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World Journal of Pharmaceutical Research SJIFResearch Impact Factor 6.805 Sonwane et al. World Journal of Pharmaceutical Volume 5, Issue 11, 1200-1208. Case Report ISSN 2277– 7105 A COMPREHENSIVE TEAM APPROACH TO MANAGE IMPACTED MAXILLARY CENTRAL INCISOR – A RARE CASE REPORT 1 *Dr. Siddharth Sonwane, 2Dr. Shweta R.K., 3Dr. B. Sunilkumar, 4Dr. Jayaesh Rai, 5 1 2 Dr. Heerala Chokotiya *Reader Department of Orthodontics Mansarovar Dental College Bhopal. Associate Professor Department of Oral Surgery Government Dental College Aurangabad. 3 Professor and HOD Department of Orthodontics Mansarovar Dental College Bhopal. 4 5 Senior Lecturer Department of Oral Surgery Mansarover Dental College Bhopal. Senior Lecturer Department of Orthodontics Mansarovar Dental College Bhopal. Article Received on 09 Sept. 2016, ABSTRACT The purpose of orthodontic therapy is to fulfill jackson‟s triad by Revised on 29 Sept. 2016, Accepted on 19 Oct. 2016 means of establishment of good occlusion, enhancing the health of the DOI: 10.20959/wjpr201611-7304 periodontium and balancing facial esthetics. In orthodontic therapy most challenging task is to alignment of impacted teeth. Maxillary *Corresponding Author central incisor impaction is rare in clinical orthodontic practice, the Dr. Siddharth Sonwane frequency of maxillary incisor impaction ranges from 0.06% to 0.2%. Reader Department of Most common cause associate with impaction are Fibrous Operculum, Orthodontics Mansarovar Lack of Space for eruption, and presence of Mesiodens etc. However, Dental College Bhopal. precise diagnosis and punctual management significantly benefits esthetic, social, psychological and functional outcomes. Through this case paper I would like to present the surgical exposure and orthodontic traction of impacted central incisor of impacted maxillary central incisor teeth. KEYWORDS: impaction, surgical exposure, orthodontic tractions, Fibrous Operculum, eruption. INTRODUCTION When tooth fails to erupt into dental arch during stipulated time period know as impacted teeth. Impaction of central incisor is rare and uncommon in orthodontic practice. The latent rationale behind impaction may be systemic or local factors such as crowding, retained or early loss of a deciduous tooth, dental trauma, and ankylosis are proposed as local factors for www.wjpr.net Vol 5, Issue 11, 2016. 1200 Sonwane et al. World Journal of Pharmaceutical Research tooth impaction, where as syndromes like cledocranial dysplasia were consider as systemic factors.[1-3] Several studies and case reports have been suggested that most significant etiological factor for impaction of central incisors is obstruction in path of eruption may be supernumerary teeth, odontome and formation of scar tissue. However, the incidences of maxillary central incisor impaction are uncommon, with a prevalence rate of 0.06% to 0.2%.[1-4] Impacted maxillary incisors can affect dental arch, facial aesthetics, self-esteem, psychological trauma and phonation. Furthermore, few studies have reported that missing anterior can impairs word like „s‟ during speech and unattractive face affecting general social interaction.[1-6] Considering orthodontic treatment objective and prognosis, there are various means to treat an impacted tooth, such as wait & watch for spontaneous eruption, Tooth extraction, surgical reposition, surgical-orthodontic approach, and dental implants.[7-9] The endeavor of this article was to present a case in which the collective surgical-orthodontic therapy had successfully guided the impacted maxillary central incisor to the dental arch without periodontal complications.[10] This treatment venture avoids postorthodontic restorations, and improved the esthetics as well as functions. CASE REPORT A 17-year-old female patient has reported todepartment of orthodontics Mansarovar dental college Bhopal madhyapradesh India, with chief complaint of missing upper front teeth and wanted to restore missing teeth, her past dental history and family history revealed no significant findings. Intra-oral findings were missing maxillary right central incisors, a Class I malocclusion, convex profile with facial symmetry and radiographically presence of mesiodense, obliteration in labial sulcus at the mucogingival junction. www.wjpr.net Vol 5, Issue 11, 2016. 1201 Sonwane et al. World Journal of Pharmaceutical Research Pretreatment panoramic radiographs revealed the overlapped impacted 11 with presence of mesiodense (Figure 1). Cephalometric analysis indicated a Class I skeletal pattern with a high mandibular plane angle. The L1 to MP angle reflects proclination of the mandibular incisors. Treatment planning: - There were several ways to retract impacted central incisor into normal occlusion, we planned to create adequate orthodontic space opening with open coil spring in relation with 11 and surgical exposure of impacted 11 followed by orthodontic traction. Followed by Finishing and permanent lingual retainers were planned. Treatment progress: Maxillary dental arch was bonded using 0.022" x 0.028" slot Roath bracket and 0.016" round niti arch wire was placed. Later 0.016" round niti arch wire was replaced by 016 austrelian AJ wilcock premium round wire with fabrication individual arch with help of bonwill hauelly arch fabrication system fallowed by 0.019"×0.025" rectangular niti arch wire and 0.019"×0.025" rectangular stainless steel arch wire. Once the alignment and leveling was achieved case was prepared for surgical exposure of central inscisor and removal mesiodense was done, Roath 0.022" x 0.028” bracket was bonded on the labial surface of the exposed tooth. With the help of 0.0009 SS ligature wire eyelets and elastic thread Orthodontic traction was done. Treatment outcome: The impacted 11 was brought into an acceptable position with acceptable overbite, overjet and intercuspation. Well inter-digitated Class I molar relationships were attained. Legendary of photographs Fig 1. Pre- photographs and opg Fig2. Initial and surgical stage Fig3. Post photographs and opg www.wjpr.net Vol 5, Issue 11, 2016. 1202 Sonwane et al. World Journal of Pharmaceutical Research 1. pre-treatment intra-oral photographs and OPG www.wjpr.net Vol 5, Issue 11, 2016. 1203 Sonwane et al. World Journal of Pharmaceutical Research 2. Initial stage and surgery www.wjpr.net Vol 5, Issue 11, 2016. 1204 Sonwane et al. World Journal of Pharmaceutical Research Post treated photograph Post treated OPG www.wjpr.net Vol 5, Issue 11, 2016. 1205 Sonwane et al. World Journal of Pharmaceutical Research DISCUSSION The incidence of unerupted maxillary incisors are rare, may be associated with hereditary, environmental, iatrogenic factors such as presence of supernumerary teeth, odontomes. Multidisciplinary approach is the best treatments planning for the impacted teeth, hence, close comprehend collaboration of orthodontist, oral surgeon and periodontist results in successful treatment outcome.[1-10] Successful treatment results Often depends up on the position of the impacted incisor (ie distance from alveolar crest, rotation, angulation and inclination) determines the surgical procedure used. Study on closed technique approach with the apically repositioned flap results in more aesthetically pleasing gingiva than (Kokich VG, Crabill KE et al 2006). However, few periodontal studies reveal that there was no significant difference between the techniques regarding periodontal attachment (Becker A, Brin I, Ben-Bassat Y et al 1990).[11,13] Several studies have been reported regarding timing of interventions and associated disadvantages, (Kuftinec MM, Stom D, et al 1955) reported that delayed intervention of both Orthodontic and surgical approach may result in difficulties in aligning the tooth in the arch.[1-14] Hence, with several studies suggesting that the younger the age, the quicker the tooth erupts.55 However, other studies have suggested that age of intervention has no effect (Uematsu S, Uematsu T, et al 2004).[1-15] There are major two technique most commonly followed during exposing surgical impacted teeth are: (a) window approach, (b) re-suture flap after bonding bracket (Levin MP, D‟Amico RA et al 1974). First approach has its own disadvantages, aligned teeth gives bulls like appearance and method second is always better (Moss JP et al 1975).[12-16] In my case, sufficient space was created with open coil spring, semi lunar flap was raised to bring teeth in to right anatomical position in the dental arch. This approach was applied as it has been shown that the “window” approach causes significant loss of attachment, recession and gingival inflammation occur on maxillary canines after surgical exposure. Thus, Semi lunar flap, preserves a part of keratinized gingival, helps in maintaining gingival attachment throughout eruption of impacted teeth, also prevent forming bull‟s appearance. www.wjpr.net Vol 5, Issue 11, 2016. 1206 Sonwane et al. World Journal of Pharmaceutical Research CONCLUSION Impaction of maxillary anterior teeth affects facial aesthetics, speech, psychological trauma and social loneliness. Hence, it is necessary to detect early, proper diagnosis; careful treatment planning and Periodic follow up during orthodontic traction. A successful result of impacted teeth always depends up on state, position and presence of enough space in the dental arch to accommodate and appropriate surgical exposure technique. FOOT NOTES Source of Support: Nil. Conflict of Interest: None declared. REFERENCES 1. Becker A, Shpack N, Shteyer A. Attachment bonding to impacted teeth at the time of surgical exposure. Eur J Orthod, 1996; 18: 457–63. 2. Kolokithas G, Karakasis D. Orthodontic movement of dilacerated maxillary central incisor. Am J Orthod. 1979; 76: 310. 3. Tanaka E, Watanabe M, Nagaoka K, Yamaguchi K, Tanne K. Orthodontic traction of an impacted maxillary central incisor. J Clin Orthod. 2001; 35: 375. 4. Uematsu S, Uematsu T, Furusawa K, Deguchi T, Kurihara S. Orthodontic treatment of an impacted dilacerated maxillary central incisor combined with surgical exposure and apicoectomy. Angle Orthod. 2004; 74: 132. 5. Kuftinec MM, Stom D. The impacted maxillary canine; II. Clinical approaches and solutions. J Dent Child. 1955; 62: 325–37. 6. Kuftinec MM, Stom D, Shapira Y. The impacted maxillary canine; I Review of concepts. ASDC J Dent Child. 1955; 62: 317–24. 7. Moss JP. An orthodontic approach to surgical problems. Am J Orthod. 1975; 63: 363–90. 8. Levin MP, D‟Amico RA. Flap design in exposing unerupted teeth. Am J Orthod. 1974; 65: 419–22. 9. Kajiyama K, Kai H. Esthetic management of an unerupted maxillary central incisor with a closed eruption technique. Am J Orthod and Dentofacial Orthop, 2000; 118: 224–28. 10. Mitchell L, Bennett TG. Supernumerary teeth causing delayed eruption – a retrospective study. Br J Orthod, 1992; 19: 41–46. www.wjpr.net Vol 5, Issue 11, 2016. 1207 Sonwane et al. World Journal of Pharmaceutical Research 11. Witsenberg B, Boering G. Eruption of impacted permanent incisors after removal of supernumerary teeth. Int J Oral Surg, 1981; 10: 423–31. 12. 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. 13. Ashkenazi M, Greenberg BP, Chodik G, Rakocz M. Postoperative prognosis of unerupted teeth after removal of supernumerary teeth or odontomas. Am J Orthod Dentofacial Orthop, 2007; 131: 614–19. 14. Vermette ME, Kokich VG, Kennedy DB. Uncovering labially impacted teeth: apically positioned flap and closed-eruption techniques. Angle Orthod, 1995; 65: 23–32. 15. Jorkjend L, Skoglund LA. Effect of non-eugenol and eugenol-containing periodontal dressings on the incidence and severity of pain after periodontal soft tissue surgery. J Clin Periodontol, 1990; 17: 341–44. 16. Sanz M, Newman MG, Anderson L et al. Clinical enhancement of post-peripodontal surgical therapy by a 0.12% chlorhexidine gluconate mouthrinse. J Periodontol, 1989; 60: 570–76. 28. www.wjpr.net Vol 5, Issue 11, 2016. 1208