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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 121-125

Management of impacted and dilacerated maxillary central incisor using tractional force

Department of Orthodontics and Dentofacial Orthopedics, Government Dental College, Bengaluru, Karnataka, India

Date of Submission09-Jun-2020
Date of Decision26-Jun-2020
Date of Acceptance19-Jul-2020
Date of Web Publication28-Jan-2021

Correspondence Address:
Dr. V N Aravinda
Department of Orthodontics and Dentofacial Orthopedics, Government Dental College, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sidj.sidj_23_20

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The prominent tooth location and root anomalies of impacted dilacerated incisors are a clinically challenging task for the orthodontist. The absence of anterior maxillary teeth has a significant impact on esthetics, speech, mastication, and psychosocial well-being in young patients. By nature of the vicinity, the impacted maxillary central incisors in children trigger a troubling condition for parents concerned with esthetics. The position, angulation, and direction of the patient's erupting tooth and crown and age are factors that hinder an impacted tooth's prognosis. Among these, the appropriate diagnosis of dilaceration is a crucial determinant of successful treatment. Decisions are made depending on the severity of dilacerations, whether the maxillary central incisor should be exposed and aligned or extracted and replaced by a prosthesis. The first treatment option always chosen to save the impacted maxillary central incisor is the exposure of the tooth surgically, followed by orthodontic traction forces. To prevent more complications, early intervention and detection of such cases are, therefore, most important. This case report elucidates the triumphant management in a 15-year-old female patient of a vertically impacted and dilacerated maxillary right central incisor positioned high in the vestibule, treated with a combined approach of surgical exposure and spontaneous orthodontic traction force.

Keywords: Dilaceration, impaction, orthodontic traction, supernumerary tooth bud

How to cite this article:
Ahmed N, Halapanavar B, Aravinda V N, Rajalakshmi S J. Management of impacted and dilacerated maxillary central incisor using tractional force. Saint Int Dent J 2020;4:121-5

How to cite this URL:
Ahmed N, Halapanavar B, Aravinda V N, Rajalakshmi S J. Management of impacted and dilacerated maxillary central incisor using tractional force. Saint Int Dent J [serial online] 2020 [cited 2022 Aug 10];4:121-5. Available from: https://www.sidj.org/text.asp?2020/4/2/121/308172

  Introduction Top

Dilaceration (Latin: dilacero = tear up) first coined by Tomes[1] as an angulation or bend in the year 1848; after this, Andreasen et al., in 1971, defined dilaceration as the abrupt deviation of the long axis of the crown or root portion of the tooth. Few authors who have different definition and terms as:[2]

  1. Becker describes it as classic dilaceration[3]
  2. Stewart describes it as tooth dilaceration to the hand of a traffic policeman.[4]

The most accepted associated causes for dilaceration are an acute mechanical injury to the primary predecessor tooth which leads to the dilaceration of the underlying developing succedaneous permanent tooth.[2] Other etiological factors include:[2]

  • Endocrine deficiencies and idiopathic developmental disturbances[3]
  • Formation of scar tissue[4]
  • Facial clefting[3]
  • Developmental disorder in primary tooth germ[5]
  • Ectopic tooth germ and lack of space.[6]

Due to the close anatomical relationship between the primary teeth apices and the permanent successor germs, any trauma before the permanent tooth eruption can lead to different malformations depending on the injury's site and extent. An additional reason that meddling with normal eruption is because of disruption in root-forming cells of the successor's tooth results in a change in the tooth's direction.[4]

The main aim of combined orthodontic treatment was to accomplish a functional occlusion, improve the health of the periodontium, and most importantly, to favor dental and facial esthetics.[1]

  Case Report Top

A 15-year-old female patient visited the Department of Orthodontics and Dentofacial Orthopaedics, Government Dental College and Research Institute, Bengaluru, with a chief complaint of missing and spacing in the upper front teeth. The patient was physically and mentally stable, with no history of dental or jaw trauma with no medical and dental health problems. Extraoral examination revealed a straight profile, straight facial divergence, competent lips, non-consonant smile, Intraorally, Angle's class1 malocclusion with missing upper right central incisor, open bite anteriorly, along with tongue thrusting habit, and average growth pattern with Grade I generalized fluorosis (very mild-ICMR Index) [Figure 1].
Figure 1: Pretreatment extraoral and intraoral photographs showing missing maxillary right central incisor

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The patients' clinical history and the radiographs determined the etiology of the impacted maxillary central incisor. Dilaceration could be the possible cause of Impacted maxillary central incisor. The panoramic and cephalometric radiograph showed a highly placed anatomic position and morphology of impacted right maxillary central incisor with short curved root dilacerated in apical one-third region [Figure 2] and [Figure 3]. Although cone-beam computed tomography ensures the accurate location of impacted maxillary central incisor, it has not been performed as the tooth was palpable properly in the buccal aspect. Panoramic radiograph also revealed supernumerary tooth bud in between the roots of #45 and #46 [Figure 2].
Figure 2: Pretreatment panoramic radiograph showing impacted dilacerated right maxillary central incisor and supernumerary tooth bud in between the roots of 45 and 46

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Figure 3: Pretreatment cephalogram showing dilacerated right maxillary central incisor in apical region

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Treatment objectives

  1. Creation of space for impacted right maxillary central incisor
  2. Exposure of the tooth surgically followed by alignment using orthodontic traction forces
  3. Correction of open bite and tongue thrusting habit
  4. Extraction of supernumerary tooth bud in the region of #45 and #46
  5. Esthetic rehabilitation to address the issue of dental fluorosis.

Treatment alternatives include prosthetic rehabilitation after surgical removal of the impacted tooth once the growth is completed. After explaining the treatment options, the patient's consent to the treatment was taken from the parents and the patient's old records were also taken.

Treatment progress

Treatment was completed in three phases as planned earlier, with initial surgical removal of supernumerary tooth buds between #45 and #46.

Leveling, aligning, and space management

The treatment procedure was started using a fixed appliance (MBT 0.022 × 0.028 slots, AO, USA) to gain space for the right maxillary central incisor. The planned archwire sequence was 0.016” nickel–titanium, 0.018” stainless steel, 0.017 × 0.025” nickel–titanium, followed by 0.019 × 0.025” stainless steel. Tongue crib [Figure 4] was given to control tongue thrusting habit. A nickel–titanium open coil spring was placed between the left maxillary central incisor and right maxillary lateral incisor on stainless steel archwire.
Figure 4: Fabrication of tongue crib appliance done for correction of tongue thrusting habit

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Surgical exposure

The oral surgeon raised the mucoperiosteal flap after adequate space creation for surgical exposure of right maxillary impacted incisor for initial leveling and aligning under local anesthesia. MBT bracket was placed on the labial aspect of impacted right maxillary central incisor with closed eruption technique. Kobayashi hook (0.009” ss) was ligated to the bracket, and continuous tractional force was applied. Triangular and box elastics were used to correct open bite.

Orthodontic traction

After 3 months of successful treatment, the crown portion appeared in the oral cavity, then piggyback archwire of 0.016” nickel–titanium sectional wire was engaged into the bracket over a 0.018” stainless steel main archwire [Figure 5] and [Figure 6]. The wire produced a continuous light force to bring the tooth closer to alignment. After 2 months of constant traction using piggyback archwire, proximal stripping of adjacent teeth was done. Once the tooth was aligned, a continuous 0.016” nickel–titanium wire, followed by 0.018” stainless steel, 0.017 × 0.025” nickel–titanium, and 0.019 × 0.025”stainless steel wire was placed. Final settling was done using elastics and repositioning of brackets with respect to #12 and #21 [Figure 5] and [Figure 6]. Once the proper occlusion was achieved with the active treatment, the fixed appliance was debonded, and for retention, fixed lingual bonded retainers were placed in both maxillary and mandibular arches.
Figure 5: Intra-oral radiograph shows aligned impacted and dilacerated maxillary right central incisor

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Figure 6: Orthodontic traction of the impacted and dilacerated maxillary right central incisor

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Treatment results

At the end of treatment, the patient showed a good facial profile with successful treatment in three phases; the impacted and dilacerated right maxillary central incisor was adequately aligned and brought into occlusion, thereby overcoming the esthetic dilemma [Figure 7]. With the proper intervention of habit breaking appliance, the tongue thrusting habit was also restricted, and the use of elastics achieved the open bite correction. There was mild root resorption, which was not obvious due to the dilaceration, and pulp testing showed a vital pulp. Surgical removal of supernumerary tooth bud was done in the region of #45 and #46 [Figure 8]. The approximate treatment duration was about 23 months [[Figure 9] OPG shows follow up Results]. No treatment was undertaken for fluorosis as the patient was not interested.
Figure 7: Final alignment and settling done using elastics

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Figure 8: Extraoral and intraoral photographs of the patient immediately after debonding

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Figure 9: Post-treatment panoramic radiograph showing well aligned dilacerated right maxillary central incisor with mild root resorption and surgical removal of supernumerary tooth bud done in the region of 45 and 46

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  Discussion Top

An anomaly in the eruption of anterior teeth has a significant impact on facial esthetics and may cause psychological problems.[1] Missing maxillary incisors also affects self-esteem and general social interaction.[7],[8],[9] Impaction of anterior maxillary teeth can be a challenging orthodontic problem. However, it is essential to inform the patient correctly, and the parents of the possibility of failure before extensive measures are undertaken to save a severely impacted tooth.[7] The frequency of maxillary incisor teeth impaction is about 0.006%–0.2%. The various other causes of maxillary permanent tooth impaction would be supernumerary teeth, loss of space, odontoma, apical follicular cysts, neoplasia, and disturbances in the path of eruption.[2]

Several reports have connoted that an impacted tooth can be brought into proper alignment in the dental arch. The following criteria are used to evaluate whether the successful alignment of the impacted tooth can take place:[10],[11],[12]

  1. The direction and orientation of the impacted tooth
  2. The stage of root completion
  3. The degree of dilacerations (direction and angulation)
  4. The presence of space for aligning the impacted tooth.[2]

There are three standard techniques for exposing unerupted teeth:[13],[14]

  1. Window excision of soft tissues
  2. An apically positioned flap
  3. A closed eruption technique.[4]

It is necessary to perform controlled traction forces combined with radiographic assessments on a regular basis to obtain favorable results.[3] Although the initial height of the impacted tooth in our patient was at the level of the apical third of the root of the adjacent erupted central incisor, the outcome of orthodontic-surgical treatment was successful. A dilacerated tooth is said to be more resistant to extrusion than a tooth with a standard root, making the apical area prone to resorption.[6],[10] Another issue that the clinician must be aware of when treating a dilacerated impacted anterior tooth is that a gingival-mucosal palatal bulge might develop as the tooth moves incisally.[6] In the present case, there was negligible root resorption. However, no obvious gingivo-mucosal bulge was noted after the treatment, which could be attributed to light orthodontic traction forces and sufficient treatment time that could have allowed for gingivo-mucosal tissue adaptation. The outcome of the orthodontic-surgical plan for the resolution of maxillary incisors depends on several factors[15],[16]

  • Narrowly attached gingiva can cause inflammation
  • Etiology of impaction
  • Location of impacted tooth and type of surgical exposure
  • Height of impacted tooth.

  Conclusion Top

Missing maxillary incisors has substantial effects on facial esthetics, which affects our proper and general social interaction. Realigning the missing central incisor and regaining the lost space are a challenge for the orthodontist, due to its multidisciplinary protocol, which is technique sensitive. Dilaceration of permanent teeth is a relatively uncommon phenomenon. However, its significance should not be underestimated, as it is the main reason for its impaction and involves complex treatment. The outcome of the orthodontic-surgical treatment in our case was very successful, thereby enhancing the patient's confidence, providing functional occlusion, and improving the patient's smile.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Tomes J. A course of lectures on dental physiology and surgery delivered at the Middlesex Hospital School. London: John W Parker; 1848.  Back to cited text no. 1
Andreasen JO, Sundström B, Ravn JJ. The effect of traumatic injuries to primary teeth on their permanent successors. I. A clinical and histologic study of 117 injured permanent teeth. Scand J Dent Res 1971;79:219-83.  Back to cited text no. 2
Becker A. Maxillary central incisors. In: Becker A., editor; The orthodontic treatment of impacted teeth. Wiley-Blackwell; 2012. pp. 70-109.  Back to cited text no. 3
Stewart DJ. Dilacerate unerupted maxillary central incisors. Br Dent J. 1978 Oct 17;145:229-33.  Back to cited text no. 4
Kalra V. The K-9 spring for alignment of impacted canines. J. Clin. Orthod. 2000;34:606-10.  Back to cited text no. 5
Gorlin RJ, Goldman HM. Thoma's oral pathology. St. Louis: Mosby; 1970. p. 104-6.  Back to cited text no. 6
Walia PS, Rohilla AK, Choudhary S, Kaur R. Review of dilaceration of maxillary central incisor: A multidisciplinary challenge. Int J Clin Pediatr Dent 2016;9:90-8.  Back to cited text no. 7
Kalra N, Sushma K, Mahapatra GK. Changes in developing succedaneous teeth as a consequence of infected primary molars. J Indian Soc Pedod Prev Dent 2000;18:90-4.  Back to cited text no. 8
Manilla AE, Katagiri MK. Orthodontic-surgical treatment of an impacted central incisor. Case report. Mexican Orthodontic Magazine 2017;5:1e8148-41-8e9189.  Back to cited text no. 9
Kannan PK, Kumar S, Palanisamy KP, Kumar TS. A case of impacted maxillary central incisor and its management: Case report. [doi: 10.4103/0975-7406.100263].  Back to cited text no. 10
Reddy PK, Raju TR, Rao PK, Venkataramana V, Yugandhar G. Traction of horizontally impacted central incisor: A case report. Ann and Essences Dent [doi: 10.5368/aedj. 2012].  Back to cited text no. 11
Felicita AS. Orthodontic management of a dilacerated central incisor and partially impacted canine with unilateral extraction - A case report. Saudi Dent J. 2017;29:185-93. doi: 10.1016/j.sdentj.2017.04.001. Epub 2017 Jun 14. PMID: 29033530; PMCID: PMC5634799.  Back to cited text no. 12
Chang NY, Park JH, Kim SC, Kang KH, Cho JH, Cho JW, et al. Forced eruption of impacted maxillary central incisors with severely dilacerated roots. Am J Orthod Dentofacial Orthop 2016;150:692-702.  Back to cited text no. 13
Orthodontic Management of Missing Maxillary Central Incisor-Case Report; 2020, February 9, IP:  Back to cited text no. 14
Pavlidis D, Daratsianos N, Jäger A. Treatment of an impacted dilacerated maxillary central incisor. Am J Orthod Dentofacial Orthop 2011;139:378-87.  Back to cited text no. 15
Goyal A, Verma M, Toteja GS, Gauba K, Mohanty V, Mohanty U, et al. Validation of ICMR index for identification of dental fluorosis in epidemiological studies. Indian J Med Res 2016;144:52-7.  Back to cited text no. 16
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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