Download Maxillary first permanent molar impaction. A conservative treatment

A conservative
treatmentapproach
Maxillary
first permanentmolarimpaction.
Maxillary first permanent molar impaction. A conservative
treatmentapproach
SusanaMaria Deon Rizzatto MSc*/ Luciane Macedo de MenezesPhD, MSc**/MarcusVinicius
Pereirade Araujo*****/
ThiesenMSc'***x/Vanessa
NeivaNunesdo Rego MSc*''.':/Guilherme
t(
*:i"+
*
Freitas
MSc!t'
Maria Perp6tuaMota
The objectiveof this clinical caseis to suggesta treatmentapproachfor impaction of the maxilluy first
permanent molars. This approach allows accessto the partially erupted tooth for orthodontic bonding
and utilization of loopsfor distalization.An important detailis the non inclwion of theprimary second molar in the orthodontic mechanics,in order to reducethe risk of early loss and preserve this tooth
until exfoliation.
J Clin Pediatr Dent 30(2):].69-7742005
INTRODUCTION AND LITERATURE REVIEW
maxillaryfirst permanentmolar initially hasa
fflhe
mesial
eruptionpathwayuntil it touchesthe disI
I
tal surfaceof the primary secondmolar.then follows a more vertical direction until it reaches the
occlusalplane.An excessivelymesialinclination generates an ectopic eruption and promotes close contact
between the mesial surface of the maxillary first permanentmolar and the distal surfaceof the primary second molar. The consequencesare impaction of the
* SusanaMa a Deon Rizzatto. Professor of Orthodontics
Dental Schoolof PUCRS.the Pontifical Catholic University
of Rio Grandedo Sul
** Luciane Mac€do de Menezes.Professor of Orthodontics
Dental Schoolof PUCRS.the Pontifical Catholic University
of Rio Grande do Sul
*r(* Marcus ViDicius Neiva Nunes do Rego. Professor of
Orthodonticsat NOVAFAPI.
****Cuilherme Thiesen. MSc in OrthodoDtiesarld Dentofacial
Orthopedicsby the Pontifical Catholic Unive6ity of Rio
Graodedo Sul
*r*** VanessaPerein de AraUjo. Master student in Orthodontics
and Denlofacial Orthopedics by the Pontifical Catholic
Universityof Rio Grande do Sul
tr"'*
Maria Perp6tua Mota Freitas MSc in O hodontics and
Dentofacial Orthopedics by the Pontifical Catholic
Universityof Rio Grande do Sul
shouldbe sentto: SusanaMaria Deon Rizzatto,
AII Coftespondence
Av. Padre Chagas,1E5/ 301,Moinhos de Vento, Porto Alegre - RS,
Brazil, CEP: 90570-080
Phone:55 (51) 33,16-3184
Email:smdr@uol.com.br
The Journal of ClinicalPodiatricDentistrv
maxillary first permanent molar, with atypical rcsorp
tion of the distobuccal root of the secood primary
molar.?o:lTherefore, early diagnmis is firndamenral,
since pressurefrom the impacted maxillary first permanent molar on the distal surfaceof the primary second molar can lead to extrusion, premature occlusal
contact,resorption and even tooth loss..
Clinical characteristicspossibly related to the
ectopiceruption of the rnaxillaryfirst permanentmolar
include delayed eruption, with partial appearanceof
the crown into the oral cavity; excessivemobility or
early exfoliation of the primary secondmolar without a
clear cause,rnesial eruption of the permanent molar
with reduction in arch perimeter, and no space for
eruption of the secondpremolars.
When this disturbanceis not opportunely detected,
root resorption of the primary second molar may
extend to the pulp chamberand the teeth may present
extreme mobility and often displacement.The patient
can complain of pain or discomfort,and could develop
a dentoalveolarabscess'.In these cases,extraction of
the primary second molar is suggested,allowing the
first permanentmolar to erupt mesiallyand use orthodontic mechanicsto regain the spaceloss.
Severaletiologic factors have been suggestedin the
literature as potential causalagentsof impactionof the
maxillary first permanent molar: abnormal angle of
eruption of this tooth, anatomy of the primary second
molar (convex distal surface), increased mesiodistal
widths of the maxillary first permanent rnolar, maxillary arch length deficiency,maxillary retrusion,agenesis of the maxillary secondpremolarsand familial tenr'?lr'r'r'r6relo
dency ':'eroJl
Volume 30. Numb€r 2/2005
169
treatmentapproach
firstpermanentmolarimpaction'A conservative
Maxillary
.
,.,#
:r:i1.
':r'i
firstpermanenl
of themaxillary
Figure1A.lnitialstageof eruption
molar.
of the
impaction
andconsequent
of eruption
Figure18.Follow-up
toothafter15months.
Prevalenceof ectopic eruption of the maxillary first
permanentmolar rangesbetween2 and 5.97o,0and is
higher amongindividualswith clefts( up to 20%) This
is due to the maxillary anteroposteriorhypoplasiaand
retrusionin relation to the cranial base,a characteristic
often associated with the craniofacial growth of
patientswith operatedcleft lip and palates.ao2'
Impaction may be reversibleor irreversible,unilateral or bilateral.'It is consideredreversiblewhen therc
is spontaneouscorrection of the mesial pathway of
eruption of the maxillary first permanent molar and
normal eruption into the oral cavity. This type of
and is diagnosedretimpactionoccursin 667oof cases?r
(Figures1A
rospectivelyby radiographicexamination?o
and 1B). When impaction is not spontaneouslycorrected, it is classifiedas irreversible (nearly 30% of
cases)and may yield to problems to the developing
occlusion.
Bjerklin and Kurol in 1983recommendedfollowing
the eruption of the permanentmolar for 3 to 6 months
when resorption of the primary second molar is not
severe enough and the degree of impaction is mild,
correction.
consideringthe Possibilityof spontaneous
However, after 7 years of age, spontaneousdisimpaction rarely occurs,and mechanicalintervention is
generallyrequired.'o
Severalalternativeshave been suggestedfor treatment of impaction of the maxillary first permanent
molar,involving the utilization of fixed applianceswith
open coils, brass wires, elastic rings and removable
7316'' '?r':' However,
appliances with coil springs.dt6
regardlessof the mechanicalapproachto be employed,
a limiting aspectin many casesis the difficult accessibility to the maxillary first permanent molar, which
may presentonly the distal surfacepartially erupted.
Therefore,the use of elasticrings and brasswires is
difficult due to the limited accessfor its placement,
mainly relatedto the depth of the contactareabetween
the two teeth.When this is attained,three force vectors
are generated:distal (on the maxillary first permanent
molar), mesial and extrusive (on the primary second
molar), even though the ideal objective is distalization
of the maxillaryfirsl permanentmolar.The extrusive
force component producesa premature occlusalcontact on the mandibular primary secondmolar, which
could increaseroot resorption, acceleratingthe possibility of early loss of the maxillary second primary
molar. Thus,the use of coils associatedto fixed appli
ances,without inclusion of the primary secondmolar,
plays a fundamental role when the priodty is disimpaction of the maxillary first permanent molar combined with maintenanceof the primary secondmolar.
170
Rationalein treatment approach
1. Promote better accessto the maxillary fi(st permanent molar.
2. Ceasethe processof active resorption of the primary secondmolar.
3. Avoid early lossof the primary secondmolar.
4. Increasethe arch perimeter.
The conservativetreatment approachsuggestedinitially comprisedincreasingthe crown of the maxillary
first permanent molar from the distobuccalcusp with
incrementsof light-cured compositeresin Thereafter,
using a piece of 0.020" wire as a guide,bracketswere
passivelybonded on the canineand first primary molar
(anchorageunits) and maxillary first permanentmolar,
without including of the secondprimary molar in the
mechanics(Figures 2A, 28, 2C, ZD). In case more
anchoragewas required, a transpalatalbar could be
usedjoining the primary first molar on both sides.
The mechanicsapplied for distalizationinvolved utilization of a passivesegmentof 0.020" stainlesssteel
archwire, a nickel-titanium open coil tightened
betweenthe maxillary first permanent molar and primary first molar (Figure 2C, 2D), with monthly activations for approximately3 to 4 months and an average
force of 80 to 100e.
The Journal of Clinical PediatricOentistrv
Volume30, Number 2/2005
treatmentapproach
Maxillaryfirst penamnt molarimpaction.A conservative
firstpermaFigure2C. Mechanics
lor distalization
of ihe maxillary
nentmolarwith oDencoil.
F€we 2A Initialdental cast
Figure 28. Clinicalcrown increaseof the maxillaryfirst permanent
molar and bonding of brackets.
Therefore,disimpactionof the maxillary first permanent molar could be effectively obtained without consequent application of forces, especiallyextrusive
forceson the primary secondmolar, which are common
when separatingelasticsand brasswires are used.Clinical and radiographicfollow-up demonstratedan interruption in the processof resorptionof the distal surface
of the primary secondmolar following the distalization
of the maxillary first permanent molar. Such finding
reinforcesthe importanceof a conservativetreatment
targeted to space maintenance through a biological
approach.After correcting the ectopic eruption, the
resin was removed and the bracket was bonded again
on the buccal aspectof the maxillary first permanent
Ths Journal of ClinlcalPodiatricDentistrv
Figur€ 2D. Occlusal aspect of the mechanics.
molar for leveling. Thereafter, the patient was
instructedto keep a strict hygieneof the area and will
be followed until the other permanent teeth erupt.
(Figures3A.,38, 3C, 3D)
CONCLUSION
When managinga clinical casewith impaction of the
maxillary first permanent molar, the dentist should
emphasizepreservation, establishing a protocol for
early diagnosisand treatment plan which targets the
recoveryof arch perimeter by distalizationof this tooth
and maintenanceof biological integrity of the primary
secondmolar.Thesebasessupportedthe propositionof
the presentconservativetreatment approach.
Volume 30. Number 2/2005
171
treatmentapproach
firstpermanentmolarimpaction.A conservative
Maxillary
Figure 3A. lmpaction ol the maxillaryfirst permanent molar and
ectooic resorotionof the primary second molar.
Figure 3C. Follow-up at 2 months after disimpaction.
Figuro 38. Mechanicslor distalization.
Figure 3D, Follow-up at 3 months after disimpaction.
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A conservative
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Volume30, Number2/2005
173