Surgical Uprighting of Mandibular Second Molars

PROBLEM STATEMENT: Impacted, unerupted or malpositioned second molars during orthodontic therapy require special attention and management in order for the teeth to normalize in their position in the arch. Management of this problem ranges from extracting the second molar to allow the third molar to erupt or removing the third molar and observation with or without orthodontic support. We present a surgical approach to managing these poorly positioned teeth using surgical exposure, forced surgical uprighting with or without the bonding of orthodontic appliances and active orthodontic uprighting forces.

MATERIALS AND METHODS: this prospective trial followed 210 impacted second molars treated in an identical fashion derived following a protocol established in 2007 in our surgical centre.  All cases were adolescent patients referred from orthodontists for the specific management of impacted second molars. The impacted molars were exposed, uprighted as much as possible, a bracket was bonded if required and the wound was packed if necessary to allow orthodontic manipulation. Active orthodontic therapy was either currently involved or previously involved. Data collection included demographic charting and panoramic radiograph documentation at the pre-surgical visit (T1); immediately post uprighting at the time of surgery (T2); and 6-22 months post uprighting (T3). Data collected included the preoperative position of the second molar and the status of the associated impacted third molar (if present). Further data measured to describe outcomes included: the clinical occlusal relationship to the opposing dentition, radiographic evidence of bone filling, radiographic description of root development and pulp testing for vitality.  Complications assessed included periodontal defects, loss of the uprighted tooth and fractured roots.

RESULTS: A total of 210 mandibular second molars were uprighted in 147 patients (64 female; 83 male) with an average age of 14.8 (range x14.2 F and 15.4y M). Orthodontic therapy was active in 96 cases and 51 cases the patients orthodontic therapy had recently been completed. Outcomes showed 205 molars were successfully uprighted.    Complications included: infected/abscess teeth in 3 cases; fractured root requiring extraction in 2 cases. All 205 teeth tested vital. Ten teeth had periodontal pocketing of more than 5mm (without bleeding) and 195 of the teeth presented with a good to excellent occlusal contact.

CONCLUSIONS: Surgically assisted forced eruption of impacted mandibular second molars (with or without orthodontic forced eruption) is a safe, successful and viable approach to managing unerupted or malpositioned mandibular second molars in an adolescent population. It provides for a predictable solution in managing impacted second molars. The technique is simple and has minimal morbidity.

Ref:

Pogrel MA. The surgical uprighting of mandibular second molars. Am J Orthod Dentofacial Orthop 1995. 108:180–183. 

Kenrad J,  Vedtofte H, Andreasen JO, Kvetny MJ, Kjær I. A retrospective overview of treatment choice and outcome in 126 cases with arrested eruption of mandibular second molars. Clin Oral Invest 2011. 15:81–87

Fu PS, Wang JC, Wu YM, Huang TK, Chen WC, Tseng YC, Tseng CH, Hung CC. Impacted mandibular second molars: A retrospective stufy of prevelance and treatment outcome. Angle Orthodontist 2013. 82:670-675.