DENTiSTRY

Mandibular Molar Protraction with Orthodontic

Temporary Anchorage Devices: A Case Report
Anurag Bhagat*, Meenu Goel†, Puneet Batra‡, Rajiv K Chugh#

Abstract
Management of patients with congenitally missing mandibular second premolars continues to challenge clinicians to find the
best treatment options. The Orthodontist must make the proper decision at the appropriate time regarding management of
the edentulous space. If space is left for an eventual prosthetic replacement, the clinician should try to create the exact amount
of space required and leave the alveolar ridge in an ideal condition for the future restoration. If the space is to be closed
orthodontically, detrimental changes to the occlusion and facial profile must be prevented. Therefore, the correct decision must
be made at the appropriate time. This paper presents a case report of a congenitally missing lower left second premolar where
molar protraction with orthodontic temporary anchorage device has been done.
Keywords: Congenitally missing second premolar, orthodontic temporary anchorage device, mandibular molar
protraction

M
any orthodontic patients have posterior
spacing due to missing mandibular teeth.
Excluding the third molars, the mandibular
second premolar is the most common congenitally
absent tooth, which is reported to occur in 2.5-5% of
the population in the USA and Europe. Such absence
ensues bilaterally in 60% of instances.1-3 There is an
assortment of treatment options if the problem is
diagnosed early during the period of mixed dentition.
These treatment modalities can be broken down into
two main groups based on the decision to keep or
extract the primary molars. The Orthodontist must
make the proper decision at the appropriate time
regarding management of the edentulous space. If
space is left for an eventual prosthetic replacement,
the clinician should try to create the exact amount of
space required and leave the alveolar ridge in an ideal
condition for the future restoration. If the space is to
be closed orthodontically, molar protraction can be an
alternative to restoration with posterior dental implants
or fixed partial dentures. Intraoral skeletal anchorage
*Consultant Orthodontist
†Senior Lecturer
‡Professor and Head
Dept. of Orthodontics
Institute of Dental Studies and Technologies, New Delhi
#Consultant Endodontist
Dr Chugh’s Dental Centre, Greater Kailash, New Delhi
Address for correspondence
Dr Rajiv K Chugh
W-5, Greater Kailash-1, New Delhi -110 048
E-mail: drchughs@gmail.com
(miniplates, screws) provides absolute anchorage for
various tooth movements without requiring patient
cooperation and anchorage preparation and gets
predictable treatment results more rapidly..4-6
Orthodontic temporary anchorage devices (TADs)
can provide skeletal anchorage for mandibular molar
protraction, avoiding the problems often encountered
with the use of dental anchorage. This article presents a
case report of a congenitally missing unilateral second
premolar for molar protraction with orthodontic
temporary anchorage device.
CASE REPORT
A female aged 13 years was referred to the dental OPD
for orthodontic consultation. Her chief complaint was
noneruption of permanent tooth after the extraction of
deciduous tooth in lower left quadrant. There was no
remarkable medical history and temporomandibular
joint function was normal (Fig. 1). A panoramic
radiograph revealed congenitally missing 35 (Fig. 2).
The two treatment options offered to the patient
were: 1) The space to be closed orthodontically by
complete mesialization of mandibular first molar
taking advantage of fresh extraction socket; 2) create
the exact amount of space required orthodontically for
an eventual prosthetic replacement. Treatment plans
were explained to the patient. The patient was not
willing for any prosthetic replacement therefore;
considering the age of the patient and taking advantage
of fresh extraction socket, protraction of lower left

338 Indian Journal of Clinical Practice, Vol. 25, No. 4, September 2014

Figure 1 a). Pre-treatment extraoral photographs.
Figure 1 b). Pre-treatment intraoral photographs.
Figure 1 c). Pre-treatment lateral cephalogram.
first and second molar to fill the extraction space
orthodontically was planned.
The patient was bonded with 0.022” MBT appliance
using ceramic brackets and molar protraction was
done on 0.019” x 0.025” stainless steel wire. Closing the
space of a primary molar, which is often 10-11 mm, is
difficult at best and may result in a midline shift and
flattening of the face.7 If the patient has a protrusive
DENTiSTRY
Figure 2. Pre-treatment panoramic radiograph.
Figure 3. IOPA showing small odontomatous mass.
profile or moderate crowding, space closure is favored.
However, in the absence of crowding and a good facial
profile, space closure has undesirable side effects. The
introduction of temporary anchorage devices, such as
miniscrew implants, has created more options for space
closure.8 By utilizing such implants, the molars can be
Indian Journal of Clinical Practice, Vol. 25, No. 4, September 2014 339
DENTiSTRY
Figure 4 a). Post-treatment extraoral photographs.
Figure 4 b). Post-treatment intraoral photographs.
protracted without side effects on the anterior teeth of
the arch.
A microscrew of 8 mm length and 1.5 mm of diameter
was placed mesial to the edentulous space to avoid
impeding the molar protraction. A small odontomatous
mass (Fig. 3) was observed which was extracted after
placement of the microscrew. An open-coil spring with
100 g of force was used to protract the mandibular
molar. The open-coil spring tips the crown enough
to provide complete space closure. In this case, the
protraction of mandibular molars was achieved
without any detrimental effect on facial balance
(Fig. 4). The minimal variation in incisor position and
the extensive molar protraction confirmed the excellent
anchorage control provided by TAD.
DISCUSSION
Congenital absence of mandibular second premolars
affects many orthodontic patients. The clinician must
make the proper decision at the appropriate time
regarding management of the edentulous space.
Protraction of mandibular molars is challenging
because of the high-density of mandibular bone. The
posterior mandible consists of thicker cortical bone with
dense, radially oriented trabeculae. Anterior dental
anchorage is often inadequate to protract even a single
340 Indian Journal of Clinical Practice, Vol. 25, No. 4, September 2014
first molar without reciprocal retraction of the incisors
or movement of the dental midline.9 The rate of molar
protraction is inversely related to the radiographic
density or cortical thickness of the resisting alveolar
bone.10 Furthermore, if the buccal and lingual cortical
plates in the edentulous region have collapsed, safe
and effective protraction may be impossible.
TADs can provide skeletal anchorage for mandibular
molar protraction, avoiding the problems often
encountered with the use of dental anchorage. The
failure rate of TADs is greater in the mandible than
in the maxilla.11,12 The primary biological factors that
determine miniscrew stability are bone density (or bone
quality),11 peri-implant soft-tissue health,11 adequacy
of peri-implant bone stock12 and operator technique.13
The greater failure rate of mandibular miniscrews,
despite the thicker mandibular cortical bone, is probably
due to root proximity (or inadequate peri-implant bone
stock) and greater buccal tissue mobility.
CONCLUSION
There are numerous options for treating a patient with
a congenitally missing mandibular second premolar.
The key to successful management is to diagnose the
problem early in the presence of mixed dentition. The
miniscrew was able to withstand multidirectional heavy
forces required for this patient’s treatment. Mandibular
molar protraction with orthodontic TADs has become
the standard of care for closing posterior edentulous
spaces.
REFERENCES
1. Thilander B, Myrberg N. The prevalence of malocclusion in
Swedish schoolchildren. Scand J Dent Res 1973;81(1):12-21.
2. Fines CD, Rebellato J, Saiar M. Congenitally missing
mandibular second premolar: treatment outcome with
orthodontic space closure. Am J Orthod Dentofacial
Orthop 2003;123(6):676-82.
 DENTiSTRY

3. Josefsson E, Brattström V, Tegsjö U, Valerius-Olsson H.
Treatment of lower second premolar agenesis by
autotransplantation: four-year evaluation of eighty
patients. Acta Odontol Scand 1999;57(2):111-5.
4. Arbuckle GR, Nelson CL, Roberts WE. Osseointegrated
implants and orthodontics. Oral Maxillofac Surg Clin
North Am 1991;3:903-19.
5. Wehrbein H, Diedrich P. Endosseous titanium implants
during and after orthodontic load-an experimental study
in the dog. Clin Oral Implants Res 1993;4(2):76-82.
6. Umemori M, Sugawara J, Mitani H, Nagasaka H,
Kawamura H. Skeletal anchorage system for open-
bite correction. Am J Orthod Dentofacial Orthop
1999;115(2):166-74.
7. Northway W. Hemisection: one large step toward
management of congenitally missing lower second
premolars. Angle Orthod 2004;74(6):792-9.
8. Kokich VG, Kokich VO. Congenitally missing
mandibular second premolars: clinical options. Am J
Orthod Dentofacial Orthop 2006;130(4):437-44.
9. Deguchi T, Nasu M, Murakami K, Yabuuchi T, Kamioka H,
Takano-Yamamoto T. Quantitative evaluation of cortical
bone thickness with computed tomographic scanning for
orthodontic implants. Am J Orthod Dentofacial Orthop
2006;129(6):721.e7-12.
10. Roberts WE. Bone physiology, metabolism, and
biomechanics in orthodontic practice. In: Orthodontics:
Current Principles and Techniques. 2nd edition, Graber
TM, Vanarsdall RL (Eds.), St. Louis: Mosby 1994:p.
193-234.
11. Miyawaki S, Koya I, Inoue M, Mishima K, Sugahara T,
Takano-Yamamoto T. Factors associated with the stability
of titanium screws placed in the posterior region for
orthodontic anchorage. Am J Orthod Dentofacial Orthop
2003;124(4):373-8.
12. Kuroda S, Yamada K, Deguchi T, Hashimoto T, Kyung
HM, Takano-Yamamoto T. Root proximity is a major
factor for screw failure in orthodontic anchorage.
Am J Orthod Dentofacial Orthop 2007;131(4 Suppl):
S68-73.
13. Park HS, Jeong SH, Kwon OW. Factors affecting the
clinical success of screw implants used as orthodontic
anchorage. Am J Orthod Dentofacial Orthop 2006;130(1):
18-25.

■■■■

Dental Trauma: Guidelines for Pediatricians Updated

Nondentists can play a key role in preventing and treating dental trauma, according to a new report by the
American Academy of Pediatrics.
In guidelines published online January 27 in Pediatrics, the academy lays out the basics of prevention, diagnosis,
and treatment for injured teeth.
In children 6 years of age and younger, oral injuries are the second most common injury, accounting for almost
20% of their injuries, writes Martha Ann Keels, DDS, PhD, chief of pediatric dentistry at Duke University in
Durham, North Carolina, and her colleagues.
Anyone who sees kids in urgent care settings needs to be prepared to treat dental trauma because often no
dentist is available and time may be of the essence, they write.
But even before considering treatment, the authors write, physicians who care for children should try to prevent
injuries to their patients’ teeth. Physicians can do this by recommending safety measures, such as stairway gates
and the removal of trip hazards.
They should also counsel their patients to wear mouth guards during sports, the authors write. Recommendations
vary, with the US National Collegiate Athletic Association recommending mouth guards for ice hockey, lacrosse,
field hockey, and football, while the American Dental Association recommends them for 29 sports.

Indian Journal of Clinical Practice, Vol. 25, No. 4, September 2014 341