Case Study

Miniscrew-Assisted Mandibular Molar Protraction: A Case Report

Aditi Gaur*, Sanjeev Kumar Verma**, Sandhya Maheshwari***, Arbab Anjum****
Abstract
The present article describes the case of a 12-year-old female patient in which mandibular
second molar protraction was performed after the extraction of a grossly damaged first
molar. A titanium miniscrew was placed in the buccal alveolar bone between the canine and
premolar to provide direct anchorage for protraction forces. A balancing lingual force was
applied. The treatment time was 22 months. Ideal overbite and overjet with good posterior
occlusion was achieved.

Keywords: Molar protraction, Miniscrew, Uprighting.

Introduction Case Report

Moyers suggested that mandibular first permanent
molar is the most common tooth to be lost due to
caries.1 Loss of permanent tooth results in undesirable
consequences such as mesial tipping and rotation of
adjacent teeth, eruption of opposing tooth into the
extraction space.2 Previously prosthetic replacement of
the edentulous spaces was considered as a sole
treatment option as molar protraction was seldom
attempted by clinicians due to increased anchorage
demands. Mandibular molar protraction is one of the
most challenging tooth movements during orthodontic
treatment. Anterior dental anchorage is often
inadequate to protract a molar without reciprocal
retraction of the incisors or movement of the dental
midline.3 The introduction of temporary anchorage
devices has enabled the orthodontists to perform
difficult tooth movements like molar protraction. The
present article describes a case report of a patient with
grossly damaged mandibular first molar which was
extracted and replaced by protraction of mandibular
second molar into the extraction space.
A 12-year-old female patient had reported with her
parents to the department of orthodontics with the
chief complaint of irregularly placed front teeth. The
clinical examination of the patient revealed a
symmetric, mesoprosopic face with convex profile and
competent lips. Intraorally, the patient had a flush
terminal molar relationship with end-on canine relation
bilaterally, and overjet of 3 mm, overbite of 4 mm,
retained deciduous second molars in all quadrants. The
patient had a restoration with respect to 36 and a
grossly damaged 46 which was previously root canal
treated (Fig. 1).
Cephalometric examination revealed a skeletal Class-I
base with hypodivergent growth pattern with an ANB of
3° and an FMA of 21° (Fig. 2).
OPG findings revealed erupting premolars in all
quadrants, erupting second molars in all quadrants,
developing third molar in all four quadrants and root
canal treated 36 (Fig. 3).

*
Senior Resident, Department of Orthodontics and Dentofacial Orthopedics, Dr. Z. A. Dental College, Aligarh Muslim University, Aligarh,
India.
**
Professor and Head, Department of Orthodontics and Dentofacial Orthopedics, Dr. Z. A. Dental College, Aligarh Muslim University,
Aligarh, India.
***
Professor, Department of Orthodontics and Dentofacial Orthopedics, Dr. Z. A. Dental College, Aligarh Muslim University, Aligarh, India.
****
Assistant Professor, Department of Orthodontics and Dentofacial Orthopedics, Dr. Z. A. Dental College, Aligarh Muslim University,
Aligarh, India.
Correspondence to: Dr. Aditi Gaur, Department of Orthodontics and Dental Anatomy, Dr. Z. A. Dental College, Aligarh Muslim University,
Aligarh, India. E-mail Id: aditigaur2289@gmail.com

© ADR Journals 2016. All Rights Reserved.

J. Adv. Res. Dent. Oral Health 2016; 1(1) Gaur A et al.

Figure 1.Clinical Examination

Figure 2.Pretreatment Cephalogram

Figure 3.Pretreatment OPG

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Gaur A et al.
Treatment Objectives
• Align and level the arches
• Achieve Class-I canine relation
• Achieve Class-I molar relation
• To achieve ideal overjet/ overbite
• Management of 46
• Maintenance of good profile
Treatment Plan
On considering the diagnostic evaluation, a fixed
mechanotherapy using MBT 022 slot was planned with
extraction of 46 and protraction of 47 into the
extraction space.
Treatment Progress
Treatment was started by extraction of grossly damaged
46 after obtaining consent from the patient’s parents.
Figure 4.Initial Alignment and Levelling following Extraction of 46
Figure 5.Miniscrew-Supported Molar Protraction Using NiTi Coil Spring
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J. Adv. Res. Dent. Oral Health 2016; 1(1)
Fixed mechanotherapy was initiated using 016 NiTi
wires in both arches, followed by 018 NiTi (Fig. 4). A
miniscrew of dimensions 1.5×6 mm was inserted with
respect to 43 and 44. 020 SS wire was ligated in the
mandibular arch and a protraction force was applied
using a NiTi closed-coil spring from the miniscrew to 47.
A balancing lingual force was provided from 43 to 47
with the help of an elastic chain stretched from lingual
button attachments. Molar protraction was achieved
within months (Fig. 5). The miniscrew was removed
once the molar protraction was completed. An
uprighting spring was designed in a 020 SS wire to
correct the angulation of the protracted 47 (Fig. 6).
Following uprighting, 016×022 NiTi wire was ligated,
followed by 017×025 and finally 019×025 wires were
ligated in both arches. Finishing and detailing was
continued for another 3 months. The total treatment
time was 22 months.
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J. Adv. Res. Dent. Oral Health 2016; 1(1) Gaur A et al.

Figure 6.Uprighting Spring for Correction of Molar Inclination

Results
A Class-I canine and molar relation was achieved optimum profile of the patient was maintained (Figs. 7-
bilaterally with an ideal overbite and overjet. The 9).

Figure 7.Post-Treatment Phtotographs

Figure 8.Post-Treatment Cephalogram

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Figure 9.Post-Treatment OPG

Table 1.Skeletal Changes

Pre Post
SNA (82) 79o 79
SNB (80) 76o 76
ANB 3.12o + 1.8o) 3o 3
Wits (-0.01 mm) -1 mm 3 mm
APP-BPP (-5 mm) 3 mm 6 mm
MM bisector (-5 mm) -3 mm -1 mm
FMA (23.83 + 2o) 21o 24
SN-MP (32-35o) 30o 33
Y Axix (59.62o + 3) 66o 69
Bjork's sum (394o) 390o 393
J ratio (62-65%) 68% 67%
Gonial angle (123 + 7o) 127o 130
Upper anterior facial height (45%) 48.1% 47%
Lower anterior facial height (55%) 51.8% 52%

Table 2.Dentoalveolar Changes

Mx1 to A-Pg: 6.74 + 1.3 mm 8 mm 6 mm
Mx 1 to NA: 4.92 + 2.05 mm 7 mm 5 mm
Mx 1 to NA: 24.02 + 5.82o 28o 21o
Mx 1 to Palatal Plane (71o) 68o 61o
Md 1 to A-Pg (-2mm to 2mm) 2 mm 2 mm
Md 1 to NB (6 + 1.7 mm) 4 mm 4 mm
Md 1 to NB (27 + 4.3o) 26o 28o
IMPA (99o) 99o 101o
Inter-incisor Angle (123o) 124o 128o

Discussion anchorage along with ensuring optimum tooth

Molar protraction is one of the most difficult
orthodontic procedures. It was suggested by Graber
that molar protraction is seldom used as a method for
management of extraction sites.4 Also loss of anterior
anchorage is a common disadvantage during molar
protraction using conventional mechanics. The use of
miniscrews has proved to be useful in preserving the
movements.
The present case involved was of a growing patient with
a grossly damaged mandibular first molar which was
extracted during orthodontic therapy considering the
poor prognosis of the tooth. A miniscrew was placed in
between the roots of canine and first premolar to
provide direct anchorage for efficient molar protraction

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J. Adv. Res. Dent. Oral Health 2016; 1(1)
with a long line of action of force.5 Freudenthaler et al.
studied the effectiveness of miniscrews in protracting
the lower molars of eight patients aged 13 to 46 years.
Either the lower first permanent molars or the
deciduous second molars were first extracted owing to
agenesis of the second bicuspids.
Miniscrews of 2 mm diameter were inserted in either
the area between the 2 premolars at the level of the
apical thirds or in the mesial side of a molar extraction
socket. A loading force of 150 g was maintained for 7 to
20 months during active treatment.6 Kyung et al.
reported on a patient in whom the lower second molars
were protracted by 9 mm with 150 g of loading force
over 9 months. Protraction was aided by miniscrews
inserted between the premolars after the lower first
molars had been extracted.7 In the present case,
mandibular second molar was protracted a distance of
10 mm during a period of 8 months. Direct protraction
from the miniscrew is often associated with undesirable
effects such as mesiolingual rotation, posterior crossbite
and openbite tendency.3 To counteract such undesirable
moments, a lingual force is required.8 An active force
was applied using an elastic chain lingually to the molar
in the present case.
Molar protraction often requires a phase of uprighting
due to the tipping of molar into the extraction site. An
uprighting spring with tipback bend was used in the
present case to allow distal crown moment and mesial
root moment of the molar.9
A finite element analysis model was given by Nihara et
al. suggesting that the most ideal force system during
molar protraction is one with a long extension arm (10
mm) with the addition of a lingual force of half or equal
magnitude of the labial force.10 In our case, we used a
buccal force without an extension arm along with a
lingual force which resulted in efficient molar
protraction. An extension arm is preferable to avoid
undesirable tipping of the molar and ensuring bodily
protraction of the molar.
Conclusion
Miniscrews provide a source of skeletal anchorage for
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Gaur A et al.
performing difficult tooth movements efficiently. The
use of miniscrews for mandibular molar protraction can
be used as a routine procedure in orthodontic practice.
Conflict of Interest: None
References
1. Moyers RE. Handbook of Orthodontics. Chicago:
Year Book Medical Publishers, 1988.
2. Kessler M. Interrelationships between orthodontics
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Date of Submission: 10th Jul. 2015
Date of Acceptance: 22nd Jan. 2016
ISSN: 2456-141X