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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 27-30

Unveiling the impacted incisor


Department of Orthodontics, A. B. Shetty Memorial Institute of Dental Sciences, Mangaluru, Karnataka, India

Date of Web Publication26-Aug-2015

Correspondence Address:
Dr. Aniket Potnis
Department of Orthodontics, A. B. Shetty Memorial Institute of Dental Sciences, Mangaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-6360.163652

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  Abstract 

Missing and unerupted maxillary incisors can have a major impact on dental and facial esthetics and were considered to be the most unattractive deviant occlusal trait. There are very few studies reporting any functional problems associated with the missing anterior teeth although some speech difficulties have been reported, particularly with the "s" sound. Although impaction of permanent tooth is rarely diagnosed during the mixed dentition period, an impacted central incisor is usually diagnosed accurately when there is delay in the eruption of tooth. As missing upper incisors are regarded as unattractive, this may have an effect on self-esteem and general social interaction and it is important to detect and manage the problem as early as possible. This case report describes the treatment of a patient with a horizontally impacted maxillary central incisor. Due to a midline shift and lack of space in the upper arch, a two stage treatment plan was developed. In the first stage, space was created by using a closed coil spring. The second stage involved surgical exposure and traction of the impacted central incisor. The patient finished treatment with a normal and stable occlusion between the maxillary and mandibular arches and an adequate width of attached gingiva.

Keywords: Impacted central incisor; orthodontic traction; surgical exposure


How to cite this article:
Potnis A, Panchasara C, Shetty A, Krishna Nayak U S. Unveiling the impacted incisor. Indian J Multidiscip Dent 2015;5:27-30

How to cite this URL:
Potnis A, Panchasara C, Shetty A, Krishna Nayak U S. Unveiling the impacted incisor. Indian J Multidiscip Dent [serial online] 2015 [cited 2019 Mar 19];5:27-30. Available from: http://www.ijmdent.com/text.asp?2015/5/1/27/163652


  Introduction Top


The objectives of orthodontic therapy are to establish a good occlusion, enhance the health of the periodontium, and most importantly to improve dental and facial esthetics. One of the most common orthodontic problems requiring surgical intervention is the noneruption of a permanent tooth. The noneruption of a permanent tooth is a frequently occurring situation which, provided the permanent tooth is not congenitally absent, may be caused by a variety of clinical abnormalities such as dense overlying bone, or excessive soft tissue which prevents their eruption. [1] Several contributing factors have been suggested that impede tooth eruption. These could be mesiodens or multiple supernumerary teeth in the anterior maxillary region, [2],[3] odontogenic tumors such as odontomas or cysts, [4],[5] alteration in the eruption path or formation of scar tissue due to trauma or premature loss of the primary incisors, [6] and abnormal root angulation or dilacerations. [7]

Normally, a tooth erupts into the oral cavity once two-thirds of root formation is complete. An impacted tooth is one that fails to erupt into the dental arch within the expected time. Studies have shown that some teeth which fail to erupt past their normal eruption time need to be surgically exposed and orthodontically aligned into their normal physiologic position in the dental arch. The most commonly impacted maxillary tooth is the canine, occurring in <2% of the general population, [8] followed by the central incisor with a frequency of 0.06-0.2%. [9] The anterior maxilla is a highly demanding area from an esthetic point of view, and orthodontic treatment of impacted maxillary incisor requires a well synchronized and interdisciplinary approach to obtain an acceptable esthetic and functional result. [10] This report describes the sequential management of an impacted tooth in the maxillary arch. The treatment success was the result of the combined efforts of an orthodontist and the oral surgeon.


  Case Report Top


A 17-year-old girl reported to the Department of Orthodontics with a chief complaint of missing upper front tooth and spacing in the upper front teeth. She was brachycephalic and euryprosopic with a straight facial profile.

Diagnosis and etiology

The patient had a balanced facial pattern. Intraoral examination revealed Angle's Class II subdivision Molar relation, Class I canine relation on both sides with overjet of 4 mm and overbite of 3 mm. The upper dental midline was shifted to the left by 3 mm. A missing maxillary permanent left central incisor [Figure 1] was diagnosed. An intraoral periapical radiograph of upper anterior region demonstrated an impacted permanent maxillary left central incisor. To confirm the position of impacted tooth, an occlusal radiograph was used [Figure 2]. The panoramic radiograph demonstrated an impacted maxillary left central incisor. The maxillary left central incisor was positioned horizontally with the tip of the crown close to the apex of the right central incisor [Figure 3].
Figure 1: Pretreatment facial and intraoral photographs

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Figure 2: Pretreatment occlusal radiograph

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Figure 3: Pretreatment panoramic radiograph and cephalogram

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Treatment objectives

  • Surgically expose the impacted left maxillary permanent central incisor, apply orthodontic traction with light forces, and align the maxillary dental arch
  • Establish Class I Molar relationship
  • Maintain Class I Canine relationship
  • Establish ideal overjet and overbite
  • Achieve optimal facial balance and esthetics.


Treatment alternatives

The following were the three possible treatment alternatives:

  • Extraction of the impacted central incisor and restoration with a bridge or an implant
  • Extraction of the impacted central incisor and closure of space, substituting the lateral incisor for the central incisor with the subsequent prosthetic restoration
  • Surgical exposure and orthodontic traction of the impacted central incisor into proper position.


Treatment plan

  • Nonextraction treatment
  • Leveling and aligning
  • Surgical exposure and orthodontic traction of the impacted central incisor into proper position
  • Finishing and detailing.


Treatment progress

Patient was presented with all the three treatment alternatives out of which, the patient chose to save the tooth and bring it into position orthodontically. The patient was treated using preadjusted edgewise appliance with 0.022 slot MBT prescription. After the initial alignment of the incisors with 0.016 NiTi wire (approximately 2 months), an open coil spring was placed between the right maxillary central incisor and the left lateral incisor [Figure 4]. By activating the open coil spring, adequate space for aligning the impacted incisor was obtained.
Figure 4: Open coil spring given to open space

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Once space had been regained, the patient was transferred to the oral surgeon, and surgical exposure (open method) of the impacted central incisor was done. A Begg's bracket was placed on the exposed surface of the impacted central incisor intraoperatively. Since the incisor was horizontally impacted, it was necessary to rotate it into proper inclination before applying orthodontic traction. Hence, a lingual button was bonded on the palatal surface of the incisor and e-chain was placed. The couple so formed brought about effective rotation of the incisor [Figure 5]. Once the incisor had rotated sufficiently, a crimpable hook with a palatal extension was added on to the basal upper arch wire (0.017 × 0.025 inch stainless steel). Two e-chains were placed; one from the Begg's bracket to the upper left canine bracket and one from the lingual button to the hook to attain proper angulation of the incisor [Figure 6].
Figure 5: Surgical exposure of incisor and e-chain placement to create a couple

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Figure 6: Palatal hook with e-chain placed

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On further exposure of the incisor crown, the basal arch wire (0.017 × 0.025 stainless steel) was stepped down in the region of the upper left central incisor. An e-chain was placed from the Begg's bracket on the incisor to the stepped down arch wire [Figure 7]. Once the incisor has reached its final position, the final alignment was done with a 0.016 × 0.022 inch NiTi wire [Figure 8]. The finishing and detailing of the arches were done using full dimension arch-wire after proper positioning of incisors.
Figure 7: Step down wire with e-chain engaged

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Figure 8: Final finishing with 0.016 × 0.022 inch NiTi wire

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  Results Top


The maxillary left central incisor was brought into an acceptable position with normal overbite, overjet, and intercuspation. Spaces in upper and lower arch were closed. Well-interdigitated Class I canine and molar relationships were attained. The exposed incisor presented an acceptable gingival contour after treatment and sufficient amount of attached gingiva. Radiographically, the newly positioned incisor revealed an intact straight root and no apparent root resorption.


  Discussion Top


Impaction of maxillary anterior teeth can be a challenging orthodontic problem. Several reports have indicated an impacted tooth can be brought into proper alignment in the dental arch. [7],[11],[12] Several clinicians have successfully treated impacted maxillary anterior teeth by proper crown exposure surgery and orthodontic traction, and indicated that an impacted tooth can be brought to proper alignment in the dental arch. [13],[14]

The current treatment modality instead of extraction has used the surgical crown exposure and orthodontic positioning of the tooth. Factors considered for successful alignment of an impacted tooth are:

  • The position and the direction of impacted tooth
  • The degree of root completion
  • The presence of space for the impacted tooth.


These factors were considered before planning treatment for this case. In this case, the periodontal status of the exposed incisor after orthodontic treatment revealed an acceptable gingival contour and attached gingiva. No further mucogingival surgery was recommended. The treatment approach of impacted maxillary teeth requires the cooperation of dental specialties such as orthodontics, oral surgery, and prosthodontics. This case demonstrated that surgical exposure and orthodontic correction might be a better treatment option than conventional extraction or the surgical approach for treatment of an impacted incisor.


  Conclusion Top


Surgical exposure and orthodontic correction offers a simplified treatment for impacted incisors. The advantages include immediate esthetic improvement; use of a single, simplified surgical procedure; simple and short orthodontic therapy; and normal gingival margins.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Becker A. The Orthodontic Treatment of Impacted Teeth. 1 st ed. United Kingdom: Mosby Company; 1998. p. 53-85.  Back to cited text no. 1
    
2.
Giancotti A, Grazzini F, De Dominicis F, Romanini G, Arcuri C. Multidisciplinary evaluation and clinical management of mesiodens. J Clin Pediatr Dent 2002;26:233-7.  Back to cited text no. 2
    
3.
Ibricevic H, Al-Mesad S, Mustagrudic D, Al-Zohejry N. Supernumerary teeth causing impaction of permanent maxillary incisors: Consideration of treatment. J Clin Pediatr Dent 2003;27:327-32.  Back to cited text no. 3
    
4.
Batra P, Duggal R, Kharbanda OP, Parkash H. Orthodontic treatment of impacted anterior teeth due to odontomas: A report of two cases. J Clin Pediatr Dent 2004;28:289-94.  Back to cited text no. 4
    
5.
Kamakura S, Matsui K, Katou F, Shirai N, Kochi S, Motegi K. Surgical and orthodontic management of compound odontoma without removal of the impacted permanent tooth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:540-2.  Back to cited text no. 5
    
6.
Ben Bassat Y, Fuks A, Brin I, Zilberman Y. Effect of trauma to the primary incisors on permanent successors in different developmental stages. Pediatr Dent 1985;7:37-40.  Back to cited text no. 6
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7.
Lin YT. Treatment of an impacted dilacerated maxillary central incisor. Am J Orthod Dentofacial Orthop 1999;115:406-9.  Back to cited text no. 7
    
8.
Ericson S, Kurol J. Longitudinal study and analysis of clinical supervision of maxillary canine eruption. Community Dent Oral Epidemiol 1986;14:172-6.  Back to cited text no. 8
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9.
Grover PS, Lorton L. The incidence of unerupted permanent teeth and related clinical cases. Oral Surg Oral Med Oral Pathol 1985;59:420-5.  Back to cited text no. 9
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10.
Kolokitha OE, Papadopoulou AK. Impaction and apical root angulation of the maxillary central incisors due to supernumerary teeth: Combined surgical and orthodontic treatment. Am J Orthod Dentofacial Orthop 2008;134:153-60.  Back to cited text no. 10
    
11.
Wasserstein A, Tzur B, Brezniak N. Incomplete canine transposition and maxillary central incisor impaction - A case report. Am J Orthod Dentofacial Orthop 1997;111:635-9.  Back to cited text no. 11
    
12.
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. 12
    
13.
Thosar NR, Vibhute P. Surgical and orthodontic treatment of an impacted permanent central incisor: A case report. J Indian Soc Pedod Prev Dent 2006;24:100-3.  Back to cited text no. 13
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14.
Kocadereli I, Turgut MD. Surgical and orthodontic treatment of an impacted permanent incisor: Case report. Dent Traumatol 2005;21:234-9.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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Abstract
Introduction
Case Report
Results
Discussion
Conclusion
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