Year : 2009 | Volume
: 27 | Issue : 1 | Page : 65--69
Orthodontic management of faciolingual horizontally impacted maxillary central incisor
HS Chawla1, A Kapur2,
1 Pedodontics and Preventive Dentistry, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Unit of Pedodontics and Preventive Dentistry, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
H S Chawla
Department of Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
This paper describes the successful alignment of a horizontally impacted maxillary central incisor positioned high in the vestibule, in a 15-year-old girl, by purely orthodontic means. A unique and innovative technique for traction was employed so as to cause minimal injury to the neighboring soft tissue. The article is a step forward in establishing the predictability of orthodontic alignment in management of such cases, which may become the method of choice over extractions or surgical repositionings.
|How to cite this article:|
Chawla H S, Kapur A. Orthodontic management of faciolingual horizontally impacted maxillary central incisor.J Indian Soc Pedod Prev Dent 2009;27:65-69
|How to cite this URL:|
Chawla H S, Kapur A. Orthodontic management of faciolingual horizontally impacted maxillary central incisor. J Indian Soc Pedod Prev Dent [serial online] 2009 [cited 2023 Feb 5 ];27:65-69
Available from: http://www.jisppd.com/text.asp?2009/27/1/65/50823
Impaction of permanent central incisors is a well-recognized entity and is usually associated with trauma to primary anterior teeth early in life. Ectopic, horizontally impacted/erupting central incisors positioned high up in the vestibule located parallel to the occlusal plane, though not common, are encountered in the clinical practice. Management options for such teeth can be: (i) surgical extraction and moving the lateral incisor to mimic the central incisor and similarly changing the anatomy of other teeth, (ii) extraction of the impacted tooth followed by an implant, (iii) surgical repositioning of the impacted tooth, and (iv) orthodontic correction of the impacted tooth. In the first option, that is, modifying lateral incisor to central incisor, the modified lateral incisor because of the inherent discrepancy in the mesiodistal width at the cervical area of the two teeth of about 2 mm always remains narrower in this region, which compromises esthetics, especially when the person has a short upper lip. The option of extraction and implant placement requires a waiting period of up to 18 years of age and cannot be undertaken at a younger more impressionable age of 8-15 years, the time when most of the impacted teeth are normally diagnosed. If undertaken early, the osseointegrated implant becomes shorter in incisocervical length with time due to passive eruption of adjacent teeth. Surgical repositioning as a treatment option, though has been successfully reported in the literature, has a likelihood of failure either due to devitalization, or later replacement resorption; surgical trauma to the child at a young age is another disadvantage. Orthodontic correction, though challenging, is more desirable as the person retains his natural tooth in the arch. It is however difficult, particularly when there is dilaceration of root in the palatolabial direction as it may fenestrate the bone on orthodontic alignment. The chances of dilacerations in palatolabial direction of extreme dimension so as to cause perforation are however rare.
Literature review reveals only eight successfully treated cases of horizontally impacted central incisors positioned high in the vestibule, ,,,,,,, two of which were managed with surgical repositioning , and six others utilized purely orthodontic means for correction. ,,,,, The most common treatment modality has always been removal of the impacted tooth which points toward the scantily reported orthodontically or surgically treated cases. The present report is that of a horizontally impacted central incisor in a 15-year-old girl in whom orthodontic movement was successfully carried out by employing different traction methods during the course of treatment as per need which are being depicted and discussed.
A 15-year-old girl reported to our department with the chief complaint of pus discharge in relation to the upper front teeth. There was no history of trauma or caries to either primary or permanent teeth. Intraoral examination revealed a missing 21 in the maxillary arch along with a retained left primary incisor (61). The rest of the permanent teeth were erupted. On complete retraction of the upper lip the tip of left permanent incisor (21) was visible high in the vestibule labially between the crowns of lateral incisor and canine and had led to hypertrophy of the surrounding mucosa with secondary infection, sloughing, and pus discharge. The left permanent incisor (22) and canine were tipped labially and mesially toward the midline, thus occupying a part of the central incisor space. The lateral incisor root was tipped palatally because of the pressure of erupting central incisor and the bulge of its root tip could be palpated on the palatal side. The molar relation was Angle's class I on both sides. The radiographic examination consisting of intraoral periapical, occlusal, and panoramic views revealed the impaction of 21 along with a slight root dilaceration toward the right side [Figure 1],[Figure 2],[Figure 3]. The patient was skeletal class I and the space analysis showed a space deficiency of approximately 5 mm in the maxillary arch.
The treatment plan comprised of regaining the space for 11 and moving the impacted tooth orthodontically into its original space. Prior to starting the orthodontic treatment the hypertrophied soft tissue around the impacted tooth was cauterized to expose enough of tooth surface to enable placement of a bracket. After tissue healing the preadjusted edgewise Roth .018 prescription was used; the brackets were bonded to the labial surfaces of the entire maxillary dentition except the left central incisor. A Begg bracket instead was bonded on the labial aspect of the impacted 21; it was chosen on account of its small size and labial site so as to allow for its uprighting along with downward movement. In the beginning, for traction, an elastomeric chain (e-chain) was applied [Figure 4] but it led to extreme hypertrophy of the tissue around the tooth leaving the Begg bracket unapproachable for replacing the e-chain; the exploration of the bracket end for placement of e-chain was traumatic and painful. The hypertrophied tissue was once again cauterized and the patient kept without any traction for about seven days for healing. An alternative method of traction was applied by tying a ligature wire in the vertical slot of the Begg bracket and twisting it to make a hook. Subsequently, an e-chain was engaged onto 11, 12, and 13 and leaving three of its loops free. The free end of the e-chain loops and the ligature wire hook were then brought together with the help of an elastic thread [Figure 5] to apply a measured extrusion force. This method proved successful and helped to provide the adequate force without any risk of devitalization of the tooth. The 21 gradually moved toward the occlusal plane by 5-6 mm and also uprighted slightly.
It, however, remained rotated clockwise approximately at an angle of 90 degrees. To correct the rotation, a secondary wire (.009, Australian stainless steel) was placed engaging the Begg bracket on 21 [Figure 6]. This partly derotated the 21. At this point of time the Begg bracket was placed on the mesiolingual surface of 21 which was now sufficiently visible; light traction was achieved with the help of a secondary arch wire (.010 Australian wire) to achieve further derotation [Figure 7]. This led to complete derotation of 21 and further brought the tooth down toward the midline. The labial surface of the tooth became completely visible and a Roth edgewise bracket was now substituted in place of Begg, on the labial surface [Figure 8]. As the 21 moved further down, the main arch wire was observed to cause hindrance in its final occlusal movement. To overcome this obstruction and have a full expression of the secondary arch wire (.010) the main arch wire (round .016) was cut between canine and premolar region on each side so that the anterior canine-to-canine segment was free from the main arch wire, which was now holding the posterior segments only [Figure 9]. The secondary arch wire was maintained in its position for light traction. With this it was possible to bring the tooth fully in alignment. It was followed by placement of 018 x 016 rectangular wire and then 018 x 017 rectangular wire to achieve final alignment/correction [Figure 10]. Post-treatment, the patient showed normal clinical crown length and gingival contour giving an esthetically pleasing result [Figure 11],[Figure 12]. The tooth (21) maintained its vitality and there was no evidence of root resorption [Figure 13].
There have been only a few case reports in the literature for the alignment of severely malposed incisor placed high in the vestibule with direction of eruption either parallel to the occlusal plane or projecting upwards, though there have been many cases reported about orthodontic alignment of various other types of impacted central incisors. In the present case report, to bring the impacted tooth to its natural position first a Begg bracket was bonded on the labial surface of the impacted tooth. Most of the authors, for such alignments have initiated traction from the lingual surface by applying either lingual buttons, ,, Begg brackets,  or edgewise incisor brackets , on this surface. Yng-Tzer et al ,  suggested that placement of the attachment on the labial surface at an acute angle of the dilacerated tooth could cause more bone reduction, thus supporting its placement on the lingual surface. No such destruction of bone was found in the present case report; rather the tooth maintained a favorable bone support throughout treatment. But in cases where the attachment causes trauma to the labial mucosa, lingual placement would be more favorable. The selection of the surface, however, may be decided on individual basis.
The technique of closed eruption has been highly recommended by most authors ,,, for aligning the impacted tooth compared to methods like excisional gingivectomy and apically positioned flap techniques on account of better esthetic results. This technique was not possible in the present case report as the tooth had already cut through the mucosa. The esthetic results achieved at the end of the treatment were however favorable/satisfactory.
The extrusion force applied on the impacted central incisor in the present case was very light and measured in the range of 50 g. This may have accounted for the little difference in the clinical crown length and maintenance of vitality of the impacted tooth postalignment. The chances of nonvitality are naturally much lower when the treatment is initiated at a younger age due to the presence of a wide apical foramen, but in the present case the patient was 16-years-old at the time of initiation of treatment. In our view, forces for traction greater than 50 g should not be applied as it may be the cause of nonvitality as reported by Setsuko et al in 2004.  The lighter forces applied did not increase the total treatment time, which was 12 months for bringing the impacted tooth in alignment and an additional 8 months for the final alignment. This is comparable to other reported cases with total treatment times of up to 36 months.  The method of orthodontic alignment of severely horizontally impacted central incisors compared to other methods is relatively free from treatment associated complications and predictable results; hence, it may become the method of choice/preferred method over extractions or surgical repositioning.
|1||Lin YT. Treatment of an impacted dilacerated maxillary central incisor. Am J Orthod Dentofac Orthop 1999;115:406-9.|
|2||Keijirou K, Hiroyuki K. Esthetic management of an unerupted maxillary central incisor with a closed eruption technique. Am J Orthop Dentofac Orthop 2000;118:224-8.|
|3||Uematsu S, Uematsu T, Furusawa K, Deguchi T, Kurihara S. Orthodontic treatment of an impacted dilacerated maxillary central incisor combined with surgical exposure and apicoectomy. Angle Orthod 2003;74:132-6.|
|4||Ming TC, Marianne M O, Cert P. Orthodontic-surgical management of an impacted dilacerated maxillary central incisor: A clinical case report. Pediatr Dent 2004;26:341-4.|
|5||Paola C, Alessandra M, Roberta C. Orthodontic treatment of an impacted dilacerated maxillary incisor: A case report. J Clin Pediatr Dent 2005;30:93-7.|
|6||Batra P, Duggal R, Prakash H. Managing morphologically atypical impacted teeth orthodontically. J Clin Pediatr Dent 2005;29:105-11.|
|7||Tzong PT. Surgical repositioning of an impacted dilacereated incisor in mixed dentition. J Am Dent Assoc 2002;133:61-6. |
|8||Kuroe K, Tomonari H, Soejima K, Maeda A. Surgical repositioning of a developing maxillary permanent central incisor in a horizontal position: Spontaneous eruption and root formation. Eur J Orthod 2006;28:206-9.|
|9||Vermette ME, Kokich VG, Kennedy DB. Uncovering labially impacted teeth: Apically positioned flap and closed-eruption techniques. Angle Orthod 1995;65:23-34.|