13652591, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13761 by University Of Delhi, Wiley Online Library on [12/10/2022].

See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
|
Received: 12 October 2021    Accepted: 4 May 2022

DOI: 10.1111/iej.13761

ORIGINAL ARTICLE

Enhanced conservation of vital pulp and apical tissues by

the application of crown rotation surgery for inversely
impacted central incisors: A follow-­up analysis of two
patients over 4 years

Yudi Bai1   | Jiantong Cui2  | Hua Sun3  | Zhifei Zhou4  | Liqiang Shi5  | Pan Li6  |

Jin Liu7,8

1
Department of Stomatology, Air Abstract
Force Medical Center, Fourth Military
Aim: To describe a novel surgical method (crown rotation surgery) to manage in-
Medical University (FMMU), Beijing,
China versely impacted central incisors with immature roots.
2
First Clinical Medical Center of PLA Methodology: Two young patients each presented with an inversely impacted max-
General Hospital, Beijing, China illary central incisor. To protect the apical tissues, the two impacted incisors were ro-
3
Lintong Sanatorium Center of PLA,
tated downwards to a relatively normal position without extraction from their bony
Xi'an, China
4 sockets.
Department of Stomatology, General
Hospital of Tibetan Military Command, Results: After crown rotation surgery, spontaneous eruption, continuous root de-
Lhasa, China velopment, and periodontal healing of the rotated incisors were observed. The pulp
5
Department of Radiology, School of retained vitality and blood flow was normal. Moreover, there were no obvious signs
Stomatology, FMMU, Xi'an, China
6
of pulp canal obliteration (PCO), as indicated by Cone Beam Computed Tomography
Zibo Stomatological Hospital, Zibo
City, China (CBCT) imaging.
7
Department of Operative Dentistry and Conclusions: By optimising protection of the vital pulp and apical tissues, crown
Endodontics, School of Stomatology, rotation surgery represents a minimally invasive, conservative, and practical surgical
FMMU, Xi'an, China
8
technique for treating inversely impacted incisors with developing roots. In contrast
Huangshan City People's Hospital,
Huangshan, China to existing surgical methods, crown rotation surgery may avoid certain complica-
tions, including PCO and abnormal or arrested root development.
Correspondence
Key learning points:
Yudi Bai, Department of Stomatology,
Air Force Medical Center, Fourth • By optimizing protection of the vital pulp and apical tissues, crown rotation
Military Medical University, Beijing surgery represents a minimally invasive, conservative and practical surgical
100142, China.
technique for treating inversely impacted incisors with developing roots.
Email: 516067319@qq.com
• In contrast to existing surgical methods, crown rotation surgery may avoid cer-
Funding information tain complications, including PCO and abnormal or arrested root development.
Key Research and Development
Projects in the field of social
KEYWORDS
development in Shaanxi Province,
China, Grant/Award Number: 2022SF-­ inverse impaction, maxillary central incisor, pulp canal obliteration, root development, root
043 dilaceration, trauma

Yudi Bai and Jiantong Cui contributed equally to the article.

© 2022 International Endodontic Journal. Published by John Wiley & Sons Ltd.

|
882    wileyonlinelibrary.com/journal/iej
 Int Endod J. 2022;55:882–888.

BAI et al.
I N T RO DU CT ION
There is a close anatomical relationship between the root
of a deciduous tooth and the permanent successor tooth,
thus making the latter more vulnerable to abnormal forma-
tion or developmental defects when the deciduous tooth
is subjected to direct physical injury or incurs trauma-­
induced periapical pathology (Flores & Onetto, 2019; von
Arx,  1993). In addition to developmental and structural
abnormalities, trauma to the deciduous dentition can also
cause tooth eruption disturbances, such as the impac-
tion of the permanent successors (Brin et al., 1984; Lenzi
et al., 2015). The prevalence of impacted maxillary central
incisors has been reported to be as high as 1.96% (Grover
& Lorton, 1985), thus ranking this condition third behind
impacted third molars (Dodson & Susarla, 2014) and max-
illary canines (Dinoi et al., 2016).
The treatment of impacted maxillary central incisors
is always a challenge for clinicians, especially with regard
to inverse impaction. The most widely used treatment
is surgical exposure followed by orthodontic extrusion
(Pinho, 2012). However, this conventional method is tech-
nically complicated, time consuming (Hu et al.,  2017)
and associated with a notable rate of failure (Topouzelis
et al., 2010). Furthermore, certain adverse outcomes have
been reported, such as root resorption, ankylosis or sub-
gingival bulge/protrusion due to a dilacerated root (Sun
et al.,  2014). Surgical therapies are also used to treat in-
verse impaction, including surgical repositioning, au-
totransplantation and replantation (Agrait et al.,  2003;
Kim et al., 2013; Kuroe et al., 2006; Plakwicz et al., 2015).
As with conventional treatment, it is almost impossible
to avoid a series of complications, including pulp canal
obliteration (PCO), abnormal or arrested root develop-
ment and detachment of the apex (Bhatia et al., 2015; Kim
et al.,  2013; Plakwicz et al.,  2015; Tsai,  2002; Tsukiboshi
et al., 2019).
(a)
(c)
F I G U R E 1   Clinical and radiographic
images of the first patient. (a, b) The
maxillary right central incisor did not
erupt. (c, d) Cone beam computed
tomography scans showed an inversely
impacted maxillary right central incisor
with an immature root.
|
13652591, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13761 by University Of Delhi, Wiley Online Library on [12/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
  
   883
This report considers a new surgical method for the
treatment of inversely impacted immature maxillary in-
cisors (Shi et al., 2021). By applying this technique to the
indicated cases, the protocols were improved, thus leading
to a protection for the immature root and the pulp/apical
tissues of the affected teeth arising from treatment-­related
damage. In this paper, two cases involving inversely im-
pacted maxillary central incisors with immature roots
were treated by crown rotation surgery. The pulp status
was evaluated during the treatment period and over a 4-­
year follow up. Our aim was to observe the prognosis of
pulp healing by applying this new surgical method in the
clinic.
MATERIALS AND METHODS
Clinical information relating to the two
patients
The first patient was a 7-­year-­old boy; his chief com-
plaint was an unerupted maxillary incisor. He had ex-
perienced trauma to the deciduous incisors at the age
of 5 years without intervention. Clinical examination
showed that the deciduous maxillary right central inci-
sor was absent. Both the adjacent incisors had erupted
(Figure 1a,b). Cone beam computed tomography (CBCT)
showed that the maxillary right central incisor was in-
versely impacted with an immature root (Figure  1c,d).
In addition, some maxillary teeth had caries, including
the right first and second deciduous molars, and the left
first deciduous molar. The maxillary left second decidu-
ous molar, and the four mandibular deciduous molars,
had been restored with preformed metal crowns due to
caries or pulpitis.
The second patient was a 6-­year-­old girl with a chief
complaint of retention of the deciduous maxillary
(b)
(d)
 |
884       CROWN ROTATION FOR IMPACTION
incisor. There was also a history of untreated dental
trauma at the age of 4 years. She had no other medical
history according to her parents. Intra-­oral examination
revealed a residual root of the deciduous maxillary right
central incisor with a sinus tract apically (Figure 2a,b).
The adjacent permanent central incisor had erupted.
CBCT images showed that the permanent maxillary
right central incisor was inversely impacted with an
immature root (Figure 2c,d). Some maxillary teeth had
caries, including the right deciduous lateral incisor, the
first deciduous molar, and the left first and second de-
ciduous molars.
Neither of the two patients had systemic diseases.
After multidisciplinary consultation, they were both rec-
ommended to undergo crown rotation surgery to reduce
damage to the apical tissues. The parents of both patients
were fully informed of the therapeutic plan and provided
written and informed consent.
Treatment procedures
Besides extracting the residual root of the deciduous
maxillary central incisor in the second patient, the
two patients underwent similar crown rotation sur-
gery procedures. Under local anaesthesia, a horizon-
tal incision and two vertical releasing incisions were
made at both ends of the edentulous alveolar ridge. A
labial mucoperiosteum flap was raised with a gingival
separator or periosteal elevator. Then, the palatal sur-
face of the impacted crown was exposed (Figure  3a).
The tooth was loosened from the surrounding tissues
with a periosteum elevator (Figure  3b), and the sur-
rounding soft tissues were also separated. The incisal
edge of the impacted incisor was then slowly rotated
downwards with a periosteal elevator (Figure 3c,d). To
(a) (b)
(c) (d)
13652591, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13761 by University Of Delhi, Wiley Online Library on [12/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
better protect the incisal edge and crown, the use of
extraction forceps and dental elevators was avoided.
Instead, a slight and brief force was exerted repeat-
edly on the incisal edge, thus leading to slow rotation
of the crown. To protect the developing pulp and peri-
apical tissues, during the rotation procedure, the apical
part was kept within the bony socket, and the range of
movement was minimized as much as possible. During
the entire rotation procedure, the operator's fingers ex-
erted protective effects to the apical tissues of the im-
pacted incisors, thus making them remain within the
alveolar sockets without incurring additional damage
or separation from the apical soft tissues. Finally, the
inversely impacted incisor was rotated to a relatively
normal position (Figure  3e); at this time, the rotated
incisor showed mobility in the labial, palatal, medial
and distal directions. The mucoperiosteum flap was
then repositioned and sutured (Figure  3f). Immediate
post-­surgical periapical radiographic imaging revealed
a relatively normal long axis and a radiolucent area
around the apex (Figure 3g).
After surgery, the two rotated incisors erupted spon-
taneously within 2–­4 weeks (Figures  3h and 4a) with
less than 1 mm mobility in the labial and palatal direc-
tions. Over the next 2 months, the incisors continued to
erupt (Figure 3i). Periapical X-­ray examination showed
that the rotated incisor formed a clear periodontal liga-
ment space that there was clear alveolar bone healing
around the root, and the periapical radiolucent area
had been reduced in size (Figure 3j). After 3 months of
fixed orthodontic aligning (Figure 4c,d), the two rotated
incisors were moved into a relatively normal position
(Figures 3k and 4e). Periapical X-­ray and CBCT images
indicated a normally developing root that featured slight
dilaceration (Figures  3l and 4f,g). Then, the patients
wore an orthodontic retainer for 1 year.
F I G U R E 2   Intra-­oral and CBCT
examinations for the second patient. (a, b,
red arrow) The residual root with a sinus
tract apically. (c, d) Cone beam computed
tomography examinations indicated an
inversely impacted central incisor with a
developing root.
 |

13652591, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13761 by University Of Delhi, Wiley Online Library on [12/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BAI et al.   
   885

(a) (b) (c) (d)

(e) (f) (g) (h)

(i) (j) (k) (l)

(m) (n) (o) (p)

F I G U R E 3   Surgical procedures and prognosis of the first patient's impacted incisor. (a) The palatal surface of the impacted crown was
exposed. (b) The incisor was loosened, and the surrounding soft tissues were also separated. (c, d) The incisal edge was slowly rotated. (e)
The crown was rotated downwards. (f) The flap was sutured. (g, red arrow) Periapical X-­ray image immediately after surgery showed a
periapical radiolucent area. (h) Two weeks after surgery, the rotated incisor erupted spontaneously. Two months later, the rotated incisor
continuously erupted (i), and the periapical radiolucent area reduced (j). At the end of treatment, the rotated incisor was aligned (k) with a
well-­developing root and periodontal status (l, red arrow). Intra-­oral view 4 years after treatment (m, n). Albeit with slight dilaceration, cone
beam computed tomography scans showed further root development without pulp canal obliteration signs of the rotated incisor (o, p, red
arrows).

Follow-­up the fifth year after surgery showed evidence of a slight

The pulp status of the two rotated incisors was checked
2 weeks after surgery, and once a month thereafter for the
next 6 months. Follow-­up examinations included clinical
and radiographical examinations.
During the 4 years of follow-­up, the rotated incisors ex-
hibited a stable and normal position in the maxillary arch,
with normal colour, overjet and overbite (Figures  3m,n
and 4h). The rotated incisors consistently showed a simi-
lar response to the electric pulp test when compared to the
contralateral central incisors (Electric Pulp Tester; Denjoy
Dental Co, Ltd.). The blood flow in the pulp of the rotated
incisors was detected by laser Doppler flowmetry (Peri
Flux System 5010, Perimed Co.), and results were similar
to that of the adjacent teeth, thus suggesting a favourable
pulpal blood flow status. Further CBCT examination in
root dilaceration; the roots had grown longer with closed
apical foramina, and the periodontal ligament space was
evident. Moreover, imaging revealed that the root canal
walls were of normal thickness, and no of PCO signs were
observed within the pulp canal system (Figures 3o,p and
4i,j).
DISC USSION
Due to the limitations in conventional treatments, sev-
eral surgical methods have been applied to treat inversely
impacted central incisors. However, these surgical pro-
cedures often include extraction of the impacted incisor
and repositioning (Kim et al., 2013; Plakwicz et al., 2015;
Tsai,  2002), similar to an avulsion injury followed by
 |

13652591, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13761 by University Of Delhi, Wiley Online Library on [12/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
886       CROWN ROTATION FOR IMPACTION

(a) (b) (c) (d)

(e) (f) (g)

(h) (i) (j)

F I G U R E 4   Treatment and prognosis of the second patient. One month after crown rotation surgery, the maxillary right central incisor
had erupted (a) with limited periapical radiolucency (b, red arrow). One month after orthodontic alignment (c), the periodontal and
periapical tissues of the rotated incisor had improved (d, red arrow). At the end stage of treatment, the treated incisor was relatively well
aligned (e) and the root developed continuously with a slight dilaceration (f, g, red arrows). Four years after treatment, the rotated maxillary
right central incisor maintained a stable position and gingival aesthetics (h). Cone beam computed tomography images showed root canal
walls with normal thickness, the closed apical foramen and no signs of pulp canal obliteration within the pulp tissue (i, j, red arrow).

replantation. However, due to extraction, the neurovascu-
lar supply of the apex deteriorates and the apical tissues of
the tooth incur damage. The development of PCO is con-
sidered to be related to luxation injuries after trauma and
damage to the neurovascular supply of the pulp (Andreasen
et al., 1987; Oginni et al., 2009; Robertson, 1998; Yaacob &
Hamid,  1986). In fact, PCO has been reported to be the
most frequently observed outcome of pulpal healing cases
(96%) following the replantation of avulsed immature
teeth (Abd-­Elmeguid et al., 2015; Tsai, 2002). As with the
replantation of avulsed immature teeth, PCO formation
was also observed in impacted incisors when treated by
existing surgical methods. Although PCO is considered as
a form of pulp revascularization (Tsukiboshi et al., 2019)
and a sign of pulp healing (Gavino Orduna et al.,  2020;
Plakwicz et al., 2015), this condition may be accompanied
by yellow discolouration in the crown (Fouad et al., 2020;
McCabe & Dummer,  2012), loss of pulpal sensibility
(Amir et al.,  2001; Gavino Orduna et al.,  2020; Oginni
et al., 2009) and difficulties when performing further root
canal treatment (American Association of Endodontics,  normal position. Meanwhile, the apical tissues were kept
(Edited 2010); McCabe & Dummer, 2012).
In addition, continued root development requires the
Hertwig's epithelial root sheath (HERS) of the immature
tooth to be intact (Andreasen et al.,  1988; Andreasen
et al.,  1990; Tsukiboshi et al.,  2019). Conventional ex-
traction surgery may impair the integrity of the apical
tissue, including breakage in the continuity of the HERS,
thus leading to an abnormal/discontinuous root shape
or the partial/total arrest of further root development
(Bhatia et al., 2015; Tsai, 2002). In addition, when extract-
ing a developing impacted incisor, the tip part of the apex
may be detached and left at its initial position within the
dental socket. Then, the detached developing apex could
continue to develop and mineralize to form a detached
apex at the initial position (Plakwicz et al., 2015; Welbury
& Walton, 1999).
As a result, it is of critical importance to optimize pro-
tection for the pulp and apical tissues of the impacted in-
cisor when performing surgical procedures. In this report,
the inversely impacted incisors were treated by crown ro-
tation surgery. In contrast to existing methodology, the im-
pacted teeth were not extracted and repositioned. Instead,
the impacted teeth were rotated downwards to a relatively
in their bony sockets and protected from damage by re-
stricting movement to an absolute minimum. The pa-
tients were then followed up over 4 years. Favourable

BAI et al.
pulpal vitality and normal pulp canal radiographic images
without obliteration were observed, thus suggesting that
crown rotation surgery led to better conservation of the
pulp and apical tissues. A favourable prognosis for the api-
cal tissues would further lead to better physiological pulp
healing and normal root development.
Furthermore, PCO can occur shortly after dental trauma
and can almost invariably be observed radiographically
within the first year after dental trauma (Abd-­Elmeguid
et al.,  2015). Previous studies have shown that after the
autotransplantation or replantation of avulsed immature
teeth, PCO started to appear as early as 3 months with a
mean onset time of 9.5  months postoperatively and de-
veloped continuously until complete root canal oblitera-
tion (Abd-­Elmeguid et al.,  2015; Tsukiboshi et al.,  2019).
Another research study showed that following reposition-
ing of an impacted central incisor, partial PCO occurred
18 months after surgery and complete PCO was visible
5 years later (Plakwicz et al., 2015). Instead, in our cases, no
signs of PCO were identified over 4 years of postoperative
follow-­up; this may be related to our surgical method and
the protection it provides for apical tissues. However, these
assumptions are only based on the two cases presented
herein.
In order to study the effect of crown rotation surgery
on pulp healing and root development, clinical studies
with larger sample sizes are now needed. In such work,
the inversely impacted maxillary central incisors treated
by crown rotation surgery should be taken as an experi-
mental group and traditional surgical techniques which
may lead to PCO (such as the surgical repositioning tech-
nique) should be taken as a control. Pulp status, such as
PCO of the treated teeth, together with root development,
should be the primary observation objectives; other peri-
odontal clinical indicators could be used as secondary ob-
servation objectives.
CON C LUS I ON
Using crown rotation surgery, no evidence of PCO signs
was observed over a 4-­year follow-­up for the treatment of
two inversely impacted maxillary central incisors. The fa-
vourable prognoses of the treated incisors demonstrated
that this novel surgical technique may better protect the
pulp vitality and apical tissues, leading to continuous nor-
mal root development and periodontal tissue formation.
ACKNOWLEDGEMENTS
This study is supported by a Grant for Key Research
and Development Projects in the field of social develop-
ment in Shaanxi Province (2022SF-­043), China. The au-
thors would like to express their gratitude to EditSprings
|
13652591, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13761 by University Of Delhi, Wiley Online Library on [12/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
  
   887
(https://www.edits​prings.cn) for the expert linguistic ser-
vices provided.
CONFLICT OF INTEREST
The authors have stated explicitly that there are no con-
flicts of interest in connection with this article.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are avail-
able from the corresponding author upon reasonable
request.
ORCID
Yudi Bai  https://orcid.org/0000-0001-6481-1417
Jin Liu  https://orcid.org/0000-0002-6408-7673
REFERENCES
Abd-­Elmeguid, A., ElSalhy, M. & Yu, D.C. (2015) Pulp canal obliter-
ation after replantation of avulsed immature teeth: a systematic
review. Dental Traumatology, 31, 43–­41.
Agrait, E.M., Levy, D., Gil, M. & Singh, G.D. (2003) Repositioning an
inverted maxillary central incisor using a combination of re-
plantation and orthodontic movement: a clinical case report.
Pediatric Dentistry, 25, 157–­160.
Amir, F.A., Gutmann, J.L. & Witherspoon, D.E. (2001) Calcific meta-
morphosis: a challenge in endodontic diagnosis and treatment.
Quintessence International, 32, 447–­455.
Andreasen, J.O., Kristerson, L. & Andreasen, F.M. (1988) Damage
of the Hertwig's epithelial root sheath: effect upon root growth
after autotransplantation of teeth in monkeys. Endodontics and
Dental Traumatology, 4, 145–­151.
Andreasen, J.O., Paulsen, H.U., Yu, Z. & Bayer, T. (1990) A long term
study of 370 autotransplanted premolars. Part IV. Root devel-
opment subsequent to transplantation. European Journal of
Orthodontics, 12, 38–­50.
Andreasen, F.M., Yu, Z., Thomsen, B.L. & Andersen, P.K. (1987)
Occurrence of pulp canal obliteration after luxation inju-
ries in the permanent dentition. Endodontics and Dental
Traumatology, 3, 103–­115.
von Arx, T. (1993) Developmental disturbances of permanent teeth
following trauma to the primary dentition. Australian Dental
Journal, 38, 1–­10.
Bhatia, S.K., Goyal, A., Gauba, K. & Acharya, S. (2015) Unusual root
development following surgical repositioning of horizontally
developing central incisor. Dental Traumatology, 31, 413–­417.
Brin, I., Fuks, A., Ben-­Bassat, Y. & Zilberman, Y. (1984) Trauma to
the primary incisors and its effect on the permanent successors.
Pediatric Dentistry, 6, 78–­82.
Dinoi, M.T., Marchetti, E., Garagiola, U., Caruso, S., Mummolo, S. &
Marzo, G. (2016) Orthodontic treatment of an unerupted man-
dibular canine tooth in a patient with mixed dentition: a case
report. Journal of Medical Case Reports, 10, 170.
Dodson, T.B. & Susarla, S.M. (2014) Impacted wisdom teeth. BMJ
Clinical Evidence, 2014, 1302.
Flores, M.T. & Onetto, J.E. (2019) How does orofacial trauma in chil-
dren affect the developing dentition? Long-­term treatment and
associated complications. Journal of Endodontics, 45, S1–­S12.
 |
888       CROWN ROTATION FOR IMPACTION
Fouad, A.F., Abbott, P.V., Tsilingaridis, G., Cohenca, N., Lauridsen,
E., Bourguignon, C. et al. (2020) International association of
dental traumatology guidelines for the management of trau-
matic dental injuries: 2. Avulsion of permanent teeth. Dental
Traumatology, 36, 331–­342.
Gavino Orduna, J.F., García García, M., Dominguez, P., Caviedes
Bucheli, J., Martin Biedma, B., Abella Sans, F. et al. (2020)
Successful pulp revascularization of an autotransplantated ma-
ture premolar with fragile fracture apicoectomy and plasma rich
in growth factors: a 3-­year follow-­up. International Endodontic
Journal, 53, 421–­433.
Grover, P.S. & Lorton, L. (1985) The incidence of unerupted per-
manent teeth and related clinical cases. Oral Surgery, Oral
Medicine, and Oral Pathology, 59, 420–­425.
Hu, H., Hu, R., Jiang, H., Cao, Z., Sun, H., Jin, C. et al. (2017) Survival
of labial inversely impacted maxillary central incisors: a retro-
spective cone-­beam computed tomography 2-­year follow-­up.
American Journal of Orthodontics and Dentofacial Orthopedics,
151, 860–­868.
Kim, S., Kim, J., Song, J.S., Choi, H.J., Choi, B.J. & Kim, S.O. (2013)
Continued root development of a surgically repositioned
human incisor tooth germ. Oral Surgery, Oral Medicine, Oral
Pathology and Oral Radiology, 115, e11–­e15.
Kuroe, K., Tomonari, H., Soejima, K. & Maeda, A. (2006) Surgical
repositioning of a developing maxillary permanent central in-
cisor in a horizontal position: spontaneous eruption and root
formation. European Journal of Orthodontics, 28, 206–­209.
Lenzi, M.M., Alexandria, A.K., Ferreira, D.M.T.P. & Maia, L.C. (2015)
Does trauma in the primary dentition cause sequelae in permanent
successors? A systematic review. Dental Traumatology, 31, 79–­88.
McCabe, P.S. & Dummer, P.M.H. (2012) Pulp canal obliteration: an
endodontic diagnosis and treatment challenge. International
Endodontic Journal, 45, 177–­197.
Oginni, A.O., Adekoya-­ Sofowora, C.A. & Kolawole, K.A. (2009)
Evaluation of radiographs, clinical signs and symptoms associ-
ated with pulp canal obliteration: an aid to treatment decision.
Dental Traumatology, 25, 620–­625.
Pinho, T. (2012) Impaction of both maxillary central incisors and
a canine. American Journal of Orthodontics and Dentofacial
Orthopedics, 142, 374–­383.
Plakwicz, P., Kapuścińska, A., Kukuła, K. & Czochrowska, E.M.
(2015) Pulp revascularization after repositioning of impacted
13652591, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13761 by University Of Delhi, Wiley Online Library on [12/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
incisor with a dilacerated root and a detached apex. Journal of
Endodontics, 41, 974–­979.
Robertson, A. (1998) A retrospective evaluation of patients with un-
complicated crown fractures and luxation injuries. Endodontics
and Dental Traumatology, 14, 245–­256.
Shi, R., Zhou, Z., Li, P., Shi, L., Sun, H. & Bai, Y. (2021) In situ rota-
tion surgery for correction of growing, inversely impacted max-
illary central incisors. American Journal of Orthodontics and
Dentofacial Orthopedics, 159, 536–­544.
Sun, H., Wang, Y., Sun, C., Ye, Q., Dai, W., Wang, X. et al. (2014)
Root morphology and development of labial inversely impacted
maxillary central incisors in the mixed dentition: a retrospec-
tive cone-­beam computed tomography study. American Journal
of Orthodontics and Dentofacial Orthopedics, 146, 709–­716.
Topouzelis, N., Tsaousoglou, P., Pisoka, V. & Zouloumis, L. (2010)
Dilaceration of maxillary central incisor: a literature review.
Dental Traumatology, 26, 427–­433.
Tsai, T.P. (2002) Surgical repositioning of an impacted dilacerated
incisor in mixed dentition. Journal of the American Dental
Association, 133, 61–­66.
Tsukiboshi, M., Yamauchi, N. & Tsukiboshi, Y. (2019) Long-­term
outcomes of autotransplantation of teeth: a case series. Journal
of Endodontics, 45, S72–­S83.
Welbury, R. & Walton, A.G. (1999) Continued apexogenesis of im-
mature permanent incisors following trauma. British Dental
Journal, 187, 643–­644.
Yaacob, H.B. & Hamid, J.A. (1986) Pulpal calcification in primary
teeth: a light microscopy study. The Journal of Pedodontics, 10,
254–­264.
How to cite this article: Bai, Y., Cui, J., Sun, H.,
Zhou, Z., Shi, L. & Li, P. et al. (2022) Enhanced
conservation of vital pulp and apical tissues by the
application of crown rotation surgery for inversely
impacted central incisors: A follow-­up analysis of two
patients over 4 years. International Endodontic
Journal, 55, 882–888. Available from: https://doi.
org/10.1111/iej.13761