Download Treatment of an upper impacted cuspid using ultrasonic

PIO-47; No. of Pages 8
ARTICLE IN PRESS
progress in orthodontics x x x ( 2 0 1 1 ) xxx–xxx
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/pio
Case report
Treatment of an upper impacted cuspid using ultrasonic
surgery and a modified RPE. A case report
Vittorio Grenga ∗ , Mauro Bovi, Raffaele Schiavoni
MD, DDS, Private practice, Rome, Italy
a r t i c l e
i n f o
a b s t r a c t
Article history:
This case report describes the possibility to use a modified rapid palatal expander like
Received 10 March 2011
anchorage to reposition an included maxillary cuspid.
Accepted 8 April 2011
Moreover it is enphasized the use of an ultrasonic device during surgery to expose the
impacted tooth.
Keywords:
© 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
Anchorage
Class I malocclusion
Impacted cuspid
Rapid palatal expander
Ultrasonic surgery
1.
Introduction
The prevalence of non eruption and/or ectopic eruption of the
maxillary canine has been reported to range from 0.8% to 2.3%.
There is a significantly higher frequency in females compared
to males. Unilateral impactions are the most common1 .
The treatment of impacted canines is often not so easy and
predictable and it may lead to failure.
The principal reasons of the failure are an inappropriate
positional diagnosis and a lack of appreciation of the considerable anchorage requirements of the case2 .
Diagnosis and treatment planning of impacted maxillary
canines can be done by using traditional radiography or more
accurately by using cone-beam computed tomography3,4 .
The comparative analysis of these methods permits to
determinate the labiopalatal position of an impacted maxillary canine.
Frequently patients with impacted upper cuspids require
maxillary expansion to create necessary space to reposition
the permanent canine5 .This can involve the preliminary use
of a rapid palatal expander (RPE).
The next phase of treatment involves the surgical exposure
of the impacted tooth and the use of orthodontic traction to
move the tooth to the occlusion.
The present article proposes the use of ultrasonic surgery to
expose the canine in palatal position and an easy modification
of RPE to allow the orthodontic repositioning of the impacted
upper canine during the stabilization period of the maxillary
expansion.
2.
Case report
A 16-year-old female presented with a Class I malocclusion,
constriction of the upper arch and palatally impacted maxillary right canine (Fig. 1).
A RPE with a 13 mm screw was inserted to correct the mild
transverse discrepancy of the upper arch and to give anchorage for canine repositioning.
∗
Corresponding author. Via Apuania 3 - 00162 Rome, Italy.
E-mail address: [email protected] (V. Grenga).
1723-7785/$ – see front matter © 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
doi:10.1016/j.pio.2011.04.003
Please cite this article in press as: Grenga V, et al. Treatment of an upper impacted cuspid using ultrasonic surgery and a modified RPE. A case
report. Prog Orthod (2011), doi:10.1016/j.pio.2011.04.003
PIO-47; No. of Pages 8
2
ARTICLE IN PRESS
progress in orthodontics x x x ( 2 0 1 1 ) xxx–xxx
Fig. 1(a-l) – Facial and intraoral photographs of the patient at the start of treatment. Note the panoramic radiograph showing
the upper right cuspid in palatal inclusion.
Please cite this article in press as: Grenga V, et al. Treatment of an upper impacted cuspid using ultrasonic surgery and a modified RPE. A case
report. Prog Orthod (2011), doi:10.1016/j.pio.2011.04.003
PIO-47; No. of Pages 8
ARTICLE IN PRESS
progress in orthodontics x x x ( 2 0 1 1 ) xxx–xxx
3
Fig. 2 – Palatal view of the upper arch with the RPE
inserted. Note the 0.022 x 0.028 inch tube soldered on the
right arm of the RPE. There is also a little auxiliary arm that
can be used during orthodontic traction.
Fig. 4 – Palatal view of the upper arch immediately after
surgical exposition of the canine crown using an ultrasonic
device. Note the TMA 0.017 x 0.025 inch sectional spring
inserted in the tube soldered to the RPE right arm.
On the right arm of the expander a 0.022 x 0.028 inch tube
was soldered (Fig. 2).
After the appliance placement, the screw was activated a
quarter of a turn (0.25 mm) once per day for two weeks.
After that the necessary expansion was achieved, the
patient underwent surgery to expose the impacted canine.
Surgery was performed under local anesthesia (Articaine
chloride 4% plus adrenaline 1/100000) after waiting 20 minutes
for vasoconstriction to take effect.
A window of palatal mucosa was excised with a radiosurgical device (Ellmann Dento-Surg 90 F.F.P., Ellmann International
Inc., Hewlett, NY, USA).
The removal of the bone covering the impacted canine
was performed by using an ultrasonic surgical device (Piezon
Master SurgeryR ,EMS, Switzerland) without flap elevation6 .
The insert used was the EX 2 (Fig. 3)
Fig. 5 – Palatal view of the upper arch three months after
the application of the TMA sectional spring and after only
one reactivation.
Fig. 3 – (a) After having done a window on the palatal mucosa with a radiosurgical device, pericoronal osteotomy has done
using an ultrasonic device (EMS with a EX2 insert). Note that the insert is parallel in relation to the dental crown, in this way
it is possible to realize an osteotomy less traumatic for the enamel.
(b) Exposition of the crown of the impacted canine: note reduced bleeding that permit to position an attachment on the
crown minimizing bonding problems.
Please cite this article in press as: Grenga V, et al. Treatment of an upper impacted cuspid using ultrasonic surgery and a modified RPE. A case
report. Prog Orthod (2011), doi:10.1016/j.pio.2011.04.003
PIO-47; No. of Pages 8
4
ARTICLE IN PRESS
progress in orthodontics x x x ( 2 0 1 1 ) xxx–xxx
Fig. 6 (a-d) – RPE was removed, the upper arch was bonded and a power chain was applied to reposition the canine.
The choice to use an open eruption method allowed
to avoid the RPE removal and to perform the orthodontic traction. A button was placed on the palatal surface
of the canine and a 0.017 x 0.025 inch TMA sectional
spring was applied by using a tube soldered on the RPE
(Fig. 4).
After one month the spring was easily reactivated and after
three months the canine was extruded in palatal position
Fig. 7 (a-d) – The canine has reached the arch and a 0.014 NiTi archwire is applied.
Please cite this article in press as: Grenga V, et al. Treatment of an upper impacted cuspid using ultrasonic surgery and a modified RPE. A case
report. Prog Orthod (2011), doi:10.1016/j.pio.2011.04.003
PIO-47; No. of Pages 8
ARTICLE IN PRESS
progress in orthodontics x x x ( 2 0 1 1 ) xxx–xxx
5
Fig. 8 (a-e) – Upper and lower arches bonded to resolve the mild crowding in the lower arch and to obtain an optimal
intercuspation.
ready to be moved to the arch (Fig. 5). The RPE was then
removed and the upper arch was bonded. The upper right
deciduous canine was extracted. A button was bonded on the
vestibular surface of the upper permanent canine to allow
the repositioning in the arch of the tooth together with the
rotation of the canine.
An upper 0.020 inch stainless steel archwire was applied in
the upper arch with a coil spring from the right first bicuspid
to the right lateral incisor to increase the space. A power chain
was applied on the button of the cuspid.
Composite was placed on the occlusal surfaces of the
upper second molars to open the bite temporarily and to
permit the movement of the maxillary right canine from
palatal to labial position without occlusal interferences
(Fig. 6).
After 4 months the canine reached the arch and so it was
possible to put a bracket on the cuspid. An upper NiTi 0.014
inch archwire was applied and the composite on the occlusal
surfaces of the maxillary second molars were removed (Fig. 7).
Three months later the canine was completely derotated
and levelled and the lower arch was bonded to resolve the
mild crowding of the anterior teeth (Fig. 8).
After 18 months of active treatment the patient was
debonded and two essix retainer were applied to be worn
nighttime.
Final records of the patient showed a good aesthetical and
functional result.
Two little spaces distal to the lateral upper incisors were
present probably due to a discrepancy between the mesiodistal diameters of the upper and lower front teeth (Fig. 9).
Please cite this article in press as: Grenga V, et al. Treatment of an upper impacted cuspid using ultrasonic surgery and a modified RPE. A case
report. Prog Orthod (2011), doi:10.1016/j.pio.2011.04.003
PIO-47; No. of Pages 8
6
ARTICLE IN PRESS
progress in orthodontics x x x ( 2 0 1 1 ) xxx–xxx
Fig. 9 (a-i) – Final records of the patient after 18 months of treatment.
Please cite this article in press as: Grenga V, et al. Treatment of an upper impacted cuspid using ultrasonic surgery and a modified RPE. A case
report. Prog Orthod (2011), doi:10.1016/j.pio.2011.04.003
PIO-47; No. of Pages 8
ARTICLE IN PRESS
progress in orthodontics x x x ( 2 0 1 1 ) xxx–xxx
Fig. 10 – Panoramic radiograph showing a good position of
the upper right canine without periodontal problems and
with the root with no sign of resorption.
The panoramic radiograph showed a good periodontal status with a correct position of the root of the canine without
resorption (Fig. 10).
3.
Discussion
The literature reveals that palatally ectopic canines that have
been surgically exposed and orthodontically aligned have a
small and clinically insignificant reduction in periodontal support compared with contralateral canines.7–9
In addition, to remove more bone than that which is
adequate for bonding a small attachment appears to be
unjustified.10
Disadvantages of surgical exposure of an impacted palatal
canine without flap elevation include inadequate visibility and
difficulty in performing a correct osteotomy to identify the
crown of the tooth. Moreover, haemorrhage makes bracket
bonding difficult.
Ultrasonic surgery with selective cutting of the tissues
allows for the performance of osteotomies through soft tissues for a clear identification of the impacted tooth without
damaging the palatal mucosa. The cavitation produced by the
ultrasonic technique facilitates hemostasis.11–13
The osteotomy is the main aspect of the surgical intervention because it allows for visualization of the enamel of the
crown of the impacted tooth, revealing the exact position of
the tooth and its relationship with the contiguous structures.
This creates space for the correct positioning of the button.
The amount of bone removed should be as small as possible, consistent with the proper placement of an orthodontic
appliance (button-chain) to allow pulling of the tooth. The
bone removal should not damage the adjacent teeth; this may
occur when the canine is very close to the roots of the lateral
and central incisors.
Use of ultrasonic instrumentation in performing the
osteotomy allows for the selective cutting of hard tissue. It
also helps to distinguish between bone, cement, and enamel.
Consequently, there is no injury to the cemento-enamel junction, which is fundamental for physiological tooth movement
and avoidance of the risk of ankylosis. Additionally, the adjacent dental structures are preserved. Damage to the involved
tooth and to the adjacent teeth is avoided because of the
extreme tactile sensitivity of the device (which allows for the
7
recognition of different materials) and because of the effectiveness of different ultrasonic cutting tools according to their
placement on the surface of attack. Tools are most effective
when they are placed perpendicular to the surface, and least
effective when parallel.
During the pericoronal osteotomy, the inserts should be
held parallel to the tooth to be exposed so that there is almost
no action on the tooth, but maximum action on the bone to
be removed. This approach allows for a safe osteotomy along
the buccal surface of the crown of the impacted tooth.
The time required for removal of the bone overlying the
impacted tooth is minimal because of the greater ease with
which the operator can move. Thus, the surgery time is
shorter, and this is particularly pleasing to young patients.
The comfort and cooperation of the patient are greatly
increased because ultrasonic instruments are less traumatic
than rotating instruments, and the use of manual chisels
and hammers can be avoided. Finally, more effective bleeding control during surgery allows for the preparation of a
dry field, which is necessary for the success of intraoperative
bonding.
The removal of the etching agent from the enamel surface of the tooth should be performed with the irrigation of
ultrasonic instrumentation because the cavitation maintains
a bloodless field.
Conflict of interest
The authors have reported no conflicts of interests.
Riassunto
Questo caso clinic descrive la possibilità di usare un espansore
palatale rapido modificato come ancoraggio per il riposizionamento
di un canino mascellare incluso. Inoltre si utilizza un dispositivo a
ultrasuoni durante l’intervento chirurgico per esporre il dente incluso.
Résumé
Cette observation médicale décrit la possibilité d’utiliser un
expanseur palatal à action rapide modifié comme ancrage pour repositionner une canine incluse au maxillaire.
Qui plus est, l’accent est mis sur l’utilisation d’un appareil à ultrasons
pendant l’opération chirgicale pour exposer la dent incluse.
Resumen
Este case report describe la posibilidad de utilizar un expansor
palatal rápido modificado como anclaje para reposicionar un canino
maxilar incluido.
Asimismo, se hace hincapié en la utilización de un dispositivo de
ultrasonidos durante la intervención quirúrgica para exponer el
diente incluido.
references
1. Andreasen JO, Petersen JK, Laskin DM. Textbook and color atlas
of tooth impactions. Copenhagen: Munksgaard;
1997.
Please cite this article in press as: Grenga V, et al. Treatment of an upper impacted cuspid using ultrasonic surgery and a modified RPE. A case
report. Prog Orthod (2011), doi:10.1016/j.pio.2011.04.003
PIO-47; No. of Pages 8
8
ARTICLE IN PRESS
progress in orthodontics x x x ( 2 0 1 1 ) xxx–xxx
2. Becker A, Chaushu G, Chaushu S. Analysis of failure in the
treatment of impacted maxillary canines. Am J Orthod
Dentofacial Orthop 2010;137:743–54.
3. Haney E, Gansky SA, Lee JS, Johnson E, Maky K, Miller AJ,
Huang JC. Comparative analysis of traditional radiographs
and cone-beam computed tomography volumetric images in
the diagnosis and treatment planning of maxillary impacted
canines. Am J Orthod Dentofacial Orthop 2010;137:590–7.
4. Maverna R, Gracco A. Different diagnostic tools for the
localization of impacted maxillary canines: clinical
considerations. Prog Orthod 2007;8:28–44.
5. Schindel RH, Duffy SL. Maxillary transverse discrepancies
and potentially impacted maxillary canines in
mixed-dentition patients. Angle Orthod 2007;77:430–5.
6. Grenga V, Bovi M. Piezoelectric surgery for exposure of
palatally impacted canines. J Clin Orthod 2004;38:446–8.
7. Burden DJ, Mullally BH, Robinson SN. Palatally ectopic
canines: closed eruption versus open eruption. Am J Orthod
Dentofacial Ortop 1999;115:634–9.
8. Schmidt AD, Kokich VG. Periodontal response to early
uncovering, autonomous eruption and orthodontic
alignment of palatally impacted maxillary canines. Am J
Orthod Dentofacial Orthop 2007;131:449–55.
9. Baccetti T, Crescini A, Nieri M, Rotundo R, Pini Prato GP.
Orthodontic treatment of impacted maxillary canines: an
appraisal of prognostic factors. Prog Orthod 2007;8:6–15.
10. Becker A, Casap N, Chaushu S. Conventional wisdom and
the surgical exposure of impacted teeth. Orthod Craniofac Res
2009;12:82–93.
11. Bovi M. La strumentazione ultrasonica in chirurgia orale.
Cap. 7: Esposizione dei denti inclusi. Quintessenza Edizioni
S.R.L. 2011.
12. Walmsley AD, Laird WR, Williams AR. Intra-vascular
thrombosis associated with dental ultrasound. J Oral Pathol
1987;16:256–9.
13. Williams AR. Intravascular mural thrombi produced by
acoustic microstreaming. Ultrasound Med Biol 1977;3:
191–203.
Please cite this article in press as: Grenga V, et al. Treatment of an upper impacted cuspid using ultrasonic surgery and a modified RPE. A case
report. Prog Orthod (2011), doi:10.1016/j.pio.2011.04.003