# Impaction vs Delayed Eruption # Question: Appreciate your feedback about this 13 yrs old female Impacted 35. Has SM right now . She is cl II both sides and upper and lower anterior are proclained . I have done fix for impacted teeth but never Invisalign. How do you stage the tx ? ![](https://outline-production-attachments.s3-accelerate.amazonaws.com/uploads/5e251020-0250-40df-b185-994531667ed4/6cdbde8d-e46c-47c9-b074-4b96dd3c5d05/image.png?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Credential=AKIA4EOUDTOVUICLPZ4P%2F20260920%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20260920T213000Z&X-Amz-Expires=86400&X-Amz-Signature=5ef12801b74aed1fab1e02dd07e3e00c718fec305174afab0009161d08863073&X-Amz-SignedHeaders=host&x-amz-checksum-mode=ENABLED&x-id=GetObject) ![](https://outline-production-attachments.s3-accelerate.amazonaws.com/uploads/5e251020-0250-40df-b185-994531667ed4/9f8c4b0d-cf92-4631-af58-b03767b35c9f/image.png?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Credential=AKIA4EOUDTOVUICLPZ4P%2F20260920%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20260920T213000Z&X-Amz-Expires=86400&X-Amz-Signature=ce8bdbb90e0b74ce7f4eb02242b236a6997f7097e41c8c7cef0e5b279a1c5b01&X-Amz-SignedHeaders=host&x-amz-checksum-mode=ENABLED&x-id=GetObject) ![](https://outline-production-attachments.s3-accelerate.amazonaws.com/uploads/5e251020-0250-40df-b185-994531667ed4/75d6bdde-3cdc-40e4-9de4-3bc9d87f58f2/image.png?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Credential=AKIA4EOUDTOVUICLPZ4P%2F20260920%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20260920T213000Z&X-Amz-Expires=86400&X-Amz-Signature=106f406417a55f2acd6523287709ec7969ac8e96df5764dd809841db74e2889c&X-Amz-SignedHeaders=host&x-amz-checksum-mode=ENABLED&x-id=GetObject) ![](https://outline-production-attachments.s3-accelerate.amazonaws.com/uploads/5e251020-0250-40df-b185-994531667ed4/1c623b3e-a69f-4bab-85db-6b197000067e/image.png?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Credential=AKIA4EOUDTOVUICLPZ4P%2F20260920%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20260920T213000Z&X-Amz-Expires=86400&X-Amz-Signature=3ed0fd30beb6779855bab4253b18e2a64f5fd1985a1af7016f0b5e58a1f38d13&X-Amz-SignedHeaders=host&x-amz-checksum-mode=ENABLED&x-id=GetObject) ![](https://outline-production-attachments.s3-accelerate.amazonaws.com/uploads/5e251020-0250-40df-b185-994531667ed4/7c924c50-9fda-4e72-89c6-2aa12fcac4d7/image.png?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Credential=AKIA4EOUDTOVUICLPZ4P%2F20260920%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20260920T213000Z&X-Amz-Expires=86400&X-Amz-Signature=b959defc902150d2280980ec5e5cf2ee6729677e58d7a1c4a9d3c65b4dc4bb04&X-Amz-SignedHeaders=host&x-amz-checksum-mode=ENABLED&x-id=GetObject) ![](https://outline-production-attachments.s3-accelerate.amazonaws.com/uploads/5e251020-0250-40df-b185-994531667ed4/9f3d939b-b00b-4860-8bda-b25d66ed6f80/image.png?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Credential=AKIA4EOUDTOVUICLPZ4P%2F20260920%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20260920T213000Z&X-Amz-Expires=86400&X-Amz-Signature=9f76ee31bc88670b3adbd3d3d69d9609e7f3911cb488544b7dd413aa07f7ff07&X-Amz-SignedHeaders=host&x-amz-checksum-mode=ENABLED&x-id=GetObject) ![](https://outline-production-attachments.s3-accelerate.amazonaws.com/uploads/5e251020-0250-40df-b185-994531667ed4/da93824f-6b67-45ec-ae73-4b25ee2b191a/image.png?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Credential=AKIA4EOUDTOVUICLPZ4P%2F20260920%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20260920T213000Z&X-Amz-Expires=86400&X-Amz-Signature=b4fc85a7a6a27a8e61b97d1714f4867d2107fc7ba50fb36790f77161a5a70a46&X-Amz-SignedHeaders=host&x-amz-checksum-mode=ENABLED&x-id=GetObject) ![](https://outline-production-attachments.s3-accelerate.amazonaws.com/uploads/5e251020-0250-40df-b185-994531667ed4/fc00eb05-1498-4afc-9c3f-d0a0aa0a0532/image.png?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Credential=AKIA4EOUDTOVUICLPZ4P%2F20260920%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20260920T213000Z&X-Amz-Expires=86400&X-Amz-Signature=8d340b720a488db85aed1f0cecf2fc967dcabad735f9c2ff9d738fc31cd7cd9d&X-Amz-SignedHeaders=host&x-amz-checksum-mode=ENABLED&x-id=GetObject) ![](https://outline-production-attachments.s3-accelerate.amazonaws.com/uploads/5e251020-0250-40df-b185-994531667ed4/1db137a1-98df-4c8f-b1a4-3d4474c8f9c8/image.png?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Credential=AKIA4EOUDTOVUICLPZ4P%2F20260920%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20260920T213000Z&X-Amz-Expires=86400&X-Amz-Signature=0653748292a82213ed8ebf4f255966f4ec59ca99c85ea236f851547bb1465abd&X-Amz-SignedHeaders=host&x-amz-checksum-mode=ENABLED&x-id=GetObject) # Answer: [https://www.loom.com/share/5bbbde7219514d3089aee9b7db3e40b4?sid=0f759d42-5340-4e38-a42a-553700ab6aff](https://www.loom.com/share/5bbbde7219514d3089aee9b7db3e40b4?sid=0f759d42-5340-4e38-a42a-553700ab6aff) This discussion addresses the case of a 13-year-old patient with an impacted lower second molar. The patient currently has a space maintainer and presents with a Class II malocclusion on both sides, upper and lower anterior proclination, and completed impactions but no history of Invisalign treatment. The first step in evaluating this situation is to determine whether the case represents a true impaction. An impaction occurs when a tooth remains unerupted for two years beyond its expected eruption time, with a high probability (over 90%) that it will not erupt on its own. If the tooth has been progressing toward eruption during that period, it is not considered impacted. Instead, this case should be classified as delayed eruption since the patient is only 13 years old. A comparison with the opposing side shows that the root structure of the affected tooth is not as developed. One potential explanation for this is early loss of the primary tooth, which may have disrupted the normal eruption pathway. Without the guiding roots of the primary tooth, the permanent tooth must navigate through bone, which is a more complex process. Delayed eruption is not uncommon and can occur due to variations in primary tooth loss timing. If the primary tooth was recently extracted and there are no signs of ankylosis, the delayed eruption should not be alarming. However, if there was no ankylosis and the reason for the delay is unknown, closer monitoring is necessary. The recommended approach is to maintain space for the unerupted molar, take a panoramic radiograph in six months, and assess whether the tooth has made progress in erupting. If the tooth begins to erupt, no intervention is needed, and the natural eruption process should be allowed to continue. If no progress is observed, the next step would be to consider actively bringing the tooth into the arch. In the meantime, Class II correction should be pursued, considering that growth is ongoing. Approaches may include distalization with Class II elastics or a bite jump, depending on the patient's midline alignment. In the present case, the midline is slightly deviated toward quadrant 2, and the current treatment plan appears to be moving the midline further off course. To correct this, sequential distalization of the teeth in quadrant 1 should be performed while focusing on a bite jump in quadrant 2. The second premolar is not fully erupted, and its actual width is likely underestimated in the digital model. To prevent tracking issues or unintentional intrusion due to the "watermelon seed effect," sufficient space should be maintained around the tooth to facilitate proper eruption. If after a year there is still no improvement in the eruption of the lower second molar, surgical intervention may be required. This would involve uncovering the tooth, bonding a button to it, and using elastics to aid in its eruption. Methods such as Kaplan hooks or Kobayashi ties can be employed to pull the tooth into position. Other techniques, including closed or open surgical approaches with chains, can also be utilized based on the specific needs of the case. Ultimately, the best approach at this stage is patience. Monitoring for six months will help determine if the tooth will erupt naturally. If it does, no further intervention is needed. If not, surgical assistance may be required to facilitate its eruption.