CASE REPORT Treatment of an impacted dilacerated maxillary central incisor

Yng-Tzer J. Lin, BDS, MSa Kaohsiung Hsien, Taiwan

Impacted incisor with dilaceration refers to a dental deformity characterized by an angulation between crown and root causing noneruption of the incisor. Surgical extraction used to be the first choice in treating the severely dilacerated incisor. In this article, a horizontally impacted and dilacerated maxillary central incisor was diagnosed radiographically. By combining two stages of the crown exposure surgery with light force orthodontic traction, the impacted dilacerated incisor was successfully moved into proper position. However, long-term monitoring of the stability and periodontal health is critical after orthodontic traction. (Am J Orthod Dentofacial Orthop 1999;115:406-9)

he problem of an impacted maxillary incisor resulting in space concerns in the anterior region of the early mixed dentition is usually a clinical challenge for orthodontists. Recent reports have shown that impacted canines or incisors could be properly positioned with the aid of direct orthodontic traction instead of surgical extraction.1-4 However, an impacted incisor with dilaceration, characterized by an angulation between crown and root, still poses a clinical dilemma because of its difficult position. The chances of failure could be due to ankylosis, external root resorption, and root exposure after orthodontic traction.5-6 Even the successful cases probably have an unesthetic gingiva of the exposed incisor and need to have periodontal surgery.7 This article presents a case of a horizontally impacted and dilacerated maxillary left central incisor. Through the two stages of surgical crown exposure, combined with orthodontic traction, the dilacerated incisor was successfully moved into proper position.
CASE REPORT

Fig 1. Pretreatment intraoral photograph shows the noneruption of the maxillary left central incisor.

Diagnosis

A 10-year-old oriental boy was brought by his parents to the childrens dental clinic of Memorial Hospital. Their chief concern was the noneruption of the upper left central incisor (Fig 1). The child was physically healthy and had no history of medical and dental trauma. Examination of the oral cavity revealed it was generally healthy with the exception of dental caries.
aDirector, Orthodontics and Pediatric Dentistry, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Taiwan. Reprint requests to: Dr. Yng-Tzer J. Lin, Department of Dentistry, Chang Gung Memorial Hospital, Kaohsiung Medical Center, #123, Ta Pei Rd, Niao Sung Hsiang, Kaohsiung Hsien, Taiwan, R.O.C. Copyright 1999 by the American Association of Orthodontists. 0889-5406/99/$8.00 + 0 8/4/90443

The patient had a skeletal Class I malocclusion and a balanced facial pattern. Intraoral examination revealed an early mixed dentition and an Angle Class I molar relationship. The analysis of the lateral cephalometric radiograph revealed normal cephalometric values according to the oriental standards. Clinical examination showed a missing maxillary left central incisor and no apparent arch length discrepancy in both maxillary and mandibular arches (Fig 1). Inadequate space distribution of the maxillary incisors causing midline deviation was due to drifting of the adjacent teeth into unoccupied space (Fig 1). The panoramic radiograph demonstrated an impacted maxillary left central incisor and a congenitally missing mandibular left lateral incisor (Fig 2A). The maxillary left central incisor was positioned horizontally with the tip of the crown close to the apex of the right central incisor. The angle between the root and the crown of the central incisor was found to be dilacerated on the lateral cephalometric radiograph at approximately 70 (Fig 2B).

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Fig 3. Crown exposure with lingual button bonded on labial surface.

Fig 4. Intraoral photograph after completion of the phase I.

Treatment Alternatives

Fig 2. A, Pretreatment panoramic radiograph discloses impacted maxillary incisor. B, Pretreatment cephalometric radiograph discloses dilacerated maxillary incisor.

The following are three possible treatment alternatives: 1. Extraction of the impacted central incisor and restoration with a bridge or an implant later when growth had ceased. 2. Extraction of the impacted central incisor and closure of the space, substituting the lateral incisor for the central incisor with subsequent prosthetic restoration. 3. Surgical exposure, orthodontic space opening and traction of the impacted dilacerated central incisor into proper position.
Treatment Progress

Treatment Objectives

1. Redistribute the space in the maxillary anterior region. 2. Restore the normal appearance of the maxillary anterior teeth. 3. Establish an acceptable occlusion despite the congenitally missing mandibular lateral incisor.

After realizing the possible treatment alternatives, the parents chose to try to save the tooth and bring it into proper position. Phase I of the treatment objective was to properly position the horizontally impacted incisor and resolve the space problem of the upper incisors.

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a 0.010-inch ligature wire on it. The flap was reclosed and sutured, leaving a tied ligature wire with a hook end protruding through the mucosa. The patient returned 2 weeks later and started orthodontic traction of the dilacerated tooth. A light force of approximately 60 to 90 g was applied by an elastomeric chain between the helix of 0.016 0.016-inch main arch wire and the protruding ligature wire. As the dilacerated tooth moved downward, the ligature wire was cut shorter to maintain the effective elastomeric chain. After the dilacerated tooth was palpable clinically, the second stage of the crown exposure was performed with a lingual button bonded on the labial surface of the crown (Fig 3). The same procedure of elastic traction continued until the impacted tooth became exposed to the oral environment. The attached button and bracket were then removed and a standard incisor bracket was bonded so that the tooth could be properly positioned. The final alignment was completed with 0.016 0.022 1-inch arch wire and an ideal overbite and overjet was established. The phase I treatment was completed within 11 months. The bands and brackets were removed and replaced with a maxillary Hawley retainer.
RESULTS

The impacted left maxillary central incisor was successfully positioned into proper alignment through the two stages of crown exposure and the elastic traction (Fig 4). Ideal overbite and overjet and resolution of the insufficient incisal space were also achieved. The exposed incisor after completed treatment presented an acceptable gingival contour and attached gingiva (Fig 4). Radiographically, the newly positioned incisor reveals an intact straight root and no apparent root resorption (Fig 5).
Fig 5. Panoramic and cephalometric radiographs after completion of the phase I. DISCUSSION

Molar bands were placed on the maxillary first permanent molars and brackets were placed on the three maxillary permanent incisors and the primary first molars and canines. The initial leveling was performed with 0.0175-inch multistrand wire, followed by 0.016inch stainless steel wire with an open coil spring in the position of the unerupted central incisor. Once adequate space was achieved, the patient was transferred to the oral surgeon for exposure of the impacted incisor. Because of the severe dilacerated tooth axis, two stages of surgical exposure of the crown were recommended. The first stage was to expose the lingual surface of the crown and attach an incisor bracket with

Although the impacted maxillary incisor occurs less frequently than the maxillary canine, it brings concerns to parents in the early mixed dentition because of noneruption of the tooth.8 Several reports recently have successfully treated impacted maxillary anterior teeth by proper crown exposure surgery and orthodontic traction.3-4 However, impaction with a severely dilacerated root is seldom reported, especially the maxillary incisor. It is probably because of the high clinical difficulty of bringing the dilacerated tooth into position; most patients probably would choose extraction with replacement of a prosthesis instead. But the philosophy seems to have changed recently. degaard9 clearly showed a case with two horizontally impacted canines and indicated that a marked dilacerated root could be

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brought into correct position. Just as the present case revealed, the dilaceration of the root would not be a great obstacle if the case had carefully planned procedures and good compliance. The cause of incisor dilaceration has not yet been clearly understood. Smith and Winter10 contributed the dilacerated permanent incisor to traumatic injury of the primary predecessor leading to root dilaceration.10 However, Stewart11 investigated 41 cases of dilacerated incisor and found that trauma accounted for only 9 cases (22%). He concluded that the anomaly was most likely due to ectopic development of the tooth germ. The treatment approach of impacted maxillary teeth requires the cooperation of dental specialties such as orthodontics, oral surgery, and prosthodontics. The current treatment modality, instead of extraction, is to have surgical crown exposure with the placement of an auxiliary, followed by orthodontic positioning of the tooth.8 The success rate of the impacted dilacerated tooth further depends on the degree of dilaceration, position of the tooth, and root formation of the tooth. A dilacerated root with an obtuse angle, lower down position, and incomplete root formation of the tooth would have a better prognosis for orthodontic traction. Studies have shown that the more bone removed during surgical exposure, the greater the bone loss after orthodontic treatment and the chance of injury to the tooth during traction.12-13 The present case used two stages of crown exposure in order to avoid more bone destruction during the first stage of crown exposure (Fig 3). This is because the placement of the attachment on the labial surface of an acute angle of the dilacerated tooth could cause more bone reduction than on the lingual surface. Therefore, the attached auxiliaries needed to switch from the lingual surface to the labial surface of the dilacerated tooth in the second stage of crown exposure to facilitate elastic traction of the tooth (Fig 3). In reality, the second stage of crown exposure was not as complicated as the first stage and was easily performed with the patient given a local anesthesia. With respect to the uncovering flap design, this case used the closed-eruption surgical technique, which returns the flap to its original location after placing an attachment on the impacted tooth.14 The technique induced natural tooth eruption of the impacted tooth

rather than conventional design of the apically positioned flap. Vermette et al14 compared these two surgical techniques and found that the apically positioned flap technique had more negative esthetic effects such as increased crown length and gingival scars than the closed-eruption technique. Consequently, it is strongly recommended that the closed-eruption technique be the treatment of choice when the tooth is impacted in the middle of alveolus or high near the nasal spine.14 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.
CONCLUSION

In conclusion, treatment of the impacted dilacerated incisor is a clinical challenge. Combining two stages of the crown exposure surgery with light force orthodontic traction may provide an effective approach for treating a severely dilacerated root. However, longterm monitoring of the stability and periodontal health of the dilacerated incisor is very important after orthodontic traction.
REFERENCES 1. Kolokithas G, Karakasis D. Orthodontic movement of dilacerated maxillary central incisor. Am J Orthod 1979;76:310-5. 2. Nashashibi IA. Orthodontic movement of a palatally displaced dilacerated, unerupted maxillary central incisor. J Pedod 1986;11:83-90. 3. Crawford LB. Impacted maxillary central incisor in mixed dentition treatment. Am J Orthod Dentofac Orthop 1997;112:1-7. 4. 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. 5. Shapira Y, Kuftinec MM. Treatment of impacted cuspids: the hazard lasso. Angle Orthod 1981;51:203-7. 6. Boyd RL. Clinical assessment of injuries in orthodontic movement of impacted teeth. Am J Orthod 1982;82:478-86. 7. Machtei EE, Zyskind K, Ben-Yehouda A. Periodontal considerations in the treatment of dilacerated maxillary incisors. Quintessence Int 1990;21:357-60. 8. Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofacial Orthop 1992;101:159-71. 9. degaard J. The treatment of a Class I malocclusion with two horizontally impacted maxillary canines. Am J Orthod Dentofacial Orthop 1997;111:357-65. 10. Smith DMH, Winter GB. Root dilaceration of maxillary incisors. Br Dent J 1981;150:125-7. 11. Stewart DJ. Dilacerate unerupted maxillary central incisors. Br Dent J 1978;145: 229-33. 12. McDonald F, Yap WL. The surgical exposure and application of direct traction of unerupted teeth. Am J Orthod 1982;89:331-40. 13. Kohavi D, Becker A, Zilberman Y. Surgical exposure, orthodontic movement, and final tooth position as factors in periodontal breakdown of treated palatally impacted canines. Am J Orthod 1984;85:72-7. 14. Vermette ME, Kokich VG, Kennedy DB. Uncovering labially impacted teeth: apically positioned flap and closed-eruption techniques. Angle Orthod 1995;65:23-32.