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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2006  |  Volume : 24  |  Issue : 2  |  Page : 100-103
 

Surgical and orthodontic treatment of an impacted permanent central incisor: A case report


1 Dept. of Pedodontics, Sharad Pawar Dental College, Sawangi (Meghe), Wardha, Maharashatra, India
2 Dept. of Orthodontics, Sharad Pawar Dental College, Sawangi (Meghe), Wardha, Maharashatra, India

Correspondence Address:
N R Thosar
Dept. of Pedodontics and Orthodontics, Sawangi (Meghe), Wardha, Maharashatra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.26025

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  Abstract 

Although impaction of a permanent tooth is rarely diagnosed during the mixed dentition period, an impacted central incisor is usually diagnosed accurately when there is delay in the eruption of tooth. In this article, the impacted incisor was moved into it's proper position with surgical exposure and orthodontic traction, after which it showed good stability.


Keywords: Impacted incisor, orthodontic traction, surgical exposure


How to cite this article:
Thosar N R, Vibhute P. Surgical and orthodontic treatment of an impacted permanent central incisor: A case report. J Indian Soc Pedod Prev Dent 2006;24:100-3

How to cite this URL:
Thosar N R, Vibhute P. Surgical and orthodontic treatment of an impacted permanent central incisor: A case report. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2017 Apr 30];24:100-3. Available from: http://www.jisppd.com/text.asp?2006/24/2/100/26025


Although impaction of permanent tooth is rarely diagnosed during the mixed dentition period, an impacted central incisor is usually diagnosed accurately when there is delay in the eruption of tooth. Many patients with impacted maxillary central incisors are referred to orthodontist by general practitioners or pediatric dentists because parents are concerned about the impaction of an incisor in the early mixed dentition, even though its occurrence is less frequent.[1],[2],[3]

Tooth impaction may result from a number of local causes. Causes of non-­eruption and impactions are:

1. Arch length discrepancy

2. Presence of supernumerary teeth

3. Mucosal or bony barrier

4. Retained deciduous teeth.[4]

Supernumerary teeth cause impaction of permanent maxillary incisors has been proved in most of the studies.[5],[6],[7],[8],[9],[10] A tooth normally erupts when half to 3 quarters of it's final root length has developed. However studies have shown that many impacted teeth do not erupt, some need a second surgical exposure and most will need orthodontic alignment.

Treatment alternatives for an impacted central incisor includes.

1. Extraction of the impacted central incisor and restoration with a bridge or an implant later when growth had ceased.

2. Extraction of the impacted central incisor and closure of the space substituting the lateral incisor for the central incisor with subsequent prosthetic restoration.

3. Surgical exposure, orthodontic space opening and traction of the impacted central incisor into proper position.[2]


  Case Report Top


A 10 year old boy was brought by his parents to the Dept. of Pedodontics. Sharad Pawar Dental College, Sawangi (Meghe), Wardha. Their chief complaint was the non-eruption of the upper left permanent central incisor. The child was physically healthy and had no history of medical and dental trauma.

The patient had a skeletal class I malocclusion and balanced facial pattern. Intraoral examination revealed an early mixed dentition and an Angle's class I molar relationship. Clinical examination showed a missing maxillary permanent left central incisor [Figure - 1] and no apparent arch length discrepancy in both maxillary and mandibular arches. Inadequate space distribution of the maxillary incisors causing midline deviation was due to drifting of the adjacent teeth into unoccupied space.

An intraoral periapical radiograph of upper anterior region demonstrated a supernumerary tooth and an impacted permanent left central incisor [Figure - 2]. To confirm the position of supernumerary tooth, upper anterior occlusal radiograph was taken which showed the presence of supernumerary tooth on the palatal side [Figure - 3].

Several treatment alternatives were explained to the patient and his parents. They agreed for the extraction of supernumerary tooth surgically followed by surgical exposure of impacted central incisor and alignment of the impacted incisor into the arch by orthodontic treatment because the patient and his parents requested for the non extraction treatment.

Keeping these treatment alternatives in mind treatment objectives of this case were as follows.

I) Surgical extraction of the supernumerary tooth.

II) Surgical exposure of the permanent left central incisor.

III) Orthodontic treatment and space regaining for proper alignment of the impacted incisor in the maxillary arch.

I) Surgical extraction of the supernumerary tooth:­

a mucoperiosteal flap on the palatal side was raised. After careful elevation of the flap, adequate amount of bone was removed using rotary cutting instruments. The supernumerary tooth was removed surgically and the extraction socket was inspected for any pathological tissue. The flap was repositioned and sutures placed for a week. The absence of supernumerary tooth is appreciated in the postoperative intraoral periapical radiograph [Figure - 4].

II) Surgical exposure of the permanent left central incisor:­

As suggested by Becker A 1998,[11] surgical exposure can be performed in 3 accepted ways.

a) Circular excision of the oral mucosa immediately overlying the impacted tooth.

b) Apically repositioning of the raised flap that incorporates the attached gingiva overlying the impacted tooth.

c) Closed eruption technique in which the raised flap that incorporates attached gingiva is fully replaced back in it's former position after an attachment has been bonded to the impacted tooth.

In this case circular excision of oral mucosa overlying the impacted tooth was carried out.

III) Orthodontic treatment and space regaining for proper alignment of the impacted incisor in the maxillary arch:­

After surgical exposure, an orthodontic bracket was bonded to the labial surface of an impacted incisor. Initially removable orthodontic plate was given. Elastics were used for orthodontic traction initially [Figure - 5].

After the crown of the impacted incisor was sufficiently erupted, it was found that the space available in the arch was not sufficient to accommodate the impacted incisor in the arch [Figure - 6]. So it was necessary to regain the space in the maxillary arch.

Orthodontic bands were placed on the maxillary 1st permanent molars. Brackets were bonded on the upper anterior incisors and primary canines of both the sides. Two Australian stainless steel arch wires were used. 0.012" Australian S. S. archwire was used for leveling of the teeth and 0.014" Australian S. S. archwire with open coilspring in position of the left central incisor was used [Figure - 7]. By activating the open coil-spring, adequate space for aligning the impacted incisor was obtained.

After obtaining the adequate space for alignment of impacted incisor in the maxillary arch, the 0.014" Australian S. S archwire with an open coil spring was removed and 0.012" Australian S.S archwire was kept and used for leveling of the teeth in the maxillary arch [Figure - 8][Figure - 9].


  Results Top


The impacted maxillary left permanent central incisor was successfully positioned into proper alignment through surgical crown exposure and the orthodontic traction [Figure - 10].

Ideal overjet and overbite and resolution of the insufficient space for proper alignment of impacted incisor in the maxillary arch was also achieved.

The exposed incisor after complete treatment presented an acceptable gingival contour and attached gingiva.


  Discussion Top


Although the impacted maxillary incisor occurs less frequently than the maxillary canine, it brings concerns to the parents in the early mixed dentition because of the non-eruption of the teeth.[12]

Several reports have successfully treated impacted maxillary anterior teeth by proper crown exposure surgery and orthodontic traction.[13],[14] Several reports have indicated that an impacted tooth can be brought to proper alignment in the dental arch.[2],[3],[14],[15],[16]

The current treatment modality instead of extraction has used the surgical crown exposure with the placement of an auxiliary followed by orthodontic positioning of the tooth. Factors considered for successful alignment of an impacted tooth are.

1) The position and the direction of impacted tooth.

2) The degree of root completion

3) The presence of space for the impacted tooth.

These factors were considered before planning treatment for this case. The present case did not use the closed-eruption surgical tech. as suggested by Vermette ME,[17] which elevates a flap and returns it back to the original location after an attachment on the impacted tooth.

Surgical exposure of the impacted incisor was conservative to allow for the placement of a bonded bracket which is in accordance with the recommendations given by Samir E. Bishara.[18] Vanarasdall R and Corn H.[19] suggested that the flap containing the keratinized tissue should be placed to cover the CEJ and 2 to 3 mm of crown which is indicated even in teeth located beyond the vestibular depth or mucobuccal fold which was taken into account for this case. In this case impacted with incisor was located near to mucobuccal fold, so minimum area of buccal mucosa was removed to locate the tip of the impacted incisor but retained the connective tissue follicle of the labial surface to permit the hemostasis. This procedure matches with the procedure suggested by Setsuo Uematsu et al .[20]

From our reports we suggest that the labial epithelial attachment on the impacted incisor should be retained so that the repositioned incisor would present an acceptable gingival contour and, attached gingiva.


  Conclusion Top


Maxillary permanent impacted left central incisor was successfully positioned in the maxillary arch by surgical exposure and orthodontic traction and showed good stability. But long term monitoring for the stability and periodontal health is very important after orthodontic traction.

 
  References Top

1.Becker A. Early treatment of impacted maxillary incisors. Am J Orthod Dentofacial Orthop 2002;121:586-7.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Lin YT. Treatment of an impacted dilacerated maxillary central incisor. Am J Orthod Dentofacial Orthop 1999;115:406-9.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Archer LE. Composites; Oral and maxillofacial Surg. 5th ed. W.B Sounders Co: Philadelphia; 1975. p. 250-390.   Back to cited text no. 3    
4.Rani MS. Synopsis of orthodontics, 2nd ed. p. 357.  Back to cited text no. 4    
5.Congialosi TJ. Management of maxillary central incisor impacted by a supernumeray tooth. J Am Dent Assoc 1982;105:812-4.  Back to cited text no. 5    
6.Folio J, Smilack ZH, Roberts MW. Clinical management of multiple maxillary anterior supernumerary teeth: Report of case. ASDC J Dent Child 1985;52:370-3.  Back to cited text no. 6  [PUBMED]  
7.Foley J. Surgical removal of supernumerary teeth and the fate of incisor eruption. Eur J Paediatr Dent 2004;5:35-40.  Back to cited text no. 7  [PUBMED]  
8.Glenn FB. Case report: Twin supernumerary maxillary central incisors, unereupted maxillary central incisors. Early orthodontic treatment in a ten year old child. Gen Orthod 1994;5:24-7.  Back to cited text no. 8  [PUBMED]  
9.Prabhu NT, Munshi AK. Surgical management of labially placed permanent maxillary central incisor after supernumerary tooth extraction; Report of a case. J Clin Pediatr Dent 1997;21:201-3.  Back to cited text no. 9  [PUBMED]  
10.lbricevic H, Al-Mesad S, Mustagrudic D, AI-Zohejry N. Supernumerary teeth causing impaction of permanent maxillary incisors: Consideration of treatment. J Clin Pediatr Dent 2003;27:327-32.  Back to cited text no. 10    
11.Becker A. The orthodontic treatment of imacted teeth. Martin Dunitz: London; 1998.  Back to cited text no. 11    
12.Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofacial Orthop 1992;101:159-71.  Back to cited text no. 12  [PUBMED]  
13.Crawford LB. Impacted maxillary central incisor in mixed dentition treatment. Am J Orthod Dentofac Orthop 1997;112:1-7.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Wasserstein A, Tzur B, Brezniak N. Incomplete canine transposition and maxillary central incisor impaction: A case report. Am J Orthod Dentofacial Orthop 1997;111:635-9.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Kolokithas G, Karakasis D. Orthodontic movement of dilacerated maxillary central incisor. Am J Orthod 1979;76:310-5.  Back to cited text no. 15  [PUBMED]  
16.Tanaka E, Watanabe M, Nagaoka K, Yamaguchi K, Tann K. Orthodontic traction of an impacted maxillary central incisor. J Clin Orthod 2001;35:375-8.  Back to cited text no. 16    
17.Vermette ME, Kokich VG, Kennedy DB. Uncovering labially impacted teeth apically positioned flap and closed eruption techniques. Angle Orthod 1995;65;23-32.  Back to cited text no. 17    
18.Samir E. Bishara. Impacted maxillary canines: A review, 1997 AJO-DO: 1992. p. 159-71.  Back to cited text no. 18    
19.Vanarsdall R, Corn H. Soft tissue management of labially positioned unerupted teeth. Am J Orthod 1977;72:53-64.  Back to cited text no. 19    
20.Uematsu S, Uematsu T, Furusawa K, Daguchi T, Kurihara S. Orthodontic Treatment of an impacted dilacerated maxillary central incisor combined with surgical exposure and Apicoectomy. The Angle Orthodontist, March 2003, vol.74, no.1, p.132-136.  Back to cited text no. 20    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10]


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