Orthosurgical Management of Bilaterally Impacted Permanent Maxillary Central Incisors: Report of Two Cases

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1 Sanjeev atana et al SE REPORT /jp-journals Orthosurgical Management of ilaterally Impacted Permanent Maxillary entral Incisors: Report of Two ases 1 Sanjeev atana, 2 Prasanna Kumar, 3 SM Londhe STRT elayed eruption of a permanent tooth is one of the commonest orthodontic problems requiring surgical intervention. Maxillary central incisor impaction is not rare in orthodontic practice, the frequency ranges from 0.06 to 0.2%. Orthosurgical guidance of impacted incisor is a clinical challenge in young patients. Successful management depends on early diagnosis, careful treatment planning and periodic reviews during orthodontic guidance of impacted tooth. Surgical exposure and orthodontic guidance offers a complete treatment for an impacted tooth. Present case series discuss the orthosurgical management of bilaterally impacted permanent maxillary central incisors with good pleasing appearances of erupted teeth having good interproximal contact, good width of attached gingiva and gingival contour. Keywords: Impacted incisors, Surgical exposure, Orthodontic guidance. How to cite this article: atana S, Kumar P, Londhe SM. Orthosurgical Management of ilaterally Impacted Permanent Maxillary entral Incisors: Report of Two ases. J Ind Orthod Soc 2014;48(4): Source of support: Nil onflict of interest: None Received on: 11/5/14 ccepted after revision: 24/6/14 INTROUTION elayed eruption of a permanent tooth is one of the commonest orthodontic problems requiring surgical intervention. tooth is considered impacted when there is delay in its eruption for more than 6 months compared to contralateral tooth. Maxillary central incisor impaction is not rare in orthodontic practice, the frequency ranges from 0.06 to 0.2%. 1 ecause of the space concerns in anterior region and being in esthetic zone, an early and careful planning is required for management of impacted maxillary incisors in mixed dentition. mong the various treatment options for 1 Senior Lecturer, 2 Reader, 3 Professor 1-3 epartment of Orthodontics, rmy ental entre (R&R) elhi, India orresponding uthor: Sanjeev atana, Senior Lecturer epartment of Orthodontics, rmy ental entre (R&R), elhi India, Phone: , drdatana@rediffmail.com management of impacted incisors, surgical exposure and orthodontic guidance should be the first choice because of the obvious advantages. 2 Orthosurgical intervention should start early to avoid unnecessary difficulties in aligning the tooth in the arch. The orthodontic guidance of an impacted tooth depends on cause of impaction, its state and position and if there is enough space in the dental arch to accommodate. Present case series discuss the orthosurgical management of bilaterally impacted permanent maxillary central incisors with good pleasing appearances of erupted teeth having good interproximal contact, good width of attached gingiva and gingival contour. SE REPORTS ase 1 15-year-old boy presented with chief complaint unesthetic smile resulting from missing upper front teeth (Fig. 1). The patient was healthy well built with balanced face and had no medical or dental history contributing to present complaint. Patient had good oral hygiene and was in permanent dentition. The malocclusion was angle lass I with bilaterally missing permanent maxillary central incisors and presence of odontomes in same region. Radiographic examination demonstrated bilaterally impacted maxillary central incisors with presence of compound odontomes in the region (Figs 1 and, 2). The treatment options discussed with parents included (a) wait and watch, (b) surgical removal of impacted teeth with odontomes and prosthodontics rehabilitation of edentulous area and (c) surgical exposure, removal of odontomes and orthodontic guidance of impacted teeth to occlusion. Parents decided for ortho-surgical guidance of impacted teeth, a written consent was obtained from the parents. Orthodontic appliance (0.018" Roth PE) was bonded on upper arch and leveling and alignment was achieved with NiTi wires. fter attaining 0.016" 0.022" SS wire in the appliance, surgical exposure was planned. full thickness mucoperiosteal flap was raised to expose the impacted teeth and compound odontomes were removed (Figs 2 and ). egg s brackets were bonded on the exposed surfaces and steel ligatures wires were tied (Fig. 2). Flap was sutured back as decided to erupt the teeth using closed eruption technique. Light traction was applied (5-15 gm per tooth) 552

2 JIOS Orthosurgical Management of ilaterally Impacted Permanent Maxillary entral Incisors: Report of Two ases Figs 1 to : Pretreatment records (case 1) Figs 2 to : Surgical phase (case 1) E F G Figs 3 to G: Treatment progress and post-treatment records (case 1) to guide the teeth to occlusion. close monitoring of the patient was done with periodic recalls and activation at 3 weeks intervals (Figs 3 to ). The total duration of active therapy was 14 months. The impacted maxillary central incisors were guided to occlusion with midline coinciding with facial midline. The final appearances of teeth were pleasing; with good interproximal contact (Fig. 3). Erupted teeth had good width of attached gingiva and gingival contour. Orthopantomogram (OPG) and radiovisiography (RVG) confirmed root parallelism, no root resorption and no evidence of periodontal bone loss (Figs 3E to G). oth incisors have slight root dilacerations in apical 3rd in distal direction. Patient is under observation in retention phase with permanent retention. ase 2 12-year-old boy presented with chief complaint unesthetic smile with missing upper teeth. The patient was healthy well built with balanced face and had no medical or dental history contributing to present complaint. Patient was in mixed dentition with fully erupted maxillary lateral incisors and missing central incisors (Fig. 4). Radiographic examination demonstrated bilaterally impacted maxillary central incisors (Figs 4 to ). Various treatment options were discussed with parents, and they decided for orthosurgical guidance of impacted teeth. written consent was obtained from the parents. The 0.018" Roth preadjusted appliance was bonded on upper arch and open coli spring was used to maintain the space available (Fig. 5). full thickness mucoperiosteal flap was raised to expose the impacted teeth; egg s brackets were bonded on the exposed surfaces and steel ligatures wires were tied (Fig. 5). Flap was sutured back as decided to erupt the teeth using closed eruption technique. Light traction was applied (<15 gm per tooth) to guide the teeth to occlusion. close monitoring of the patient was done with The Journal of Indian Orthodontic Society, October-ecember 2014;48(4):

3 Sanjeev atana et al Figs 4 to : Pretreatment records (case 2) E Figs 5 to F: Treatment progress (case 2) F periodic recalls and activation at 3 weeks intervals. egg s brackets were replaced with preadjusted edgewise appliance (PE) brackets once the incisors erupted into oral cavity " NiTi pigiback wire was used to guide the incisors into occlusion (Figs 5 to F). The total duration of active therapy was 20 months. The impacted maxillary central incisors were guided to occlusion with pleasing appearances and good interproximal contacts and good width of attached gingiva and gingival contour (Fig. 6). Orthopantomogram and RVG confirmed root parallelism, no root resorption and no evidence of periodontal bone loss (Figs 6 to ). Twenty-one has slight root dilacerations in apical 3rd in distal direction and has conical morphology (Fig. 6). Patient was given permanent retention and is under observation in retention phase. ISUSSION n impacted tooth is one which failed to erupt in oral cavity with in its expected time of eruption (two-third root completion). Management of an impacted maxillary incisor is a challenging orthodontic problem. The causes of impaction of incisor can be broadly divided into obstructive and traumatic. The obstructive causes include supernumerary teeth, odontome, tissue scaring or lack of adequate space. 3-7 The traumatic causes include trauma to developing tooth bud or tooth, dilacerations, ankylosis or acute traumatic intrusion The maxillary incisor must be erupted and should take their correct position in arch before the eruption of maxillary canines. When maxillary canines erupt their crowns will move downward and mesially, so they will push the central 554

4 JIOS Orthosurgical Management of ilaterally Impacted Permanent Maxillary entral Incisors: Report of Two ases Figs 6 to : Post-treatment records (case 2) and lateral incisors toward each other and close any space between them. The treatment options for an impacted incisor include: wait and watch, surgical exposure and orthodontic guidance or extraction of impacted tooth. Factors determining the successful alignment of impacted tooth are: (1) the position and direction of the impacted tooth, (2) the degree of root completion, (3) the degree of dilacerations, and (4) the presence of space for the impacted tooth. The techniques for surgical exposure of impacted incisor include: open eruption technique (excisional uncovering), apically positioned flap and closed eruption technique. In open eruption technique, the impacted tooth is surgically uncovered and an attachment is bonded on the exposed surface. The wound is allowed to heal through secondary healing and orthodontic traction is applied to guide it to desired position. In closed eruption technique, a full thickness mucoperiosteal flap is raised, attachment is bonded on the exposed surface of the impacted tooth with an auxiliary and flap is sutured back in place. The mechanics of guiding the impacted canine is basically the same regardless of whether the eruption is open or closed. multidisciplinary approach is required for successful guidance for an impacted tooth in occlusion. 11 The orthosurgical management of an impacted incisor depends on its state of development, position and if there is enough space in the dental arch to accommodate. Early detection and diagnosis minimize the negative impact of impacted tooth on the dental arch (tilting of adjacent teeth) and psychological trauma to the patient. Obstruction/cause of impaction if present should be removed as soon as possible. Once the obstruction is removed, one should expect the spontaneous eruption of impacted tooth provided no other etiological factor present, otherwise orthodontic traction is required to guide the impacted tooth to its destination. 12,13 dequate space should be present/created for the erupting tooth, requires orthodontic intervention prior to surgical exposure and guidance. losed eruption technique should be followed to guide the impacted tooth through attached gingiva. Periodontal health of impacted tooth should be given due considerations, guided tooth should have sound and stable within alveolar bone, good attached gingival width 14, 15 with no sign of dehiscence, mobility or root resorption. ONLUSION Orthosurgical guidance of impacted incisor is a clinical challenge in young patients. Successful management depends on early diagnosis, careful treatment planning and periodic reviews during orthodontic guidance of impacted tooth. Surgical exposure and orthodontic guidance offers a complete treatment for an impacted tooth. However, the orthosurgical guidance of impacted maxillary incisor may not be possible every time. areful case selection and proper treatment planning is of utmost importance and one should not make any heroic attempt. REFERENES 1. Grover PS, Lorton L. The incidence of unerupted permanent teeth and related clinical cases. Oral Surg Oral Med Oral Pathol 1985;59(4): The Journal of Indian Orthodontic Society, October-ecember 2014;48(4):

5 Sanjeev atana et al 2. Pinho T, Nevers M, lves. Impacted central incisor: surgical exposure and orthodontic treatment. m J Orthod entofac Orthop 2011;140(2): Giancotti, Grazzini F, e ominicis F, Romanini G, rcuri. Multidisciplinary evaluation and clinical management of mesiodens. J lin Pediatr ent 2002;26(3): Ibricevic H, l-mesad S, Mustagrudic, l-zohejry N. Supernumerary teeth causing impaction of permanent maxillary incisors. J lin Pediatr ent 2003;27(4): atra P, uggal R, Kharbanda OP, Parkash H. Orthodontic treatment of impacted anterior teeth due to odontomas: a report of two cases. J lin Pediatr ent 2004;28(4): Morning P. Impacted teeth in relation to odontomas. Int J Oral Surg 1980;9(2): ndreasen JO, Sundstrom, Ravn JJ. The effect of traumatic injuries to primary teeth on their permanent successors. clinical and histologic study of 117 injured permanent teeth. Scand J ent Res 1971;79(3): rin I, Zilberman Y, zaz. The unerupted maxillary central incisor: review of its etiology and treatment. S J ent hild 1982;49(7): Koch H, Schwartz O, Klausen. Indications for surgical removal of supernumerary teeth in the premaxilla. Int J Oral Maxillofac Surg 1986;15(3): Langowska-damczyk H, Karmanska. Similar locations of impacted and supernumerary teeth in monozygotic twins: a report of two cases. m J Orthod entofac Orthop 2001;119(1): Rizzatto SM, de Menezes LM, llgayer S, atista EL Jr, Freitas MP, Loro R. Orthodontically induced eruption of a horizontally impacted maxillary central incisor. m J Orthod entofac Orthop 2013;144(1): ecker. Early treatment for impacted maxillary incisors. m J Orthod entofac Orthop 2002;121(6): Veis, Tziafas, Lambrianidis T. case report of a compound odontoma causing delayed eruption of a central maxillary incisor: clinical and microscopic evaluation. J Endod 2000;26(8): Frank, Long M. Periodontal concerns associated with the orthodontic treatment of impacted teeth. m J Orthod entofac Orthop 2002;121(6): rand, khavan M, Tong H, Kook Y, Zernik JH. Orthodontic, genetic and periodontal considerations in the treatment of impacted maxillary central incisors: a study of twins. m J Orthod entofac Orthop 2000;117(1):