impaction of both maxillary central incisors and a canine · impaction of both maxillary central...

CASE REPORT

Impaction of both maxillary central incisorsand a canine

Teresa PinhoGandra, Paredes, Portugal

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374

This case report describes the treatment of a 14-year-old adolescent patient who had 2 impacted maxillary cen-tral incisors with distoangular root dilacerations. He also had an impacted maxillary left canine, with the crowncompletely overlapping the root of the lateral incisor, and insufficient space. The general dentist referred this pa-tient because themaxillary central incisors had still not erupted 2 years after extraction of the retained deciduousincisors. A unilateral expander with a modified vestibular arch and an attachment spring on the right side wasused to correct the posterior crossbite on the right side and improve the positions of the teeth. The expansionappliance was also applied as a high anchorage device to move the central incisors and the left canine into po-sition during the initial stages. After this phase, fixed appliances were used to redistribute the space in the an-terior maxillary region to create enough space for repositioning the impacted teeth. This procedure restoredthe normal appearance of the maxillary arch, with good periodontal health and without evidence of root resorp-tion, apart from the distoangular root dilacerations of the 2 maxillary central incisors. (Am J Orthod DentofacialOrthop 2012;142:374-83)

Eruptive disturbances are alterations of normaltooth eruption, including accelerated, delayed,failed, or deviated in the direction of tooth erup-

tion, and can be related to general or local etiologic fac-tors.1 An impacted central incisor is usually diagnosedduring the mixed dentition, because maxillary central in-cisors usually erupt before the canines, when a child isbetween 8 and 10 years of age.2

The principal local factors involved in this anomalyare supernumerary teeth, odontomas, and trauma.1,3-5

Dilaceration can be a sequel of trauma and isassociated with maxillary central incisor eruptionfailure.5,6 The dilaceration can be mild, moderate, orsevere and can alter the eruptive pathway of the tooth,causing impaction.5-8

The purpose of this case report is to describe thetreatment of a patient with both maxillary central inci-sors impacted with distoangular root dilacerations. The

ssor, Department of Orthodontics, Centro de Investigac~ao Ciencias da(CICS), Instituto Superior de Ciencias da Sa�ude-Norte/CESPU, Gandra,

gal.uthor reports no commercial, proprietary, or financial interest in the prod-r companies described in this article.t requests to: Teresa Pinho, Centro de Investigac~ao Ciencias da Sa�ude,to Superior de Ciencias da Sa�ude-Norte, Rua Central de Gandra, 1317,116, Gandra, PRD, Portugal; e-mail, [email protected], September 2010; revised and accepted, October 2010.5406/$36.00ight � 2012 by the American Association of Orthodontists..1016/j.ajodo.2010.10.027

maxillary left canine was also impacted, and a unilateralposterior crossbite was present on the right side.

DIAGNOSIS AND ETIOLOGY

A 14-year-old boy was referred by his dentist becauseneither maxillary central incisor had erupted 2 years afterextraction of both retained central and left lateral decid-uous incisors (Fig 1). He had a permanent dentition, andhis chief complaint was an unesthetic smile because ofthe unerupted maxillary central permanent incisors(Fig 2).

The patient was physically healthy and had a historyof dental trauma when he was 7 years old. However,there was no mention of any tooth displacements or in-trusion injuries. The facial photographs showed a con-cave profile and a retruded upper lip with an obtusenasolabial angle (Fig 2). There were no gross asymme-tries. This patient had no parafunction or dysfunction,and the examination and history disclosed no temporo-mandibular joint disorders.

Both maxillary central incisors were impacted andlacked adequate space for proper eruption because ofthe drift of adjacent teeth into the unoccupied spaces(Figs 2-4). The maxillary dentition exhibited a narrowasymmetric dental arch with a unilateral right posteriorcrossbite (from the right lateral incisor to the right firstmolar), which was due to lingual tipping and a slightmandibular functional shift. There was significant

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Fig 1. Initial panoramic x-ray, before the extraction of theretained temporary incisors, when the patient was 12years old.

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dental crowding in the maxillary arch, with a Class IImolar relationship on the right side and a Class Irelationship on the left side. No crowding was presentin the mandibular arch, even though the mandibularright canine was malpositioned. Overjet and overbitewere �2.3 and �5.5 mm, respectively.

The radiographs showed 2 impacted maxillary cen-tral incisors with root dilacerations and an impactedmaxillary left canine (the incisal tip of the canine over-lapped the root of the lateral incisor9 (Fig 4). Thecephalometric analysis showed a normal skeletal pat-tern with normal inclination of the mandibular inci-sors and proclination of the impacted incisorscontributing to the acute interincisal angle (Figs 5and 6; Table).

TREATMENT OBJECTIVES

The following treatment objectives were establishedfor this patient: (1) correction of the posterior crossbiteand attainment of adequate space for positioning theimpacted central incisors, (2) distal positioning of theright canine to improve its relationship, and (3) fixedappliances to gain adequate space for repositioningthe impacted teeth and to create a stable functional oc-clusion.

TREATMENT ALTERNATIVES

Three treatment alternatives were developed: (1) ex-traction of the unerupted central incisors and restorationwith a bridge or implants later when growth had ceased;(2) extraction of the unerupted central incisors with au-totransplantation after orthodontic space opening; and(3) orthodontic space opening, uncovering and tractionof the impacted teeth, and alignment of these teeth intotheir proper positions.

American Journal of Orthodontics and Dentofacial Orthoped

TREATMENT PLAN

The treatment plan consisted of 2 stages. The firstphase involved unilateral expansion (due to the rightcrossbite). The second stage involved fixed appliancesallowing redistribution of the space in the anterior max-illary region to create enough space for the tractionof the impacted teeth and their alignment to obtaina good final occlusal relationship.

TREATMENT PROGRESS

In the first stage, a unilateral expansion appliancewith a modified vestibular arch and an attachmentspring was placed to improve the transverse maxillaryconstriction, the lingual tipping, and the slight func-tional crossbite (Fig 7). After the crossbite correction,a Class I molar relationship was obtained on the rightside (Fig 8, C).

Immediately after the active phase of expansiontherapy, a closed-eruption technique was used tobond a bracket on the right central incisor and a buttonattachment on the vestibular surface of left central in-cisor and the left canine (Fig 8, A). A 0.010-in ligaturewire and elastics were attached and replaced every dayto apply light forces in the vertical and distal direc-tions, respectively (Fig 8, B). The expansion appliancewas removed when the impacted teeth appeared inthe arch and the maxillary left canine was distal tothe root of the lateral incisor. After that, brackets(0.022-in slot) were placed on all maxillary and man-dibular teeth.

During maxillary arch alignment and leveling withnickel-titanium archwires, a T-spring (0.016-in steelarch) was placed on the 2 central incisors to improvetheir positioning (Fig 8, D). Once the maxillary archwas in a relatively rigid stabilizing wire (0.018 30.025-in stainless steel), and adequate space for the 3teeth had been obtained (by activating the open-coilspring), a nickel-titanium auxiliary archwire was en-gaged into the central incisors and eventually into thecanine when it had moved to a more distal position(Fig 9, A). When the canine was close to the dentalarch, detailing occlusal bends were made in the 00.0183 0.025-in stainless steel main archwire to adjust thealignment of the canine (Fig 9, B). After the maxillaryleft canine was moved into the dental arch, root posi-tioning was achieved with sequential rectangular steelarchwires (0.18 3 0.025-in and 0.019 3 0.025-in withtip-back posterior control).

In the mandibular arch, the primary alignment andleveling were achieved with a sequence of 0.014- and0.018-in nickel-titanium archwires, which were later re-placed by rectangular nickel-titanium archwires (0.016

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Fig 2. Pretreatment extraoral and intraoral photos.

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3 0.022 and 0.019 3 0.025 in). A multiloop edgewisearchwire was placed 3 months before finalization ofthe orthodontic treatment to improve the intermaxillaryocclusion (Fig 9, C).

The active treatment took 24 months. Photographs,dental casts, and panoramic and cephalometric radio-graphs were gathered at the end of the treatment,and impressions were taken to create a maxillary cir-cumferential retainer (Figs 10-13). A lingual bondedretainer was placed on the mandibular incisors andcanines.

TREATMENT RESULTS

The impacted teeth were positioned into properalignment with the assistance of direct traction, produc-ing a complete anterior dentition with good alignmentof the gingival margins and a nice smile. The upper lipretrusion was improved. Bilateral Class I canine relation-ships and ideal overjet and overbite were obtained onboth sides (Figs 10 and 11). The final radiographs

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showed intact roots, proper root alignment, and noroot problems with the central incisors, the right lateralincisor, and the left canine, except for the dilacerationsthat were already present (Figs 1 and 4). The left lateralincisor had some apical root resorption probably causedby the initial canine position and the orthodontic forceapplication (Fig 12).

The cephalometric analysis at the end of the treat-ment showed that the patient maintained a goodskeletal relationship and improvements in the overjetand overbite relationships (Figs 13 and 14; Table)from the treatment and also from the favorable growth(Fig 15). One year after the orthodontic treatment,the dental occlusion and the smile remained stable(Fig 16).

DISCUSSION

Impacted maxillary central incisors in a child posea disturbing esthetic dilemma, by virtue of their location.It is important to properly inform the patient and the

Journal of Orthodontics and Dentofacial Orthopedics

Fig 3. Pretreatment dental casts.

Fig 4. Pretreatment panoramic x-ray.

Fig 5. Pretreatment cephalometric radiogram.

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parents of the possibility of failure before extensivetreatment is undertaken to save the severely impactedteeth.10

Traumatic dental injury to a deciduous tooth ora bone fracture can damage the underlying permanenttooth germ; this could disturb its development andincrease dental anomalies such as significant root dila-ceration.5 Our patient had dental trauma when he was7 years old, but there was no mention of dental dis-placement or intrusion. But even if this had happenedat the age of 7 years, it would have been too late tocreate root dilaceration. Also, the integrity of the rootsof the deciduous incisors (Fig 1) and the vitality of thepermanent teeth did not suggest that the trauma


caused the change in the axial inclination of theunerupted teeth, as demonstrated by Kolokithas andKaakasis.11

At 12 years of age, the maxillary right and left cen-tral deciduous incisors were present with intact roots.This means that the dilacerations were probably due


Fig 6. Pretreatment cephalometric tracing.

Table. Cephalometric analysis before and after treat-ment

Cephalometricmeasurement Norm

Beforetreatment

Aftertreatment

FMIA (�) 67 6 3 61.4 63.8FMA (�) 25 6 3 27.2 24.5IMPA (�) 88 6 3 91.4 91.7SNA (�) 82 6 2 83.2 86.9SNB (�) 80 6 2 81.4 84.3ANB (�) 1-5 1.8 2.7Ao Bo (mm) 2 6 2 �7.0 �5.9UI/NA (�) 22 6 2 32.3 20.2Occlusal plane (�) 8-12 14.0 12.3Z-angle (�) 75 6 5 80.9 74.2Posterior facialheight (mm)

45 48.7 58.5

Anterior facialheight (mm)

65 76.4 80.4

Index post ant 0.69 0.67 0.7Overjet (mm) 2.5 6 2.5 �2.3 4.0Overbite (mm) 2.5 6 2.5 �5.5 3.2Interincisal angle (�) 126 6 10 120.3 133.0

Ao Bo, Sagittal disparity between Ao and Bo, orthogonal projectionsof A and B on the occlusal plane; index post ant, relationship be-tween the anterior vertical facial height and posterior vertical facialheight.

378 Pinho

to the obstructed eruption that was aggravated by re-tention of the deciduous teeth. However, 2 years afterextraction of the deciduous teeth, spontaneous erup-tion of the central permanent incisors did not occur,so the main reason for the impactions seems to bethe root dilaceration. This is supported by previousstudies showing that the success rate of an impacteddilacerated tooth depends on the degree of dilacera-tion, the position of the tooth, and the amount ofroot formation.8,12

Other studies have shown that damage to the toothfollicle during extraction of the supernumerary toothresulted in impaction of permanent teeth.13,14 Ifsupernumerary teeth are extracted when the incisorsare immature, damage to their developing roots couldresult in dilaceration, which might then preventeruption.15 However, as already stated, there was nohistory of surgical intervention before the age of 12years. This fact was corroborated by the first pano-ramic radiograph done at this age showing the persis-tence of the maxillary right and left central deciduousincisors and the left lateral deciduous incisor. There-fore, the possible causes of the dilacerated roots ofboth the central incisors could have been the ectopicdevelopment and abnormal positions of the toothbuds. Stewart16 studied 41 cases of root dilacerationand reported that only 22% of the patients had a his-tory of trauma, and also proposed that root


dilaceration was more likely caused by ectopic devel-opment of the tooth germ.

Apart from the dilacerations in this patient, the posi-tion and orientation of the impacted teeth were not toounfavorable, but the amount of root formation was notideal. The best time for treatment of eruptive disturbancesis in the early stages,2,15,17 because the maturity of thedental root influences eruptive movements and supportsthe conservative management of the uneruptedincisor.15 However, failure to erupt the impacted teethmight occur and could be due to ankylosis or externalroot resorption.10,18,19

The surgical approach for uncovering impactedteeth is commonly directed at exposure of the crownand bonding of a button, attachment, or bracket topermit light mechanical forces.1,14,20 These forcesshould be light to prevent bracket debonding, toothankylosis, gingival recession, or cant of the maxillaryocclusal plane.21 In this patient, the improvement inthe position of the impacted teeth was facilitated bythe high anchorage provided by the expansionappliance. In the second stage of treatment, a nickel-titanium auxiliary archwire exerted light and continu-ous forces to erupt the impacted teeth graduallywithout side effects.

The closed-eruption technique is considered a goodsurgical choice for unerupted teeth to enhancethe long-term esthetic and periodontal status.22,23


Fig 8. A, Exposure and traction of the central incisors and the left canine; B, elastics with vertical anddistal directions in the central incisors and the left canine, respectively; C, Class I molar relationship onthe right side;D, fixed bimaxillary appliance and T-spring (0.016-in steel arch) on the buccal surfaces ofthe 2 central incisors.

Fig 9. A, Auxiliary archwire engaged in the canine; B, detailing occlusal bend in 00.018 3 0.025-instainless steel main archwire to adjust the alignment of the canine with the auxiliary archwire; C, finalstage with the multi-loop edgewise archwire.

Fig 7. Unilateral right expansion with a modified vestibular arch and a protrusion spring in the rightanterior side.

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Evaluation of the treatment outcome showed goodperiodontal support and normal gingival contours withadequate width of keratinized attached gingiva and noperiodontal bone loss. This resulted in adequate crownlengths, which contributed positively to the patient's


smile line. The closed-eruption technique used in thispatient seemed to be a good surgical choice. However,when the initial position of an impacted central incisoris high in an area of unattached gingiva, an excisionaltechnique could be necessary to expose the tooth. In


Fig 10. Extraoral and intraoral photos after orthodontic treatment.

380 Pinho

these cases, once the impacted tooth erupts, a secondaryperiodontal procedure might be necessary to augmentthe keratinized attached gingiva.20

Recent case reports have shown that unerupted teethcould be properly positioned with surgical-orthodontictraction1,8,12,20,24,25 or through autotransplantation orintra-alveolar surgical uprighting.26-28 If rootdilaceration is significant and oriented labially8 or in-volves neighboring teeth,5 endodontic treatment andapicoectomy have been suggested instead of extraction.In this patient, apart from the distoangular root dilacer-ations of the 2 maxillary central incisors at the end of thetreatment, surgical-orthodontic traction of the 3 teethwas considered the best alternative.

CONCLUSIONS

The treatment of 2 impacted maxillary central inci-sors, an impacted left canine without sufficient space,and the additional problems of root dilaceration and


posterior crossbite presented a clinical challenge. Aclosed-eruption technique and the sequential tractionof the impacted teeth with light orthodontic forces alongwith palatal expansion were effective approaches tosuccessfully bring the teeth into occlusion.

REFERENCES

1. Brin I, Zilberman Y, Azaz B. The unerupted maxillary central inci-sor: review of its etiology and treatment. ASDC J Dent Child 1982;49:352-6.

2. Crawford LB. Impacted maxillary central incisor in mixed dentitiontreatment. Am J Orthod Dentofacial Orthop 1997;112:1-7.

3. Pinho T, Ustrell Torrent J, Correia Pinto J. Retention of perma-nent incisors by mesiodens: a case report. Gnathos 2005;7:35-42.

4. Witsenburg B, Boering G. Eruption of impacted permanent upperincisors after removal of of supernumerary teeth. Int J Oral Surg1981;10:423-31.

5. Valladares Neto J, de Pinho Costa S, Estrela C. Orthodontic-surgi-cal-endodontic management of unerupted maxillary central inci-sor with distoangular root dilaceration. J Endod 2010;36:755-9.


Fig 11. Posttreatment dental casts.

Fig 13. Postreatment cephalometric radiogram.

Fig 12. Postreatment panoramic x-ray.

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6. Nagaraj K, Upadhyay M, Yadav S. Impacted maxillary centralincisor, canine, and second molar with 2 supernumerary teethand an odontoma. Am J Orthod Dentofacial Orthop 2009;135:390-9.

7. Mattison GD, Bernstein ML, Fischer JW. Lateral root dilaceration:a multi-disciplinary approach to treatment. Endod Dent Traumatol1987;3:135-40.

8. Uematsu S, Uematsu T, Furusawa K, Deguchi T, Kurihara S. Ortho-dontic treatment of an impacted dilacerated maxillary central in-cisor combined with surgical exposure and apicoectomy. AngleOrthod 2004;74:132-6.

9. Jacobs SG. The impactedmaxillary canine. Further observations onaetiology, radiographic localization, prevention/interception ofimpaction, and when to suspect impaction. Aust Dent J 1996;41:310-6.

10. Brand A, Akhavan M, Tong H, Kook YA, Zernik JH. Orthodontic,genetic, and periodontal considerations in the treatment of im-


pacted maxillary central incisors: a study of twins. Am J OrthodDentofacial Orthop 2000;117:68-74.

11. Kolokithas G, Karakasis D. Orthodontic movement of dilaceratedmaxillary central incisor. Report of a case. Am J Orthod 1979;76:310-5.


Fig 16. Dental occlusion and smile 1 year after orthodon-tic treatment.

Fig 15. Pretreatment and posttreatment cephalometrictracings superimposed on the sella-nasion plane atsella.

Fig 14. Postreatment cephalometric tracing.

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12. Lin YT. Treatment of an impacted dilacerated maxillary central in-cisor. Am J Orthod Dentofacial Orthop 1999;115:406-9.

13. Gorski JP, Marks SC Jr. Current concepts of the biology of tootheruption. Crit Rev Oral Biol Med 1992;3:185-206.

14. Kolokitha OE, Papadopoulou AK. Impaction and apical root angu-lation of the maxillary central incisors due to supernumerary teeth:combined surgical and orthodontic treatment. Am J OrthodDentofacial Orthop 2008;134:153-60.

15. Mason C, Azam N, Holt RD, Rule DC. A retrospective study of un-erupted maxillary incisors associated with supernumerary teeth. BrJ Oral Maxillofac Surg 2000;38:62-5.

16. Stewart DJ. Dilacerate unerupted maxillary central incisors. BrDent J 1978;145:229-33.

17. Becker A. Early treatment for impacted maxillary incisors. Am JOrthod Dentofacial Orthop 2002;121:586-7.

18. Sabri R. Treatment of a Class I crowded malocclusion with anankylosed maxillary central incisor. Am J Orthod Dentofacial Or-thop 2002;122:557-65.

19. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central in-cisor by single tooth dento-osseous osteotomy and a simple dis-traction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.

20. Pinho T, Neves M, Alves C. Impacted maxillary central incisor:surgical exposure and orthodontic treatment. Am J Orthod Dento-facial Orthop 2011;140:256-65.

21. Kokich VG, Mathews DP. Surgical and orthodontic management ofimpacted teeth. Dent Clin North Am 1993;37:181-204.

22. Vermette ME, Kokich VG, Kennedy DB. Uncovering labiallyimpacted teeth: apically positioned flap and closed-eruptiontechniques. Angle Orthod 1995;65:23-32.


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23. Chaushu S, Dykstein N, Ben-Bassat Y, Becker A. Periodontal statusof impacted maxillary incisors uncovered by 2 different surgicaltechniques. J Oral Maxillofac Surg 2009;67:120-4.

24. Tanaka E, Hasegawa T, Hanaoka K, Yoneno K, Matsumoto E,Dalla-Bona D, et al. Severe crowding and a dilacerated maxillarycentral incisor in an adolescent. Angle Orthod 2006;76:510-8.

25. Chew MT, Ong MM. Orthodontic-surgical management of an im-pacted dilacerated maxillary central incisor: a clinical case report.Pediatr Dent 2004;26:341-4.


26. Tsai TP. Surgical repositioning of an impacted dilacerated incisorin mixed dentition. J Am Dent Assoc 2002;133:61-6.

27. Maia RL, Vieira AP. Auto-transplantation of central incisor withroot dilaceration. Technical note. Int J Oral Maxillofac Surg2005;34:89-91.

28. Kuroe K, Tomonari H, Soejima K, Maeda A. Surgical repositioningof a developing maxillary permanent central incisor in a horizontalposition: spontaneous eruption and root formation. Eur J Orthod2006;28:206-9.


impaction of both maxillary central incisors and a canine · impaction of both maxillary central...

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