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Retained Second Molars: Therapeutic Approach

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Retained Second Molars: Therapeutic Approach DOI: 10.1051/odfen/2015020 J Dentofacial Anom Orthod 2015;18:405 © The authors Retained second molars: therapeutic approach J. Vexiau1, B. Castaneda2,3,4 1 Dental surgeon, CECSMO 4 Paris VII, Pitié-Salpêtrière Hospital Group 2 Dentofacial Orthopedics Dept., Paris, France 3 Laboratory of Molecular Oral Pathophysiology, INSERM UMR 1138, Paris, France 4 Faculty of Odontology, University of Antioquia, Colombia ABSTRACT Second molar eruption abnormalities are quite rare, and thus there is no precise consensus protocol for their setting. Several therapeutic solutions will be presented here: purely orthodontic, or associating orthodontics and surgery. KEY WORDS Permanent second molar, primary failure of eruption, mechanical failure of eruption, treatment of retained molars INTRODUCTION Second molar eruption abnormality is In case of MFE, or when a diagnosis of fairly rare, but seems to be slightly increas- PFE is uncertain, several solutions may be ing (1% according to Cho, 20083). Several considered: orthodontic or surgical treat- etiologies have been suggested. Locally, a ment, a combination of the two, or absten- trend away from premolar extraction and tion. Conversely, if the diagnosis of PFE is in favor of space-maintaining treatments certain, surgery is preferable, associated to could partly explain the increase14. orthodontic treatment or not. Various treatments are available for sec- Other factors are to be taken into account ond molar eruption pathology. Etiology in guiding treatment (see below). plays a role in determining treatment. As these abnormalities are not widespread, Primary failure of eruption (PFE), de- there is no well-defined therapeutic proto- fined by Proffit in 198112, is to be dis- col. Various solutions have been described: tinguished from mechanical failure of orthodontic, or combining orthodontics and eruption (MFE), defined by Suri in 200216. surgery, as with miniscrews or miniplates. Diagnosis, however, is often difficult, Although based on simple case reports or still and it is often attempted to position the in the experimental stages, they will be pre- retained tooth. sented here, to help clinicians in their practice. Address for correspondence: Article received: 3-05-2015. Juliette Vexiau – CECSMO4 Pitié-Sapêtrière, Accepted for publication: 1-06-2015. Bâtiment d’Odonto-Stomatologie 47-83 Boulevard de l’Hôpital This is an Open Access article distributed under the terms of the Creative Commons Attribution 75013 Paris, F rance License (http://creativecommons.org/licenses/by/4.0), E-mail: juliette. [email protected] which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1 Article available at https://www.jdao-journal.org or https://doi.org/10.1051/odfen/2015020 J. VEXIAU, B. CASTANEDA FACTORS INFLUENCING THERAPEUTIC DECISION-MAKING Retention is diagnosed on several dental apex), tooth inclination, pres- criteria, including progression of the ence of adjacent third molar, associ- contralateral tooth or occlusal level of ated first molar retention, intra-oral the second as compared to the first visibility, etc. molar if the tooth has emerged into The type of bone tissue around the the oral cavity without meeting the tooth also plays a part in choice of first molar occlusion plane. treatment: teeth retained or impact- Treatment is guided by several fac- ed in the mandible are surrounded by tors, depending on patient age, root much denser bone tissue than in the edification stage (open or closed maxilla. ORTHODONTIC SOLUTIONS Many authors have described a Moreover, most reports concerned variety of means of positioning re- second molars in mesial inclination, tained or impacted second molars in although this is far from being the the arcade. Surgical exposure is usu- most frequent state of affairs (Fig. 1). ally required, to allow a button, tube Before detailing the various sys- or hook to be attached for traction. tems for setting retained or impacted In most cases, and especially in the second molars, some biomechanical mandibular arcade, the adjacent third reminders will be given. molar, when present, is extracted. When distalizing force is applied to There have been many more a mesially inclined molar, this induces reports of retained or iimpacted man- a momentum leading to distal ver- dibular than maxillary second molars. sion of the tooth. Figure 2 shows that Figure 1 Panoramic view: Angélique, 15 years old. Class II divi- sion 1 associated with retention of mesially inclined Figure 2 mandibular second molars at an angle >25° to the Distalizing and extrusive force applied by the ortho- first molar axis (Thanks to Dr Sylvie Legris). dontic system, with anti-clockwise rotation. 2 Vexiau, J. Castaneda B. Retained second molars: therapeutic approach RETAINED SECOND MOLARS: THERAPEUTIC APPROACH the force applied by the orthodontic moment tending to upright the mesi- system sets up an anti-clockwise ally inclined tooth; fixing the tube at moment that uprights the mesially 90° creates a much stronger moment inclined tooth; this also induces egres- and greater uprighting displacement. sion, which may need controlling. During treatment, the straight arch Lau et al.6 described what they does not include the first molar, so as called “routine” straight arch tech- to increase the flexibility of the arch niques for setting mesially inclined and reduce force so as to avoid un- retained mandibular second molars: wanted effects such as root resorp- after surgically releasing the dis- tion or problems at the attachment. tal side of the tooth, they insert an The authors add that the posterior compressed open spring between maxillary occlusion planes had to the first and second molars, with the be raised to enable molar uprighting tube glued to the latter at 90° to the without occlusal interference. In this occlusal plane so as to promote up- case, this did not impair the results of righting. If the tube were glued paral- treatment. lel to the occlusion plane, the tooth Elastic bands (e.g., criss-cross) would basically move backward, and may be used as back-up to complete the distalization force would induce a occlusion of the repositioned second molar. Elevation planes on the posterior teeth may, in some patients, espe- cially those with facial hyperdiver- gence, induce unwanted mandibular opening and/or gap. Figure 4 Below, occlusal view of ring with welded spring and Figure 3 custom-made hook; above, occlusal view of system a) 37 and 47 retained despite extraction of 34 and 44. in position, with ring fixed to the molar mesial to the b) 8 months later, 37 and 47 well-positioned in the tooth to be uprighted, hook glued to tooth to be arcade. (Thanks to Dr Sylvie Legris). uprighted and spring in position. J Dentofacial Anom Orthod 2015;18:405 3 J. VEXIAU, B. CASTANEDA Ziegler18 likewise reported a sys- arcade, with a .016 × .022 or .019 × tem using a compressed open spring .025 steel bracket, depending on the between the first mandibular molars type of attachment. The reported cas- and the second, mesially inclined in es did not involve third molar germec- retention, onto which an attachment tomy to upright the second molar. system was fitted. He called this Another example concerns a young “versatile molar uprighting mechan- patient presenting with dentomaxil- ics” and developed it over a period lary dysharmony and retained second of some 15 years, ending up with a molars, managed by extraction of the system using self-ligating brackets. first maxillary and second mandibular A sectional bracket is placed be- premolars. Resolution of posterior tween the first molar and the second crowding allowed spontaneous pro- molar, to be uprighted, (or between gression of both second molars. In the second and third, as Ziegler also other cases of dentomaxillary dys- applied this system for third molars), harmony, premolar extraction is not and a compressed screw uprights the enough to enable spontaneous pro- mesially inclined molar. In one of his gression. Such, for example, was the cases, like Lau et al., he did not include case of the patient shown in Figure 1, the first molar to help upright the sec- with retained second molars. ond. Anchorage involved the whole The first premolars were extracted. The second mandibular molars were in retention, but with the distal part of the vestibular side accessible, and could be managed by glued minitubes and a .014 copper NiTi arch. In a second step, a .018 steel arch with coiled loops was fitted between the first and second molars. This type of system has the same effect as a spring, but with better mechanical control. The entire arcade is included, Figure 5 ensuring anchorage while the second Modified Loca system. molars are uprighted (Fig. 3a and b). Figure 6 Figure 7 Sawicka technique. a) Santoro et al., lingual view: b) occlusal view. 4 Vexiau, J. Castaneda B. Retained second molars: therapeutic approach RETAINED SECOND MOLARS: THERAPEUTIC APPROACH Miao et al.8 and Ma et al.7 described that .019 × .025 steel would be better a technique applied essentially for than the .020 Australian wire, to opti- mandibular third molars but also mize anchorage and minimize incisor sometimes successfully for mandib- vestibular drift. ular second molars (Fig. 4). Sawicka et al.14 described a system Miao et al. fitted a custom-made initially including just the mandibular hook to the molar to be repositioned, incisor-canine sector and 2 TMA sec- with a ring on the adjacent tooth and tional brackets fixed distally to the a .018 steel spring welded to the ring; canines and linked to the 2 mesially the spring exerted a distalizing but also inclined molars, creating a strong le- slightly extrusive force on the tooth. ver arm (Fig. 6). The 6 anterior teeth Ma et al. fitted a custom-made support a .017 × .025 steel sectional hook to the tooth to be uprighted bracket in .018 grooves; a figure-of- after surgical exposure; a ring with eight ligature connects them, and a .016 steel spring was fixed to the anchorage is completed by a glued adjacent molar, intended to exert a contention.
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