JIOS

10.5005/jp-journals-10021-1289
Management of Unilaterally Impacted Permanent Mandibular First, Second and Third Molars
Case report

Management of Unilaterally Impacted Permanent

Mandibular First, Second and Third Molars
1
Rohit Mehrotra, 2Akshita Mehrotra, 3Jagruti Mistry

ABSTRACT While impactions of single teeth in a quadrant are rou­

This case report describes the treatment of a teenage patient tinely encountered by most orthodontists, multiple impacted
with simultaneous impaction of all three right mandibular molars in the same quadrant are an unusual occurrence and
permanent molars. The impacted first and second mandibular are likely to present as a highly challenging clinical situation.
molars were surgically exposed and orthodontically erupted This article reports and discusses the management of a rare
into good alignment and occlusion while the impacted third
molar in the same quadrant was extracted. The unique clinical case of simultaneous unilateral impaction of mandibular
presentation, various treatment alternatives, the decision first, second and third molars using a combined surgical and
making process in finalizing the treatment plan and its clinical orthodontic approach.
implementation are discussed.
DIAGNOSIS
Keywords: Impacted molar, Orthodontic, Eruption, Uprighting.

How to cite this article: Mehrotra R, Mehrotra A, Mistry J. A 15-year-old boy reported to our practice with the chief
Management of Unilaterally Impacted Permanent Mandibular complaint of ‘missing’ teeth in his right mandibular posterior
First, Second and Third Molars. J Ind Orthod Soc 2014; area. He also complained of spacing and ‘shifted’ teeth in the
48(4):419-428. lower right quadrant and desired treatment for the same. His
Source of support: Nil intraoral examination confirmed that no erupted permanent
Conflict of interest: None
molars were present on the right mandibular quadrant. The
most posterior tooth clinically visible in the lower right
Received on: 17/8/13 quadrant was the second premolar, which appeared to be
Accepted after Revision: 10/10/13 very distally positioned, leading to spacing. The patient’s
past dental, medical and family history revealed nothing
INTRODUCTION significant.
Extraorally (Figs 1A to C), the patient had a mildly
Impaction is defined as failure of tooth eruption caused convex profile. His lips were competent and their position
by a physical obstacle in the eruption path or abnormal with respect to the E-line was normal. Vertically, he had an
position of the tooth germ.1 While impaction of third average angle facial growth pattern and gingival display
molars is a common problem, the incidence of mandibular on smiling was within acceptable limits. His upper dental
second molar impaction is quite low and is reported to be midline was shifted slightly to the right.
around 0.06 to 0.3%.2-4 Impacted mandibular first molars Intraorally (Figs 2A to E), both upper quadrants and
are extremely rare, with a reported prevalence of less than the lower left quadrant had fully erupted permanent teeth
0.01%.2,5 Various treatment options for an impacted tooth till the first molars. The second permanent molars were
include extraction with or without prosthetic replacement erupting on the left side but was not seen yet on the upper
or orthodontic space closure, surgical repositioning, right side. On the left side, molar relation was Class I and
transplantation and orthodontically assisted eruption with canine relation between end on and Class I. On the right side
or without surgical uncovering.6-10 canine relation was Class I but the lower premolars appeared
to have migrated distally significantly with resultant spacing.
1,2
Anteriorly, the overjet and overbite was slightly greater
Private Practitioner, 3Professor
than normal. The lower left second premolar had turner’s
1,2
Private Practice, Mumbai, Maharashtra, India hypoplasia.
3
Department of Oral and Maxillofacial Surgery, Yogita Dental The orthopantomogram (Fig. 3) revealed that all
College and Hospital, Ratnagiri, Maharashtra, India permanent teeth were present but the right mandibular first,
Corresponding Author: Rohit Mehrotra, Private Practitioner, second and third molars were severely impacted. Crowns of
Mumbai, Maharashtra, India, Phone: 26162111, e-mail: contact@ first and second right mandibular molars were ‘looked’ into
smileprofile.com
each other with the first molar distally tipped and second

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Rohit Mehrotra et al

A B C
Figs 1A to C: Pretreatment facial photographs

A B C

D E
Figs 2A to E: Pretreatment intraoral photographs

molar horizontal while the right lower third molar was c. Surgical exposure and orthodontic assisted eruption and
displaced high in the ramus. repositioning of lower right second molar.
Lateral cephalogram (Fig. 3 and Table 1) revealed that d. Extraction of lower right third molar to be done only
the patient had a skeletal Class I average angle facial pattern after ensuring good prognosis of orthodontic treatment
with mildly increased labial inclination of the incisors. of lower right first and second molars. This would keep
alternative treatment options open.
TREATMENT PLANNING Alternative treatment options that were considered
Analysis of diagnostic records revealed that the space are extraction of either the lower right first or second
available was not sufficient to accommodate all three right molar and utilizing the lower right third molar to provide
mandibular molars properly in the arch. Hence, one molar satisfactory occlusion. More radical and invasive options like
would definitely have to be extracted and two molars could transplantations and surgical tooth repositioning were also
be correctly positioned in the arch. considered. Lastly, the option of extracting all three molars
Our preferred treatment plan involved the following and providing implant prosthesis with ridge preservation and
steps: if needed, bone grafting procedures was also contemplated.
a. Mesialization of lower right second premolar to create Besides correction of the impacted right mandibular
space for the molars. molars, achieving a Class I occlusion with proper alignment
b. Surgical exposure and orthodontic assisted eruption and and leveling of the arches and good dental and facial esthetics
mesialization of lower right first molar. was also part of the treatment objectives.

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Management of Unilaterally Impacted Permanent Mandibular First, Second and Third Molars

Fig. 3: Pretreatment orthopantomogram and lateral cephalogram

Table 1: Summary of cephalometric analysis

Measurement Pretreatment Post-treatment
SNA 81° 81°
SNB 78.5° 79°
ANB 2.5° 2°
Wits AO & BO coincident BO > AO by 0.5 mm
U1 to NA 6.5 mm, 29° 6 mm, 26°
U1 to SN 109° 107°
L1 to NB 6 mm, 30° 5.5 mm, 24°
IMPA 100° 94°
L1 to APog 2.5 mm, 29° 2 mm, 24°
Fig. 4: Orthopantomogram after alignment and mesialization of
U1 to L1 119° 127° lower right second premolar
GoGn to SN 29° 28°
Jarabak ratio 64.8% 66.1%
A forsus spring (3 M Unitek) was placed on the right side
U-lip to E-line –1.5 mm –1.5 mm
between the upper first molar and lower canine to reinforce
L-lip to E-line 0 0.5 mm
anchorage for mesializing the lower first molar and also
slightly intrude the upper posteriors. As soon as the lower
TREATMENT PROGRESS
right first molar had erupted sufficiently to expose its buccal
Treatment was initiated in both arches with 0.022″ MBT surface, the initial attachment was removed and 0.022" MBT
appliance. A soldered transpalatal arch was placed to control buccal tube was bonded to move it into its correct position.
eruption of upper right molars and reinforce anchorage. Radiographs taken at this stage showed correctly positioned
Initial alignment in the lower arch was obtained using lower right first molar with mesially inclined impacted lower
round nickel-titanium archwires which helped primarily right second and third molars (Figs 7A and B). A second
to derotate the distally positioned right lower second surgery was done to expose and bond 0.022" MBT buccal
premolar. Mesialization of the right lower second premolar tube on the lower right second molar and simultaneously
was subsequently done using sliding mechanics on 0.018″ extract the lower right third molar (Figs 8A and B). Sectional
Stainless Steel archwires (Fig. 4). After completing upper 0.014" round nickel-titanium wire piggybacked on the main
alignment, the teeth in each arch were ligated and upper and archwire was used to erupt the lower right second molar.
lower 0.019" × 0.025" stainless steel archwires placed. The The same erupted severely lingually inclined and corrective
next step was to ‘unlock’ the lower right first molar from the torque was applied using a series of rectangular archwires
second molar by mesially uprighting and extruding it into its (Figs 9A and B).
proper position (Figs 5 and 6). A minimally invasive surgical After correcting the lower right second molar, finishing
procedure was done to expose the most easily accessible and detailing of the occlusion was done (Figs 10A to E).
mesial surface of the impacted first molar and a Begg’s This included planning for a full ceramic crown on lower
bracket was bonded close to the mesiobuccal line angle. left second premolar, which had turner’s hypoplasia and
Mesial traction was initiated using chain elastics from the its small size was contributing to an interarch tooth size
mandibular right first molar to the right mandibular canine. discrepancy in the left posterior region. Open coil springs

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Rohit Mehrotra et al

A B
Figs 5A and B: Uprighting and eruption of lower right first molar—use of the forsus appliance (and TPA) to reinforce
anchorage and prevent extrusion of upper right posterior segment

A B
Figs 6A and B: Uprighting and eruption of lower right first molar: (A) Before and (B) progress

A B
Figs 7A and B: Lower right first molar fully aligned. Orthopantomogram at this stage, reveals mesioangular impaction of
lower right second molar and insufficient space for lower right third molar

were placed to create mild spaces on the mesial and distal of Attachments were left bonded on the buccal of upper right
the same premolar and correct the occlusion. The lower left second molar and lingual of lower right second molar for
second premolar was purposefully finished in infraocclusion another month after the rest of the appliance was removed
to keep its reduction to a minimum while placing the full for use of settling elastics and to ensure stability.
ceramic crown. Class II elastics were used for a short time to The patient maintained a very poor level of oral hygiene,
achieve and maintain Class I canine and molar relationship. especially in the last 2 years of the treatment. This resulted
Upper and lower canine to canine lingual bonded retainers in decalcification and several carious lesions which were
were placed and the orthodontic appliance was debonded restored subsequent to debonding. Temporary composite
(Figs 11A to E). The total treatment time was 46 months. restorations had been placed on mesial and distal of lower

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Management of Unilaterally Impacted Permanent Mandibular First, Second and Third Molars

A B
Figs 8A and B: Surgical exposure and bonding of an attachment on lower right second molar along with
extraction of lower right third molar

A B
Figs 9A and B: Lower right second molar uprighting and erupting into oral cavity.
The lingually inclined second molar was torqued using a series of rectangular wires

A B C

D E
Figs 10A to E: Finishing wires. Patient maintained very poor oral hygiene especially in the later stages.
Lower left second premolar being positioned for full ceramic crown with minimal reduction

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Rohit Mehrotra et al

A B C

D E
Figs 11A to E: Intraoral photographs immediately after debonding

left second premolar just prior to debonding to maintain second molars were surgically exposed and orthodontically
space for the full ceramic crown, which was placed 6 weeks moved into good alignment and occlusion. A Class I molar
after completing orthodontic treatment. The impacted lower and canine relation with normal overjet and overbite was
left third molar was extracted during the finishing stages achieved post-treatment which was stable 6 months after
of orthodontic treatment. completing orthodontic treatment (Figs 12A to F). The
patient had a pleasant profile with competent lips and good
facial, dental and smile esthetics at the end of the treatment
TREATMENT RESULTS
(Figs 13A to C).
The treatment objectives as per our preferred treatment plan Post-treatment OPG (Fig. 14) reveals that the root
were achieved in this case. The right mandibular first and parallelism with respect to lower left canine and second

A B C

D E F
Figs 12A to F: six months post-treatment intraoral photographs

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A B C
Figs 13A to C: Post-treatment facial photographs

Fig. 14: Post-treatment OPG and lateral cephalogram

premolar could have been better. However, the development usually due to ectopic eruption while impaction of second
of decalcification areas and frank carious lesions forced us molars is commonly due to arch length deficiency.
to curtail the finishing stage of the treatment. Though the Primary retention is defined as cessation of eruption
upper and lower dental midlines were made coincident, of a normally placed and normally developed tooth before
slight dental midline shift to the right remained which was gingival emergence without a recognizable physical barrier
accepted. A comparison of pretreatment and post-treatment in the eruption path. A disturbance or abnormality in the
lateral cephalograms (Table 1) showed minor changes with dental follicle, which fails to initiate metabolic events for
improvement in labiolingual inclination of the incisors. bone resorption to enable eruption is thought to be the cause
of primary retention.12 Primary retention can be suspected
DISCUSSION when the eruption of a tooth is delayed by two or more
According to Andreason et al 11 three main causes of years.1 Radiographically, a primary retained molar would
eruption disturbances are ectopic position of the tooth germ, mostly show a normal orientation in its eruption path.
obstacles in the eruption path and failures in the eruption Secondary retention refers to cessation of eruption of a
mechanism. Raghoebar et al1 have for diagnostic purposes tooth after gingival emergence without a physical barrier
classified eruption disturbances of teeth into the following in the eruption path or ectopic position of the tooth. The
three categories: impaction, primary retention and secondary most accepted reason for secondary retention is ankylosis
retention. of the tooth and infraocclusion is the most reliable clinical
Impaction is the cessation of the eruption of a tooth finding.13,14
caused by a clinically or radiographically detectible physical Another condition, although rare, that has been used in
barrier in the eruption path, or due to an abnormal position connection with unerupted teeth, most commonly molars,
of the tooth. Radiographically, an impacted molar before is primary failure of eruption.15,16 This was defined by
emergence would show an abnormal orientation in its Profitt and Vig as a condition wherein nonankylosed teeth
eruption path. It is believed that impaction of first molars is fail to erupt fully or partially because of malfunction of

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Rohit Mehrotra et al

the eruption mechanism. The typical features include plantation were also considered.17-20 If indicated, surgical
nonsyndromic eruption failure without mechanical repositioning is a more favorable procedure to transplantation
obstruction, infraocclusion, significant posterior open because the tooth roots are not removed from the socket and
bite, and inability to move affected teeth orthodontically. hence, there is greater chance of preserving the blood supply
Diagnosis is difficult and mostly achieved by exclusion. to the tooth and the roots are not exposed to contamination
In this case the affected first, second and third molars with saliva. While this would have drastically shortened
can be classified as impacted since they were displaced from the orthodontic treatment time, there was the increased
their normal positions, had improper angulations and the first risk of complications like nonvitalization, ankylosis, root
and second molar crowns were ‘locked’ into each other, thus resorption, root fracture and injury to inferior alveolar
impeding eruption. The follicle and periodontal ligament neurovascular bundle. Considering the age of the patient,
of the affected teeth appeared normal on radiographs. The these procedures can at best be considered alternatives if
past dental, medical and family history elicited nothing for some reason orthodontic treatment is contraindicated,
contributory to ascertain the etiology. has poor prognosis or fails. The fact that the roots of the
With the space analysis it was evident that it would right mandibular first and second molars were completely
not be possible to accommodate all three molars in the formed further increased the chances of complications with
arch. Our preferred treatment plan which was successfully these procedures.
implemented in this case was to surgically expose and The option of extracting all the three molars and
orthodontically bring into position the impacted lower right planning for prosthesis was considered too aggressive and
first and second molars and extract the third molar. It was undesirable, taking into account the patient’s age and the
also contemplated to extract either of the impacted first and fair prognosis of orthodontic treatment. This treatment
second molars and bring the third molar into occlusion. option would keep the complexity and timing of orthodontic
However, all the molars were very distally positioned and treatment to a minimum, but create the need of prosthetic
would require mesialization. If the lower right first molar replacement of two molars. Placement of implants would
was extracted, the horizontally impacted second molar would have to be delayed till growth had reduced to adult levels.
not only have to be uprighted but also require considerable Till that time, retention would need to be planned to
mesialization to move into position of the first molar. Opting prevent supraeruption of the upper right posteriors and
for extraction of the lower right second molar would appear distal movement of lower premolars. There would also be
to ease the uprighting of the impacted first molar. However, the need for ridge preservation and/or bone augmentation
the issue of bringing lower right third molar into functional procedures to facilitate implants. The possibility of surgical
occlusion as the second molar would remain. In this case, the complications would also be higher with this treatment
lower right third molar was displaced considerably high in approach. Moreover, no replacement works better or has
the ramus with a horizontal angulation. While spontaneous better long-term prognosis than one’s own healthy natural
improvement in the position of the lower right third molar teeth in good functional occlusion.
could be expected if adequate space was created, there We decided to initially move the impacted first molar
would be a considerable waiting period for the same and into position after creating space by mesialization of the
the extent to which the concerned third molar would move lower right second premolar. Disimpacting the lower right
into position to function as the second molar could not be first molar from the second molar by tipping it mesially into
predicted. Most probably, this would have involved another the space created would move it toward its final desirable
phase of orthodontics later and considerably lengthen the position. Also, the impacted first molar could be exposed
treatment time. Also, till the lower right third molar could and bonded with a minimally invasive surgical approach.
be brought into its final position, it would be necessary to One treatment approach that was considered was to initially
prevent supraeruption of the upper right molars. A study by extract the lower right third molar and expose and bond an
Magnussen and Kjellberg10 on impacted and retained second attachment on the second molar. However, the molars were
molars also describes extraction of the impacted second anyway positioned distal to their final desirable position and
molar with the intention of replacing it with the third molar any mechanics that would move the lower right second molar
as the least successful treatment regimen. Thus, moving any more distal to free the lower right first molar would be
the impacted first and second right mandibular molars into considered unfavorable. This would prolong treatment time
position and eventually extracting the third molar appeared and also tax anchorage later in the treatment. Moreover, due
to be the best option. to the uncertain etiology, it was considered prudent not to
Other options like surgical repositioning and trans­ extract the lower right third molar at the beginning of the

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Management of Unilaterally Impacted Permanent Mandibular First, Second and Third Molars

treatment. This would keep alternative treatment options and treatment planning in this case. However, we are of the
open should there be a need to revise our treatment plan. opinion that the same can be an excellent diagnostic tool
A forsus spring (3M Unitek) was used during uprighting for three dimensional assessment and optimizing treatment
and mesialization of the lower right first molar. Along with approach in complicated impaction cases.
the transpalatal arch, this adequately reinforced anchorage
for the impacted first molar correction. Miniscrews could REFERENCES
have been used for anchorage in this case. However,
1. Raghoebar GM, Boering G, Vissink A, Stegenga B. Eruption
since the forsus spring also simultaneously enabled slight disturbances of permanent molars: a review. J Oral Pathol Med
intrusion of the upper right posterior segment, prevented the 1991;20(4):159-166.
supraeruption of upper right first molar till the lower first 2. Grover PS, Lorton L. The incidence of unerupted permanent
molar was corrected and helped achieve a Class I canine and teeth and related clinical cases. Oral Surg Oral Med Oral Pathol
1985;59(4):420-425.
molar relationship on the right side, it was our appliance of
3. Varpio M, Wellfelt B. Disturbed eruption of the lower second
choice in this case. molar: clinical appearance, prevalence and etiology. ASDC J
Many methods have been advocated for orthodontically Dent Child 1988;55(2):114-118.
correcting a mesioangularly impacted mandibular second 4. Bondemark L, Tsiopa J. Prevalence of ectopic eruption,
molar. Several techniques21,22 like the ‘pole arm’ spring impaction, retention and agenesis of the permanent second molar.
Angle Orthod 2007;77(5):773-778.
apply an uprighting and distalizing force without the need
5. Valmaseda-Castellon E, De-la-Rosa-Gay C, Gay-Escoda C.
for surgical exposure and bonded attachment by engaging the Eruption disturbances of the first and second permanent molars:
mesial surface of the second molar below the contact point. results of treatment in 43 cases. Am J Orthod Dentofacial Orthop
Other techniques23-28 utilize an attachment bonded on the 1999;116(6):651-658.
6. Fu PS, Wang JC, Chen CH, Huang TK, Tseng CH, Hung CC.
second molar and the use of coil springs, sectional archwire,
Management of unilaterally deep impacted first, second and
superelastic niti wire, different varieties of uprighting third mandibular molars. Angle Orthod 2012;82(3):565-571.
springs, and miniscrew skeletal anchorage. In the lower right 7. Resch D. Clinical management of unilaterally impacted
quadrant, a progressive improvement in the positioning of mandibular first and second molars. J Clin Orthod 2003;37(3):
the second molar was seen during mesialization of the second 162-164.
8. Haralabakis NB, Tsianou A, Nicolopoulos C. Surgical correction
premolar and uprighting of the first molar, and we expected
of mesially impacted mandibular second molars. J Clin Orthod
it to react very favorably to orthodontic force. As it was 2003;37(4):209-212.
considered necessary to extract the lower right third molar 9. Kurol J. Impacted and ankylosed teeth: why, when, and how to
for creating sufficient space for the lower right second molar, intervene. Am J Orthod Dentofacial Orthop 2006;129(4):86-90.
we decided to bond a buccal tube on the second molar in the 10. Magnusson C, Kjellberg H. Impaction and retention of second
molars: diagnosis, treatment and outcome—A retrospective
same surgical procedure. A sectional round nickel titanium
follow-up study. Angle Orthod 2009;79(3):422-427.
wire was considered a simple and comfortable method for 11. Andreasen JO, Petersen JK, Laskin DM. Textbook and Color
the initial eruption of the impacted second molar into the Atlas of Tooth Impactions 1997:199-208.
oral cavity following which rectangular archwires were used 12. Marks SC, Schroeder HE. Tooth eruption: theories and facts.
for effective three dimensional control of tooth position. Anat Rec 1996;245:374-393.
13. Raghoebar GM, Boering G, Jansen HW, Vissink A. Secondary
One issue which somewhat compromised treatment
retention of permanent molars: a histologic study. J Oral Pathol
results was decalcification and development of carious Med 1989;18(8):427-431.
lesions. This was due to the lack of oral hygiene maintenance 14. Raghoebar GM, Boering G, Vissink A. Clinical, radiographic and
by the patient coupled with the long duration of orthodontic histological characteristics of secondary retention of permanent
treatment. In retrospect, this could have been one factor in molars. J Dent 1991;19(3):164-170.
15. Proffit WR, Vig KW. Primary failure of eruption: a possible
favor of considering surgical uprighting of the impacted
cause of posterior open bite. Am J Orthod 1981;80(2):173-190.
second molar. However, repeated patient assurance toward 16. Ahmad S, Bister D, Cobourne MT. The clinical features and
improving hygiene and his insistence on avoiding any aetiological basis of primary eruption failure. Eur J Orthod
alternative treatment were factors which tilted our decision 2006;28(6):535-540.
to achieve maximum results with orthodontic treatment. 17. Johnson JV, Quirk GP. Surgical repositioning of impacted
mandibular second molar teeth. Am J Orthod Dentofac Orthop
Due to high caries index, we decided to place a crown
1987;91(3):242-251.
on the hypoplastic lower left second premolar, which also 18. Pogrel MA. The surgical uprighting of mandibular second
corrected the interarch tooth size discrepancy and ensured molars. Am J Orthod Dentofac Orthop 1995;108(2):
good occlusion. 180-183.
A cone beam CT scan was not used during the diagnosis 19. Schatz JP, Joho JP. Indications of auto transplantation of teeth

The Journal of Indian Orthodontic Society, October-December 2014;48(4):419-428 427

Rohit Mehrotra et al

in orthodontic problem cases. Am J Orthod Dentofac Orthop buccal sectional archwire technique. Am J Orthod Dentofacial
1994;106(4):351-357. Orthop 1991;99(3):276-280.
20. Thomas S, Turner SR, Sandy JR. Auto transplantation of teeth: 25. Eckhart JE. Orthodontic uprighting of horizontally impacted
Is there a role? Br J Orthod 1998;25(4):275-282. mandibular second molars. J Clin Orthod 1998;32(10):621-624.
21. Bach RM. Nonsurgical uprighting of mesially impacted lower 26. Park DK. Australian uprighting spring for partially impacted
molars. J Clin Orthod 2011;45(12):679-681. second molars. J Clin Orthod 1999;33(7):404-405.
22. Fu PS, Lai CH, Wu YM, et al. Uprighting impacted mandibular 27. Sawicka M, Racka-Pilszak B, Rosnowska-Mazurkiewicz A.
permanent second molars with the tip-back cantilever technique. Uprighting partially impacted permanent second molars. Angle
J Dent Sci 2008;3(3):174-180. Orthod 2007;77(1):148-154.
23. Aksoy AU, Aras S. Use of nickel titanium coil springs for 28. Giancotti A, Muzzi F, Santini F, Arcuri C. Miniscrew treatment
partially impacted second molars. J Clin Orthod 1998;32(8): of ectopic mandibular molars. J Clin Orthod 2003;37(7):
479-482. 380-383.
24. Kogod M, Kogod HS. Molar uprighting with the piggyback

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