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CASE REPORT
Year : 2019  |  Volume : 37  |  Issue : 4  |  Page : 409-413
 

Interceptive management of ectopically erupting central incisor - A case report


Department of Pedodontics and Preventive Dentistry, JSS Academy of Higher Education and Research, JSS Dental College and Hospital, Mysore, Karnataka, India

Date of Web Publication7-Nov-2019

Correspondence Address:
Dr. Brinda Suhas Godhi
Department of Pedodontics and Preventive Dentistry, JSS Academy of Higher Education and Research, JSS Dental College and Hospital, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_193_19

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   Abstract 


Radicular cysts are considered to be rare in the primary dentition comprising 0.5%–3.3% of the total number of radicular cysts in both primary and permanent dentition. Ectopic eruption is an eruption disturbance with the prevalence of 5.6% with majority being permanent central incisors. Etiology for eruption disturbance commonly includes odontoma, cysts, supernumerary teeth, and crown-root malformation. Ectopic eruption of permanent incisor due to radicular cyst associated with traumatized primary incisor is a very rare clinical entity that requires timely interception. The present case illustrates the clinical feature and multi-disciplinary management of ectopic eruption of permanent central incisor in a 9-year-old girl child.


Keywords: Ectopic eruption, management, primary dentition, radicular cyst


How to cite this article:
Godhi BS, Shanbhog R, Chanchala H P. Interceptive management of ectopically erupting central incisor - A case report. J Indian Soc Pedod Prev Dent 2019;37:409-13

How to cite this URL:
Godhi BS, Shanbhog R, Chanchala H P. Interceptive management of ectopically erupting central incisor - A case report. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2019 Nov 13];37:409-13. Available from: http://www.jisppd.com/text.asp?2019/37/4/409/270477





   Introduction Top


Attaining stable occlusion with esthetics and function through space supervision and eruption guidance is an integral component of comprehensive oral health care in pediatric dentistry.[1] The maxillary anterior teeth often referred to as the “social six” are the most prominent teeth in an individual's smile. The normal eruption, position, and morphology of these teeth are crucial for facial esthetics and phonetics.[2]

Ectopic eruption is an eruption disturbance referred as the eruption of tooth in a position that is not its normal position in the dental arch. Many theories have attempted to explain the etiology of ectopic eruption. However, the multifactorial process of growth and development makes it difficult to identify the specific primary etiological factors of ectopic eruption.[3] The prevalence of ectopic eruption is 5.6%, with majority being permanent central incisors. In the maxilla, ectopic eruption is more often unilateral, as opposed to the mandible where ectopic eruption is usually bilateral. There is no evidence of sex predilection.[4]

Eruption disturbances of maxillary permanent incisors create problem in terms of esthetics and occlusion in the early mixed dentition.[5] The etiology of eruption disturbance of permanent incisors is commonly related to odontoma, cysts, supernumerary teeth, and crown and root malformation because of the trauma transmitted from primary predecessors.[6]

Radicular cysts originate from epithelial remnants of the periodontal ligament as a result of inflammation that is generally a consequence of pulp necrosis.[7] Radicular cysts are considered to be rare in the primary dentition comprising only 0.5%–3.3% of the total number of radicular cysts in both the primary and permanent dentition because of the biological cycle of primary teeth.[8],[9]

Most radicular cysts develop slowly and do not become very large. Patients do not experience pain unless acute inflammatory exacerbation is present, and the lesions are often detected only during routine radiographic examination.[10] Untreated radicular cyst could be harmful to the patient's dental development as it may displace the successor tooth or results in its nonvitality.[11]

The purpose of this article was to report and illustrate the management of ectopic eruption of permanent central incisor in a 9-year-old female child with a radicular cyst in relation to primary incisor and discuss the etiological factors and treatment of this lesion based on a review of the literature.


   Case Report Top


A 9-year-old girl in excellent physical health visited the dental clinic with a chief complaint of discoloration and irregular placement of the upper front tooth. The patient presented with a history of trauma to the upper front teeth 4 years ago. Intraoral examination of the patient presented with mixed dentition, retained and discolored maxillary right primary central incisor, erupting permanent upper right lateral incisor, and ectopically erupting permanent upper right central incisor [Figure 1]. On radiographic examination, maxillary right primary central incisor revealed well-defined radiolucency of 1 cm × 1 cm with thin sclerotic border. It also confirmed the ectopic eruption of permanent upper right central incisor due to the presence of cyst [Figure 2].
Figure 1: Preoperative photograph

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Figure 2: Preoperative radiographs

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Diagnosis

Based on clinical and radiographic examination, the present case was provisionally diagnosed with Angle's Class I malocclusion with periapical cyst or radicular cyst in relation to maxillary right primary central incisor and ectopic eruption with upper right permanent central incisor. The differential diagnosis was traumatic bone cyst, globulomaxillary cyst, and aneurysmal bone cyst.

Treatment plan

Treatment was planned in two phases:

  • Surgical phase with the extraction of maxillary right primary central incisor and enucleation of radicular cyst
  • The second phase consisted of orthodontic alignment of ectopically erupting upper right permanent central incisor.


Surgical phase

Parents of the patients were explained regarding the treatment plan and a written consent was obtained before start of the procedure. Under local anesthesia, maxillary right primary central incisor was extracted. A triangular mucoperiosteal flap was raised to expose expanded, thinned out the buccal cortical plate. The cyst was enucleated and sent for histopathological examination. Surgical exploration confirmed the nonassociation of the cyst to the successive permanent teeth. Primary closure was done following debridement and hemostasis [Figure 3]. Postsurgical healing was uneventful.
Figure 3: Intraoperative photograph surgical phase

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Histopathology

Histopathological examination revealed cystic epithelial lining supported by connective tissue capsule. The epithelial lining was stratified squamous nonkeratinized showing arcading pattern. The connective tissue capsule was collagenous with moderate amount of chronic inflammatory cells, blood vessels, hemosiderin pigmentation, and hyaline bodies. Correlating these features with the clinical findings, the diagnosis of the radicular cyst was made [Figure 4].
Figure 4: Cystic squamous nonkeratinized epithelial lining supported by connective tissue capsule (histopathology H and E, ×40)

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Orthodontic phase

Postsurgical intraoral periapical radiograph revealed the condensation of bone with coarse trabecular pattern suggestive of the healed radicular cyst [Figure 5]. Initially, space for right permanent central incisor was created using a removable appliance with finger spring by distalizing the permanent right lateral incisor and left permanent central incisor. Then, using modified removable Hawley's appliance as anchorage and elastic as active component right permanent central incisor with bondable button was pulled to an extent that sufficient crown portion to bond the regular bondable bracket was exposed. Later, a 2 × 4 appliance with archwire sequence, 0.016 nickel–titanium, 0.016 stainless steel followed by 0.018 stainless steel was planned to align the right permanent central incisor in its correct position and axial inclination [Figure 6]. After total active treatment, the appliance was debonded. The position remained stable after 12 months of the follow-up [Figure 7].
Figure 5: Postoperative radiograph

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Figure 6: Orthodontic phase photographs. (a) Removable appliance with finger spring to create space for erupting incisor. (b) Modified removable Hawley's appliance as anchorage and elastic as active component with bondable button. (c) 2 × 4 appliance for aligning central incisor. (d) Aligned central incisor

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Figure 7: Postoperative photograph

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   Discussion Top


Radicular cysts originating from primary teeth are considered rare. The frequency is low because pulpal and periapical infections in deciduous teeth tend to drain more readily than those of permanent teeth and antigenic stimuli which evoke the changes, leading to the formation of the radicular cyst may be different.[12] The reported frequency of cysts associated with primary teeth is low as compared to permanent dentition may be due to the fact that, extracted primary teeth are not submitted for pathological examination.[8] As these cysts are asymptomatic till secondarily infected, they are usually diagnosed during routine radiographs. In the present case, also the patient was asymptomatic; the cyst was associated with primary right central incisor which was discolored and radiographic examination revealed the presence of radicular cyst in relation to primary right central incisor and the presence of ectopic eruption of a permanent upper right central incisor.

The patient with an untreated radicular cyst may present with the following consequences: swelling, tenderness, tooth mobility, and a bluish tinge caused by the buccal expansion of the cortical plates. Furthermore, displacement of the successor tooth or, even more unforgiving, the loss of its vitality may result.[13],[14],[15] In the present case, the asymptomatic radicular cyst had displaced the permanent incisors apically and resulted in ectopic positioning. In the present case, the trauma had occurred at a relatively later age, so the effect on the permanent successor tooth may have been limited and the development of radicular cyst which has displaced permanent right central incisor distally. Depending on the position of the ectopic incisor, various treatment options exist. If there is minimal deviation from the normal eruptive position, it may be possible to extract the corresponding primary incisor and allow the incisor to find its way into normal position. However, in the present case, the tooth was deviated to a larger extent, present almost between canine and lateral incisors. Hence, the treatment was planned in two phases which included the surgical phase followed by an orthodontic phase.

As a part of orthodontic treatment, 2 × 4 was used in the early mixed dentition for the treatment of both anterior crossbite and alignment of ectopic incisors.[16]

Meanwhile, care was taken to avoid un-torquing the permanent lateral, permanent central incisors (ugly duckling stage) and prevent possible root resorption of the laterals against the crown of the unerupted permanent canines.[17] Clinical experience has shown that light forces are more effective than strong ones in moving ectopically erupted teeth and achieving a good gingival position. When extensively deviated ectopically erupted incisors are moved into the arch, discrepancies are often observed between the gingival levels of the affected and neighboring teeth. The application of light forces is more effective than strong ones in moving ectopically erupted teeth and achieving acceptable gingival position.[18] In the present case following fixed orthodontic therapy, the gingiva of the repositioned central incisor was almost on par with the left permanent central incisor, thus eliminating the need for gingival plastic surgery.

If the case was left untreated, ectopic erupting permanent right central incisor would have pushed the right lateral incisors lingually to block the path for erupting right permanent canine. This was prevented by intercepting the malocclusion at the right time and treating with a multidisciplinary approach.


   Conclusion Top


Regaining sufficient space and ensuring sufficient traction in the right direction allowed us to move the ectopically erupted permanent right central incisor into the correct position thus preventing a malocclusion in the developing dentition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Suresh KS, Uma HL, Nagarathna J, Kumar P. Management of ectopically erupting maxillary incisors: A case series. Int J Clin Pediatr Dent 2015;8:227-33.  Back to cited text no. 1
    
2.
Tanki JZ, Naqash TA, Gupta A, Singh R, Jamwal A. Impacted maxillary incisors: Causes, diagnosis and management. IOSR J Dent Med Sci 2013;5:41-5.  Back to cited text no. 2
    
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Huber KL, Suri L, Taneja P. Eruption disturbances of the maxillary incisors: A literature review. J Clin Pediatr Dent 2008;32:221-30.  Back to cited text no. 3
    
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de Almeida CM, Gomide MR. Prevalence of natal/neonatal teeth in cleft lip and palate infants. Cleft Palate Craniofac J 1996;33:297-9.  Back to cited text no. 4
    
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Tanaka E, Watanabe M, Nagaoka K, Yamaguchi K, Tanne K. Orthodontic traction of an impacted maxillary central incisor. J Clin Orthod 2001;35:375-8.  Back to cited text no. 5
    
6.
Kuvvetli SS, Seymen F, Gencay K. Management of an unerupted dilacerated maxillary central incisor: A case report. Dent Traumatol 2007;23:257-61.  Back to cited text no. 6
    
7.
Lapusneanu L, Radulescu M, Arhire A, Filip A. Case report. Cystic lesions of the maxilla – Clinical considerations and differential diagnosis. Romanian J Rhinol 2017;7:26.  Back to cited text no. 7
    
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Ramakrishna Y, Verma D. Radicular cyst associated with a deciduous molar: A case report with unusual clinical presentation. J Indian Soc Pedod Prev Dent 2006;24:158-60.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Bhaskar SN. Oral surgery – Oral pathology conference no. 17, Walter Reed Army Medical Center. Periapical lesions – Types, incidence, and clinical features. Oral Surg Oral Med Oral Pathol 1966;21:657-71.  Back to cited text no. 9
    
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Penumatsa NV, Nallanchakrava S, Muppa R, Dandempally A, Panthula P. Conservative approach in the management of radicular cyst in a child: Case report. Case Rep Dent 2013;2013:123148.  Back to cited text no. 10
    
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Subramanya PL. Radicular cyst associated with deciduous incisor: A rare case report. Int J Clin Pediatr Dent 2012;5:217-9.  Back to cited text no. 11
    
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Delbem AC, Cunha RF, Vieira AE, Pugliesi DM. Conservative treatment of a radicular cyst in a 5-year-old child: A case report. Int J Paediatr Dent 2003;13:447-50.  Back to cited text no. 12
    
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Gandhi S, Franklin DL. Presentation of a radicular cyst associated with a primary molar. Eur Arch Paediatr Dent 2008;9:56-9.  Back to cited text no. 13
    
14.
Wood RE, Nortjé CJ, Padayachee A, Grotepass F. Radicular cysts of primary teeth mimicking premolar dentigerous cysts: Report of three cases. ASDC J Dent Child 1988;55:288-90.  Back to cited text no. 14
    
15.
Lustig JP, Schwartz-Arad D, Shapira A. Odontogenic cysts related to pulpotomized deciduous molars: Clinical features and treatment outcome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:499-503.  Back to cited text no. 15
    
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McKeown HF, Sandler J. The two by four appliance: A versatile appliance. Dent Update 2001;28:496-500.  Back to cited text no. 16
    
17.
Sasakura H, Yoshida T, Murayama S, Hanada K, Nakajima T. Root resorption of upper permanent incisor caused by impacted canine. An analysis of 23 cases. Int J Oral Surg 1984;13:299-306.  Back to cited text no. 17
    
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Cozza P, Mucedero M, Ballanti F, De Toffol L. A case of an unerupted maxillary central incisor for indirect trauma localized horizontally on the anterior nasal spine. J Clin Pediatr Dent 2005;29:201-3.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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