Download Orthodontic treatment for an unerupted and severely rotated

Orthodontic treatment for an unerupted
and severely rotated maxillary central
incisor. A case report
Y. FUJITA, T. TAKAHASHI, K. MAKI
ABSTRACT. Background Many reports have indicated the treatment for permanent teeth with disturbed eruption
due to the presence of supernumerary teeth. However, successful treatment for an unerupted maxillary incisor with
severe rotation and another maxillary incisor with disturbed eruption by a supernumerary tooth is quite rare. Case
report We treated a 7-year-old Japanese male with an unerupted and severely rotated maxillary right incisor,
along with a maxillary left incisor due to interference with eruption by an inverted supernumerary tooth.
Orthodontic treatment using surgical exposure, traction and guidance of the rotated right incisor, and maxillary
expansion following extraction of the supernumerary tooth were performed. Follow-up At 27 months following
extraction of the supernumerary tooth, and comprehensive orthodontic treatment led the malposititioned central
incisors to a functional position and stable occlusion
KEYWORDS: Supernumerary tooth; Maxillary central incisors, Orthodontic treatment.
Introduction
Disturbances of eruption of permanent teeth are
considered to be common anomalies that occur during
teeth eruption in the mixed dentition period, and may
result from a number of general and local factors, such
as Down’s syndrome, cleidocranial dysostosis,
prolonged retention of deciduous teeth, abnormal
positioning of tooth buds, odontoma, trauma of
primary teeth [Shapira et al., 2000; Angle and
Rebellato, 2005; Betts and Camilleri, 1999; Batra et
al., 2004; Cozza et al., 2003], and supernumerary teeth
with the latter reported to be the most common cause
of unerupted maxillary central incisors [Ochoa
Grijalva and Kuster, 1993]. Many reports have
indicated that the treatment of choice for impaction or
delayed eruption of the maxillary central incisors is
orthodontic traction following surgical exposure of the
teeth [Batra et al., 2004; Ochoa Grijalva and Kuster,
Division of Developmental Stomatognathic Function Science
Department of Growth and Development for Function
Kyushu Dental College, Japan
e-mail:[email protected]
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 1/2008
1993; Agrait et al., 2003; Crawford, 1997; Thosar and
Vibhute, 2006; Cozza et al., 2003]. On the other hand,
several studies have found that a number of patients
with impacted or delayed eruption of maxillary central
incisors experienced spontaneous eruption following
only removal of the causes, such as supernumerary
teeth when sufficient space was available [Bryan et al.,
2005; Leyland et al., 2006; Cozza et al., 2006].
However, such successful treatment for an unerupted
maxillary incisor with severe rotation is quiet rare.
In the present patient, we performed comprehensive
orthodontic therapy including surgical treatment for
the unusual condition of the maxillary left incisor due
to interference of eruption by an inverted
supernumerary tooth, along with an unerupted
maxillary right incisor with severe rotation.
Case Report
A seven-year-old male came to our dental clinic,
with the chief complaint of non-eruption of the
permanent maxillary right incisor. The medical history
of the patient was unremarkable. A clinical
examination revealed the presence of early mixed
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Y. FUJITA ET AL.
edentulous area showed more fibrous gingival tissue
(Fig. 1). Occlusal caries were found in both first
permanent molars.
A radiographic examination revealed the presence of
an inverted supernumerary tooth overlapping the root
of the maxillary left incisor. Further, the maxillary
right incisor was completely impacted with a 90
degrees of distal rotation around its long axis. Root
development of both permanent central incisors was at
the initial stage (Fig, 2a, 3). Cephalometric analysis
revealed normal values according to Japanese
standards, except a greater inclination of the
mandibular plane (Fig. 3). From these findings, the
treatment plan for this case was as follows.
1. Surgical exposure and orthodontic treatment of the
impacted and rotated upper right incisor.
2. Extraction of the supernumerary tooth.
3. Space regaining for proper alignment of the rotated
upper central incisors.
Two months after the first appointment, the patient
underwent surgical exposure of the impacted right
incisor. At the same time, the inverted supernumerary
dentition composed of the following permanent teeth:
mandibular first molars, mandibular central incisors,
and maxillary left incisor. The maxillary left incisor
region had an enlarged labial gingiva: the adjacent
FIG. 1 - Pre-treatment intraoral photograph.
a
b
c
d
FIG. 2 - Periapical radiographs of the maxillary incisors. a. Before treatment. b. Three months after surgical exposure.
c. Three months after initiating orthodontic traction. d. Completion of orthodontic treatment.
a
b
FIG. 3 - Pre-treatment panoramic (a) and cephalometric (b) radiographs.
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DENTISTRY • 1/2008
ORTHODONTIC TREATMENT OF INCISORS
a
b
c
b
a
FIG. 5 - Post-treatment intraoral photographs.
tooth was removed. Three months later, bilateral
central incisors erupted spontaneously. The periapical
radiograph revealed appreciable movement of the
impacted permanent right incisor, though the rotation
remained (Fig. 2b). Therefore a button was bound to
the labial surface of the upper right incisor. One week
later, orthodontic traction was initiated. An additional
auxiliary spring was soldered to the base arch, and a
power chain was applied between the attachment and
the auxiliary spring. At that point, the power chain was
applied from the medial side of the crown in order to
correct the rotation.
Three months after initiating orthodontic traction,
the rotation of the upper right incisor was nearly
completely corrected (Fig. 2c, 4a), therefore both
lingual arch and labial button were removed. One
week later, a quad helix was applied to the upper arch
for labial movement of the right incisor (Fig. 4b). One
month later, a lingual arch was applied to the lower
arch in order to correct linguoversion of the
mandibular lateral incisors. Six months after initiating
labial movement of the upper right incisor, a lack of
available space for the upper incisors was apparent.
Therefore, a rapid expansion device was applied in
order to create adequate space (Fig. 4c).
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 1/2008
FIG. 4 - Intraoral photographs taken
during treatment.
a. Three months after initiating the
orthodontic traction.
b. Immediately after application of a
quad helix.
c. Prior to maxillary expansion.
d. Three months after expansion of
the maxillary dental arch.
b
c
Three months after initiating maxillary expansion,
adequate space for teeth alignment was obtained and
the upper incisors reached the occlusal plane. Bands
were placed on the upper first permanent molars and
brackets were bonded from the lateral incisors. A
0.016-inch Ni-Ti wire was placed on the upper first
molars and between the lateral incisors, and alignment
of the upper anterior teeth was initiated (Fig. 4d). After
wire adjustment for 6 months, the periapical
radiograph revealed that root development of the
upper left incisor was completed, though that of the
upper right incisor was not (Fig. 2d). Further, the
upper central incisors were aligned in the proper
position and stable occlusion was achieved (Fig 5).
Thereafter, the patient used a removable Hawley
retention appliance for the following 6 months.
Discussion
Supernumerary teeth are reported to occur in
permanent dentition in 1.5% to 3.36% of the general
population, while they are found in 0.03% to 0.66% of
the population in primary dentition. Most
supernumerary teeth are located within the maxillary
central incisor region with complications of
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Y. FUJITA ET AL.
uneruption of the permanent incisors, midline
diastema, rotation and displacement of the incisors
[Luten, 1967; Buenviaje and Rapp, 1984; Tay et al.,
1984; Tyrologou et al., 2005].
For treatment of maxillary central incisors that
interfere with eruption due to supernumerary teeth,
Bryan et al. [2005] and Leyland et al. [2006] proposed
that in the majority of cases spontaneous eruption will
occur, if sufficient space is available, following only
removal of the supernumerary teeth. Mason et al.
[2000] reported that nearly 75% of incisors with an
immature root erupted spontaneously after removal of
an associated supernumerary tooth. On the other hand,
several authors have reported cases of supernumerary
tooth removal and orthodontic traction for impacted
maxillary permanent incisors [Ochoa Grijalva et al.,
1993; Thosar and Vibhute, 2006; Cozza et al., 2003].
In the present case, an inverted supernumerary tooth
was found in the maxillary left incisor region.
However, incomplete root development of the
permanent left incisor, inadequate space for eruption
of the left incisor, and the vertical eruption of the left
incisor were noted. Therefore, we considered that the
eruption disturbance would be solved by extraction of
the supernumerary tooth alone.
In the present patient, delayed eruption of a
maxillary permanent right incisor with severe rotation
was also found. Several causes of delayed eruption and
rotation of permanent teeth have proposed, such as
traumatic injury of a primary tooth causing damage to
the corresponding permanent tooth or an abnormal
position of the tooth bud. However, our patient had no
apparent dental or alveolar trauma. Therefore, the
cause of delayed eruption and rotation in this case may
be the presence of a supernumerary tooth. A number of
successful treatments for delayed eruption and rotation
of permanent teeth have been reported including the
use of techniques such as orthodontic repositioning
and surgical reimplantation [Shapira et al., 2000;
Angle and Rebellato, 2005; Betts and Camilleri, 1999;
Batra et al., 2004]. However, cases of a delayed tooth
eruption accompanied with severe rotation are
extremely rare. Initially, we considered that correction
of the rotation would be quite difficult. Orthodontic
treatment after surgical exposure was simply
completed instead of prosthetic treatment, because of
the request of the parents.
Successful alignment of an impacted tooth depends
on its position and direction, degree of root
completion, and presence of space for the impacted
tooth [Bryan et al., 2005]. In the present case, root
development of the impacted upper incisor was
immature. By using a lingual arch and quad helix,
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severe rotation was nearly completely corrected after
surgical exposure of the upper right incisor. Because of
lack of available space for the erupted upper incisors,
an anterior and bilateral rapid expansion device was
applied. After obtaining adequate space, we placed
brackets on the upper incisors and applied orthodontic
force to the upper incisors. Thus, the severe rotation of
the upper right incisor was completely corrected.
The main complication following treatment of
rotation is relapse. It has been reported that early
treatment and a longer retention period were necessary
to reduce the possibility of relapse [Ahrens et al.,
1981]. The present patient also had a risk of relapse of
the upper right incisor after rotational correction,
therefore, we planned a long-term retention for the
maxilla by wearing removable Hawley appliance. Two
years after initial treatment, the upper central incisors
reached a normal position and stable occlusion in the
early mixed dentition period. However, long-term
monitoring for the bone growth of this patient is
necessary until normal permanent occlusion is
reached.
Conclusion
We treated a rare case of an unerupted maxillary
right incisor with severe rotation, and the unusual
condition of a maxillary left incisor due to interference
with eruption by the presence of an inverted
supernumerary tooth in the early mixed dentition. We
performed the comprehensive orthodontic treatment
using surgical exposure, traction and guidance of the
right incisor, and maxillary expansion following
extraction of the supernumerary tooth. As a result, the
maxillary incisors were aligned into a functional
position and stable occlusion.
Acknowledgements
We are grateful to late Dr. Reiji Seo for valuable
comments in the preparation of the manuscript.
References
Agrait EM, Levy D, Gil M, Singh GD. Repositioning an inverted
maxillary central incisor using a combination of replantation
and orthodontic movement: a clinical case report. Pediatr Dent
2003; 25:157-160.
Ahrens DG, Shapira Y, Kuftinec MM. An approach to rotational
relapse. Am J Orthod 1981; 80:83-91.
Angle AD, Rebellato J. Dental term management for a patient with
cleidocranial dysostosis. Am J of Orthod Dentofacial Orthop
2005; 128:110-117.
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 1/2008
ORTHODONTIC TREATMENT OF INCISORS
Batra P, Duggal R, Kharbanda OP, Parkash H. Orthodontic
treatment of impacted anterior teeth due to odontomas: a report
of two cases. J Clin Pediatr Dent 2004; 28:289-294.
Betts A, Camilleri GE. A review of 47 cases of unerupted
maxillary incisors. Int J Paediatr Dent 1999; 9:285-292.
Bryan RA, Cole BO, Welbury RR. Retrospective analysis of factors
influencing the eruption of delayed permanent incisors after
supernumerary tooth removal. Eur J Paediatr Dent 2005; 6:84-89.
Buenviaje TM, Rapp R. Dental anomalies in children: a clinical
and radiographic survey. J Dent Child 1984; 51:42-46.
Cozza P, Gatto R, Marino A, Mucedero M. Case report: two nasal
floor compound odontomas associated with impacted maxillary
incisor. Eur J Paediatr Dent. 2003; 4:99-102.
Cozza P, Mucedero M, Ballanti F, De Toffol L. Supernumerary
teeth and mental retardation: the importance of early surgical
intervention. Eur J Paediatr Dent. 2006; 7:45-49.
Crawford LB. Impacted maxillary central incisor in mixed
dentition treatment. Am J Orthod and Dentofacial Orthop 1997;
112:1-7.
Leyland L, Batra P, Wong F, Llewelyn R. A retrospective
evaluation of the eruption of impacted permanent incisors after
extraction of supernumerary teeth. J Clin Pediatr Dent 2006;
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 1/2008
30:225-231.
Luten JR. The prevalence of supernumerary teeth in primary and
mixed dentitions. J Dent Child 1967; 34:346-353.
Mason C, Azam N, Holt RD, Rule DC. A retrospective study of
unerupted maxillary incisors associated with supernumerary
teeth. Br J Oral Maxillofac Surg 2000; 38:62-65.
Ochoa Grijalva JF, Kuster CG. Supernumerary teeth removal and
orthodontic tooth repositioning: a case report. J Clin Pediatr
Dent 1993; 17:95-98.
Shapira J, Chaushu S, Becker A. Prevalence of tooth transposition,
third molar agenesis, and maxillary canine impaction in
individuals with Down syndrome. Angle Orthod 2000; 70:290296.
Tay F, Pang A, Yuen S. Unerupted maxillary anterior
supernumerary teeth: report of 204 cases. J Dent Child 1984;
51:289-294.
Thosar NR, Vibhute P. Surgical and orthodontic treatment of an
impacted permanent central incisor: A case report. J Indian Soc
Pedod Prev Dent 2006; 24:100-103.
Tyrologou S, Koch G, Kurol J. Location, complications and
treatment of mediodentes—a retrospective study in children.
Swed Dent J 2005; 29:1-9.
47