Log in Register

Login to your account

Username *
Password *
Remember Me

Create an account

Fields marked with an asterisk (*) are required.
Name *
Username *
Password *
Verify password *
Email *
Verify email *
Captcha *

Captcha Image Reload image challenge


Orthodontics

Abstract

Introduction: Several surgical and orthodontic treatment options are available to disimpact the canine or any other impacted tooth. But the closed eruption technique has the best long-term prognosis. The tooth is surgically exposed, an attachment is bonded to it, flap is re-sutured over it and an orthodontic extrusive force is delivered to bring the tooth into occlusion. Case Description: This is a case of 26 year old male with impacted 13, 23, 32 and 33 which was diagnosed clinically and from the pre-treatment radiographs. Conclusion: At the end of the treatment normal occlusion was achieved. Keywords: impacted, closed eruption, mucoperiosteal flap

Introduction
Impacted teeth are defined as teeth with delayed eruption or that are not expected to erupt completely based on clinical and radiographic assessment. Third molars, maxillary canines, maxillary and mandibular premolars, and maxillary central incisors are the frequently impacted teeth. The prevalence of impacted maxillary canines is 0.9–2.2%, but mandibular canine impaction is less frequent. 1 The mandibular canine is impacted less often but poses every bit of a treatment challenge. Factors such as damage to adjacent structures and periodontal health of the aligned unerupted canine should be considered. 2 Clark treated many of these patients by surgical intervention only, making a "tunnel" from the impacted tooth to the oral cavity and thus removing some resistance to eruption of the tooth. A one-step surgical intervention is also possible and well documented. The impacted tooth can be removed and re implanted in its proper position. Nevertheless, the prognosis for these treatments may be very uncertain in many cases. 3,4
The most common methods of uncovering canine impactions have been the excisional gingivectomy and the apically positioned flap techniques. Only a few surgeons have used the closed eruption technique. The esthetic and functional outcomes of these procedures, such as effects on gingival height, clinical crown length, and width of attached gingiva, gingival scarring, relapse potential, and attachment levels need to be critically assessed in order to identify the optimal method of uncovering labial impactions.5 Vanarsdall and Corn evaluated more than 75 labially impacted teeth which had been uncovered using a split thickness apically positioned flap. The closed eruption technique is believed by some to be the best method of uncovering labially impacted teeth, especially if the tooth is located high above the mucogingival junction or deep in the alveolus where an apically positioned flap may be difficult or impossible to use successfully. With the closed eruption technique, the crown of the tooth is exposed, an attachment is fixed to it, and the flap is sutured back over the crown. A wire or chain extends from attachment through the coronal part of the flap. Some clinicians believe that the closed eruption produces the best esthetic and periodontal results. 6,7 Case Description
A 26yrs old male reported to the orthodontic office with the chief complaint of gaps between upper and lower front teeth (Fig 1). On radiographic examination it was observed that 13, 23, 32, 33 were impacted (Fig 2, 3). Both the upper and lower arches were bonded with MBT prescription. Arches were levelled and aligned in flexible wires. 019X.025 Stainless steel wires and piggyback .016 coaxial wire were ligated thereafter. The case was then posted for surgery to expose the impacted teeth by closed eruption technique (Fig 4) in which the crown of the tooth is exposed by surgery under local anaesthesia. Using an aspirating syringe, 1:200,000 epinephrine and 2% lignocaine were infiltrated into facial and palatal tissues. The mucoperiosteal flap was raised along the gingival margin and the damage to the soft-tissue flap was deemed of utmost importance — in particular, the periosteum, which was handled with all possible care. Cortical bone was removed with 3 or 5 mm chisels from the alveolus. Only a sufficient portion of the tooth was exposed to allow for isolation and bonding of the bracket. A minimal lingual flap was raised and the follicle around the tooth was removed . This was to ensure that the tooth could be isolated because tags of follicle tend to contaminate the etchant and thereby nullify its effect. The tooth was irrigated with sterile water and dried with the aspirator. An attachment was bonded to it directly with Transbond light cure composite resin and moisture insensitive (MIP) primer, and the mucoperiosteal flap was then repositioned and sutured back over the crown with 3.0 black silk, leaving only a twisted wire passing through the mucosa to apply the orthodontic traction. The wire protruding through the mucosa was cut to a suitable length and fashioned into a hook. It was thought advisable to give the patient a course of antibiotics postoperatively for 5 days . Sutures were removed 1 week later. There were no postoperative complications. Orthodontic forces are then applied to the attachment to move the impacted tooth into occlusion.
After the eruption of the lower 32 and33; the flap was raised to expose the upper 13 and 23 by the same above mentioned procedure. Once the impacted teeth had erupted in the oral cavity, then the residual spaces were closed. Post treatment OPG revealed that bone support and the axial inclination of the dis-impacted teeth was maintained. The treatment was completed in 22 months. After the completion of the active phase of the treatment the patient, upper and lower bonded retainers were placed for retention.

Discussion

Pathological sequelae like cysts, tumours, external/internal resorption of the impacted teeth and/or adjacent teeth, transmigration, referred pain and periodontitis have been associated with tooth impaction. The clinician can investigate the presence and position of the cuspid by visual inspection, palpation and radiography. In the approach to the orthodontic patients, the application of traditional radiographic techniques is indispensable. There are four treatment options for impacted teeth; observation, intervention, relocation and extraction.
Orton et al, reported a principal of treating unerupted canines by assessing the vertical axial eruptive path and suggested that labial tipping of 45° is generally orthodontically untreatable. Horizontal position, age of the patient, vertical height and bucco-palatal position in descending order of importance are the factors which determine the difficulty of canine alignment. When the interceptive treatment fails, efforts to reposition impacted teeth surgically or orthodontically should be considered. The prognosis of orthodontically erupting and repositioning an impacted tooth within the alveolar process depends on the angulation and position of the impacted tooth, available space, and presence of keratinized gingival tissue, patient cooperation and the length of treatment time.
In the surgical management of impacted canines the surgeon must choose between closed eruption versus an apically positioned flap to expose the tooth and facilitate its orthodontic eruption. In the present case we chose closed eruption as the impacted teeth were situated quite high, so a gingivectomy procedure could lead to removal of all the attached gingiva for the canine and result in an alveolar mucosal attachment. An apically repositioned flap could not be used, as the gingival tissue was perforated in one area by the impacted canine and the keratinized mucosa available above the perforation would be inadequate. Labially impacted canines uncovered with an apically positioned flap have more unesthetic sequelae, such as increased clinical crown length, increased width of attached tissue, gingival scarring, intrusive relapse and damaged periodontium than those uncovered with the closed eruption technique. 8,9
It is desirable to deliver a light force in the occlusal direction, using elastics, elastic chain, Ni Ti spring, or tie wire. Cole et al have described the use of magnets in the management of teeth that fail to erupt. We used ligature wire as traction attachment. Ligature wires were tied to the 0.016" Ni Ti wire which would get deformed under the traction force. The spring back property of Ni Ti would bring the wire in its original shape thus transmitting a continuous traction force to the tooth through ligature wire. Ligature was adjusted every week to maintain traction force. The aim of this case report is to demonstrate the potential of aligning extremely malpositioned, bilaterally impacted canines and lateral incisor.

Conclusion

The 4 impacted permanent teeth (13, 23, 32, 33) were brought into proper alignment and occlusion (Fig 5). Radiographically, all the impacted teeth displayed intact roots and proper root inclination and crown angulations (Fig 6) Class I buccal relation with ideally aligned upper and lower arches. Proper overjet and overbite was achieved. An esthetic soft tissue drape was achieved.
Fig 1 - Intra-oral pre-treatment photographs Fig 2 – Pre-treatment panoramic radiograph

Fig 3 – Pre-treatment maxillary occlusal radiograph Fig 4 – Lower surgical exposure by closed eruption technique with bonded attachment on teeth

Fig 5 – Post treatment photographs of upper and lower arches Fig 6 – Post treatment panoramic radiograph


References:
  1. Bishara SE. Impacted maxillary canines. Am J Orthod Dentofac Orthop 1992;101:159-71.
  2. McDonald F, Yap WL. The surgical exposure and application of direct traction of unerupted teeth. Am J Orthod 1986;89:331–40.
  3. Genison AM, Straus RE. The direct bonding technique applied to the management of the maxillary impacted canine. J Am Dent Assoc 1974;89:1332–37.
  4. Ericson S, Kurol J. Incisor resorption caused by maxillary cuspids. A radiographic study. Angle Orthod 1987;57:332–46.
  5. Vermette ME, Kokich VG, Kennedy DB: Uncovering labially impacted teeth: apically positioned flap and closed eruption techniques, Angle Orthod 1994;65(1):23-34.
  6. Kokich VG, Mathews DP. Surgical and orthodontic management of impacted teeth. Dent Clin N Am 1993;37:181-204.
  7. Alling CC, Catone GA. Management of impacted teeth. J Oral Maxillofac Surg 1993;51:3-6.
  8. Ohman I, Ohman A. The eruption tendency and changes of direction of impacted teeth following surgical exposure. Oral Surg Oral Med Oral Pathol 1980;49:383-9.
  9. Boyd RL. Clinical assessment of injuries in orthodontic movement of impacted teeth II: surgical recommendations. Am J Orthod 1984;86:407-18.

Page 92 of 92