CASE REPORT

Rescue therapy with orthodontic traction

to manage severely impacted mandibular
second molars and to restore an alveolar
bone defect
Yoon Jeong Choi,a Jong-Ki Huh,b Chooryung J. Chung,c and Kyung-Ho Kimd
Seoul, Korea

This case report describes the successful treatment of severely impacted mandibular second molars with severe
apical root resorption of the mandibular first molars. The vertically impacted second molars were orthodontically
moved (using orthodontic mini-implants) without additional root resorption of the first molars. The orthodontic
treatment provided a satisfactory and stable outcome by improving the periodontium surrounding the first and
second molars. The treatment also eliminated the need for prosthetic treatment by preserving the first and
second molars. (Am J Orthod Dentofacial Orthop 2016;150:352-63)

I
mpaction of the mandibular second molar is rela-
tively rare, with a prevalence of 0% to 2.3%.1-5
Second molar disturbances result from inadequate
arch length, ectopic position of the follicle, an obstacle
in the path of eruption, or failure of the eruption
mechanism.2,6-8 A second molar impaction is
categorized in terms of its angulation as mesial,
vertical, or distal.2 Most impacted second molars are
mesially inclined and can be corrected and brought
into the occlusion by orthodontic uprighting.8
Treatment of an impacted second molar is considered
in the following sequence, starting with the most con-
servative option: orthodontic tooth movement, surgical
repositioning, transplantation, and extraction of the
From the College of Dentistry, Yonsei University, Seoul, Korea.
a
Assistant professor, Department of Orthodontics, Institute of Craniofacial
Deformity.
b
Professor and chair, Department of Oral and Maxillofacial Surgery, Gangnam
Severance Hospital.
c
Associate professor, Department of Orthodontics, Gangnam Severance Hospital,
Institute of Craniofacial Deformity.
d
Professor and chair, Department of Orthodontics, Gangnam Severance Hospital,
Institute of Craniofacial Deformity.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Kyung-Ho Kim, Department of Orthodontics,
Gangnam Severance Hospital, Institute of Craniofacial Deformity, College of
Dentistry, Yonsei University, 211 Eonjuro, Gangnam-gu, Seoul 135-720, Korea;
e-mail, khkim@yuhs.ac.
Submitted, June 2015; revised and accepted, September 2015.
0889-5406/$36.00
Ó 2016 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2015.09.031
352
impacted tooth. The orthodontic approach is the treat-
ment of choice, with a success rate of 70%.5 This treat-
ment is ideal for an impacted second molar during early
adolescence when second molar root formation is still
incomplete and before the complete development of
the mandibular third molars.9 If left untreated, the
impacted second molar can cause further problems
such as root resorption, caries and periodontitis of the
adjacent molars, cysts, malocclusion, pericoronal
inflammation, and pain.4,5,10,11
Several reports have presented the successful treat-
ment of an impacted second molar by orthodontic up-
righting or surgical repositioning.7,9,12,13 For
complicated problems, the decision-making procedure
is difficult because of uncertain etiology, lack of stan-
dard therapy, and few reported cases.13
We report an adult with vertically impacted mandib-
ular second molars accompanied by severe apical root
resorption of the first molars. Our aims were to describe
and discuss the treatment and the 3.5 years of successful
retention in which the vertically impacted second molars
were orthodontically moved into their appropriate posi-
tions without additional apical root resorption of the
first molars.
DIAGNOSIS AND ETIOLOGY
A 19-year-old man was referred from a private clinic
because of impaction of the mandibular second molars
(Figs 1-4). The second molars were vertically impacted
beneath the distal roots of the first molars, which were
Choi et al
Fig 1. Pretreatment extraoral and intraoral photographs.
slightly extruded. The distal roots showed severe apical
resorption, but they were not treated because their
vitality and mobility were within normal limits with no
specific symptoms. According to the patient, his
mandibular third molars had been extracted
approximately 8 months before because of horizontal
impaction over the second molars. The maxillary right
second molar was overextruded because of the
impacted opposing tooth.
The patient had a good profile and mild facial asym-
metry with deviation of the chin and the mandibular
dental midline to the right side (Fig 1). His dentition
was well aligned with Class I molar and canine relation-
ships (Fig 2). The lateral cephalometric radiograph indi-
cated a normal skeletal relationship with an ANB angle
of 2.9 and a hyperdivergent facial profile (Figs 3
and 4; Table). The computed tomogram showed a buc-
coapical position of the second molars and severe apical
American Journal of Orthodontics and Dentofacial Orthopedics
353
resorption of the first molar distal roots (Fig 5). The first
molars had infrabony defects on the distal surfaces. On
the basis of these findings, the patient was diagnosed
as having a skeletal Class I malocclusion with vertical
impaction of the mandibular second molars and severe
apical root resorption of the mandibular first molars.
TREATMENT OBJECTIVES
The treatment objectives were to establish a func-
tional occlusion by bringing all teeth into occlusion
without additional problems and to maintain the hard
and soft tissue profiles.
TREATMENT ALTERNATIVES
The decision of the most appropriate treatment plan
for this patient was influenced by 2 major factors: (1) the
difficulty of orthodontic traction or surgical extraction
August 2016  Vol 150  Issue 2
354 Choi et al

Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment lateral cephalogram and cephalometric tracing.

of the impacted second molars, and (2) the prognosis of
each procedure. The treatment alternatives were (begin-
ning with the most conservative option) preservation of
the first and second molars, extraction of the first mo-
lars, extraction of the second molars, and extraction of
the first and second molars.
The first option would preserve the first and
second molars by moving the second molars backward.
This option would be the least invasive and eliminate
the need for additional prosthetic treatment. In addition,
the alveolar bone levels of the first and second molars
could be expected to improve.14,15 However, the long-
term prognosis of severely resorbed roots is unclear,
and the possibility of ankylosis of the second molars is
uncertain. Furthermore, it would take a long time to
bring the impacted second molars into occlusion.
The second option was to extract the first molars and
substitute the first molars with the second molars. The
extraction procedure of the first molars would not be
as invasive as extraction of the second molars. The or-
thodontic treatment would be simpler, and the treat-
ment duration would be shorter than in the first

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Choi et al 355

Fig 4. Pretreatment panoramic radiograph.

These treatment alternatives were discussed with the

Table. Cephalometric measurements
patient. Because of his recent history of extraction of the
23 months mandibular third molars, he was reluctant to undergo
(locking Retention additional extractions. Preservation of all mandibular
Measurement Initial resolved) Posttreatment (3.5 years)
molars would be ideal for this patient in spite of the
SNA ( ) 82.1 82.0 82.9 82.5
SNB ( ) 79.2 75.8 78.6 78.4 long treatment duration and the possibility of ankylosis
ANB ( ) 2.9 6.2 4.3 4.1 of the second molars and additional root resorption of
Wits (mm) 0.3 1.0 0.1 0.3 the first molars. This treatment would yield a predictable
ork sum ( )
Bj€ 399.4 403.3 401.1 401.3 outcome, unless the second molars were ankylosed. The
SN-MP ( ) 39.5 43.3 41.1 41.3
infrabony defects around the first and second molars
Gonial angle ( ) 123.7 123.5 123.8 124.4
Facial height 63.4 61.9 63.1 63.9 reportedly could be improved in association with ortho-
ratio dontic tooth movement.14,15 Furthermore, the
U1-SN ( ) 99.3 101.2 98.0 98.4 treatment would allow the patient to maintain
IMPA ( ) 93.2 94.7 90.0 90.5 proprioception and adaptive capacity in the
Upper lip 2.0 5.1 0.8 0.6
periodontal ligament space and not create a large
to E-line
(mm) bone defect at the impacted sites.17 Therefore, we
Lower lip 3.4 4.9 2.0 1.8 selected the first option, and the patient gave signed
to E-line informed consent for treatment.
(mm)

option. However, 2 implants would be necessary to TREATMENT PROGRESS

restore the missing mandibular molars. Furthermore, if
the impacted second molars were diagnosed as having
ankylosis, 4 implants would be required.
The third option was to preserve the first molars and
extract the second molars, and the fourth option was to
extract the first and second molars. These options have
the potential risks of nerve damage and a large bone
defect after extraction of the apically impacted
second molars; this complicates prosthetic work.16
With the third option, the longevity of the first molars
cannot be guaranteed because of severe root resorption.
However, intrusion of the maxillary right second molar
would be the only orthodontic procedure required;
thus, the total treatment duration can be shortened.
Two orthodontic mini-implants (1.8 mm in diameter,
9.0 mm long; Ortholution, Gyeonggi-do, Korea) were
placed in the retromolar areas on each side. Reinsertion
of orthodontic traction force would be difficult because
of the apical positioning of the impacted second molars;
therefore, when the impacted second molars were surgi-
cally exposed, we connected them to mini-implants with
nickel-titanium coil springs (Tomy, Tokyo, Japan)
(Fig 6). The nickel-titanium coil springs were replaced
once for reactivation of the force. After 23 months of
traction, the second molars were positioned distal to
the first molars, and locking was resolved. However,
because of the buccoapical positioning of the impacted
second molars, the adjacent first molars—particularly on

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356 Choi et al

Fig 5. Pretreatment computed tomograms: sagittal and coronal sections showing buccoapical impac-
tion of the mandibular second molars.

Fig 6. Panoramic radiograph immediately after implantation of the orthodontic mini-implants and
bonding of the attachments.

Fig 7. Progress intraoral photographs 23 months after orthodontic traction of the impacted teeth.

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Choi et al 357

Fig 8. Progress lateral cephalograms and cephalometric tracing.

Fig 9. Intraoral photographs 34 months after orthodontic traction of the impacted teeth.

the left side—were extruded and moved lingually; this re-
sulted in an anterior open bite and clockwise rotation of
the mandible (Figs 7 and 8).
Roth prescription metal brackets (0.018 in; Tomy)
were bonded on the mandibular teeth to level and align
the first and second molars. Intrusion of the extruded
maxillary right second molar was started using 2 ortho-
dontic mini-implants (1.8 mm in diameter, 7.0 mm long;
Ortholution) placed on the mesial side of the tooth. After
11 months of leveling and alignment, several problems
remained: an anterior open bite, a Class II relationship
on the right side, spacing of the mandibular dentition,
and maxillary and mandibular midline deviations to
the left and right sides. We decided to perform an addi-
tional implantation of an orthodontic mini-implant to
the maxillary left side and began the intrusion of the
maxillary molars with a transpalatal arch to correct the
anterior open bite (Fig 9). The Class II relationship and
the midline deviations were corrected by distalizing the
maxillary dentition to the right and by moving the
mandibular teeth to the left using the remaining space.
After 14 months of further treatment, the appliances
were removed, and lingual fixed retainers were bonded
from canine to canine in both arches. Additional circum-
ferential retainers were delivered with instructions for
the patient to wear them full time for the first 6 months.

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358 Choi et al

Fig 10. Posttreatment photographs.

Fig 11. Posttreatment dental casts.

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Choi et al
Fig 12. Posttreatment lateral cephalogram, cephalometric tracing, and panoramic radiograph.
TREATMENT RESULTS
The impacted second molars were fully erupted and
brought into occlusion. The right second molar was sur-
rounded with a normal and healthy periodontium,
whereas the left second molar showed malformed buccal
cusps and approximately 6 mm of probing depth on the
distal surface. There was no additional apical root
resorption of the mandibular first molars. Their vitality
and mobility were within the normal range and without
specific symptoms. New bone formation was noticed on
the distal aspects of the first molars. Class I canine and
molar relationships were achieved, and proper overjet
and overbite relationships were established (Figs 10-12).
The cephalometric radiograph and superimposition
demonstrated clockwise rotation of the mandible after
the treatment. The mandible rotated clockwise during
traction of the second molars. Later it partially moved
back to the original position and maintained the final
American Journal of Orthodontics and Dentofacial Orthopedics
359
position during the posttreatment follow-up period
(Fig 13).
After 3.5 years of retention, the treatment results
were maintained (Figs 14 and 15). The periapical
radiograph and cone-beam computed tomography im-
ages confirmed that the mandibular right
second molar was surrounded by a normal periodon-
tium. However, the left second molar showed deficient
buccal and distal alveolar bones with approximately
6 mm of probing depth on the distal surface. No further
apical root resorption occurred on the first molars, and
their vitality and mobility were maintained throughout
the retention period (Fig 16).
DISCUSSION
This case report demonstrates the successful ortho-
dontic movement of vertically impacted second molars
without additional root resorption of the first molars.
August 2016  Vol 150  Issue 2
360
Fig 13. Cephalometric superimposition (before, during,
and after treatment, and after 3.5 years of retention).
The results were stable 3.5 years after treatment. We es-
tablished a functional occlusion by bringing the
impacted second molars into occlusion and improving
the infrabony defects around the posterior teeth. How-
ever, the treatment duration was long, and a periodontal
pocket formed on the distal surface of the mandibular
left second molar.
In this patient, the ectopic position of the follicle
could have been a cause of the eruption disturbances
of the second molars. The apical root resorption of the
first molars supports this assumption and shows the
importance of early diagnosis of second molar impac-
tions.14 The best time for treating a second molar impac-
tion is reportedly between 11 and 14 years of age when
root formation is incomplete.9,14,15 A patient's age has
little impact on the outcome of the orthodontic
technique14; however, a delay in treatment can cause
various pathologic problems such as caries, periodonti-
tis, pericoronitis, and resorption of the first molar
roots.4,5,10,11,14 Therefore, if the patient had been
examined at an earlier age, the apical resorption of the
first molars could have been prevented, and the
treatment duration would have been shorter.
The lack of a standard therapy for impacted
second molars made it difficult to determine a final
plan and to obtain a predictable outcome. We retained
the first and second molars in spite of the long treatment
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Choi et al
and its complexity. Dental implants can replace ex-
tracted molars; however, there is no evidence in terms
of survival rate to support placing implants instead of re-
taining natural teeth.18 In addition, extraction of the
second molars may result in periodontal problems on
the distal surfaces of the first molars and may be risky
because of the large bone defect and the possibility of
nerve damage and mandibular fracture.19,20 By
contrast, orthodontic movement of the second molars
can minimize these problems by building up the
osteoperiodontal tissue distal to the first molars.14,21 In
addition, improving the infrabony periodontal defect
has a good long-term prognosis.15,22 The periapical
radiographs obtained before treatment, immediately
after treatment, and 3.5 years after treatment
demonstrated new bone formation and its retention
on the distal side of the first molars. However,
48 months of treatment may risk periodontal health
and tooth structure.13 We therefore continuously
encouraged the patient to maintain good oral hygiene,
particularly for the posterior teeth.
The treatment duration can be shortened, unless
extrusion with lingual movement of the first molars fol-
lowed by clockwise rotation of the mandible occurs.
Extrusion would be prevented if only distal forces
without a vertical force vector were applied to the
impacted teeth until locking was resolved. However,
the undesirable movement of the first molars was inev-
itable because of the inherent extrusive nature of the or-
thodontic force and the anatomic limitation in applying
a true horizontal force. Lingual movement of the first
molars was obvious on the left side after the impacted
second molars appeared (Figs 7 and 8). The left
second molar was impacted buccally relative to the
first molar (Fig 5); therefore, the traction force included
a lingual vector, which caused lingual movement of the
first molars.
To correct the anterior open bite, an intrusion
force was delivered to the maxillary molars using or-
thodontic mini-implants.23 The intrusion of the
extruded mandibular first molars was also performed
with an archwire to level the second molars, although
the amount of the counteracting intrusion force may
have been minimal because extrusive movement oc-
curs faster and more easily than intrusive movement.
Furthermore, the amount of intrusion of the mandib-
ular molars using orthodontic mini-implants is
limited because of the difficulty of applying an intru-
sive force on the lingual side24; therefore, we could
not intrude the mandibular first molars to the same
degree that they had been extruded. The treatment
was consequently finished with the mandible rotated
backward.
Choi et al
Fig 14. Retention photographs.
The result was stable 3.5 years after treatment,
although long-term follow-up is recommended for the
resorbed distal roots of the first molars and the peri-
odontal pockets on the distal surfaces of the left
second molars. Apical root resorption of the mandibular
first molar distal root after fixed appliance treatment
reportedly is, on average, 0.81 mm.25 In this patient,
the first molar distal roots showed apical resorption of
less than 0.2 mm during treatment, and the distal roots
maintained their length until the last follow-up. There-
fore, we expect no additional apical resorption.
With regard to the periodontal pocket of the left
second molar, the serial periapical radiographs showed
that the pocket had formed during the initial leveling
stage after the impacted tooth appeared in the oral cav-
ity (Fig 16). Before the intraoral exposure of the tooth,
the miniscrews and the coil spring had been covered
by soft tissue. However, after the exposure, gingival
swelling surrounding the tooth and the coil spring
seemed to have resulted in localized inflammation and
American Journal of Orthodontics and Dentofacial Orthopedics
361
consequently the deep periodontal pocket.26 The pocket
did not improve spontaneously, even after 3.5 years of
retention, although it was not aggravated once it devel-
oped. We instructed the patient on the importance and
method of hygiene control, and he has maintained
good hygiene.
Several factors should be considered before deciding
on a final treatment plan for mandibular second molar
impaction. The position and degree of second molar
impaction, the presence of third molars, the pathologic
conditions of the first molars, patient cooperation, and
so on affect the decision-making procedure and the final
treatment outcome.5,10,14,15 We discussed with the
patient the possible benefits and risks of each
treatment alternative, and he chose the most
conservative option that we suggested. The treatment
was successful in terms of stability and preservation of
the first and second molars without additional root
resorption, although it had the potential risks of
periodontal problems for the left second molar.
August 2016  Vol 150  Issue 2
362
Fig 15. Retention lateral cephalogram, cephalometric tracing, and panoramic radiograph.
CONCLUSIONS
This case report illustrates the process of diagnosis,
treatment, and retention of severely impacted mandib-
ular second molars. Orthodontic traction of impacted
second molars can stop apical root resorption of the
adjacent first molars and contribute to improving the
alveolar bone level of the impacted teeth and the adja-
cent teeth by building up the osteoperiodontal tissues
distal to the first molars. In addition, a functional occlu-
sion can be achieved by bringing the impacted teeth into
occlusion. However, an early diagnosis of the impaction
could prevent the pathologic changes and would shorten
the treatment duration by making the treatment simpler.
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Fig 16. Top, Cone-beam computed tomograms: sagittal and coronal sections show improvement of
the infrabony defects on the distal surfaces of the first molars, coronal movement of the alveolar
bone with the second molars, and the infrabony defect on the distal surface of the mandibular left
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