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CASE REPORT
Year : 2017  |  Volume : 35  |  Issue : 1  |  Page : 94-97
 

Ectopic eruption of maxillary central incisor through abnormally thickened labial frenum: An unusual presentation


1 Department of Paedodontics and Preventive Dentistry, J.N. Kapoor, D.A.V Centenary Dental College, Pt. B.D. Sharma University, Yamuna Nagar, Haryana, India
2 Department of Periodontology, J.N. Kapoor, D.A.V Centenary Dental College, Pt. B.D. Sharma University, Yamuna Nagar, Haryana, India

Date of Web Publication31-Jan-2017

Correspondence Address:
Neeraj Gugnani
Department of Paedodontics and Preventive Dentistry, J.N. Kapoor, D.A.V Centenary Dental College, Yamuna Nagar - 135 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.199229

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   Abstract 

Ectopic eruption is a deviation from the normal eruption pattern, making the tooth erupt out of its normal position, and possibly causing resorption of adjacent primary teeth. A wide range of etiological factors may be responsible for ectopic eruption of the teeth, so their management depends on the correction of the established etiological factor. The present case report describes an unusual case of ectopically erupted central incisor encased within an abnormally thickened labial frenum, which was treated by orthodontic repositioning of the ectopically erupting tooth after frenectomy.


Keywords: Ectopic eruption, frenectomy, orthodontic repositioning, thickened labial frenum


How to cite this article:
Gugnani N, Pandit I K, Gupta M, Gugnani S, Vishnoi A, Sabharwal O, Manhas S. Ectopic eruption of maxillary central incisor through abnormally thickened labial frenum: An unusual presentation. J Indian Soc Pedod Prev Dent 2017;35:94-7

How to cite this URL:
Gugnani N, Pandit I K, Gupta M, Gugnani S, Vishnoi A, Sabharwal O, Manhas S. Ectopic eruption of maxillary central incisor through abnormally thickened labial frenum: An unusual presentation. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2017 Apr 26];35:94-7. Available from: http://www.jisppd.com/text.asp?2017/35/1/94/199229



   Introduction Top


Ectopic eruption is a disturbance in which the tooth does not follow its usual path of eruption and is deviated from its normal position in the occlusion.[1] Although any tooth can show ectopic path of eruption, studies show that ectopic eruption of upper and lower permanent central incisors amounts to more than half of the total frequency.[2] Ectopic eruptions may be seen in many other regions of the maxillofacial skeleton including palate, maxillary sinus, condyle, orbit, or even through skin.[3]

Ectopic eruption of the permanent teeth may occur due to many causes including trauma, infection, cyst, the presence of supernumerary tooth, and crowded dentition.[4] Intrusive trauma to primary tooth is also one of the significant causes of ectopic eruption of the successors.[5]

Management of ectopically erupting teeth depends on the correction of established etiological factor that may include extraction of retained primary teeth or removal of cyst/pathology causing the deviated pattern, followed by orthodontic repositioning of the tooth within the arch, if required. However, if the tooth erupts in some other regions of the body, for example, palate, maxillary sinus, and condyle, the extraction of the tooth may be the only choice.

The present case report describes management of an interesting and unusual case of ectopically erupted maxillary central incisor that was completely encased within the labial frenum.


   Case Report Top


A healthy 13-year-old girl reported to the outpatient Department of Paedodontics and Preventive Dentistry, J.N. Kapoor, D.A.V Centenary Dental College, Yamuna Nagar, with chief complaint of faulty eruption of the upper right front tooth. Intraoral examination revealed ectopically erupting permanent maxillary right central incisor, completely encased within the maxillary labial frenum, and was not visible on routine clinical examination [Figure 1].
Figure 1: Ectopic erupting central incisor, encased in a pseudo-pouch of hypertrophied maxillary frenum, also showing space loss

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The tooth was displaced to a horizontal position at the level of labial sulcus, forcing the incisor to erupt at the position of labial frenum. With time, incisal aspect of horizontally erupting central incisor had led to chronic soft-tissue irritation of maxillary frenum leading to its hypertrophy and formation of hypertrophied “pseudo-pouch.”

Hypertrophied frenum encased the tooth completely, making it invisible in normal mouth-opening positions. The extent of encasing in the “pseudo-pouch” was such that the tooth could only be visualized when the patient's upper lip was stretched upward and outward. Moreover, there occurred displacement of adjacent incisors resulting in a loss of space [Figure 2].
Figure 2: Visible central incisor, seen by outstretching the lip and frenum, some space is also regained by the use of coil spring

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Treatment was planned in three stages: Regaining space for ectopically erupting central incisor; surgical excision of hypertrophied frenum; and orthodontic repositioning/alignment of the incisor. Semi-fixed orthodontic treatment was initiated, and a coil spring was placed between maxillary left central incisor and right lateral incisor to regain the space for accommodating ectopically erupted central incisor. Within 2 weeks, while partial space was regained, phase II treatment was initiated and frenectomy was planned. The procedure was started with administration of local anesthesia followed by surgical excision of the frenum.

For this, a V-shaped full-thickness incision was placed at the gingival base of frenal attachment [Figure 3]. Complete fibrous tissue attached to the lip was dissected, and the incised margins were sutured, and periodontal dressing (Coe-Pak, GC-America) was used to cover the surgical site. Sutures were removed after 8 days, and the patient was again recalled at 2 weeks and at 1, 2, and 3 months.
Figure 3: V-shaped full-thickness incision placed at the gingival base of frenal attachment with complete fibrous tissue removal

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One month following frenectomy, the movement of ectopic central incisor in the occlusal direction was seen resulting in dramatic healing of the labial mucosa and frenum. During this period, the lost space also recovered completely, and the ectopic incisor was guided into full occlusion within the arch [Figure 4]. After 3 months, when the incisor was properly aligned in the arch [Figure 5], fixed orthodontic appliances were removed, following which bonded lingual retention was given using Ribbond.
Figure 4: Central incisor engaged in orthodontic wire, to guide its alignment

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Figure 5: Well-aligned central incisor, good esthetics, and function

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   Discussion Top


Intrusion is defined as the displacement of tooth into the alveolar bone.[6] Intrusive luxations constitute 4.4%–22% of traumatic injuries in primary dentition and are most commonly encountered in children between 1 and 3 years of age.[7]

Owing to anatomic proximity between the root of primary tooth and its permanent successor, trauma to primary dentition may cause either the developmental disturbances or deviation in the path of eruption of their successors, leading to its impaction or ectopic eruption.[8] Management of intruded primary incisor depends on the direction and severity of intrusion and generally includes watchful waiting for spontaneous re-eruption of intruded tooth or extraction, if required.[7] Final decision depends on dentist's clinical expertise and his interpretation of radiographs.

The case presented is a similar case, in which the patient had history of trauma at 3 years where the incisor got intruded, but because of the unmet treatment, it led to the displacement of permanent incisor tooth bud and its subsequent ectopic eruption at vestibular depth in a soft-tissue pseudo-pouch encasing involving the labial frenum. Treatment of such an ectopically erupted tooth requires a multidisciplinary approach, involving surgical exposure, orthodontic treatment, and sometimes prosthodontic rehabilitation.

In a similar case reported by Canoglu et al., orthodontic extrusion and respacing was carried out in a 9-year-old patient using a modified fan-type removable expansion appliance.[9] However, in our case, age of the patient was 15 years, and comparatively more space was required to be regained; therefore, an open coil spring was used. In a study, von Fraunhofer et al.[10] concluded that coil springs deliver a relatively constant force over a range and result in up to 7 mm tooth movement. In accordance to these findings, partial space was regained within 2 weeks in our case which was followed by frenectomy to expose the tooth.

Fixed orthodontic therapy was continued to achieve proper aligning leading to good esthetic and functional rehabilitation. Since, frenectomy is followed by scar tissue formation which may result in relapse, a bonded lingual retainer (Ribbond) was used for prolonged retention.


   Conclusion Top


A meticulous clinical examination along with proper history is mandatory in patients with eruption/developmental anomalies. Pediatric dentists should be prepared to make correct diagnosis and plan the most suitable treatment for each patient, especially in case of ectopically erupting teeth to avoid any further damage to the dentition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Pomarico L, Primo LG, Noce D. Ectopic eruption of the maxillary central permanent incisors and mandibular first permanent molars: Report of an unusual case. Quintessence Int 2006;37:677-83.  Back to cited text no. 1
    
2.
Kumagai E, Sai S, Nozaka K, Yamada S, Amari E. Clinical study of ectopic eruption of permanent incisors and first molars. Shoni Shikagaku Zasshi 1989;27:30-40.  Back to cited text no. 2
    
3.
Goh YH. Ectopic eruption of maxillary molar tooth – An unusual cause of recurrent sinusitis. Singapore Med J 2001;42:80-1.  Back to cited text no. 3
    
4.
Portela MB, Sanchez AL, Gleiser R. Bilateral distal ectopic eruption of the permanent mandibular central incisors: A case report. Quintessence Int 2003;34:131-4.  Back to cited text no. 4
    
5.
Manuja N, Nagpal R, Singh M, Chaudhary S. Management of delayed eruption of permanent maxillary incisor associated with the presence of supernumerary teeth: A case report. Int J Clin Pediatr Dent 2011;4:255-9.  Back to cited text no. 5
    
6.
Albadri S, Zaitoun H, Kinirons MJ; British Society of Paediatric Dentistry. UK National Clinical Guidelines in Paediatric Dentistry: Treatment of traumatically intruded permanent incisor teeth in children. Int J Paediatr Dent 2010;20 Suppl 1:1-2.  Back to cited text no. 6
    
7.
Diab M, elBadrawy HE. Intrusion injuries of primary incisors. Part III: Effects on the permanent successors. Quintessence Int 2000;31:377-84.  Back to cited text no. 7
    
8.
Bassiouny MA, Giannini P, Deem L. Permanent incisors traumatized through predecessors: Sequelae and possible management. J Clin Pediatr Dent 2003;27:223-8.  Back to cited text no. 8
    
9.
Canoglu E, Akcan CA, Baharoglu E, Gungor HC, Cehreli ZC. Unusual ectopic eruption of a permanent central incisor following an intrusion injury to the primary tooth. J Can Dent Assoc 2008;74:723-6.  Back to cited text no. 9
    
10.
von Fraunhofer JA, Bonds PW, Johnson BE. Force generation by orthodontic coil springs. Angle Orthod 1993;63:145-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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