An orthodontic extrusion and uprighting of impacted mandibular permanent second molar

Kanika Gupta Verma; Lalita Singla; Nidhi Gupta; Mahima Saini

doi:10.4103/ais.ais_34_20

Users Online: 425

CASE REPORT

Year : 2020 | Volume : 10 | Issue : 1 | Page : 36-39

An orthodontic extrusion and uprighting of impacted mandibular permanent second molar

Kanika Gupta Verma¹, Lalita Singla¹, Nidhi Gupta², Mahima Saini¹
¹ Department of Paediatric and Preventive Dentistry, Surendra Dental College & Research Institute, H.H. Gardens, Power House Road, Sri Ganganagar, Rajasthan, India
² Department of Oral and Maxillofacial Surgery, Trauma Center and Superspeciality Hospital, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission	23-Jul-2020
Date of Acceptance	25-Sep-2020
Date of Web Publication	06-May-2021

Correspondence Address:
Dr. Kanika Gupta Verma
Department of Pedodontics & Preventive Dentistry, Surendera Dental College & Research Institute, H.H Gardens, Power House Road, Sriganganagar, Rajasthan
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/ais.ais_34_20

Abstract

Tooth impaction is a dental anomaly which is defined as cessation of eruption of tooth. It is caused by a physical barrier in the eruption path or abnormal position of the tooth. Impaction of permanent second molar is not a common condition. Early detection and treatment of impaction reduces the risk of complications associated with this condition. There are several treatment options for impacted tooth which depends on the degree of tooth inclination as well as the required tooth movement. The present case report presents a case of 14-year-old male patient with mesially impacted permanent second molar. The case presents the surgical and orthodontic management with orthodontic extrusion and uprighting of concerned impacted tooth.

Keywords: Mandibular second molar tooth, tooth extrusion, tooth impaction, tooth uprighting

How to cite this article:
Verma KG, Singla L, Gupta N, Saini M. An orthodontic extrusion and uprighting of impacted mandibular permanent second molar. Arch Int Surg 2020;10:36-9

How to cite this URL:
Verma KG, Singla L, Gupta N, Saini M. An orthodontic extrusion and uprighting of impacted mandibular permanent second molar. Arch Int Surg [serial online] 2020 [cited 2023 Mar 29];10:36-9. Available from: https://www.archintsurg.org/text.asp?2020/10/1/36/315399

Introduction

Tooth impaction is failure of its eruption due to presence of a supernumerary tooth or an odontoma, lack of adequate space in the arch, an abnormal eruption path, or idiopatic factors.^[1] In the permanent dentition, third molars are the most commonly impacted, followed by maxillary canines and mandibular second premolars. Impaction of the mandibular permanent second molars (MM2) is a rare condition.^[1] Prevalence of impacted second molars varies from 0% 2.3%.^[2] There are three forms of MM2 impaction according to its axial inclination: mesially, distally inclined or vertically positioned. Among these, mesial inclination is the most common.^[3] Varpio and Wellfelt described more eruption disturbances of MM2 in males than females; bilateral impaction was seen in 23% of the cases, with a predominance of impaction on the right side.^[4] It has been observed in various studies that the age at which impaction of MM2 occurs vary from 9 to 26 years.^[5] It is observed that 6-month to 1 year delay occur in eruption of a permanent mandibular second molar as compared with its contralateral counterpart. But when eruption of a permanent tooth is at least 2 years behind schedule, disorder eruption should be suspected.^[6]

Early detection and treatment is important to avoid risk of impaction. This may also eliminate the need for complicated orthodontic and surgical treatment.^[7] The goal of treatment following impaction is to save the tooth in the arch and to restore form and function. This is achieved by surgical exposure of the impacted tooth followed by orthodontic interventionthat involves space regaining, uprighting and extrusion of an impacted tooth.^[8] A good treatment option includes orthodontically assisted eruption with or without surgical uncovering. The orthodontic treatment approach includes an attachment bonded to the surgically uncovered buccal or distobuccal surface and subsequently some uprighting force delivered by NiTi-coil spring, superelastic NiTi wire, a variety of uprighting springs, or a sectional arch wire.^[9]

The aim of present article is to discuss a case report showing an uncommon case of impacted mandibular permanent second molar and its management with surgical and orthodontic intervention.

Case Report

A 14-year-old male patient reported to the Department of Pediatric and Preventive Dentistry, Surendera Dental College and Research Institute, Sriganganagar with the chief complaint of getting his tooth restored in lower right back region. Patient had undergone root canal treatment with respect to 46 from a local practitioner. On soft tissue examination, gingiva was reddish pink in color with rolled out margins and bleeding on probing was present. On hard tissue examination, type of dentition seen was permanent dentition with Angle's Class I on left side and class II molar relationship on right side. Dental caries were noticed with respect to 11, 12, 14, 15, 16, 21, 22, 24, 25, 26, 34, 35, 36, 44, and 45 [Figure 1]a,[Figure 1]b. Before subjecting patient to prosthetic rehabilitation with respect to 46 (mandibular permanent first molar), an intraoral periapical radiograph was adviced to analyze the status of root canal treatment in relation to 46 and eruption status of unerupted 47 (mandibular right permanent second molar). Intraoral periapical radiograph revealed an incomplete obturation in all the root canals of 46, with no associated periapical and inter radicular radiolucency. However, accidently it was revealed that 47 was mesially impacted with complete root formation. The patient was adviced an orthopantomographto assess the status of complete dentition. Orthopantomograph revealed mesially impacted 47 under cemento-enamel junction of 46 and tooth bud of 48 (Nolla stage 7) was overlying the impacted 47 [Figure 1]c. The treatment planned was surgical extraction of the mandibular third molar followed by surgical exposure and orthodontic extrusion and uprighting of 47.

Figure 1: (a, b) Preoperative photograph of maxillary and mandibular arches; (c) preoperative Orthopantomograph showing impacted right mandibular permanent second molar

Click here to view

Treatment plan

Before starting the procedure, vitals were checked and blood investigations were done. All investigations were found to be within normal limit. The treatment procedure was explained to patient's parents and informed consent was obtained. The extraction of 48 was done surgically and after 10 days, complete healing of the socket was evident. During the orthodontic treatment, composite restorations were done with respect to 11, 12, 14, 15, 16, 21, 22, 24, 25, 26, 34, 35, 36, the surgical exposure of 47 was done using electrocautery, so as to keep the exposure site bloodless [Figure 2]a,[Figure 2]b. After exposure, a curved bracket was bonded over the exposed occlusal surface of 47. One end of 0.06” NiTi Superelastic wire was inserted into bonded bracket and another end was fixed with composite over occlusal surface of 46 [Figure 3]a. Light continuous force around 50 g was applied by NiTi wire. The initial change of inclination was noticed 4 weeks after the application of the device. After intervals of two months, NiTi wire was changed twice. After another two months, uprighting and extrusion of 4 mm has been achieved. Begg's brackets were now bonded on the buccal surface of 46 and 47, with an open coil spring (.010” × 0.030”) inserted in 0.06” NiTi Superelastic wire to distalize 47, so as to achieve the uprighting movements after achieving distalization of 1 mm [Figure 3]b. After three months, 47 was observed to be in perfect occlusal relationship with total extrusion of 8 mm [Figure 4]a. Intraoral periapical radiograph was taken which revealed that the mandibular second molars had been successfully uprighted in proper position with adequate bone formation and healthy periodontal ligament lining [Figure 4]b. After successful treatment debonding was done followed by complete oral prophylaxis. During the orthodontic treatment, composite restorations were done with respect to 11, 12, 14, 15, 16, 21, 22, 24, 25, 26, 34, 35, 36, 44. Patient is adviced oral hygiene instructions and follow up visit after every three months. First follow up visit revealed maintenance of oral hygiene and perfect occlusal relationship with respect to 47.

Figure 2: (a) Showing electrocauterization with respect to 47; (b) showing exposure 44. Patient is adviced oral hygiene instructions and follow up visit after every three months. First follow up visit revealed maintenance of oral hygiene and perfect occlusal relationship with respect to 47

Click here to view

Figure 3: (a) Showing curved bondable bracket with NiTi wire placement on occlusion surface of 47 and 46; (b) showing NiTi wire with spring placement on buccal surface of 47 and 46

Click here to view

Figure 4: (a) Postoperative occlusion view showing occlusal relationship with respect to 17 and 47; (b) Intraoral periapical radiograph showing healthy PDL and bone formation around 47

Click here to view

Discussion

Due to the low prevalence of impacted mandibular second molars, less information regarding its clinical management is available. Many etiological factors have been associated with mandibular second molar impaction such as crowding, arch length deficiency, odontoma, ectopic development and eruption of mandibular second molar.^[10] Sometimes a normally developing mandibular second molar suddenly changes its inclination and becomes impacted, while on the contralateral side it erupts normally. The proper time for its treatment is when the patient is 11- to 14-year-old, during early adolescence, when root formation of second molar is still incomplete and before the third molars complete their development in close approximation to the second molars. If left untreated the impacted mandibular second molars can cause root resorption, dental caries, odontogenic cyst, periodontal problems or may cause anterior crowding.^[11] There are different treatment options for correction of impacted lower second molars. One of the treatment option is surgical repositioning and transplantation of impacted second molar, but it may cause pulp necrosis, ankylosis, or root resorption. Another option is extraction of the impacted tooth and letting the third molar erupt, this treatment option has a disadvantage, being long time interval between the extraction of the second molar and the eruption of the third molar, that can result in tipping or impaction of third molar.^[12] Usually, the third molar can hinder the distal movement of the impacted second molar, implying the need for surgical extraction of third molar.^[13] In the present case report, a minimal invasive technique was used to upright and extrude mandibular second molar using NiTi wire. This technique has advantages of being simple in design, easy chair side procedure, less time consumption, and efficiency.

Conclusion

Treatment of the mandibular second molar impaction is difficult, unpredictable, and challenging for a pedodontist. Careful clinical and radiological examination with appropriate appliance can provide successful treatment outcomes. Simple orthodontic management after surgical exposure of impacted mandibular second molar has the advantage of being less complicated procedure with more patient acceptability. With the use of super elastic NiTi wire, the management of this problem becomes much easier and less complicated as compared to complete fixed orthodontic intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Alligri F, Putrino A, Cassetta M, Silvestri A, Barbato E, Galluccio G. The mandibular permanent second molars and their risk of impaction: A retrospective study. Eur J Pediatr Dent 2015;16:246-50.
2.	DiBagno D, Busch LS, Rinchuse DJ. Uprighting impacted mandibular second molars using NiTi wire. Orthod Pract 2015;6:40-4.
3.	Enache AM, Nicolescu I, Georgescu CE. Mandibular second molar impaction treatment using skeletal anchorage. Rom J Morphol Embryol 2012;53:1107–10.
4.	Varpio M, Wellfelt B. Disturbed eruption of the lower second molar: Clinical appearance, prevalence, and etiology. ASDC J Dent Child 1988;55:114-8.
5.	Proffit W and Fields H. Contemporary orthodontics. 3^rd ed.. St Louis, Mo: Mosby; 2000. p. 11,541.
6.	Cho SY, Ki Y, Chu V, Chan J. Impaction of permanent mandibular second molars in ethnic Chinese school children. J Can Dent Assoc 2008;74:521.
7.	Shpack N, Finkelstein T, Lai YH, Kuftinec MM, Vardimon A, Shapira Y. Mandibular permanent second molar impaction treatment options and outcome. Open J Dent Oral Med 2013;1:9-14.
8.	Rajesh R, Naveen V, Amit S, Baroudi K, Sampath Reddy C, Namineni S. Treatment of ectopic mandibular second permanent molar with elastic separators. Case Rep Dent 2014;2014:621568.
9.	Swaicka M, Racka-Pliszak B, Rosnowska-Mazurkiewicz A. Uprighting partially impacted permanent second molars. Angle Orthod 2007;77:148-54.
10.	Manosudprasit M, Wangsrimongkol T, Pisek P, Chantaramungkorn M. Management of bilateral severely impacted mandibular second molars: A Case Report. J Med Assoc Thai 2013;96(Suppl 4):S157-61.
11.	Reddy SK, Uloopi KS, Vinay C, Subba Reddy VV. Orthodontic uprighting of impacted mandibular permanent second molar: A case report. J Indian Soc Pedod Prevent Dent 2008;26:29-31.
12.	Peddu R, Nuvusetty B, Dokku A, Devikanth L. Orthodontic uprighting of severely impacted mandibular permanent second molar with TMA spring. J NTR Univ Health Sci2018;7:276-80. [Full text]
13.	Fu PS, Lai CH, Wu YM, Tsai CF, Huang TK, Zeng JH. Uprighting impacted mandibular permanent second molars with the tip-back cantilever technique-cases report. J Dent Sci 2008;3:174-80.