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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 51  |  Issue : 1  |  Page : 46-50

Orthodontic management of impacted central incisor: A clinical challenge


1 Reader, Department of Orthodontics and Dentofacial Orthopedics, Subharti Dental College, Meerut, Uttar Pradesh, India
2 Reader, Department of Orthodontics and Dentofacial Orthopedics, PDM Dental College, Bahadurgarh, Haryana, India
3 Prof. and Head, Department of Orthodontics and Dentofacial Orthopedics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
4 Associate Prof., Department of Orthodontics and Dentofacial Orthopedics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission20-Jan-2016
Date of Acceptance12-Nov-2016
Date of Web Publication31-Jan-2017

Correspondence Address:
Amit Kumar Khera
Department of Orthodontics and Dentofacial Orthopedics, Subharti Dental College, Meerut, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-5742.199249

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  Abstract 

Multiple treatment options are available for patients who have impacted incisor. This paper shows a case in which orthodontic as well as surgical considerations in 10-year-old female child were presented in the management of impacted central incisor. The orthodontic treatment plan included three steps – creation of space, exposure of crown, and forced eruption. A unique and innovative technique for orthodontic traction (0.017 × 0.025 TMA wire with palatal extension) was employed to move the maxillary incisor into arch, with minimum injury to neighboring soft tissue. After the successful management of impacted teeth, it is very important to periodically review the periodontal condition and stability.

Keywords: Impacted incisor, orthodontic traction, surgical exposure


How to cite this article:
Khera AK, Rohilla A, Tandon P, Singh GP. Orthodontic management of impacted central incisor: A clinical challenge. J Indian Orthod Soc 2017;51:46-50

How to cite this URL:
Khera AK, Rohilla A, Tandon P, Singh GP. Orthodontic management of impacted central incisor: A clinical challenge. J Indian Orthod Soc [serial online] 2017 [cited 2019 May 19];51:46-50. Available from: http://www.jios.in/text.asp?2017/51/1/46/199249


  Introduction Top


Unerupted teeth are often encountered in the orthodontic practice. The nonappearance of maxillary central incisors even after eruption of adjacent maxillary lateral incisors is abnormal; an impacted central incisor is usually diagnosed accurately based on clinical and radiographic evaluation. Impaction of maxillary permanent incisors is not a frequent case in the dental practice, but its treatment is challenging because of these teeth's importance to facial esthetics. As a general rule, it is pedodontists or general dental practitioners who, during a routine dental examination, discovers and records the existence of an over-retained deciduous tooth.[1],[2],[3] The prevalence of maxillary central incisor impaction ranges from 0.06% to 0.2%.[4]

Central incisor impaction may result from a number of local and systemic factors.[5] Over-retained deciduous teeth, supernumerary teeth, or ectopic eruption and crowding are the most common etiological factors for impacted central incisors. Careful planning and interdisciplinary approach are required in the management of impacted central incisor. Successful management of impacted central incisor is really a clinical challenge for orthodontist because there are chances of failure due to ankylosis, loss of attachment, external root resorption, and root exposure after orthodontic retraction. Improper surgical technique for flap design may lead to crown lengthening and loss of attachment which is functionally and esthetically unacceptable and needs to have periodontal surgery.

Patients usually willing to save his/her impacted teeth even after orthodontists suggest several treatment plans.[6],[7] This paper presents a case with a deeply impacted maxillary right incisor that was managed by combined orthodontic-surgical technique.


  History and Diagnosis Top


A 10-year-old female child came to the Department of Orthodontics with a chief complaint of missing upper front teeth. The child was physically healthy and had no history of medical and dental disease. On extraoral examination, her face was symmetrical with convex lateral profile. The patient intraoral examination showed late mixed dentition. Intraoral examination revealed half-cusp Class II (end on) molar relationship, with an overbite of 8 mm and an overjet of 4 mm [Figure 1]. The arch length-tooth material discrepancy was 5 mm in the upper arch and 4 mm in the lower arch, as calculated from Moyers' prediction tables.
Figure 1: (a) Pretreatment extraoral photographs of 10-year-old female patient. (b) Pretreatment intraoral photographs of 10-year-old female patient

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  Radiographic and Cephalometric Evaluation Top


Evaluation of the lateral cephalometric radiograph revealed a skeletal Class II (ANB-6°) malocclusion with hyperdivergent growth pattern (FMA-31). The orthopantomogram and intraoral periapical radiographs showed an impacted maxillary right central incisor with odontoma. Dentascan evaluation confirmed the presence of the right impacted maxillary incisor surrounded by odontoma [Figure 2]. Although it is generally considered that deeply impacted incisor has a poor prognosis, we decided to expose the tooth and bring it into the arch orthodontically because the patient and her parents requested for not extracting the impacted incisor.
Figure 2: Radiographs showing odontoma impeding the eruption of upper right permanent central incisor

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Treatment objectives

  1. Create the space for impacted central incisor
  2. Orthodontic traction of impacted tooth
  3. Establish an acceptable functional occlusion.


Treatment options

The following are three possible treatment options.

  1. Creation of space for impacted tooth, surgical crown exposure and removal of odontoma, and orthodontic traction of the impacted central incisor
  2. Extraction of the impacted central incisor and temporary restoration with removable prosthetic denture, followed by a permanent restoration with bridge or an implant when growth ceases
  3. Extraction of the impacted central incisor and closure of the space, converting the lateral incisor into the central incisor with subsequent prosthetic restoration.


Treatment plan

The treatment was planned in three steps.

  1. Expansion of the maxillary dental arch to create the space for impacted right central incisor
  2. Surgical exposure of impacted central incisor and removal of odontoma
  3. Traction of maxillary right central incisor, with special attention to the gingival recession.


Treatment progress

Bands were made on the maxillary first permanent molars and semifixed maxillary expansion plate delivered. After 5 months, the 0.022 × 0.028 edgewise appliances were placed on the three maxillary permanent incisors. The initial alignment was performed with a 0.016-inch Ni-Ti wire, followed by a 0.016-inch stainless steel wire. The patient was referred to the oral surgeon for exposure of the impacted incisor. The surgeon followed the closed eruption technique and raised a wide mucoperiosteal flap. The bone and the connective tissue covering the tooth were removed, and two odontomas were removed and sent for pathological examination. Crown was exposed for bonding the lingual button with a ligature wire tied to it. The flap was closed after bonding the lingual button, and the ligature wire was brought out and passively tied to the archwire. After 2 weeks, orthodontic traction of the impacted incisor was started. A 0.017 × 0.025 TMA wire with palatal extension was ligated to maxillary arch for traction [Figure 3]. A force of approximately 50 g was applied by an elastic module. The button was removed, and a bracket was bonded when the incisor reached in the oral cavity and 0.014 cu Ni-Ti auxiliary wire was ligated to bring the tooth in the proper alignment [Figure 4]. Twin block appliance was given to the patient to correct skeletal class II pattern, and customized vertical pull chin cup was given to the patient for night time wear to control the vertical growth [Figure 5]. After the alignment of impacted incisor, torquing of this incisor was done with 0.019 × 0.025 stainless-steel wire.
Figure 3: After 5 month of space opening, odontoma was surgically removed and impacted central incisor exposed and lingual button bonded; 0.017 × 0.025 TMA wire with palatal extension was made on cast and ligated in patient mouth. Orthodontic traction started with elastic module

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Figure 4: After the eruption of impacted central incisor, lingual button was replaced by bracket and 0.014 cu Ni-Ti auxiliary wire was ligated to bring the tooth into the proper alignment

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Figure 5: Twin block appliance given to the patient to correct skeletal Class II pattern, and customized vertical pull chin cup given to the patient for night time wear to control the vertical growth

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  Results Top


After 30 months of active treatment, impacted right central incisor was successfully bring in proper position and normal functional occlusion was established [Figure 6]. The repositioned incisor had slightly irregular gingival contour. The posttreatment radiograph showed no root resorption or alveolar bone loss [Figure 7]. The profile was greatly improved due to twin block therapy [Figure 8]. Regarding esthetic factors, patient was satisfied with the results.
Figure 6: (a) Posttreatment extraoral photographs of the patient. (b) Posttreatment intraoral photographs of patient

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Figure 7: Posttreatment radiographs of patient

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Figure 8: Superimposition of the patient

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  Discussion Top


The literature showed that perfect alignment of impacted incisor can be achieved by careful treatment planning.[2],[8],[9],[10] The successful management of the impacted central incisor is often a difficult task and enquires the joint expertise. It is important that orthodontist and oral surgeon together prepare a full proof treatment plan based on scientific rationale.

In the present case, the findings of periapical and occlusal radiographic images in the maxillary anterior region revealed the presence of an impacted maxillary right central incisor with odontoma, but precise position of impacted tooth and odontoma was not accurately evaluated. It is now possible to acquire three-dimensional (3D) images of the oral and maxillofacial structures by computed tomography (CT) on a high resolution of 0.001 mm 3 voxels with minimal radiation exposure, and these 3D images can provide a better visualization of many anatomical structures. CT images can be used to locate the precise position of impacted and supernumerary teeth to make an accurate diagnosis and to design treatment strategies that would result in less invasive surgical intervention. The present case highlights the superiority of CT images compared with conventional intraoral radiographs with regard to surgical treatment planning of impacted central incisor and odontoma. We requested a CT scan to achieve a more detailed assessment of the shape and position of the impacted tooth and odontoma. CT showed the existence of an odontoma in proximity to the crown of the impacted teeth as well as proximity of impacted incisor to nasal floor. However, neither of the 2D radiographic techniques was able to accurately depict the size or anatomy of the impacted tooth. After evaluating the Dentascan (CT scan), the surgeon decided to go for labial crown exposure of the impacted incisor, so the Dentascan helped us to be more prepared for surgical exposure of the tooth. In this patient, the closed eruption technique was used for surgical exposure because this technique is recommended as best when the tooth is impacted near the nasal spine. A study conducted by Becker et al. showed that closed eruption surgical exposure gives good esthetic result when compared with the unaffected side.[11] Holland [12] has recommended that the movement axis of the impacted tooth must be within 90°. The extrusion force applied on impacted central incisor in present case was very light in the range of 50 gm. The forced eruption of impacted central incisor in high vestibular area can be prevented by applying force from palatal side so that tooth erupts as close to alveolar crest and through attached gingiva.[13],[14] With respect to the flap design, in this case, we used the closed eruption surgical technique, but the tooth erupted through the nonattached gingiva because of the surgical difficulty in exposing the buccal surface of tooth (proximity to the nasal floor); the attachment was bonded on the mesial edge of the impacted incisor, so during traction, the tooth was rotated mesiopalatally by the traction force, leading to the loss of control and eruption of the distal edge through the nonattached gingiva. Once the tooth pierced the buccal mucosa, we use the 0.017 × 0.025 TMA wire with palatal extension to increase the palatal vector to prevent the complete eruption in the buccal vestibule. The periodontal examination showed slightly increase crown length and irregular gingival contour of exposed teeth. We advised the parents for flap surgery to improve the periodontal condition of exposed teeth, but parents refuse for this. They were satisfied with treatment results.


  Conclusions Top


The successful management of impacted central incisor is a clinical challenge. There is also a risk of periodontal problem after alignment. Hence, the periodontal care is very critical. To minimize relapse, a fiberotomy or a bonded fixed retainer may need to be considered for retention.

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.
Becker A. Early treatment for impacted maxillary incisors. Am J Orthod Dentofacial Orthop 2002;121:586-7.  Back to cited text no. 1
    
2.
Lin YT. Treatment of an impacted dilacerated maxillary central incisor. Am J Orthod Dentofacial Orthop 1999;115:406-9.  Back to cited text no. 2
    
3.
Archer LE. Composites. Oral and Maxillofacial Surgery. 5th ed. Philadelphia, PA: WB Saunders Company; 1975. p. 250-390.  Back to cited text no. 3
    
4.
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. 4
    
5.
Bishara SE. Impacted maxillary canines: A review. Am J Orthod Dentofacial Orthop 1992;101:159-71.  Back to cited text no. 5
    
6.
Lundberg M, Wennström JL. Development of gingiva following surgical exposure of a facially positioned unerupted incisor. J Periodontol 1988;59:652-5.  Back to cited text no. 6
    
7.
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. 7
    
8.
Maynard JG Jr, Ochsenbein C. Mucogingival problems, prevalence and therapy in children. J Periodontol 1975;46:543-52.  Back to cited text no. 8
    
9.
Kolokithas G, Karakasis D. Orthodontic movement of dilacerated maxillary central incisor. Report of a case. Am J Orthod 1979;76:310-5.  Back to cited text no. 9
    
10.
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. 10
    
11.
Becker A, Brin I, Ben-Bassat Y, Zilberman Y, Chaushu S. Closed-eruption surgical technique for impacted maxillary incisors: A post orthodontic periodontal evaluation. Am J Orthod Dentofacial Orthop 2002;122:9-14.  Back to cited text no. 11
    
12.
Holland DJ. The surgical positioning of unerupted, impacted teeth (surgical orthodontics). Oral Surg Oral Med Oral Pathol 1956;9:130-40.  Back to cited text no. 12
    
13.
Sicher H. Orban's Oral Histology and Embryology. 6th ed. Philadelphia: CV Mosby Co.; 1966.  Back to cited text no. 13
    
14.
Vermette ME, Kokich VG, Kennedy DB. Uncovering labially impacted teeth: Apically positioned flap and closed-eruption technique. Angle Orthod 1995;65:23-32.  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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Introduction
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