal rotation of the
target molar without bonding or banding brackets on mandibular left second molar (Fig 3), which could not
the other teeth because it usually results in unwanted be controlled by only 1 miniscrew. One miniscrew slot
tooth movement.10 is too short to hold the wire firmly to give sufficient con-
The method described here uses 2 miniscrews as or- trol to the molar. Two miniscrew slots with a proper in-
thodontic brackets and can control the impacted molar terval distance are needed to firmly hold the wire.
position 3-dimensionally by placing a rectangular con- Nonetheless, the patient was satisfied with the outcome;
necting wire. This method combines the advantages of there were no functional or food impaction problems.
direct and indirect anchorage with miniscrews. There is The important findings of this case were twofold: (1) if
no need for additional orthodontic brackets or tubes the miniscrew's thread direction can resist the moment
on the other teeth; therefore, there are no side effects generated from the uprighting force (ie, a right mini-
from unwanted tooth movement. Without multiple screw with a counterclockwise thread direction, or a
brackets on teeth, it is still possible to use various crea- left miniscrew with a clockwise thread direction), the
tive wire designs (loops or helices) to upright and control miniscrew may survive; and (2) if the slot length of the

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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

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
Fig 9. Miniscrew connecting wire can be attached to the can adjust the couple moment generated in the tube,
button bonded on the occlusal table of the molar to give a thereby controlling the angulation (second order) of
similar force system as the Halterman appliance or the the tooth. If the mesial loop is opened, extrusion of
ramal miniscrew. the tooth will occur; if both the mesial and distal
loops of the horizontal wire are opened, extrusion with
miniscrew head is long enough to hold the wire firmly, distal tipping will occur (Fig 14). If mesial angulation
the molar position may be controlled properly. As a sum- of the second molar is not severe (as with the left
mary, the manufacture of miniscrews with appropriate second molar of patient 3), a horizontal looped wire
directions of the threads and sufficiently long slot with widened mesial and distal loops will solve the prob-
head designs could contribute to successful uprighting lem. From the occlusal view, when buccal or lingual
and precise control of the molar position using the positioning of the second molar is needed, the wire
biomechanics presented here without having to place can be adjusted as shown in Figure 15. A passively fitting
additional multibrackets on other teeth. wire can be buccally (or lingually) bent to move the tooth
Two types of wire loops were used in the 3 patients: buccally (or lingually) in a parallel or nonparallel direc-
vertical and horizontal. Initially, a multiple vertical tion, as described by Burstone.21 Parallel activation
looped wire was used to apply distalizing force to the may result in buccal (or lingual) movement of the tooth
crown of the impacted or mesially tipped molar. Instead with rotation, whereas nonparallel activation results in
of vertical loops, an open-coil spring can be used to pro- buccal (or lingual) movement without rotation. Buccal
vide the distalizing force, as shown in the photographs or lingual movement can alter the buccolingual inclina-
of patient 1. Our experiences have shown that loops 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 uprighting is prohibited. To overcome this problem,
a nickel-titanium open-coil spring was initially used to frequent fine wire adjustments are required; these can
apply the uprighting force. This rigid wire is good for become tiresome. Therefore, we turned to a multiple ver-
rotational control of the molar during application of tical looped wire. This wire is flexible, and since tooth
the uprighting force, but rigidity can limit the uprighting movement is not halted, the uprighting process evolves
movement: binding of the wire occurs, and further 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. A buccal 2-miniscrew system is basically a 2-couple
However, flexibility resulted in loss of control and distal moment system in which the center of rotation is
rotation of the molar. This distal rotation can be cor- changed by altering the couple moment generated in
rected by inserting a straight rigid wire (a horizontally the molar tube. Lee et al10 showed the limitation of their
looped wire or a no-looped wire) into the molar tube af- single-force system in patients with lingually tipped or
ter uprighting the molar. These 2 types of uprighting rotated molars and patients with molar extrusion. In
methods have advantages and disadvantages. In our our patients 2 and 3, the second molar showed severe
opinion, there is no one method that is superior to other mesial impaction with its center of rotation (bifurcation
methods. area) located close to the occlusal plane. Distal rotation

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Mah et al 859

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 disadvantage of this system is the use of 2
the bifurcation area would cause extrusion of the tooth miniscrews. Most of the previous biomechanical options
(Fig 14). In such cases, more complex biomechanics for uprighting the molars used 1 miniscrew; the addition
should be provided using our 2-miniscrew system, for of a second miniscrew might be a burden to both the pa-
example. tient and the orthodontist. However, based on our expe-
In the 3 patients presented, various metal alloys and rience with this system, we have concluded that the
wire sizes were used. When the moment exerted from the benefit from eliminating the need for multiple bracket-
wire during uprighting of the second molar is expected ing is preferable to the risk or burden of using 1 more
to be high, the wire should be rigid enough to neutralize miniscrew. Another disadvantage is the inconvenience
the loosening moment between the miniscrews. On the of the looped wire for both the patient and the operator.
other hand, force to the tooth should be light enough The looped wire is custom-bent; this can become tire-
to provide biologically proper tooth movement: loops some to the operator. However, once the wire is formed,
between the miniscrew and the molar tube are needed only minor adjustments are required, and little technical
to lighten the force. This is particularly needed in the skill is needed. The patient may feel uncomfortable with
initial phase of molar uprighting: a more angulated the bulky wire design, but it is tolerable.
tube on the molar exerts more moment on the miniscrew. It has been advocated that if the third molars inter-
In the final stage of fine-tuning the molar position, the fere with the distal uprighting of the second molars,
moment generated from molar uprighting becomes they may need to be extracted. However, according to
negligible, and the wire no longer needs to be rigid. How- the spatial relationship between the second and third
ever, and because the distance between the miniscrew molars, the third molar may help the second molar's up-
and the molar tube is long, a strong wire without loops righting.22 The third molar may provide changes in the
should be used for fine-tuning the molar position. There- position of the center of rotation for a mesially impacted
fore, nickel-titanium wires and round wires are not rec- second molar, thereby preventing space opening ante-
ommended in treatments with this system. The wire rior to the second molar. In patient 3, third molar extrac-
between the miniscrews should be rigid enough to over- tion was not helpful in uprighting the second molar
come the loosening moment exerted by the molar tube. and therefore not needed; in patient 1, the value of

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860 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.

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