ORIGINAL ARTICLE

Three-dimensional finite element

analysis of the uprighting movement of
mandibular mesially inclined second
molars
Bowen Zheng, Junyi Ran, Jia He, Enas Senan Ali Mohammed Al-Yafrusee, Yang Zhao, and Yi Liu
Shenyang, Liaoning, China

Introduction: The mesially inclined mandibular second molar can be supported upright by the microimplant
anchorage. This study established the finite element model to analyze the displacement trend and periodontal
ligament (PDL) stress distribution of the uprighting mandibular second molar with the microimplant under
different conditions. Methods: A 3-dimensional model of the mandible and dentition was established. The
mesial inclination of the mandibular second molar was 30 , 45 , and 60 . Microimplants were implanted
between the buccal side of the second premolar and the first molar and in the distal part of the mandibular
second molar, respectively. Six groups were set, each loaded with 0.5 N of force. The second molar initial
displacement trend and PDL stress distribution were evaluated. Results: The PDL stress of mandibular second
molars in all groups was within the physiological limit, and the PDL stress of mandibular second molars in the
distal implant groups was lower than that of mandibular second molars in the mesial implant groups. PDL stress
concentration in the cervical area. Tooth displacement decreased as the mesial inclination angle of the second
molars increased. The sagittal displacement of mesial implant groups was larger, and there was a tendency of
mesiobuccal torsion when standing uprighting; the vertical displacement of distal implant groups was larger, and
there was a tendency of distal lingual torsion when standing uprighting. Conclusions: Distal microimplant has a
better extrusion effect on the mesially inclined second molar, whereas mesial microimplant has a better effect on
the distal movement. The optimal orthodontic force for microimplant traction on mesially inclined second molars
is 0.5-0.8 N. (Am J Orthod Dentofacial Orthop 2024;165:314-20)

B
ecause of increasingly refined dietary habits, the difference. The prevalence of impaction of permanent
development of teeth and mandibles are not mandibular second molars was reported to be 0.0%-
completely matched, and the incidence of mesi- 2.3% globally and 1% in the Chinese population, but
ally impacted mandibular second molars has been it is higher in orthodontic patients, about 2%-3%.1-4
increasing in recent years.1 Second molar impaction The development of tooth germs of permanent mo-
mainly occurs in the mandible, without obvious gender lars starts from the junction of the maxillary tubercle
and the mandibular body.5 The mesial impaction of
From the Department of Orthodontics, School and Hospital of Stomatology, mandibular second molars is caused by many factors,
China Medical University, Liaoning Provincial Key Laboratory of Oral Diseases, such as inadequate space for eruption, premature loss
Shenyang, Liaoning, China.
of a primary molar leading to the excessive distance be-
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported. tween the first and second molars, and a lack of guidance
This study was supported by the Liaoning Province Doctoral Research Start-up by the distal root of the first molar, and the obstructed
Fund project (2022-BS-150), the Shenyang Young and middle-aged Scientific
eruption because of pathology (eg, odontoma, dentiger-
Innovative Talent Support Program (RC210001), and the Orthodontic Research
Project of Youth Clinical Research Foundation of Chinese Stomatological Asso- ous cyst).2,6,7 The correct construction of the molar is
ciation (CSA-02022-09). crucial to the masticatory function. The mesial inclina-
Address correspondence to: Yi Liu, Department of Orthodontics, School and Hos-
tion of the mandibular second molar will lead to dental
pital of Stomatology, China Medical University, Liaoning Provincial Key Labora-
tory of Oral Diseases, Nanjing North St 117#, He-Ping, Shenyang 110002, pulp and periodontal problems for itself and its adjacent
Liaoning, China; e-mail, [email protected]. mesial teeth and will also affect the height of one third of
Submitted, January 2023; revised and accepted, September 2023.
the surface and the vertical occlusal distance.8
0889-5406/$36.00
Ó 2023 by the American Association of Orthodontists. All rights reserved. Orthodontic uprighting, surgical uprighting, and
https://doi.org/10.1016/j.ajodo.2023.09.014 extraction of the affected teeth are all methods to treat
314

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Zheng et al 315

molar inclination.9 Orthodontic uprighting molars are from the alveolar crest top on the buccal side of the sec-
more acceptable to patients because of their minimal ond premolar and the first molar.11 The mandibular sec-
invasive trauma. The common orthodontic methods ond molars in groups D, E, and F inclined mesially by
for uprighting mesially inclined molars can be divided 30 , 45 , and 60 in turn, and microimplants were in-
into 2 types: tooth anchorage, including various Nitinol serted in the distal 5 mm of the second molars perpendic-
springs and segmental arches, and microimplant bone ular to the bone surface.12 The parameters of the
anchorage.10 Orthodontists usually insert microimplants microimplant in all groups were 10.0 mm in length and
in the premolar area or the retromolar area. A distalizing 1.5 mm in diameter.
and uprighting movement was produced, which avoided All 3D models were imported into the Ansys software
the undesirable movement of the other molars. (version 19.2; Ansys, Canonsburg, Pa). Isotropic,
Therefore, in this study, microimplants were inserted homogeneous, and continuous linear elastic material
between the mandibular second premolar and first molar properties with small deformation conditions as defined
and at the retromolar area to upright different inclination in this study.13 Material parameters were derived from pre-
molars. The biomechanical effects of microimplants at vious investigations and listed in Table I.14-18 Meshing
different positions on uprighting molars were analyzed each model using 10-node tetrahedral elements. Each
to select appropriate methods and orthodontic force for model consisted of about 30,000 elements through the
uprighting mesially inclined second molars with different convergence test in our study. All models were established
inclinations in clinical practice. with 328,367, 328,002, 328,178, 328,148, 328,002, and
328,178 elements sequentially (Fig 1, D).
MATERIAL AND METHODS The degree of freedom of the inferior margin of the
A 21-year-old female subject was selected for our mandible was assumed to be 0 in all 3 directions of x,
study. Inclusion criteria were (1) Angle Class I molar and y, and z, which was considered fixed. There was a
canine relationships, (2) Standard tooth anatomic bonded contact constraint between teeth, brackets,
morphology, (3) normal development of tooth root buccal canals, periodontal membranes, roots, alveolar
morphology and length, and (4) no periodontal disease. bones, and microimplants. The first premolar, second
Written informed consent has been signed by the premolar, and first molar of the mandible have a bonded
subject. This study was approved by the ethics committee contact relationship without relative sliding. A
of Stomatology Hospital of China Medical University. This three-dimensional coordinate system was constructed
study selected the posterior border of the right mandible in which the x-axis corresponds to the mesial-distal
to the mesial of the mandibular right first premolar as the direction, the y-axis to the buccolingual direction, and
research scope. The head helical cone-beam computed the z-axis to the crown-root direction. The positive x
tomography was performed using the iCAT cone-beam value was defined as the mesial direction, positive y as
computed tomography system (KaVo 3D eXam; KaVo the lingual direction, and positive z as the crown
Dental, Bismarckring, Germany) at these settings: 37.1 direction. All groups set the loading force to 0.5 N
mA, 120 kVp, the scan time of 17.8 seconds, voxel size with a loading force duration of 1 second under all
of 0.3 mm, axial slice thickness of 0.3 mm, and field of working conditions.19,20 The origin of force also
view of 23317 cm, with a resolution of 768 3 768 pixels. differed, as uprighting was achieved by (A, B, C) using
The digital imaging and communications in medicine an elastomeric chain or (D, E, F) using an open coil
data were imported into the Mimics software (version spring and a 0.016-in stainless steel uprighting spring
20.0; Materialise, Leuven, Belgium), and the models of between the implant and the molar (Fig 2). Von Mises
the mandible, mandibular first premolar, first molar, stress and displacement of the mandibular second molar
and second molar were reconstructed according to the on each model were analyzed.
threshold settings. These initial models were imported
into the reverse engineering software Geomagic Studio RESULTS
(3D System, Rock Hill, SC) for surface optimization. Figure 2 and Table II display the result of mandibular
Subsequently, we adjusted the matching relationship second molar displacement. In the sagittal direction, the
of each part in NX software (NX 12; Siemens, Nuremberg, crown of the mandibular second molar moved distally,
Germany) and established six 3-dimensional (3D) models the root moved mesially in all groups, and the crown
(Fig 1, C). In groups A, B, and C, the mandibular second displacement was significantly greater than the root,
molars inclined mesially by 30 , 45 , and 60 in turn, indicating that the second molar undergoes uprighting
and microimplants were inserted at an angle of 20 with movement while moving distally. The displacement of
the alveolar bone surface at a distance of about 5 mm groups A, B, C, D, E, and F decreased in turn, and the

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Fig 1. Flow chart of establishing finite element models: A, Initial models of the mandible, mandibular
first premolar, first molar, and second molar were reconstructed according to the threshold; B, Models
for surface optimization; C, 3D models; D, Finite element models.

to the buccal side. The displacement of the second molar

Table I. Young’s modulus and Poisson’s ratio for
in groups A, B, and C increased in turn, and the
various materials
maximum displacement occurred at the mesiobuccal
Material Young’s modulus (Mpa) Poisson’s ratio cusp. A small amount of lingual displacement of the
Cortical bone 13,700 0.26 distal cusp indicates that the crown tends to mesial
Cancellous bone 1370 0.30 buccal torsion. The crown of the second molar moved
Tooth 20,000 0.30
to the lingual side, whereas the root moved to the buccal
PDL 0.68 0.49
Buccal tube 210,000 0.30 side in groups D, E, and F. The displacement of the
Miniscrew 103,000 0.33 crown was significantly greater than that of the root,
indicating that the second molar tended to move to
the lingual side. The displacement of the second molar
maximum displacement occurred at the distal buccal tip in groups D, E, and F decreased successively, and the
of the second molar. maximum displacement occurred at the distal buccal
In the horizontal direction, the crown of the mandib- tip, and the displacement of the distal cusp was greater
ular second molar moved to the buccal side, and the root than that of the mesial cusp, manifesting that the crown
moved to the lingual side in groups A, B, and C, and the tended distal lingual torsion.
crown displacement was significantly greater than the In the vertical direction, the crown of the mandibular
root, indicating that the second molar tended to move second molar in all groups was elongated, the root was

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Zheng et al 317

Fig 2. Origin of force: A, elastomeric chain; B, open coil spring.

neck edge and buccal neck-to-root bifurcation area,

Table II. The initial displacement of the second molar with the maximum value on the lingual neck close to
(mm) the mesial. In contrast, the PDL stress in the distal micro-
Displacement (mm) implant groups was concentrated around the neck edge
and the buccal neck-to-root bifurcation area, with the
Group Angle x-axis y-axis z-axis
maximum value on the mesial neck close to the buccal.
A 30 1.32 0.87 0.82
B 45 1.15 0.11 0.81
C 60 0.99 0.12 0.75 DISCUSSION
D 30 0.99 0.12 0.13
Ensuring that anchorage meets the demand and
E 45 0.97 0.86 0.12
F 60 0.87 0.53 0.12 maintains stability in orthodontic treatment is often
challenging. Microimplant anchorage has been proven
to simplify the overall mechanics and reduce anchorage
depressed, and the crown displacement was significantly loss, and it is recognized as an excellent auxiliary
larger than the root, demonstrating that the second anchorage device with simple operation of placement
molar tended to elongate and stand upright. The and removal.20 Therefore, our study established a micro-
displacement of the second molar in groups A, B, and implant uprighting molar model to study biomechanics.
C decreased in turn, and the maximum displacement With the increase of the mesial inclination angle of
occurred at the mesial buccal tip. The displacement of the second molar, the sagittal and vertical displacement
the mesial cusp was larger than that of the distal cusp, of the molar gradually decreased, which may be that the
indicating that the crown tended to have distal inclina- resistance of the alveolar bone to the molar increased
tion. The displacement of the second molar in groups E, with the increase of the inclination angle. The sagittal
D, and F decreased in turn, and the maximum displace- displacement of the molar in the mesial microimplant
ment occurred at the mesial buccal cusp. The displace- groups was larger than that in the distal microimplant
ment of the buccal cusp was greater than that of the groups, whereas the vertical displacement was the oppo-
lingual cusp, indicating that the crown had a lingual site. Therefore, It is better to insert the microimplant in
inclination. the distal side of the molar to uprighting mesially in-
Figures 3 and 4 and Table III display the result of clined second molar with a lower inclination angle,
periodontal ligament (PDL) equivalent stress of the whereas, for the second molar with a large mesially incli-
mandibular second molar. The maximum equivalent nation angle, it is better to insert the microimplant in the
stress of the PDL of the mandibular second molar with mesial side of the molar to achieve distal displacement.
an inclination of 30 medially was almost no difference. Orthodontists expect more vertical extension for the
With the increase of mesial inclination angle, the PDL impacted molar in the low mesial position during the or-
equivalent stress in mesial microimplant groups thodontic treatment. In contrast, when the impacted
increased, whereas that in the distal microimplant molar crown height is sufficient, an excessive vertical
groups decreased gradually. The PDL equivalent stress extension may lead to problems such as early molar con-
distribution was similar when the microimplants were tact, occlusal trauma, and open bite. In the horizontal
in the same position. The PDL equivalent stress in mesial direction, the mesial implant is located on the buccal
microimplant groups was relatively concentrated at the side of the buccal tube of the second molar, causing

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Fig 3. A, B, C: The mesial microimplant groups, the mandibular second molars inclined mesially by
30 , 45 , and 60 in turns; D, E, F: The distal microimplant groups, the mandibular second molars in-
clined mesially by 30 , 45 , and 60 in turns.

the maximum displacement of the mesial cusp (toward movement occurs. There is no uniform standard for the
the distal buccal side), and the whole crown twists in traction force of uprighting mesially inclined molar. The
the distal buccal direction. The distal implant was on results of this study demonstrated that the maximum
the lingual side of the buccal tube of the second molar, equivalent stress of the PDL of the mandibular second
which caused the maximum displacement of the distal molar in each group was lower than the maximum stress
cusp (toward the distal lingual side), and the whole level of 26 kPa proposed by Lee et al.21 In our linear finite
crown twists in the distal lingual direction. Therefore, element model, the stress of the PDL increased linearly
according to the position of microimplant anchorage, with the increase of traction force. Therefore, in combina-
attention should be paid to prevent the adverse displace- tion with the ideal PDL stress range, the most appropriate
ment of the second molar, such as buccal inclination, correction force for the microimplant traction force of
lingual inclination, and distal torsion. mesially inclined second molar was calculated to be
The appropriate traction force value is closely related 0.5-0.8 N, which is consistent with the 50-80 g of force
to the inclination angle, the force application point, and correction force recommended by Tamer et al.4 Raveli
the force application direction when the tooth tipping et al22 uprighted the mesially inclined second molar using

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Zheng et al 319

Fig 4. A, B, C: The mesial microimplant groups, the mandibular second molars inclined mesially by
30 , 45 , and 60 in turns; D, E, F: The distal microimplant groups, the mandibular second molars in-
clined mesially by 30 , 45 , and 60 in turns.

increased, whereas that in the distal microimplant

Table III. Maximum Von Mises values in PDL groups gradually decreased. This may be due to the
Group Angle Von Mises stress (MPa) increased inclination angle; the pressure point of the
A 30 0.0146 PDL in the mesial microimplant groups was closer to
B 45 0.0151 the implant, whereas in the distal microimplant group,
C 60 0.0160 the opposite was true. The stress of the PDL in the
D 30 0.0146 distal microimplant groups was slightly lower than in
E 45 0.0143
F 60 0.0123
the mesial microimplant groups. Although the stress
was concentrated in the neck area, the maximum
a cantilever system with a missing first molar. The equivalent value of PDL in the mesial microimplant
treatment effect of 75 g of orthodontic force was positive, groups was near the lingual side of the neck, whereas
similar to this experiment’s results. that in the distal microimplant groups was near the
With the increase of the mesial inclination angle of buccal side of the mesial neck, which was related to
the second molar, the equivalent stress value of the the position of the microimplant. Previous studies
PDL in the mesial microimplant groups gradually have found that root resorption often occurs in the

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320 Zheng et al

apical region,23 whereas our study demonstrated that €

4. Tamer _I, Oztaş E, Marşan G. Up-to-date approach in the treatment
the stress in the process of uprighting molar was of impacted mandibular molars: a literature review. Turk J Orthod
2020;33:183-91.
concentrated in the neck region, suggesting that ortho-
5. Bondemark L, Tsiopa J. Prevalence of ectopic eruption, impaction,
dontists should pay attention to the stress in the neck retention and agenesis of the permanent second molar. Angle Or-
region and the risk of root resorption in the process of thod 2007;77:773-8.
an uprighting inclined molar. 6. Lau CK, Whang CZ, Bister D. Orthodontic uprighting of severely
However, this study has some limitations. To control impacted mandibular second molars. Am J Orthod Dentofacial Or-
thop 2013;143:116-24.
the experimental variables, the mandibular first and sec-
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our study were limited to mesial inclination, but there
9. Turley PK. The management of mesially inclined/impacted
was likely a certain degree of buccolingual inclination mandibular permanent second molars. J World Fed Orthod
in the clinic, which can also explain the difference be- 2020;9:S45-53.
tween the observed tooth movement and the simulated 10. Miyahira YI, Maltagliati LA, Siqueira DF, Romano R. Miniplates as
tooth movement. skeletal anchorage for treating mandibular second molar impac-
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11. Jung YR, Kim SC, Kang KH, Cho JH, Lee EH, Chang NY, et al. Place-
CONCLUSIONS ment angle effects on the success rate of orthodontic microim-
The distal microimplant has a better extrusion effect plants and other factors with cone-beam computed tomography.
Am J Orthod Dentofacial Orthop 2013;143:173-81.
on the mesially inclined second molar, whereas the mesial
12. Martino F, Hernandez R. Uprighting of a semi-impacted mandib-
microimplant has a better effect on the distal movement. ular second molar with microimplant anchorage. J World Fed Or-
The optimal orthodontic force for microimplant traction thod 2013;2:e159-62.
on mesially inclined second molars is 0.5-0.8 N. 13. Yettram AL, Wright KW, Houston WJ. Centre of rotation of a
maxillary central incisor under orthodontic loading. Br J Orthod
1977;4:23-7.
ACKNOWLEDGMENTS
14. Yoon S, Lee DY, Jung SK. Influence of changing various parameters
The authors thank teachers and students in the in miniscrew-assisted rapid palatal expansion: a three-dimensional
School and Hospital of Stomatology, China Medical Uni- finite element analysis. Korean J Orthod 2019;49:150-60.
15. Hedayati Z, Shomali M. Maxillary anterior en masse retraction us-
versity, for their continuous help and support.
ing different antero-posterior position of mini screw: a 3D finite
element study. Prog Orthod 2016;17:31.
AUTHOR CREDIT STATEMENT 16. Baghdadi D, Reimann S, Keilig L, Reichert C, J€ager A, Bourauel C.
Biomechanical analysis of initial incisor crowding alignment in the
Bowen Zheng contributed to conceptualization,
periodontally reduced mandible using the finite element method. J
methodology, investigation, and original draft prepara- Orofac Orthop 2019;80:184-93.
tion; Junyi Ran contributed to conceptualization, meth- 17. Feng Y, Kong WD, Cen WJ, Zhou XZ, Zhang W, Li QT, et al. Finite
odology, software, and data curation; Jia He contributed element analysis of the effect of power arm locations on tooth
to validation and data curation; Enas Senan Ali Mo- movement in extraction space closure with miniscrew anchorage
in customized lingual orthodontic treatment. Am J Orthod Dento-
hammed Al-Yafrusee contributed to manuscript review
facial Orthop 2019;156:210-9.
and editing; Yang Zhao contributed to validation; and 18. Lena Sezici Y, Gediz M, Akış AA, Sarı G, Duran GS, Dindaro glu F.
Yi Liu contributed to formal analysis, resources, and su- Displacement and stress distribution of Kilroy spring and nickel-
pervision. titanium closed-coil spring during traction of palatally impacted
canine: a 3-dimensional finite element analysis. Orthod Craniofac
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