Impacted maxillary central incisor: Surgical exposure and orthodontic treatment

Open surgical exposure of two horizontally impacted maxillary incisors combined with orthodontic treatment: A case report

INTRODUCTION

Maxillary anterior teeth that have not erupted may substantially alter the appearance of the teeth and face. Orthodontists often encounter a clinical challenge while dealing with an impacted maxillary incisor, which creates space problems in the anterior region. The purpose of this paper is to describe the well-synchronized orthodontic and surgical treatment of a horizontally impacted maxillary central incisors.

CASE PRESENTATION

A male patient, aged 27, presented with a complaint of unerupted two maxillary front teeth. This resulted in the displacement of adjacent teeth into the vacant region. An intraoral examination revealed a Class II molars on both sides, a deep curve of the space with a 2.3 mm overjet, and an edge-to-edge bite of 0.1 mm. The 3D cone beam computed tomography (CBCT) imaging unveiled a labial impacted and a rotation of approximately 90 degrees (horizontal impacted) on both central maxillary incisors.

DISCUSSION

The self-ligating bracket was installed and orthodontic traction aligned the affected tooth in the dental arch. To reach the labial surface of the impacted incisor, open surgical exposure by window excision of soft tissues with a laser was preferable due to the large bulge in the sulcus. Because self-ligating bracket systems employed modest pressures to position the maxillary right central incisor in the arch, the window surgical technique did not produce gingival scarring or increased clinical crown length.

CONCLUSION

The impacted upper central incisor was successfully treated using a collaborative interdisciplinary (surgical-orthodontic) approach, which resulted in a favorable aesthetic and functional outcome.

Labial inverse dilaceration of bilateral maxillary central incisors: A case report

BACKGROUND

Dilaceration is a rare dental developmental anomaly characterized by an abrupt deviation along the longitudinal axis of the root in which an angulation forms between the root and the crown. Here, we report on dilacerated bilateral maxillary central incisors in mixed dentition.

CASE SUMMARY

A 10-year-old girl presented with a chief complaint of unerupted central incisors. An oral examination and radiography provided the basis for a diagnosis of dilaceration of the maxillary central incisors. After surgical exposure of the impacted teeth, a button with an attached chain was applied to the palatal surface of teeth 11 and 21. After 8 mo, a button was bonded to the labial surface of the crown to fix an elastic chain and move the teeth toward the maxillary arch. Finally, a fixed appliance was applied to tooth alignment to Class 1 malocclusion using a 0.019 × 0.025-inch nickel-titanium wire. After 3 years of follow-up, the clinical findings and radiographic assessment showed that the roots had developed with vital dental pulp and healthy periodontium, were acceptable aesthetically, and showed no resorption.

CONCLUSION

The rare occurrences of dilacerated bilateral maxillary central incisors can be successfully treated through surgical exposure and orthodontics.

Harmonizing Dentofacial Balance: A Comprehensive Exploration of Class 1 Malocclusion Resolution With Impacted Maxillary Central Incisor Management

Permanent maxillary central incisor impaction is generally a rare phenomenon. Because the anterior teeth have a huge impact on a patient's facial aesthetics, missing anterior teeth are of major concern to patients who seek orthodontic treatment. However, correcting this type of malocclusion poses a challenge to the orthodontist. This case report of a 16-year-old male patient with an impacted maxillary right central incisor takes us through a series of events that are necessary to treat this type of malocclusion. The presenting case also had an impacted supernumerary tooth which was the primary cause for permanent tooth impaction. A combined treatment approach is usually needed to manage this type of case involving both the orthodontist and the surgeon.

Comparison of spontaneous eruption and modified closed eruption technique with palatal traction in alignment of impacted maxillary central incisor teeth

BACKGROUND

Central incisor impaction is a rare condition with potentially severe clinical and psychological implications for the patient. Treatment techniques vary according to the pretreatment situation and individual factors. The aim of this study was to compare the esthetic outcomes and treatment times between two different approaches.

MATERIALS AND METHODS

In this retrospective study, thirty-one consecutive patients (13 boys, 18 girls; average age 9.5 ± 2.3 years) with a total of 34 impacted permanent upper central incisors were included in the study. Patients were divided into two groups according to method of treatment. Group A comprised patients in whom spontaneous eruption occurred after space opening (n = 12), and Group B comprised patients in whom teeth showed no eruption and required treatment with a modified closed eruption method with palatally oriented traction (n = 19). Treatment time and esthetic outcomes were assessed and compared between groups.

RESULTS

The mean treatment time was 22.0 ± 6.7 months, and all teeth were successfully aligned. No statistically significant difference in average treatment time was found between groups in baseline characteristics (p > 0.05). The amount of attached gingiva was significantly smaller when compared to contralateral reference teeth in the closed eruption group (Group B; p = 0.03). However, no difference in amount of attached gingiva was found between both groups (p = 0.26). Additionally, no difference in the clinical crown length was found between groups (p = 0.27).

CONCLUSION

The closed eruption method with palatal traction directed at the peak of the alveolar crest provided results comparable to the physiologic tooth eruption.

Dimensional and morphologic characteristics of unilateral impacted maxillary central incisors

INTRODUCTION

This cross-sectional study aimed to investigate the crown and root characteristics of impacted central incisors compared with spontaneously erupted contralateral incisors and the influence of etiologic and local factors on their dimensions.

METHODS

Forty-five patients (22 boys, 23 girls) who underwent orthodontic treatment for unilateral impaction of maxillary central incisors were referred for cone-beam imaging. Dimensions of the impacted and contralateral incisors were assessed using Dolphin 3D software (Dolphin Imaging & Management Solutions, Chatsworth, Calif). Paired t test and linear regression were used to compare the characteristics of the impacted and contralateral teeth.

RESULTS

Contralateral and impacted central incisors showed statistically significant differences for root length (95% confidence interval [CI], 2.32-3.46; P <0.001), mesiodistal crown-root angulation (95% CI, 4.09-15.95; P = 0.001), and labiolingual crown-root angulation (95% CI, -18.69 to -4.70; P = 0.002). Etiologic factors did not alter the dimensions of incisors (95% CI, -1.17 to 0.76; P = 0.672). According to the multiple linear regression the independent variables associated with root length of contralateral and impacted incisors were sex (β = -0.904; 95% CI, -1.62 to - 0.19; P = 0.014) and the presence of impaction (β = -2.87; 95% CI, -3.67 to -2.07; P <0.001).

CONCLUSIONS

Regardless of their etiology, the impacted incisors showed roots that were 2.89 mm shorter than the contralateral incisors and had greater angulation in the mesiodistal and labiolingual directions. Girls showed a reduction of 0.904 mm (7.6%) on the lengths of roots of both impacted and contralateral central incisors. The presence of impaction led to a reduction of 25% in incisor root lengths. Approximately 30% of the impacted teeth showed crown-root angulations >20° resulting in an increased distal and labial angulation of the root apical portion.

Judgement in artificial eruption of embedded teeth from an oral surgery perspective: review article

Impacted teeth are a frequent phenomenon encountered by every clinician. The artificial eruption of embedded teeth is the process of directing an impacted tooth into normal occlusion. This procedure is currently attracting attention, with the aim of finding the best technique to use according to each case. This article presents key information regarding impacted incisors, canines, and premolars. In addition, we describe the most common techniques to use for artificial eruption, the open and closed techniques. We review the literature concerning these techniques and outline how clinicians can manage every type of impacted tooth.

A Modified Palatal Appliance for Forced Eruption of Impacted Central Incisor

A 9-year-old female was referred by her general dentist for an evaluation of an impacted maxillary left central incisor. Her maxillary left primary incisors showed crossbites and her right central incisor showed an edge-to-edge bite which caused gingival recession on the mandibular right central incisor. After treatment, the impacted maxillary central incisor erupted successfully. An optimal overbite and overjet were also achieved, and her gingival recession was improved.

Implant supported prosthesis on edentulous mandible with multiple impacted teeth - a case report with 5 year follow up

Multiple impacted teeth are quite often syndromically related, which could be hormonal or metabolic. It may be also due to infection, cyst, or trauma. A number of idiopathic multiple impacted teeth cases have been reported in the literature. In most of these situations, the impacted teeth are few in number. Here, we present a case with all mandibular teeth impacted. The number of reports in the literature of rehabilitation of such a clinical situation is very less. Impacted teeth can significantly complicate the rehabilitation of an otherwise straight forward case. When all teeth are impacted, the situation becomes even more complex. This case report illustrates prosthodontic rehabilitation of mandibular arch of a 24-year-old, asyndromic patient with implant-retained dentures following the surgical removal of impacted teeth. The objective of presenting this clinical report is primarily to increase the awareness, with which, the rehabilitation can be handled in a similar situation and also for the fact that such a report is a rarity.

Alveolar Bone and Epithelial Attachment Status following Two Different Closed-eruption Surgical Techniques for Impacted Maxillary Central Incisors

Aim

Two eruption surgical techniques are commonly described for the treatment of upper impacted central incisors (ICIs): Open and closed. Currently, the closed-eruption surgical technique (CEST) is the most commonly used, as it allows for the best esthetic and periodontal results.

The aim of this study was to determine the effect of traction discontinuation on maxillary central incisor sulcal depth and alveolar bone ridge levels compared with contralateral incisors, when CEST is used.

Materials and methods

Our study involved 28 unilateral impacted maxillary central incisors treated by CEST. Thirteen teeth were subjected to traction interruption for a month at the time of emergence of the crown, while 15 teeth underwent continuous traction. One year after treatment, periapical digital X-rays, anterosuperior cone beam computerized tomography (CBCT) scanning, and periodontal probing of the ICIs and contralateral central incisors (CCIs) were performed. Student’s t-test was used to study whether a statistically significant difference between continuous and interrupted tractions takes place while using the CCI measurements as reference.

Results

There was a statistically significant difference between the two techniques only for the following measurements: Mesial probing (p-value 0.039352), labial bone level (p-value 2.58E-08), and palatal bone level (p-value 2.56E-06).

Limitations

A larger sample size and longer term follow-up are needed to draw more robust conclusions.

Conclusion

A temporary discontinuation during traction of the tooth appears to positively impact treatment outcome on ICIs.

Clinical significance

• The CEST leads to the best periodontal status for ICIs.

• The discontinuation of traction at the emergence of the tooth allows the supracrestal fibers to insert into the cement in a proper way.

How to cite this article: Sfeir E, Gholmieh M, Skaf Z, Mourad A. Alveolar Bone and Epithelial Attachment Status following Two Different Closed-eruption Surgical Techniques for Impacted Maxillary Central Incisors. Int J Clin Pediatr Dent 2018;11(4):317-322.

Taking advantage of an unerupted third molar: a case report

Introduction:

Treatments with dental surgery seek to displace tooth to the correct position within the dental arch.

Objective:

To report a clinical case that took advantage of an unerupted third molar.

Case history:

A male patient, 18 years of age, was referred by his dentist to evaluate the third molars. The clinical exam revealed no visible lower third molars. The computed tomography (CT) exam showed the presence of a supernumerary tooth in the region of the mandibular ramus, on the left side, and impaction of the third molar, which was causing root resorption on the second molar, thus making it impossible to remain in the buccal cavity. The preferred option, therefore, was to remove both second molar and the supernumerary tooth, in addition to attaching a device to the third molar during surgery for further traction.

Results:

After 12 months, the third molar reached the proper position.

Conclusion:

When a mandibular second permanent molar shows an atypical root resorption, an impacted third molar can effectively substitute the tooth by using an appropriate orthodontic-surgical approach.

Prevalence, characteristic features, and complications associated with the occurrence of unerupted permanent incisors

This study examined the prevalence, characteristic features, and complications associated with the occurrence of unerupted permanent incisors among children and adolescents attending a university dental teaching hospital. A retrospective review was performed of the clinical records of children and adolescents who attended the Prince Philip Dental Hospital, Hong Kong between 2005 and 2014. All patients who had at least one unerupted permanent incisor tooth were included. A total of 266 subjects with 320 unerupted permanent incisors were identified. The prevalence of unerupted permanent incisors among children and adolescents was 2.0%. Permanent maxillary central incisors (70.6%) were the most commonly affected teeth. The most common cause for unerupted incisors were dilacerations (n = 83, 36.7%) for maxillary central incisors; developmental dental anomalies (n = 22; 30.6%) together with unfavorable root development (n = 22; 30.6%) for maxillary laterals incisors; and abnormal tooth/tissue ratio (n = 11, 50.0%) for mandibular incisors. A majority of unerupted incisors presented with complications the most common being ectopic/displacement/rotation of the unerupted incisors (46.6%), loss of space (36.9%) and midline shift (27.5%). In conclusion, the causes were distinct for different manifestations of unerupted permanent incisors. As the majority of unerupted incisors presented with complications, a systematic and organized method of history taking as well as clinical and radiographic examinations is mandatory in the diagnosis of unerupted permanent incisors.

CO2 Laser-Mediated Apically Positioned Flap in Areas Lacking Keratinized Gingiva

BACKGROUND AND OBJECTIVES

Autogenous gingival grafts are considered the "gold standard" for gingival augmentation, however they require a second surgical site for graft harvesting. Apically positioned flaps (APFs) represent an alternative method in soft tissue augmentation procedures. Limited information is available relative to the effectiveness of laser-mediated APF in augmenting keratinized gingiva (KG). The aim of this paper is to evaluate soft tissues changes following APF using CO2 laser in mandibular incisors with minimal KG and high labial frenum attachment.

MATERIALS AND METHODS

A total of 20 patients with minimal amount of KG (< 2 mm) on the labial aspect of one mandibular incisor and high buccal frenum insertion were selected for treatment. Only 19 completed the last follow-up visit. An APF consisting of a single superficial horizontal incision just coronal to the mucogingival junction using CO2 laser, elevation of a split-thickness flap, and suturing of the flap to the periosteum in an apical position was performed. The apico-coronal height of KG was measured at baseline, and at 3, 6 and 12 months postoperatively.

RESULTS

Uneventful healing was observed in all patients and an increase in KG of 2-3 mm was obtained. Most patients rated the procedure and the postoperative course as non painful.

CONCLUSIONS

CO2 laser-assisted APF procedure is a minimally invasive treatment modality associated with reduced risk of bleeding and predictable increase in the height of KG.

[Reason for failure in the treatment of impacted and retained teeth]

The positioning of an impacted or retained tooth in either children or adults presents a real challenge for the two practitioners involved, the orthodontist and the surgeon in charge of the surgical exposure. The maxillary canine is the tooth most often impacted in the anterior segment, with a prevalence of 2% in the general population. One can understand, therefore, the functional and esthetic challenge for the surgical-orthodontic team whose aim will be to reposition the impacted or retained tooth in the arch. A large number of mistakes must be avoided in order to achieve a satisfactory result for both the patient and the practitioner. Modern imaging techniques should be used to obtain a precise diagnosis of the location of the tooth and to perform surgery which will spare the tooth in question as well as the surrounding anatomic structures. The directions and forces of the traction used will need to be carefully thought out in order to move the tooth into its final position on the arch in optimal conditions. The periodontal setting will be optimized and checked at every step of the treatment. The aim, in fact, is to anticipate the onset of periodontal problems on the grounds that prevention is easier than cure.

Review of Dilaceration of Maxillary Central Incisor: A Mutidisciplinary Challenge

Traumatic injuries to primary dentition may interfere with the development of permanent dentition. Among the many malformations, dilaceration is particularly important to the clinician. Management of dilacerated maxillary central incisor requires a multidisciplinary approach. The main purpose of this review is to present the etiological factors, the mechanism, clinical features, radiographic features and treatment of dilaceration of the maxillary central incisors. How to cite this article: Walia PS, Rohilla AK, Choudhary S, Kaur R. Review of Dilaceration of Maxillary Central Incisor: A Multidisciplinary Challenge. Int J Clin Pediatr Dent 2016;9(1):90-98.

Management of Impacted Maxillary Central Incisor: Modified Nance Arch Application

This is a case report of a patient who presented to Wenzhou Medical University--Orthodontic Department at 8 years of age with missing right maxillary central incisor. A detailed clinical and radiographic examination was carried out and treatment plan formulated to surgically expose the impacted incisor and use the modified nance arch (MNA) appliance for orthodontic traction of the tooth in line of arch as phase one treatment followed by phase two treatment with fixed appliances.

An efficient biomechanical approach for the management of an impacted maxillary central incisor

Treatment of an impacted maxillary central incisor poses a unique challenge to the orthodontist because of its position within the esthetic zone, requiring careful management of the soft tissues and an effective biomechanical setup for alignment. This article describes a novel method of extending an extrusion wire from cross tubes attached on the base archwire for forced eruption of impacted central incisors. The effectiveness and versatility of this method are demonstrated with 2 patients.

Clinical recommendations for management of mesiodens and unerupted permanent maxillary central incisors

BACKGROUND

Un-erupted maxillary incisors may result secondary to supernumerary teeth. Despite the removal of such mesiodentes, orthodontic traction of a permanent un-erupted maxillary incisor may be required.

REVIEW

The literature regarding the impacted maxillary central incisor(s) was reviewed and all pertinent publications on the subject assessed. The review specifically relative to mesiodentes, surgical exposure and orthodontic management was interpreted together with the clinical experience of a number of the authors' cases. From this analysis a set of recommendations was developed.

RECOMMENDATIONS

(1) A sufficient arch space has to be ensured or orthodontically created for permanent maxillary central incisor(s). (2) Early surgical extraction of a mesiodens or mesiodentes (ideally before 7 years of age), with simultaneous closed surgical exposure of the permanent impacted maxillary incisor with bonding of an attachment with gold chain. (3) Re-evaluation after 2-3 months to assess for any natural eruption of the maxillary central incisor. (4) Application of orthodontic traction in the event of non-eruption.

CONCLUSION

Early diagnosis of the presence of mesiodentes is imperative. Appropriate surgical and/or orthodontic traction is often indicated with regular post-surgical follow-up assessments.

Macrodontic maxillary incisor in alagille syndrome

This case report describes the surgical-orthodontic guided-eruption of a deeply impacted macrodontic maxillary central incisor in a 10-year-old patient with Alagille syndrome (ALGS). In the first stage, orthodontic treatment with fixed appliance on deciduous teeth allowed to create enough space for the eruption of the maxillary right central incisor. The second stage included closed surgical exposure and vertical traction. After impacted tooth erupted in the proper position, accessory periodontal treatment and dental reshaping procedures may be indicated to camouflage macrodontic incisor with the adjacent teeth. This is the first report that presents a patient with ALGS undergoing orthodontic and surgical treatment.

Impaction of both maxillary central incisors and a canine

This case report describes the treatment of a 14-year-old adolescent patient who had 2 impacted maxillary central incisors with distoangular root dilacerations. He also had an impacted maxillary left canine, with the crown completely overlapping the root of the lateral incisor, and insufficient space. The general dentist referred this patient because the maxillary central incisors had still not erupted 2 years after extraction of the retained deciduous incisors. A unilateral expander with a modified vestibular arch and an attachment spring on the right side was used to correct the posterior crossbite on the right side and improve the positions of the teeth. The expansion appliance was also applied as a high anchorage device to move the central incisors and the left canine into position during the initial stages. After this phase, fixed appliances were used to redistribute the space in the anterior maxillary region to create enough space for repositioning the impacted teeth. This procedure restored the normal appearance of the maxillary arch, with good periodontal health and without evidence of root resorption, apart from the distoangular root dilacerations of the 2 maxillary central incisors.

Pre-treatment radiographic features predict root resorption of treated impacted maxillary central incisors

OBJECTIVES

To determine independent predictors of root resorption for surgical-orthodontic treatment of impacted maxillary central incisors.

SETTING AND SAMPLE POPULATION

The Department of Dentistry at Show Chwan Hospital, Changhua, Taiwan. Eighty patients with unilateral osseous-impacted maxillary central incisors receiving a surgical-orthodontic treatment.

MATERIAL AND METHODS

This is a retrospective observational study. Root resorption and its predictors were abstracted from patients' charts, pre-treatment cephalometric radiographs, and post-treatment periapical radiographs. Predictors included demographics, treatment duration, crown angle, crown height, crown depth, and root dilacerations.

RESULTS

The patients' mean age was 9.2 ± 2.3 years (6.4-20.6 years), and 60% were females. Impacted maxillary central incisors had greater root resorption than naturally erupted contralateral incisors (Δ = -2.8 mm, p < 0.001). Independent predictors of root resorption for impacted maxillary central incisors were shown by linear regression analysis to be crown height (β = -0.2, p < 0.01), crown depth (β = -0.3, p = 0.001), treatment duration (β = 0.2, p < 0.01), and root dilacerations (β = 3.1, p = 0.001).

CONCLUSIONS

Impacted maxillary central incisors had greater root resorption during surgical-orthodontic treatment than their naturally erupted contralateral incisors. Predictors of a greater root resorption were highly and deeply impacted incisors, longer treatment, and root dilacerations. These predictors may help to inform patient and family counseling before treatment.