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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2008  |  Volume : 26  |  Issue : 1  |  Page : 29-31

Orthodontic uprighting of impacted mandibular permanent second molar: A case report

Department of Pediatric Dentistry, College of Dental Sciences and Hospital, Davangere - 577 004, Karnataka, India

Correspondence Address:
C Vinay
Department of Pediatric Dentistry, College of Dental Sciences and Hospital, Davangere - 577 004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.40319

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The mandibular second molars can become impacted beneath the crown of the first molars due to various causes and fail to erupt normally. Presented herewith is a case report of orthodontic uprighting of a mesioangular impacted mandibular right permanent second molar. Though various treatment options were available, an uprighting push spring appliance was used as it is easy to fabricate and produces distal tipping and uprighting of the impacted tooth without the necessity of surgical assistance, bone removal, or splinting. The uprighting of the mandibular second molar was achieved within two months.

Keywords: Impacted, orthodontic uprighting

How to cite this article:
Reddy S K, Uloopi K S, Vinay C, Subba Reddy V V. Orthodontic uprighting of impacted mandibular permanent second molar: A case report. J Indian Soc Pedod Prev Dent 2008;26:29-31

How to cite this URL:
Reddy S K, Uloopi K S, Vinay C, Subba Reddy V V. Orthodontic uprighting of impacted mandibular permanent second molar: A case report. J Indian Soc Pedod Prev Dent [serial online] 2008 [cited 2023 Feb 1];26:29-31. Available from: http://www.jisppd.com/text.asp?2008/26/1/29/40319

   Introduction Top

Impaction of permanent teeth is a common clinical occurrence and may involve any tooth in the dental arch. The teeth most often impacted, in order of frequency, are the maxillary and mandibular third molars, the maxillary canine, and the mandibular second premolar. Mandibular second molar impactions have not been reported; the real incidence is unknown but it is estimated to be around 3 in 1000. [1]

When found, second molar impaction often presents a challenging problem to the dentist. The usual age of presentation is between 11 and 13 years and although some cases undoubtedly self-correct, it is equally true that many do not. [2] A number of techniques have been described, involving both surgical and orthodontic treatment. The ideal procedure should allow the establishment of a normal functional occlusal relationship, without associated periapical or periodontal pathology. The present case report is of orthodontic uprighting of a mesioangular impacted mandibular right permanent second molar.

   Case Report Top

A 12-year-old girl visited the department of pediatric dentistry complaining of pain in relation to the lower right back tooth region. After taking the relevant history, a diagnostic intraoral periapical radiograph was obtained, which revealed deep caries with pulpal involvement in relation to 46, with widening of the lamina dura. The mandibular right second permanent molar was tipped mesially and was obliquely impacted under the distal surface of a non-vital permanent first molar. The developing mandibular third molar bud was lying over the distal root of the second molar [Figure - 1].

Initially the chief compliant of the patient was addressed by performing a multivisit root canal treatment in relation to 46 [Figure - 2], followed by restoration with stainless steel crown. The orthodontic uprighting of 47 was planned by using push spring and mini-hook system. A push spring consisting of two bends was fabricated by using 0.018-inch stainless steel wire. The push spring was oriented towards the distal surface of the stainless steel crown in relation to 46 by soldering the retentive arm on the lingual surface of the crown. A mini-hook was fabricated using 0.014-inch wire and bonded on to the occlusal surface of 47, which would be engaged by the push spring.

Under local anesthesia, the impacted mandibular second molar was surgically exposed and the mini-hook was bonded onto the occlusal surface [Figure - 3],[Figure - 4]. The push spring appliance was then cemented onto the stainless steel crown on first molar and the distal end of the spring was engaged into the mini-hook [Figure - 5],[Figure - 6]. The push spring was progressively activated every 2 weeks to get the desired result. Within a period of 2 months the tooth was completely upright. The push spring was removed and the same stainless steel crown was recemented. After 6 months, an IOPA radiograph revealed complete uprighting of 47, with bone regeneration [Figure - 7],[Figure - 8].

   Discussion Top

Due to the low frequency of mesially impacted second molars, little information regarding it is available in the dental literature. Clinical findings in this case, such as unilateral occurrence in the right side of the mandible and the mesial inclination, are consistent with the reported literature. [1]

Most published literature concerning impacted second molars assume that inadequate arch length is the principal cause of impaction. However, arch length discrepancy is not the only cause of second molar impaction; on occasion, second molar impaction can occur when arch length is more than adequate for normal eruption. Eruption of the second molar requires guidance by the distal root of the first molar. Excess space between the developing second molar crown and the first molar roots allows the developing second molar to become inclined more mesially and thus become impacted under the distal height of contour of the first molar. [3]

Other proposed causes of second molar impaction include delayed emergence of the second premolars, premature primary molar extraction, ankylosed primary molars, dentigerous cysts, competition for space by the third molar, and odontomas. [3] Sometimes a normally developing mandibular second molar may, for reasons unknown, suddenly change its inclination and become obliquely or horizontally impacted, while on the contralateral side it erupts normally. [1] This might have been the reason in this case, as 47 was mesioangularly impacted, while 37 had erupted.

The proper time to treat these impactions is when the patient is 11-14 years old, during early adolescence, when the second molar root formation is still incomplete and before the third molars complete their development in close approximation to the second molars. [1] In the present case, the patient was 12 years old, the second molar root formation was incomplete, and the third molar was not completely developed.

If left untreated the impacted mandibular second molars can cause clinical problems such as root resorption, caries, and periodontal breakdown of the first molar, or may cause anterior crowding as was evident in this case. The various treatment options proposed, depending on the clinical situation, are as follows: [4]

  1. If the molar is only slightly tipped to the mesial aspect, the clinician may insert a brass ligature or separating band to enable self-correction and eruption of the molar into its ideal position.
  2. Extraction of an impacted mandibular second molar that appears to have no chance of uprighting may allow the third molar to erupt into the second molar's position.
  3. Surgical uncovering and bonding and bracketing, followed by orthodontic uprighting and forced eruption.
  4. Surgical uprighting and repositioning of the mandibular second molar, with or without extraction of the third molar.

A better alternative to extraction or surgical repositioning of an impacted mandibular second molar is its surgical uncovering followed by orthodontic uprighting. This can be accomplished without the extraction of the adjacent third molar.

A variety of orthodontic appliances and techniques have been suggested for uprighting of impacted second molars following their exposure. A bonded attachment to the distobuccal surface with a spring fixed in a vertical lingual sheath; push spring; interarch vertical elastics; and a removable appliance with an uprighting spring have been used for initial uprighting. Other appliances include a pin placed on the crown of the impacted second molar and auxiliary springs, bonded tube on the buccal surface and uprighting spring. [1] A significant advantage of the orthodontic uprighting technique is the distal tipping and uprighting of impacted teeth, without the necessity of surgical assistance, bone removal, or splinting. This is the reason orthodontic uprighting was planned in this case.

The basic biomechanics of uprighting impacted molars involves a rotational couple, so that the roots of the impacted molar move mesially, while the crown moves distally. In clinical practice, the movement cannot be a simple rotation because the molar is impacted in bone or soft tissue and it is difficult to apply force in an ideal direction. With the uprighting spring described in this case, when the push spring is activated, it produces not only a distal force but also a light occlusal force. The point of alveolar bone opposite or beneath the distal neck of the impacted molar serves as a fulcrum for the force couple. The result is a combination of rotation, translation, and occlusal movement. [5]

   Conclusion Top

With early diagnosis and recognition of potentially developing impaction, practitioners can initiate corrective measures. Although surgical uprighting of impacted mandibular second molars appears to be a quick and easy procedure, orthodontic uprighting techniques are more advantageous and offer better long-term prognosis, with no adverse effects on pulpal or supporting structures. The timing of treatment and the biomechanics involved determine the success.

   References Top

1.Shapira Y, Borell G, Nahlieli O, Kuftinec MM. Uprighting mesially impacted mandibular permanent second molars. Angle Orthod 1998;68:173-8  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Pogrel MA. The surgical uprighting of mandibular second molars. Am J Orthod Dentfacial Orthop 1995;108:180-3  Back to cited text no. 2    
3.McAboy CP, Grumet JT, Siegel EB, Iacopino AM. Surgical uprighting and repositioning of severely impacted mandibular molars. J Am Dent Assoc 2003;134:1459-62  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Frank C. Treatment options for impacted teeth. J Am Dent Assoc 2000;131:623-32  Back to cited text no. 4    
5.Miao YQ, Zhong H. An uprighting appliance for impacted mandibular second and third molars. J Clin Orthod 2006;40:110-6  Back to cited text no. 5  [PUBMED]  


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8]

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