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Q U I N T E S S E N C E I N T E R N AT I O N A L

Deep impacted mandibular second molar:

A case report
Ronaldo Célio Mariano1/Lúcia de Carvalho Freire Mariano2/
Willian Morais de Melo3

Impaction of mandibular second molars is relatively rare. A case of a deep impacted

mandibular right permanent second molar in a 26-year-old woman is presented. This arti-
cle describes the extraction of the tooth and reports the risks of the surgical procedure.
Careful manipulation of tissues and correct application of mechanical principles involved
in tooth extractions allowed surgical success. (Quintessence Int 2006;37:773–776)

Key words: impacted teeth, mandibular second molar, tooth extraction

Genetic and environmental factors are
included in the multifactorial nature of tooth
eruption, which may be disturbed at any
stage of development.1 Impacted teeth are
those prevented from erupting by some
physical barrier in the eruption path. Lack of
space, due to crowding of the dental arches
or to premature loss of primary teeth with
subsequent partial closure of their area, is a
common factor in the etiology of partially or
completely impacted teeth.
Most classifications of impacted molars
result from radiographic analysis of the third
molar. The classification system employs a
description of the tooth angulation (Winter’s
1
Chairman and Professor, Department of Clinical and Oral
Surgery, School of Dentistry, Unifal-MG Federal University,
Alfenas, Minas Gerais, Brazil.
2
Research Assistant, Department of Clinical and Oral Surgery,
School of Dentistry, Unifal-MG Federal University, Alfenas, Minas
Gerais, Brazil.
3
Trainee, Department of Clinical and Oral Surgery, School of
Dentistry, Unifal-MG Federal University, Alfenas, Minas Gerais,
Brazil.
Reprint Requests: Dr Ronaldo Célio Mariano, Department of
Clinical and Oral Surgery, School of Dentistry, Unifal-MG Federal
University, R. Gabriel Monteiro da Silva, 714, 37130-000 – Alfenas,
Minas Gerais, Brazil. Fax: +35 3292-9039. E-mail: mariano@
unifal-mg.edu.br
classification2) and relationship to the anteri-
or border of the mandibular ramus and
occlusal plane (Pell-Gregory classification3).
The 2 classification systems are used in com-
bination to determine the difficulty of an
extraction.4,5 Based on classification sys-
tems, the impacted second molar can
acquire a vertical, distoangular, mesioangu-
lar, or horizontal position, and, rarely, a trans-
verse impaction in relation to the long axis of
the first molar. The occlusal plane can be
used as a reference to check the depth of the
second molar.
Impaction of the mandibular second
molar is a relatively rare dental anomaly, with
a reported incidence of about 3 in 1,000
(0.003%)6,7; unilateral impaction of the
mandibular second molar is more common
than bilateral impaction, and impactions
occur more frequently in the mandible than
in the maxilla. They are found more often in
men than women and more frequently on the
right side than on the left. Impacted
mandibular second molars are often mes-
ially inclined,8 and the etiology of mesially
angulated, ectopically erupting mandibular
second molars seems to relate to mandibular
arch crowding in the anterior region.9,10

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Mariano et al
Fig 1 Preoperative partial panoramic radiograph.
During the last decade, various treatment
methods have been suggested, including
conservative and radical approaches (tooth
extraction). Depending on the tooth’s posi-
tion, the depth of the impacted tooth com-
pared with the height of the adjacent molar
determines the difficulty of removal of the
impaction or orthodontic treatment. The
degree of difficulty of extraction is measured
by the thickness of the overlying bone. The
relationship between the impacted mandibu-
lar second molar and the mandibular canal
should be considered in treatment planning.
This case report describes the extraction
of a mesially angulated, impacted mandibu-
lar right permanent second molar and pro-
vides information on the risks and benefits of
oral surgery.
CASE REPORT
A 26-year-old woman visited the Department
of Oral Surgery with the chief complaint of an
unerupted mandibular right second molar.
Her medical history was unremarkable, with
no apparent systemic problems. Intraoral
examination revealed the presence of the
mandibular right first and third molars and
satisfactory occlusion. There was no trismus
or limitation of mouth opening.
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Fig 2 A buccal mucoperiosteal flap with ostectomy and
dental crown sectioning.
Radiographically, a distally impacted
mandibular right second molar associated
with a large radiolucency around the crown
was seen (Fig 1). The mandibular right sec-
ond molar exhibited a deep distal angulation
and was deeply impacted. The patient
reported no history of trauma to the jaws.
The patient used 1 g amoxicillin as pro-
phylactic antibiotic and 4 mg dexametha-
sone to reduce the pain and edema, both
preoperatively, together with 0.12% chlorhex-
idine digluconate mouthrinse 3 times daily
for 7 days, beginning 1 day before tooth
extraction.
The deep impacted mandibular second
molar was extracted in a surgical procedure
under local anesthesia. The surgeon raised a
buccal mucoperiosteal flap. A sterile high-
speed handpiece cooled with sterile saline
solution was used for osteotomy and crown
sectioning (Fig 2). To close the wound, 3-0
silk suture was used. After 7 days, the
sutures were removed.
The patient healed uneventfully, and both
clinical and radiographic examinations at 1-
month (Fig 3) and 1-year (Fig 4) follow-up
revealed good results.
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Fig 3 One-month postoperative radiographic view.
DISCUSSION
The prevalence of impacted mandibular sec-
ond molars is low, but this disturbance in the
normal process of eruption can cause signif-
icant problems. Treatment options for impact-
ed second molars are (1) surgical reposition-
ing with or without removal of the adjacent
third molar, (2) removal of the second molar
allowing eruption of the third molar, (3) trans-
plantation of the third molar to the socket of
the second molar, (4) buccal uprighting of
the second molar with conventional ortho-
dontic methods, and (5) orthodontic traction
of the second molar with a titanium mini-
screw for skeletal anchorage.11 The option of
conservative treatment for the second molar
was not considered because of the impossi-
bility of distalization of the third molar to
achieve space for the second and third
molars, due to the arch-length deficiency
associated with severe distal inclination of the
deep impacted mandibular second molar.
Impacted second molars refractory to
orthodontic treatment are frequent prob-
lems. The proper period for definitive treat-
ment of these impactions is during early ado-
lescence, generally from 11 to 14 years of
age.12 Recently, the introduction of mini-
screws for immediate loading has changed
the clinical and biomechanical approach to
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Mariano et al
Fig 4 One-year postoperative radiographic view.
the problem,13,14 mainly for adult patients. In
the present case report, the achievement of
space was not performed because the occlu-
sion was satisfactory. Moreover, a conserva-
tive orthodontic method has serious limita-
tions, the prognosis is not always positive,
and if the second molar is deeply impacted,
the orthodontic treatment can be particularly
complex because of the difficulty in placing
the conventional devices for molar upright-
ing. Therefore, extraction of the second
molar was the viable option.
The complications of surgery to treat
impacted mandibular second molars were
explained to the patient, who agreed with the
necessity of extraction. Analysis of the mor-
bidity of deep impacted molars includes sev-
eral risks. Obvious anatomic risks are the
inferior alveolar nerve and the mental nerve.15
Damage to either of these nerves is one of
the causes of altered postoperative sensation
after buccal access. Although this alteration
is usually brief (lasting only a few days), it
may extend for weeks or months; on rare
occasions, it can be permanent. Paresthesia
did not occur in the present case. For
anatomic reasons, displacement of roots dur-
ing attempted luxation with elevators can
occur, as can displacement of roots into the
mandibular canal or through the thin lingual
bone into the submandibular region. It is very
important to know the technique and have
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Mariano et al
manual dexterity. Tooth sectioning is usually
preferred to excessive bone removal, which
should generally be limited to the tooth
crown; a minimum number of sutures, strate-
gically placed to immobilize the flap, should
be used.
Pathologic mandibular fracture is a com-
plication of certain types of difficult extraction
typically occurring 14 days after extraction of
third molars, implying potential weakening of
the mandible as a consequence of inflam-
matory remodeling.15–17 In the present case,
mandibular fracture did not occur, as exces-
sive forces were not applied with elevators. In
this case, bleeding was also totally controlled
during surgery.
Infection is the most common cause of
delayed healing. Any type of surgical inter-
vention in the oral cavity can, in principle, be
complicated by infections such as alveolar
osteitis, abscess formation, and periostitis.4
There was no moderate or severe pain nor
the usual signs and symptoms of infection,
such as fever, swelling, and erythema, in the
postoperative period in this case.
Careful manipulation of tissues and the
correct application of mechanical principles
involved in tooth extractions allowed surgical
success.
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THIS DOCUMENT
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