Pavlidis-2011-Treatment of an Impa

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Treatment of an impacted dilacerated maxillarycentral incisor

Dimitrios Pavlidis,a Nikolaos Daratsianos,b and Andreas Jagerc

Bonn, Germany

Thediagnosis of an impacted incisor with dilaceration refers to a dental deformity characterized by an angulation

between the crown and the root, causing noneruption of the incisor. In the past, surgical extraction was the first

choice in treating severely dilacerated incisors. The purpose of this case report was to present the correction of

a horizontally impacted and dilacerated central incisor through 2-stage crown exposure surgery combined with

continuous-force orthodontic traction. The tooth was successfully moved into its proper position. The treatment is

discussed, and the orthodontic implications are considered, with a review of the current literature on this topic.

(Am J Orthod Dentofacial Orthop 2011;139:378-87)

The abnormality of root dilaceration, which pres-ents itself as the deformed development of a tooth,

has been long recognized.1,2 The term refers to anangulation, which can occur anywhere along the lengthof the toothie, its crown, cementoenamel junction,along the root, or only involving the apex of the rootresulting in disruption of the normal axial relationshipof the tooth.3 The malformation occurs by displacementof the crown, usually during early tooth development, ina vestibular or, less frequently, palatal direction, while

root growth is still progressing in a cranial direction. Inthe literature, a distinction is also made between vestib-

ular and lateral root bending.4With continued tooth de-

velopment, later tooth eruption becomes unlikely, andthe tooth remains unerupted.

Most frequently, this deformation occurs unilaterallyin the maxillary permanent central incisors. It has as also

been reported in the maxillary deciduous incisors,5 themandibular permanent incisors,6 and the maxillary per-

manent canines and premolars.7 There are also few re-ports of patients having 2 affected dilacerated teeth (in1 patient, 11 and 21 were involved; in 2 others, 21

and 22 were simultaneously affected

8

).

Dilacerations are estimated to occur in 3% of all per-manent dentitions. However, the etiology of dilaceration

is not yet fully understood. Traumatic injury to the de-ciduous predecessors8 and ectopic development of thetooth germ9 are the 2 commonly cited causes of thisanomaly, so that the entity has continued to present

something of a clinical puzzle.The treatment of a dilacerated anterior tooth is chal-

lenging for the clinician, because of its difficult positionand the abnormality of the root. Treatment often in-

volves surgical removal with subsequent orthodonticmethods to either close the space or keep it open until

the patient reaches an age when implants or prosthetictreatment can be performed. Both methods have associ-ated problems. Alternatively, surgical exposure followed

by orthodontic traction is suggested to save an impacteddilacerated incisor.

This article presents a patient with a horizontally im-

pacted and dilacerated maxillary left central incisor. Withthe help of 2 stages of surgical crown exposure com-

bined with continuous orthodontic traction, the dilacer-ated incisor was successfully moved into its proper

position.

DIAGNOSIS AND ETIOLOGY

A 10-year-old white girl was referred by her generaldentist to the orthodontic department of the Universityof Bonn in Germany for consultation. The chief concern

was the noneruption of the maxillary left central incisor;this had resulted in an unesthetic appearance and a psy-chologic compromise (Figs 1 and 2). The child wasphysically healthy, and there was no evident history ofa traumatic injury in the frontal oral region. However,

because of the severely displaced position of 22, with

From the Department of Orthodontics, School of Dentistry, University of Bonn,

Bonn, Germany.aResident.bVice Director.cProfessor and head.

The authors report no commercial, proprietary, or financial interest in the

products or companies described in this article.

Reprint requests to: Andreas Jager, Department of Orthodontics, School of

Dentistry, University of Bonn, Welschnonnenstrasse 17, 53111 Bonn, Germany;

e-mail, [email protected].

Submitted, April 2009; revised and accepted, October 2009.

0889-5406/$36.00

Copyright 2011 by the American Association of Orthodontists.

doi:10.1016/j.ajodo.2009.10.040

378

CASE REPORT
mailto:[email protected]:[email protected]


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Fig 1. Pretreatment extraoral and intraoral photographs.

Fig 2. Dental casts showing noneruption of the maxillary left central incisor.

Pavlidis, Daratsianos, and Jager 379

American Journal of Orthodontics and Dentofacial Orthopedics March 2011 Vol 139 Issue 3


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an incisal cant, dental trauma could not be excluded.Examination of the oral cavity showed dental caries in

the deciduous teeth and a deep insertion of themaxillary labial frenulum.

The patient had a skeletal Class I occlusion with a bal-anced facial pattern. The analysis of the lateral cephalo-

metric radiograph disclosed normal cephalometricvalues. Intraoral examination showed an early mixeddentition and an Angle Class I molar relationship. Theimpaction of the maxillary left central incisor had re-sulted in drifting of the adjacent teeth with a resultantmidline deviation and a 45 mesial rotation of the leftlateral incisor. The impacted incisors crown was palpa-

ble high in the labial sulcus. There were minor arch

length discrepancies in both arches and a crossbite ofthe first molar on the right side.

The panoramic and maxillary occlusal radiographsdemonstrated an impacted maxillary left central incisor

(Fig 3). The tooths morphology and position were easily

visible in the lateral cephalometric radiograph (Fig 4),showing a horizontally displaced tooth, with its crownrotated more than 100 from normal, and its incisal tip

just below the floor of the nose. The palatal surface ofthe crown was facing forward like the hand of a traffic

policeman,9

and the root was shortened. It was not pos-sible to exactly define the root apex on the conventional

radiographs.Thus, a TC-Dentascan (NewTom, Newtom Deutsch-

land AG, Marburg, Germany) was performed, and evalu-ation confirmed the presence of the impacted toothlocalized in the body of the premaxilla with a bend atthe roots apical third (Fig 5). The dilacerated tooth

showed complete apex formation. In addition, the toothhad a marked labiopalatal curvature adjacent to thecortical plate of the bone of the palatal vault, and thecrown-root angle was judged to be about 45. The use

Fig 3. A and B, Pretreatment panoramic and maxillary occlusal radiographs disclosing the impacted

maxillary incisor.

Fig 4. A, Pretreatment cephalogram showing the dilacerated maxillary incisor; B, cephalometric tracing.

380 Pavlidis, Daratsianos, and Jager

March 2011 Vol 139 Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics


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of TC-Dentascan was essential to show the root dilacer-ation and to focus on potential problems associated with

the orthodontic movement of the tooth.

TREATMENT ALTERNATIVES AND OBJECTIVESThe following treatment options were considered.

1. Surgical extraction of the impacted incisor andrestoration with a prothesis or an implant after or-thodontic space opening when growth had ceased.

2. Surgical extraction of the impacted incisor, ortho-dontic space closure, and prosthodontic restoration

of the left lateral incisor as the central incisor ata later stage.

3. Orthodontic space opening, uncovering the toothby using the closed eruption technique and ortho-

dontic traction of the tooth into proper alignment.

The treatment options were explained to the parents,and it was decided to attempt to bring the tooth intoalignment.

TREATMENT PROGRESS

The patient was referred to the general dentistfor res-

toration of the carious deciduous teeth. Subsequently,a fixed appliance was placed on the maxillary teeth to

create space for the impacted central incisor. Bandswith lingual Burstone slots were placed on the maxillaryfirst molars, and orthodontic brackets were bonded to

the 3 anterior permanent teeth. Initially, the posteriorcrossbite was corrected with an asymmetrically activatedtranspalatal arch. Afterward, the rotated left lateral inci-sor was aligned by means of a cantilever, which was fullyinserted to the lateral incisors slot and ligated to the leftmolar band. Leveling was then continued with a 0.0175-in multistrand wire, followed by a 0.016 3 0.016-in

beta-titanium alloy wire and a 0.016 3 0.022-instainless steel wire with an open-coil spring in theposition of the unerupted central incisor (Fig 6).

Once adequate space was achieved, the patient was

transferred to the oral surgeon for exposure of the

impacted incisor. Because of the severe displacement,2 stages of surgical exposure of the crown were recom-mended. The first stage was to expose only the lingualsurface of the crown and attach a gold chain (Fig 7, A

and B). By using local anesthesia, a full thickness muco-periosteal buccal flap was raised. The incisor crown mor-phology was normal, with no enamel defects, so that theprocedure of bonding the gold chain was carried out

without problems. To use the closed-eruption technique,the flap was repositioned and sutured, leaving the goldchain protruding through the mucosa (Fig 7, C).10

The patient returned 8 days later, and orthodontic

traction was initiated. Continuous orthodontic forcewas applied to bring the tooth occlusally into the arch.A force of 60 to 90 g was applied by means of a cantileverfrom the main archwire via a cross-washer. After 4

months of traction, the tooth was close to eruption buc-cally. At that point, the patient was referred again to theoral surgeon to place an attachment but, this time, onthe buccal surface of the crown. Because the tooth

was close to eruption, the surgeon removed only minoroverlying tissue and at the same time corrected the

deep insertion of the labial frenulum (Fig 8, A).By the ninth month of treatment, the incisor was

brought closer to alignment. During the traction, a pala-tal bulge developed (Fig 8, B). The continuous tractionalso resulted in infraocclusion of all maxillary incisors,

an inevitable side effect. At that time, an orthodontic

Fig 5. Two records of the TC-Dentascan showing the special anatomy of the tooth.

Fig 6. Intraoral situation before surgery.




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bracket was bonded upside down on the labial surface.In addition, the rest of the permanent dentition was

bonded to initiate labial root torque for the incisor andto close the anterior open bite.

Leveling was performed with a 0.0175-in multistrandwire, followed by a 0.0163 0.016-in beta-titanium ally

wire and a 0.016 3 0.022-in stainless steel archwire inboth arches (Fig 8, C-E). The palatal bulge was com-pletely reduced, and ideal overbite, overjet, and intercus-pation were established (Figs 9 and 10). The bands and

brackets were removed, and maxillary and mandibularHawley retainers were placed.

TREATMENT RESULTS

By using of a combination of 2 stages of crownexposure and continuous orthodontic traction, the im-pacted dilacerated maxillary left central incisor wassuccessfully positioned into proper alignment in thedental arch. During treatment, the patient had com-promised oral health, which resulted in cervical decal-

cification of the maxillary anterior teeth and mildgingival inflammation after treatment. The exposedincisor had an acceptable gingival contour, which sig-nificantly improved at the 6-month recall. A slightly

Fig 7. A, B, and C, Surgical exposure of the impacted tooth with the closed-eruption technique.

Fig 8. Documentation of the orthodontic treatment: A, situation 1 week after the second stage of sur-

gical exposure combined with labial frenulum correction; B, after 6 weeks, a significant palatal bulge

was clinically manifest; C-E, leveling and alignment of the arch.




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longer crown height was noticeable. Radiographically,

the previously impacted incisor showed a dilaceratedroot displaced in the alveolar bone (Figs 11 and 12).This is why the root was not palpable labiallyunderneath the alveolar mucosa. No root resorption

was evident, the tooth was asymptomatic, and pulptesting showed a vital pulp. Total treatment time

was about 18 months (Fig 13).

DISCUSSION

The authors of most oral surgery textbooks considersurgical removal of a dilacerated, unerupted maxillaryincisor the usual course of treatment.11However, reportsof successfully treated dilacerated impacted maxillary

anterior teeth have been published.7,12-19 degaard7

presented a patient with 2 horizontally and severely im-pacted and dilacerated maxillary canines, and indicatedthat a marked dilacerated tooth could be brought into

correct position. Just as our patient showed, the dilacer-

ation of the root is not a great obstacle, if the case iscarefully planned and compliance is good.

Most authorities agree that there are 2 possiblecauses of dilaceration. The most widely accepted cause

is trauma.8 However, traumatic injuries cannot account

for all cases of dilaceration, especially for those of decid-uous teeth. An idiopathic developmental disturbance

was proposed as another possible cause in patientswith no clear evidence of trauma.9

The treatment of dilacerated anterior teeth is al-ways a clinical dilemma. Failure due to ankylosis, ex-

ternal root resorption, and root exposure afterorthodontic traction is possible. Ankylosis can hardly

be tested unless orthodontic force is applied to the af-fected tooth. In case of ankylosis, surgical luxation toallow further orthodontic movement has been used

with considerable success.20

Fig 9. Records directly after debonding.




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A dilacerated tooth is said to be more resistant to ex-trusion than a tooth with a normal root, making the api-cal area more prone to resorption.21 However, in our

patient, no obvious root resorption could be detected,suggesting that, in the case of dilaceration, root resorp-

tion can hardly be predicted. Radiographic controls dur-ing orthodontic traction would seem to be wise.

Depending on the degree of dilaceration, the apicalportion of the root can penetrate the labial cortical plate,

so that it would be intraorally palpable in the labial sul-cus.5 In severe cases, the root apex can even be exposedinto the oral cavity, so that surgical endodontics, end-odontic treatment, and apicoectomy would be indi-

cated.17 In our patient, although the radiographicexamination showed an acute angulation of the tooth,the root apex was not palpable after tooth uprighting,suggesting that the dilaceration was less pronounced

than the TC-Dentascan had shown. It can be concludedthat the radiographic examination must be considered

with caution. Orthodontic tooth traction can be attemp-ted in borderline cases but should be closely monitored.In case of root apex palpation, traction should bestopped, and reevaluation is recommended. In anotherreport, a permanent mandibular incisor was naturallyerupted with the root orthoaxially displaced in the alve-

olar ridge, despite severe root dilaceration, beginningjust below the cementoenamel junction.6 In this case,the crown was severely buccally inclined, and for thisreason tooth removal was chosen.

The treatment approach for impacted maxillary teethrequires close cooperation of dental specialties such as

orthodontics, oral surgery, endodontics, and prostho-dontics. Studies have shown that, when more bone is re-moved during surgical exposure, there is greater boneloss after orthodontic treatment.22,23 Two stages of

crown exposure can prevent greater amounts of bonedestruction during the first stage of crown exposure

because the placement of the attachment on the labialsurface of a severely angulated dilacerated toothtypically requires more bone removal than placementon the lingual surface. Therefore, the attached

auxiliaries need to be switched from the lingualsurface to the labial surface in the second stage of

Fig 10. Posttreatment casts.

Fig 11. Posttreatment panoramic radiograph showing no

signs of root resorption of the aligned left central incisor.




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crown exposure to facilitate traction and uprighting of

the tooth (Fig 8, A).Another issue that the clinician must be aware of

when treating a dilacerated impacted anterior tooth isthat a gingivo-mucosal palatal bulge might develop as

the tooth moves incisally (Fig 8, B). This bulge in our pa-

tient was caused by marked curvature of the tooth,which, in the pretreatment position of the tooth, wasclose to the cortical plate of the palatal vault (Fig 5).Thus, as the tooth erupted, the palatal bulge becamemore prominent. Singh and Sharma15 were the first todescribe this finding. They stopped traction when the

palatal bulge became extremely prominent, since theywere afraid of losing tooth vitality. Subsequently, theyadded labial root torque and a step-up bend in themain archwire. Once the palatal bulge had been reduced,incisor traction was continued. In our patient, a different

design of mechanics was used to resolve this problem.

The incisor bracket was bonded on the labial surfaceof the tooth with a rotation of 180. By placing a full-size rectangular wire, the tooth was significantly up-righted, resulting in bulge elimination.

There are 2 others options for the treatment of dila-cerated incisors cited in the literature: surgical reposi-tioning24 and tooth autotransplantation.25

Prophylaxis of root dilaceration is undoubtedly animportant issue. In the management of dilacerated inci-sors, manipulation of the inherent potential of Hertwigs

epithelial root sheath is fundamental to a successful out-come. Therefore, if orthodontic treatment is considered,

it is crucial that the treatment is started early. Thispermits the epithelial root sheath to be redirected andoffers the chance for the developing root to adapt tothe correct spatial relationship of the aligned crown. A

clinical report confirms root adaptation of dilaceratedimpacted teeth.24 Moreover, a dilacerated tooth with

incomplete root formation should have a better progno-sis for orthodontic traction.12 It is strongly recommen-ded that all teeth that have not erupted 6 months afterthe normal eruption date should be examined radio-graphically to ascertain any possible cause for the de-

layed eruption.26,27 Intervention should begin as early

as possible, so that normal root development cancontinue. The longer the tooth is retained, the poorerthe prognosis for eruption, axial root growth, andorthodontic traction.

Even in a patient with severe dilaceration of the an-

terior teeth, if extraction of the impacted tooth and res-

toration with a prosthesis or an implant is necessary,orthodontic traction can be performed initially to im-prove esthetics and also to achieve and functionally

maintain the height of the alveolar process.19

CONCLUSIONS

Treatment of an impacted dilacerated incisor is a clin-ical challenge, which should be undertaken by the or-thodontist following carefully planned procedures. A

joint orthodontic, oral surgery, endodontic, and pros-

thodontic examination and approach are of outmostimportance.

Fig 12. A, Posttreatment cephalogram proving that penetration of the cortical bone from the

dilacerated root apex was avoided; B, cephalometric tracing.




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We thank the surgeons M. Tzoumpas and Yango Pohlfor their common treatment of the patient.

REFERENCES

1. British Standards Institution. Glossary of terms relating to den-

tistry. London, United Kingdom: British Standards Institution;

1983.

2. Fox J. The natural history and diseases of the teeth. 2nd ed.

London, United Kingdom: Cox and Son; 1814.3. Shafer WG, Hine MK, Levy BM. A textbook of oral pathology. 4th

ed. Philadelphia: W.B. Saunders; 1983. p. 40.

4. Andreasen JO. Textbook and color atlas of traumatic injuries to the

teeth. 3rd ed. Copenhagen, Denmark: Munksgaard; 1994. p. 457-94.

5. KilpatrickNM, Hardmann PJ,WelburyRR. Dilacerationof a primary

tooth. Int J Paediatr Dent 1991;1:151-3.

6. Chadwick SM, Millet D. Dilaceration of a permanent mandibular

incisor: a case report. Br J Orthod 1995;22:279-81.

7. degaard J. The treatment of a Class I malocclusion with two

horizontally impacted maxillary canines. Am J Orthod Dentofacial

Orthop 1997;111:357-65.

8. Smith DMH, Winter GB. Root dilaceration of maxillary incisors. Br

Dent J 1981;150:125-7.

9. Stewart DJ. Dilacerated unerupted maxillary central incisors. Br

Dent J 1978;145:229-33.

10. Vermette ME, Kokich VG, Kennedy DB. Uncovering labially

impacted teeth: apically positioned flap and closed-eruption tech-

niques. Angle Orthod 1995;65:23-34.

11. Davies PHJ, Lewis DH. Dilacerationa surgical/orthodontic

solution. Br Dent J 1984;156:16-8.

12. LinYTJ. Treatment of an impacted dilacerated maxillary central in-

cisor. Am J Orthod Dentofacial Orthop 1999;115:406-9.

13. ChewMT, Ong MMA. Orthodontic-surgical managementof an im-pacted dilacerated maxillary central incisor: a clinical case report.

Pediatr Dent 2004;26:341-4.

14. Mattison GD, Bernstein ML, Fischer JW. Lateral root dilaceration:

a multi-disciplinary approach to treatment. Endod Dent Traumtol

1987;3:135-40.

15. Singh GP, Sharma VP. Eruption of an impacted maxillary central

incisorwith an unusual dilaceration. J Clin Orthod 2006;40:353-6.

16. Cozza P, Marino A, Condo R. Orthodontic treatment of an im-

pacted dilacerated maxillary incisor: a case report. J Clin Pediatr

Dent 2005;30:93-8.

17. McNamara T, Woolfe SN, McNamara CM. Orthodontic manage-

ment of a dilacerated maxillary central incisor with an unusual

sequela. J Clin Orthod 1998;32:293-7.

Fig 13. Superimpositions of the lateral cephalograms showing the dental and skeletal changes duringorthodontic treatment: A, superimposition on the anterior cranial base (S-N); B, superimposition on the

maxillary base (Spa-Spp); and C, superimposition on the mandibular base (Gn-Go).




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18. Sandler PJ, Reed RT. Treatment of a dilacerated incisor. J Clin Or-

thod 1988;22:374-6.

19. Uematsu S, Uematsu T, Furusawa K, Deguchi T, Kurihara S. Ortho-

dontic treatment of an impacted dilacerated maxillary central in-

cisor combined with surgical exposure and apicoectomy. Angle

Orthod 2004;74:132-6.20. Takahashi T, Takagi T, Moriyama K. Orthodontic treatment of

traumatically intruded tooth with ankylosis by traction after sur-

gical luxation. Am J Orthod Dentofacial Orthop 2005;127:

233-41.

21. Graber TM, Swain BF. Orthodontics: current principles and tech-

niques. St Louis: C.V. Mosby; 1985. p. 231-4.

22. McDonald F, Yap WL. The surgical exposure and application of di-

rect traction of unerupted teeth. Am J Orthod 1982;89:331-40.

23. Kohavi D, Becker A, Zilbermann Y. Surgical exposure, orthodontic

movement and final position as factors in periodontal breakdown

of treated palatally impacted canines. Am J Orthod 1984;85:72-7.

24. Tsai TP. Surgical repositioning of an impacted dilacerated incisorin mixed dentition. J Am Dent Assoc 2002;133:61-6.

25. Filippi A, Pohl Y, Tekin U. Transplantationof displacedand dilacer-

ated anterior teeth. Endod Dent Traumetol 1988;14:93-8.

26. Munns D. Unerupted incisors. Br Dent J 1981;8:39-42.

27. Becker A. Early treatment for impacted maxillary incisors. Am J

Orthod Dentofacial Orthop 2002;121:586-7.


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