CLINICIAN'S CORNER

An efcient biomechanical approach for the

management of an impacted maxillary central
incisor
Taranpreet K. Chandhoke,a Sachin Agarwal,b Jonathan Feldman,a Raja A. Shah,c Madhur Upadhyay,a
and Ravindra Nandad
Farmington, Conn, and Albuquerque, NM

Treatment of an impacted maxillary central incisor poses a unique challenge to the orthodontist because of its
position within the esthetic zone, requiring careful management of the soft tissues and an effective biomechanical setup for alignment. This article describes a novel method of extending an extrusion wire from cross tubes
attached on the base archwire for forced eruption of impacted central incisors. The effectiveness and versatility
of this method are demonstrated with 2 patients. (Am J Orthod Dentofacial Orthop 2014;146:249-54)

mpaction of the maxillary central incisors occurs

frequently in the population, nearly as commonly
as impacted maxillary canines.1 Normal eruption of
the central incisor typically occurs between 8 and
10 years of age.2-4 Any delay in eruption can have a
potential impact on the eruption of other anterior
teeth (eg, the maxillary canines) and can also result in
space loss and midline deviation.5 The 2 primary causes
of impaction are trauma to the deciduous central incisor
resulting in a developmental disturbance of the tooth
bud and mechanical obstruction in the path of eruption
caused by a supernumerary tooth or odontoma.6-9
Treatment of an impacted central incisor requires a
multidisciplinary approach, with periodontal surgical
exposure followed by orthodontic forced eruption.
Orthodontic extrusion of impacted teeth has classically
been managed using elastomeric chains or threads,10-12
nickel-titanium overlays, cantilevers,13,14 and extrusion
arches.15 Because of force decay, elastomerics do not
a
Assistant professor, Division of Orthodontics, Department of Craniofacial Sciences, School of Dental Medicine, University of Connecticut, Farmington, Conn.
b
Resident, Division of Orthodontics, Department of Craniofacial Sciences, School
of Dental Medicine, University of Connecticut, Farmington, Conn.
c
Private practice, Albuquerque, NM.
d
Professor and head, Department of Craniofacial Sciences, Alumni Endowed
Chair, School of Dental Medicine, University of Connecticut, Farmington, Conn.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
Address correspondence to: Taranpreet K. Chandhoke, Division of Orthodontics,
University of Connecticut Health Center, 263 Farmington Ave, MC1725,
Farmington, CT 06030; e-mail, chandhoke@uchc.edu.
Submitted, August 2013; revised and accepted, September 2013.
0889-5406/$36.00
Copyright 2014 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.09.017

deliver a continuous force to the tooth over the treatment

period and might be less efcient.16-18 Placement of a
continuous exible wire, such as a nickel-titanium wire,
can be used to deliver a constant force but can lead to
side effects, with reciprocal intrusion of the adjacent teeth.
A nickel-titanium overlay or piggy-back wire enables
application of a constant force while also minimizing
side effects with a rigid stainless steel base archwire, for
example. However, the rate of movement can be affected
by the friction on the adjacent ligated brackets, thereby
further slowing the process.19 In addition, it can be a challenge to titrate the force level exerted.20,21 Cantilevers and
extrusion arches can offer further benets with the
delivery of a continuous force with minimal friction,
since they are not ligated to adjacent teeth. In addition,
the forces can be measured and well controlled because
the device is anchored to a rigid base arch.22 A particular
challenge of using cantilevers and extrusion arches for
impacted incisors specically is in determining the anchor
position, which often needs to pass the canine curvature.
This typically leads to bowing of the auxiliary wire and
patient discomfort.
Here, we describe an efcient and comfortable design
for extruding impacted central incisors using a crosstube extrusion arch. Two patients are presented to illustrate the basic framework and method of activation as
well as creative ways to use this clinical setup for controlling the vector of eruption and applying torque.
The cross-tube extrusion wire has 2 cross tubes, 2 mm
wide (Ortho Technology, Tampa, Fla), placed through the
base 0.019 3 0.025-in stainless steel archwire (Fig 1).
The cross tube consists of 2 tubes, 0.022 3 0.028 in, soldered at 90 to each other, so that a wire can be inserted
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250

Fig 1. Cross-tube extrusion arch assembly in its passive state.

both horizontally and vertically. The cross tubes are

crimped mesial to the canines and can also be welded
in place to prevent sliding along the arch. A
0.017 3 0.025-in CNA beta-titanium wire (Ortho Organizers, Carlsbad, Calif) is used to apply a consistent extrusive force that can be titrated.23 The distance between the
cross tubes is then measured, and 90 bends are placed in
the CNA wire at the specied distance, so that the auxiliary wire can be placed into the vertical component of the
cross tubes. Once in place in the cross tubes, the ends are
cinched, and the setup is placed in the patient's mouth in
this inactivated or passive state. Then the activated extrusion wire is drawn toward the labial vestibule and ligated
to the bonded attachment or exposed chain with steel
ligatures or thread.
Patient 1

A 15-year-old postpubertal girl in the permanent

dentition came with a chief complaint of an unerupted
maxillary right central incisor (Fig 2, A). Her previous
medical and dental histories were nonincidental. A Class
I occlusion with minimal overjet and overbite was noted.
The crown of the maxillary right central incisor was
palpable in the labial vestibule, above the mucogingival
junction. A periapical radiograph (Fig 2, B) indicated a radiopaque mass in the path of eruption of the right central
incisor consistent with a compound odontoma. The orthodontic plan was to treat the patient without extractions
and to use the closed surgical exposure method followed
by orthodontic traction to erupt the impacted incisor.
The patient was bonded using 0.022 3 0.028-in twin
brackets (Ortho Organizers) with a McLaughlin-BennettTrevisi (MBT) prescription. During the leveling and
aligning stage, the patient was referred to an oral surgeon for an excisional biopsy of the compound odontoma, closed surgical exposure, and bonding of a

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traction hook on the impacted central incisor. Once

the
remaining
dentition
was
aligned
on
0.019 3 0.025-in stainless steel archwires and space
was developed for the right central incisor, the crosstube extrusion arch assembly was placed (Fig 2, C).
With a force gauge, 80 to 100 g of force was applied,
and the extrusion arch was ligated to the gold chain
with ligature wire. The incisor erupted through the
attached gingiva within 4 months (Fig 2, D). At the
time of debond, a minimal gingival height discrepancy
was noted (Fig 2, E), and some root resorption was
seen on the panoramic radiograph (Fig 2, F).
Patient 2

A 12-year-old pubertal girl came with a chief

complaint of maxillary incisor crowding. Her previous
medical and dental histories were nonincidental.
The pretreatment facial examination showed a mesofacial pattern with a concave soft-tissue prole caused
by a prognathic mandible and a high mandibular plane
angle. The patient had 100% maxillary incisor display
on smiling. The maxillary midline was shifted to the right
by 2 mm, and the mandibular dental midline was coincident with the facial midline.
The intraoral examination indicated a full complement of teeth except for the maxillary right central
incisor and left canine. The maxillary anterior teeth
were in crossbite (Fig 3, A). The mandibular arch was
well aligned with mild crowding. Minimal overbite was
noted with 1 mm of negative overjet. The molars were
in a half-cusp Class III relationship with a bilateral posterior crossbite. The radiographic examination showed
that the maxillary right central incisor was horizontally
impacted and inclined toward the maxillary left central
incisor, which had a dilacerated root (Fig 3, B). Whereas
surgical treatment is planned once the patient completes

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Fig 2. Patient 1: A, pretreatment frontal intraoral photograph showing the absence of the maxillary right
central incisor; B, periapical radiograph showing the impacted maxillary right central incisor and odontoma; C, intraoral photograph showing the active state of the cross-tube extrusion arch; D, eruption of
the maxillary right central incisor; E, posttreatment frontal intraoral photograph showing alignment of
the maxillary right central incisor; F, composite panoramic image showing the alignment of the maxillary
right central incisor with some root resorption.

Fig 3. Patient 2: A, pretreatment frontal intraoral photograph showing absence of the maxillary right
central incisor; B, periapical radiograph showing the impacted maxillary right central incisor with a
mesial inclination; C, space development for the maxillary right central incisor; D, force directed in a
mesial, incisal, and labial direction with the archwire hook placed mesial to the impacted tooth;
E, cone-beam computed tomography image showing the extent of extrusion of the impacted maxillary
right central along the long axis; F, line of the force to the incisor now directed in a distal, incisal, and
labial direction with the help of the second archwire hook.

growth, phase 1 therapy was initiated for the correction

of the transverse discrepancy and alignment of the
impacted central incisor.

After rapid maxillary expansion with a hyrax appliance, the patient was bonded with 0.022 3 0.028-in
twin brackets (3M Unitek, Monrovia, Calif) with an

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Fig 4. Patient 2: Auxiliary archwire placed gingivally for application of palatal root torque: A, day of insertion; B, at 1 month; C, at 2 months; D, at debond (36 months of treatment); E, the cone-beam computed
tomography image shows alignment and root resorption of the maxillary right central incisor.

MBT prescription, and the remaining dentition was

aligned on 0.019 3 0.025-in stainless steel archwires.
The central incisor space was developed using a nickeltitanium coil spring (Fig 3, C). To align the impacted
central incisor, a closed exposure method was again
used with the traction hook bonded on the labial surface
of the impacted incisor and the full-thickness ap repositioned.
Alignment of the impacted central incisor was
planned in 3 phases. In the rst phase, the line of force
was directed along the long axis of the tooth (ie, mesial,
incisal, and labial direction). It was accomplished with an
archwire hook crimped mesial to the long axis of the
tooth (Fig 3, D). Once the crown of the incisor reached
the alveolar crest, a small volume cone-beam computed
tomography image was taken to evaluate the extent of
extrusion and localize the tooth position. This showed
that the impacted central incisor had extruded and was
approximating the crown of the left central incisor
(Fig 3, E). In addition, there was dilaceration of the right
central incisor root, with the root tip curved palatally on
the axial sections. To achieve uncontrolled tipping and
move the crown in a lateral direction, a second archwire
hook was crimped on the extrusion arch adjacent to the
maxillary right lateral incisor region and ligated to the
bonded attachment (Fig 3, F).
For the nal phase, palatal root torque was required.
The central incisor was bonded with a twin bracket, and
the cross-tube extrusion arch was repositioned in the
gingival direction. The auxiliary archwire started with a
0.016-in CNA wire (Fig 4, A) and was sequentially

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upgraded to a 0.019 3 0.025-in CNA wire (Fig 4, B

and C). Signicant mesiodistal correction and palatal
root torque were achieved. The patient was then debonded and placed in retention until the completion
of growth and reevaluation for the start of presurgical
orthodontics (Fig 4, D). Root resorption was noted
both apically and on the palatal extension of the dilacerated root (Fig 4, E).
DISCUSSION

Periodontal and orthodontic management of the

impacted central incisor poses a number of signicant
challenges, particularly because of the position within
the esthetic zone. Careful soft-tissue management is
required to ensure a successful long-term esthetic
outcome. There are 2 main types of surgical exposure
to uncover and extrude impacted incisors: open and
closed eruption.24 Open eruption involves exposing the
tooth and replacing the ap apically, leaving the coronal
portion of the tooth exposed, whereas in closed eruption, the ap is replaced and sutured in its original position overlying the tooth.25 Since impacted central
incisors are typically found above the mucogingival
junction, use of a closed-eruption approach might
ensure adequate keratinized tissue and better gingival
contours once the incisor is aligned.26 Studies have
shown less recession, better bone support, and superior
periodontal parameters overall with the closed-eruption
method.27,28 The closed-eruption method was used for
both patients discussed here.

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Fig 5. A, Biomechanics of the traditional extrusion arch; B, biomechanics of the cross-tube extrusion
arch. da, Distance between the point of force application and the molar tube; a, distance between the
molar tube and the center of resistance of the maxillary teeth; b, distance between the point of force
application and the center of resistance of the maxillary teeth; Cres, center of resistance of the dentition;
Mc, moment of the couple; Mf, moment of the force; F, force applied by extrusion arch; Fr, reciprocal
force acting on the molar tube or the cross tube; db, distance between the point of force application
and the cross tube.

A sound biomechanical approach is also required for

the successful management of impacted central incisors.
From a mechanical perspective, a cantilever is the ideal
system for delivering a continuous extrusive force. As
an auxiliary archwire, it allows free movement of the
impacted tooth with no interference from the adjacent
teeth. However, because of the difculty in attaching a
cantilever to the anterior region of the arch, a traditional
extrusion arch is often better suited to accomplish forced
eruption, allowing the posterior extension if the arch is
to be engaged in the molar tube.15 It works on the principle of a 1-couple force system, with an extrusive force
on the anterior component and an intrusive force on the
posterior together with a counterclockwise moment.29
This is illustrated in Figure 5, A, where the extrusive
force is on the impacted incisor and the reciprocal force
is on the molar. The remaining dentition serves as a
continuous, single anchorage unit. The net moment
generated is a combination of the counterclockwise
moment of the couple by the V-bend and the clockwise
moment of the force generated by the reciprocal force
acting distal to the estimated center of resistance of
the maxillary dentition, resulting in an overall moment
in a counterclockwise direction.
The force system of the cross-tube extrusion arch is
similar to that of the traditional extrusion arch (Fig 5,
B). With the application of the force at the central
incisor, the reciprocal force is at the cross tube with

the counterclockwise moment generated on the posterior segment, equivalent to the force times distance between the incisor and the cross tube. Since the reciprocal
force is anterior to the center of resistance of the dentition, the moment of the force generated is counterclockwise. Therefore, the sum of these moments yields an
overall moment in a counterclockwise direction, similar
in magnitude to the traditional extrusion arch described
previously.
CONCLUSIONS

It has been reported that the 2 primary factors that

contribute to successful treatment of impacted teeth
are well-controlled anchorage and sufcient torque for
an ideal esthetic outcome.30,31 Torque correction can
be a particular challenge, especially in cases of
dilacerations of the incisor root.32 Most importantly,
during the active treatment phase, it is important to
design a biomechanical method that is comfortable for
the patient. The cross-tube extrusion arch can address
all of these challenges. Although the traditional extrusion arch is ideal for incisor extrusion of partially or fully
erupted teeth, there are some drawbacks when it is used
for an impacted tooth. The traditional extrusion arch can
be bulky and become lodged in the vestibule when
ligated to an apically positioned, submerged central
incisor. In addition, bowing can occur as the extrusion

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arch extends around the canine curvature to be passed

through the auxiliary tube on the molar. The advantage
of the cross-tube extrusion arch is that its anchor point is
more anteriorly positioned, with minimal extension into
the vestibule. It is therefore more comfortable for the patient while having a similar force system as the traditional extrusion arch. Moreover, as illustrated by
patient 2, it can be used to steer the impacted tooth
by easily changing the line of the force when required.
In addition, it can also be used to upright the tooth mesiodistally and to apply torque, making it biomechanically efcient, effective, and versatile.
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American Journal of Orthodontics and Dentofacial Orthopedics