Systematic Review Article

Comparison between orthodontic and surgical uprighting of mandibular

molars: a systematic review
Frantzeska Karkazia; Nikolaos Karvelasb; Antigoni Alexiouc; Sotiria Gizanid; Apostolos I. Tsolakise

ABSTRACT

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Objectives: To evaluate and compare the efficiency of orthodontic treatment and surgical
uprighting of first and second mandibular molars.
Materials and Methods: An electronic literature search in PubMed, Science Direct, Embase,
Scopus, Web of Science, Cochrane Library, LILACS, and Google Scholar, as well as a hand
search was conducted by two independent researchers to identify relevant articles up to January
2022. In addition, a manual search was done that included article reference lists, grey literature,
and dissertations. The risk of bias of the included prospective and retrospective studies was
assessed with the Risk Of Bias Tool In Non-randomized Studies of Interventions (ROBINS-I)
assessment tool.
Results: A total of six nonrandomized clinical trials (non-RCT) evaluating the efficiency of
mandibular molar orthodontic and/or surgical uprighting were included. The quality analysis
showed certain defects of the Non-RCTs included and, according to the criteria used, the majority
of the articles were judged to be of moderate quality.
Conclusions: Based on the evidence, orthodontic and surgical uprighting appear to be effective
treatment methods for mandibular molars. Surgical uprighting may be associated with more
complications than orthodontic uprighting. However, the existing literature on the subject is limited,
heterogeneous, and methodologically limited. Therefore, the outcomes should be interpreted
carefully. (Angle Orthod. 2022;93:104–110.)
KEY WORDS: Uprighting; Mandibular molars; Conventional biomechanics; Systematic review

INTRODUCTION
Failed or delayed eruption of first and second
permanent molars is uncommon, with reported
a
Orthodontist, Department of Orthodontics, Faculty of Den-
prevalence ranging from 0.1% to 4.6%.1,2 Ectopic
tistry, Marmara University, Istanbul, Turkey. eruption, insufficient space, excessive tooth size and
b
Doctorate Degree Candidate, Department of Orthodontics, obstruction in the eruption path, or anomalies in the
Faculty of Dentistry, Grigore T. Popa University, Iasi, Romania. eruption process may cause partial or whole molar
c
Postgraduate Student, Epidemiology-Research Methodolo-
impaction.3 Second-molar impaction is more common
gy in Biomedical Sciences, Clinical Practice and Public Health,
Medical School, National and Kapodistrian University of Athens, in the mandible than in the maxilla, with 88% of all
Athens, Greece. impacted mandibular second molars being mesially
d
Associate Professor and Head, Department of Paediatric angulated.4
Dentistry, School of Dentistry, National and Kapodistrian The abnormal eruption of mandibular second molars
University of Athens, Athens, Greece.
e
Associate Professor, Department of Orthodontics, School of
appears to be related to craniofacial morphology
Dentistry, National and Kapodistrian University of Athens, including Class II malocclusion, reduced mandibular
Athens, Greece. gonial angle, vertical condylar growth, and decreased
Corresponding author: Frantzeska Karkazi, DMD, Department distance from the first molar to the mandibular ramus.5
of Orthodontics, Faculty of Dentistry, Marmara University, Mandibular second molar impaction is also associated
Istanbul, Turkey
(e-mail: fkarkazi@yahoo.com) with appliances, such as a lingual arch or lip bumper,
that maintain or further worsen the posterior arch
Accepted: August 2022. Submitted: April 2022.
Published Online: October 14, 2022 length deficiency.6,7
Ó 2023 by The EH Angle Education and Research Foundation, Treatment options include orthodontic and surgical
Inc. uprighting and extraction with or without transplantation

Angle Orthodontist, Vol 93, No 1, 2023 104 DOI: 10.2319/041822-298.1

MANDIBULAR MOLAR UPRIGHTING: A SYSTEMATIC REVIEW 105

of the third molar into the extraction site.8–11 Orthodontic

uprighting can be accomplished using either a seg-
mental12,13 or a straight wire technique.14,15 Both
treatment approaches have certain disadvantages,
such as molar extrusion, undesirable reciprocal move-
ment of the anchorage units, and extended treatment
duration.13
Surgical uprighting is a procedure performed by an
oral surgeon to tip the impacted molars into an
optimized vertical position in the socket, preserving

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apical vessels at the root apices.10,16,17 Some compli-
cations of the technique include pulpal necrosis,
ankylosis, and external root resorption.10
Currently, the outcomes of surgical and orthodontic
uprighting have not been systematically compared in
the literature. The aim of this systematic review was to
critically assess the evidence derived from nonrandom-
ized controlled trials to identify and evaluate studies
that used conventional biomechanics or surgical
procedures to upright first and second mandibular
molars.

MATERIALS AND METHODS Figure 1. PRISMA Diagram.

A literature search aimed to identify articles con-

cerning uprighting of mandibular molars by using Eligibility Criteria
orthodontic or surgical uprighting. The search ob- For the systematic review, due to the scarcity of
served published studies up to June 2022. RCTs on this subject, RCTs and Non-RCTs on
human patients of any age, gender, ethnicity, or
Data Sources and Searches malocclusion evaluating the efficiency of orthodontic
An electronic search via PubMed, Science Direct, and surgical uprighting of mandibular molars were
Embase, Scopus, Web of Science, Cochrane Library, included. There were no language, publication year,
LILACS, and Google Scholar was conducted to identify or status restrictions. Case reports/series, literature
articles appropriate to the inclusion criteria. In addition, reviews, laboratory studies, and studies on patients
a manual search was conducted that included article with syndromes and/or craniofacial deformities were
reference lists, grey literature, and dissertations. The excluded.
first (FK) and second (NK) authors assessed the
retrieved records independently and in duplicate. Data Extraction
Although they were not blinded to the identity of the
A customized data collection form was developed
authors or the conclusions of the studies, they used the
same method to assess the eligibility of all retrieved and used to collect information from the selected
records. All controversies were resolved by discussion studies. This information included authors, year of
with the fourth co-author (AIT). publication, study design, treatment method, reason
To identify relevant studies, a combination of the of inclination, sample size, tooth description, molar
Boolean operators AND/OR and MeSH/non-MeSH axial inclination, treatment time, and outcomes. Two
terms was used. The algorithm selected for the search authors (FK and NK) extracted all essential data
strategy was (mandibular molars OR lower molars OR independently in the customized predesigned extrac-
impacted molars AND uprighting OR orthodontic tion form. The same two authors double-extracted
uprighting OR conventional biomechanics OR tipping data for a random sample of 10% of the included
spring OR frictional mechanics OR surgical uprighting studies to assess data reliability. During the extrac-
OR surgical verticalization OR surgical repositioning). tion process, any disagreements were resolved by
This review follows the PRISMA (Preferred Reporting consulting a third reviewer (AIT) until a final consen-
Items for Systematic Reviews and Meta-analysis) sus was reached to provide an independent decision
Statement (Figure 1).18,19 on the conflict.

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106 KARKAZI, KARVELAS, ALEXIOU, GIZANI, TSOLAKIS

Table 1. Descriptive Table of the Most Adequate Articles in the Literature Related to Mandibular Molar Uprighting Included in the Present Studya
Sample Size,
Reason of Male/Female Description of
Author Design Method Inclination (Mean Age) Tooth/ Number
Mangusson & Retrospective study Orthodontic treatment Retained/ 87 patients, 42/45 Mandibular second
Kjellberg, 2009 with segmental Impacted (15 y) molars/24
archwire or
Surgical exposure and
luxation of 7
Extract 8 and surgical
exposure/ luxation of 7
Kenrad et al., Retrospective study No treatment Retained/ 106 patients, 60/46 Mandibular second

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2011 Orthodontic treatmen Impacted (11.2 y) molars/7
Surgical exposure of the
second molar
Fu et al., 2012 Retrospective study Orthodontic uprighting Impacted 96 patients 66/74 Mandibular second
(26.5 y) molars/125
Pogrel, 1995 Retrospective study Surgical uprighting Impacted 16 patients (14.1 y) Mandibular second
molars/22

Padwa et al., Retrospective study Surgical uprighting Impacted 16 patients (13 y) Mandibular second
2017 molars /19

Caminiti et al., Retrospective study Surgical uprighting Impacted 177 patients (14.8 y) Mandibular second
2020 molars/260

a
CT indicates computed tomography scans; f, female; m, male; NA, not available; OPG, orthopantomograph; OU, orthodontic uprighting; SU,
surgical uprighting; þ, positive; Y, years old.

Quality Analysis The quality analysis showed certain defects of the

Non-RCTs included and, according to the criteria used,
The risk of bias of the included studies in this
the majority of the articles were judged to be of
systematic review was assessed with the Risk Of Bias moderate quality. Two of the articles, however, were
In Non-randomized Studies of Interventions [ROBINS- judged as having a serious risk of bias quality (Table
I] assessment tool, with the overall risk of bias ranging 2).9,17 The most serious and frequent shortcomings
by low, moderate, or serious. To assess study quality, were the inability of the studies to measure unbiased
different quality appraisal tools were used, specifically outcomes16,17,20 and bias in the missing data.9,17 In three
designed for each type of study. The studies were studies, the classification of intervention status could
estimated by confounding bias, bias in the selection of have been affected by knowledge of the outcome and
participants, bias in interventions, bias in missing data, thus were judged as uncertain.16,17,20 None of the
bias in outcomes, and bias in reported results.18 studies8,9,11,16,17,20 reported whether assessors were
However, a statistical meta-analysis was not possible blinded to the intervention received. Four studies9,11,16,20
to perform due to the heterogeneity of the included did not indicate whether there was a consecutive
data. inclusion/exclusion of participants. In the end, two
analyzed studies had a serious risk of bias,9,17 and four
RESULTS studies had a moderate risk of bias.8,11,16,20

A total of 958 articles were selected by the initial DISCUSSION

strategy. After applying the inclusion criteria, 567
studies were excluded. Only six articles matched the Summary of Evidence
inclusion criteria and were chosen for systematic The current systematic review summarizes evidence
review. The study included six retrospective analyses. from nonrandomized studies concerning the treatment
Table 1 summarizes the six studies found in the current of molar uprighting with orthodontic or surgical treat-
literature search and their treatment approach- ment. Out of the initial 958 hits from the literature
es.8,9,11,16,17,20 search, the majority of the studies in the literature were

Angle Orthodontist, Vol 93, No 1, 2023

MANDIBULAR MOLAR UPRIGHTING: A SYSTEMATIC REVIEW 107

Table 1. Extended
Treatment
Molar Axial Duration 3rd Molar Radiographic
Inclination (8) (Mean) Extraction Diagnosis Complications Outcomes
NA 8.3 mo þ CT, OPG, and/or NA OU: good results: 6, not
periapical satisfied: 8
radiographs SU: good results: 2, not
satisfied: 1
SU and 8s extractions:
good results: 5, not
satisfied: 3
NA NA NA OPG NA OU: 100% acceptable

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results

31-608 3.6 mo NA Periapical radiographs NA Effective eruption of 125

impacted MdM2s
NA NA NA OPG Osteitis, pulpal 21 teeth with firm and in
calcification, nonvital on good occlusion with
electric pulp testing excellent new bone
formation
122.6 6 34.98 to the NA 50% of cases OPG Pulpal obliteration, There were 2 failures
occlusal plane periapical radiolucency, (10.5%).
and root resorption were
seen in 31.6%
Lingual: 3, Horizontal: 34, NA 86.9%, were OPG Infection/abscess in 3 255 molars were
Partial: 198 removed molars, fractured roots successfully uprighted
in 2 molars

case report/series; only six trials (involving 457 molybdenum alloy (TMA) archwire. When the upright-
mandibular first and second molars) matched the ing spring was connected to the anchor teeth and the
inclusion/exclusion criteria. The six included studies distal bend was placed between the distal contact and
showed certain defects and, based on the criteria, the the first molar tube, the spring was activated, creating
majority of the articles were judged to be of moderate an uprighting and distal force. The other two studies
quality. included did not go into great detail about the
segmental approach used.8,9
Orthodontic Uprighting In the literature, however, several uprighting ortho-
dontic treatment approaches (segmental or straight
A segmental technique was used in three of the wire) have been described, such as uprighting springs,
studies included.8,9,11 Fu et al.11 used uprighting springs open push coils, prefabricated Sander springs, helical
(pole arm) made from a 0.016 3 0.022-inch titanium uprighting springs, tip-back cantilevers, and interarch

Table 2. Risk of Bias in Nonrandomized Studies Used for the Systematic Review (ROBINS-I Assessment Tool)
Mangusson & Kenrad et Pogrel, Padwa et al., Caminiti
Author Kjellberg, 2009 al., 2011 Fu, 2012 1995 2017 et al., 2020
Risk of bias
Bias due to confounding LOW LOW LOW LOW LOW LOW
Bias in selection of participants into the LOW MODERATE LOW LOW LOW LOW
study
Bias in classification of interventions MODERATE MODERATE MODERATE MODERATE LOW LOW
Bias due to deviations from intended LOW LOW LOW MODERATE LOW LOW
interventions
Bias due to missing data MODERATE SERIOUS LOW LOW SERIOUS LOW
Bias in measurement of outcomes LOW LOW LOW MODERATE SERIOUS MODERATE
Bias in selection of the reported result LOW MODERATE LOW LOW LOW LOW
Overall risk of bias MODERATE SERIOUS MODERATE MODERATE SERIOUS MODERATE

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108 KARKAZI, KARVELAS, ALEXIOU, GIZANI, TSOLAKIS

mechanics.13,14,15,21–23 In the segmental technique, an unpredictable. This could be caused by trauma to the
anchorage unit is usually required, such as a lingual apical vessels or the Hertwig’s sheath.30
arch,24 a continuous or segmental rectangular SS The mean angle change achieved in the study by
wire,11,21 or skeletal anchorage.25 The uprighting spring Pogrel was 23.5 6 16.18 (P , .001) and the mean
could be fabricated from stainless steel),26 TMA distal bone level of the adjacent first molar was 3.41 6
archwire, mostly 0.17 3 0.25-inch,12,13,21,23 or Memory 1.52 mm preoperatively and 1.45 6 0.54 mm postop-
Titanol.21,22 eratively (42.5% improvement, P , .001).16
In the straight-wire technique, nickel–titanium (NiTi)
wires, open coil springs, and elastic separators are Success Rate
mostly used.14,15,27–29 Lau et al. presented a method
According to Mangusson and Kjellberg, orthodontic

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using a 0.016–0.022-inch copper-NiTi archwire with a
uprighting had a success rate of 42%, while surgical
push-coil spring to create space for the eruption of
uprighting was 50%.8 The sample of lower mandibular
impacted mandibular second molars.14 Mansour et al.
molars, however, was significantly reduced, so the
introduced the molar uprighting simplified technique
findings should be considered cautiously.
(MUST) in which a NiTi wire was passed through a
Orthodontic uprighting seemed to have 100%
double tube attached to the second molar and a single
success rate in the studies of Kenrad et al. and Fu et
tube attached to the first molar, emerging at the distal
al.9,11 However, surgical uprighting showed a lower
end through the second molar auxiliary tube and
success rate, but was still clinically favorable. Out of
ligated to the premolar.15 Manosudprasit et al. used a
the 350 molars, 338 were successfully uprighted
NiTi archwire combined with an open-coil spring
(96.75%).9,8,16,17,20 The remaining 12 molars had to be
between mandibular first and second molars along
extracted due to subsequent submerging and root
with vertical elastics to achieve an adequate occlu-
resorption/infection around the uprighted tooth, which
sion.27
developed into osteitis and root fracture.17,16,20
In the literature, uprighting time differed widely.
According to La Monaca, orthodontic and surgical
Mangusson and Kjellberg observed that the uprighting
uprighting had a 100% success rate, but when
treatment time lasted 8.3 months (range: 1–20
surgical-orthodontic uprighting were combined, the
months).8 Fu found that males had a mean uprighting
success rate was significantly lower (34/48 molars,
period of 3.62 6 0.71 months and females had a mean
70.8%).31
uprighting period of 3.54 6 0.56 months. The period of
uprighting was related to the depth of impaction: the
Third Molar Extraction
more deeply, horizontally, or distally impacted, the
initial uprighting period was longer. However according Third molar extraction enables the creation of a
to case studies, the average uprighting treatment time corticomedullar void distal to the second molar, which
ranged from 2 weeks to 15 months.7,21,28,29 reduces the treatment time.32 Additionally, although
third molar extraction is useful to obtain more space for
Surgical Uprighting luxation, it is not always considered necessary.31 Its
presence may create a wedge effect against the
Five of the included studies used surgical upright-
second molar to improve the immediate postoperative
ing.8,9,16,17,20 Surgical uprighting incorporates luxation of
stability of the uprighted position. Also, the third molar
the impacted tooth. Additionally, a small amount of
may be used as a future replacement if the second
buccal crest bone is removed from around the crown
molar ultimately requires extraction.
prior to luxation to ensure that the cementoenamel
According to Padwa, the posterior eruption space
junction and root surfaces remain covered. The tooth
was not influenced by third molar retention or
then tips superiorly and distally until the occlusal surface
extraction. However, due to the inability of the second
is approximately level with the occlusal plane and the
molar to be uprighted, the third molar was extracted in
molar is rotated on its root apices and repositioned
50% of the study cases.17
within its socket to preserve the apical vessels.8–10,16,17,20
In case of excessive tooth mobility, a buccal wire of
Complications
approximately 0.5-mm diameter from the first to the
second molar can be used for immediate stabilization. Orthodontic uprighting complications include hyper-
This wire should be left in place for about 4 weeks. trophy of the mucosa and poor oral hygiene.33 Surgical
Prophylactic antibiotics could be given to all patients uprighting was associated with complications such as
prior to surgery and continued for 24 hours.16 In addition, pulpal calcification, misalignment, infection/abscess in
though root formation appears to occur subsequently in three molars, increased (more than 5 mm) periodontal
cases of incomplete root formation, it is inconsistent and pocketing, root fracture, and nonvital indication on

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MANDIBULAR MOLAR UPRIGHTING: A SYSTEMATIC REVIEW 109

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