dentistry journal

Case Report Uprighting Impacted Mandibular Second Using a Skeletal Anchorage: A Case Report

Federica Altieri , Rosanna Guarnieri, Martina Mezio, Gabriella Padalino, Angela Cipollone, Ersilia Barbato and Michele Cassetta *

Department of Oral and Maxillofacial Sciences, “Sapienza” University of Rome, 6-00161 Rome, Italy; [email protected] (F.A.); [email protected] (R.G.); [email protected] (M.M.); [email protected] (G.P.); [email protected] (A.C.); [email protected] (E.B.) * Correspondence: [email protected]; Fax: +39-06-5016612

 Received: 5 November 2020; Accepted: 17 November 2020; Published: 18 November 2020 

Abstract: The aim of this case report is to present an innovative combined orthodontic-surgical technique to disimpact mandibular second molar (MM2) using an orthodontic miniscrew and an elastic chain. The impact on the Oral health-related quality of life (OHRQoL) was also evaluated. Using the present techinique, it is possible to expose the impacted , insert a self-drilling miniscrew in the retromolar area, and remove the bud of third mandibular molar. At the same time the orthodontic force is applied with the use of an elastomeric chain that connects the head of miniscrew and vestibular and oral buttons bonded on MM2. A close traction is performed for the whole treatment time without the reactivation of the elastic force. The use of skeletal anchorage allowed the disimpaction of impacted MM2 in a short treatment time (about three months) avoiding the typical biomechanical side effects of traditional orthodontic appliance and increasing the effectiveness of the treatment. Further studies are necessary to evaluate the real advantages and disadvantages of this combined orthodontic-surgical approach.

Keywords: molar impaction; mandibular second molar; molar uprighting; impacted teeth; orthodontics; TADs; miniscrew

1. Introduction Mandibular second molar (MM2) impaction is an infrequent event [1] compared to other dental anomalies [2–4], characterized by an increase in prevalence over the years [5,6]. A high impaction risk of MM2 is associated with a mesial angulation form, which is also the most common (88%) [1,5,6]. When the initial mesial inclination of MM2 is greater than 20◦/30◦ this is significantly associated with MM2 impaction [5,6]. Management of mesially-angulated impacted MM2 often requires an interdisciplinary approach. The treatment options depend both on the degree of tooth inclination and the required tooth movement. The position of a slightly-tipped MM2 can be corrected by placing a brass wire separator between the teeth [7–9]. A more severe inclination needs a combined orthodontic-surgical technique [10–12]. The best time to treat impacted MM2s is when the development of the MM2 roots is still incomplete [12]. The best surgical procedure and the total treatment time for the MM2 disimpaction require an accurate assessment of the initial position of the impacted second molar. Nowadays, with the introduction of miniscrews, it has become possible to solve the MM2 impaction in a short treatment time, reducing and avoiding biomechanical side effects and increasing the effectiveness of the treatment [13]. The temporary anchorage devices (TADs) have the advantages of being relatively inexpensive, easy to place and remove. Miniscrews can be inserted in many places in the and [14–16] and are

Dent. J. 2020, 8, 129; doi:10.3390/dj8040129 www.mdpi.com/journal/dentistry Dent. J. 2020, 8, x 129 FOR PEER REVIEW 22 of of 7

In addition, a minimal degree of cooperation is required during the treatment. The aims of this case predictablereport are: enough to be used routinely in dental practice. In addition, a minimal degree of cooperation is required during the treatment. The aims of this case report are: • to show an innovative combined orthodontic-surgical procedure to solve a moderately tomesially-impacted show an innovative mandibular combined second orthodontic-surgical molar (MM2) using procedurean orthodontic to solve miniscrew a moderately with an • mesially-impactedelastic chain; mandibular second molar (MM2) using an orthodontic miniscrew with an • elasticto evaluate chain; the impact of this procedure on the Oral health–related quality of life (OHRQoL). to evaluate the impact of this procedure on the Oral health–related quality of life (OHRQoL). 2.• Materials and Methods 2. Materials and Methods 2.1. Case Presentation 2.1. Case Presentation The present procedure, used at the Department of Oral and Maxillo-Facial Sciences of “Sapienza”The present University procedure, of Rome, used atallows the Department MM2 disimpaction of Oral and employing Maxillo-Facial a submucosal Sciences of orthodontic “Sapienza” miniscrewUniversity ofwith Rome, an allowselastic MM2 chain. disimpaction A 12-year-old employing Caucasian a submucosal female orthodonticpatient was miniscrew referred withto the an Departmentelastic chain. of A 12-year-oldOrthodontics Caucasian of “Sapienza” female Univer patientsity was of referred Rome to to thesolve Department several tooth of Orthodontics impactions. Theof “Sapienza” patient’s Universitymedical history of Rome showed to solve nothing several re toothmarkable. impactions. The patient The patient’s referred medical to a previous history orthodonticshowed nothing treatment remarkable. with a The lingual patient arch referred in the to mandible a previous to orthodontic gain space. treatment Intraoral with examination a lingual revealedarch in the a mandiblemolar Class to gain II malocclusion space. Intraoral with examination not centered revealed midlines, a molar an Classoverjet II malocclusionof 2 mm and with an overbitenot centered of 5 midlines,mm. The anpatient overjet showed of 2 mm a severe and an crowding overbite ofof 5 maxilla mm. The (7 patientmm) with showed no space a severe for maxillarycrowding ofcanines maxilla eruption. (7 mm) with A nomoderate space for crowding maxillary canineswas present eruption. in Athe moderate mandible crowding (6 mm). was presentTemporomandibular in the mandible joints (6 mm). were Temporomandibularhealthy. joints were healthy. The panoramic radiograph showed the presence of several impacted teeth (Figure1 1).). AngleAngle ofof inclination of MM2 was measured, as described by Evans [17]. [17]. The The angle angle of of the the left left MM2 MM2 was was 30°, 30◦, the angle ofof thethe rightright MM2MM2 waswas 4040°.◦. Cephalometric measurements were performed using lateral cephalometric radiography that showed a Class II skeletalskeletal relationshiprelationship (ANB(ANB == 22°),◦), brachyfacial growth pattern (MP-SN = 30.5°;30.5◦; FMA FMA == 17.5°)17.5◦) and and palatal palatal inclination inclination of of the upper (U1—ANS-PNS = 107.0°).107.0◦).

FigureFigure 1. 1.Pretreatment Pretreatment panoramic panoramic radiographradiograph showing bilaterally bilaterally impacted impacted MM2 MM2 and and upper upper canines. canines.

2.2. Treatment Plan The objectives of treatment were to solve: • maxillary canines impaction (1.3 and 2.3);2.3); • • MM2 impaction (3.7 and 4.7) • The following three treatment options to solve MM2 impaction were presented: a conventional orthodontic treatmenttreatment with with lingual lingual arch arch with with a posterior a posterior arm; aarm; cantilever a cantilever arm supported arm supported by a miniscrew by a miniscrewor teeth; a closeor teeth; traction a close with traction a retromolar with a retr miniscrewomolar connectedminiscrew toconnected an elastic to chain. an elastic chain. The patient’s need was to solve the dental impactions in the shortest possible time without masticatory limitation.limitation. TheThe treatment treatment plan plan was was to removeto remove the the impacted impacted maxillary maxillary canines canines and toand solve to solveMM2 impactionMM2 impaction using a combined using a orthodontic-surgical combined orthod techniqueontic-surgical with orthodontictechnique miniscrewswith orthodontic and an miniscrewselastic chain. and The patientan elastic was informedchain. The of thepatient risks, advantageswas informed and disadvantagesof the risks, ofadvantages this therapeutic and disadvantagesapproach and providedof this therapeutic written informed approach consent and pr toovided undergo written the procedures. informed consent to undergo the procedures.

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The advantages of this technique are: the the abse absencence of of orthodontic device device in in the oral cavity (submerged technique)technique) allowing allowing the the maintenance maintenance of good of oralgood hygiene oral hygiene without masticatorywithout masticatory limitation. limitation.Furthermore, Furthermore, the orthodontic the tractionorthodontic was nottraction reactivated, was not reducing reactivated, the number reducing of appointments the number and of appointmentsimproving the and patient’s improving comfort. the patient’s comfort. The main disadvantage was the need to perform a flapflap toto removeremove thethe miniscrew.miniscrew. The guidelinesguidelines of theof declarationthe declaration of Helsinki of Helsinki were followed. were Thefollowed. investigation The investigation was independently was independentlyreviewed and approved reviewed by and the localapproved ethics committeeby the local of Policlinicoethics committee Umberto of I-Sapienza Policlinico University Umberto of I-SapienzaRome (Rif. University 5951 on date of 22Rome April (Rif. 2020). 5951 on date 22 April 2020).

2.3. Surgical-Orthodontic Surgical-Orthodontic Treatment ofof anan ImpactedImpacted MM2MM2 The day of surgery the patient was treated by a single operator, an expert orthodontist and oral surgeon (MC).(MC). LocalLocal anesthesia anesthesia with with mepivacaine mepivacaine (20 (20 mg mg/mL)/mL) associated associated with wi epinephrineth epinephrine in the in ratio the 1:100,000ratio 1:100,000 (Optocain, (Optocain, Molteni Molteni Dental Dental S.r.l) was S.r.l) administered. was administered. A mucoperiosteal A mucoperiosteal flap extending flap extending from the fromfirst molar the first to the molar retromolar to the arearetromolar both on area the buccalboth on and the lingual buccal side and was lingual reflected side to was expose reflected the bone to exposesurrounding the bone the impactedsurrounding MM2 the (3.7) impacted and the MM2 third (3 mandibular.7) and the molarthird mandibular (MM3) bud. molar Bone was (MM3) carefully bud. Boneremoved, was ascarefully required, removed, for the MM3 as required, germectomy. for the Immediately MM3 germectomy. afterwards, Immediately a self-drilling afterwards, miniscrew a wasself-drilling inserted miniscrew in the retromolar was inserted area by in a cordlessthe retromolar screwdriver area by with a cordless a torque screwdriver calibration system with a (ISD900, torque calibrationNSK, Tochigi, system Japan). (ISD900, The fixture NSK,Tochigi, insertion Japan). torque The was fixture set at 40insertion N/cm. torque was set at 40 N/cm. The site and angle of insertion, the length an andd the diameter of titanium miniscrew (BENEfit, (BENEfit, psm, Tuttlingen, Germany) were determined in the planning phase on a panoramicpanoramic radiograph (length 13 mm; 2.3 mm diameter) and clinically confirmedconfirmed during the surgery. After the self-drilling miniscrew insertion,insertion, twotwo metal metal brackets brackets were were bonded bonded on theon buccalthe buccal and oraland surfacesoral surfaces of MM2 of .MM2 Atcrown. the endAt the of end surgery of surgery an elastic an elastic chain chain was secured was secured to the to miniscrew the miniscrew head head and and connected connected to the to themetal metal brackets brackets bonded bonded on buccal on andbuccal oral surfacesand oral of MM2surfaces crown of (FigureMM2 2crownA,B); a(Figure close /submerged 2A,B); a close/submergedtraction was performed. traction On was the perf headormed. of the On miniscrew the head wasof the screwed miniscrew an abutment was screwed with twoan abutment brackets (Figurewith two2A,B); brackets an elastic (Figure chain 2A,B); was an applied elastic to chain each was bracket applied (Figure to each2B). Eachbracket elastic (Figure chain 2B). was Each activated elastic chainbetween was the activated bonded between button on the the bonded surface button of the secondon the molarsurface to of the the bracket second of molar the miniscrew. to the bracket A short of theelastic miniscrew. chain was A usedshort that elastic was chain stretched was approximatelyused that was stretched twice. Finally, approximately the surgical twice. site was Finally, sutured the (Figuresurgical2 C).site was sutured (Figure 2C).

Figure 2. ((A,,B)) View of inserted self-drilling miniscrew in the retromolar area, the buccal and oral metal brackets onon thethe crowncrown of of mandibular mandibular second second molar molar (MM2) (MM2) and and the the orthodontic orthodontic traction traction with with the theelastomeric elastomeric chain; chain; (C) Surgical(C) Surgical incision incision closure closure with with sutures. sutures.

Oral health–related quality of life (OHRQoL) was assessed using the Italian version of the short-form oral oral health health impact impact profile profile with with 14 14 qu questionsestions (OHIP-14) (OHIP-14) that that represent represent 7 dimensions 7 dimensions of OHRQOL:of OHRQOL: functional functional limitation, limitation, physical physical pain, pain, psychological psychological discomfort, discomfort, physical physical disability, disability, psychological disability,disability, social social disability, disability, and handicapand handicap [18,19]. The[18,19]. patients The received patients the questionnairereceived the questionnaireafter being instructed after being in itsinstructed use. The in self-administered its use. The self-administered questionnaire questionnaire was filled out was by filled the patients out by preoperativelythe patients preoperatively (baseline; T0), (baseline; 3 days post-surgery T0), 3 days (T1),post-surgery and 7 days (T1), post-surgery and 7 days (T2). post-surgery Answers were(T2). Answersmade on anwere ordinal, made 5-point, on an ordinal, adjectival 5-point, scale (0adjectival never, 1 hardlyscale (0 ever, never, 2 occasionally, 1 hardly ever, 3 fairly 2 occasionally, often, 4 very 3 fairlyoften). often, OHRQoL 4 very is characterizedoften). OHRQoL by summary is characterized scores of by the summary OHIP-14 scores items. of Higher the OHIP-14 scores reveal items. a Higherstronger scores negative reveal influence a stronger on OHRQoL. negative influence on OHRQoL. Ibuprofen was recommended for pain control. Antibiotic therapy (1 gr of amoxicillin) was prescribed 1 h before intervention and twice a day for 5 days.

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Ibuprofen was recommended for pain control. Antibiotic therapy (1 gr of amoxicillin) was Dent. J. 2020, 8, x FOR PEER REVIEW 4 of 7 prescribedDent. J. 2020, 8 1, x h FOR before PEER intervention REVIEW and twice a day for 5 days. 4 of 7 The patient was checked every month until the uprighting of MM2 was complete. TheThe patientpatient waswas checkedchecked everyevery monthmonth untiluntil thethe uprightinguprighting ofof MM2MM2 waswas complete.complete. The same elastic chain was not changed for the whole time of therapy. TheThe samesame elasticelastic chainchain waswas notnot changechangedd forfor thethe wholewhole timetime ofof therapy.therapy. The MM2 was considered upright when the mesial marginal ridge was above the distal contours TheThe MM2MM2 waswas consideredconsidered uprightupright whenwhen thethe mesialmesial marginalmarginal ridgeridge waswas aboveabove thethe distaldistal of first mandibular molar (MM1) (Figure3). contourscontours ofof firstfirst mandibularmandibular molarmolar (MM1)(MM1) (Figure(Figure 3).3).

FigureFigure 3.3. Post-treatmentPost-treatmentPost-treatment panoramicpanoramic panoramic radiographradiograph radiograph showinshowin showinggg thethe the correctcorrect correct inclinationinclination ofof 3.7 3.7 before before miniscrewminiscrew removal.removal.

AtAt the the end end of of therapy therapy the the miniscrew miniscrew was was remo removedremovedved (Figure (Figure 4 4)4)) and andand the thethe other otherother impacted impactedimpacted MM2 MM2MM2 was waswas treatedtreated both both withwith thethe samesame miniscrewminiscrew andand withwithwith thethethe samesamesame orthodonticorthodonticorthodontic surgicalsurgicalsurgical procedure.procedure.procedure.

Figure 4. (A,B) The elastic chain, brackets and (C) the miniscrew removal. (D) The final position in Figure 4.4. ((AA,,BB)) TheThe elasticelastic chain, chain, brackets brackets and and (C ()C the) the miniscrew miniscrew removal. removal. (D )(D The) The final final position position in the in the arch of 3.7. archthe arch of 3.7. of 3.7.

3.3. Results Results NoNo important important adverse adverse eventsevents oror sideside eeffectseffectsffects werewerewere recorded.recorded.recorded. TheThe OHIP-14 OHIP-14 filled filledfilled out out by by the the patient patient before before the the tr treatmenttreatmenteatment (T0), (T0), and and 3 3 (T1) (T1) and and 7 7 (T2) (T2) days days after after surgerysurgery hadhadhad a aa total totaltotal score scorescore of 15ofof points1515 pointspoints (T0 =(T0(T03; T1== 3;3;= 8;T1T1 T2 == =8;8;4). T2T2 A == deterioration 4).4). AA deteriorationdeterioration in OHRQoL inin OHRQoLOHRQoL was observed waswas observedonlyobserved after onlyonly 3 days afterafter of surgery;33 daysdays ofof an surgsurg improvementery;ery; anan improvementimprovement in OHRQoL inin wasOHRQoLOHRQoL observed waswas after observedobserved 7 days afterafter of the 77 daysdays procedure ofof thethe withprocedureprocedure almost withwith a complete almostalmost aa restoration completecomplete restoratrestorat (OHIP-14ionion= (OHIP-14(OHIP-144) of pre-treatment == 4)4) ofof pre-treatmentpre-treatment value. value.value. TheThe MM2 MM2 impaction impaction waswas correctedcorrected inin 9292 days.days.

4.4. DiscussionDiscussion ManagementManagement ofofof MM2 MM2MM2 impaction impactionimpaction is considered isis consideredconsidered very very diveryfficult difficultdifficult and unpredictable andand unpredictableunpredictable and is a challengeandand isis aa challengeforchallenge both orthodontist forfor bothboth orthodontistorthodontist and oral surgeon. andand oraloral Close surgeon.surgeon. collaboration CloseClose collaborationcollaboration between the betweenbetween two specialists thethe twotwo specialistsspecialists is needed toisis neededachieveneeded toto the achieveachieve MM2 disimpaction. thethe MM2MM2 disimpaction.disimpaction. An early diagnosis AnAn earlyearly anddiagnosisdiagnosis early treatmentandand earlyearly aretreatmenttreatment the keys areare for thethe successful keyskeys forfor successfulcorrectionsuccessful of correctioncorrection MM2 impaction. ofof MM2MM2 Inimpaction.impaction. addition, In itIn is addition,addition, important itit is tois important disimpactimportant the toto disimpactdisimpact MM2 as soon thethe as MM2MM2 it is diagnosedasas soonsoon asas itbecauseit isis diagnoseddiagnosed of the contact becausebecause with ofof the thetheMM1 contactcontact that withwith could thethe cause MM1MM1 root thatthat resorption, couldcould causecause caries, rootroot and resorption,resorption, periodontal caries,caries, problems. andand periodontalperiodontalTreatment problems.problems. options for an impacted MM2 can include extraction, orthodontic uprighting, surgicalTreatmentTreatment uprighting, optionsoptions and for surgical-orthodonticfor anan impactedimpacted MM2MM2 approach cancan includeinclude [20–22 ].extraction,extraction, Many orthodontic orthodonticorthodontic appliances uprighting,uprighting, and surgicalsurgical uprighting,uprighting, andand surgical-orthodonticsurgical-orthodontic aapproachpproach [20–22].[20–22]. ManyMany orthodonticorthodontic appliancesappliances andand techniquestechniques havehave beenbeen suggestedsuggested forfor thethe uprightinguprighting ofof moderatelymoderately mesially-imesially-impactedmpacted molarsmolars [20–22].[20–22]. Nowdays,Nowdays, thanksthanks toto miniscrews,miniscrews, itit isis possiblepossible toto reducereduce biomechanicalbiomechanical sideside effectseffects andand toto solvesolve thethe MM2MM2 impactionimpaction inin aa shortshort treatmenttreatment timetime [23–25].[23–25].

Dent. J. 2020, 8, 129 5 of 7 techniques have been suggested for the uprighting of moderately mesially-impacted molars [20–22]. Nowdays, thanks to miniscrews, it is possible to reduce biomechanical side effects and to solve the MM2 impaction in a short treatment time [23–25]. The present technique allows, in a single appointment, the exposure of the impacted tooth, the insertion of the screw, the extraction of the third molar bud and the activation of the orthodontic traction. Regarding the combined use of miniscrews and elastic chains, few similar studies exist in the literature [24,25]. Miyahira et al. [24] treated an impacted MM2 with a miniplate and an elastic chain. Although the technique appears to be predictable and quick, the use of two miniscrews, and the difficulty of maintaining oral hygiene around the miniplate, could cause a grater patient discomfort. Zen et al. [25] described the uprighting of a MM2 using a miniscrew with a Nichel-Titanium closed coil spring, from the miniscrew to a single lingual button, replaced every month. Unlike the techniques described above, the present procedure is a close traction technique. A miniscrew is inserted in the retromolar area and two brackets or buttons attachments are bonded on the crown of MM2; an elastic chain is connected from the head of the miniscrew to the two buttons, minimizing the size of the orthodontic device, reducing chair time and improving the patient comfort compared to complex segmental biomechanics. The force application generates a counterclockwise moment, allowing control of the movement and the collateral effects and, consequently, promoting rapid disimpaction and distalization of the crown. Moreover, this procedure allows an absolute control of the anchorage and no unwanted movement of adjacent teeth [23–25]. The retromolar area seems particularly suitable for screw insertion, considering the presence of compact cortical bone tissue which immediately provides excellent primary stability. According to Finotti et al., after third molar extraction, the creation of a cortico-medullar void distal to the second molar, or appositely surgically performed is important to reduce the treatment time [26]. Nowadays, computer-guided miniscrew-supported orthodontic appliances can be realized [27,28] thanks to dedicated software that matches the stereolithography STL files of the dental arch with the DICOM images of the CBCT. However, in the present technique, the miniscrew has been inserted freehand because in the retromolar area there is usually a sufficient quality and quantity of bone. The insertion of a miniscrew in this area does not require a CT scan but the information provided by an orthopanoramic radiograph is sufficient. In addition, the simplicity of the orthodontic appliance does not require a custom-made appliance.

5. Conclusions In conclusion, it can be stated that the combined use of miniscrew and elastic chains could be a valid procedure for moderate mesially-impacted MM2. In a single surgical time the MM3 germectomy, the miniscrew insertion and the orthodontic traction are performed, without a negative impact on the OHRQoL. Certainly, an early diagnosis can prevent impaction of these teeth, enabling a more conservative treatment approach, so a radiographic follow-up of the dental eruption process should be encouraged to observe an early delay in the eruption of the MM2. It must be highlighted that the efficacy of this approach must be further investigated to evaluate the real advantages and disadvantages of this technique.

Author Contributions: F.A.: conception and design, acquisition of data, drafting and revising of the manuscript; R.G.: drafting and revising of the manuscript; M.M.: drafting and revising of the manuscript; G.P.: acquisition of data; A.C.: drafting and revising of the manuscript; E.B.: manuscript final approval. M.C.: conception and design and manuscript final approval. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Conflicts of Interest: The authors declare no conflict of interest. Dent. J. 2020, 8, 129 6 of 7

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