Pacific Coast Society of Orthodontists Bulletin Winter 2019 - 24

Let's Talk About That

I'll go to work on developing a treatment plan. I
initially sent the records to Dr. Earl Johnson, who
has published his technique of distalizing molars
using a super elastic NiTi coil spring threaded
onto an 0.018-in stainless-steel wire with helices.4
His initial response was, "I've had very good luck
with the normal distal tipping technique. Initially,
partial surgical uprighting may help." The next
day, after further evaluation, he responded, "All
the cases I uprighted were in young patients with
fairly short roots. Your case is older with long
roots. If you upright the molar, its occlusal surface
will be quite extruded. Have you considered having the second molars extracted and transplanting the third molars in the second molars sites?"
I next consulted with Dr. William Northway, an
innovative clinician who has published on many
diverse topics in orthodontics. Dr. Northway
responded, "I have never tested impaction to this
degree. I think the most certain prognosis would
involve extracting the lower second molars and
allowing the third molars to develop and migrate.
Once it becomes necessary to provide traction, I
would place temporary anchorage devices (TADs)
or bone plates." He sent along the records of a
case beautifully treated in this manner.
I then sent the records to our PCSO Bulletin Editor-in-Chief Dr. Jae Hyun Park, who referred me
to an article by Kravitz et al., "Surgical Uprighting
of Lower Second Molars."5 I decided to contact Dr.
Neal Kravitz personally, with the caveat that I was
concerned that surgical uprighting could lead to
complications such as loss of pulp vitality or ankylosis. He responded, "I have used three surgeons
over the last twelve years and treated 50-100
surgically impacted second molars. I have never
had any ankylose. Please send me the panorex."
Following his review of the panorex, he responded, "This is certainly not ideal. The roots are fully
formed. My suggestion would be to extract the
second molars and allow the third molars to drift."
Dr. Adrian Becker from Jerusalem, Israel, is
internationally renowned for his research and
publications. Surely, I thought, he'll provide me

24

with a definitive treatment plan. After reviewing
the records, Dr. Becker recommended extracting
all four third molars and surgically exposing all
four second molars. He then recommended bonding an eyelet to the mandibular second molar and
attaching a twisted soft steel ligature bent in the
shape of a hook. Zygomatic plates are then surgically placed, using three fixation screws, with
the vertical arm passing through the soft tissue
into the vestibule with the end bent up to form
a traction hook. The patient would then need to
attach elastics from the exposed portion of the
zygomatic plate to the twisted ligature hook on
the mandibular second molars.
Boy, was I confused! By the time this family
presented to my office, the parents had obtained
information from two orthodontists and an oral
surgeon. They had been given enough information that they now had formulated some good
questions. In researching the different options I
had received, I came up with some questions of
my own. These questions and the answers I found
will form the basis of this issue's column.
Let's first examine the first alternative proposed:
extracting the lower third molars, exposing and
bracketing the second molars, and orthodontically
uprighting.
How Predictable Is This Approach?
The literature is replete with case reports on the
uprighting and aligning of impacted second molars
with numerous biomechanical approaches using
the adjacent teeth or miniscrews as anchorage.
Studies that have examined the success of this approach report that it is probably the most predictable of the different treatment options. Magnusson
and Kjellberg reported a 70% success rate.6
How Necessary Is the Surgical Exposure of the
Impacted Molars?
Earl Johnson commented that many orthodontists are incredibly buccal attachment oriented.
Bonding to the buccal requires much more tissue
removal. Minimal exposure and occlusal bonding
is much easier on everybody.4

PCSO Bulletin

Winter 2019



Pacific Coast Society of Orthodontists Bulletin Winter 2019

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Winter 2019

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