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

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Uprighting Impacted Mandibular Second Molar Using a Skeletal Anchorage: a Case Report dentistry journal Case Report Uprighting Impacted Mandibular Second Molar 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 tooth, 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 maxilla and mandible [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 incisors (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. Dent. J. 2020, 8, 129 3 of 7 Dent. J. 2020, 8, x FOR PEER REVIEW 3 of 7 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
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