|Year : 2015 | Volume
| Issue : 2 | Page : 57-59
Maxillary central incisor impaction due to childhood trauma and orthodontic intervention
Ganesh Chinthan1, Kiran Nagarahalli2
1 Department of Orthodontics, Kannur Dental College, Kannur, Kerala, India
2 Department of Orthodontics, AECS Maaruti College of Dental Sciences and Research Centre, Bengaluru, Karnataka, India
|Date of Web Publication||22-Mar-2016|
Dr. Ganesh Chinthan
Department of Orthodontics, Kannur Dental College, Kannur, Kerala
Source of Support: None, Conflict of Interest: None
The maxillary central incisors play an important role in smile esthetics. The absence of a central incisor can affect esthetics, phonetics, and function. Permanent maxillary central incisor impaction can occur due to supernumerary teeth, cyst, abnormal tooth bud position, trauma to the deciduous incisor in childhood, etc. The purpose of this article is to discuss maxillary central incisor impaction due to childhood trauma and orthodontic intervention in its management, with an example of a case treated by two-stage surgical exposure and orthodontic traction.
Keywords: Childhood trauma, maxillary central incisor impaction, orthodontic traction
|How to cite this article:|
Chinthan G, Nagarahalli K. Maxillary central incisor impaction due to childhood trauma and orthodontic intervention. Afr J Trauma 2015;4:57-9
| Introduction|| |
The permanent maxillary central incisor starts mineralization at 3-4 months of age. The crown of the tooth is completed at around 4-5 years of age and erupts into the oral cavity at 7-8 years of age. The root formation is completed at around 10 years of age. The central incisor appears to be more rectangular or square in shape, with crown width around 9 mm. The length of the root is usually 2-3 mm longer than the length of the crown, variations are seen sometimes.  Between 0 and 10 years age, the number of boys with dental trauma corresponds to 55%, and girls 45%.  The more affected age group is between 1 and 4 years.  The most common type of traumatic injury is the intrusion type, around 29.3%.  Permanent tooth eruption disturbances after injury to deciduous predecessor are found to be around 17.97%. 
The prevalence of permanent maxillary central incisor impaction is in the range of 0.006-0.2%.  Sometimes, spontaneous eruption of impacted central incisor can be seen after the removal of any hard and soft tissue barriers. A dilacerated central incisor is less likely to show spontaneous eruption into its correct position and hence orthodontic intervention will be needed. 
| Case Report|| |
A 9-year-old boy reported to the Department of Orthodontics, AECS Maaruti College of Dental Sciences and Research Centre, Bengaluru [Figure 1]. Patient's father complained of a missing upper right permanent tooth. He gave a history of childhood trauma to the patient due to a fall, during playtime at school, but failed to remember the exact age at which the trauma occurred. On examination, over-retained fractured deciduous right central incisor was found. The incisal edge of the permanent central incisor was palpable deep in the vestibule. Panoramic radiograph showed a dilacerated permanent maxillary right central incisor which had rotated upwards, as if moving towards nasal cavity [Figure 2]. Lateral cephalometric radiograph revealed the angulation of its crown [Figure 3]. Interdisciplinary treatment approach was planned. The over-retained deciduous incisor was extracted. Straight wire appliance therapy was ideal and was suggested but patient chose Beggs appliance. So, Beggs brackets were bonded to the teeth and the permanent maxillary first molars were banded. Initial alignment was done with 0.016″ nickel titanium wire for 3-4 months. Next, 0.018″ stainless steel Australian wire was placed for 2 months followed by 0.020″ special plus Australian wire as the base wire. Then the impacted central incisor was surgically exposed by using a full thickness flap, and a Beggs bracket was bonded to the exposed lingual surface of the crown [Figure 4] and a pigtail ligature wire connected the bracket to the piggy back 0.014″ niti archwire, through the closed full thickness flap. The impacted central incisor was gradually pulled by the piggy back nickel titanium wire, by closed eruption technique [Figure 5]. The tooth rotated down, this was clearly evident on an Intraoral periapical (IOPA) radiograph after a few months. Now, a second-stage surgical exposure was done to expose the crown of the right central incisor and the lingual attachment was removed and a Beggs bracket was bonded on the buccal surface [Figure 6] and connected through a pig tail ligature wire to the piggy back niti wire. Orthodontic traction force was exerted and the central incisor moved down and penetrated the mucosa to make its appearance in the oral cavity [Figure 7]. Later, it was aligned and leveled in the arch, to increase the smile esthetics.
|Figure 2: Panoramic radiograph indicating the location of the permanent maxillary right central incisor|
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|Figure 3: Lateral cephalometric radiograph denoting the crown's inclination|
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|Figure 4: First-stage surgical exposure to expose the lingual surface of the crown and the Beggs bracket attached|
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|Figure 5: Closed eruption technique using a piggy back nickel titanium archwire|
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|Figure 6: Second-stage surgical exposure to attach a Beggs bracket on the labial surface of the crown|
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| Discussion|| |
During the early part of their development, the permanent central incisor crowns will be positioned lingual and superior to the apices of the deciduous incisors. Later during eruption, they migrate in a labial and inferior direction. Oblique resorption of the roots of deciduous incisors can now be seen.  Abnormalities in the location of the permanent central incisor tooth buds can be seen sometimes which can affect its eruption path. Over-retained deciduous incisor can also affect its eruption. There are other causes of failure of eruption of the permanent central incisors, such as ectopic development of tooth germ, presence of supernumerary teeth and odontomas, ankylosed deciduous predecessor, cysts, etc. 
A blow from a labial direction of sufficient force can displace the deciduous central incisor crown in a lingual direction with its root displaced in a labial direction.  But due to the superior and lingual position of permanent central incisor tooth bud in relation to its deciduous incisor root, the permanent incisor will not be usually displaced and continue to erupt in its normal path. In case the blow is such that it is in line with the long axis of the deciduous incisor, then an intrusion type injury of the deciduous incisor can take place, causing alterations in further development of the permanent incisors.  It can be in the form of a mild hypoplastic discoloration of the enamel, or anatomic malformations of crown or root (dilacerations), or pulp death and sequestration of tooth bud. The final shape and position of the developing tooth will be dictated by the magnitude and direction of the blow to the deciduous predecessor. When the point of impact of the resorbing deciduous incisor root is palatal surface of the developing central incisor crown, then there can be an upward and labial rotation of the calcified crown portion of the tooth. This can produce an abnormal angulation between the crown and root (dilaceration) giving the tooth an abnormal final morphology. Such teeth fail to erupt into their correct position or remain impacted affecting the function and smile esthetics. 
Management of impacted central incisor depends on many factors. A multidisciplinary approach may be necessary.  Cone beam computed tomography permits oral surgeons to visualize the position and surgical anatomy of the tooth as it will be seen in the operating theater and allows orthodontists to plan directional traction. ,
Treatment can be divided into three phases: (1) Surgical exposure and bonding of an orthodontic attachment. (2) Eruption of impacted tooth by application of extrusion force. (3) Three-dimensional positioning of the impacted tooth. ,,
| Conclusion|| |
Childhood trauma can cause permanent central incisor impaction. Management requires careful planning and an interdisciplinary approach to move the incisor to its correct position in the arch using light orthodontic traction force.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Nelson SJ. Wheeler′s Dental Anatomy, Physiology and Occlusion. 9 th
ed. India: Saunders; 2010.
do Espírito Santo Jácomo DR, Campos V. Prevalence of sequelae in the permanent anterior teeth after trauma in their predecessors: A longitudinal study of 8 years. Dent Traumatol 2009;25:300-4.
Grover PS, Lorton L. The incidence of unerupted permanent teeth and related clinical cases. Oral Surg Oral Med Oral Pathol 1985;59:420-5.
Becker A. Orthodontic Treatment of Impacted Teeth. 3 rd
ed. USA: Wiley Blackwell Publishers; 2012.
Huber KL, Suri L, Taneja P. Eruption disturbances of the maxillary incisors: A literature review. J Clin Pediatr Dent 2008;32:221-30.
Becker A, Chaushu S, Casap-Caspi N. Cone-beam computed tomography and the orthosurgical management of impacted teeth. J Am Dent Assoc 2010;141 Suppl 3:14S-8S.
Pavoni C, Mucedero M, Laganà G, Paoloni V, Cozza P. Impacted maxillary incisors: Diagnosis and predictive measurements. Ann Stomatol (Roma) 2012;3:100-5.
Lin YT. Treatment of an impacted dilacerated maxillary central incisor. Am J Orthod Dentofacial Orthop 1999;115:406-9.
Nienkemper M, Wilmes B, Lübberink G, Ludwig B, Drescher D. Extrusion of impacted teeth using mini-implant mechanics. J Clin Orthod 2012;46:150-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]