Managing Mandibular Second Molar

Impaction: A Systematic Review and

Meta-Analysis
Selene Barone, DDS,* Alessandro Antonelli, DDS,* Tecla Bocchino, DDS, PhD,y
Lucia Cevidanes, DDS, PhD,z Ambra Michelotti, DDS,x and Amerigo Giudice, MD, PhDk
Purpose: Mandibular second molar (M2M) impaction is a serious eruption disorder. The purpose of this
systematic review was to analyze the therapeutic approaches for M2M impaction. The objective of the
meta-analysis was to summarize the success of the surgical, surgical-orthodontic, and orthodontic treat-
ment.
Methods: A PRISMA-guided search strategy was conducted by 2 authors in 5 databases up to January
2023. Randomized and nonrandomized clinical trials were considered. Case reports, case series with<5
patients, and reviews were excluded. Methodological quality was assessed using Newcastle–Ottawa scale
and Cochrane Collaboration tool for nonrandomized and randomized clinical trials, respectively. Out-
comes were as follows: 1) treatment success rate defined by the repositioning of impacted M2M in the
dental arch with normal functional occlusal relationship and periodontal health; 2) time-to-
repositioning as time-to-event analysis; and 3) complications. Meta-analysis examined treatment success
differences with 3 approaches: orthodontic (uprighting maneuvers/traction), surgical (surgical proced-
ures/strategic extractions), and surgical-orthodontic (combined surgical and orthodontic procedures) as
the exposure variable. The quantitative analysis also compared the success rate using third molar removal
as the secondary predictor variable. The c2 test determined the statistical heterogeneity (I2); a cut-off of
70% was used to select the common or random effects model. Odds ratio (OR) and 95% confidence interval
(CI) were recorded.
Results: A total of 1,102 articles were retrieved. After full-text reading, 16 articles were included and
1008 M2Ms were analyzed. Nine studies had fair quality, 6 studies had good quality, and 1 had unclear
risk of bias. Managing impacted M2Ms showed a moderate to high success rate (66.7 to 100%). Significant
differences favoring surgical treatment over orthodontic treatment were observed for M2M uprighting
(OR = 4.97; CI: 1.49 to 16.51; P = .01).No differences were detected comparing surgical and surgical-
orthodontic treatment (OR = 1.00; CI: 0.03 to 37.44; P = .99), or orthodontic and surgical-orthodontic
treatment(OR = 4.14; CI: 0.43 to 40.14; P = .22).Third molar removal showed no significant correlation
with M2M uprighting (OR = 1.98; CI: 0.24 to 16.03; P = .5).

*Candidate, Resident, Department of Health Sciences, School of S.B. and A.A. contributed equally to this manuscript.
Dentistry, Magna Graecia University of Catanzaro, Viale Europa, Conflict of Interest Statement: None of the authors have any rele-
Catanzaro, Italy. vant financial relationships with a commercial interest.
yAdjunct Professor, Section of Orthodontics and Address correspondence and reprint requests to Prof Giudice:
Temporomandibular Disorders, Department of Neurosciences, Magna Graecia University of Catanzaro, Viale Europa 88100, Cata-
Reproductive Sciences and Oral Sciences, University of Naples nzaro, Italy; e-mail: [email protected]
Federico II, Naples, Italy. Received March 9 2023
zProfessor, Department of Orthodontics and Pediatric Dentistry, Accepted August 20 2023
School of Dentistry, University of Michigan, Ann Arbor, MI. Ó 2023 Published by Elsevier Inc. on behalf of the American Association of Oral
xProfessor, Section of Orthodontics and Temporomandibular and Maxillofacial Surgeons
Disorders, Department of Neurosciences, Reproductive Sciences 0278-2391/23/01033-9
and Oral Sciences, University of Naples Federico II, Naples, Italy. https://doi.org/10.1016/j.joms.2023.08.168
kOral and Maxillofacial Surgeon, Professor, Department of Health
Sciences, School of Dentistry, Magna Graecia University of
Catanzaro, Viale Europa, Catanzaro, Italy.

1403
1404 MANAGING MANDIBULAR SECOND MOLAR IMPACTION

Conclusion: Despite study limitations, both orthodontic and surgical management of impacted M2M can
be effective suggesting that clinicians are able to choose best treatment for most cases.
Ó 2023 Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial
Surgeons
J Oral Maxillofac Surg 81:1403-1421, 2023

Mandibular second molar (M2M) impaction is a with a retruded and sagittally underdeveloped
serious, although rare, disorder of eruption.1-3 mandible and a smaller mandibular gonial angle are
Although the true prevalence is still unknown, M2M morphologic features associated with impacted
impaction ranges from 0.03% to 0.65% of M2M, as shown for third molar impaction.7,10,17,21
adolescents, with a peak of 4.6% among those who Changes in eruption may alter the position of the
require orthodontic treatment.4-8 However, as mandibular second molar and alter its relationship to
recorded by Fan et al, there has been an increasing surrounding structures. To date, cone-beam computed
trend in M2M impaction in recent years.9,10 The inci- tomography (CBCT) allows a better visualization of
dence of impacted M2M is often detected between the 3-dimensional position of the impacted M2M
11 and 14 years of age, with a male preva- with more details in all the 3 spatial axes.22 In the cor-
lence.3,5,7,11,12 The diagnosis of M2M impaction can onal view, a vertically-oriented impaction of M2M
sometimes be delayed because no symptoms occur could create a closer relationship with the alveolar
and no primary tooth exfoliation is expected.13 nerve, according to its level of infraocclusion and the
Although several theories have been proposed, the eti- root development.1,4 In the axial view, a lingual posi-
ology of M2M impaction is still debated and both inter- tion of M2M could reduce the distance from the lingual
nal and external factors may be involved.4,5,7,13,14 nerve, which is close to the cortical plate.4 Both of
Internal factors may include an ectopic position of these altered eruption paths should be evaluated
the follicle or a failure of the eruption process (M2M with caution during the diagnostic phases, consid-
ankylosis).14,15 External factors depend on 1) deficit ering the potential risk of the surgical maneuvers.4,22
of retromolar space; 2) disorders of the primary denti- In the sagittal direction, a distal angulation could affect
tion; 3) alteration of adjacent permanent teeth; and 4) both the mandibular ramus and the third molar follicle,
obstacles in the M2M eruption path.4,5,7,13-15 while a mesial angulation or a more severe horizontal
Inadequate space for eruption is the most obvious impaction could result in root resorption and peri-
cause of impaction, considering the distance odontal damage of the first permanent molar.4
between the distal surface of the mandibular first To date, case reports or case series are the most
molar (M1M) and the mandibular ramus.5,7,16-18 common articles in the literature on eruption disor-
Several conditions can contribute to a reduction in ders of M2M.9,23-25 Despite the excellent results of
retromolar space, such as severe mandibular impacted M2Ms reported in these studies, a
crowding or ankylosis of the primary molar, which classification of the degree of difficulty for the
does not allow mesial displacement of the first characterization of the mandibular second molar is
permanent molar. On the other hand, premature loss still lacking.
of the primary molar could determine an excessive The purpose of this study was to systematically re-
mesial shift of the first molar, and its distal root view the treatment approaches for impacted M2M.
results in a lack of eruption guidance for M2M.4,5,13 The first objective of the meta-analysis was to summa-
As early as 1995, Shapira stated that the eruption rize the therapeutic success by analyzing the type of
path of the M2M could be compared to that of the treatment (surgical, surgical-orthodontic, or orthodon-
maxillary canine, in which the root of the lateral tic). The second objective of the meta-analysis was to
incisor plays an important guiding role.18 Eruption compare the therapeutic success rate with and
impairment could also be caused by adjacent supernu- without the third molar removal.
merary teeth or ectopic mandibular third molar (M3M)
position. However, as reported by some authors, alter- Materials and Methods
ation in the third molar position should be evaluated as
a contributing factor and not as the main cause of M2M ELIGIBILITY CRITERIA
impaction.7,13 With increasing frequency, local patho- A systematic review was conducted according to
logic bone lesion (eg, dentigerous cyst, tumor) may PRISMA guidelines and PICOS (participants, interven-
interfere with the obstructed eruption path of the tion, comparisons, outcomes, and study design)
mandibular second molar.4,5,13-15 Finally, genetic criteria including patients with mandibular second
background may influence M2M eruption in terms of molar impaction. The purpose was to analyze and
craniofacial structure.15,19,20 A class II malocclusion compare surgical and/or orthodontic treatment.
BARONE ET AL 1405

Outcomes focused on success rate, periodontal and studies, number of the included patients, type of inter-
endodontic sequelae, bone defects, and root damage. vention, methodological approach, outcomes, study
In terms of study design, randomized control trials results, and author’s conclusion.
(RCTs) and nonrandomized prospective or retrospec-
tive studies (case-control studies, cohort studies,
case series with more than 5 patients) were included. VARIABLES
Exclusion criteria were related to topic (all articles that The first predictor variable in the study was the ther-
did not fit the purpose of this study), and study design apeutic approach, which was divided into 3 cate-
(abstracts, editorials, expert opinions, animal studies, gories: surgical treatment, orthodontic treatment,
case reports, case series with less than 5 patients, and orthodontic and surgical treatment.
and review articles). Surgical treatment: This category included only sur-
gical procedures without orthodontic treatment. The
INFORMATION SOURCES, SEARCH STRATEGY, AND surgical procedures comprised surgical exposure, sur-
STUDY SELECTION gical uprighting, surgical repositioning, extraction of
the third molar alone, and strategic extraction of the
Five databases (PubMed, Cochrane Library, Google
first and second molars to properly reposition the re-
Scholar, Scopus, Web of Science) were investigated
maining teeth.
for the electronic search up to January 2023. The
Orthodontic treatment: This category involved or-
term sequence used in the PubMed search was as fol-
thodontic uprighting without any surgical procedures.
lows: ‘‘((((mandibular second molar) AND (impac-
Orthodontic interventions were utilized to achieve the
tion)) AND (therapy)) NOT (case report)) NOT
desired tooth positioning.
(systematic review)’’, ‘‘((((orthodontic treatment)
Orthodontic and surgical treatment: This category
AND (surgical treatment)) AND (impacted lower
encompassed a combination of surgical-orthodontic
second molar)) NOT (case reports[MeSH Terms]))
uprighting It involved both orthodontic techniques
NOT (review, systematic[MeSH Terms])’’, ‘‘((((ortho-
and surgical interventions, which could include
dontic treatment) OR (surgical treatment)) AND
removal of the third molar and removal of mucosal
(impacted lower second molar)) NOT (case reports
or bone coverage, as necessary, to achieve the desired
[MeSH Terms])) NOT (review, systematic[MeSH
outcome.
Terms])’’. The term sequences used in the other search
The second predictor variable was the M3M
databases were: ‘‘((orthodontic treatment OR surgical
removal (yes/no).
treatment) AND (impacted lower second molar))’’
The outcomes were as follows: 1) the treatment suc-
and ‘‘(mandibular second molar) AND (impaction)
cess rate defined by the repositioning of the impacted
AND (therapy)’’ with a restricted search avoiding sys-
M2M in the dental arch with normal functional
tematic review, ‘‘((((orthodontic treatment) OR (surgi-
occlusal relationship and periodontal health; 2) the
cal treatment)) AND (impacted lower second molar))
time to repositioning defined by the time-to-event
NOT (case reports)) NOT (review, systematic)’’,
outcome; and 3) complications.
‘‘(((therapy) AND (impacted lower second molar))
NOT (case reports)) NOT (review, systematic)’’. A
manual search was performed by reading the refer- QUALITY ASSESSMENT
ence lists of the included studies. No language or pub-
The analysis of the methodological quality was per-
lication date restriction were applied.
formed independently by the same 2 investigators.
The electronic search was conducted indepen-
Nonrandomized clinical trials were assessed using
dently by 2 investigators (SB and AA). After screening
Newcastle–Ottawa quality assessment scale and ran-
titles and abstracts, studies were assessed for eligi-
domized clinical trials were assessed using the Co-
bility. Full-text reading was performed if missing infor-
chrane Collaboration Tool.26,27
mation persisted. A third author (AG) discussed and
The Newcastle-Ottawa Scale (NOS) is a validated
resolved any disagreements between the 2 investiga-
tool based on a star rating system with 8 items in 3 do-
tors. Cohen’s kappa coefficient (k) was calculated to
mains (selection, comparability, and outcome) for the
assess inter-rater reliability between the 2 in-
qualitative assessment of the included studies. Each
vestigators.
study can be rated as poor, fair, or good/high quality.
The Cochrane Collaboration Tool is a validated in-
DATA ITEMS AND COLLECTION strument that assesses study design and methodology
Data extraction was performed in parallel by the according to 6 domains (selection bias, performance
same 2 authors (SB and AA) from the eligible studies. bias, detection bias, attrition bias, reporting bias, other
The following data were collected for qualitative anal- bias). Each domain expresses the risk of bias in the
ysis: author, publication date, country of the included format low, high, or unclear.
1406 MANAGING MANDIBULAR SECOND MOLAR IMPACTION

SUMMARY MEASURES AND APPROACH TO

SYNTHESIS
Search results:
A meta-analysis for proportions was conducted to 1102 studies by 5
summarize the categorical variables using a graphical databases Duplicates removal:
scheme of estimated effects. It focused on 2 different 588 studies
outcomes: 1) successful therapy by comparing surgi-
cal, surgical-orthodontic, and orthodontic treatment
for impacted M2Ms; and 2) successful therapy with
and without M3Ms removal. Statistical heterogeneity Screening:
(I2) was calculated by examining the c2 test for selec- 514 studies
Exclusion:
tion of the common- or random-effects model. Hetero- 468 studies after reading
geneity was assessed to define a weighted effect of the title and abstracts
included studies, and the results were expressed as
odds ratio (OR) in conjunction with 95% confidence
Full text analysis: 46
interval (CI). studies Exclusion:
The time-to-event analysis enabled the assessment
30 studies after full text
of the duration for M2M repositioning, while consid- reading
ering distinct treatment types (surgical, surgical-
orthodontic, and orthodontic) as discriminating vari- Qualitative analysis:
ables. The event in focus was the successful M2M re- 16 studies
positioning, and the time interval was measured in Quantitative analysis:
days. Kaplan–Meier curve was automatically gener- 5 studies
ated to visualize the output. Median time when the
event (M2M repositioning) occurred in the 50% of pa- FIGURE 1. PRISMA diagram of the studies’ selection.
tients was recorded. A P-value <.05 was considered Barone et al. Managing Mandibular Second Molar Impaction.
statistically significant. J Oral Maxillofac Surg 2023.

Results randomized prospective clinical trial were

STUDY SELECTION included.5-7,11-13,15,22,23,25,28-33
A total of 1,102 articles were retrieved from 5 data- A total of 1,008 mandibular second molars with
bases. After removing duplicates (n = 588), 514 arti- eruption anomalies were analyzed.5-7,11-
13,15,22,23,25,28-33
cles were screened for title and abstract, of which The majority of patients were
468 articles were excluded. The main reason for rejec- adolescents, ranging in age from 10 to 17 years of
tion was a topic that differed from the study objectives, age (mean age 16 years).5-7,11-13,15,22,23,25,28-33 Only 3
followed by exclusion of case series with fewer than 5 studies reported results also in adult patients up to
patients, case reports, and review articles. After 28, 58, and 67 years of age, respectively.7,23,28
reading the full text of the remaining 46 studies, 30 ar- Impacted M2M was mostly diagnosed by 2-
ticles were dismissed because they were case reports dimensional radiographs (periapical radiograph and
or case series with less than 5 patients. A total of 16 ar- panoramic radiograph), except for 2 studies in which
ticles were finally included in the systematic review 3-dimensional records were initially made with CT
(Fig 1). The coefficient of inter-rater agreement scans.5-7,11-13,15,22,23,25,28-33 The initial position of the
was k = 0.93. impacted M2M was reported in 11 studies using 4
different methods: 1) measurement of the angle
between the long axis of M1M and M2M (vertical
STUDY CHARACTERISTICS position: angle <20 ; mesial inclination: 20 < angle
Six studies were conducted in the United States < 60 ); 2) calculation of the angle between the
of America, 3 studies in Italy, 2 studies in Spain, occlusal plane of M1M and that of M2M; 3) depth of
and the remaining 5 studies were conducted impaction assessed by the linear distance between
in Canada, Sweden, Turkey, Taiwan, and the M2M crown and the occlusal plane of M1M; 4)
Denmark.5-7,11-13,15,22,23,25,28-33 The year of the Pell and Gregory classification.5-7,22,23,25,28-31,33
publication ranged from 1972 to Most of M2Ms showed a mesially inclined partial
2022.5-7,11-13,15,22,23,25,28-33 In terms of study design, impaction.5,6,22,23,29-33 One study described
15 nonrandomized studies (2 prospective cohort therapeutic results in the treatment of ‘‘kissing
studies, 2 retrospective case-control studies, and molars’’ in which the impacted M2M showed a distal
11 retrospective cohort studies) and 1 inclination.28 Two studies reported the difficulty of
BARONE ET AL 1407

impaction related to mucosal and/or bone coverage.7,25 9 studies (Table 1, Fig 2).5,7,11,13,22,23,28,31,32 Six studies
Five studies did not specify clearly the pretreatment reported good quality.6,12,15,25,30,33 The most critical
impaction of the impacted M2M.11-13,15,32 Four studies item of the New Castle–Ottawa scale was in the
reported a short follow-up, ranging from 4 to comparability domain. The randomized prospective
6 months.6,28-30 Most of the included studies reported clinical trial showed an unclear risk of bias (Fig 2).29
a postoperative follow-up of 12 to 18 months.5,12,15,22,33
For some patients, Terry, Davis, and Pogrel were able to
record postsurgical data also up to 15, 2, and 6 years, QUALITATIVE ANALYSIS - STUDY OUTCOMES
respectively.12,30,33 Six studies did not report the Therapeutic alternatives for impacted M2M were
follow-up duration.7,11,13,23,31,32 categorized into 8 different options: orthodontic up-
In order to evaluate the therapeutic efficacy of a righting, surgical-orthodontic uprighting, surgical
given technique, the following outcome variables exposure, surgical uprighting, surgical repositioning,
were considered: 1) success of M2M repositioning extraction of the first or second molar, third molar
with correct occlusion; 2) time for M2M repositioning; extraction, and surgical removal of pathologic lesions
3) M2M root damage (altered root growth, root frac- (Tables 2 and 3).5-7,11-13,15,22,23,25,28-33
ture, or root resorption); 4) M2M pulp chamber or
periodontal damage (endodontic lesion or altered 1. Orthodontic Uprighting
crestal bone height); 5) pathological condition of Five studies reported results after orthodontic up-
the continuous area (bone defects or bone lesions); righting.7,11,13,15,23 It can be performed when an
6) symptomatic sequelae; and 7) relapse or adequate coronal surface of the impacted M2M is
failure after treatment (no repositioning or M2M already visible.7,23 The mandibular second molar is
extraction).5-7,11-13,15,22,23,25,28-33 usually mesially inclined against the distal surface of
the first permanent molar.7 This procedure allows
RISK OF BIAS WITHIN STUDIES the distal tipping of M2M and its guided repositioning
through 2 available biomechanics: pushing from the
For nonrandomized studies, the analysis of the
mesial side or pulling from the distal side.7,15,23 The
methodological assessment showed fair quality in
success rate of this procedure (149 impacted M2Ms)
ranged from 46.2% to 100%.7,11,13,15,23 Young patients
Table 1. NEWCASTLE-OTTAWA QUALITY ASSESS- (12 to 19 years old) had significantly better results than
MENT adults, showing a shorter time for uprighting.7,13,23 No
correlation was found between sex and the outcomes
Newcastle-Ottawa
of orthodontic uprighting, while a more horizontal
Scale Outcome Quality
Author, Year (Range, 0-9) Assessment
M2M inclination and a greater depth contributed to
poor results.7,13,15,23 Significant advantages were re-
Johnson and Taylor, 4 Fair corded using miniscrews with direct or indirect skel-
197231 etal anchorage.7,11 As reported by several authors,
Davis et al, 197630 6 Good the presence of an adequate retromolar space for
Terry and Hegtvegt, 6 Good M2M is mandatory to achieve correct uprighting.7,11,13
199333 Orthodontic uprighting can lead to a high success rate
Pogrel, 199512 6 Good of M2M repositioning, limiting long-term complica-
Valmaseda-Castellon 4 Fair tions such as pulp necrosis or periodontal risk that
et al, 199913 are more common in surgical approaches.7,13
Going and Reyes- 4 Fair
Lois, 199932
2. Surgical-Orthodontic Uprighting
Magnusson and 6 Good
Kjellberg, 200915
Eight studies aimed to describe the postoperative re-
Kenrad et al, 2009 4 Fair sults after surgical-orthodontic uprighting of impacted
Gulses et al, 201228 4 Fair M2M.5-7,13,25,29,31,32 It is the same procedure of ortho-
Fu et al, 201223 3 Fair dontic uprighting, but its indication concerns a deeper
Padwa et al, 20175 4 Fair impaction of the mandibular second molar (mesially
La Monaca et al, 4 Fair angled with total bone impaction or horizontally posi-
20197 tioned).6,7,25,31,32 In these cases, surgery can be effec-
Abate et al, 202022 4 Fair tive in removing bone coverage, exposing the dental
Caminiti et al, 20206 6 Good crown, and eventually dislocating the tooth to allow
Lorente et al, 202225 6 Good the positioning of the orthodontic appliance for trac-
Barone et al. Managing Mandibular Second Molar Impaction. tion.5-7,25,29,31,32 Sometimes, the surgical goals could
J Oral Maxillofac Surg 2023. include the removal of the third molar to obtain
1408 MANAGING MANDIBULAR SECOND MOLAR IMPACTION

sufficient space for M2M repositioning.5,6,25,29,32 The

success rate of this approach was the primary
outcome variable of all the 8 studies (401 impacted
M2Ms), ranging from 66.7 to 100%, with a percentage
of 98.1% in the study with the largest sample size (260
impacted M2Ms).5-7,13,25,29,31,32 Minimal postopera-
tive discomfort with limited complications have
been reported: periodontal lesions (6.7%), root blunt-
ing (20.4%), and bone resorption (9.4%).5-7,13,25,29,31,32
However, 1 study recorded 100% on positive cold
FIGURE 2. Quality assessment of the included randomized clinical
testing for uprighted M2Ms.6 There is no consensus trial.
regarding the successful uprighting of M2M in relation Barone et al. Managing Mandibular Second Molar Impaction.
to age, gender, impaction angle, impaction depth, ret- J Oral Maxillofac Surg 2023.
romolar space, and concomitant extraction of the adja-
cent third molar.5,7 Two studies observed that
anatomical root alteration and a contact between the move the mesial marginal ridge of M2M to the level
M2M root apex and the roof of the mandibular canal of the distal marginal ridge of M1M, but subsequent or-
could be possible conditions for delayed successful thodontic refinement may be necessary.5,7 It is indi-
eruption.7,25 As reported by Lorente and colleagues, cated when the roots are two-thirds developed, with
miniscrew and skeletal devices should be considered adequate retromolar space, and in cases of limited
for the treatment of severe M2M impactions, allowing M2M angulation.5,7,15,30 Complete root formation,
the application of higher force with a strategic biome- divergent roots, and inclination greater than 75
chanical system.25 compared from the long axis of the first molar are se-
vere contraindications to surgical uprighting to avoid
3. Surgical Exposure complications such as root fracture, root resorption,
Surgical exposure was reported in 5 or pulpal obliteration.5,7,15,30 The success rate of 81
studies.7,11,13,15,22 This involves removal of mucosa surgically uprighted M2Ms ranged from 66.7 to
and bone overlying the crown of the impacted M2M, 100%.5,7,15,30 Although this technique showed rapid
allowing a spontaneous eruption of the tooth.7,13,22 results and minimal postsurgical discomfort, a low per-
It is indicated only when surrounding tissues prevent centage of long-term periodontal and endodontic post-
the eruption mechanism of the molar.7,11,22 Good pre- operative complications could occur.5,7,30
dictive factors include incomplete root development
and a tooth position closer to the normal position (ver- 5. Surgical Repositioning
tical or slightly mesially inclined).7,11,13,22 After local Three studies described the postoperative out-
anesthesia, a mucosal incision should be done distal comes of surgical repositioning.7,12,33 The technique
to the first molar to proceed with a mucoperiosteal is similar to surgical uprighting, but with a more
flap elevation to expose the tooth alveolus.22 A total aggressive procedure that results in bodily movement
of 70 cases were treated with surgical exposure and of the impacted tooth, moving it to an entirely new po-
the success rate ranged from 60 to 100%.7,11,13,15,22 sition within the jawbone.7,12,33 Sometimes, an ortho-
In the study with the largest sample size, a comparison dontic appliance is necessary to stabilize excessive
between 33 treated cases and 35 untreated controls tooth mobility.12 It is imperative to have adequate ret-
was performed, reporting a significant difference in romolar space for molar repositioning.7 The 3 studies
M2M eruption after 12 months of follow-up.22 Howev- retrospectively described a short-term success rate of
er, an accurate diagnosis of M2M impaction is manda- 100% (46 impacted M2Ms).7,12,33 Surgical reposition-
tory for this approach to achieve successful ing could guarantee an immediate solution for
results.11,13,22 impacted M2M, but several complications were
observed in terms of dental, bone, and periodontal
4. Surgical Uprighting damage, so it should be indicated only in patients
Four studies reported data after treatment of who refuse other orthodontic treatment.7
impacted M2M with surgical uprighting.5,7,15,30 This
involves inducing molar tipping by creating a fulcrum 6. Extraction of the First or Second Molar
at its root apex, accompanied by a slight luxation Four studies reported data on the extraction of the
through controlled force, thereby lifting the tooth first or second molar as a strategic therapeutic
into the occlusal plane.5,7 Surgical bone removal could approach to facilitate the repositioning of the remain-
be performed distally to increase the space available ing molars.7,11,13,15 This approach is usually consid-
for uprighting.30 The procedure should be able to ered when the first molar is severely compromised
 BARONE ET AL
Table 2. QUALITATIVE ANALYSIS OF THE 16 INCLUDED STUDIES

Author Study Sample Radiographic Exam

Year M2M Position Therapeutic Approach Outcomes
Journal Type of Study Age (yr) M3M Extraction Follow-Up Results and Conclusion

Johnson and Taylor31 Prospective case 20 M2M Periapical rx Success of M2M repositioning in Success rate: 100%
1972 series Mesially impacted (30- Surgery + orthodontics occlusion
Am J Or USA 50 between M2M and No M3M extraction NR
M1M)
11-13 yr
Davis et al30 Prospective case 21 M2M Surgical uprighting (+splint - Continue root growth All teeth were in good alignment; buccal or lingual
1976 series Mesially-inclined with autogenous bone - Normality of pulp cham- inclination was recorded in 4/21 teeth after 2 yr.
Am J Or USA partially impacted graft) bers One tooth required additional treatment due to
(22.5-54 between 32% of cases - Normality of crestal bone inadequate uprighting. No periodontal pockets
M2M and M1M) height adjacent to the re- were found, and periapical radiographs showed
10-17 yr (mean age 13 yr) positioned tooth excellent bone height. In all uprighted molars,
- Pathology of continuous continued root growth occurred, and there was no
areas lesion found in the pulp chamber. Follicular cysts
were found to involve 3 impacted third molars.
Rx follow-up: immediately
post-op, 6 mo, 1 yr, 2 yr (4 pts
were lost to follow-up)
Terry and Hegtvegt33 Retrospective case 16 patients OPG - Occlusal stability All uprighted teeth achieved occlusal stability and
1993 series Partially erupted Surgical uprighting - Pulpal or periodontal have not become mobile. No pulpal or periodontal
OOOO mesioangular M2M 100% sequelae lesions have occurred during the follow-up period.
USA NR - Bone defects In the postoperative radiographic exams, bone fill
- Root resorption has been observed in the defects. No evidence of
root resorption was recorded on follow-up
1-15 yr radiographs.
Pogrel12 Retrospective case 16 patients with 22 M2M OPG - Immediate success rate The following results were reported:
1995 series Mesially impacted M2Ms Surgical uprighting (minimal - Bone defect and peri- Immediate Success rate: 17/22
Am J Or Dent Orth 11.7-17.9 yr (mean age apical movement, and no odontal lesion Splint for mobile tooth: 5/22
USA 14.1 yr) teeth were removed from - Continue root formation Continue root formation: 12/22
the sockets) - Pulp vitality18 mo-6 yr Closed apices: 22/22
18/22 Pulp vitality: 6/22
Extraction: 1/22

1409
 1410
Table 2. Cont’d

Author Study Sample Radiographic Exam

Year M2M Position Therapeutic Approach Outcomes
Journal Type of Study Age (yr) M3M Extraction Follow-Up Results and Conclusion

Valmaseda-Castell
on Retrospective case 28 M2M OPG A molar was considered functional
Eleven M2M were extracted for bad prognosis or
et al13 series 3 degrees of Different techniques: only if it had an acceptable because the patients refused a treatment. The
1999 infraocclusion (mild, surgical uprighting and position in the dental arch, success rate of conservative treatment was
Am J Or Dent Orth moderate, or severe) orthodontic traction, occluded with the antagonist, approximately 50% (1/2). The increased age at
Spain for impacted M2Ms surgical exposure, and was asymptomatic. diagnosis, severity of the cases, and the difficulty
Mean age: 17.3  2.2 yr orthodontic traction, NR and uncertainty of conservative treatment can
transplantation, and contribute to this poor result. Orthodontic
extraction. treatment of impacted M2M had a 75% (3/4)
Extraction of third molars success rate. In cases of surgical exposure with or
was considered if they without surgical luxation of M2M, M3M extraction
were found to interfere in the same operation is recommended when there
with the chosen is posterior crowding in the dental arch because
treatment (9 M3M) M3M could prevent M2M eruption even if it is not
the direct cause of the noneruption of these molars.
Going and Reyes- Case series 40 patients OPG - Success rate in terms of a Success rate: 100%. The time required for M2M
Lois32 unerupted, partially Surgical orthodontic normal functional occlusal uprighting ranged from 3 to 9 mo. Minimal
1999 impacted, mandibular uprighting relationship postoperative discomfort was reported, and there
JOMS molars The presence or absence of - Pulp or periodontal damage were no cases of paresthesia or infection.
USA NR M3M does not interfere - Root fracture

MANAGING MANDIBULAR SECOND MOLAR IMPACTION

with the success of the - RelapseNR
procedure.
Magnusson and Descriptive, 70 impacted M2M CT + OPG + periapical rx - Erupted in good occlusion Eight M2M were left untreated. Most cases (80%) were
Kjellberg15 retrospective, NR - Extract 7, replaced - Erupted without good oc- treated with either surgical or orthodontic
2009 longitudinal 11-19 yr (mean age: by 8 clusion interventions. Only 42% of the treated M2M
Angle Orthod follow-up study 15 yr) - Extract 8, 7 erupted - Failed to erupt (1 yr after achieved successful results. Surgical exposure was
Sweden - Orthodontic treat- treatment) the most successful therapy, with a success rate of
ment 66.7%. The success rate was 63.6% when
The mean follow-up period: combining surgical exposure with M3M extraction
- Surgical exposure, 7 22 mo (range: 4-106 mo)
erupted or M2M luxation. Extraction of the second molar,
replaced by the third molar, was the treatment that
- Extract 8 and surgi-
did not yield successful results.
cal exposure/luxa-
tion of 7
- Extract 6, 7 erupted
- Surgical exposure
and luxation of 7
27%
 BARONE ET AL
Kenrad et al Retrospective study 106 patients with 126 OPG The treatment outcome was Success rate: 66 out of the cases (52.4%). Group B, C,
2009 M2M - No treatment (group defined as acceptable when all and F had the smallest sample size, but they
Clin Oral Invest Easy and complicated A) molar cusps were in occlusion. showed the following success rates: 100, 90, and
Denmark impacted M2Ms - Orthodontic treat- NR 100%, respectively. In the 2 largest groups of
11.2  19.8 yr ment (group B) patients (D and E), the percentages of unacceptable
- Surgical exposure treatment outcomes were 25.9 and 23%,
(group C) respectively.
- Removal of M3M
(group D)
- Removal of M2M
(group E)
- Autotrasplantation of
M3M (group F)
In 29 patients M3M
were extracted as
therapy
Gulses et al28 Retrospective case 7 patients OPG + CT - Data regarding the manage- Three of the kissing molars showed dentigerous cyst
2012 series Impacted kissing Surgical removal ment formation, and 2 exhibited granulomatous changes
Oral Health and mandibular molars Extraction of M3M - Existence of an associated in the adjacent dental follicle. Following surgical
dental 17-58 yr (mean age: pathology and any compli- removal, 3 patients experienced mild paraesthesia
management 27.4 yr) cations of the lower lip, which resolved within 3 to 6 mo
Turkey - Differences during the postoperatively.
follow-up period were
collected from the patients’
records
3-6 mo
23
Fu et al Retrospective study - 140 patients with 183 OPG or periapical rx - Time for uprighting; Fifty-eight M2M were left untreated and removed for
2012 Case series M2M - Orthodontic upright- - Success rate in relation to bad prognosis. The time required for M2M
Angle Orthod Impacted angle between ing age, sex, impacted angle, uprighting ranged from 2 to 5 mo in most cases.
Taiwan occlusal plane of M1M - M2M extractionNR and impacted depth Significant differences in the initial uprighting
and occlusal plane of every 6 wk period were observed when comparing the 3
M2M (31-60 ) – Depth groups of patients with different impacted depths
of impaction: 9-12 mm (P < .05). There was a positive correlation between
11-67 yr (mean age the impacted angle and impacted depth with the
26.5  8.4 yr) initial uprighting period. A longer initial uprighting
period was observed when M2M was deeply,
horizontally, or distally impacted.

1411
 1412
Table 2. Cont’d

Author Study Sample Radiographic Exam

Year M2M Position Therapeutic Approach Outcomes
Journal Type of Study Age (yr) M3M Extraction Follow-Up Results and Conclusion

Padwa et al5 Retrospective case- - Study group: 16 OPG - Primary outcome: success All uprighted molars were classified as type IA. At the
2017 control study patients with 19 Surgical uprighting or failure of the procedure latest follow-up, no periodontal bone levels on
JOMS impacted M2M M3M extraction if space for (failure defined as need for M1M or M2M were greater than 3 mm. Pulpal
USA - Control group: 16 M2M uprighting is extraction during the obliteration, periapical radiolucency, and root
patients with no missing (50% of cases) follow-up period) resorption were found in 31.6% (n = 6), 10.5%
impacted M2M - Secondary outcome vari- (n = 2), and 5.3% (n = 1) of repositioned M2M,
ables: change in the Pell respectively. Two teeth (10.5%) required extraction
Pell and Gregory
and Gregory classification, during the follow-up period. No patients reported
classification: type pain or infection during the follow-up period. The
postoperative long axis
IA (n = 5; 26.4%), mean change in the M2M angulation was
angle, postoperative peri-
type IB (n = 9; odontal bone levels on the 23.5  16.1 (P < .001). The preoperative posterior
47.3%), type IC distal aspect of the adjacent eruption space was 53.6% longer in the control
(n = 1; 5.3%), type first molar and on the than in the treatment group (P < .001), and it
IIB (n = 3; 15.7%), mesial and distal aspects of increased postoperatively more in the treatment
and type IIC (n = 1; the second molar, postop- group than in the control group (P < .001).
5.3%). The angle of erative posterior eruption
the long axis of the space, presence of periapi-
impacted M2M to cal radiolucency, pulpal
the occlusal plane obliteration, or root

MANAGING MANDIBULAR SECOND MOLAR IMPACTION

resorption.
13  1.1 yr (range,
11 to 15.2 yr) Radiographic follow-up af-
ter 12 mo
Cassetta and Altieri29 Randomized 14 patients with 20 OPG - Primary outcome: determi- The impaction of M2M was resolved in all patients.
2017 prospective impacted M2M Surgical-orthodontic nation of the total treat- The mean treatment time in group A was
Ijoms clinical pilot study M2M with mesial treatment with MM3 ment time for M2M 170.9  9.21 days, while in group B it was
Italy inclination between germectomy (group A) or uprighting, with or without 174.4  10.56 days, with no statistically significant
25 and 40 ; MM2 without MM3 M3M germectomy. The difference (P = .44). No adverse events or side
with a depth of germectomy (group B) M2M was considered up- effects were recorded. MM3 germectomy did not
impaction between 4 M3M germectomy in the righted when the mesial influence the treatment time in this sample, but it
and 10 mm study group marginal ridge was above had a negative impact on the quality of life when
12.9  0.5 yr the distal contours of M1M. compared to patients without germectomy.
- Secondary outcome: evalu-
ation of the influence of
germectomy on quality of
lifeAll patients were fol-
lowed up until uprighting of
the M2M was complete.
Initial follow-up 7 days after
surgery and then every
20 days
 BARONE ET AL
La Monaca et al7 Retrospective study 97 impacted M2M OPG The treatment outcome was Success rate: 92 out of 97 lower second molars
2019 Mucosal and/or bone - Orthodontic upright- considered positive when M2M (94.8%). Young age and depth influence the
AJO-DO coverage for impacted ing achieved correct alignment in successful treatment of M2M, while axial
Italy M2M - Surgical-orthodontic the dental arch. In cases of M2M inclination and sex did not show any significant
14.08  4.04 yr (range 5- uprighting extraction, the outcome was correlation. The prevalence of a positive outcome
28 yr) - Surgical uprighting considered positive if the was significantly lower for total bone crown
- Surgical reposition- adjacent molars erupted and coverage (21 out of 28 M2M, 75.0%) compared to
ing aligned correctly at the end of osteomucosal or mucosal crown coverage (120 out
treatment. of 133 M2M, 90.2%; P = .016). Surgical uprighting
- Surgical exposure
NR achieved a positive outcome in all 38 treated M2Ms
- First or second molar (87.6%). A success rate of 100% was found with
extraction surgical exposure (10 molars), orthodontic
- Third molar extrac- uprighting (7 molars), and surgical repositioning
tion (8 molars). The removal of pathologic conditions
- Removal of patho- that prevented molar eruption, such as odontomas,
logic conditions supernumerary teeth, and cysts, resulted in an
M3M was extracted excellent prognosis (18 out of 18 molars). The
only to achieve more extraction of irretrievable M1Ms or M2Ms allowed
space the mesial drift of the subsequent molar, with a
positive outcome (17 out of 22 molars, 77.3%).
Third molar extraction as the only therapy in
second molar retention was performed in 8 cases,
with 1 failure.
Abate et al22 Retrospective case– - Study group: 33 OPG - Treatment outcome: spon- The success rate in the study group was 90.9% (30 out
2020 control study impacted M2M; 33 M2M operculectomy and taneous eruption occurred of 33 impacted M2Ms), whereas in the control
Dentistry J - Control group: 35 included in the study within 1 yr after surgical group it was only 8.5% (3 out of 35 M2Ms). A
Italy impacted group. The control group uncovering. statistically significant difference between the
M2MMesially in- consisted of 35 unerupted - Occlusion was considered study group and the control group was observed
 M2M that were monitored successful if M2M erupted (P < .001).
clined (angle > 40 )
or vertically (20 - without performing any vertically and the occlusal
treatment.
40 ) positioned surface of the retained
Third molars are usually tooth was 2 mm or less
M2Ms (angle be- extracted in both cases to from the occlusal plane.-
tween M2M and easy M2M eruption After 12 mo
M1M)
mean age
15.9  1.7 yr

1413
 1414
Table 2. Cont’d

Author Study Sample Radiographic Exam

Year M2M Position Therapeutic Approach Outcomes
Journal Type of Study Age (yr) M3M Extraction Follow-Up Results and Conclusion

Caminiti et al6 Retrospective, single- 177 patients with 260 OPG - Success rate Among the 260 second molars treated in this study, 5
2020 group cohort impacted M2Ms Surgical-orthodontic - Periodontal consequences teeth (1.9%) required removal after surgical
AJO-DO study Horizontal, lingual, or uprighting - Endodontic consequences uprighting (3 for infection/abscess were removed
Canada partially erupted M2M M3M removal in 226 (86.9%) within the first month after operation, and 2 teeth
- Occlusal consequences
Mean age was failed because of fracture of the roots during
- Root development
14.5  1.7 yr for uprighting). Or the remaining successful molars (n.
females and All patients were followed for 255) at the time of follow-up, periodontal
15.1  2.2 yr for males a minimum period of 6 mo measurements showed pocketing depths greater
postsurgically (for >100 pa- than 5 mm in 17 teeth (6.7%), without bleeding on
tients the follow-up was probing. Root blunting occurred in 52 molars
longer than 5 yr). Time of (20.4%). Adequate bone fill was found in 233 teeth
follow-up ranged from 6 to based on radiographic examination (90.6%).
Endodontic examination showed all M2Ms have
22 mo (mean 12.1 mo).
tested positive on spot cold testing. Final tooth
position and the subsequent occlusal contact were
influenced by the preoperative position of the
tooth.
Lorente et al25 Observational, 11 impacted M2Ms CBCT + OPG The molar eruption was considered Success rate: 100%. However, 1 molar did not reach
2022 prospective Vertical, distal, or mesial Surgically assisted successful if it erupted in a good ideal occlusion despite its appearance in the oral
M2M angulation $45

MANAGING MANDIBULAR SECOND MOLAR IMPACTION

Prog Ortho cohort study orthodontic procedure vertical position with the cavity. No relationship was found between clinical
Spain (angle between M2M using a miniscrew- occlusal surface <2 mm from the or CBCT variables and the time from surgery to
and M1M) + severe supported pole technique occlusal plane eruption. Only molars presenting anatomical root
bone depth of the to force the eruption of The end of the follow-up was alteration were independently associated with a
M2M (from the impacted or retained defined as the moment in which longer treatment time until eruption compared to
occlusal plane to the molars the retained or impacted M2M molars without the alteration (152.3 vs 69.1 days,
midpoint of the The extraction of the third broke out through the overlying P = .025) (b: 107, P = .027). In this sample, surgical-
occlusal surface of the molar was only mucosa. Mean time: orthodontic treatment yielded good short-term
impacted M2M): prescribed if the bud was 126.8  117.3 days results and a high success rate.
molars were classified blocking the M2M
according to whether eruption.
they were impacted or
retained.
Mean age: 13.9  1.9 yr

Abbreviations: CBCT, cone beam computed tomography; M1M, mandibular first molar; M2M, mandibular second molar; M3M, mandibular third molar; NR, not reported; OPG,
orthopantomography.
Barone et al. Managing Mandibular Second Molar Impaction. J Oral Maxillofac Surg 2023.
BARONE ET AL 1415

by the impaction, or when there are multiple disadvan- guide the clinician in choosing the most appropriate
tages to restoring the impacted M2M.7,11,13,15 The suc- therapeutic approach among the previously listed
cess rate reported in the studies ranged from 7.7 to treatment options for M2M.7
77.3% (108 impacted M2Ms).7,11,13,15 The surgeon
has a key role because he should be able to extract
QUANTITATIVE ANALYSIS
the impacted molar without damaging the periodontal
membrane of the distal tooth.15 In case of extraction of Five studies were included in the quantitative assess-
the second molar, it is possible to 1) wait for the spon- ment, and a meta-analysis for proportions was per-
taneous mesial drift of the third molar; 2) perform or- formed.6,7,11,13,15 Five studies reported data on
thodontic traction of the third molar; or 3) perform impacted M2Ms treated with orthodontic traction or
autotransplantation of the third molar in the extrac- surgical treatment alone.6,7,11,13,15 With regard to the
tion site.7,11,13,15 None of these approaches can guar- success rate, their results were subjected to a meta-
antee predictable results, considering the long-term analysis for proportions.6,7,11,13,15 Significant differ-
prognosis of the tooth.7,11,13,15 Mesial drifting of ences were found between surgical treatment alone
M3M is indicated only if it is a bud without root devel- (222 M2Ms) and orthodontic treatment alone (23
opment.7,13,15 The most important suggestion is to M2Ms) for M2M uprighting (I2 = 13%; OR = 4.97;
monitor the occlusal result, either because the mesial 95% CI: 1.49 to 16.51; P = .01) (Fig 3).7,11,13,15 Addi-
drifting could be associated with a mesial tipping, or tionally, no significant differences were observed
because the upper antagonist could extrude exces- when comparing surgical treatment alone (176
sively.7,13 Orthodontic treatment is probably a good M2Ms) to a combination of surgical and orthodontic
option, mainly considering the new available devices treatment (196 M2Ms) (I2 = 84%; OR = 1.00; 95% CI:
that could improve the final outcomes.11 On the con- 0.03 to 37.44; P = .99), or when comparing orthodon-
trary, autotransplantation can cause unpredictable tic treatment alone (18 M2Ms) to a combination of or-
pulpal necrosis and periodontal damage, mainly in thodontic and surgical treatment (46 M2Ms) (I2 = 0%;
adult patients in whom the root development OR = 4.14; 95% CI: 0.43 to 40.14; P = .22) (Figs 4,
is complete.7 5).6,7,11,13,15 A meta-analysis for proportions was also
performed to evaluate the therapeutic success rate in
7. Extraction of Third Molar relation to M3M removal (Fig 6). Four studies were
The results of third molar extraction were reported included: a total of 280 M2Ms were treated in addition
in 4 included studies.7,11,15,29 Surgical removal of M3M to third molar extraction, while in 164 cases the M3M
is indicated when the third molar is an obstacle to the was not removed.6,11,13,15 Given the heterogeneity
eruption path of the impacted M2M, which is still able (I2 = 75%), the random effects model was selected.
to erupt.7 The success rate ranged from 33 to 100% (62 No difference between the 2 groups was observed
impacted M2Ms).7,11,15 To achieve good results, M3M (OR = 1.98; CI 0.24 to 16.03; P = .5).
removal should be supported by an early diagnosis The time-to-event analyses recorded that median
of M2M impaction to improve and correct its eruption time when the event (M2M repositioning) occurred
path.7,11 In most cases, M3M extraction can be a surgi- in the 50% of patients was 0 days after surgical treat-
cal procedure combined with the other approaches ment, 180 days after surgical-orthodontic treatment,
described previously (surgical-orthodontic uprighting; and 108 days after orthodontic treatment (P = .0001)
surgical uprighting; surgical repositioning).7,11,15,29 In (Fig 7). Over a 6-month follow-up, the majority of
these cases, the surgical removal of the third molar can M2Ms (approximately 80% after orthodontic treat-
be useful to obtain sufficient space for M2M replace- ment, and 70% after surgical or surgical-orthodontic
ment in the dental arch, mainly in late adolescents.7 treatment) were effectively repositioned. Within the
Regarding the treatment time, Cassetta and colleagues initial year, all techniques exhibited roughly an 80%
found no difference comparing M2M uprighting with positive outcome rate.
or without surgical removal of M3M in younger pa-
tients (approximately 5.7 months).29
Discussion
8. Surgical Removal of Pathologic Lesions Therapeutic approaches for impacted mandibular
Two studies described the management of impacted second molars require a synergy between oral sur-
M2M involved in pathologic lesions.7,28 The preva- geons and orthodontists to define an accurate diag-
lence ranged from 19 to 33%.7,28 Surgery may be per- nosis and consider the degree of difficulty of each
formed to remove bone lesions for histopathologic case. This systematic review aimed to summarize the
analysis.7,28 In these cases, the extent of the lesion, therapeutic strategies for M2M impaction, with a
the location of the impacted M2M, its root develop- meta-analysis focusing on the difference in success
ment, and the conditions of the adjacent teeth should rates between orthodontic and surgical therapy.
1416 MANAGING MANDIBULAR SECOND MOLAR IMPACTION

Table 3. SUMMARY OF THE OUTCOME VARIABLES ACCORDING TO THE THERAPEUTIC APPROACH

Number of Outcome Variable

Therapeutic Impacted
Approach M2Ms Success rate Treatment Time Complications

Orthodontic 149 from 46.2 to 100% 1-20 mo Debonding of the appliance;

uprighting periodontal lesions; root
blunting
Surgical- 401 66.7-100% 3-9 mo Minimal postoperative
orthodontic discomfort; food debris;
uprighting miniscrew failure;
periodontal lesions; root
blunting; bone resorption
Surgical 70 60-100% Within 12 mo Adjunctive approaches could
exposure be needed
Surgical 81 66.7-100%. Immediate Tooth mobility; fracture of the
uprighting repositioning roots; pulp necrosis;
pocketing depth; infection;
root blunting; bone
resorption
Surgical 46 short-term success immediate Tooth mobility; fracture of the
repositioning rate of 100% repositioning roots; pulp necrosis;
periodontal lesions;
pocketing depth; infection;
root blunting; bone
resorption
Extraction of 108 7.7-77.3% Immediately – Infection; pulp necrosis of the
the first or 20 mo transplanted tooth;
second molar periodontal lesions of the
adjacent tooth; pocketing
depth of the adjacent tooth;
root blunting of the treated
tooth with orthodontically
traction; debonding of
orthodontic appliance; bone
resorption
Extraction of 62 33-100% Alone: Alone: Infection; periodontal
the third approximately lesions of the adjacent tooth;
molar 5.7 mo pocketing depth of the
Combined with adjacent tooth; bone
other resorption
techniques: Combined with other
immediately – techniques: tooth mobility;
20 mo fracture of the roots; pulp
necrosis; periodontal lesions;
pocketing depth; infection;
root blunting; debonding of
orthodontic appliance; bone
resorption
Surgical 27 Influenced by the Influenced by the Removal of pathologic lesions
removal of therapeutic therapeutic combined with other
pathologic strategy and strategy and techniques: tooth mobility;
lesions anatomical anatomical fracture of the roots; pulp
conditions conditions necrosis; periodontal lesions;
following the following the pocketing depth; infection;
removal of the removal of the root blunting; debonding of
pathological pathological orthodontic appliance; bone
lesion lesion resorption; bone deficiency
Barone et al. Managing Mandibular Second Molar Impaction. J Oral Maxillofac Surg 2023.
BARONE ET AL 1417

FIGURE 3. Random-effects and meta-analysis on the therapeutic successful rate (event) by comparing orthodontic (experimental) and surgical
(control) treatment for impacted M2Ms.
Barone et al. Managing Mandibular Second Molar Impaction. J Oral Maxillofac Surg 2023.

An accurate diagnosis of M2M impaction is manda- biomechanics. The final decision depends on diag-
tory to define the best approach among the different nostic items, patient-related factors, and operator-
therapeutic options. This condition should be recog- related items. Diagnostic items include the available
nized as early as possible in order to start treatment diagnostic tools, the severity of impaction, the pres-
at the optimal age.14 Early adolescence has been ence of pathologic bone lesions, and the current status
considered the best time to treat impacted M2M of the involved and adjacent teeth. Patient-related
because its root development is not complete and items include the patient’s age and cooperation with
the third molar is still a germ bud.4,14,15,29,34 Although treatment. Operator-related items include the ortho-
some authors reported good results in adult patients, dontist’s skill in using the available devices, the sur-
younger subjects had better outcomes with a faster geon’s skill in performing the most appropriate
improvement of their clinical condition.1,4,14,23 procedure, and their previous experience.
The therapeutic decision for impacted M2Ms should A total of 1,008 impacted mandibular second molars
be made after a synergistic collaboration between the were analyzed in this systematic review. Most of the
oral surgeon and the orthodontist. Thirty surgical and impacted M2Ms were treated combining surgical treat-
orthodontic considerations should be assessed sepa- ment and orthodontic traction with a high success
rately to highlight the risks and benefits of the available rate.5-7,11,13,23,25,15,29,31,32 Considering the nature of
treatment options. A 3-dimensional analysis, which the included articles, which primarily consist of retro-
evaluates M2M impaction in all 3 spatial axes, is funda- spective cohort studies, our meta-analysis was limited
mental for both the surgeons, who must avoid intrao- to 5 studies.6,7,11,13,15 However, these studies provided
perative damage to surrounding structures, and the valuable data that allowed for comparative analyses of
orthodontist, who must manage the most favorable the different treatment strategies.6,7,11,13,15 Although

FIGURE 4. Random-effects and meta-analysis on the therapeutic successful rate (event) by comparing surgical-orthodontic (experimental) and
surgical (control) treatment for impacted M2Ms.
Barone et al. Managing Mandibular Second Molar Impaction. J Oral Maxillofac Surg 2023.
1418 MANAGING MANDIBULAR SECOND MOLAR IMPACTION

FIGURE 5. Random-effects and meta-analysis on the therapeutic successful rate (event) by comparing orthodontic (experimental) and surgical-
orthodontic (control) treatment for impacted M2Ms.
Barone et al. Managing Mandibular Second Molar Impaction. J Oral Maxillofac Surg 2023.

the variations in sample sizes among the different surgical-orthodontic therapy) were effectively reposi-
treatment groups should be considered when inter- tioned. The slight variance in timing between ortho-
pretating the results, our meta-analysis consistently dontic and surgical-orthodontic therapies can be
shows the effectiveness of surgical treatment in man- attributed to the increased complexity of cases
aging M2M impaction.7,11,13,15 In a distinct subset of managed via the surgical-orthodontic approach, which
impacted M2Ms, immediate success is achieved demands additional surgical steps alongside orthodon-
through the surgical procedure itself, swiftly reposi- tic traction, especially in instances of deeper impac-
tioning M2Ms within the dental arch. The orthodontic tion or complete inclusion. This extended timeframe
treatment is frequently necessary to stabilize the posi- accounts for the difference of a few months. Neverthe-
tion of the repositioned M2M or refine the occlusal less, over the first year, all techniques exhibited an
relationship. On the other hand, the orthodontic approximate 80% rate of positive outcomes. In the
approach often requires the support of surgical tech- balancing of surgical and orthodontic approaches,
niques to achieve successful outcomes, and moderate anamnestic data can be very important in the diag-
evidence supports this conclusion.7,11,13,15 Prior to or- nostic phase and can influence clinical manage-
thodontic traction, surgical procedures can effectively ment.4,5,35 As reported previously, age is not
remove mucosal and bone coverage, thereby exposing considered an obstacle in the treatment of impacted
the dental crown for a proper positioning of the ortho- M2M, but a more favorable prognosis could be
dontic appliance. Additionally, surgery can also assist achieved when the M2M roots are not yet fully devel-
in dislocating the tooth and removing any obstructing oped.7,12,13 As described by La Monaca and colleagues,
third molars, if necessary. Within this cohort, a 6- tooth movement in adolescents is easier and more
month follow-up period revealed that a majority of appropriate than in adults, who are often intolerant
M2Ms (approximately 80% following orthodontic to fixed orthodontic therapy.7 Furthermore, in the
treatment and around 70% following surgical or decision-making protocol, the initial M2M angulation

FIGURE 6. Random-effects and meta-analysis on the therapeutic successful rate (event) with (experimental) and without (control) third molar
removal.
Barone et al. Managing Mandibular Second Molar Impaction. J Oral Maxillofac Surg 2023.
BARONE ET AL 1419

FIGURE 7. The Kaplan-Meier curve depicting the time to M2M repositioning is represented by the solid line, indicating the probability of a
successful outcome over time. Dotted lines delineate the confidence intervals of this event probability. As is evident from the visual representation,
it’s clear that within the cohort of impacted M2Ms, only a subset after surgical treatment achieved this outcome at t = 0 days, attributable to the
concurrent implementation of a surgical procedure and successful repositioning within the dental arch (where the surgical procedure coincided
with successful repositioning). Over a 6-month follow-up period, a majority of M2Ms (approximately 80% after orthodontic treatment and 70%
after surgical or surgical-orthodontic treatment) were effectively repositioned. Within the initial year, all techniques demonstrated an approxi-
mate 80% positive outcome rate.
Barone et al. Managing Mandibular Second Molar Impaction. J Oral Maxillofac Surg 2023.

can also play an important role.4,7 The sample extraction when possible.6,11,13,15 Considering a total
analyzed in this study was mostly characterized by of 444 M2Ms, different therapies were considered in
mesially inclined M2Ms with different severity of addition to or without M3M removal. As reported in
bone impaction. Mesial inclination is the most com- this review, M3M removal is often part of other strate-
mon position for impacted M2M, mainly due to an gies, because third molar extraction alone could be
abnormal eruption path.4,7,36 This position often al- the successful treatment only in selected cases of early
lows for a less complex treatment for M2M reposition- diagnosis of mild M2M impaction that does not require
ing, as the tooth usually still has the potential to erupt. significant uprighting maneuvers. Sometimes, the surgi-
Regarding M2M angulation, the calculation of the cal goals could include the removal of the third molar to
angle between the long axis of the M2M and the per- obtain sufficient space for M2M repositioning.5,6,25,29,32
manent first molar can be crucial, ranging from 13 As reported by Kim et al, the development of the retro-
to 75 .15,19,23,37-41 Depending on the severity of M2M molar space can be predicted by age and sex, as it in-
impaction, surgery can effectively remove bone creases by 1.5 mm per year in girls and boys up to 14
coverage, expose the dental crown, and eventually and 16 years of age, respectively. Furthermore, as
dislocate the tooth to allow the positioning of the shown by Padwa et al, surgical procedures could also
orthodontic appliance for traction.5-7,25,29,31,32 The improve mandibular bone remodelling in adolescents.5
more appropriate clinical approach for M2M impac- The results of this comparative analysis support the
tion should also focus on periodontal evaluation. notion that the third molar does not interfere with
Although Padwa and colleagues found that peri- M2M uprighting if it is not a physical obstacle to the
odontal defects did not worsen after orthodontic up- eruption path of M2M. As reported in the literature,
righting of impacted M2Ms, an accurate preoperative retention of the third molar could be doubly useful.5
evaluation should be mandatory to support the deci- It could simulate a distal wedge effect, improving the
sions of both the surgeon and the orthodontist.5 postoperative stability during M2M uprighting.5 In
The decision-making protocol for the therapeutic cases of failure of M2M uprighting, it could be replaced
approach for impacted M2Ms should also consider by a spontaneous or guided mesial drift.5
the necessity of third molar removal. The results of A noteworthy aspect to consider is the quality of the
this review could support clinicians in avoiding M3M existing literature on this topic, which presents a
1420 MANAGING MANDIBULAR SECOND MOLAR IMPACTION

limitation in this review. A significant portion of these 158:849–855, 2020. https://doi.org/10.1016/j.ajodo.2019.

11.016
studies fall under the nonrandomized category, accom-
7. La Monaca G, Cristalli MP, Pranno N, Galluccio G, Annibali S,
panied by notable diversity in their comparative Pippi R. First and second permanent molars with failed or de-
groups. This diversity emanates from variations in layed eruption: Clinical and statistical analyses. Am J Orthod
Dentofacial Orthop 156:355–364, 2019. https://doi.org/10.
study designs and patient populations. While this di- 1016/j.ajodo.2018.09.020
versity could introduce some variability, it also under- 8. Han T, Christensen BJ. Surgical treatment of impacted mandib-
scores the complexity and multifaceted nature of the ular second molars: A systematic review. J Oral Maxillofac Surg
80:29–36, 2022. https://doi.org/10.1016/j.joms.2021.08.160
topic under investigation. 9. Kim KJ, Park JH, Kim MJ, Jang HI, Chae JM. Posterior available
This study aimed to describe the indications and space for uprighting horizontally impacted mandibular second
outcomes of the available therapeutic approaches for molars using orthodontic microimplant anchorage. J Clin Pe-
diatr Dent 43:56–63, 2019. https://doi.org/10.17796/1053-
M2M impaction, highlighting their advantages and dis- 4625-43.1.11
advantages. Qualitative analysis showed a moderate to 10. Fan W, Gao D, Wang Y, et al. Three-dimensional measurement
good evidence, although most of the included articles and analysis of mandibular characteristics in subjects with
impacted mandibular second molars. Orthod Craniofac Res
are nonrandomized studies. The quantitative analysis 23:332–341, 2020. https://doi.org/10.1111/ocr.12375
revealed no significant distinctions among the 3 thera- 11. Kenrad J, Vedtofte H, Andreasen JO, Kvetny MJ, Kjær I. A retro-
peutic approaches, underscoring that orthodontic, spective overview of treatment choice and outcome in 126
cases with arrested eruption of mandibular second molars.
surgical-orthodontic, and surgical interventions for
Clin Oral Investig 15:81–87, 2011. https://doi.org/10.1007/
impacted M2Ms can all be effective. Although the 3 s00784-009-0364-3
therapies have distinct approaches, they yield similar 12. Pogrel MA. The surgical uprighting of mandibular second mo-
lars. Am J Orthod Dentofacial Orthop 108:180–183, 1995.
results, suggesting that clinicians are able to choose https://doi.org/10.1016/s0889-5406(95)70081-1
best treatment for most cases. Additionally, third molar 13. Valmaseda-Castell on E, De-la-Rosa-Gay C, Gay-Escoda C. Eruption
removal did not provide any benefits or lead to a disturbances of the first and second permanent molars: Results of
treatment in 43 cases. Am J Orthod Dentofacial Orthop 116:651–
higher success rate in M2M uprighting, as M3M did 658, 1999. https://doi.org/10.1016/s0889-5406(99)70200-3
not interfere with the eruption path of M2M. However, 14. Lau CK, Whang CZ, Bister D. Orthodontic uprighting of severely
the conclusions of this systematic review should be impacted mandibular second molars. Am J Orthod Dentofacial
Orthop 143:116–124, 2013. https://doi.org/10.1016/j.ajodo.
confirmed by conducting prospective analyses on ho- 2011.09.012
mogeneous samples compared with matched control 15. Magnusson C, Kjellberg H. Impaction and retention of second
groups determined by a detailed randomization pro- molars: Diagnosis, treatment and outcome. A retrospective
follow-up study. Angle Orthod 79:422–427, 2009. https://doi.
cess. For this purpose, clinicians could benefit from org/10.2319/021908-97.1
implementing a classification of difficulty for M2M 16. Boynton T, Lieblich SE. Surgical uprighting of second molars.
impaction. A data-driven classification system should Atlas Oral Maxillofac Surg Clin North Am 21:235–237, 2013.
https://doi.org/10.1016/j.cxom.2013.05.001
be the future goal, testing over multiple sites to assess 17. Cassetta M, Altieri F, Calasso S. Etiological factors in second
its validity and reliability. Future prospects could mandibular molar impaction. J Clin Exp Dent 6:e150–e154,
involve the use of machine learning and artificial intel- 2014. https://doi.org/10.4317/jced.51382
18. Shapira Y, Borell G, Nahlieli O, Kuftinec MM. Uprighting mesially
ligence to generate detailed input which could be impacted mandibular permanent second molars. Angle Orthod
helpful in the diagnosis and, eventually, in the final 68:173–178, 1998. https://doi.org/10.1043/0003-3219(1998)
decision-making protocol. 068<0173:UMIMPS>2.3.CO;2
19. Shapira Y, Finkelstein T, Shpack N, Lai YH, Kuftinec MM,
Vardimon A. Mandibular second molar impaction. Part I: Ge-
References netic traits and characteristics. Am J Orthod Dentofacial Orthop
140:32–37, 2011. https://doi.org/10.1016/j.ajodo.2009.08.034
1. Derton N, Palone M, Siciliani G, Albertini P, Cremonini F, 20. Baccetti T. Tooth anomalies associated with failure of eruption of
Lombardo L. Resolution of lower second molar impaction first and second permanent molars. Am J Orthod Dentofacial Or-
through miniscrew-supported biomechanics: A proposal for a thop 118:608–610, 2000. https://doi.org/10.1067/mod.2000.
simplified classification. Int Orthod 19:697–706, 2021. https:// 97938
doi.org/10.1016/j.ortho.2021.09.008 21. Barone S, Antonelli A, Averta F, et al. Does mandibular gonial
2. Johnsen DC. Prevalence of delayed emergence of permanent angle influence the eruption pattern of the lower third molar?
teeth as a result of local factors. J Am Dent Assoc 94:100–106, A three-dimensional study. J Clin Med 10:4057, 2021. https://
1977. https://doi.org/10.14219/jada.archive.1977.0268 doi.org/10.3390/jcm10184057
3. Varpio M, Wellfelt B. Disturbed eruption of the lower second 22. Abate A, Cavagnetto D, Fama A, Matarese M, Bellincioni F,
molar: Clinical appearance, prevalence, and etiology. ASDC J Assandri F. Efficacy of operculectomy in the treatment of 145
Dent Child 55:114–118, 1988 cases with unerupted second molars: A retrospective case-
4. Turley PK. The management of mesially inclined/impacted control study. Dent J 8:65, 2020. https://doi.org/10.3390/
mandibular permanent second molars. J World Fed Orthod 9: dj8030065
S45–S53, 2020. https://doi.org/10.1016/j.ejwf.2020.09.004 23. Fu PS, Wang JC, Wu YM, et al. Impacted mandibular second mo-
5. Padwa BL, Dang RR, Resnick CM. Surgical uprighting is a suc- lars. Angle Orthod 82:670–675, 2012. https://doi.org/10.2319/
cessful procedure for management of impacted mandibular sec- 102111-656.1
ond molars. J Oral Maxillofac Surg 75:1581–1590, 2017. https:// 24. Choi YJ, Huh JK, Chung CJ, Kim KH. Rescue therapy with ortho-
doi.org/10.1016/j.joms.2017.02.027 dontic traction to manage severely impacted mandibular second
6. Caminiti MF, El-Rabbany M, Lou T, Reinish EI. Surgical up- molars and to restore an alveolar bone defect. Am J Orthod Den-
righting of mandibular second molars: A single-group retro- tofacial Orthop 150:352–363, 2016. https://doi.org/10.1016/j.
spective cohort study. Am J Orthod Dentofacial Orthop ajodo.2015.09.031
BARONE ET AL 1421

25. Lorente C, Lorente P, Perez-Vela M, Esquinas C, Lorente T. Treat- Oral Pathol 75:674–676, 1993. https://doi.org/10.1016/0030-
ment of impacted or retained second molars with the 4220(93)90420-9
miniscrew-supported pole technique: A prospective follow-up 34. Sawicka M, Racka-Pilszak B, Rosnowska-Mazurkiewicz A. Upright-
study. Prog Orthod 23:36, 2022. https://doi.org/10.1186/ ing partially impacted permanent second molars. Angle Orthod
s40510-022-00432-5 77:148–154, 2007. https://doi.org/10.2319/010206-461R.1
26. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa 35. Barros SE, Faria J, Jaramillo Cevallos K, Chiqueto K, Machado L,
Scale (NOS) for Assessing the Quality of Nonrandomised Studies Noritomi P. Torqued and conventional cantilever for uprighting
in Meta-Analyses; 2000 mesially impacted molars: A 3-dimensional finite element anal-
27. Higgins JP, Thompson SG, Spiegelhalter DJ. A re-evaluation of ysis. Am J Orthod Dentofacial Orthop 162:e203–e215, 2022.
random-effects meta-analysis. J R Stat Soc Ser A Stat Soc 172: https://doi.org/10.1016/j.ajodo.2022.07.014
137–159, 2009. https://doi.org/10.1111/j.1467-985X.2008. 36. Shpack N, Finkelstein T, Lai YH, Kuftinec MM, Vardimon A,
00552.x Shapira Y. Mandibular permanent second molar impaction treat-
28. Gulses A, Varol A, Sencimen M, Dumlu A. A study of impacted ment options and outcome. Open J Dent Oral Med 1:9–14, 2013.
love: Kissing molars. Oral Health Dent Manag 11:185–188, 2012 https://doi.org/10.13189/ojdom.2013.010103
29. Cassetta M, Altieri F. The influence of mandibular third molar 37. Soganci AE, Akbulut AS, Sahin G. A novel method for measuring
germectomy on the treatment time of impacted mandibular sec- tooth angulation in permanent mandibular second molars with
ond molars using brass wire: A prospective clinical pilot study. delayed tooth eruption. J Orthod 48:260–267, 2021. https://doi.
Int J Oral Maxillofac Surg 46:905–911, 2017. https://doi.org/ org/10.1177/14653125211003911
10.1016/j.ijom.2017.03.027 38. Evans R. Incidence of lower second permanent molar impac-
30. Davis WH, Patakas BM, Kaminishi RM, Parsch NE. Surgically up- tion. Br J Orthod 15:199–203, 1988. https://doi.org/10.1179/
righting and grafting mandibular second molars. Am J Orthod bjo.15.3.199
69:555–561, 1976. https://doi.org/10.1016/s0002-9416(76) 39. Cho SY, Ki Y, Chu V, Chan J. Impaction of permanent mandibular
80028-0 second molars in ethnic Chinese schoolchildren. J Can Dent As-
31. Johnson E, Taylor RC. A surgical-orthodontic approach in up- soc 74:521, 2008
righting impacted mandibular second molars. Am J Orthod 61: 40. Cassetta M, Altieri F, Di Mambro A, Galluccio G, Barbato E.
508–514, 1972. https://doi.org/10.1016/0002-9416(72)90156-x Impaction of permanent mandibular second molar: A retrospec-
32. Going RE Jr, Reyes-Lois DB. Surgical exposure and bracketing tive study. Med Oral Patol Oral Cir Bucal 18:e564–e568, 2013.
technique for uprighting impacted mandibular second molars. https://doi.org/10.4317/medoral.18869
J Oral Maxillofac Surg 57:209–212, 1999. https://doi.org/10. 41. Alligri A, Putrino A, Cassetta M, Silvestri A, Barbato E,
1016/s0278-2391(99)90244-6 Galluccio G. The mandibular permanent second molars and
33. Terry BC, Hegtvedt AK. Self-stabilizing approach to surgical up- their risk of impaction: A retrospective study. Eur J Paediatr
righting of the mandibular second molar. Oral Surg Oral Med Dent 16:246–250, 2015