Management of an abnormally erupting dilacerated incisor-a case report

..// J ; CLINICAL ) 0(]~ Ind Orthod Soc 2006; 39:189-197 Management of an abnormally erupting dilacerated incisor-a case report Sridevi Padmanabhan, MDS, Diplomate, Indian Board of Orthodntics Prof, Dept. of Orthodontics, SriR amac handra Dental Co llege and Hosp itals Porur, Chenn ai-600116 Abstract Keywords Dilaceration is a development deformity which commonly affects the maxillary central incisors. Extraction,orthodontic traction and surgery are some of the treatment options reported. This case report describes the management of an abnormally erupting, severely dilacerated incisor with a combination of orthodontics, endodontics and adjunctive surgery. Dilacerated incisor, orthodontic traction, adjunctive surgery. Introduction Dilaceration is a developmental deformity that results from a disturbance of the relationship between uncalcified and already calcified portions of a developing toothl. Dilaceration can occur anywhere along the length of the root or at the junction of the crown and root. 2 Trauma has been proposed as the common etiological factor 3 ;4. Smith and Winter 4 found trauma to be an episode in twenty two out of thirty one patients; however, another study found a history of trauma only in nine out of forty one dilacerated incisors and it has also been proposed that, when the crown of the dilacerated tooth is labially placed, there must be some degree of ectopic developments of the tooth germ. Dilaceration commonly affects the maxillary central incisors probably because of the propensity for trauma. 6 Cases of dilacerated incisors have been treated both with a combination of surgery and orthodontics7 and by orthodontic traction alone. 8 ;9;lo This case report describes a dilacerated central incisor whose prognosis at the outset could be considered bleak because of the severity of the dilaceration and the sharp angle between the crown and the root. Treatment of dilacerated teeth with an obtuse angle is predicted to be more successfu I. 1 0 Extraction and a prosthesis was an obviously tempting alternative. However, the absence of the canine on the same quadrant and the requirement for comprehensive orthodontic treatment was adequate reason to attempt to bring the tooth into alignment. The total treatment time was 23 months and the dilacerated tooth was brought into the arch with acceptable esthetics. Follow-up over a period of six months revealed that the tooth showed no mobility and was asymptomatic. Pre-Treatment Assessment Patient Details 1. Initials: T.S 2. Sex: Male 3. Date of Birth: 7-4-1988 4. Age at start of treatment: 13 years, one month Patient's Complaints Patient complained of pain and swelling in relation to the upper lip and had noticed a tooth erupting causing discomfort over the last two months. Relevant Medical History No relevant medical history. Clinical Examination: Extra-Oral Features Patient was of mesomorphic build with normal gait and posture. Face was mesoprosopic with incompetent swollen lips. Profile was convex with an average clinical FMA. 189

Sridevi Fig. 1 : a,b-pre-treatment photographs; extraoral Fig. 1a Fig. 1 b Fig. 2a Fig. 2b Fig. 2c Fig. 2 : a-e-pre-treatment photographs; intraoral Fig. 2d Fig. 2e Fig. 3a Fig. 3b Fig. 2c Fig. 3 : a-e-pre-treatment mode ls Fig. 3d Fig. 3e 190

'. // ) LcJ~ J Ind Orthod Soc 2006; 39: 189-197 Fig. 4 : a-pre-treatment Lateral Cephalogram b- OPC c-pre-treatment cephalometric tracing Fig 5 : a,b,c Mid-treatment photographs Fig. 6 : a,b-post-treatment extraoral photographs 191

Sridevi Clinical Examination: Intra-Oral Features Soft tissues: The upper lip was continuous with the soft tissue surrounding the maxillary upper left central incisor and upper lip retraction was limited and induced bleeding. There was gingival recession in relation to 31. Oral hygiene: Poor, with stains on the palatal surfaces of the upper teeth and calculus on the lingual surfaces of the mandibular incisors. Erupted teeth present: 17,16,15,14,13,12,11 21,22,24,25,26,27 47,46,45,44,43,42,41 31,32,33,34,35,36,37 General dental condition: Poor oral hygiene. Pit cavities on the lingual surfaces of 12,22 and on the occlusal surface of 16. Crowding/Spacing Maxillary arch: Asymmetrical with upper midline shifted to left. The maxillary left central incisor was oriented almost at 90 to the adjacent teeth with merely the incisal third exposed at a level cervical to the crown of the adjacent tooth. The tooth was impinging on the upper lip causing pain and swelling and bleeding on retraction of the lip. Mandibular arch: Crowding with exaggerated curve of spee. Arch length tooth size discrepancy of 4 mm. Occlusal Features Incisor relationship Overjet (mm) Overbite Centrelines : Class I : 4mm : 5mm : Not coinciding. Upper midline shifted to left. Left buccal segment relationship : End-on Right buccal segment relationship : Class I Crossbites : 16 in cross bite Displacements : Mandibular lateral incisors lingually displaced. Other occlusal features Pre-treatment radiographs taken: Lateral cephalogram, OPG Unerupted teeth 18,28,38,48 Teeth absent 23 Teeth of poor prognosis : 21,31 Other relevant radiographic findings: OPG confirms absence of 23. Lateral cephalogram and OPG reveal dilacerated upper left central incisor with an abnormal angulation between crown and root and the apical third of the root at a very sharp angle to the rest of the tooth. Other Special Tests I Analyses Vitality test done on 21 showed a vital pulp. Table I: Cephalometric Analysis Variable Sagittal Skeletal Relationship Pretreatment Normal l SNA 82 82 SNB 77 80 I ANB 5 2, Wits appraisal 4mm Omm Dental Base Relationship L Upper incisor to NA ( mm/deg) 300/4 mm 22 /4mm Lower Incisor to NB {mm/de~ 22 /4 mm 25 /4mm l Upper Incisor to SN Plane 112 102 Lower incisor to mandibular. p.!ane angle (lmpa) 89 90 I Dental Relationship- Inter- incisal angle 127 132 Lower incisor to APo line 3mm 0-2 mm Over bite 5mm 2-4 mm Overjet 4mm 2-4 mm Vertical Skeletal Relationshif>s Maxillary - mandibular planes angle 18 25 SN Plane - Mand Plane 30 32 Upper anterior face height Lower anterior face height 45 mm 54mm Face height ratio 45:55 45: 55 Jarabak Ratio 64 63-65 Maxillary length B4mm 92±3.7 _MandibUlar len2th - effective (McNamara) 99mm 114±4.9 192

J Ind Orthod Soc 2006; 39:189-197 lower lip to Ricketts E Plane Nasolabial Angle Interpretation Soft Tissues 2 mm -2 mm 107 102 +/_8 Skeletal Class" Base with a normal maxilla and a retrognathic mandible with an average growth pattern. Proclined upper anteriors and retroclined lower anteriors. Protrusive lower lip and average nasolabial angle. Diagnostic Summary A case of a borderline skeletal class" with a normal maxilla and retrognathic mandible with a horizontal growth pattern, superimposed with a dentoalveolar malocclusion Angle's class I with crowding. The striking feature was the dilacerated maxillary left incisor which showed an abnormal path of eruption. Problem List 1. Abnormal path of eruption of dilacerated 21. 2. Convex profile 3. Crowding in lower arch. 4. Exaggerated curve of Spee 5. Deep bite 6. Cross bite of 16 7. Missing 23. 8. Upper midline shifted to left. Aims and Objectives of treatment 1. To bring the dila~erated incisor into the arch. 2. To alleviate crowding 3. Flatten the curve of spee and open the bite. 4. To correct cross bite of 16 5. To correct upper midline and create a functional class" molar relation. Minor adjunctive surgery Excision of the restraining soft tissue surrounding dilacerated 21 at the start of treatment. Major adjunctive surgery Nil Table II: Post-treatment Cephalometric Analysis Variable SNA SNB ANB Sagittal Skeletal Relationship -===' Pretreatment Post -treatment 4mm 3mm Dental Base Relationshi :=::::::~====~ Up er incisor to NA {mmldeg} 300/4 mm 31 /4 mm lower Incisor to NB {mm/de} 22 /4 mm 25 /6 mm Upp'er Incisor to SN Plane 112 112 Inter- incisal angle lower incisor to APo line Over bite Overjet Maxi"a '=====;;:;:: Dental Relationshi.-.;.o.;L------ 127 3mm 5mm 4mm Vertical Skele tal Relationship-s - mandibular Ian es angle 18 SN Plane - Mand Plane Upper anterior face height 30 45 mm 120 3mm 2mm 3mm 19 32 48mm Treatment Plan lower anterior face height S4mm 56mm Extractions: 14 and 31 Appliances Preadjusted edgewise appl iance (.022 Roth prescription). Special anchorage requirements Minimum anchorage in the upper arch. Modified palatal arch in the upper and lingual arch in the lower. Face height ratio 45:55 Jarabak Ratio 64 Maxi"ary length 84mm Mandibular leng!h - effective {McNamara} 99mm Soft Tissues lower lif> to Ricketts E Plane 2mm Nasolabial Angle 107 0 46: 54 65 85 mm 114 mm Omm 110 193

Sridevi Additional dental treatment Restorations on palatal surfaces of 12,22 and occlusal su rface of 16. Endodontic treatment of 21 to be considered after orthodontic treatment. Minimal grinding of the palatal cusp of 24 to prevent interference during lateral and protrusive excursions. Proposed retention strategy Fixed canine to canine retainer on the lower arch. Fibre reinforced composite bonded on the upper anteriors 11,12,21,22 in addition to UHA Prognosis for stability Questionable prognosis of 21. Treatment Progress Start of active treatment: 25-05-01 Age at start of active treatment: 13 years, one month. End of active treatment: 25-05-01 Active treatment time: 23 months. End of retention: Permanent retention for upper arch. Key Stages in Treatment Progress Date Stage ==== 1. 25-05-01 Soft tissue around 21 resected and upper lip relieved. 2. 28-05-01 Palatal arch with helix soldered to upper molar bands. Lingual button bonded onto 21. Elastomeric string tied to apply lingual and incisal force to 21. 3. 2-08-01 21 shows a more occlusal and lingual position. 31 extracted. - 4. 3-08-01.022 Roth set up strapped on upper arch. 016 copper niti fixed Lower lingual arch fixed. 5. 29-08-01 Brackets bonded on lower teeth. 016 niti wire fixed. 6. 5-12 -01 21 shows a more normal position and inclination. 24 extracted. 7. 16-02-02 Upper and lower rectangular niti fixed on upper and lower arch ===== 8. 6-04-02 Adequate space created for 21. Trauma to 21. IOPA reveals no abnormalities. Archwire not engaged on 21. To keep under observation for a few weeks. 9. 29-06-02 21 brought into the arch in line with adjacent teeth. 10. 26-07 -02 Second molars banded. Settling to start. 11 28-04-03. Appliance debonded. 12. 3-05-03 21 vital. Flap raised and dilacerated root apex exposed. Retrograde single sitting RCT and apicectomy done. 13. 4-5-03 Flap raised in relation to 23. Lateral transposition flap done to correct gingival recession. Post Treatment Assessment Occlusal Features Incisor relationship Overjet (mm) Overbite Centrelines Left buccal segment relationship Class I 3 mm 2mm Upper midline coinciding with facial midlines. Lower midline not applicable since 31 was extracted. : Class" Right buccal segment relationship: Class" Crossbites Displacements Functional occlusal features Other occlusal features Nil Nil : Mutually protected occlusion. Complications Encountered During Treatment Trauma to 21.Patient complained of pain. IOPA revealed no abnormalities. Appliance made passive with regard to 21 for an observation of 4-6 weeks. Pulp vitality tests after the observation period showed a normal vital pulp. Treatment subsequently resumed. Gingival recession in relation to 43 mid treatment. Additional lingual root torque given to reduce root prominence. Subsequently after debonding the appliance, frenum relieved and a lateral transposition gingival graft done. 194

'.. // J LcJ~ J Ind Orthod Soc 2006; 39: 189-197 Fig. 7c Fig. 7 : a-e-post-treatment intraoral photographs Fig. 8c Fig. 8 : a-e-post-treatment model Fig. 8e Fig 9 : a-post-treatment Lateral Ceph, b - Post-treatment OPG, c - Post-treatment IOPA 195

Sridevi Fig 10 : Post-treatment cephalometric tracing -"..< -- - p"'" Fig. 11 : a-overall superimposition registered on Sella. Nasion line at Nasion Fig. 11 : b-maxillary and mandibular superimpositions. Occlusal Indices Parameter Start Finish Change % Change Radiographs Taken Towards/At End of Treatment Value 28 96.5 Radiographs taken: OPG, Lateral Ceph, IOPA of 21. Relevant findings: OPG and IOPA revealed bone loss to nearly half the root length. Lateral Ceph showed the apical 1/3 rd of 21 directed labially implying a fenestration of the labial cortical plate. Interpretation of Post-Treatment Ceph Relative greater growth of mandible reducing the degree of convexity. Axial inclination of upper anteriors relatively unchanged.uprighting of lower incisors as a consequence of flattening the curve of spee. Improved lip competence with slightly more obtuse nasolabial angle.. Critical Appraisal The severity of the dilaceration and the sharp angle between the crown and the root presented a questionable prognosis; however, the absence of the canine on the same quadrant and the requirement for comprehensive orthodontic treatment was adequate reason to attempt to bring the tooth into alignment. The total treatment time was 23 months and the dilacerated tooth was brought into the arch with acceptable dental esthetics. However, it was not possible to achieve adequate torque for 21 since the root apex was directed labially. The lower crowding was alleviated and the curve of spee was flattened. Growth was favourable reducing the convexity of the face achieving a pleasing profile. Lip competence was improved. Although the post treatment IOPA showed bone loss, the tooth showed minimal mobility and the patient had no discomfort. Communications Dr. Sridevi Padmanabhan, MDS Diplomate, Indian Board of Orthodontics Prof., Dept. of Orthodontics, Sri Ramachandra Dental College and Hospitals Porur,Chennai-600116 e-mail:sridevipadu@gmail.com 196

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