Orthodontic Uprighting of Impacted Mandibular Permanent Second Molar: A Case Report

ISSN 0970 - 4388
Orthodontic uprighting of impacted mandibular permanent second molar:

A case report
REDDY S. K.a, ULOOPI K. S.b, VINAY C.c, SUBBA REDDY V. V.d
Abstract
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
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.
Introduction
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.
Under local anesthesia, the impacted mandibular second

molar was surgically exposed and the mini-hook was bonded
onto the occlusal surface [Figures 3 and 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 [Figures 5 and 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 [Figures 7 and 8].
Case Report
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].
Discussion
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,
Post-graduate Student, bAssociate Professor, cReader, dPrincipal,

Professor and Head, Department of Pediatric Dentistry, College of
Dental Sciences and Hospital, Davangere - 577 004, Karnataka, India
29
J Indian Soc Pedod Prevent Dent - March 2008
Impacted mandibular permanent second molar
Figure 1: IOPA radiograph showing mesioangular impacted

second molar
Figure 5: Photograph showing push spring appliance after

cementation
Figure 2: IOPA radiograph after completion of root canal

filling in 46
Figure 6: IOPA radiograph after cementation of push spring

appliance
Figure 3: Photograph showing surgical exposure of the

impacted second molar/47
Figure 7: IOPA radiograph showing uprighted 47
Figure 4: Photograph showing bonded minihook on impacted

mandibular right second molar/47
Figure 8: Photograph showing uprighted 47
30
Impacted mandibular permanent second molar
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]
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.
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 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]
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.
Conclusion
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 molars 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.
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.
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.
5.
References
1.
2.
3.
4.
Shapira Y, Borell G, Nahlieli O, Kuftinec MM. Uprighting mesially

impacted mandibular permanent second molars. Angle Orthod
1998;68:173-8
Pogrel MA. The surgical uprighting of mandibular second molars.
Am J Orthod Dentfacial Orthop 1995;108:180-3
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
Frank C. Treatment options for impacted teeth. J Am Dent Assoc
2000;131:623-32
Miao YQ, Zhong H. An uprighting appliance for impacted mandibular
second and third molars. J Clin Orthod 2006;40:110-6
Reprint requests to:

Dr. C. Vinay,
Department of Pediatric Dentistry,
College of Dental Sciences and Hospital,
Davangere - 577 004, Karnataka,
India.
E-mail: vinaychandrappa@yahoo.co.in
A variety of orthodontic appliances and techniques have

been suggested for uprighting of impacted second molars
following their exposure. A bonded attachment to the
31

Orthodontic Uprighting of Impacted Mandibular Permanent Second Molar: A Case Report

Uploaded by

Copyright:

Available Formats

Orthodontic Uprighting of Impacted Mandibular Permanent Second Molar: A Case Report

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Orthodontic Uprighting of Impacted Mandibular Permanent Second Molar: A Case Report

Uploaded by

Copyright:

Available Formats

ISSN 0970 - 4388

Orthodontic uprighting of impacted mandibular permanent second molar:

Initially the chief compliant of the patient was addressed

Under local anesthesia, the impacted mandibular second

Post-graduate Student, bAssociate Professor, cReader, dPrincipal,

J Indian Soc Pedod Prevent Dent - March 2008

Impacted mandibular permanent second molar

Figure 1: IOPA radiograph showing mesioangular impacted

Figure 5: Photograph showing push spring appliance after

Figure 2: IOPA radiograph after completion of root canal

Figure 6: IOPA radiograph after cementation of push spring

Figure 3: Photograph showing surgical exposure of the

Figure 7: IOPA radiograph showing uprighted 47

Figure 4: Photograph showing bonded minihook on impacted

Figure 8: Photograph showing uprighted 47

J Indian Soc Pedod Prevent Dent - March 2008

Impacted mandibular permanent second molar

second molar impaction can occur when arch length is more

distobuccal surface with a spring fixed in a vertical lingual

Other proposed causes of second molar impaction include

The basic biomechanics of uprighting impacted molars

The proper time to treat these impactions is when the patient

If left untreated the impacted mandibular second molars

With early diagnosis and recognition of potentially developing

A better alternative to extraction or surgical repositioning of an

Shapira Y, Borell G, Nahlieli O, Kuftinec MM. Uprighting mesially

Reprint requests to:

A variety of orthodontic appliances and techniques have

J Indian Soc Pedod Prevent Dent - March 2008

You might also like