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com

An Uprighting Auxiliary for Deeply


Impacted Mandibular Molars
ALDO GIANCOTTI, DDS, MS
FRANCESCO GERMANO, DDS
MARIO GRECO, DDS

E ctopic impaction of mandibular second molars


is a rare and challenging dental anomaly, often
requiring a multidisciplinary treatment approach.1-5
•  Difficulties in bonding to an impacted tooth.
To overcome these difficulties, we have
developed an auxiliary system consisting of a sec-
Solutions involving surgical repositioning alone tion of mesh,* a 150g nickel titanium closed-coil
have caused side effects that may affect long-term spring,** and a titanium miniscrew. We call the
tooth vitality.6-11 Therefore, the accepted approach system the G-Molar-Up.
has been to combine orthodontic and surgical
procedures, with careful anchorage planning to Appliance Design
avoid undesirable vertical tooth movements.12-16
To fabricate the G-Molar-Up auxiliary, cut a
Skeletal anchorage has proven to be a re­­liable
piece of mesh to an appropriate size and ligate it
method of maintaining the archform while allow-
to the nickel titanium coil spring (Fig. 1). Insert a
ing segmental orthodontic treatment in these
titanium miniscrew in the retromolar area. After
cases.17-25
surgical exposure of the impacted molar, bond the
Another alternative is to extract the impacted
mesh section to the tooth’s occlusodistal surface
second molar and move the third molar orthodon-
and immediately attach the spring to the mini­
tically. Although such a method can simplify the
screw head.
orthodontic mechanics, it requires a more invasive
The G-Molar-Up device has some notable
surgical procedure. The success of the treatment plan
advantages:
will depend on proper timing and biomechanics.
•  The mesh section provides a larger attachment
Three major factors complicate treatment of
area that is easily contoured to the molar surface.
a deeply impacted molar:
•  Miniscrew insertion distal to the center of re­­
•  The biomechanically unfavorable position of the
tooth’s center of rotation. *Leone S.p.A., Florence, Italy; www.leone.it.
•  The tooth’s horizontal inclination. **Dentsply GAC International, Bohemia, NY; www.gacintl.com.

Dr. Giancotti Dr. Germano Dr. Greco

Dr. Giancotti is an Assistant Professor and Dr. Greco is a postgraduate student, Department of Orthodontics, and Dr. Germano is a Clinical
Consultant, Department of Oral Surgery, Fatebenefratelli Hospital, University of Rome “Tor Vergata”, Rome, Italy. Contact Dr. Giancotti at Viale
Gorizia 24/c, 00198 Rome, Italy; e-mail: giancott@uniroma2.it.

VOLUME XLVII  NUMBER 4 ©  2013 JCO, Inc. 255


An Uprighting Auxiliary for Deeply Impacted Mandibular Molars

sistance generates an appropriate biomechanical to compensate for the lack of mandibular develop-
system. ment. Because the maxillary third molars were too
•  Nickel titanium springs exert a continuous force close to the maxillary sinus for safe extraction, the
without requiring reactivation. inclined and overerupted maxillary second molars
were extracted.
The G-Molar-Up technique was attempted
Case Report
first on the left side of the lower arch. In a single
A 15-year-old male presented with a Class II surgical appointment, a miniscrew (Excalibur
malocclusion and a severe deep bite (Fig. 2). The SIA,*** 10mm long, 1.8mm in diameter) was in­­
panoramic radiograph showed deep impaction of serted in the retromolar area; the mandibular left
the mandibular second molars and severe impac- third mo­­lar was extracted; and the G-Molar-Up
tion of the maxillary third molars. The treatment device was connected to the miniscrew head and
plan involved resolution of the mandibular and bonded to the exposed surface of the second molar
maxillary molar impactions, followed by surgery (Fig. 3).
Two months later, the lower right third molar
was extracted. Over the following two months, the
second molar showed slight spontaneous upright-
ing, somewhat reducing the severity of impaction
(Fig. 4A). At this point, a G-Molar-Up device was
bonded to the right second molar, with traction
from a miniscrew in the retromolar region (Fig. 4B).
No reactivations of the coil springs were re­­
***SIA Orthodontic Manufacturer, Caserta, Italy; www.
Fig. 1  A. G-Molar-Up auxiliary. siaorthodontics.com.

Fig. 2  15-year-old male patient with Class II skeletal and dental maloc-
clusion before treatment. Upper second molars are extruded and third
molars impacted; lower second and third molars are horizontally ori-
ented, with second molars deeply impacted.

256 JCO/APRIL 2013


Giancotti, Germano, and Greco

A B C
Fig. 3  A. Miniscrew placed in lower left retromolar region.  B. Lower left third molar extracted.  C. G-Molar-Up
auxiliary attached between miniscrew and deeply impacted lower left second molar.

A B
Fig. 4  A. Spontaneous uprighting of lower right second molar after extraction of third molar.  B. G-Molar-Up
auxiliary bonded to lower right second molar and activated.

quired, although the mesh attachment was rebond- erupted into the second-molar positions, and the
ed more proximally when the mesial surface of patient was scheduled for a recall appointment to
each second molar was accessible (Fig. 5). After plan future surgical treatment.
about 10 months of traction, the crown of the lower
left second molar was accessible enough to bond
Conclusion
a fixed sectional appliance for refinement of the
molar position and torque (Fig. 6A). Three months Orthodontic treatment involving eruption
later, the same procedure was followed with the and uprighting of deeply impacted mandibular
lower right second molar (Fig. 6B). second molars requires careful timing of third-
After 18 months of active treatment, both molar extractions and space-opening forces. More­
mandibular second molars had been completely over, the planned biomechanics must provide an
uprighted and moved into their proper positions, efficient force system while minimizing undesir-
with most of the tooth movement effected by the able side effects. The G-Molar-Up system, as
G-Molar-Up auxiliaries (Fig. 7). In the meantime, shown here, is a predictable treatment option in
the maxillary third molars had spontaneously such cases.

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An Uprighting Auxiliary for Deeply Impacted Mandibular Molars

B
Fig. 5  A. Progress of lower left second-molar eruption over three months, including relocation of bonded
mesh pad to mesiobuccal cusp. B. Progress of lower right second-molar eruption over three months,
including relocation of bonded mesh pad to mesial surface.

A B B
Fig. 6  Brackets and sectional nickel titanium wires placed for right (A) and left (B) second-molar positioning
and torquing.

258 JCO/APRIL 2013


Giancotti, Germano, and Greco

Fig. 7 After 18 months of uprighting upper and lower molars.

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