CASE REPORT

Efficient usage of implant anchorage to treat

overerupted maxillary first molar and mesially
inclined mandibular molars
Ritsuko Ohura,a Shingo Kuroda,b Takumi Takahashi,c Yuko Tomita,d and Eiji Tanakae
Tokushima, Japan

This case report demonstrates the efficient use of implant anchorage in a patient with mesially inclined mandibular
molars and an overerupted maxillary molar. A 14-year-old girl had an overerupted maxillary right first molar, pos-
sibly because of severely inclined mandibular right molars. Two-step use of miniplate anchorage in the right zygo-
matic process was proposed. As the first step, the overerupted maxillary first molar was intruded with elastic chains
from the miniplate for 10 months. Then the maxillary right molars were distalized by using the miniplate to correct
the Class II molar relationship. In the mandible, the first molar was extruded with intermaxillary elastics applied from
the miniplate to the molar for 7 months after the uprighting of the mandibular right second molar. The results sug-
gest that the use of 2-step implant anchorage is efficient for intrusion and distalization of maxillary molars and ex-
trusion and uprighting of mandibular inclined molars. (Am J Orthod Dentofacial Orthop 2011;139:113-22)

I
nfraocclusion or missing teeth often cause mesial
tipping of adjacent or opposing teeth, and it is fre-
quently observed in the mandibular posterior region.
Mandibular mesially inclined teeth become a problem
not only in the mandible, but also in the maxilla with
overeruption of opposing teeth. As a result of these pro-
cesses, the occlusal plane becomes canted, and occlusal
interferences might be produced. Orthodontic treatment
to correct the overerupted molar is recommended before
uprighting the mandibular teeth. However, real intrusion
is considered extremely difficult with conventional or-
thodontic mechanics, because of insufficient anchorage.
Recently, bone-anchored orthodontics has become
a new treatment strategy.1-16 Titanium miniplates or
miniscrews placed in bone provide absolute anchorage for
various tooth movements without patient cooperation.
Additionally, bone-anchored tooth movement does not
From Department of Orthodontics and Dentofacial Orthopedics, Graduate School
of Oral Sciences, The University of Tokushima, Tokushima, Japan.
a
Graduate student.
b
Associate professor.
c
Senior assistant professor.
d
Clinical instructor.
e
Professor and chair.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Shingo Kuroda, Department of Orthodontics and Dento-
facial Orthopedics, The University of Tokushima Graduate School of Oral Sci-
ences, 3-18-15 Kuramoto-Cho, Tokushima 770-8504, Japan; e-mail, kuroda@
dent.tokushima-u.ac.jp.
Submitted, February 2009; revised and accepted, May 2009.
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.05.025
induce reciprocal movement of other teeth. Recently,
successful maxillary molar intrusion has been reported
with implant anchorage.4,6-13 Furthermore, maxillary
molars have also been moved distally by using
bone-anchored orthodontics.14-16
In conventional orthodontic mechanics, several
methods have been proposed for uprighting inclined
mandibular molars: eg, upright spring, lingual arch
appliance, and multi-bracket appliance with high-pull J-
hook headgear or Class III elastics.17-19 In addition, the
use of implant anchorage has already been reported for
molar uprighting.20-22 However, most reports describe
the uprighting of mandibular second molars, and there
are few reports using implant anchorage to upright
severely inclined mandibular first and second molars.
This case report demonstrates the usefulness of
implant anchorage in a patient with mesially inclined
mandibular first and second molars and the compensa-
tory overeruption of the maxillary first molar.
DIAGNOSIS AND ETIOLOGY
The patient was 14 years 1 month old when she came
with an overerupted maxillary right molar and mesially
inclined mandibular right molars (Fig 1). She complained
about difficulty chewing because of the mesial inclina-
tion of the mandibular right molars. Her facial profile
was straight with adequate lip prominence compared
with the esthetic line and no facial asymmetry. Overjet
and overbite were 13.0 and 12.5 mm, respectively.
The molar relationships were Class II on the right side
113
114
Fig 1. Pretreatment photographs (age, 14 years 1 month).
and Class I on the left side (Fig 2). The maxillary right
first molar was overerupted, and the mandibular right
first molar was infraoccluded. The intraoral radiograph
showed cemental hyperplasia of the mandibular right
first molar without clear delineation of the lamina dura
(Fig 3). The mandibular right second molar was signifi-
cantly inclined. There was moderate incisor crowding
in both arches. The arch length discrepancies were
–4.5 mm in the maxilla and –4.0 mm in the mandible.
The maxillary dental midline was deviated 1.0 mm,
and the mandibular midline was 2.0 mm to the right
of the facial midline. Periodontal problems and
temporomandibular joint disorders were not found.
Cephalometric analysis indicated a skeletal Class I
relationship (ANB, 3.9 ) (Table). The mandibular plane
angle was within the normal range, but the gonial angle
was larger than the Japanese norm (MP/FH, 31.1 ;
January 2011  Vol 139  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Ohura et al
gonial angle, 131.5 ).23 The mandibular body length
was within the normal range. Although the maxillary in-
cisors showed a normal labiolingual inclination, the
mandibular incisors were tipped more lingually (IMPA,
82.8 ). The maxillary right first molar was significantly
extruded (U6/PP, 28.0 mm), but the mandibular right
first molar was intruded (L6/MP, 29.0 mm).
TREATMENT OBJECTIVES
From these findings, this patient was diagnosed as
having moderate crowding with a skeletal Class I jaw-
base relationship. The maxillary right first molar was
significantly overerupted, and the mandibular second
molar was mesially inclined, possibly because of infraoc-
clusion of the mandibular right first molar. The
treatment objectives were (1) to correct the molar rela-
tionship on the right side, the mesial inclination of the
Ohura et al 115

Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment radiographs.

American Journal of Orthodontics and Dentofacial Orthopedics January 2011  Vol 139  Issue 1
116 Ohura et al

overerupted maxillary molar in this patient. The mandibu-

Table. Cephalometric summary
lar dental midlines were slightly deviated to the right with
Japanese respect to the facial midline before treatment. Tooth ex-
Variable norm SD Pretreatment Posttreatment traction or the use of implant anchorage would be required
Angular ( ) on the left side in both jaws for midline correction. How-
ANB 2.8 2.4 3.9 3.7
SNA 80.8 3.6 79.4 79.4
ever, facial asymmetry was not observed, and the midline
SNB 77.9 4.5 75.5 75.7 deviation was considered almost acceptable at the initial
MP-FH 30.5 3.6 31.1 30.6 examination. Additionally, the patient was not concerned
Gonial angle 122.1 5.3 131.5 130.0 about the midline deviation. She complained only about
U1-FH 112.3 8.3 111.1 114.8 difficulty in chewing on the right side. Therefore, we did
L1-MP 93.4 6.8 82.8 85.9
Interincisal 123.6 10.6 135.1 128.8
not plan to correct the dental midline deviation.
angle
Occlusal plane 16.9 4.4 0.1 6.7
TREATMENT PROGRESS
Linear (mm) We planned a 2-step use of implant anchorage,
S-N 67.9 3.7 75.0 74.9 because of the complicated problems. In the first step,
N-Me 125.8 5.0 137.6 138.2
Me/NF 68.6 3.7 44.5 46.5
intrusion of the overerupted maxillary right first molar
Ar-Go 47.3 3.3 48.7 49.7 was performed. In the second step, distalization of the
Ar-Me 106.6 5.7 117.0 120.0 maxillary right dentition was accomplished with implant
Go-Me 71.4 4.1 77.0 77.5 anchorage. In addition, extrusion and uprighting of the
Overjet 3.1 1.1 3.0 3.0 mandibular right first molar were achieved with bone
Overbite 3.3 1.9 2.5 2.5
U1/PP 31.0 2.3 32.5 32.3
anchorage (Fig 4).
U6/PP* 24.6 2.0 28.9 25.8 Initially, 0.022-in slot preadjusted edgewise appli-
L1/MP 44.2 2.7 47.6 47.9 ances were placed on the mandibular arch except for
L6/MP* 32.9 2.5 29.0 32.4 the first and second molars on the right side. During
leveling with nickel-titanium archwires, a titanium mini-
*Right side.
plate (Dentsply Sankin, Tokyo, Japan) was implanted in
the right zygomatic process, and the mandibular right
mandibular molars, and the extrusion of the maxillary third molar was extracted to improve access for upright-
first molar; (2) to maintain ideal overjet and overbite; ing the inclined molars.
and (3) to achieve a functional Class I occlusion. Four months after miniplate placement, the intrusion
of the overerupted maxillary first molar was started with
elastic chains placed between the plate and a maxillary
TREATMENT ALTERVATIVES lingual arch appliance (Fig 5, A, C, and D). The lingual
The maxillary first molar was significantly extruded arch appliance was required to prevent the buccal incli-
and had a Class II malocclusion on the right side; there- nation of the first molar that would be caused by the
fore, we planned to place a titanium miniplate in the intrusive force (Fig 5, C). Simultaneously, the uprighting
right zygomatic process as bone anchorage for maxillary of the mandibular right second molar was initiated with
molar intrusion and distalization. Without skeletal an- an uprighting spring (Fig 5, A, B, D, and E).
chorage, absolute intrusion of the overerupted molar Ten months after starting the molar intrusion, the
would be impossible. Maxillary premolar extraction lingual arch appliance was removed, and distal move-
could be considered to treat the Class II malocclusion, ment of the maxillary right teeth was started to correct
but the patient had moderate crowding with an accept- the Angle Class II relationship on the right side. The max-
able facial profile and a strong desire to avoid tooth ex- illary right molars were moved distally with a nickel-
tractions except for the third molars. Therefore, we chose titanium open-coil spring placed between the first molar
maxillary molar distalization. The molars could be distal- and the second premolar. The counteraction force was
ized with conventional fixed appliances, but this would cancelled with wire ligation from the miniplate to the ca-
require patient cooperation in wearing an extraoral nine. The canine and the premolars were retracted with
device or intermaxillary elastics to prevent side effects. elastic chains from the miniplate. After achieving maxil-
Mesial inclination of the mandibular molars on the lary molar intrusion, extrusion and uprighting of
right side could also be treated by traditional uprighting the mandibular right first molar were started with inter-
mechanics including Class III elastics. However, Class III maxillary elastics applied between the miniplate and the
elastics applied to the maxillary molars directly might molar (Fig 6). After an additional 7 months, the molar
worsen the Class II intermaxillary relationship and the was aligned.

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Ohura et al 117

Fig 4. Schematic illustrations of the use of 2-step implant anchorage.

Fig 5. Photographs during treatment: A, C, and D, the maxillary right first molar was intruded with an
elastic chain through the occlusal plane placed between the miniplate and a lingual arch appliance;
A, B, D, and E, the mandibular right second molar was uprighted with an upright spring.

In the finishing and detailing phase, the mandibu-
lar incisors were reduced in size to improve the crowd-
ing and disharmony of the anterior tooth-size ratio.
After 31 months of active orthodontic treatment, an
acceptable occlusion was achieved, and the edgewise
appliances were removed. Immediately after removal,
a Begg-type retainer in the maxilla and a Hawley-
type retainer in the mandible were placed. In addition,
a lingual bonded retainer was placed in the mandibu-
lar arch.

American Journal of Orthodontics and Dentofacial Orthopedics January 2011  Vol 139  Issue 1
118 Ohura et al

Fig 6. Photographs during treatment: an intermaxillary elastic was used to extrude the mandibular first
molar.

Fig 7. Posttreatment photographs (age, 16 years 11 months).

TREATMENT RESULTS achieved, and adequate overjet and overbite were main-
The facial photographs show that overall facial bal- tained. The mandibular right first and second molars
ance was maintained. Acceptable occlusion was were significantly uprighted, and the molar

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Ohura et al 119

Fig 8. Posttreatment dental casts.

Fig 9. Comparison of dental casts on the right side: A and B, pretreatment; C and D, posttreatment.

relationships were changed to Class I on the both sides. DISCUSSION

The maxillary and mandibular dental midlines were
coincident (Figs 7 and 8).
Cephalometric analysis indicated no marked skeletal
changes. The maxillary right first molar was intruded 3.1
mm and distalized 2.0 mm at the crown level. The man-
dibular right molar was extruded by 3.4 mm (Figs 9-11,
Table). With these results, the appropriate occlusion was
achieved, and the canted occlusal plane was improved.
After 1 year of retention, the occlusion was stable,
and a good facial profile was also maintained.
In this patient, the mandibular right first molar had
tipped severely toward the mesial aspect and was in in-
fraocclusion, and the adjacent second molar was also in-
clined mesially. In addition, the maxillary first molar on
the same side had a Class II relationship and was consid-
erably overerupted, because of infraocclusion of the op-
posite teeth. Therefore, complicated orthodontic
mechanics were required to improve these problems,
and the use of 2-step implant anchorage was proposed
for this patient.

American Journal of Orthodontics and Dentofacial Orthopedics January 2011  Vol 139  Issue 1
120
Fig 10. Posttreatment radiographs.
In the first step, before uprighting the mandibular
first molar, intrusion of the maxillary first molar was re-
quired to maintain the vertical intermaxillary relation-
ships. In conventional orthodontic mechanics, absolute
molar intrusion has been considered almost impossible.
Recently, several reports have demonstrated molar intru-
sion by using implant anchorage.4,6-13 Therefore, we
placed a miniplate near the right zygomatic process.
Elastomeric chains extended from the miniplate to the
lingual arch and passed over the occlusal surface of
the maxillary first molar. This approach resulted in
successful intrusion of the molar without patient
cooperation. During the maxillary molar intrusion, the
mandibular right second molar was uprighted with
uprighting springs.
In the second step, the maxillary right dentition
was distalized to correct the Class II relationship,
and the mandibular right first molar was extruded
by using implant anchorage. Several reports of maxil-
lary molar distalization with bone anchorage showed
that more than 2.7 mm of distal movement can be
achieved.14-16 As for the miniplate, Sugawara et al15
January 2011  Vol 139  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Ohura et al
reported that the average amount of distalization of
the maxillary first molars was 3.8 mm at the crown
level. In our study, the maxillary molars were distal-
ized predictably in accordance with the necessity to
correct the anteroposterior molar relationship. Inter-
maxillary elastics were worn between the plate and
the tooth for 7 months to correct the infraocclusion
of the mandibular first molar. As a result of this elas-
tic application, the first molar was extruded to the oc-
clusal level without any reciprocal extrusion of the
maxillary posterior teeth or clockwise rotation of the
mandible.
Park et al20 introduced the uprighting method for
mesially inclined second molars in both jaws using
miniscrews. Giancotti et al21 performed traction and
uprighting of impacted second molars using minis-
crews after extraction of the mandibular third molars.
Sakai et al24 and Sugawara et al25 also reported up-
righting mandibular molars using bone anchorage. In
these reports, the implant anchorage was placed in
the retromolar area, and the orthodontic force for up-
righting was directly applied to the targeted teeth.
Ohura et al
Fig 11. Superimposition of cephalometric tracings at pretreatment (black line) and posttreatment (red
line): A, superimposed on sella-nasion plane at sella; B, superimposed on the anterior palatal contour;
C, superimposed on the mandibular plane at menton. The maxillary and mandibular molars on the right
side were illustrated.
However, our patient had malocclusions in both jaws.
In such a case, implant anchorage in both jaws might
be recommended to simplify the mechanics. However,
minimal surgical invasion and lower financial cost are
desirable. Therefore, we placed a miniplate only in
the maxillary posterior region and used vertical inter-
maxillary elastics for uprighting and extruding the
mandibular molars.
Yun et al22 reported that indirect upright positioning
of teeth was achieved by miniscrew anchorage placed in
the alveolar bone in front of mesially inclined mandibu-
lar second molars. Kuroda et al26 reported miniscrew an-
chorage use for indirect traction of impacted teeth, and
good outcomes were obtained. Not only were the molars
uprighted with less invasiveness, but also the tooth
movements in various directions were possible by
suppressing undesirable counteractions with indirect
implant anchorage. The indirect use of implant anchor-
age broadens orthodontic diagnosis and expands the
treatment possibilities.
CONCLUSIONS
The use of 2-step implant anchorage is efficient for
intrusion and distalization of maxillary molars and
extrusion of inclined mandibular molars.
American Journal of Orthodontics and Dentofacial Orthopedics
121
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