CLINICIAN’S CORNER
Managing second molars
Earl Johnson
Mill Valley, Calif
Second molars can create great delays in orthodontic treatment if they are not managed intelligently. The pur-
pose of this article was to describe common torque and position problems of the second molars and techniques
for managing them. A simple technique for freeing mesially impacted second molars is presented. (Am J Orthod
Dentofacial Orthop 2011;140:269-73)
A
ligning second molars is a challenge for a clinical
orthodontist. When these teeth erupt, they are
often tipped, with the mandibular second mo-
lars tipped lingually and the maxillary second molars tip-
ped buccally. Even if the crowns move into their correct
positions in the normal arch form, the roots are often
misplaced, producing excessive palatal root torque in
the maxillary arch (with low-hanging lingual cusps)
and excessive buccal root torque in the mandible (de-
pressed lingual cusps). To add insult to injury, the man-
dibular second molars are often impacted; this can be
a consequence of aggressive arch-length conservation
in the mixed or transitional dentition.
After preliminary leveling, the maxillary second mo-
lars often have extruded lingual cusps requiring intru-
sion and buccal root torque. The mandibular second
molars are often depressed in relation to the first molars
and need lingual root torque.
The second molars often erupt late during treatment,
tempting the practitioner to ignore them altogether. The
purpose of this article is to present methods to prevent,
minimize, or correct the problems listed above.
TIMING OF TREATMENT
Comprehensive treatment or phase 2 treatment
should not be started until the mandibular second mo-
lars can be correctly banded (or bonded). Waiting for
these molars before starting treatment will definitely
shorten treatment time and better maintain patient co-
operation, which wanes drastically when treatment
drags on. The maxillary second molars usually erupt
Health sciences clinical professor, University of California at San Francisco;
adjunct clinical professor, School of Dentistry, University of the Pacific, San
Francisco, Calif.
Reprint requests to: Earl Johnson, 390 Throckmorton Ave, Mill Valley, CA 94941;
e-mail, earljohnsondds@comcast.net.
Submitted, revised and accepted, October 2009.
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.10.048
a bit later and can be banded at the quality-control reset
appointment.1 This will avoid the later time-consuming
step of banding and releveling the second molars after
the other teeth have been leveled. This is especially
true if a second molar is impacted. Impactions can be
dealt with easily with a minimal appliance before full
fixed appliances. All remaining teeth can stay unbanded
while the impacted molar is freed and allowed to erupt. If
a distal operculum is preventing banding, it can be easily
removed with an electro-surgery procedure by using
local infiltration anesthesia (Fig 1).
IMPACTED MANDIBULAR SECOND MOLARS
Most impacted mandibular second molars are tipped
mesially and need to be tipped distally so that they can
clear the mandibular first molar (Fig 2).
Sometimes, the second molar’s distal movement is
blocked by a mesially displaced third molar. If the third
molar is impacted or incapable of ever erupting into a use-
ful position, consider having it extracted when the oral
surgeon exposes the occlusal aspect of the second molar.
Oral surgeons do not like taking out third molars in 12- to
13-year-olds, but they are specialists, and this is a neces-
sary part of their field. Please emphasize that only the oc-
clusal aspect of the second molar needs to be freed of
tissue. The attachment should be bonded just to the
occlusal surface of the tipped second molar.
TECHNIQUE
1. Surgically expose just the occlusal surface; extract
the third molar at the same time, if indicated.
2. Fabricate a custom eyelet and bond it in the second
molar’s central groove with the vertical loop por-
tion touching the distal portion of the first molar
(Fig 3, A).
3. Pass a light stainless steel ligature wire through the
vertical custom eyelet loop.
269
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Fig 1. If an operculum is present, it can be removed with electro-surgery.
Fig 2. Mesially impacted second molar and poor root
resorption of the deciduous second molar.
4. Fabricate the 0.018-in stainless steel sectional arch
and adjust the arm length so that its terminal loop
will lay directly distally to the custom eyelet loop
(Fig 3, B).
5. Place the 100-g superelastic open-coil spring over
the 0.018-in stainless steel sectional arch.
6. With a Mathieu needle holder, compress the open-
coil spring 100% and lock the needle holder to
hold the compressed spring in place.
7. Holding the sectional spring assembly outside the
mouth, thread the same stainless steel ligature
wire (Step 3) through the sectional’s terminal loop.
8. Thread the mesial end of the .018 sectional arch
into the distal opening of the first molar tube
and slide the sectional wire mesially through the
first molar tube until the needle holder touches
the distal aspect of the first molar tube (Fig 3, C).
9. Take a second Mathieu needle holder and lock it
onto the sectional wire where it emerges from
the mesial side of the first molar tube. This will
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Johnson
continue to hold the nickel-titanium (NiTi) spring
compressed when the more distal needle holder is
released and removed.
10. Release and remove the more distal Mathieu nee-
dle holder (Fig 3, D).
11. Tighten the prethreaded stainless steel ligature un-
til the terminal end loop of the .018 sectional wire
is firmly tied to the vertical loop of the custom
eyelet. Cut the excess ligature free and tuck the
remaining pigtail (Fig 4).
12. Release and remove the remaining Mathieu needle
holder. This will allow the compressed NiTi spring
to drive the sectional wire distally, and to apply
a constant distal tipping force to the second molar.
13. Adjust the length of the remaining sectional wire
mesial to the first molar tube. Then bend the very
mesial end 90 towards the teeth and away from
the cheek. Make sure there is enough wire remaining
mesial to the first molar tube to allow the sectional
wire to slide distally enough as the spring expands
and the second molar tips distally to clear the first
molar. If the 90 bend is too close to the molar
tube, the sectional will be prevented from tipping
the second molar far enough.
MANAGING MAXILLARY SECOND MOLARS
At the end of comprehensive orthodontic treatment,
the maxillary second molar should be positioned with its
occlusal surface slightly above the occlusal plane formed
by the buccal-segment teeth mesial to it. The crown
should be tipped slightly distally, with its root tipped
slightly mesially, resulting in a slight curve of Spee in
the second molar region (the occlusal plane should not
be completely flat through the second molars; if so,
the extruded second molar will open the bite exces-
sively). The crown should follow the curve of Wilson
Johnson 271

Fig 3. A, Fabrication of the 0.014-in custom eyelet. The eyelet is bent perpendicular to the twisted pigtail,
which is bonded in the central groove with the eyelet touching the first molar. B, Exploded view of the distal
tipping assembly. C, The 100-g superelastic spring is held fully compressed as the 0.018-in wire is placed
through the first molar tube from the distal aspect. D, A second needle holder locks on the wire so that the
spring will remain compressed after the distal needle holder is released. With the needle holder locked me-
sially, use the prethreaded ligature wire to tie the looped end of the 0.018-in wire to the custom eyelet.

Increasing the lingual crown torque to 30 reduces

Fig 4. The 0.018-in stainless steel distal tipping assem-
bly is tied in. The 100-g superelastic spring is severely
compressed against the first molar tube because the
arm end is tied snugly to the bonded custom eyelet.
exhibited by the first molar without a low-hanging lin-
gual cusp. The crown should also be rotated so that
a line connecting its buccal cusps is parallel to a similar
line on the first molar.
Andrews’s standard straight-wire torque prescription
for the maxillary second molar is 10 .2 However, this
prescription is not always adequate to correct second
molars that erupt flared buccally with excessive lingual
root torque. Slot play, long interbracket distance, and
lighter square finishing arches (0.017 3 0.017 inch in
a 0.018 3 0.025-inch tube) routinely result in undercor-
rected second molars with the 10 prescription.
the need for adding lingual crown torque during the fi-
nal finishing procedures. If you use heavier finishing
arches, using less torque will still work, if you compen-
sate for slot play and then some. (All nominal bracket
prescriptions in orthodontic catalogs are in terms of
crown torque [angulation of the facial surface]. How-
ever, the intent of a torque prescriptions or activation
is to correctly achieve proper facio-lingual root position.
When considering a change in a torque prescription,
keep in mind that a larger plus or smaller minus means
more lingual root movement, and a smaller plus or larger
minus means more facial root movement.)
The maxillary second molar tube placement should
routinely produce an elevated and tipped second molar.
Offset the second molar tube toward the occlusal margin
to intrude the second molar in relation to the first molar.
Tip the mesial aspect of the tube 3 toward the gingiva
to produce a slight distal tipping of the crown.
When banding the maxillary second molar, the fol-
lowing steps are necessary.
1. Do not seat the band as far gingivally as you seated
the first molar band. This will increase the vertical
differential between the 2 teeth and tend to intrude
the second molar.
2. Seat the band a bit more mesially than distally. This
will accentuate the distal tipping of the crown.
3. Paying attention to Steps 1 and 2 will produce a more
defined transition from a flat occlusal plane to a curve

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Fig 5. Turbo torque 1. The archwire is held vertically be-
fore its placement in the second molar tube. After insert-
ing the wire into the tube, the entire arch is rotated
90 so that it can be engaged and ligated to most of the
remaining teeth in the arch.
of Spee in the second molar region. This, along with
the accentuated torque prescription, will lift the often
present hanging lingual cusp out of the way.
MANDIBULAR SECOND MOLARS
Andrews’s standard straight-wire torque prescription
is 34 .2 However, mandibular second molars often
erupt tipped lingually with excessive buccal root torque.
Slot play, long interbracket distance, and lighter square
finishing arches (0.017 3 0.017 inch in a 0.018 3
0.025-inch tube) routinely result in undercorrected sec-
ond molars when the 34 prescription is used. Decreas-
ing the lingual crown torque prescription to 10
consistently reduces the need for reducing torque with
archwire bends during finishing procedures. If you use
heavier finishing arches, using slightly more negative
torque would work if you still compensate for slot play
and then some.
Mandibular second molar tube placement should
routinely produce a second molar that is at the same
height as the first molar with level marginal ridges. Of-
ten, after preliminary leveling, the mandibular second
molar is somewhat submerged in relation to the first mo-
lar. This phenomenon occurs because most of us seat the
mandibular first molar band more gingivally than is
ideal, slightly below the marginal ridges to avoid prema-
ture contact between the maxillary molar’s buccal cusp
and the mandibular molar’s buccal attachment. To com-
pensate for this commonly observed phenomena, offset
the second molar tube gingivally. This usually results in
equal vertical distances from the archwire slots to the
buccal cusps and marginal ridges of both teeth. Any mi-
nor discrepancies can be easily adjusted with a step bend
in normal 0.017 3 0.017-in square stainless steel finish-
ing arches.
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Johnson
Fig 6. Turbo torque 2. The 0.018 3 0.018-in NiTi turbo-
torqued wire in place. The wire is activated an additional
90 between the second premolar bracket and the second
molar tube. The archwire bypasses the first molar tube
assembly completely (no ligation or placement in tube)
while all other teeth are fully tied in.
EFFICIENT TORQUE CONTROL OF SECOND
MOLARS
Nothing is more frustrating than trying to achieve ex-
tensive second molar torque correction late in treatment
with conventional stainless steel finishing arches. Every-
thing else is done, and you must spend another 3 to 4
months correcting the second molar torque. Ideally,
this would have been finished earlier in treatment.
Four factors can help minimize this problem: (1) use
the prescriptions as described above, with maxillary mo-
lar torque of 30 and mandibular molar torque of 10 ;
(2) finish leveling with a full fit square wire; (3) correct
severe torque problems early by using the turbo-
torque technique; and (4) fine tune the torque with
a 0.017 3 0.017-in stainless steel wire.
TURBO TORQUE
My usual leveling wire sequence with an 0.018-in slot
is 0.014-in NiTi, 0.016-in NiTi, and 0.018 3 0.018-in
NiTi. Before placing the 0.018 3 0.018-in square NiTi
wire, I check for second molar torque problems. If, for
example, a maxillary second molar needs buccal root
torque, I do the following.
1. Hold the new archwire so that its occlusal plane is
90 to normal (vertical instead of horizontal with
one buccal leg directly above the opposite buccal
leg) (Fig 5).
2. Place the distal end of the archwire into the second
molar tube.
3. Rotate the rest of the archwire until it is orientated
in it normal fashion: parallel to the occlusal plane.
4. Place the free end of the archwire in the contralat-
eral second molar tube.
Johnson
5. Ligate all remaining teeth in the arch normally with 1
exception: bypass (buccally) the first molar just me-
sial to the second molar that is being torqued (Fig 6).
Do not run the archwire through the first molar tube
or bracket. Do not ligate the archwire to the first
molar tube or bracket.
The net result is that the archwire has an additional
90 of activation but has, at the same time, had its
torsional stiffness effectively reduced by a third be-
cause the interbracket distance has been increased by
a factor of 3 (by bypassing the first molar bracket or
tube). This hyper-activated square NiTi wire will torque
the second molar over a longer distance without re-
peated reactivations (Fig 6). This technique can be
used equally well with lingually tipped mandibular
second molars.
When the torque problem has been resolved, remove
the square archwire and then replace and retie it
American Journal of Orthodontics and Dentofacial Orthopedics
273
normally so that you can continue leveling the affected
premolar, first molar, and second molar regions.
The only side effect can be minor palatal tipping of the
bypassed first molar. This can be easily taken care of
with a lingual arch or a transpalatal arch. The net effect
of turbo-torquing is to correct torque issues early and
rapidly, thus drastically reducing overall treatment times.
You can turbo-torque both second molars in the same
arch at the same time. One side can finish torque correc-
tion earlier than the other side. If so, just remove the
archwire, tie in the corrected side normally, and continue
turbo-torquing the side that needs more correction.
REFERENCES
1. Carlson SK, Johnson E. Bracket positioning and resets: five steps to
align crowns and roots consistently. Am J Orthod Dentofacial
Orthop 2001;119:76-80.
2. Andrews LF. Straight Wire, the Concept and Appliance. San Diego,
CA: L.A. Wells Company; 1989.
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