April 2023 Orthodontics 105

Tricks of the Trade:

A Simple Way to Manage
Impacted Second Molars
Were you a Damon enthusiast? Wondering a a
what to do with all those self-ligating brackets
and molar tubes you still have lying around?
Outlined in this Trick of the Trade is a simple
method for aligning impacted second molars
using self-ligating molar tubes.
Impaction of second molars has a reported
incidence of between 0.03% and 1.7% in the
general population, with a higher incidence
encountered in orthodontic patients.1–5 The
second molars are usually mesio-angularly
impacted against the distal surface of the first
molar, and to attempt disimpaction requires
a distalizing and uprighting force. This can be b b
applied using an uprighting spring attached
to the main archwire, or a mini-screw.4 The
problem with this method is, that apart from
involving some intricate wire bending, to ensure
adequate vertical anchorage, the main archwire
needs to be a minimum of 0.018” stainless steel
that can only be placed following levelling and
aligning. This can lead to a delay in treatment
while the second molar is then aligned
before the working archwire can be placed to
complete levelling of the lower arch and any
space closure. Therefore, it would be better to
disimpact the second molar at the same time
as the initial phase for levelling and aligning
the lower arch. Alternatively, skeletal anchorage Figure 1. (a) Lower left second molar mesio-
can be used in the form of a mini-screw to angularly impacted. (b) Labial fixed appliance
which an uprighting spring can be applied.6 with Damon tube on first molar with compressed
Sometimes in milder cases of impaction nickel titanium pushcoil on initially aligning Figure 2. (a) Lower second molar now
of the second molar, this can be achieved just nickel titanium archwire applying distalizing and disimpacted. (b) Working archwire in place and
uprighting force to second molar. final space closure.
by placing an attachment on the lower second
molar and engaging the archwire. However,
in more severe cases, the tooth will need a
distalizing force that can be applied using References 4. Shpack N, Finkelstein T, Lai YH et al. Mandibular permanent
compressed coil spring. With traditional molar 1. Varpio M, Wellfelt B. Disturbed eruption of the lower second second molar impaction treatment options and outcome.
tubes this can be very difficult to apply. However, molar: clinical appearance, prevalence, and etiology. ASDC J Open J Dent Oral Med 2013; 1: 9e14.
with self-ligating tubes, the coil spring can be Dent Child 1988; 55: 114–118. 5. Shapira Y, Finkelstein T, Shpack N et al. Mandibular second
placed on the archwire, positioned mesially to 2. Grover PS, Lorton L. The incidence of unerupted permanent molar impaction. Part I: Genetic traits and characteristics.
teeth and related clinical cases. Oral Surg Oral Med Oral Am J Orthod Dentofacial Orthop 2011; 140: 32-7. https://doi.
the impacted second molar and then engaged
Pathol 1985; 59: 420–425. https://doi.org/10.1016/0030- org/10.1016/j.ajodo.2009.08.034
and activated as the slot on the self-ligating tube 4220(85)90070-2 6. Turley PK. The management of mesially inclined/impacted
is closed (Figure 1). Once the second molar is 3. Fu PS, Wang JC, Wu YM et al. Impacted mandibular second mandibular permanent second molars. J World Fed
distalized and uprighted, it can be then be fully molars. Angle Orthod 2012; 82: 670–675. https://doi. Orthod 2020; 9(3S): S45–S53. https://doi.org/10.1016/j.
engaged and treatment completed (Figure 2). org/10.2319/102111-656.1 ejwf.2020.09.004

Andrew DiBiase, Consultant Orthodontist, East Kent Hospitals University NHS Foundation Trust. Elizabeth O’Higgins, Consultant
Orthodontist, Kings College Dental Institute, London. Email: andrewdibiase@nhs.net