|Year : 2012 | Volume
| Issue : 4 | Page : 329-332
Surgical management of impacted incisors in associate with supernumerary teeth: A combine case report of spontaneous eruption and orthodontic extrusion
D Das1, J Misra2
1 Department of Pedodontics and Preventive Dentistry, Kalinga Institute of Dental Sciences, Kolkata, West Bengal, India
2 Department of Pedodontics and Preventive Dentistry, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India
|Date of Web Publication||19-Mar-2013|
Department of Pedodontics and Preventive Dentistry, Kalinga Institute of Dental Sciences, Bhubaneswar, Odisa
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Maxillary permanent incisors impaction is not a frequent case in dental practice, but its treatment is challenging because of its importance to facial esthetics. Supernumerary teeth are the main cause of impaction of upper incisors. Supernumerary teeth when present can cause both esthetic and pathologic problems. Early detection of such teeth is most important if complications are to be avoided. In this reported case, the orthopantamogram of a 9-year-old boy revealed two impacted supernumerary teeth in the maxillary anterior region, which was interfering with the eruption of the permanent central incisors. The impacted supernumerary teeth were surgically removed, 11 was repositioned in the arch as it was situated very high in the arch, close to the nasal floor. Twenty-one erupted spontaneously but orthodontic force was applied over 11 to bring it into the occlusion and alignment was achieved with 0.014 mm NiTi wire.
Keywords: Impacted incisors, orthodontic extrusion, supernumerary teeth
|How to cite this article:|
Das D, Misra J. Surgical management of impacted incisors in associate with supernumerary teeth: A combine case report of spontaneous eruption and orthodontic extrusion. J Indian Soc Pedod Prev Dent 2012;30:329-32
|How to cite this URL:|
Das D, Misra J. Surgical management of impacted incisors in associate with supernumerary teeth: A combine case report of spontaneous eruption and orthodontic extrusion. J Indian Soc Pedod Prev Dent [serial online] 2012 [cited 2020 Feb 28];30:329-32. Available from: http://www.jisppd.com/text.asp?2012/30/4/329/108932
| Introduction|| |
Impaction of maxillary permanent incisors is not a frequent case in dental practice, but its treatment is challenging because of these teeth importance to facial esthetics. Supernumerary teeth are the main cause of the impaction of upper incisors. 56-60% of pre-maxillary supernumerary teeth cause impaction of permanent incisors. 
The supernumerary teeth (hyperdontia) is a state which can be defined as any teeth or tooth like substance in excess of the usual configuration of the normal number of deciduous or permanent teeth.  Although several theories have been submitted to explain their development, the precise etiology of supernumerary teeth is not clearly understood.  But the common suggestion about etiology of supernumerary teeth is considered to develop as a result of horizontal proliferation or a hyperactivity of the dental lamina. 
The frequency of supernumerary tooth in the maxillary incisor region is very common  . A study was conducted in Australia demonstrated that supernumerary teeth were most frequently located in maxillary incisor region (64.3%) with mesiodens accounting for 32.4% of such presentation. In decreasing order of frequency came supernumeraries in the maxillary third molar region (29.6%), mandibular third molar region (7.0%), mandibular premolar region (7%), maxillary pre-molar region (4.2%) and mandibular incisor region (4.2%). 
After removal of the obstacle from the path of eruption a impacted tooth either erupt spontaneously if it has conserved its eruptive force or orthodontic force is required to bring the tooth in normal position. This case report describes the management of a bilateral central incisor impaction, caused by two supernumerary teeth in the path of their eruption, both by surgical and orthodontic approach.
| Case Report|| |
A 9-years-old boy was referred to the out patient department of the Department Of Pedodontics and Preventive Dentistry of Dr. R. Ahmed Dental College and Hospital with a chief complain of missing upper front teeth since after exfoliation of his milk tooth. He had got a very good set of all other teeth except upper central incisors [Figure 1]a and b.
|Figure 1: (a and b) Pre operative view. (c) Preoperative orthopantamograph. (d and e) Post operative view|
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History and intraoral examination
There was no such significant medical history. Visual inspection of that area not revealed any significant change. On palpation, the gingiva of maxillary incisors area was found to be very hard. No any bulging was found during primary inspection.
On radiographic examination, OPG. shows [Figure 1]c the presence of two supernumerary teeth in the eruption path of central incisors. Eleven was more distally and higher in position in the dental arch and the root was almost completed. The respective supernumerary tooth was also more higher in position in bone then that of the left side's counter-part 21 was in favourable position in the arch and the root was not yet fully completed.
With the help of a single intra oral peri-apical radiograph it was very difficult to locate the actual position of the supernumerary teeth with their respective incisor teeth, so tube shift method (taking an another X-ray by changing the angle of X-ray tube only) was undertaken. It was founded that the roots of the supernumerary teeth were in palatal to the permanent incisors but the crown were labially placed, i.e., they were obliquely placed in the maxilla. So decision was made for a surgical extraction of supernumerary teeth followed by repositioning of 11 from labial aspect.
After proper local anaesthesia, full thickness labial flap was raised from 13 to 23 region. The crown of 21 and a small portion of the crown of the respective supernumerary teeth were seen under a thin cover of labial cortical bone. Eleven and the respective supernumerary teeth were not visible immediately after flap elevation. They were located under a thick hard bony covering. After an adequate bone removal, extraction of supernumerary teeth [Figure 2]a were done. Repositioning of 11 was in the socket of the extracted superneumarary tooth and by removing some portion of alveolar bone, maintaining the balance with 21 [Figure 2]b. At-last suture was placed and instructions were given to not to disturbed the surgical filed till healing.
|Figure 2: (a) Extraction of superneumarary done. (b) Repositioning of 11 done. (c) Spontaneously eruption of 21. (d) Unerupted 11 after 4 months of surgery|
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At the end 2 nd post-operative month, spontaneous eruption of 21 was observed [Figure 2]c. But 11 remained under soft tissue for next 4 post-operative month [Figure 2]d. Then the decision was made for orthodontic extrusion of 11, Beg's brackets were placed [Figure 3]a and orthodontic retraction (very light force at about 60-90 g) was given with the help of a arch wire an elastics [Figure 3]b. It came in to the arch in slightly rotated condition [Figure 3]c. Final alignment was done with the help of a 0.014 mm NiTi arch [Figure 3]d and e wire. On subsequent follow-up upto 2 years [Figure 1]d and e the central incisors give positive response in pulp testing.
|Figure 3: (a) Begs' brackets placed. (b) Traction given. (c) View after orthodontic extrusion. (d) and (e) A lignment done|
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| Discussion|| |
Impaction defines a tooth that cannot or will not erupt into its normal functional position in time.  Although supernumerary teeth could erupt normally, they may remain impacted. The most common complication of supernumerary teeth is failure of eruption of maxillary incisors.  In this case report supernumerary teeth were responsible for failure of eruption of maxillary central incisors.
There were no skeletal abnormalities or birth defect associated with this reported case. The probable causal factors were supernumerary teeth and angulations of teeth germs. Recent study in Turkey was aimed to analyze the frequency and radiological feature of mesiodens in a group of children (23,000 pediatric patients) demonstrated that the main complications of supernumerary teeth were delayed eruption of the permanent incisors (38.8%), maxillary midline diastema (17.6%), axial rotation or inclination of erupted permanent incisors (16.4%), and resorption of the adjacent teeth (4.7%).
Methods of management of crowding or impaction due to supernumerary are; remove super-numerary teeth or tooth only, remove supernumerary teeth and bone overlying impacted teeth, incision of fibrous tissue over the alveolar ridge to promote the eruption with or without orthodontic traction.  Surgical exposures of impacted incisors or surgical repositioning have been used to bring impacted teeth into occlusion. , The disadvantage of the combined surgical/orthodontic therapy is required a longer treatment period and some complication including ankylosis, non-vital pulps and root resorptions may be encountered. When an extensive amount of bone is removed or an open approach method is used to expose the impacted teeth, surgically, periodontal complication can be occurred such as gingival recession, delay in periodontal healing, gingivitis, bone loss and decrease in the width of keratinized gingiva. 
In this report we have done the extraction the supernumerary teeth (three) followed by removal of the overlying bone and surgical repositioning of the incisors. The patient was advised to not to disturbed the surgical filed very often until adequate soft tissue and bony healing occurs, other wise the repositioned incisor may get displaced. Twenty-one erupted normally as the root was not completed during the time of surgery and obstacles (superneumamary teeth) was removed from its path of eruption. Orthodontic extrusion for 11 was carried out as it failed to erupt. As it lack the eruptive forces because the root of the right central incisor was almost completed at the time of surgery and the tooth was repositioned in the arch. At last incisor alignment achieved with the help of a NiTi wire. In the present case the duration of treatment was around 28 months and the aligned maxillary incisor remained vital and responded normally to percussion and mobility and sensitivity testing.
| Conclusion|| |
Supernumerary teeth may result in the failure in eruption of adjacent permanent incisors. Early diagnosis of the presence and removal of supernumerary teeth is essential. Maxillary permanent incisors were successfully positioned in the maxillary arch by surgical repositioning and orthodontic traction, which showed good stability. Long-term monitoring of the stability and periodontal health of the impacted incisor should be evaluated following orthodontic traction.
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[Figure 1], [Figure 2], [Figure 3]