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J Oral Maxillofac Surg70:e438-e440, 2012

Soft Tissue and Occlusal Management inthe Surgical Uprighting of Impacted

Molars: Technical NoteKen Anderson, DDS,* Keith Murtagh, DDS,† and

Harry G. Sacks, DDS‡

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The treatment of impacted mandibular second mo-lars (Fig 1) is a common problem faced by oral andmaxillofacial surgeons and orthodontists. Bringingthe impacted tooth into its correct position in thedental arch is important in the prevention of cariesand periodontal problems on the distal root of thefirst molar and in preventing arch-length discrepan-cies.1 Orthodontic uprighting, with or without theuse of temporary anchorage devices, has limita-tions, including a lack of access to the crown forthe placement of an orthodontic appliance and thedifficulty in applying appropriate directional force.Other variables that affect successful orthodonticuprighting include the experience of the orthodon-tist, the age of the patient, the degree of rootformation, and the depth of the impaction. Surgi-cally assisted uprighting provides access to bond anorthodontic bracket, decreases the need for com-plex mechanics, and significantly shortens orth-odontic treatment time. Complications of surgicaluprighting include the possibility of root fracture,devitalization resulting in inflammatory or replace-ment resorption, and the possible need for end-odontic therapy. Numerous publications in the lit-erature have reported high levels of success for thisprocedure, with minimal morbidity.1-6 Several tech-

iques have been described, with the primary dif-erence being whether or not the third molar isemoved to allow distal movement of the second

Received from the Department of Oral and Maxillofacial Surgery,

Brookdale University Hospital, Brooklyn, NY.

*Chief Resident.

†Senior Resident.

‡Attending, Department of Oral and Maxillofacial Surgery, Ja-

maica Hospital Medical Center, Jamaica, NY; Private Practice, New,

Hyde Park, NY.

Address correspondence and reprint requests to Dr Sacks: 2035

Lakeville Road, Suite 204, New Hyde Park, NY 11040; e-mail:

harrysacks@me.com

© 2012 American Association of Oral and Maxillofacial Surgeons

278-2391/12/7008-0$36.00/0

ttp://dx.doi.org/10.1016/j.joms.2012.04.046 M

e438

olar.1,3,5,6 Slow luxation with minimal force isniversally advised to minimize complications.When the second molar is deeply impacted orhen the third molar is removed simultaneously, aucoperiosteal flap is developed using a buccalockey-stick incision. Because of the short alveolar

ength, when the wound is closed, the mobile flaprequently covers the distal half of the crown of theprighted tooth. This subjects the tissue to occlusalrauma, increasing postoperative pain and edema,akes oral hygiene difficult, and compromises the

bility to immediately engage the arch wire into therthodontic bracket. When uprighting is delayednd the maxillary second molar has supraerupted,he potential exists to reseat the mandibular secondolar into the presurgical position owing to hyper-

cclusion.Conspicuous in its absence in the literature is the

ack of discussion of soft tissue wound closure andaintenance of the occlusal position of the up-

ighted tooth when a supraerupted maxillary secondolar is present. The focus of this technical note is toresent the authors’ technique to address these com-on occurrences. The benefits of the technique in-

lude 1) maintenance of the buccal keratinized gin-iva; 2) ease of postoperative oral hygiene; 3)mproved orthodontic access; and 4) the preventionf hyperocclusion.

FIGURE 1. Impacted lower right second molar.

nderson, Murtagh, and Sacks. Surgical Uprighting of Impacted

olars. J Oral Maxillofac Surg 2012.

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ANDERSON, MURTAGH, AND SACKS e439

Technique

After completion of the surgical uprighting of thesecond molar (Fig 2),2-4 suturing the buccal flap

resents periodontal concerns and difficulty withrthodontic bracket access (Fig 3). When the flap isutured distal to the newly uprighted tooth, theuccal tissue has a tendency to rise over the distalcclusal surface, resulting in inaccurate positioningf keratinized tissue and potential occlusal trauma-ism, increasing postoperative pain and edema. Toddress this problem, the authors suture the flap tohe buccal cortex of the mandible at the distobuc-al line angle of the second molar. A small osteot-my is made using a surgical handpiece with a 701ur directing the bur from the buccal cortex distalo the uprighted second molar distally into the thirdolar extraction site (Fig 4). The buccal flap isicked up with a 3-0 or 4-0 braided polyglactinuture through the keratinized distal papillae of theecond molar and then passed through the buccalsteotomy. After the suture is passed through thesteotomy, it can be technically difficult to pick uphe needle. The use of a small 3/8 round needle and

curved clamp facilitates this maneuver. A sur-eon’s knot is then tied. The vertical portion of the

FIGURE 2. Lower right second molar after uprighting.

Anderson, Murtagh, and Sacks. Surgical Uprighting of ImpactedMolars. J Oral Maxillofac Surg 2012.

FIGURE 3. Soft tissue covering the uprighted tooth before closure(arrow).

Anderson, Murtagh, and Sacks. Surgical Uprighting of Impacted

Molars. J Oral Maxillofac Surg 2012. M

uccal hockey-stick incision is closed loosely (Fig). An orthodontic bracket with a buccal tube isonded to the uprighted tooth and the occlusion isvaluated.5 If there is any hyperocclusion, a buttonf composite is bonded on the occlusal surface ofhe first molar to provide sufficient disclusion of thepposing tooth (Fig 6). The occlusal button is re-oved by the orthodontist 10 to 14 days postoper-

tively, when the blood clot on the mesial of the

FIGURE 4. Osteotomy through the buccal cortex (arrow).

nderson, Murtagh, and Sacks. Surgical Uprighting of Impactedolars. J Oral Maxillofac Surg 2012.

FIGURE 5. Buccal flap sutured through the osteotomy.

nderson, Murtagh, and Sacks. Surgical Uprighting of Impacted

olars. J Oral Maxillofac Surg 2012.

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e440 SURGICAL UPRIGHTING OF IMPACTED MOLARS

second molar has organized sufficiently to preventreseating of the lower second molar. At that time,the arch wire is engaged in the buccal tube andorthodontic mechanics are begun.6

Discussion

The technique described offers a simple methodfor soft tissue and occlusal management after thesurgical uprighting of impacted second molars. Pre-venting periodontal soft tissue defects, the ability

FIGURE 6. Composite occlusal button (arrow).

Anderson, Murtagh, and Sacks. Surgical Uprighting of ImpactedMolars. J Oral Maxillofac Surg 2012.

for early application of orthodontic forces, easing

the maintenance of oral hygiene for the patient, andprevention of reseating of the treated tooth repre-sent important benefits of using this technique. Theauthors strongly recommend extraction of the de-veloping third molar at the time of uprighting toallow for maximal repositioning of the second mo-lar. If the decision to leave the third molar is made,the placement of the bony perforation may be moredifficult and compromise proper tissue anchorage.Furthermore, injury to the crown of the developingthird molar can also occur. After osseous healing ofthe third molar extraction site, probing depths onthe distal of the second molars are negligible. Theauthors have used this technique in more than 30cases and have had excellent results without anycomplications (Fig 7).

References1. Sawicka M, Racka-Pilszak B, Rosnowska-Mazurkiewicz A: Up-

righting partially impacted permanent second molars. AngleOrthod 77:1, 2007

2. Fieldhouse J, Shields C: Surgical uprighting of an impactedmandibular second molar. Dent Update 24:8, 1997

3. McAboy CP, Grumet JT, Siegel EB, et al: Surgical uprighting andrepositioning of severely impacted mandibular molars. J AmDent Assoc 134:11, 2003

4. Shipper G, Thomadakis G: Bone regeneration after surgical re-positioning of impacted second molars; a case report. DentTraumatol 19:2, 2003

5. Pogrel MA: The surgical uprighting of mandibular second mo-lars. Am J Orthod Dentofacial Orthop 108:2, 1995

6. Kaufman PS, Sacks HG, Schabes GA, et al: Surgical orthodonticmanagement of impacted second molars. N Y State Dent J 55:8,

FIGURE 7. Ten days postoperatively.

nderson, Murtagh, and Sacks. Surgical Uprighting of Impactedolars. J Oral Maxillofac Surg 2012.

1989