- Email: [email protected]
Surgical repositioning of impacted mandibular second molar teeth
UJ
I ~e~Qsitioning
of impaetc?
rnQ~a~ teeth a V. Johnson, Houston, Texas
D.D.S., M.S.,* and George
P, Quirk,
5.
fmpacted second molars refractory to orthodontic treatment are frequent problems, The family and the orthodontist should be on the alert for them. A philosophy for their management and the authors’ experience over the past 13 years are presented. The proper time for definitive treatment of these impactions is during early adolescence, generally in the 1 I- to 14-year range. ~rn~a~tion of the second molar is usually a problem of arch length deficiency. There may be an associated problem with a third molar impaction. The alternatives for impacted second molar treatments are (1) surgical repositioning with or without adjacent third molar removal, (2) removal of the second molar allowing the third molar to erupt, and (3) transplantation of the third molar to the second molar socket. In the authors’ experience, surgical repositioning has provided the most promising results of the three choices. Technical aspects of surgical repositioning are discussed along with case selection criteria. Six cases are presented to demonstrate typical problems and their management. With proper timing and intervention, the prognosis is excellent for repositioning second molar ~rnpact~~~s. (AM J ORTHOD DENTOFAC ORTHOP 1987;91:242-51.) Key words: Impacted second molars, surgical repositioning, molar removal
mpacted second molars refractory? to orthodontic treatment are frequent problems for which the family dentist and the orthodontist should be alert. Successful treatment may require a multidisciplinary approach that includes the general practitioner, orthodontist, and oral surgeon. The purpose of this article is to relate a philosophy as to their management and the experience of the authors over the past 13 years. The proper time for definitive treatment of these impactions is during early adolescence, generally in the II- to 14”year range. This observation has also been made by other authors. Peskin and Graber’ specifically noted that patients 13 to 14 years of age had a better prognosis for surgical repositioning of second molar teeth. Johnson and Taylor’ cited the 1 l- to 13-year range as optimum. Davis,3 reporting on surgical repositioning of second molars, had a mean age of under 13 years. In our experience those impactions requiring treatment are most frequently in the mesioangular position.
Impaction of the second molar is usually a problem of arch length deficiency. This may occur in more than
*In private practice. oral and maxillofacial surgery. ?Techniques used for orthodontic treatment may include the use of stainless steel crowns, pin screws, ligation, and bond brackets. In many cases the orthodontist is not able to properly position second molar impactions.
42
autotransplantation,
eruption,
early second
one quadrant, although it is much more common in the mandible than the maxilla. Infrequently, there may be an associated problem of follicular cyst formation on the second molar. More commonly, an impacted third molar bud may compete for position. If the second molar has not erupted at its normal time, especially if the others have erupted, local conditions should be evaluated. An impending problem can be recognized from the physical examination, radiographic survey, projiected space estimate, jaw growth patterns, and tooth position. The alternatives for impacted second molar treatments are (1) surgical repositioning with or without adjacent third molar removal, (2) removal of the second molar allowing the third molar to erupt, and (3) transplantation of the third molar to the second molar socket. SURGICAL
REPOSITIONIN
The decision to surgically reposition these teeth should be reached after the o~hodo~tist is satisfied that there is no other alternative. In reviewing the literature, the precedent for surgical repositioning of teeth is set in reports on autotransplantation. Guralnich4 reported his experience over a period of I5 years. Studies by Apfel’ and Miller6 relate extensive work on autotransplantation of teeth Tam and Hale,7 in separate articles, used third molars with partially formed roots as transplants to replace
Case report
-
Fig. 1. Flap design for exposure molar impaction. Brass separating
-
TISSUE REMOVAL INCISION
of impacted second molars wire is not illustrated.
carious first molars. Hale states that 3 to 5 mm is the ideal stage of development for transplantation. The single most signi$cant common factor for success in these studies is performing the transplants be,fore the roots are completely formed. Repositioning is certainly analogous to transplantation with the exceprion that the tooth is not removed from its socket. A rationale for surgical repositioning of teeth was written by Laskin and Peskin.’ They differentiated between tipping and bodily movement of these impactions. Tipping procedures essentially do not radically change the apex position that serves as the axis for movement of the crown. Teeth with mature or closed apices were found to be less likely to develop pulpal necrosis witb this procedure. The apex and crown positions are changed with bodily movement. Teeth with partially formed apices were most suitable for this movement, which is analogous to transplantation. Laskin and Peskin specify one half root formation as the optimum stage for bodily movement. In summary, for the greater distance the apex is moved, there is a proportional risk of pulpal necrosis.
The procedure may be performed under local or general anesthesia. An initial buccal incision is made at the junction of the distal gingival margin of the first
with
distal
extension
for removal
of third
molar and carried posteriorly to the second molar if its crown is erupted. If the second molar is completely covered with soft tissue, the incision is extended posteriorly approximately 1 cm over the retromolar area. The mucoperiosteum is reflected just enough to ex the crown of the impacted second molar, adjacent and distal bone, and the third molar area (Fig. 1). At this point the third molar is carefully sectioned for removal. Every effort is made to conserve bone. If there is sufficient posterior and buccal space, the second molar is simply elevated distally with a straight elevator. Some cases may require bone removal to attain proper position, particularly on the distal and buccal areas. These are usually situations where there is no space for the second molar crown in the-posterior alveolus. These cases have more distal bone to resist the repositioning procedure. If there is no third molar impaction, it is frequently necessary to create space. A no. 8 round bur in a slowspeed straight handpiece is used to remove the distal bone, being very careful to avoid root damage to the involved tooth. The resulting space also provides a stable posterior stop. A 22-gauge brass separating wire is used to secure the elevated tooth at its contact point with the first molar. This provides a method of further distal correction if the orthodontist so desires. No other appliance is usually used for fixation and the tooth may be banded or bonded in 3 or 4 months.
h.
Johnson and Quirk
1. Orthod.
Deiltofac. Orthup. March 1987
Fig. 2 (Cont’d). D, Eight-month foilow-up radiograph. E, Panoramic film taken 7 years after surgical treatment before third molars were removed. Note that in this case third molar bud was not removed. If the case were to be treated at present, third molar bud would be removed at time of repositioning. (Case, courtesy of Marion Ford, D.D.S.)
Fig 2. Case 1. A, Radiograph Tooth exposed, ligated, and paction surgically repositioned.
of impacted packed open
second molar. 8, with gauze. C, Im-
It may be necessary to properly remove and contour the retromolar tissue if the second molar is a complete impaction (Fig. 1). This is done after the repositioning so that the tooth-to-tissue relation may be observed and adjusted. Attached gingivae must be left on the buccal margin. An absence of attached gingivae would create a detrimental periodontal problem. A single chromic gut suture is then placed through the gingiva at the mesial aspect and distal of the positioned tooth. The occlusion must be carefully evaluated after the
tooth is positioned and before the patient 1sdismissed. Supraerupted maxillary opponent teeth may be in traumatic occlusion with the repositioned tooth and must be equilibrated. An extreme buccal or lingual crown position of the malposed tooth may make simple elevation impossible. a If satisfactory initial positioning is not possible, elevation may be performed. A second procedure in a few months to complete the positioning, should it be necessary, will accomplish the final result. it must always be remembered that elevation of the m&al marginal ridge of the second molar above the distal crest of contour of the first molar is imperative for stability. Healing is usually uneventful. prophylactic antibiotics and steroids, as regularly used with impacted third molar surgery, are prescribed. Patients are followed for a period of 2 years after surgical trealrnent, at 6-month intervals for radiographic and clinical evvidence of pulpal necrosis. After the second molar is in a satisfactory position and soft tissue healing is complete, the distal aspect of the tooth may still be covered with soft tissue that might
Volu.me 9 I Number 3
Fig. 3. Case 2. A through F, Panoramic radiographs. A, Four and one half years before surgery, third molar buds in rami are above developing second molar buds. 8, One year before surgical treatment, second molars are assuming mesioangular impaction position. C, Position of the second molars at the time of surgery.
reoccur after excision. This may be an indication of insufficient arch length and has the potential of creating periodontal problems in time. IS~~SSIQ In our experience the third molar, if present, is removed before repositioning the second molar. Ini-
tially, we believed that the space was needed for distal movement of the second molar crown. This is not true except in selected cases. Davis and associate? reported a favorable experience repositioning 21 second molars without removal of the third molar. However, since loss of the second molar from this procedure is unusual, one can hardly justify leaving the impacted third molars
6
Johnson
and
Quirk
Fig. 3 (Cont’d). D, Tooth position at time of surgical treatment and after repositioning. right second molar is in good vertical position but still in buccal version. E, Six months ~osto~sr~tivel~ the teeth have erupted vertically, but mandibular right second molar is still in buccal veision. F, ~~~htes~ months after surgery, mandibular right second molar has been repositioned by cross elastics (Case, courtesy of Sam A. Winkelmann, D.D.S.)
and later subjecting the patient to another procedure for their removal. Other authors advocate the use of an absorbable gelatin sponge (Gelfoam) or autogenous alveolar bone to stabilize the repositioned second mo1ars.‘z3 In the cases we have treated, this has not been necessary. Bone readiEy fills in the defect in the mesial portion of the alveolus left by the elevated tooth.
CASE
1
C.W., a 33-year-old female patient (Fig. 2, A through E), was the first case in which surgical repositioning was used for an impacted second molar (1971). The patient bad an impacted mandibular left second molar and an associated follicular cyst. The orthodontist referred her for exposure and ligation of the tooth. Her mother stated that another dentist
Case
report
Fig. 4. Case 3. A and 6, Panoramic radiographs. A, Repositioning performed and in this case maxillary left second molar was in traumatic occlusion and required equilibration. B, Six months postoperative. (Case, courtesy of Stephen D. Kerr, D.D.S.)
had advisedthem to remove the tooth. The tooth was exposed, Ligated, and packed open with gauze. Eight months later the patient returned with a request to place a stainlesssteel crown over the impacted tooth. The orthodontist was unable to move the tooth and, due to the position, it was impossible to place a crown. Surgically repositioning of the impaction was performed.
B.H., a l&year-old male patient, had a developing bilateral mandibular secondmolar impaction problem as demonstrated by multiple panoramic radiographs (Fig. 3, A through F). CASE
3
T.V., a 15-year-old male patient, presented with bilateral impacted mandibular second molars (Fig. 4, A and B). CASE
4
D.B., a E2-year-old female patient, presented with an impending impaction of the mandibular second molars (Fig. 5, A through C). She was initially treated by early removal of the third molar buds. Repositioning of the impacted mandibular second molars was performed 18 months later.
CASE
5
C.G., a 13-year-old male patient, had an inreresting combination of impacted maxillary and mandibular right second molars and four impacted third molars (Fig. 6, A through C) , CASE
6
A.W., a 12-year-oldmale patient, presentedwith impending bilateral mandibular second molar impactions (Fig. 7, A through C). REMOVAL
OF THE SECOND
MQL
If the second molar cannot be elevated or is unfavorably positioned (deep horizontal impactions or extreme buccal or lingual version), the second molar may be removed to allow space for the eruption of the third molar. Liddle’ advocates this treatment as an alternative to removal of premolars. Obviously, this eliminates the impacted second molar problem. This author reports good results by diagnosing space problems between age 8 and 12 years. Wilson lo has described similar results in more than 500 patients. In our experience impacted mandibular third molars do not favorably erupt iz place of the see as high a percentage as do maxillary tee&h
Fig. 5. Case 4. A through C, Panoramic radiographs. A, Patient presented with impending impaction and C, of mandibular second molars. Both mandibular third molars were removed at this time. Eighteen months later patient returned for repositioning of impacted mandibular second molars. (Case, courtesy of Patrick Alessandra, D.D.S.)
and Wilson have not had this experience and they reart no significant problems with regard to the manibular third molars erupting properly. It is important to note that their patients had their second molars removed at a time when the third molar roots were very immature.
The last possibility, and probably the least attractive, would be removal of the second molar and trans-
plantation of the third molar into its position. This involves a high degree of risk, especially in the older patient with closed apices on the third molar. The result would be an almost certain loss of vitality in the transplant. In younger patients with incomplete roots, the autotransplant has a greater chance of survival, Although transplantation is a consideration, most patients in early adolescence can adequately be managed by one of the other methods.
g. 6. Case 5. A through C, Panoramic radiographs. A, Combination andibuiar right second molars and four impacted third molars. B, Due right maxilla, we elected to remove maxillary right second molar to andibular second molar was repositioned and the remaining third molar follow-up film. (Case, courtesy of Sam A. Winkelmann, D.D.S.)
of impacted maxiliary and to “stacking” of molar buds allow third molar to erupt. buds removed. C, One year
SUMMARY For the best results with repositioning of the impacted second molar, recognition and treatment must begin in early adolescence. This takes advantage of incomplete root formation and a more vascular and resilient bony bed. After closure of the apex, the technical difficulty, particularly with repositioning, increases as well as the incidence of complications and failure. With proper interception and treatment, the rognosis is excellent.
Further research on the problem of impacted second molars should be undertaken. This would be an excellent clinical project for the teaching centers. It seems that with our present knowledge of facial growth, inherent patterns of space problems could be piu~oi~ted by a system of criteria to alert the orthodontist to an apparent developing impaction problem. This would more accurately dictate the proper time to initiate corrective measures. Skeletal jaw types and molar rela-
Johnson and Quirk
Fig. 7. Case 6. A through C, Panoramic radiographs. A, Panoramic radiograph taken 1 year before surgery. Four premolars have already been removed. f3, One month after surgery. Four third molars were removed on this patient with mandibular second molar repositioning. Note that brass separating wires were not initially used in this case, allowing molars to tip mesially. Teeth were banded and treatment was completed. C, Two years after surgical intervention. (Case, courtesy of Sam A. Winke~ma~n,
tionships should be analyzed to determine in which groups this is most prevalent. With a more precise systern of early diagnosis, perhaps surgical repositioning could be avoided. We would like to express our gratitude to Dan C. West, D.D.S., and W. Bonham Magness, D.D.S., of the University of Texas Health Science Center at Houston, Dental Branch, Department of Orthodontics, for their advice and aid in the preparation of this article.
REFERENCES
1. Peskin S, Graber TM. Surgical repositioning of teeth. J Am Dent Assoc 1970;80:1320-6. 2. Johnson E, Taylor RC. A surgical-orthodontic approach in uprighting impacted mandibular second molars. AIM 4 ORTKOD 1972;61:508-14.
3. Davis WH, Patakas BM, Kaminishi RM, Pars& NE. Surgically uprighting and grafting second molars. Ah{ J ORTI~QD 1976; 69:555-61.
4. Guralnich WC. Autogenous and allogenic transplants. J Oral Surg 1970;28:575-7.
5. Apfel H. Transplantations of the unernpted third molar tooth. J Oral Surg 1956;9:96. 6. Miller HM. Tooth transplantation. J Oral Surg 1951;9:68. 7. Symposium. Transplantation, reimplantation and surgical positioning of teeth. Oral Surg Oral Med Oral Path01 1956;9:3-122, 125-92. 8. Laskin DM, Peskin S. Surgical aids in orthodontics. Dent Clin North Am 1968509-24. 9. Liddle DW. Second molar extraction in orthodontic treatment. AM J ORTHOD 1917;72:555-616.
10. Wilson dontic
HE. Extraction of second permanen? treatment. Orthodontist 1971;3: 1X-24.
Reprint requests to: Dr. James V. Johnson 3838 Hillcroft Houston, TX 77057
moiars
in &ho-
I ~e~Qsitioning
of impaetc?
rnQ~a~ teeth a V. Johnson, Houston, Texas
D.D.S., M.S.,* and George
P, Quirk,
5.
fmpacted second molars refractory to orthodontic treatment are frequent problems, The family and the orthodontist should be on the alert for them. A philosophy for their management and the authors’ experience over the past 13 years are presented. The proper time for definitive treatment of these impactions is during early adolescence, generally in the 1 I- to 14-year range. ~rn~a~tion of the second molar is usually a problem of arch length deficiency. There may be an associated problem with a third molar impaction. The alternatives for impacted second molar treatments are (1) surgical repositioning with or without adjacent third molar removal, (2) removal of the second molar allowing the third molar to erupt, and (3) transplantation of the third molar to the second molar socket. In the authors’ experience, surgical repositioning has provided the most promising results of the three choices. Technical aspects of surgical repositioning are discussed along with case selection criteria. Six cases are presented to demonstrate typical problems and their management. With proper timing and intervention, the prognosis is excellent for repositioning second molar ~rnpact~~~s. (AM J ORTHOD DENTOFAC ORTHOP 1987;91:242-51.) Key words: Impacted second molars, surgical repositioning, molar removal
mpacted second molars refractory? to orthodontic treatment are frequent problems for which the family dentist and the orthodontist should be alert. Successful treatment may require a multidisciplinary approach that includes the general practitioner, orthodontist, and oral surgeon. The purpose of this article is to relate a philosophy as to their management and the experience of the authors over the past 13 years. The proper time for definitive treatment of these impactions is during early adolescence, generally in the II- to 14”year range. This observation has also been made by other authors. Peskin and Graber’ specifically noted that patients 13 to 14 years of age had a better prognosis for surgical repositioning of second molar teeth. Johnson and Taylor’ cited the 1 l- to 13-year range as optimum. Davis,3 reporting on surgical repositioning of second molars, had a mean age of under 13 years. In our experience those impactions requiring treatment are most frequently in the mesioangular position.
Impaction of the second molar is usually a problem of arch length deficiency. This may occur in more than
*In private practice. oral and maxillofacial surgery. ?Techniques used for orthodontic treatment may include the use of stainless steel crowns, pin screws, ligation, and bond brackets. In many cases the orthodontist is not able to properly position second molar impactions.
42
autotransplantation,
eruption,
early second
one quadrant, although it is much more common in the mandible than the maxilla. Infrequently, there may be an associated problem of follicular cyst formation on the second molar. More commonly, an impacted third molar bud may compete for position. If the second molar has not erupted at its normal time, especially if the others have erupted, local conditions should be evaluated. An impending problem can be recognized from the physical examination, radiographic survey, projiected space estimate, jaw growth patterns, and tooth position. The alternatives for impacted second molar treatments are (1) surgical repositioning with or without adjacent third molar removal, (2) removal of the second molar allowing the third molar to erupt, and (3) transplantation of the third molar to the second molar socket. SURGICAL
REPOSITIONIN
The decision to surgically reposition these teeth should be reached after the o~hodo~tist is satisfied that there is no other alternative. In reviewing the literature, the precedent for surgical repositioning of teeth is set in reports on autotransplantation. Guralnich4 reported his experience over a period of I5 years. Studies by Apfel’ and Miller6 relate extensive work on autotransplantation of teeth Tam and Hale,7 in separate articles, used third molars with partially formed roots as transplants to replace
Case report
-
Fig. 1. Flap design for exposure molar impaction. Brass separating
-
TISSUE REMOVAL INCISION
of impacted second molars wire is not illustrated.
carious first molars. Hale states that 3 to 5 mm is the ideal stage of development for transplantation. The single most signi$cant common factor for success in these studies is performing the transplants be,fore the roots are completely formed. Repositioning is certainly analogous to transplantation with the exceprion that the tooth is not removed from its socket. A rationale for surgical repositioning of teeth was written by Laskin and Peskin.’ They differentiated between tipping and bodily movement of these impactions. Tipping procedures essentially do not radically change the apex position that serves as the axis for movement of the crown. Teeth with mature or closed apices were found to be less likely to develop pulpal necrosis witb this procedure. The apex and crown positions are changed with bodily movement. Teeth with partially formed apices were most suitable for this movement, which is analogous to transplantation. Laskin and Peskin specify one half root formation as the optimum stage for bodily movement. In summary, for the greater distance the apex is moved, there is a proportional risk of pulpal necrosis.
The procedure may be performed under local or general anesthesia. An initial buccal incision is made at the junction of the distal gingival margin of the first
with
distal
extension
for removal
of third
molar and carried posteriorly to the second molar if its crown is erupted. If the second molar is completely covered with soft tissue, the incision is extended posteriorly approximately 1 cm over the retromolar area. The mucoperiosteum is reflected just enough to ex the crown of the impacted second molar, adjacent and distal bone, and the third molar area (Fig. 1). At this point the third molar is carefully sectioned for removal. Every effort is made to conserve bone. If there is sufficient posterior and buccal space, the second molar is simply elevated distally with a straight elevator. Some cases may require bone removal to attain proper position, particularly on the distal and buccal areas. These are usually situations where there is no space for the second molar crown in the-posterior alveolus. These cases have more distal bone to resist the repositioning procedure. If there is no third molar impaction, it is frequently necessary to create space. A no. 8 round bur in a slowspeed straight handpiece is used to remove the distal bone, being very careful to avoid root damage to the involved tooth. The resulting space also provides a stable posterior stop. A 22-gauge brass separating wire is used to secure the elevated tooth at its contact point with the first molar. This provides a method of further distal correction if the orthodontist so desires. No other appliance is usually used for fixation and the tooth may be banded or bonded in 3 or 4 months.
h.
Johnson and Quirk
1. Orthod.
Deiltofac. Orthup. March 1987
Fig. 2 (Cont’d). D, Eight-month foilow-up radiograph. E, Panoramic film taken 7 years after surgical treatment before third molars were removed. Note that in this case third molar bud was not removed. If the case were to be treated at present, third molar bud would be removed at time of repositioning. (Case, courtesy of Marion Ford, D.D.S.)
Fig 2. Case 1. A, Radiograph Tooth exposed, ligated, and paction surgically repositioned.
of impacted packed open
second molar. 8, with gauze. C, Im-
It may be necessary to properly remove and contour the retromolar tissue if the second molar is a complete impaction (Fig. 1). This is done after the repositioning so that the tooth-to-tissue relation may be observed and adjusted. Attached gingivae must be left on the buccal margin. An absence of attached gingivae would create a detrimental periodontal problem. A single chromic gut suture is then placed through the gingiva at the mesial aspect and distal of the positioned tooth. The occlusion must be carefully evaluated after the
tooth is positioned and before the patient 1sdismissed. Supraerupted maxillary opponent teeth may be in traumatic occlusion with the repositioned tooth and must be equilibrated. An extreme buccal or lingual crown position of the malposed tooth may make simple elevation impossible. a If satisfactory initial positioning is not possible, elevation may be performed. A second procedure in a few months to complete the positioning, should it be necessary, will accomplish the final result. it must always be remembered that elevation of the m&al marginal ridge of the second molar above the distal crest of contour of the first molar is imperative for stability. Healing is usually uneventful. prophylactic antibiotics and steroids, as regularly used with impacted third molar surgery, are prescribed. Patients are followed for a period of 2 years after surgical trealrnent, at 6-month intervals for radiographic and clinical evvidence of pulpal necrosis. After the second molar is in a satisfactory position and soft tissue healing is complete, the distal aspect of the tooth may still be covered with soft tissue that might
Volu.me 9 I Number 3
Fig. 3. Case 2. A through F, Panoramic radiographs. A, Four and one half years before surgery, third molar buds in rami are above developing second molar buds. 8, One year before surgical treatment, second molars are assuming mesioangular impaction position. C, Position of the second molars at the time of surgery.
reoccur after excision. This may be an indication of insufficient arch length and has the potential of creating periodontal problems in time. IS~~SSIQ In our experience the third molar, if present, is removed before repositioning the second molar. Ini-
tially, we believed that the space was needed for distal movement of the second molar crown. This is not true except in selected cases. Davis and associate? reported a favorable experience repositioning 21 second molars without removal of the third molar. However, since loss of the second molar from this procedure is unusual, one can hardly justify leaving the impacted third molars
6
Johnson
and
Quirk
Fig. 3 (Cont’d). D, Tooth position at time of surgical treatment and after repositioning. right second molar is in good vertical position but still in buccal version. E, Six months ~osto~sr~tivel~ the teeth have erupted vertically, but mandibular right second molar is still in buccal veision. F, ~~~htes~ months after surgery, mandibular right second molar has been repositioned by cross elastics (Case, courtesy of Sam A. Winkelmann, D.D.S.)
and later subjecting the patient to another procedure for their removal. Other authors advocate the use of an absorbable gelatin sponge (Gelfoam) or autogenous alveolar bone to stabilize the repositioned second mo1ars.‘z3 In the cases we have treated, this has not been necessary. Bone readiEy fills in the defect in the mesial portion of the alveolus left by the elevated tooth.
CASE
1
C.W., a 33-year-old female patient (Fig. 2, A through E), was the first case in which surgical repositioning was used for an impacted second molar (1971). The patient bad an impacted mandibular left second molar and an associated follicular cyst. The orthodontist referred her for exposure and ligation of the tooth. Her mother stated that another dentist
Case
report
Fig. 4. Case 3. A and 6, Panoramic radiographs. A, Repositioning performed and in this case maxillary left second molar was in traumatic occlusion and required equilibration. B, Six months postoperative. (Case, courtesy of Stephen D. Kerr, D.D.S.)
had advisedthem to remove the tooth. The tooth was exposed, Ligated, and packed open with gauze. Eight months later the patient returned with a request to place a stainlesssteel crown over the impacted tooth. The orthodontist was unable to move the tooth and, due to the position, it was impossible to place a crown. Surgically repositioning of the impaction was performed.
B.H., a l&year-old male patient, had a developing bilateral mandibular secondmolar impaction problem as demonstrated by multiple panoramic radiographs (Fig. 3, A through F). CASE
3
T.V., a 15-year-old male patient, presented with bilateral impacted mandibular second molars (Fig. 4, A and B). CASE
4
D.B., a E2-year-old female patient, presented with an impending impaction of the mandibular second molars (Fig. 5, A through C). She was initially treated by early removal of the third molar buds. Repositioning of the impacted mandibular second molars was performed 18 months later.
CASE
5
C.G., a 13-year-old male patient, had an inreresting combination of impacted maxillary and mandibular right second molars and four impacted third molars (Fig. 6, A through C) , CASE
6
A.W., a 12-year-oldmale patient, presentedwith impending bilateral mandibular second molar impactions (Fig. 7, A through C). REMOVAL
OF THE SECOND
MQL
If the second molar cannot be elevated or is unfavorably positioned (deep horizontal impactions or extreme buccal or lingual version), the second molar may be removed to allow space for the eruption of the third molar. Liddle’ advocates this treatment as an alternative to removal of premolars. Obviously, this eliminates the impacted second molar problem. This author reports good results by diagnosing space problems between age 8 and 12 years. Wilson lo has described similar results in more than 500 patients. In our experience impacted mandibular third molars do not favorably erupt iz place of the see as high a percentage as do maxillary tee&h
Fig. 5. Case 4. A through C, Panoramic radiographs. A, Patient presented with impending impaction and C, of mandibular second molars. Both mandibular third molars were removed at this time. Eighteen months later patient returned for repositioning of impacted mandibular second molars. (Case, courtesy of Patrick Alessandra, D.D.S.)
and Wilson have not had this experience and they reart no significant problems with regard to the manibular third molars erupting properly. It is important to note that their patients had their second molars removed at a time when the third molar roots were very immature.
The last possibility, and probably the least attractive, would be removal of the second molar and trans-
plantation of the third molar into its position. This involves a high degree of risk, especially in the older patient with closed apices on the third molar. The result would be an almost certain loss of vitality in the transplant. In younger patients with incomplete roots, the autotransplant has a greater chance of survival, Although transplantation is a consideration, most patients in early adolescence can adequately be managed by one of the other methods.
g. 6. Case 5. A through C, Panoramic radiographs. A, Combination andibuiar right second molars and four impacted third molars. B, Due right maxilla, we elected to remove maxillary right second molar to andibular second molar was repositioned and the remaining third molar follow-up film. (Case, courtesy of Sam A. Winkelmann, D.D.S.)
of impacted maxiliary and to “stacking” of molar buds allow third molar to erupt. buds removed. C, One year
SUMMARY For the best results with repositioning of the impacted second molar, recognition and treatment must begin in early adolescence. This takes advantage of incomplete root formation and a more vascular and resilient bony bed. After closure of the apex, the technical difficulty, particularly with repositioning, increases as well as the incidence of complications and failure. With proper interception and treatment, the rognosis is excellent.
Further research on the problem of impacted second molars should be undertaken. This would be an excellent clinical project for the teaching centers. It seems that with our present knowledge of facial growth, inherent patterns of space problems could be piu~oi~ted by a system of criteria to alert the orthodontist to an apparent developing impaction problem. This would more accurately dictate the proper time to initiate corrective measures. Skeletal jaw types and molar rela-
Johnson and Quirk
Fig. 7. Case 6. A through C, Panoramic radiographs. A, Panoramic radiograph taken 1 year before surgery. Four premolars have already been removed. f3, One month after surgery. Four third molars were removed on this patient with mandibular second molar repositioning. Note that brass separating wires were not initially used in this case, allowing molars to tip mesially. Teeth were banded and treatment was completed. C, Two years after surgical intervention. (Case, courtesy of Sam A. Winke~ma~n,
tionships should be analyzed to determine in which groups this is most prevalent. With a more precise systern of early diagnosis, perhaps surgical repositioning could be avoided. We would like to express our gratitude to Dan C. West, D.D.S., and W. Bonham Magness, D.D.S., of the University of Texas Health Science Center at Houston, Dental Branch, Department of Orthodontics, for their advice and aid in the preparation of this article.
REFERENCES
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