CLINICIAN’S CORNER

Treatment of ectopic mandibular second molar

with titanium miniscrews
Aldo Giancotti, DDS, MS,a Claudio Arcuri, MD, DDS,b and Alberto Barlattani, MD, DDSc
Rome, Italy

The use of a Cizeta titanium miniscrew (Cizeta Surgical, Bologna, Italy) for treating an impacted mandibular
second molar is presented in this report. The surgical procedure for placing the miniscrew and the subsequent
orthodontic management are described, including orthodontic traction with a nickel-titanium closed-coil spring
exerting 50 g of force. We concluded that the titanium miniscrew for skeletal anchorage is effective in treating
deeply impacted mandibular second molars. (Am J Orthod Dentofacial Orthop 2004;126:113-7)

M
andibular second molar impaction is a rela- miniscrews in treating deeply impacted mandibular sec-
tively rare dental anomaly, with a reported ond molars.
incidence of about 3 in 1000 (0.03%)1,2; its
treatment can sometimes be difficult for both the ortho- MATERIAL AND METHODS
dontist and the oral surgeon. Unilateral impaction of the
Cizeta Modul System 2.0 (Cizeta Surgical, Bolo-
mandibular second molar is more common than bilateral
gna, Italy) miniscrews for orthodontic anchorage are
impaction, and impactions occur more frequently in the
made of pure medical titanium and have a partial thread
mandible than in the maxilla. They are found more often
that measures 2.0 mm on the external side; the minis-
in men than in women and more frequently on the right
crews are available in lengths of 7, 9, and 11 mm, and
side than on the left. Impacted mandibular second molars
the emergent diameter is 2.3 mm (Fig 1). The minis-
are often mesially inclined.3 During the last decade,
crews have a breaking load of 869 N/mm2. They can be
various methods of treatment have been suggested, in-
purchased in a kit that also includes a drill and a
cluding conventional and unconventional approaches.4-9
screwdriver for surgical phases.
Shellhart et al10 used dental implants in extraction sites to
The miniscrew is inserted under local anesthesia. A
upright mandibular second molars. Recently, the introduc-
water-cooled pilot drill is used to prepare the surgical
tion of miniscrews for immediate loading has changed the
site with either a direct or an indirect surgical tech-
clinical and biomechanical approach to the problem.
nique. The direct method is characterized by the surgi-
Kanomi,11 Costa et al,12 Lee et al,13and Park et al14 have
cal incision of the mucosa before the drill insertion and
shown the use of titanium miniscrews for immediate
then the suture of the flap. In the indirect method, the
loading as an alternative anchorage system and discussed
pilot drill is used without removing the mucosa; this is
possible sites of insertion. Freudenthaler et al15 inserted 12
indicated when a thick gingiva is present.
titanium bicortical screws horizontally as anchorage for
When the surgical site has been prepared by using
mandibular molar protraction in 8 patients. Park et al16
the appropriate drill, the miniscrew is inserted with the
reported molar uprighting by means of microimplant
provided screwdriver (Fig 2).
anchorage in patients with mesially tipped second molars
The titanium miniscrew must have immediate good
due to the loss of the adjacent first molar. More recently,
primary stability, and it must be loaded immediately for
Maino et al17 introduced the spider screw for skeletal
mechanical stability. At the end of orthodontic treat-
anchorage for prerestorative treatment in adult patients.
ment or when the miniscrew is no longer needed for
The aim of this article is to describe our experience with
anchorage, it is removed (local anesthesia is recom-
From the University of Rome “Tor Vergata,” Fatebenefratelli Hospital, Isola mended) with the screwdriver. The oral mucosa usually
Tiberina, Rome, Italy heals in just a few days.
a
Assistant professor, Department of Orthodontics.
b
Associate professor, Department of Oral Pathology.
c
Professor and chief, Department of Dentistry. CASE REPORT
Reprint requests to: Dr Aldo Giancotti, Viale Gorizia 24/c, 00198 Rome, Italy;
e-mail, giancott@uniroma2.it. A 27-year-old man had good, untreated occlusion.
Submitted, May 2003; revised and accepted, August 2003. Unfortunately, the mandibular left second molar was
0889-5406/$30.00
Copyright © 2004 by the American Association of Orthodontists. deeply impacted, and the adjacent third molar was over
doi:10.1016/j.ajodo.2003.08.025 erupted (Fig 3).
113
114 Giancotti, Arcuri, and Barlattani
Fig 1. Cizeta titanium miniscrew and application kit.
Fig 2. Placement of 9-mm screw in retromolar region (transmucosal or indirect method).
The orthodontic treatment was to extract the third
molar and place a miniscrew in the retromolar region to
upright the impacted second. We used an indirect or
transmucosal method, perforating the cortical bone
without making a surgical flap.
After extracting the third molar, the crown of the
impacted second molar was exposed, and an orthodon-
tic bracket was bonded with a light-cured composite. A
7-mm miniscrew was placed the same day, and ortho-
dontic traction was applied by means of a closed-coil
spring tied from the mini-screw to the orthodontic
bracket, exerting about 50 g of force (Fig 4).
The orthodontic bracket bonded to the crown was
replaced mesially as soon as possible. A successive
finishing phase with a fixed appliance was needed to
align the roots (Fig 5). The miniscrew was removed
after 8 months of active treatment when the crown
positioning was complete (Fig 6). The active treatment
lasted 9 months (Fig 7).
DISCUSSION
Although the prevalence of impacted mandibular
second molars is low, this disturbance of the normal
American Journal of Orthodontics and Dentofacial Orthopedics
July 2004
process of eruption can cause significant problems.
This anomaly is often complicated by overeruption of
the opposing teeth and periodontal compromising of the
adjacent teeth. Various conventional methods have
been proposed to upright mesially impacted second
molars; the more commonly proposed treatment tech-
niques include:
● Attaching uprighting springs to a second molar
buccal tube. This requires placing a separator be-
tween the mandibular first and second molars and
then surgical removal of the mucosal or bony barrier
on the impacted molar.5
● Surgical placement of separating wires. This method
is complicated, provides limited tooth movement,
and can cause periodontal problems.18
● Placing pins in the dentition. Placing and cementing
the pins and restoring the pinholes can be difficult.18
● Cementing a partial crown to the exposed part of the
second molar, allowing tooth movement with
springs.18
Surgical treatment has also been proposed for reposi-
American Journal of Orthodontics and Dentofacial Orthopedics Giancotti, Arcuri, and Barlattani 115
Volume 126, Number 1

Fig 3. Ectopic mandibular second molar in a 27-year-old man.

Fig 4. Seven-millimeter titanium miniscrew was inserted just behind extracted third molar and
immediately loaded with 50-g force on nickel-titanium closed coil spring. After crown extruded,
tooth was uprighed with fixed sectional appliance.

tioning deeply impacted molars.18-23 Surgical tech-
niques include:
● Surgically uprighting the second molar and splinting
with autogenous bone grafts.19
● Surgically replacing alveolar bone with cancellous
bone to speed up the correction of the impacted
tooth’s axial inclination.22 This method has serious
limitations, the prognosis is not always positive, and,
if the second molar is deeply impacted, the ortho-
dontic treatment can be particularly complex because
of the difficulty in placing the conventional devices
for molar uprighting. Moreover, this technique can
require a complex surgical procedure, and the pulpal
or periodontal posttreatment complications must be
strongly considered.24
CONCLUSIONS
Using titanium miniscrews as absolute anchorage
offers several advantages and can aid in achieving an
optimal treatment outcome. The miniscrews have good
mechanical retention and, as recently demonstrated in
dogs,20 can function as rigid osseous anchorage against
orthodontic load for 3 months with a minimal (less than
3 weeks) healing period. This permits their immediate
loading with light and continuous forces by nickel-
titanium closed-coil spring or elastomeric thread.
Moreover, the retromolar placement of the miniscrews
has relevant biomechanical advantages, permitting the
application of force distal to the center of resistance of
the second molar and facilitating vertical control during
the extrusion phase of treatment. The use of preloaded
nickel-titanium closed-coil springs offers adjunctive
benefits. Reactivation of the system is unnecessary,
thus reducing patient discomfort, chair time, and ap-
pointment frequency. The surgical procedures for plac-
ing and removing the miniscrews are well tolerated by
patients and, in our experience, have little risk of
infection.
116 Giancotti, Arcuri, and Barlattani American Journal of Orthodontics and Dentofacial Orthopedics
July 2004

Fig 5. Progress radiographs.

Fig 6. Miniscrew removed with dedicated screwdriver.

Fig 7. Posttreatment radiographs after 8 months of active treatment.

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