Ramus screws: the ultimate solution for

lower impacted molars

Chris H. Chang, Joshua S. Lin, and W. Eugene Roberts

It is usually desirable to recover horizontally impacted mandibular molars.

Impacted third molars may also be valuable dental units if the adjacent first or
second molars are compromised or missing. Uprighting horizontally
impacted third molars prior to extraction may be a wise measure to avoid
damaging the second molar and its periodontium and inferior alveolar nerve
during a surgical extraction procedure. However, uprighting horizontally
impacted molars is complex and/or difficult for the orthodontist and oral
surgeon. Lin (2011 [1]) reviewed six different methods for recovering deeply
impacted molars, and concluded that the most reliable and effective
approach was to surgically expose the deeply impacted molars and
upright them with traction via a ramus screw (Lee et al., 2014 [2]; Lin
et al., 2014 [3]). From a biomechanics perspective, the anterior ramus of the
mandible is an ideal location for an anchorage screw. However, this anatomic
area appears to be a high risk site because it is covered with thick, mobile soft
tissue (Lin et al., 2015 [4]). This article is aimed at increasing the confidence of
clinicians relative to the use of ramus screws by reviewing the treatment
planning, surgical procedures, orthodontic mechanics, and reliability of the
procedure. (Semin Orthod 2018; 24:135–154.) & 2018 Elsevier Inc. All rights
reserved.

Introduction (LR), and (3) teeth in each quadrant are

numbered from 1 to 8 relative to the midline
orizontally impacted mandibular molars
H are complex problems that are refractory
to routine orthodontic treatment (Fig. 1).
(modified Palmer notation).
An efficient treatment strategy requires
development of anchorage devices that were
Relative incidence of impaction is highest for
suitable for the challenging intraoral sites outside
mandibular and maxillary third molars, followed
the alveolar process. Roberts et al.9 utilized
by maxillary canines and mandibular second
osseointegrated implants as extra-alveolar (E-A)
molars.5 The prevalence of impacted second
temporary anchorage devices (TADs) for closing
molars is ≤2.3%.6,7 The latter may be due to
edentulous spaces in the mandibular arch. These
ectopic position, obstacles in the path of erup-
retromolar devices were reliable and efficient,
tion, and/or failure of the tooth eruption
but not suitable for uprighting horizontal L7
mechanism.8 For this report the following
impactions because there was no convenient
nomenclature will be used: (1) upper (U) and
site for an osseointegrated fixture distal to
lower (L) arches, (2) the dental arches are
the impaction. Subsequently, Kanomi10 and
divided into four quadrants, upper left (UL)
others11,12 introduced multiple types of tita-
and right (UR), and lower left (LL) and right
nium alloy (Ti) miniscrews that were placed in
the alveolar process between the roots of teeth.
Beethoven Orthodontic Center, Hsinchu, Taiwan; Beethoven These interradicular (I-R) devices were not well
Orthodontic Center, Hsinchu, Taiwan; Mechanical Engineering, suited for complex problems like horizontal
Indiana University & Purdue University, Indianapolis, Indiana impactions, and furthermore they often had a
46236. high failure rate particularly in the posterior
Corresponding author. Tel.: +317-823-6115, 317-410-2805.
E-mail: werobert@iu.edu
mandible. In addition, I-R TADs had other lim-
itations13–16 including damaging the roots of
& 2018 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0 teeth, moving within bone, and interference with
https://doi.org/10.1053/j.sodo.2018.01.012 the path of tooth movement, so they were

Seminars in Orthodontics, Vol 24, No 1, 2018: pp 135–154 135

136 Chang et al

Figure 1. Deep horizontal impaction of lower molars is one of the most challenging orthodontic problems.

not suitable for managing deep horizontal
impactions.
Realizing the deficiency of TADs (retromolar
and I-R) in managing horizontal impactions,
Chang et al.13 expanded the E-A TAD concept by
developing a 2 mm diameter stainless steel (SS)
bone screw (Fig. 2) that was suitable for dense
cortical bone sites, such as the mandibular buccal
shelf (MBS). The MBS bone screw is placed
lateral to the first (6s) and second (7s) molars, so
it does not interfere with the retromolar location
of horizontal impactions, or the path of tooth
movement within the alveolar process. However,
active mechanics to recover horizontal
impactions with MBS bone screws are complex
and difficult to control. To better address the
mechanical problems, bone screws are placed in
the anterior ramus of the mandible to provide a
more superior and posterior direction of
traction, along the plane of the impaction.
Simple and efficient mechanics are designed to
upright the impacted lower molars with ramus
screw anchorage. In this article, a report for a
patient with deeply impacted lower 7s is
presented, along with a detailed discussion of
treatment plan options, mechanical design, step-
by-step surgical procedures, and other clinical
insights. Critical clinical considerations are the
primary failure rate, the ideal material for
ramus screw construction, and design of the
devices. Detailed mechanics are presented for
treating deeply horizontally impacted lower
molars (7s).
Case report, treatment options and
mechanical design
A 27-year-old male presented with deeply
impacted LL7 and LR7, and a mesially tipped
LL8. The other third molars (LR8, UR8 and
UL8) were also impacted (Fig. 3). Chief
complaints were poor function and possibility
of further damage to the dentition. This complex
set of anomalies required a careful consideration
of the etiology to establish a reliable basis for
treatment planning. The etiology may be an

Figure 2. The 2 × 14 mm stainless steel OrthoBoneScrew® is designed to be inserted in the anterior ramus of the
mandible as a self-drilling fixture.
 Ramus screws: the ultimate solution for lower impacted molars
Figure 3. A pre-treatment panoramic radiograph (above) and intra-oral occlusal photographs (below) document
a challenging malocclusion with multiple impacted molars.
aberrant orientation or position of a tooth bud(s)
leading to an abnormal path(s) of eruption.
Treatment options
Avoiding treatment was not a viable consid-
eration because it failed to address the patient’s
chief complaints.
Upper arch
1. Extract impacted U8s: It may be difficult to
extract the 8s without damaging the roots of
the 7s. Furthermore the extraction site may
heal with a soft tissue defect on the distal of the
7s which would offer a poor prognosis for the
affected teeth.
2. Extract the U7s: Allow for spontaneous eruption
of the U8s. This is an attractive option because
it involves less surgical risk, but the impacted
U8s may not erupt properly.
Lower arch
1. Extract L7s and L8s: Place a subperiosteal
membrane for guided bone regeneration, and
137
subsequently place implants to restore the L7s.
The concerns for this option are the possibility
of damaging the inferior alveolar nerve, and
healing of the surgical site is unpredictable.
2. Extract L8s and align L7s with a ramus screw: This
is an attractive option if the deeply impacted
L7s can be moved and there are no complica-
tions in placing or removing the ramus screw
(Fig. 4).
After a thorough discussion of the pros and
cons of each approach, the patient selected the
second option for each arch: extract U7s and L8s,
place bilateral mandibular ramus bone screws,
and bond attachments on the distal surface of
each impacted L7 (Fig. 5).
Mechanical design
Deciding between extraction or uprighting for
deeply impacted teeth is a challenging aspect of
treatment planning. Factors affecting the deci-
sion include severity of the impaction, its position
relative to critical anatomical structures (inferior
alveolar nerve and lingual artery, etc.), pre-
existing conditions of impacted teeth (caries,
root dilaceration, periodontal health, etc.), and
138 Chang et al

Figure 4. The treatment plan was to extract the molars marked with an X, upright the L7s (lower curve arrows),
and allow the U8s to erupt normally.

difficulty of the surgical procedure. If ortho-
dontics is indicated, an efficient mechanics plan
is required.
Uprighting the impacted L7s with ramus screw
anchorage was by far the most cost-effective
option compared to a restorative solution
because of the unpredictability of nerve
injury, post-operative healing of the extraction
site, bone augmentation if needed, implant
placement, and subsequent restoration
procedures.
Many methods of uprighting molars have
been proposed,1 but the present mechanical
design is simple, effective and expedient.
Impactions will usually erupt if all obstructions
are removed in the path of eruption, such as the

Figure 5. Segments of a postoperative panoramic radiograph show the mechanics in the posterior quadrants to
upright lower impacted molars. A button was bonded on the right side and an eyelet was used on the left side to
apply traction to the impactions as shown by the curved arrows.
 Ramus screws: the ultimate solution for lower impacted molars 139

All of the potential etiologic factors were

addressed by extracting the L8s and gently lux-
ating the horizontal 7s (Fig. 7A).

Figure 6. Etiology, treatment and complications
potential of a L7 horizontal impaction in the mandible
is related to multiple variables: 1. overlying impacted
third molar (L8) (blue), 2. cortical bone superior to
the crown of the impaction (red), 3. potential ankylosis
of the L7 (yellow), 4. distal undercut of the adjacent L6
(green), and 5. the mandibular canal (pink) is very
close to the root of the impacted L7.
Tips 2
Design an effective force system for uprighting
the impacted tooth (teeth).2,18 Uprighting a
deep horizontal impaction requires both occlusal
and distal components of force to unlock the
impaction from its position against the first molar
root, and then upright it. Avoid bonding a
bracket on the adjacent L6 until the impacted L7
is at least partially uprighted. This will allow the
L6 to move out of the way if necessary to prevent
root resorption. E-A TADs can provide favorable
anchorage without side effects on the dentition.
The dense cortical bone of the ramus is a good
site for a specifically designed TAD (Fig. 7B).

dental follicle, other impacted teeth and/or
pathology.17 There are two essential tips for
ensuring routine success (Fig. 6).
Tips 1. Carefully consider the etiology of the
problem (Fig. 6)
a. Impacted L8 putting pressure on the under-
lying L7
b. Thick cortical bone blocking the eruption of
the L7
c. Ankylosis of the L7, and/or
d. The crown of the L7 engaging the undercut
on the distal of the L6.
Surgical procedures
Under local anesthesia, the L8s were extracted.
An explorer was used to locate the crowns of L7s,
because tooth surface is smooth and hard, while
bone is crunchy and irregular. Once the L7
crowns were located, bone was removed with a
high-speed handpiece down to the cementoe-
namel junction (CEJ) to expose the distal surface
of the L7s. The horizontally oriented L7s were
surgically luxated to rule out ankylosis, and an
attachment was bonded on the distal surfaces
(Fig. 5). Then, bone screws (OrthoBoneScrew®,
2 × 14 mm, Newton’s A Ltd, Hsinchu, Taiwan)
were inserted in the ramus of the mandible

Figure 7. (A) After extraction of the lower third molar (dotted blue), the covering bone (red) was removed with a
high-speed handpiece. (B)The OBS was inserted into the ascending ramus, then the elastic chains (power chains)
were used for traction to upright the horizontally impacted L7. Note that the adjacent L6 was not bonded so that it
was free to move out of the way if it was contacted during the uprighting of the impacted L7.
140
Figure 8. Left: under local anesthesia, the insertion site for the OBS in the left ramus is marked with a surgical
explorer by penetrating the soft tissue to the bone. Right: the insertion site for the ramus screw is parallel but about
5–8 mm above the mandibular occlusal plane.
bilaterally (Fig. 8). Elastic chains, anchored by
the bone screws, were stretched and connected
to the attachments bonded on the distal surfaces
of the L7s (Fig. 7). To control bleeding, the soft
tissue wound was closed with interrupted sutures,
which were removed after one week. Five months
(5 m) into treatment the second molars were
sufficiently uprighted so that routine brackets
were bonded on the buccal surfaces (Fig. 9).
Discussion
Etiology of impaction
Failure of permanent teeth to erupt is a chal-
lenging diagnostic consideration because they
are difficult to detect when first manifest
during the mixed dentition period. Previous
reports7,8,19,20 classified failure of eruption into
the general categories of impaction, primary
retention or secondary retention (Table 1).
Impaction is defined as a tooth failing to erupt
because of its functional position relative to the
occlusal plane due to ectopic eruption or a
physical barrier in the path of eruption or
abnormal eruptive direction.8,20 Primary reten-
tion is the cessation of eruptive process for a
tooth in a normal eruptive position in the
absence of any physical barrier. The etiology may
be a genetic disturbance in eruption or failure of
the dental follicle to resorb normally. When the
tooth has a normal radiographic orientation for
eruption but is at least 2 years behind schedule,
primary retention (failure to erupt) is probable.
Secondary retention is the cessation of passive
Chang et al
eruption after a tooth has emerged, which is
usually diagnosed from infra-occlusion due to an
acquired ankylosis.19
According to the differential diagnosis, there
are also different treatment options based on the
etiologic factors. If the impaction is due to a
physical barrier blocking the path of eruption,
provide adequate space in the arch and then
remove obstacles, such as odontogenic tumors,
cysts or a supernumerary tooth. If the desired
path of eruption is not along the long axis of the
impaction, uncovering the tooth, bonding an
attachment, and orthodontic traction may be
needed.
If there are no apparent etiologic factors,
primary retention is default diagnosis. The usual
treatment is to orthodontically create a desired
path for eruption (if needed), surgically expose
the crown of the tooth, bond an orthodontic
attachment on the enamel, luxate the impaction
to disrupt ankylosis if present, and apply traction
along the desired path of tooth movement.
For the present patient, the suspected etiology
of L7s impaction was a mesial orientation of the
tooth buds and/or superior position of the L8
tooth buds that blocked the normal path of
eruption. The anomalous path of eruption
resulted in the occlusal surfaces of the L7s
infringing on the roots of the adjacent L6s,
bilaterally. When a L7 is horizontally impacted
against the L6 root, the distal curvature of the L6
crown may prevent uprighting of the L7. Sub-
sequently, dense cortical bone occlusal to the L7
crown and the overlying L8 impaction become
physical barriers to L7 uprighting. Ankyloses of
 Ramus screws: the ultimate solution for lower impacted molars 141

Figure 9. The panoramic films were taken immediately after surgery (0 m), and then at the 1st, 2nd, 4th and 5th
month of treatment as indicated. Standard molar tubes were bonded on the buccal surface of the L7s after 5
months (5 m) of traction.

impactions is always a lingering concern, so most Ramus as a TAD site

surgeons prefer to luxate the impaction when it is
uncovered. To avoid bleeding interfering with
the bonding procedure, the modest luxation is
usually performed after the attachment has been
bonded on the crown of the impaction.
An efficient, yet simple mechanism is required
to recover deeply impacted or mesially tipped
(mesio-angular) mandibular molars. Lin1
reviewed six different methods for recovering
142 Chang et al

Table 1. A decision-making flowchart, to efficiently treat an impaction, begins with an

ordered process for the diagnosis and etiology, that serves as the basis for the
preferred treatment.7,8,19,20 The differential diagnosis considers three possibilities:
primary retention, physical barrier and/or ectopic eruption. Primary retention and
ectopic eruption lead to a specific treatment sequence, but a physical barrier must be
differentiated into a lack of space or an object blocking eruption. All the possibilities
lead to the preferential treatment which is eruption of the tooth into normal function.
If recovery of the impaction fails, then the diagnosis is secondary retention and/or
ankylosis, and the probable treatment is extraction (lower right).

deeply impacted molars, and concluded that the
most reliable and efficient approach was surgical
exposure and uprighting with traction via a
ramus bone screw.2,3 The selection of the ana-
tomical site and the screw design (Fig. 2) was
based on a careful study of anatomy of the
anterior ramus (Fig. 10). The optimal site for
a direct line of traction without occlusal
interference is midway between the external
and internal oblique ridges of the ascending
ramus, about 5–8 mm above the occlusal plane
(Figs. 8 and 10).
2 × 14 mm screws
Previous studies with mandibular buccal
shelf,1,9,14 utilized 2 × 12 mm stainless steel
screws (SS), because the soft tissue was less than

Figure 10. From the occlusal perspective (A), note the relatively smooth, broad area between the internal and
external oblique ridges. In the lateral view (B) note that the insertion point for the bone screw (red arrow) is
distant from the mandibular foramen and inferior alveolar canal. The insertion site for a ramus screw, as shown
with a red arrow in each plane, is between the external and internal oblique ridges, is parallel but about 5–8 mm
superior to the occlusal plane.
 Ramus screws: the ultimate solution for lower impacted molars 143

Figure 11. The insertion sites for two types of E-A bone screws are compared. (A) A 2 × 12 mm screw is well
secured in ~3 mm of bone in the mandibular buccal shelf, leaving adequate clearance above the soft tissue of
~5 mm, for routine oral hygiene. (B) The ramus screw must penetrate much thicker soft tissue to engage bone, so a
2 × 14 mm SS screw is required to achieve the same results.

3 mm thick. A 12 mm screw length was adequate
to leave  5 mm of clearance between soft tissue
and the head of the screw after installation
(Figs. 11–13). On the other hand, a ramus screw
must penetrate much thicker soft tissue before
engaging the dense cortical bone of the
Figure 12. (A) A clinical photograph shows that the
head of a ramus screw is ~5 mm above the soft tissue
for hygiene access. (B) Consistent with 5 mm of soft
tissue clearance the average bone engagement for a
ramus screw is ~3 mm.
mandible. A 14 mm screw was necessary to pro-
vide at least 5 mm of soft tissue clearance, after
the bone has been penetrated 3 mm or more
(Fig. 12).4
Complications and failure rate of ramus screw
For TADs in a challenging intraoral site like the
anterior ramus of the mandible, major concerns
were complications and failure. The anatomical
structure presenting the most serious risk for
complication, is the neurovascular bundle of the
inferior alveolar (mandibular) canal (Fig. 10).
Under usual clinical conditions, the ramus TAD
site is about 15–20 mm away from the neurovas-
cular bundle. Once the screws are inserted,
postoperative panoramic films revealed that
the screw tip is within 5–8 mm of the man-
dibular canal (Figs. 13 and 14). Fig. 15 is a series
of drawings that illustrate the details for utilizing
a ramus screw to upright a horizontally impacted
molar. If a clinician carefully follows the detailed
instructions provided, the risk of complications is
minimal.
Retromolar osseointegrated implants,9 and
the original E-A TADs, have about the same
failure rate as other osseointegrated prosthetic
abutments (o5%), but the risk of failure for
common I-R miniscrews is much greater,
which may relate to their highly variable
shape, diameter (1.0–2.3 mm), and length
(4–21 mm).14–16,21–26 Rather than reporting
failure incidence, many authors report the clinical
experience with I-R TADs as a mini-implants for
ort% to 95%, with an average of about 84%.27–29
To correct a wide variety of malocclusions,
144 Chang et al

Figure 13. The muscle in the retromolar area is composed of (A) traversing fibers of the medial pterygoid and (B)
anterior fibers of the temporalis that are inserting into the medial aspect of the mandibular ramus.

SS miniscrews are used in E-A sites such as the
MBS and infrazygomatic crest (IZC) for retracting
or protracting individual teeth or entire arches. A
large study of 1680 consecutive MBS miniscrews
reported a failure rate of only 7.2%,13 which is
considerably lower than for I-R miniscrews in the
mandible (19.3%) or the maxilla (12.0%).30,31
A detailed review of TAD failure at multiple
skeletal sites was conducted in order to design a
reliable bone screw for recovering horizontal
molar impactions.32 Based on the previous
experience with buccal shelf bone screws,13 it
is surprising that none of the ramus screws
loosened during the initial 4 months of
traction. Only 2 out of 40 ramus screws (5%)
failed to serve as adequate anchorage for
uprighting the horizontal impaction (Table 2).
Neither “failure” was for a loose screw, but there
was soft tissue hyperplasia and severe
inflammation around both TAD heads that was
associated with poor oral hygiene in adolescents.
Both patients with the initial failures were
successfully treated by removing the screws,
resecting the hyperplastic tissue, and replacing
the TAD in an adjacent location. From the
experience to date, it is clear that the “success”
of ramus screws depends primarily on
appropriate hygiene measures. So it is very
important to provide hygiene instructions and
monitor soft tissue inflammation at each
appointment.33
Screw fractures in the absence of pre-drilling
Fracture is a significant risk for small diameter
(o2 mm) screws made of brittle materials like
titanium or titanium alloy, and inserted into
dense cortical bone with a self-drilling techni-
que.34 A fractured screw is worrisome for the
patient, and may result in injury to adjacent
tissue, or block the desired site for a TAD. Risk of
screw fracture is decreased by increasing the
diameter of the screw to at least 2 mm, using a
tougher material such as stainless steel (SS), and

Figure 14. Panoramic films was taken immediately after 3 ramus screw insertions to evaluate the angulation of the
screws, and estimate their proximity to the neurovascular bundle. None of the screws were closer than 5 mm to the
inferior alveolar canal.
 Ramus screws: the ultimate solution for lower impacted molars 145

Figure 15. A series of eleven drawings illustrate the anatomic details for ramus screw placement. (A) An occlusal
semitransparent view illustrates the anatomy of a horizontally impacted molar. (B) A similar perspective shows the
position of the ramus screw distal and superior to the impaction. (C) A medial view shows a ramus screw that is
oriented along the occlusal plane. (D) An attachment, with an elastic chain attached, is bonded to the crown of the
impaction. (E) The elastic chain is attached to the head of the screw to apply superior and distal traction at the start
of active treatment (0 m). (F) Uprighting progress is shown at 1 month (1 m), (G) Reactivation is shown by
engaging the second loop in the chain at 1 m. (H) The chain is trimmed with scissors. (I–K) Progress is illustrated
from 2–4 M, respectively. See text for details.
146 Chang et al

Table 2

drilling a pilot hole for the screw. The latter is not self-drilling screws made of SS is a practical
practical because of the thick soft tissue covering approach for decreasing fracture risk. On the
the anterior ramus, but using 2 mm diameter contrary, increasing the length of a screw to

Figure 16. The pre-treatment panoramic radiograph at 10 years and 1 month (10y01m) old patient shows
the positions of the LR7 (#47), LR6 (#46) and LR5 (#45). Relative to the alveolar crest (dotted yellow line), the
occlusal surface of tooth #46 was inferior to both #45 (green lines) and #47 (pink line). Eight months later the
panoramic film at 10y09m showed that the occlusal surfaces of teeth #45 and #47 had reached the alveolar ridge
and were close to emerging in the oral cavity. However, the position of #46 was unchanged so the relative
difference in the levels of the occlusal surfaces was increased, as shown by the green and pink lines in the lower
film.
 Ramus screws: the ultimate solution for lower impacted molars 147

Figure 17. Pre-treatment radiographic and intraoral photographs at 11y0m document the impaction of the LR6
immediately prior to the emergence of the LR5 and LR7.

Figure 18. A CBCT scan shows the sagittal view of the impaction (upper left) with a vertical gold line marking the
frontal cut through the mesial root of the LR6 shown in the upper right illustration. The dilacerated root is
impinging on the inferior alveolar nerve (IAN) along the lingual surface of the cortical plate of bone.
148 Chang et al
Figure 19. The surgical uncovering of the LR6
(above) required carefully removing all the bone
(blue) superior to the crown as shown in the radio-
graph (below). See text for details.
14 mm renders it more susceptible to a flexure-
related fracture. However to date none of the
screws have fractured, so all considered 2 ×
14 mm SS bone screws appear well suited as
ramus TADs.
Figure 20. An elastomeric chain was attached to an
eyelet bonded on the occlusal surface of the LR6. The
opposite end of the chain was stretched and attached
to the head of the ramus screw to apply distal and
superior traction to the impacted LR6.
Figure 21. The post-operative buccal view (0 m) of the
operated site shows the elastomeric chain from ramus
screw entering the wound.
Case 1—impacted lower first molar
A 10 yr 01 mo girl and her parents presented for
orthodontic evaluation with a chief complaint of
poor chewing ability. A panoramic radiograph
documented delayed eruption of the LR6 (#46 in
FDI tooth nomenclature) compared to complete
eruption of the LL6 (#36). The lack of occlusal
contact resulted in over-eruption of its antago-
nist (UR6, #16) and poor functional oc-
clusion (Fig.16). Eight months later, a follow-up
panoramic radiograph (10 yr 09 mo) revealed no
progress in the eruption of the LR6. The distance
from the tooth to the alveolar crest had increased
as the rest of the dentition extruded with growth.
Furthermore, the desired path of eruption was
decreased in width between teeth 45 and 47
(Figs. 16 and 17). A cone-beam computed
tomography (CBCT) scan was ordered to eval-
uate the impacted tooth and surrounding tissue
(Fig. 18). The roots of #46 were in close pro-
ximity to the inferior cortical plate of the
Figure 22. The post-operative frontal view (0 m)
shows the wound is closed with interrupted catgut
sutures for hemostasis.
 Ramus screws: the ultimate solution for lower impacted molars 149

Figure 23. Panoramic radiographs document the extrusion of the LR6 and its emergence into the oral cavity: 0 m
immediately post-operative, 2 m after 2 months of traction, and 4 m when the medial aspect of the occlusal surface
has emerged.

mandible, the inferior alveolar nerve (IAN) was via a ramus screw to extrude the impacted LR6
compressed on the mesial surface of the up to the occlusal plane.
dilacerated apex of the root.

Step by step surgical procedures

Treatment plan
Surgical exposure of LR6 (#46) was followed by
bonding an attachment on the occlusal surface of
the impaction, and applying orthodontic traction
First: Under local anesthesia the mobile LR 2nd
primary molar (#85) was removed for a better
view of the surgical field, and to help clear a path
of eruption for the LR6.

Figure 24. A pre-treatment panoramic radiograph (above) and intraoral radiographs (below) of an eleven year old
(11 y/o) patient show a deeply impacted LR6 compared to the contralateral LL6 which was in normal occlusion.
150 Chang et al

Figure 25. An immediate post-operative panoramic film (left) is compared to progress films exposed 2 month
later (middle) and 6 month later (right).

Second: A buccal flap was reflected after a mid-
crestal incision, and the cortical bone between
teeth 45 and 47 was removed with a carbide bur
in a high-speed handpiece.
Note: A surgical explorer is used to confirm
that all bone is removed superior to the crown
of tooth 46 (Fig. 19). Then modestly luxate the
tooth with an elevator to fracture any areas of
ankylosis that may be present.
Third: An eyelet with an elastic chain attached
was bonded on the occlusal surface of the
impacted LR6. Subsequently an OrthoBone-
Screw® (OBS) 2 × 14 mm (Newton′s A Ltd,
Hsinchu, Taiwan) was inserted in the ramus of

Figure 26. Pre-treatment panoramic radiograph and intra-oral photographs of a 19-year-old (19 y/o) patient show
horizontal impactions of the lower second molars (LR7 and LL7), but the LR7 is more deeply impacted under the
LR8.
 Ramus screws: the ultimate solution for lower impacted molars 151

Figure 27. Paired intraoral photographs and panoramic films show the progress in uprighting a LR7. The
immediate post-operative views are at zero months (0 m). Two month (2 m) and four month (4 m) documentation
of progress is shown in the middle and lower views, respectively.

the mandible. The elastic chain was stretched bond a buccal molar tube to receive the lower
from the eyelet to the screw to apply traction to archwire (Fig. 23).
the first molar (Fig. 20–22).

Note: After insertion of the ramus screw, the
patient was asked to close the mandible to
confirm that there was no occlusal interfer-
ence on the screw or the surrounding
soft tissue (Fig. 21). Interrupted catgut
sutures closed the wound for post-operative
hemostasis, and were removed a few weeks
later (Fig. 22).
Two months later (4th month of treatment)
the impacted tooth was sufficiently extruded to
Case 2—Impacted lower first molar
An 11-year-old boy presented with a deeply
impacted LR6 (FDI #46) with an enlarged dental
follicle, compared to the complete eruption of the
LL6 (#36) (Fig. 24). The adjacent 2nd deciduous
molar was extracted and the impacted molar was
surgically exposed. An eyelet fitted with an elastic
chain was bonded on the distal aspect of the
occlusal surface, and a 2 × 14 mm OBS was
inserted in the anterior ramus of the mandible,
152
Figure 28. The impacted LR7 was well aligned as shown in the post-treatment panoramic radiograph. However,
unusual osseous anatomy was apparent in the lower left molar area: resorption of the distal root of the LL6, and a
large radiolucency between the LL6 and LL7. Follow-up care unrelated to the impaction was indicated. See text for
details.
distal to the impaction. The elastic chain was
activated by attaching it to the ramus screw,
thereby applying traction to extrude and
upright the LR6. Panoramic radiographs
documented the immediate postoperative result
and two months of orthodontic progress (Fig. 25).
Case 3—Impacted lower second molar
A 19-year-old male presented for orthodontic
consultation with chief complaints of delayed
eruption of mandibular molars, poor masticatory
function and irregular dentition. Several ortho-
dontists had previously recommended extraction
of all four lower molars, and restoration of the
occlusion with implant-supported prostheses
(Fig. 26). The treatment plan proposed was
extraction of four molars: RU8, LU8, LR8 and
LL7. The deeply impacted LR6 was uprighted
and extruded with a 2 × 14 mm ramus OBS, and
the dentition was aligned with a passive self-
ligating bracket system (Fig. 27). Treatment
progress was documented postoperatively, at 2
Chang et al
months, and at 4 months in Fig. 27. After 40 months
of active treatment, all appliances were removed
(Fig. 28). Upper clear and lower fixed anterior
retainers were delivered as planned. However, the
post-treatment panoramic radiograph revealed
additional pathology in the lower left quadrant: a
radiolucency on the mesial root, root resorption of
the distal root of the LL6, and a large interproxial
radiolucency between LL6 and LL7. These
radiographic evidences are consistent with a LL6
endodontic problem. This issue must be further
evaluated and treated as needed.
Conclusions
1. A horizontally impacted mandibular molar
can be uprighted and aligned by direct
traction from a 2 × 14 mm SS bone screw,
inserted in the anterior ramus of the
mandible.
2. The method is expedient, efficient, and
predictable.
3. It is critical to maintain at least 5 mm
clearance from the soft tissue to the screw
 Ramus screws: the ultimate solution for lower impacted molars
head for facilitating oral hygiene to control
soft tissue irritation.
4. The failure rate of the E-A ramus screws (5%)
is slightly less than for buccal shelf bone screws
(7.2%), and is much less than I-R miniscrews
in the maxilla (12%) or in the mandible
(19.5%).30,31
5. The two failures for the first 40 ramus bone
screws were due to poor hygiene, and both
patients were retreated with the same method
to a desirable outcome.
6. In effect, the ramus screw anchorage mech-
anism was 100% successful for recovering
periodontally healthy, horizontally impacted
mandibular molars.
Acknowledgment
Thanks to Mr. Paul Head for proofreading this article
and Dr. Rungsi Thavarungkul for the beautiful illustrations.
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