Impacted lower second molars

Note:by convention, when we view patients' images, right and left are reversed so that it appears that you are standing in front of the person looking at them. Any mention of "right" or "left" on this site refers to the patient's right or left.

This patient started treatment under the care of another orthodontist. The patient's original panoramic xray does not reveal anything particularly unusual in the areas of the lower second and third molars (wisdom teeth). It appears that the lower second molars could possibly become stuck on the backs of the teeth in front of them, but I have seen cases that appeared similar to this one where the second molars have been able to erupt. My major concern on this xray would have been the eruptive path of the upper third molars: both appear to be erupting straight down towards the backs of the teeth in front of them. This xray was taken on 10/18/91 when he was 12 years old.

About 2 years later, a progress xray was taken prior to the removal of the braces. The lower third molars had tipped forward about 55 degrees each. This is extremely unusual and totally unpredictable based upon their original positions. The third molars were impacting the second molars. The patient was referred to an Oral Surgeon for an evaluation, and the determination was made to remove the lower third molars and follow the eruption of the lower second molars (it was hoped that the lower second molars would erupt on their own). With respect to the upper third molars, the hope was that these teeth would erupt more to make access to them for their removal easier. This xray was taken on 9/2/94.

I took over his case on 7/1/95. A progress xray was taken on 8/1/96. There was very little eruption of the lower second molars that had taken place over the course of 2 years. At this point the options were:

Do nothing. Since bone does not attach to the crown portion of teeth, and since there did not appear to be any bone above the crowns of his lower second molars, I was concerned that these areas would be prone to infection.

Extract the lower second molars. This would leave the patient with only one lower molar to chew with. This is not the best scenario for the remaining first molar since this tooth now has to contend with biting forces that are normally distributed over more teeth. These forces that are now relatively excessive could damage the first molar (increased wear, increased risk of gum problems, etc.). The oral surgeon was also concerned about the fact that the roots of the lower second molar on the left were so close to the lower border of the patient's jaw that this may lead to a jaw fracture either during the attempt to remove the tooth, or during the healing stage. The oral surgeon was also concerned about the proximities of the roots of the lower second molars to the nerve that provides sensation to the front teeth and lip; extracting these teeth ran the risk of damage to this nerve (this would lead to either a partial numb feeling (paresthesia) that may or may not go away, or total loss of feeling in these areas (permanent anesthesia)).

Attempt to bring the lower second molars in. The oral surgeon felt (and I agreed) that the best option was to try to bring these teeth in. Even if I was only partially successful and I was able to move these teeth away from the nerve and lower border of his jaw, this would make the extraction of these teeth less likely to result in harm to the patient. After presenting the above options to the patient and his mother (the patient was 17 years old at this point), we decided to proceed with this option.

Braces were put back on his lower teeth to provide anchorage to attempt to bring in the second molars. This progress xray was taken on 4/6/98.

Treatment progressed very slowly, and rather than the second molars moving, they were moving all of his other teeth (you can see that his first molars were tipping backwards and moving down towards the second molars. You can't see it in this picture, but the first molars were also tipping outwards towards the positions of the second molars). This xray was taken on 3/22/99.

The patient needed to have the braces off because of a military committment, and I was forced to discontinue his treatment before the best possible result could be obtained. At this point his back teeth did not touch and he has had a significant amount of root resorption (the roots of his lower teeth became shorter from the strain of trying to bring in the second molars). Some of his lower teeth are tipped. He also needs to have the upper third molars evaluated for removal, since it is apparent that there is no chance that these teeth will ever be able to erupt. This xray was taken on 5/23/00.

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