p e d i a t r i c d e n t a l j o u r n a l 3 2 ( 2 0 2 2 ) 1 2 3 e1 2 8

Available online at www.sciencedirect.com

Pediatric Dental Journal

journal homepage: www.elsevier.com/locate/pdj

Case Report

Impacted mandibular primary second molar: A

case report

Yasutaka Yawaka a,*, Kyoko Shinoguchi b, Makoto Fujii a,c,

Shohei Oshima d
a
Dentistry for Children and Disabled Persons, Department of Oral Functional Science, Faculty of Dental Medicine,
Hokkaido University, Kita 13 Nishi 7, Kita-ku, Sapporo 060-8586, Japan
b
Shinoguchi Pediatric Dental and Orthodontic Clinic, Atsubetsuminami 1-11-10, Atsubetsu-ku, Sapporo 004-0022,
Japan
c
Hinode Dental Office, Minami 1 Nishi 4-13, Chuo-ku, Sapporo 060-0061, Japan
d
Clinic of Dentistry for Children and Disabled Persons, Hokkaido University Hospital, Kita 14 Nishi 5, Kita-ku,
Sapporo 060-8648, Japan

article info abstract

Article history: We present a case of 6-year- and 10-month-old boy with an impacted primary molar. An x-
Received 10 March 2022 ray photograph revealed the impacted mandibular right primary second molar with small
Received in revised form hard tissue on the crown of the tooth as an obstacle. We extracted the small hard tissue
17 May 2022 and the mandibular right primary second molar.
Accepted 25 May 2022 A histopathological examination of the obstacle revealed a tooth germ containing
Available online 18 June 2022 dental papilla, dentin, and enamel. The obstacle was diagnosed as the tooth germ of the
mandibular right second premolar.
Keywords: In conclusion, the early detection of impacted primary molars is important for chil-
Impacted primary tooth dren's healthy growth and development.
Mandibular © 2022 The Authors. Published by Elsevier Ltd on behalf of Japanese Society of Pediatric
Primary second molar Dentistry. This is an open access article under the CC BY license (http://creativecommons.
Obstacle org/licenses/by/4.0/).
Permanent successor

impaction is similar to that of all other primary teeth together.

1. Introduction
Pindborg described the “impaction of teeth” as any tooth that
remains unerupted in the jaw beyond the time at which it
should normally erupt. The impaction of primary teeth is rare.
The incidence rate of mandibular primary second molar
Therefore, re-impacted primary molars should not be
confused with impacted primary molars. Tooth impaction can
be classified into local and systemic factors [1].
To date, pediatric dentists have reported some cases of
impacted primary molars [2e15]. However, the impacted pri-
mary molar is known to affect chewing function, the primary

* Corresponding author. Dentistry for Children and Disabled Persons, Department of Oral Functional Science, Faculty of Dental Medicine,
Hokkaido University, Kita 13 Nishi 7, Kita-ku, Sapporo 060-8586, Japan.
E-mail addresses: yawaka@den.hokudai.ac.jp (Y. Yawaka), info@shinoguchi.com (K. Shinoguchi), hb02mac@gmail.com (M. Fujii),
shohei@den.hokudai.ac.jp (S. Oshima).
https://doi.org/10.1016/j.pdj.2022.05.002
0917-2394/© 2022 The Authors. Published by Elsevier Ltd on behalf of Japanese Society of Pediatric Dentistry. This is an open access
article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
124 p e d i a t r i c d e n t a l j o u r n a l 3 2 ( 2 0 2 2 ) 1 2 3 e1 2 8

dental arch, and the occlusal plane. Moreover, the eruption

space of the permanent successor is reduced by the impacted
primary molar. Therefore, impacted primary molars should be
treated with a suitable approach for the healthy growth and
development of child.
The condition is caused by systemic or local etiological
factors. The local etiology of an impacted primary tooth can be
divided into two groups [1]. One is the impact primary tooth
itself [2,3], whereas other causes include mechanical blocking
by an odontoma [4e7], other types of odontogenic tumors
[5,16e19], ankylosis [2,5,8,20], dentigerous cysts [4], myxofi-
brous hyperplasia [5,9] and hyperplasia of the collagen fiber
[21]. There have been reports of an impacted primary tooth
with an unknown cause [5,10e12,22,23]. Other report [24]
showed only the impacted primary molars, without identifi-
cation of the cause.
The present report describes a case of impacted mandib-
ular right primary second molar owing to the permanent
successor being a mechanical obstacle.

2. Case report

A 6-year- and 10-month-old Japanese boy was referred to the

Clinic of Dentistry for Children and Disabled Persons, Hok-
kaido University Hospital, Sapporo, Japan by a private clinic
because of a complaint of mandibular right primary second
molar eruption failure. No associated pain or discomfort was
reported. The patient's medical history did not suggest any
hereditary etiology. His parents hoped to approach for a long
time with an orthodontic treatment.
No symptoms of the syndrome were evident, and his his-
tory did not reveal any dental trauma or infection. Clinical
examination showed an unerapted mandibular right primary
second molar (Fig. 1). No evidence of soft tissue swelling or
discoloration of the mandibular right primary molar was
observed. A panoramic x-ray photograph showed an impacted
mandibular right primary second molar and small oval hard
tissue on the crown of the tooth that acted as an obstacle.
Moreover it showed two maxillary median impacted super-
numerary teeth (Fig. 2a). However, we could not confirm the
small hard tissue on the crown of the primary second molar
using the pediatric dental x-ray photograph (Fig. 2b). The roots
of the impacted primary second molar showed the end of root
formation, and flared and short compared with the erupted
mandibular left primary second molar. The roots of the former
were also markedly caved and thin. The periodontal ligament
space of the mandibular right primary second molar was
confirmed. Computed tomography (CT) revealed an obstruc-
tive small disc-shaped hard tissue on the occlusal surface of Fig. 1 e Intraoral photographs at the first visit, a: Palatal
the mandibular right primary second molar (Fig. 3). The tooth view, b: Frontal view, c: Lingual view, and d: Part of the
germ of the mandibular right second premolar was not mandibular right primary second molar with a mirror. The
observed around the mandibular right primary second molar mandibular right primary second molar was unerupted,
on the x-ray photographs and CT scans. We discussed about and the maxillary left primary canine and supernumerary
this case with oral surgeons and orthodontics of Hokkaido tooth were fused. No evidence of soft tissue swelling or
University Hospital. We thought that the small hard tissue discoloration of the mandibular right primary molar was
interfered with the eruption of the mandibular right primary observed.
 p e d i a t r i c d e n t a l j o u r n a l 3 2 ( 2 0 2 2 ) 1 2 3 e1 2 8 125

Fig. 2 e X-ray photographs at the first visit, a: A panoramic x-ray photograph. b: Dental x-ray photograph. A panoramic x-
ray photograph revealed an impacted mandibular right primary second molar with small oval hard tissue on the crown of
the mandibular right primary second molar as an obstacle. Moreover the x-ray photograph showed two maxillary median
impacted supernumerary teeth. However, the pediatric dental x-ray photograph did not show the small oval hard tissue on
the crown of the mandibular right primary second molar.

second molar. In addition, the primary second molar could not
erupt due to its root shape. Because, the primary second molar
did not have the eruptive forces and showed large undercuts
against the mechanical tractions. Furthermore, there was no
mandibular right second premolar as permanent successor.
We created a treatment plan that included the extraction of
the small hard tissue, mandibular right primary second molar,
and maxillary median impacted supernumerary teeth. After
operation, the space maintenance for the mandibular right
second premolar was not implemented. We intended mesial
movement of the mandibular right first molar. Ultimately, the
permanent dental arch and occlusion can be controlled by
orthodontic treatment. Informed consent was obtained from
the patient and his parents.
The extraction of the obstacle, mandibular right primary
second molar and maxillary median impacted supernumerary
teeth was performed under general anesthesia. The extraction
of the impacted primary molar was difficult. The tooth was
luxated using elevators. However, we were unable to extract
the tooth in a lump. Owing to the root morphology, the tooth
was extracted via a hemisection.
A histopathological examination of the obstacle revealed
a tooth germ contained dental papilla, dentin, and enamel
in the process of formation (Fig. 4). The obstacle was diag-
nosed as the tooth germ of the mandibular right second
premolar.
The surgical area showed good healing. The follow-up was
performed by the pediatric dentists and the orthodontics. The
postoperative course showed slight the mesial movement of
the mandibular right first molar. However, the maxillary right
and left incisors did not erupted in oral cavity (Fig. 5). Ortho-
dontic treatment was initiated when the patient was 10 years
and 8 months old.
3. Discussion
There have been reports of obstacles to impacted primary
molars [4e7,9,13e19,21,25e27]. The obstacle in this case was a
permanent successor. Similarly, some previous case reports
on impacted primary molars showed that the obstacle was a
permanent successor [13e15,25e27].
126 p e d i a t r i c d e n t a l j o u r n a l 3 2 ( 2 0 2 2 ) 1 2 3 e1 2 8
Fig. 3 e The computed tomography (CT) images of the part
of mandibular right primary second molar, a: Small disc-
shaped hard tissue (arrow) as an obstacle at the part of
mandibular right primary second molar., b: The mandibular
right primary second molar (arrow head) below the obstacle.
The extracted permanent successor was a tooth germ
containing developing enamel and dentin. The x-ray photo-
graphs did not show any other features of the tooth germ
around the unerupted primary second molar. Therefore, oral
pathologists diagnosed the obstacle as the tooth germ of the
mandibular right second premolar. However, the crown of the
mandibular left primary second molar in the lower jaw was
observed to have already approximately formed. The devel-
opmental stage of the right primary second molar was
different compared with that of the left. The position of the
permanent successor and the development space were
thought to be the reasons for these differences.
Some previous reports have suggested ankylosis can lead
to an impacted primary molar [2,5,8,20]. The primary second
molar in this case did not show ankylosis. The etiology of
ankylosis is not known, although in some cases, trauma,
infection, disturbed local metabolism, or genetic influence has
been considered an important etiological factor [20]. We think
that as the first tooth is impacted for whatever reason, the
second tooth cannot erupt, resulting in ankylosis. There are
clear reasons for this.
Ooe [28] explained changes in the positions of the primary
molar and premolar germs in detail: in the mandibular jaw,
“in postnatal life, the anlage of the premolar also moves to a
position above the occlusal surface of its predecessor,” and
then “the anlages of the first and second premolars are located
in the mesial area and superficial to the occulusal surface of
the first and the second deciduous molars, respectively,” “the
deciduous molar has not yet erupted but the roots have
slightly elongated. The premolar anlage is right in the center
and lingual to the crown of its predecessor,” “the bell-shaped
second premolar still lies in the cervical area of its predeces-
sor,” “the latter is seen slightly below the cervical level near
the distal root of its predecessor,” and “the premolar germs lie
between the roots of the deciduous molars.”
If there is no abnormality, the permanent successor reaches
the furcation area of the primary molar. However, permanent
successor may not move and develop near/on the occlusal
plane of the primary molar for whatever reason. Such case
reports have been published. However, these reports do not
mention the reason for this. We think the reason is the mal-
positioning of the permanent successor and/or abnormality of
the eruption path of the primary molar [13e15,25e27]. How-
ever, the reason for this is not yet clearly understood.
As per a previous report, treatment for the inverted pri-
mary second molar and permanent successor as a premolar
were classified into four types: both teeth are extracted, only
the permanent successor is extracted, only the primary sec-
ond molar is extracted, and the primary second molar and the
permanent successor are observed periodically [15].
The treatment in this case involved the extraction of both
teeth. Jarvinen [10] suggested that an unerupted primary molar
should be extracted, but the extraction time should be defined
carefully by considering the development of a succedaneous
premolar. It is thought that the extraction time in this case was
early. However, a permanent successor was also extracted.
Therefore, we believe that the extraction time is still appro-
priate. We decided to extract both teeth, since the space for the
development of the permanent successor was very small, and
improvement with observation only was unlikely.
The histopathological features of the permanent successor
showed calcification. However, the development space for
permanent successor was very small. We think that the per-
manent successor was not healthy. Amir et al. [2] reported a case
wherein the succedaneous premolar did not develop properly
after extracting the mandibular primary second molar. Conse-
quently, we believe that the proposed approach was suitable.
In conclusion, we experienced a case of an impacted pri-
mary second molar. The influence of impacted primary mo-
lars on function and form, such as chewing function, primary
dental arch form, and occlusal plane is great. Moreover, the
eruption space of the permanent successor was reduced by
the impacted primary molar. Therefore, the early detection of
impacted primary molars is important for children's healthy
growth and development.
 p e d i a t r i c d e n t a l j o u r n a l 3 2 ( 2 0 2 2 ) 1 2 3 e1 2 8 127

Fig. 4 e Photomicrographs of the obstacle (H &E staining), Soft and hard tissues were divided into two specimens during
section preparation. a: Soft tissue with immature dental papilla-like fibrous tissue. Bar ¼ 500 mm. b, c and d: Hard tissues
consisting of dentin (b and c) and enamel (d) during crown formation. c: Higher magnification of dentin shown in b. b:
bar ¼ 500 mm. c: bar ¼ 100 mm. d: bar ¼ 100 mm.

Fig. 5 e A panoramic x-ray photograph taken when the patient was 9 years and 3 months old, The mandibular right first
molar showed slight mesial movement. However, the maxillary right and left incisors did not erupt into the oral cavity.
128 p e d i a t r i c d e n t a l j o u r n a l 3 2 ( 2 0 2 2 ) 1 2 3 e1 2 8

[13] Tsukamoto S, Braham RB. Unerupted second primary molar

Declaration of competing interest positioned inferior to the second premolar: clinical report. J
Dent Child 1986;53:67e9.
All of the contributing authors declare no conflicts of interest. [14] Borsatto MC, Sant'Anna AT, Niero H, Soares UN, Pardini LC.
Unerupted second primary mandibular molar positioned
inferior to the second premolar: case report. Pediatr Dent
references 1999;21:205e8.
[15] Okawa R, Nakano K, Nomura R, Fujita K, Kamakura N,
Matsumoto M, et al. Inverted maxillary second primary
molar and permanent successor teeth: X-ray photographic
[1] Pindborg JJ. Impaction of tooth. In: Pathology of the dental
evaluations. Pediatr Dent J 2009;19:123e9.
hard tissues. Copenhagen: Munksgaard; 1970. p. 241e7.
[16] Kitamura R, Matsubara R, Kawano S, Sakamoto,
[2] Amir E, Duperon DF. Unerupted second primary molar. J
Kiyoshima T, Nakamura S. A case of odontogenic fibroma
Dent Child 1982;49:365e8.
including an impacted primary molar of the maxilla. Jpn J
[3] Rasmussen P, Kotsaki A. Inherited primary failure of
Oral Maxillofac Surg 2018;64:528e33 [in Japanese)].
eruption in the primary dentition: report of five cases. J Dent
[17] Lukinmaa PL, Hietanen J, Laitinen JM, Malmstrom M.
Child 1997;64:43e7.
Mandibular dentinoma. J Oral Maxillofac Surg 1987;45:60e4.
[4] Motokawa W, Braham RL, Morris ME, Tanaka M. Surgical
[18] Yamagata K, Onizawa K, Ishigami T, Yoshida H. A case with
exposure and orthodontic alignment of an unerupted
eruption of impacted deciduous tooth after extirpation of
primary maxillary second molar impacted by an odontoma
central odontogenic fibroma. J Jpn Stomatol Soc
and a dentigerous cyst: a case report. Quintessence Int
2001;50:253e5 [in Japanese)].
1990;21:159e62.
[19] Watanabe T, Mori A, Nakano K, Bessho K. Adenomatoid
[5] Otsuka Y, Mitomi T, Tomizawa M, Noda T. A review of
odontogenic tumor associated with an unerupted primary
clinical features in 13 cases of impacted primary teeth. Int J
tooth. J Oral Maxillofac Surg Med Pathol 2020;32:473e6.
Paediatr Dent 2001;11:57e63.
[20] Mishra SK, Jindai MK, Singh RP, Stark TR, Hashmi GS.
[6] Memarpour M, Rahimi M, Bagheri A, Mina K. Unerupted
Submerged and impacted primary molars. Int J Clin Pediatr
primary molar teeth positioned inferior to the permanent
Dent 2010;3:211e3.
premolar: a Case report. J Dent 2012;9:79e82.
[21] Nakagawa H, Fukui R, Sakaki H, satou H, Narita K, Kimura H.
[7] Takashima Y, Morikawa Y, Takagi A, Matsumi Y,
A case of impacted primary second molar. Pediatr Oral
Matsumura T, Iida S, et al. Odontoma associated with
Maxillofac Surg 2005;15:138e42 [in Japanese)].
unerupted primary tooth in primary dentition e three
[22] Raghoebar GM, Boering G. An unerupted deciduous molar.
cases28; 2018. p. 19e24.
Oral Surg Oral Med Oral Pathol 1991;71:521e2.
[8] Ben-Bassat Y, Brin I, Fuks AB. Occlusal disturbances resulting
[23] Sfasciotti GL, Di Carlo G, Marini R, Colaci R, Solidani M,
from neglected submerged primary molars. J Dent Child
Polimeni A. Surgical management of impacted primary
1991;58:129e33.
teeth: report of two cases. Eur J Paediatr Dent
[9] Hayashi-Sakai S, Taguchi Y, Noda T. Failure of tooth eruption
2017;18:19e22.
involving a mandibular primary first molar: a case report. J
[24] Bianchi SD, Roccuzzo M. Primary impaction of primary teeth:
Dent Child 2005;72:16e20.
a review and report of three cases. J Clin Pediatr Dent
[10] Jarvinen SHK. Unerupted second primary molars: report of
1991;15:165e8.
two cases. J Dent Child 1994;61:397e400.
[25] Bateman RC, Emmering TE. Deciduous impaction. Oral Surg
[11] Seki N, Ashikaga M, Oka M, Shimooka S. A case of an
1976;42:852.
impacted maxillary second primary molar following surgical
[26] Park JK. Submerged impacted primary molar. Oral Surg Oral
exposure and orthodontic guidance. Jpn J Ped Dent
Med Oral Pathol 1979;48:383.
1988;26:621e30 [in Japanese)].
[27] Jameson GD, Burke PH. Inversion of second deciduous molar
[12] Yamaoka M, Yamamoto S, Tsubouchi J, Nakai Y, Yakushiji N,
and second premolar. Br Dent J 1987;162:265e6.
Shimono T. The sequel of the permanent successor after
[28] Ooe T. Change of positions of deciduous molar and premolar
surgical exposure and traction of the impacted second
germs during development. Okajimas Folia Anat Jpn
primary molar: a case report with a 9-year follow-up. Jpn J
1968;44:83e97.
Ped Dent 2002;40:858e62 [in Japanese)].