A case of impacted maxillary central incisor and its management.

Impaction of maxillary permanent central incisor is not a frequently reported case in dental practice, but its treatment is challenging because of its importance to facial esthetics. Early detection of such teeth is most important if complications are to be avoided. We report a case of a 14-year-old female with an impacted central incisor tooth in the maxillary anterior region. The impacted supernumerary tooth which was preventing the eruption of permanent incisor was surgically removed. Combined approach with surgical exposure and the application of an orthodontic force brought the impacted left maxillary central incisor down to its proper position in the dental arch.

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 non-eruption of a permanent tooth. The non-eruption 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 prevents their eruption. Other origins include various local causes such as odontoma, arch space loss, or presence of supernumerary teeth.[1]

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 surgical exposure and orthodontic traction of impacted central incisor after surgical exposure of impacted maxillary central incisor teeth is presented in this case report.

Case Report

A 15-year-old female patient has been referred to the dental hospital in Madurai, Tamil Nadu, India, with a chief complaint of missing maxillary central incisor. There was no significant medical history. Past dental history revealed that the patient had earlier visited a dental clinic where she had been diagnosed with a congenitally missing central incisor and was advised to wear a removable partial denture. The patient was wearing the removable partial denture for the past 3 years. For a more definitive treatment, the patient visited this dental hospital.

Clinical examination revealed orthognathic facial profile and presence of good facial balance in all proportions. An intraoral examination revealed the presence of all permanent teeth except for the right upper central incisor. Panoramic (orthopantomogram or OPG), periapical radiographs were taken to establish a good idea about the position and morphology of unerupted right permanent central incisor in maxilla. Tooth was bulging in the labial sulcus at the mucogingival junction [Figure 1]. Its position was very high up in the alveolar bone with a thick layer of soft tissue covering the crown in a vertical direction. The largest width of the crown of erupted permanent left central incisor was 8 mm. The space available for unerupted right permanent central incisor in maxilla was 8 mm. It was decided to do surgical exposure of impacted tooth and then bond a bracket on the labial surface of the tooth and bring down to its normal position.

Figure 1

Pre-treatment view

Begg brackets were bonded on permanent maxillary left central incisor, lateral incisor, and left canine and right lateral incisor and Right canine. 0.020 inches A. J. Wilcock arch wire was used for anchorage. After the crown of the impacted incisor was surgically exposed [Figure 2], a Begg bracket was bonded to the exposed incisor and 0.010 A. J. Wilcock wire of supreme grade was used to align the right central incisor [Figure 3]. The patient showed normal clinical crown length with acceptable gingival contour and width. The patient was pleased with the esthetic results [Figure 4]. At 6-month follow-up, the left maxillary incisor remained vital and responded normally to percussion and mobility and sensitivity testing with good width of attached gingiva.

Figure 2

Surgical exposure of the impacted incisor

Figure 3

Bracket bonding and aligning

Figure 4

Post-treatment view

Discussion

An anomaly in the eruption of anterior teeth can affect facial esthetics and may cause psychological problems. Several techniques have been developed as a choice of treatment for this scenario. If the impacted tooth is extracted, loss of alveolar bone is anticipated. Following the healing period, the alveolar ridge becomes thinner and deficient, with these disadvantages in mind, facilitating eruption of the natural tooth and maintaining natural appearance become the goals of orthodontic treatment. As a result, surgical exposure and orthodontic treatment approaches are accepted for such impacted teeth.

Several reports have indicated an impacted tooth can be brought into proper alignment in the dental arch. The following factors are used to determine whether successful alignment of an impacted tooth can take place: (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.[2-7]

Orthodontic and surgical intervention should not be delayed to avoid unnecessary difficulties in aligning the tooth in the arch.[8] Various surgical techniques have been described for exposing impacted teeth before orthodontic tooth movement.[9] Two of the most commonly used surgical exposure techniques for labial impacted teeth are: (1) exposure of the entire labial aspect to the anatomic crown with total excision of all keratinized tissue (the window approach) and (2) a technique which exposes only 4–5 mm of the most superficial portion of the labial aspect of the cusp tip while maintaining 2–3 mm of keratinized tissues.[1011]

In this case, the available space for tooth alignment was sufficient and tooth was brought into right anatomical position in the dental arch. It has been suggested and shown that the “window” approach causes statistically significant loss of attachment, recession and gingival inflammation occur on maxillary canines after surgical exposure.[11] Therefore, a part of keratinized gingiva must be preserved or an apical flap should be used. This approach aims at obtaining keratinized gingiva around the entire erupting tooth. It is important for a tooth to erupt through attached gingival, and not through alveolar mucosa.[9-11] If the impacted tooth is diagnosed with its root completely formed or if present in an unfavorable position, combination of surgical and orthodontic treatment has to be carried out.

Conclusion

Impaction of maxillary anterior teeth can be a challenging orthodontic problem. The treatment of an unerupted tooth will depend on its state, position, and presence of enough space in the dental arch to accommodate. If eruption is delayed, the permanent tooth should be exposed because it is important to allow the tooth to erupt into correct position as soon as possible. Impaction of maxillary permanent incisors is not a frequent case in dental practice, but its treatment is challenging because of the importance of these teeth in facial esthetics.