CASE REPORT

Replacement of a first molar and 3 second

molars by the mesial inclination of 4 impacted
third molars in an adult with a Class II Division
1 malocclusion
Hiroshi Tomonari,a Takakazu Yagi,a Takaharu Kuninori,a Takahiro Ikemori,b and Shouichi Miyawakic
Kagoshima, Japan

This case report presents the successful replacement of 1 first molar and 3 second molars by the mesial incli-
nation of 4 impacted third molars. A woman, 23 years 6 months old, had a chief complaint of crowding of her
anterior teeth and linguoclination of a second molar on the left side. The panoramic radiographic images showed
that the maxillary and mandibular third molars on both sides were impacted. Root resorption on the distal sur-
faces of the maxillary second molars was suspected. The patient was given a diagnosis of Angle Class II Division
1 malocclusion with severe crowding of the anterior teeth and 4 impacted third molars. After we extracted the
treated maxillary second premolars and the second molars on both sides, the treated mandibular second pre-
molar and the second molar on the left side, and the root canal-filled mandibular first molar on the right side,
the 4 impacted third molars were uprighted and formed part of the posterior functional occlusion. The total active
treatment period was 39 months. The maxillary and mandibular third molars on both sides successfully replaced
the first and second molars. The replacement of a damaged molar by an impacted third molar is a useful treat-
ment option for using sound teeth. (Am J Orthod Dentofacial Orthop 2015;147:755-65)

R
etained asymptomatic third molars pose a risk for treatment with extraction of the permanent first molars
second molar incident pathology in middle-aged similarly increases the eruption spaces of the third
and older adults.1,2 Prophylactic extraction of molars and decreases their impaction.6 The alignment
unerupted asymptomatic third molars is frequently of the permanent third molars after the extraction of
performed to prevent the risk of adjacent second molar the permanent first or second molars is a useful option
pathology (eg, caries, periodontitis, resorption of for adult patients when the permanent first or second
adjacent tooth roots).3 However, it has been reported molars are severely damaged.7
that a maxillary or a mandibular permanent third molar An important concern of permanent molar extraction
was uprighted and acceptably replaced the second molar is the prognosis of the presence and eruption of the third
after extraction in orthodontic treatment.4,5 Orthodontic molar.5 Excessive tilting of the third molars,6 advanced
development of their roots,4,5 and older patient age4,5
are important for the successful eruption of the third
From the Department of Orthodontics, Field of Developmental Medicine, Health molars. Some authors have recommended not
Research Course, Graduate School of Medical and Dental Sciences, Kagoshima
University, Kagoshima, Japan. extracting the second molar if the third molar has a
a
Assistant professor. buccolingual orientation8 or if the angle with the first
molar is greater than 30 .9 Unsuccessfully erupted third
b
Postgraduate student.
c
Professor and department chair.
All authors have completed and submitted the ICMJE Form for Disclosure of Po- molars reportedly occur in older patients with higher
tential Conflicts of Interest, and none were reported. Nolla developmental stages.4 Several reports have shown
Address correspondence to: Shouichi Miyawaki, Department of Orthodontics, that maxillary and mandibular third molars replace sec-
Kagoshima University, Graduate School of Dental Sciences, 8-35-1 Sakuragaoka,
Kagoshima City, Kagoshima 890-8544, Japan; e-mail, miyawaki@dent. ond molars quite successfully, although these were in
kagoshima-u.ac.jp. growing patients (ages, 13.2-16.6 years).5,6,10-12
Submitted, March 2014; revised and accepted, May 2014. Because the permanent molars erupt at an early age
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists. and are prone to dental decay, conservative treatment
http://dx.doi.org/10.1016/j.ajodo.2014.05.030 has frequently been performed before orthodontic
755
756 Tomonari et al

Table. Cephalometric measurements

Pretreatment Posttreatment Postretention Japanese norm for
Measurement (23 y 6 mo) (27 y 1 mo) (28 y 6 mo) women (Mean 6 SD)
SNA ( ) 80.5 80.5 80.5 80.8 6 3.6
SNB ( ) 75.0 74.5 74.5 77.9 6 4.5
ANB ( ) 5.5 6.0 6.0 2.8 6 2.4
Facial angle ( ) 82.5 82.0 82.0 84.2 6 4.4
Angle of convexity ( ) 13.0 13.5 13.5 7.6 6 5.0
Y-axis ( ) 68.0 68.5 68.5 66.1 6 3.6
Mandibular plane angle ( ) 34.5 35.0 35.0 30.5 6 3.6
Occlusal plane to SN ( ) 16.5 16.5 19.0 16.9 6 4.4
U1 to SN ( ) 111.0 93.0 94.0 105.9 6 8.8
U1 to FH ( ) 119.5 101.0 102.0 112.3 6 8.3
L1 to MP ( ) 102.0 91.5 93.0 93.4 6 6.8
FMIA ( ) 43.5 53.5 52.0 56.0 6 8.1
Interincisal angle ( ) 104.0 132.5 130.0 123.6 6 10.6
U1 to A-Pog (mm) 14.5 7.5 8.0 6.2 6 1.5
L1 to A-Pog (mm) 10.0 4.5 5.0 3.0 6 1.5
E-line: upper lip (mm) 3.5 1.0 1.0 3.0 6 1.0
E-line: lower lip (mm) 9.5 4.0 5.0 1.1 6 1.5
Overjet (mm) 4.5 3.0 3.0 3.1 6 1.1
Overbite (mm) 1.0 2.0 2.5 3.3 6 1.9

treatment begins in adult patients.7 Therefore, in adults, Panoramic radiographic findings showed that the
it is necessary to carefully consider the prognosis of ex- maxillary third molars on both sides were impacted,
tracting a damaged permanent premolar or molar in and root resorption on the distal surface of maxillary
addition to extraction for orthodontic reasons. second molars was suspected (Fig 3). There was excessive
In this case report, we present the successful replace- mesial tipping of the impacted mandibular third molar
ment of 1 first molar and 3 damaged second molars by 4 on both sides. The mandibular first molar on the right
mesially tilted impacted third molars, and the extraction side and the mandibular first and second premolars
of a restored second premolar using miniscrew were root canal-filled and largely restored.
anchorage in an adult with severe crowding of the ante- In comparison with Japanese norms, the cephalo-
rior teeth and 4 impacted third molars. metric analysis showed a skeletal Class I jaw base
relationship (ANB angle, 5.5 ) with a high mandibular
DIAGNOSIS AND ETIOLOGY plane angle (MP-FH, 34.5 ) (Fig 3, Table). The maxillary
A woman, who was 23 years 6 months old, came to and mandibular incisors were labially inclined (U1-FH
the orthodontic department of Kagoshima University angle, 119.5 ; L1-MP, 102.0 ).
Hospital in Kagoshima, Japan. Her chief complaints An optoelectric jaw-tracking system (Gnatho-
were crowding of the maxillary and mandibular anterior Hexagraph II; GC International, Tokyo, Japan) was
teeth and linguoclination of the second molar on the left used to record jaw movement with 6 degrees of
side. She also felt that it was difficult to masticate on the freedom. During the maximum open-close exercise,
left side because of a scissors-bite malocclusion of the no asymmetric or limited movements of the bilateral
second molars. She had a convex profile, and the maxilla condyles and no obvious lateral shift of the mandib-
and the lower lip were slightly protruded (E-line: upper ular incisor were observed. In the unilateral mastica-
lip, 3.5 mm; lower lip, 9.5 mm) (Table). She also had cir- tory test with chewing gum, the maximum closing
cumoral musculature strain on lip closure. No facial velocity on the right side (the nonscissors-bite side)
asymmetry was evident in the frontal view (Fig 1). was faster than the velocity on the left side (the
On intraoral examination, the canine and molar rela- scissors-bite side), and there was a more stable chew-
tionships were Class I on both sides, but she had a ing pattern on the right side than on the left side. She
scissors-bite of the second molar on the left side. Overjet realized her tendency to chew primarily on the
was 4.5 mm, and overbite was 1.0 mm. The dental nonscissors-bite side during natural mastication in
midline was coincident with the facial midline. On dental daily life. No temporomandibular disorder signs or
cast analysis, the arch length discrepancies were 12.5 symptoms were observed by the questionnaire and
mm in the maxilla and 8.2 mm in the mandible (Fig 2). in the clinical examination.

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Tomonari et al 757

Fig 1. Pretreatment facial and intraoral photographs.

TREATMENT OBJECTIVES We planned to extract the restored maxillary second

The patient was given the diagnosis of an Angle Class premolars on both sides to keep the first premolars in
II Division 1 malocclusion with bimaxillary protrusion, good condition and to use miniscrews to reinforce the
severe crowding of the anterior teeth, scissors-bite of anchorage of the maxillary molars (Fig 4). We also chose
the second molar on the left side, root damage of the to extract the maxillary second molars on both sides
maxillary second molars caused by the impacted third because the panoramic photograph indicated root dam-
molars, and excessive tilting of the impacted mandibular age. Extractions of the root canal-filled and restored
third molars on both sides. The treatment objectives mandibular first molar on the right side, the mandibular
were to improve lip protrusion and crowding of the second premolar, and the mandibular second molar on
anterior teeth, erupt and align the impacted third the left side were performed to erupt and align the
molars, and achieve a good facial profile and functional impacted mandibular third molars with excessive mesial
occlusion. tilting on both sides.

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Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment radiographs.

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Fig 4. Panoramic tracing at pretreatment.

Fig 5. Root resorption of the extracted maxillary second molars at the distal surfaces: A, maxillary sec-
ond molar on the right side; B, maxillary second molar on the left side.

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TREATMENT ALTERNATIVES
Extraction of the first premolars effectively relieves
an anterior discrepancy and corrects a labioclination of
the anterior teeth, which improves lip protrusion. Howev-
er, in preference to the first premolars, the molars and the
second premolars may be chosen for orthodontic extrac-
tion for various reasons such as large restorations, root
canal-filled teeth, and root resorptions. Because there
was no damage to the maxillary first premolars on the
left side and the mandibular first and second premolars
on the right side and the maxillary first premolars had bet-
ter form than the second premolars, we decided to extract
the restored second premolars on both sides and the
restored and root canal-filled mandibular first molar.
However, this pattern of maxillary extraction is a clear
disadvantage for correcting labioclination of maxillary
anterior teeth. Thus, we used miniscrews for skeletal
anchorage to retract the 6 maxillary anterior teeth.
Another alternative is the extraction of 4 impacted
third molars. However, the maxillary second molars on
both sides were suspected of having root resorption at
the distal surfaces by the third molars, and they had
been largely restored. The correction of a scissors-bite
often results in downward and backward rotation of the
mandible because of maxillary and molar extrusion, which
tends to worsen the skeletal Class II relationship in patients
with a high mandibular plane angle. In addition, the
extraction of the mandibular first molar gains space by
advancing the second molar on the right side. We were
certain that the 4 third molars would appear and have
normal sizes and forms. We planned for 4 upright third
molars and replaced the second molar with the third molar
Fig 6. Panoramic radiograph during the upright posi-
after the extraction of the maxillary second molars on both tioning of the 4 third molars: A, pretreatment; B, 9 months
sides, the mandibular second molar on the left side, and after active treatment; C, 23 months after active treat-
the mandibular first molar on the right side. ment.

TREATMENT PROGRESS teeth and the mandibular posterior teeth, stainless steel
The maxillary second premolars and the second wires were also installed to initiate distal movement
molars on both sides, the mandibular second premolar of the premolars with elastic chains. Five months
and second molar on the left, and the mandibular first after distal movement of the 5 premolars, edgewise ap-
molar on the right side were extracted. Both sides pliances were placed on the maxillary and mandibular
showed serious root resorption of the distal surfaces of anterior teeth and on the partially erupted mandibular
the maxillary second molars (Fig 5). After 0.018-in third molar on the right side. Miniscrews (Dual-Top;
preadjusted edgewise appliances were placed on the Jeil Medical, Seoul, Korea) with a length of 8.0 mm
maxillary and mandibular posterior teeth, initial align- and a diameter of 1.6 mm were implanted between the
ment was achieved with 0.018-in nickel-titanium roots of the maxillary first premolar and the first molar
sectional archwires. Three months after the extraction to reinforce the posterior anchorage during distal move-
of the maxillary second molars on both sides and the ment of the anterior tooth retractions. After leveling and
mandibular second molar on the left side, the edgewise aligning the anterior teeth with nickel-titanium arch-
appliance was placed on the 3 erupted third molars to wires, 0.016 3 0.022-in stainless steel archwires were
position them upright in place of the second molars. placed, and retraction of the 6 anterior teeth was started
Five months after leveling and aligning the maxillary with elastic chains and miniscrews for skeletal

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Tomonari et al 761

Fig 7. Posttreatment facial and intraoral photographs.

anchorage. The stainless steel wires were then positioned maxillary and mandibular third molars, and ideal inter-
to coordinate the 2 arch forms (Fig 6). The total active cuspation of the teeth were achieved with improve-
treatment period was 39 months. After the edgewise ap- ments in anterior crowding and in the tilting of the
pliances were removed, maxillary and mandibular impacted maxillary and mandibular third molars
lingual bonded retainers were placed. (Figs 7-9). Retraction of the upper and lower lips
significantly improved the patient's facial profile. A
panoramic radiograph demonstrated acceptable root
TREATMENT RESULTS paralleling. Cephalometric superimposition showed
Normal overjet (3.0 mm) and overbite (2.0 mm), lingual inclination of the maxillary and mandibular
Class I canine relationships on both sides, a Class I incisors (U1-SN: 93.0 ; L1 to mandibular plane:
molar relationship on the left side, a Class II molar rela- 91.5 ) and an increased interincisal angle (132.5 )
tionship on the right side, good positioning of the (Table). The maxillary and mandibular impacted third

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Fig 8. Posttreatment dental casts.

Fig 9. Posttreatment radiographs.

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Tomonari et al 763

Fig 10. Superimposition of the cephalometric tracings at pretreatment, posttreatment, and postreten-
tion: A, the sella-nasion plane at sella; B, palatal plane at ANS; C, mandibular plane at menton.

molars erupted and were uprighted, and the mandib- on the left side. This is extremely difficult to correct with
ular plane angle was slightly increased (Fig 10). In orthodontic treatment.13 Furthermore, from the pano-
the comparisons of masticatory jaw movements during ramic radiographs, we confirmed the presence of the
the maximum open-close exercise and the unilateral maxillary and mandibular third molars with good anat-
gum chewing before and after the treatment period, omy on both sides. When the maxillary second molars
there were no obvious changes in mastication. are extracted, there is a 96.2% to 99% probability that
However, there was no asymmetrical chewing pattern the maxillary third molars will erupt in a good or accept-
in the maximum closing velocity. The occlusion and able position.5,12 This patient's maxillary third molars
facial profile were stable for 1 year 5 months after partially erupted only 3 months after extraction of the
active treatment (Fig 11), and no signs or symptoms second molar, and they were aligned by edgewise
of temporomandibular disorder have been noted. appliances.
With respect to the impacted mandibular third
molars, reportedly 66.2% to 83.0% of mandibular third
DISCUSSION molars erupt in a good position, and 0% to 5.4% of
The decision to pursue orthodontic extraction mandibular third molars do not erupt after a first or sec-
should be based on a proper diagnosis, the patient's ond molar extraction.4-6 Some authors have suggested
facial profile, the functional occlusion, the dental con- that an angle of more than 25 of the mandibular
dition, and the treatment time. In adults, the permanent third molar before extraction of the second molar is
molars or premolars have frequently been restored by associated with poorer results,14 and an angle of more
the time orthodontic treatment begins. In the choice than 30 is a contraindication to extraction.9 Some
of permanent tooth extraction in these dental condi- research indicates that unsuccessfully erupted third mo-
tions, it is necessary to carefully consider damaged teeth lars occur in older patients with a high Nolla develop-
that may require extractions, orthodontic solutions to mental stage.4 In this patient, who was 23 years 6
esthetic problems, arch length discrepancies, and molar months old, excessive mesial tilting of the mandibular
and canine relationships. In our patient, the mandibular third molars on both sides and the mostly closed root
first molar on the right side was restored by a large inlay, apices were assessed by pretreatment panoramic radio-
treated by a root canal filling, and suspected to have graphs. However, the mandibular third molars were
resorption of the distal surface, based on the panoramic partially erupted and able to be placed with the edgewise
radiograph. There was a buccal crossbite resulting from appliance within 12 months after the extraction of the
the lingual inclination of the mandibular second molar second molar and the first molar. The mandibular third

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764 Tomonari et al

Fig 11. Postretention facial and intraoral photographs.

molars on both sides acceptably replaced the first and been associated with the subsequent eruption of these
second molars. Premolar or molar extraction therapy re- teeth after molar extraction. The third molars have the
duces the frequency of third molar impaction by highest rate of impaction of all teeth.16 When the perma-
increasing the eruption space and allowing mesial move- nent first or second molars are severely damaged by the
ment of the molars during space closure.12 Further for- time orthodontic treatment begins, replacement of the
ward movement of the third molars in the arch is mandibular second molars by the third molars from
reportedly accelerated after the extraction of teeth— the posterior functional occlusion should also be consid-
especially the molars.15 Furthermore, the third molar ered in the treatment plan.
on the left side was partially erupted, and the crown of Miniscrews have recently been used as a method of
the impacted third molar on the right side was assessed skeletal anchorage because they can be inserted easily
as having little impaction in alveolar bone. The vertical into various positions with less invasive, simpler place-
position of the impacted third molars could also have ment surgery and sufficient stability.17-19 In this patient,

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Tomonari et al 765

because the extraction of the first premolars was effective 4. De-la-Rosa-Gay C, Valmaseda-Castellon E, Gay-Escoda C. Sponta-
for relieving the anterior discrepancy and correcting the neous third-molar eruption after second-molar extraction in or-
thodontic patients. Am J Orthod Dentofacial Orthop 2006;129:
labioclination of the anterior teeth, we planned to extract
337-44.
the restored maxillary second premolars on both sides 5. De-la-Rosa-Gay C, Valmaseda-Castell
on E, Gay-Escoda C. Predic-
instead of the first premolars, and we enhanced the tive model of third molar eruption after second molar extraction.
maxillary posterior anchorage with miniscrews. As a Am J Orthod Dentofacial Orthop 2010;137:346-53.
result, the stationary anchorage of the maxilla with 6. Bayram M, Ozer M, Arici S. Effects of first molar extraction on third
molar angulation and eruption space. Oral Surg Oral Med Oral
miniscrews achieved minimum mesial movement of the
Pathol Oral Radiol Endod 2009;107:e14-20.
maxillary molars, improved the facial profile, and resolved 7. Ay S, Agar U, Biçakçi AA, K€ oşger HH. Changes in mandibular
the anterior discrepancy with the remaining the first third molar angle and position after unilateral mandibular first
premolars on both sides, which had better forms than did molar extraction. Am J Orthod Dentofacial Orthop 2006;129:
the second premolars and lacked damage on the left side. 36-41.
8. Battagel JM, Ryan A. Spontaneous lower arch changes with and
A scissors-bite is a malocclusion characterized by
without second molar extractions. Am J Orthod Dentofacial Or-
buccal inclination or buccoversion of a maxillary poste- thop 1998;113:133-43.
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fluences the choice of chewing side in patients with a uni- 11. Livas C, Halazonetis DJ, Booij JW, Katsaros C. Extraction of maxil-
lateral posterior scissors-bite.20 Our patient had been lary first molars improves second and third molar inclinations in
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ing side. Although no obvious changes of the masticatory 2011;140:377-82.
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path were found, an asymmetrical chewing pattern in the
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treatment, resulted in symmetry during unilateral masti- facial Orthop 2001;119:226-38.
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