Mandibular left second molar tipping: how should I manage this?

Let me give you a pearl about impacted thirds, they can't be erupted into occlusion if they are within the mandibular ramus. My rule of thumb is that there needs to be a 90 degree angle from the retro molar area behind the third to the ramus. Typically with impacted thirds it will be 45 degrees. There is not enough room distally and the muscle attachments and soft tissue will drape over the back of the crown . This is kind of a moot point since we don't have a panorex. Every once in a while I will encounter a patient who has room for the thirds and you see this nice little 90 degree angle with room in front of the ramus, this can be maintained hygienically and I don't advise removal in these cases. And of course if the first, or second molars are iffy the third is a nice back up if these teeth are lost. I'll be honest with a molar implant sites I routinely don't place a spacer but I follow the case monthly until osteointegration is complete. This was unusual to have the second molar tip and I will keep an eye on my future cases!

Dear Sb oms, I agree without a panorex or a view of the third molar roots, look at the relationship of the crown to the second molar. Also I stated that 6 months is not a usual time frame and who knows the periapicals are not aligned or oriented. But the poster must have made a clinical judgement that he doesn't have enough clinical room for the crown hence he took the film, we all know that periapicals can be misleading. And you know what, third molars do cause tipping of second molars, it needs to go. When partial odontectomies are performed, third molar root molars exhibit movement between six-twelve months per my clinical experience. Honestly what do you think caused the second molar to tip?

Hi CRS, "And you know what, third molars do cause tipping of second molars, it needs to go." I have been for years telling my patients that the studies don't back up the idea that erupting or impacted wisdom teeth impart a forward crowding force. I then defer to the orthodontists who (I thought) make this claim. Although I haven't read any of the studies to which I refer, and there are always other reasons why removing the impacted wisdom teeth is a good idea. Reading your above comment, however, I am wondering if I have been mistaken for all these years. "Honestly what do you think caused the second molar to tip?" On that same idea I have always understood it to be mostly related to occlusal forces. As you know, all teeth are angled in a forward direction with the anterior teeth being more pronounced than the molars. This creates a forward vector of force every time the teeth are brought together that is unrelated to the presence of wisdom teeth. Forward movement would be observed more in patients who are clencher/grinders. So in this particular case the impacted wisdom tooth clearly needs to go, but I would have expected the same tipping if it were not present. #18 took the opportunity to move because the space maintainer in front of it was removed, and because it had less bone to move through.

I agree when the third molar is that close in an older patient I routinely graft, sometimes place emdogain depending on the situation at surgery. Sometimes patients are viewed with "implant goggles" I can fix a lot if things when dentistry 101 is not followed but I feel bad for the patient when these things are ignored . I see a lot of crowned second molars when I remove the thirds. I try to have a good "flight plan" I believe it was called treatment planning in dental school, I often will make a mini treatment plan for my referring dds, I find it helps communication and gives the restoring doctor a heads up when treating their patients. It is usually appreciated and helps the team approach. Thanks for the post!

It is really unfair that the patient would not comply with the recommended treatment make sure you document the refused that treatment in the chart. Then when you consent the patient for the orthodontic uprighting tactfully state that this treatment was most likely necessary due to drifting of the second molar and the need to remove the drifted third molar to allow banding of the second. That way you stated the facts without getting into blame or any question of why the third or second are malposed. I agree with Sboms and Hughes that there is no absolute reason why the drift occurred but this gets the matter in the consent without being punitive. Be sure to charge the patient appropriately for these needed extra services. It is tricky because the patient needs to understand that the recommended extraction was not done, that's why I give the simple explanation of eruptive force as previously mentioned. Half the time when we explain treament plans to our patients they blankly stare at the X-rays and ask "what are the white things?(fillings)God bless em! You solved the mystery with the patient being 22y.o. and helped me personally since I have not had this happen yet and will put the experience in my mental file! The ortho corrections are really great I'm impressed with these posts! Best of luck and again thanks for reading!