Don’t Forget the Second Molars“There is no excuse for failing to address the second molars in our treatment planning, especially considering the wealth of information available to the practicing orthodontist today. It is up to us to apply the therapeutic concepts that have already been developed for dealing with these challenging teeth, so that we can achieve the best possible long-term results for our patients.”
Back to Clinical Orthodontics, I would like to talk about the issue of including the second molars in fixed appliance treatment. The case for habitual bonding of the second permanent molars in orthodontic treatment with fixed appliances has been made on many occasions in orthodontic literature. however, it seems that -to date- many of us still overlook this vital step and do not perform it on a regular and consistent basis, thus loosing the potential benefits of such a measure. I, for one, have been guilty of this on many occasions in the past. The reasons for this way of thinking are many; some subscribe to the notion that including the 2nd molars in the appliance might lead to an unwanted decrease in overbite especially in anterior open bite and high-angle cases, due to their posterior extrusive effect; the so-called “wedge” effect. others consider bonding the 2nd molars as only extra work due to their position in the oral cavity; often difficult access and difficult isolation. The difficulties are numerous when attempting to band the 2nd molars, but direct bonding also can lead to bond failure more often than not, due to the difficult moisture control in many cases. Many practitioners will bond 2nd molars only if deemed necessary when there is a gross malalignment or rotation affecting the 2nd molar in relation to the 1st molars – often not from the start – and will not bond them otherwise. However, with a higher percentage of adult patients seeking orthodontics, we often encounter issues such as inappropriate buccolingual alignment, mesiodistal tip and axial alignment, incorrect root torque, and marginal ridge discrepancies with the adjacent first molars. All these issues necessitate correction in order to be able to achieve optimal results.
In the ( MBT) philosophy, for example, It is recommended to always bond the 2nd molars slightly more to the occlusal to avoid extrusion and adversely affecting the overbite. This is certainly something I’ve been personally doing for a long time, with excellent results and minimal adverse effects on overall occlusion even in high angle cases. When using self-ligated bracket systems, bonding the 2nd molars is considered mandatory – as in the Damon System philosophy. The short article by Dr. Robert G. Keim (VOLUME 41 : NUMBER 05 : PAGES (243-244) 2007) published in The Editor’s Corner in the Journal of Clinical Orthodontics (JCO) in 2007 is well worth a read.
What is your opinion and experience in relation to this topic? Do you regularly include the 2nd permanent molars with fixed appliance treatment? I would love to read your thoughts in the comments.
The Orthodontic Notefile 
I think it would vary from case to case, you cannot really have a uniform protocol for all cases. If the second molars are in good position or if first molars are excessively rotated/tipped, I would rather bond them later in treatment, once first molars are aligned, so that I can use the 2nd molars as a reference ( Mulligan, common sense mechanics)
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Thanks for your comment. I do tend to agree with that notion, although I find that I usually end up bonding them later in the majority of cases if I didn’t bond them early on at the start!.. But yes, I personally try to approach it in the same common sense you mention above. Thanks again.
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Dear Shadi, thanks for your post. I personally included the second molars in all my finished and in progress patients, and I will include them in my future patients as well. I find no contraindication including them as long as we know where/when to go and what to achieve. I finish my txs up to ABO standards; leveled marginal ridges, parallel roots, no Discrepancies in anterior guidance (incisal and lateral excursions). It is true that there might be no deflective occlusal contacts (DOCs) on 7s as we finish tx if they were not included, but I am 100% certain i won’t have them if I include 7s in tx.
I agree that bonding 7s might not be the most pleasing clinical procedure, neither cutting a heavy wire flush to it, but with time it becomes easier as the learning curve goes up.
Again Shadi, I thank you for your nice posts.
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Thank you for you comment and kind words Dr Ammar. Indeed, I tend to also agree with you that including them solves more problems than it creates. Finishing to those high standards you mention should be a goal and priority for all of us, in all cases. Thanks again for taking part in this discussion.
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Always meticulous and carful in subject choice Dr.Shadi…Bravo!
Personally…bonding 2nd permanent molars…it’s mattter of practice:real intelligence comes for an ability to decide in timely manner (the right time) and to select the most beneficial treatment (the right treatment)…for example with extruded 1st mollars :if you start bonding 2nd Ms from the very beginning meant pure suicide…..However bonding them during orthodontic treatment, becomes a real calvary for us when wires sequences is usually repeated…..!!!
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Thank you Dr Rachid. Yes, It is sometimes “tricky” to decide when to bond 2nd molars. From the feedback from various discussions with colleagues, I’m finding that this particular clinical point is very variable and that was exactly the main driver for me to write this post. Thanks a lot for your valuable input in this matter.
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so, any suggestion when to bond up 2nd molar?? when change wire innot 016 niti or in 18×25 heat niti?
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Thank you for your question. Ideally and most of the time the best time to bond 2n molars is at the start of treatment if possible, unless they are still not fully erupted, it’s best to engage them as soon as possible.
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Excellent article and addresses a subject we all often think about.
I personally always bond the second molars, except for growing children when the treatment finishes before the second molars are fully erupted and they are erupting in a good position.
(& Yes they have the highest bond failure than any other bracket, but in my opinion this is not a good enough reason not to bond or rebond them).
Excellent article
Thanks
Yaz
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Thanks Yaz for your comment and valuable insights my friend.
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IT WOULD BE GOOD TO BOND THE LOWER 2ND MOLARS TO OPEN UP THE BITE IN A CLOSED BITE CASE . YOU WOULD BE SLIGHTLY PUSHING THE 2ND MOLAR BACK SLIGHTLY IN THE RAMUS ( like a nut in a nut cracker) AND ALSO ADVANCING THE LOWER INCISORS with the net effect of opening up the bite. By the same token, band both the upper and lower 2nd molars in a open bite case. This would flatten both arches and close the bite.
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Thanks for your valuable comment. I agree that this would be a good general rule to follow.
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hi, i have problem when bonding up 2nnd molar tube as pt keep coming back due to dislodge. patient dont want to be band it up. any way to fix this or prevent dislodgement of 2nd molar tube ? ( it seems pt keep biting the 2nd molar tube if i place occlusally)
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When this type of issue keeps happening, it’s better to ensure bite raising – if the case permits – as well as using at least a 16 Niti or in some cases a 14 SS wire can be helpful until a rectangular wire is able to be inserted. This problem usually disappears at this stage.
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