10.59987/ads/2012.3-4.100-105
Background. When the incisors do not erupt at the expected time, it is crucial for the clinician to determine the etiology and formulate an appropriate treatment plan.
Aim. The aim of this report is to provide useful information for immediate diagnosis and management of impacted maxillary incisors using the interceptive treatment: removal of obstacles and rapid maxillary expansion (RME). Design. An accurate diagnosis may be obtained with clinical and radiographic exam such as panoramic radiograph, computerized tomography (CT) and cone beam computerized tomography (CBCT). It’s important to know the predictive measurements of eruption evaluated on panoramic radiograph: distance from the occlusal plane, maturity, angulation and vertical position of the unerupted incisors. Early diagnosis is important and interceptive orthodontic treatment, such as removal of obstacles and orthopedic rapid maxillary expansion (RME), may correct disturbances during the eruption through recovering space for the incisors and improving the intraosseus position of delayed teeth.
Results. RME treatment following the surgical removal of the obstacle to the eruption of maxillary incisors leads to an improvement of the intraosseus position of the tooth.
Conclusions. The angulation and the vertical position of the delayed tooth appear to be important in trying to predict eruption. The improvement of the intraosseus position of the unerupted incisor, obtained by removal of the odontoma and rapid maxillary expansion, permits a conservative surgery and the achievement of an excellent esthetics and periodontal result.
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Annali di stomatologia
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Impacted maxillary incisors: diagnosis and predictive measurements
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Impacted maxillary incisors: diagnosis and predictive measurements
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                                                                                                              Case report


Impacted maxillary incisors:
diagnosis and predictive measurements




                                                                                               li
                                                                                            na
Chiara Pavoni                                                   Key words: eruption disturbances, odontoma, maxillary
Manuela Mucedero                                                expansion, orthodontic traction, close eruption tech-
                                                                nique.




                                                                                         io
Giuseppina Laganà
Valeria Paoloni
Paola Cozza
                                                                Introduction




                                                                                      az
Department of Orthodontics, University of Rome Tor              Impaction of the maxillary incisor poses a problem at an
Vergata, Italy                                                  earlier age (1); this pathologic condition is reported less
                                                                frequently than that of third molars or canines. Impaction




                                                                        n
                                                                of maxillary permanent incisors occurs in 0,2-1% of the
Corresponding author:                                           population (2), early referral of patients in the mixed den-




                                                                     er
Giuseppina Laganà                                               tition is common due to concern of parents and general
Department of Orthodontics, University of Rome                  dentists regarding delayed eruption of the permanent
Tor Vergata, Rome, Italy                                        maxillary central incisors (3,4).
Via G. Baglivi, 5/E                                             As missing upper incisors are regarded as unattractive
00161 Roma, Italy
Phone: +39 06 44232321
E-mail: giuseppinalagana@libero.it
                                           nt                   this may have an effect on self-esteem and general so-
                                                                cial interaction, and it is important to detect and manage
                                                                the problem as early as possible (5).
                                         iI
                                                                The maxillary incisors are the most prominent teeth in an
                                                                individual’s smile, they are also the teeth that are on
                                                                maximum display during speech in most individuals and
                                       on

Summary                                                         the normal eruption, position and morphology of these
Background. When the incisors do not erupt at the ex-           teeth are crucial to facial esthetics and phonetics (6).
pected time, it is crucial for the clinician to determine the   Early diagnosis is very important and interceptive ortho-
etiology and formulate an appropriate treatment plan.           dontic treatment could not only improve skeletal malrela-
Aim. The aim of this report is to provide useful informa-
                               i


                                                                tionship and eliminate functional interferences, but also
tion for immediate diagnosis and management of
                            iz


                                                                may correct disturbances during the eruption (7).
impacted maxillary incisors using the interceptive treat-
ment: removal of obstacles and rapid maxillary expan-
sion (RME).
             Ed




Design. An accurate diagnosis may be obtained with              Etiology
clinical and radiographic exam such as panoramic radi-
ograph, computerized tomography (CT) and cone beam              Literature reveals several causes of failure or delayed
computerized tomography (CBCT). It’s important to know          eruption of maxillary incisors.
the predictive measurements of eruption evaluated on            Eruption failure may occur if pathological obstructions,
panoramic radiograph: distance from the occlusal plane,         such as supernumerary teeth, odontomas, cysts, develop
 IC




maturity, angulation and vertical position of the               in the eruptive path of the incisor (6,8).
unerupted incisors. Early diagnosis is important and in-        Supernumerary teeth and odontomas are the most com-
terceptive orthodontic treatment, such as removal of            mon cause: 56-60% of supernumerary teeth cause im-
obstacles and orthopedic rapid maxillary expansion              paction of permanent incisors due to a direct obstruction
C




(RME), may correct disturbances during the eruption             for the eruption (9).
through recovering space for the incisors and improving         Eruption failure can also be caused by tooth malformation
the intraosseus position of delayed teeth.
                                                                or dilacerations. Dilacerations occur after trauma to a
Results. RME treatment following the surgical removal of
                                                                primary tooth, where the developing permanent tooth
©




the obstacle to the eruption of maxillary incisors leads
                                                                bud is damaged due to close proximity to the primary
to an improvement of the intraosseus position of the
                                                                tooth. The degree of damage of the permanent tooth de-
tooth.
Conclusions. The angulation and the vertical position of        pends on the developmental stage of the tooth in ques-
the delayed tooth appear to be important in trying to pre-      tion, as well as the type and direction of the trauma in-
dict eruption. The improvement of the intraosseus posi-         flicted (6,10).
tion of the unerupted incisor, obtained by removal of the       Other possible causes of lack of eruption of maxillary in-
odontoma and rapid maxillary expansion, permits a con-          cisors are: ectopic position of the tooth bud (11), non-vi-
servative surgery and the achievement of an excellent           tal or ankylosed primary teeth (12), early extraction (or
esthetics and periodontal result.                               loss) of deciduous teeth, mucosal barriers in the path of

100                                                                             Annali di Stomatologia 2012; III (3/4): 100-105
Impacted maxillary incisors: diagnosis and predictive measurements


eruption that acts as a physical barrier to eruption, en-         mesiodistal and vestibulopalatal dimensions at its summit
docrine abnormalities, bone disease (5).                          signifies that the tooth is impacted deeper (8).

                                                                  Radiographic assessment
Diagnostic procedures                                             Diagnosis of impacted tooth is verified and its location de-




                                                                                                   li
                                                                  termined through radiographic evaluation (13).
When the incisors do not erupt at the expected time, it is        Panoramic radiograph is considered the standard radi-




                                                                                                na
crucial for the clinician to determine the etiology and for-      ographic first-step examination for treatment planning of
mulate an appropriate treatment plan. An accurate diag-           impacted teeth because it imparts a low dose while giv-
nosis may be obtained after thorough clinical and radi-           ing the best radiographic survey (11,17). This film is
ographic exams. It is also imperative to review a patient’s       useful because it is unique in that it will show the entire




                                                                                             io
medical history to rule out local or systemic conditions (6).     dentition as a whole (6), it may reveal the existence of an
Patients and parents should be questioned regarding               impacted tooth, the degree of root resorption for the cor-
any history of dental trauma even in early childhood (13).        responding primary tooth (15), and the depth of im-
Diagnosis of the delayed tooth is usually made on the ba-         paction (8).




                                                                                          az
sis of clinical and radiographic findings (14).                   Lateral cephalometric is another film that is particularly
Clinical inspection and palpation of the alveolar process         useful if there is a supernumerary tooth or dilacerations
is recommended (15).                                              present because it allows visualization in several dimen-
                                                                  sions (6).




                                                                           n
Clinical examination                                              To be in a position to recommend the best line of treat-
An intra-oral examination should be undertaken to iden-           ment and to plan an appropriate strategy, the orthodon-




                                                                        er
tify retained deciduous teeth, buccal-palatal swelling and        tists requires the following information: the exact positions
availability of suitable space for the incisor (9mm for a         of the crown and root apex of the impacted tooth and the
central and 7 mm for lateral incisors) (5).                       3-dimensional orientation of its long axis; the proximity of


                                              nt
Important clinical signs are over-retention of the corre-
sponding primary teeth while the contralateral perma-
nent tooth has already erupted; substantial reduction in
the available space for permanent tooth eruption or space
                                                                  the impacted tooth to the roots of the adjacent teeth; the
                                                                  presence of pathology such as supernumerary teeth,
                                                                  odontomes, apical granulomas or cysts, and their spatial
                                                                  relationship with the impacted tooth; the presence of ad-
                                            iI
closure; rotation and inclination of the adjacent teeth; el-      verse conditions affecting the adjacent teeth, including
evation of the soft tissue of the palatal or labial mucosa        root resorption; the 3 dimensional anatomy of the crown
depending on the tooth location; absence of a bulge in the        and root of the impacted tooth (17).
                                          on

buccal sulcus at 1-1.5 years before the expected time of          CT has proved to be superior to other radiographic
tooth eruption (11,14,15).                                        method in visualizing bone tissue: 3D CT images clearly
The pathognomic sign which indicates impaction of a               show the intraosseus location, inclination and morphology
central incisor is the presence on the arch of the homo-          of impacted teeth as well as the distance from adjacent
                                 i


lateral lateral incisor, as this points to an anomaly in the      structures (18,19).
                              iz


central incisor eruption process (8).                             Due to the highly detailed three-dimension information ob-
Deviation from normal sequence of eruption, e.g. lateral          tained, computerized tomography is the method of choice
incisors erupt prior to the central incisor, or eruption of ad-   for accurately defining the position of an unerupted tooth
              Ed




jacent teeth occurred 6 months previously (with both in-          and identifying any root resorption of adjacent teeth not
cisors unerupted-lower incisors erupted one year previ-           detectable by other methods (6). The highly detailed in-
ously), are other signs of delayed eruption of maxillary          formation and the excellent tissue contrast without blur-
incisors (5,16).                                                  ring and overlapping of adjacent structures outweighs
The position of the adjacent teeth in the arch should be          the high radiation dose, limited availability, and high cost
noted as well as whether they are upright or tilted toward        (18,20).
 IC




the missing tooth. This may be helpful in determining the         Three-dimensional imagery enables analysis of the precise
location of the unerupted tooth: once it is close to its nor-     location and orientation of impacted teeth, their situation
mal eruption path the neighboring teeth may tilt, but when        relative to obstacles to eruption, their external and internal
the unerupted tooth is far from its normal eruption path the      anatomy, the labial and palatal bone thickness; any resorp-
C




adjacent teeth may close the space in a more bodily kind          tion of the adjacent teeth or pathological bone loss; the
of movement (10).                                                 presence or absence of a continuous radiolucent line be-
                                                                  tween the root and the bone (possible ankylosis) (8).
Palpation of the alveolar region                                  Recently cone-beam CT (CBCT) has been introduced ad
©




Palpation is a valuable adjunct in final location of the          a technique dedicated to the imaging of dental and max-
unerupted tooth, it may also help in the radiographic             illofacial structures. It has one-sixth of the radiation of
evaluation (10).                                                  computed tomography, is more time efficient, more cost
On palpation of the area, the clinician is likely to en-          effective, is still able to provide three dimensional images,
counter a palatal or labial bulge that will help determine        excellent bone differentiation and an unlimited number of
the position of the unerupted tooth (6). In order to locate       views (6,17). Its disadvantages include spatial resolu-
the crown of the impacted tooth, we locate a painless, in-        tion of subtle structures that is slightly inferior to that of CT
compressible, palatal or vestibular fibromucosal protruber-       and limited representation of soft tissues (due to the
ance. An edentulous ridge with particularly small                 lower radiation dose) (17).

Annali di Stomatologia 2012; III (3/4): 100-105                                                                               101
C. Pavoni et al.


Predictive measurements of eruption evaluated
on panoramic radiograph
Mitchell and Bennet in 1992 classified the distance of the
unerupted permanent tooth from the occlusal plane as:
near, vertical displacement within coronal 1/3 root of ad-




                                                                                                  li
jacent teeth, horizontal displacement < ½ tooth width; mid,
vertical displacement within middle 1/3 root of adjacent




                                                                                               na
tooth, horizontal displacement > ½ tooth width but <1
tooth width; far, greater displacement (21) (Fig. 1). The
maturity of the unerupted incisors is assessed by Cvek’s
classification. The teeth with wide, divergent root ends




                                                                                            io
and a root estimated to be less than half the final length
were allocated to group 1. Those teeth with roots between        Figure 3. Brian et al. measurement.
one-half and two-thirds the final root length were allocated
to group 2, and those with roots two-thirds of their final




                                                                                         az
length to group 3. The teeth with open apical foramina and
nearly full root length were placed in group 4 and those
with completed roots in group 5 (22) (Fig. 2).




                                                                          n
                                                                       er
                                            nt
                                          iI
                                                                 Figure 4. Smailiene et al. measurement.


                                                                 Case report
                                        on

Figure 1. Mitchell and Bennet measurement.
                                                                 Aim of this report was to show the interceptive manage-
                                                                 ment of a case with an impacted central maxillary incisor
                                                                 caused by odontoma in a young patient.
                                  i
                               iz


                                                                 History and initial examination
                                                                 A 9-year-old Caucasian girl was referred by his general
                                                                 dentist to the Department of Orthodontics of the Univer-
               Ed




                                                                 sity of Rome “Tor Vergata” for evaluation. The chief com-
                                                                 plaint was concern about an eruption disturbance, which
                                                                 had resulted in an unaesthetic appearance.

                                                                 Diagnosis
                                                                 The patient had balanced facial pattern with a convex pro-
 IC




                                                                 file, and an asymmetric ugly smile. Intraoral clinical exam-
Figure 2. Cvek’s classification.
                                                                 ination showed a mixed dentition, an altered sequence of
                                                                 eruption and the absence of the maxillary right central in-
                                                                 cisor (Figs. 5, 6).
C




Bryan et al. estimated the angle of the long axis of the
unerupted permanent tooth to the mid-sagittal plane (23)
(Fig. 3).
The vertical position of impacted permanent incisors in
©




relation to the contralaterally erupted central incisor was
analyzed by Smailiene et al.. To determine initial verti-
cal position of impacted tooth, the thirds of the root
length of the erupted contralateral central incisor were
used. Three possible vertical positions of impacted inci-
sor have been defined: v1- sector at the level of gingi-
val third of the root; v2- sector at the level of middle third
of the root; v3 – sector at the level of apical third of the
root (9) (Fig. 4).                                               Figure 5. Pretreatment intraoral photograph, frontal view.

102                                                                                Annali di Stomatologia 2012; III (3/4): 100-105
Impacted maxillary incisors: diagnosis and predictive measurements




                                                                                                  li
                                                                                               na
                                                                 Figure 7. Measurements at T1.


                                                                 Treatment plan




                                                                                            io
                                                                 The odontoma was removed (2), and a Palatal Expander
                                                                 was bonded in the maxillary arch. The expansion of up-
                                                                 per arch permitted to obtain good correction of the inter-




                                                                                         az
                                                                 arch relationship to favour teeth alignment, dental inter-
                                                                 cuspation and functional movements, and to improve
                                                                 intra osseous incisor position (24) (Fig. 8).




                                                                          n
                                                                       er
                                              nt
                                            iI
                                          on

Figure 6. Pretreatment extraoral photograph, smile view.

                                                                 Figure 8. Intraoral frontal view during maxillary expansion.
Occlusal analysis revealed a molar Class I relationship.
There was significant dental crowding in the upper and
                                 i


lower arches. The maxillary right central incisor was ab-        The patient underwent a modify Rapid Maxillary Ex-
                              iz


sent and the maxillary right lateral incisor was erupting        pander (25) designed with two Crozat wire Chromium
with lack of space for the central incisor in the line of the    Cobalt 0.028 arms soldered on the metal arms placed in
arch. Overjet and overbite were 3 mm.                            a forward position; these arms are situated mesial to the
              Ed




Radiological examinations are performed to complete              right deciduous canine and to the left central incisor in
clinical evaluation. The panoramic radiograph showed             order to create and mantain space for the absent tooth
an odontoma located in the eruption path of permanent            (Fig. 9). Activation of the screw was continued until the
maxillary right incisor. It was not possible to exactly define   palatal cusps of the maxillary posterior teeth were in con-
the place of impacted incisor.                                   tact with the buccal cusps of the mandibular posterior
TC-Dentascan evaluation confirmed the presence of a              teeth. After expansion, the patient was retained with
 IC




composite odontoma in the body of the premaxilla, near           the expander in place for 6 months. Following the reten-
the crown of impacted incisor.                                   tion period the expander was removed and the patient
Cephalometric analysis revealed a skeletal Class I mal-
occlusion (ANB T1: 3°) and a dolichofacial pattern (FMA
C




T1: 31°). Lower incisor showed good inclination on
mandibular plane (IMPA T1: 92°).
The vertical position of the delayed permanent incisor in
relation to the contralaterally erupted central incisor was
©




v2, while its angulation to the mid-sagittal plane was 20°
(Fig. 7).

Treatment objectives
The following treatment objectives were established: 1)
surgical removal of obstacle, 2) orthopedic maxillary ex-
pansion to recover space for the eruption of the incisor
and to improve the intra osseous position of delayed
maxillary incisor, 3) recovery of impacted tooth.                Figure 9. Intraoral occlusal view during maxillary expansion.


Annali di Stomatologia 2012; III (3/4): 100-105                                                                                 103
C. Pavoni et al.


was made available for clinical examination and radi-
ographs to monitor the intra osseous position of the de-
layed incisor.
On the panoramic radiographs the right central incisor
showed an improvement of the initial vertical position




                                                                                                           li
(sector v1) and angulation (12°) (Fig. 10).




                                                                                                        na
                                                                                                     io
                                                                        Figure 12. Intraoral frontal view at the end of orthodontic traction.




                                                                                                  az
Figure 10. Measurements at T2.


8 months after odontoma removal a surgical exposure




                                                                                 n
and traction of the impacted right central incisor were
planned. Surgical exposure has been performed using a




                                                                              er
closed eruption technique (4), in which the raised flap that
incorporates attached gingival is fully replaced to its for-
mer position. In fact the gingival flap was sutured back in


                                                 nt
such a way that the bracketed crown was not exposed
into the oral cavity. Special care was given to preserve the
bone, mucoperiostum and gingival tissues around the
crown. The patient returned two weeks later, after soft tis-
                                               iI
sue healing, and the elastomeric chain (60-90 g) was tied
with tension to the open coil (8). The patient was seen                 Figure 13. Post treatment intraoral photograph, frontal view.
every three weeks (Fig. 11).
                                   i         on
                                iz
               Ed
 IC




Figure 11. Intraoral frontal view of the orthodontic traction stages.


Once the impacted tooth had erupted, brackets were
C




placed on the upper arch and it was tied to an archwire
(0.016 x 0.022-in multibraid stainless steel) (Fig. 12).
Interim radiographs were requested to verify the root po-
sitioning.
©




Active treatment took 14 months to recovery delayed in-
cisor in dental arch. She is currently on routine patient re-
call. At the end of dentition the patient will be revaluated
for a second phase of treatment with fixed appliance.

Treatment results
The patient showed a good smile arch and balanced pro-
file (Figs. 13, 14).
The impacted maxillary right central incisor was brought                Figure 14. Post treatment extraoral photograph, smile view.

104                                                                                        Annali di Stomatologia 2012; III (3/4): 100-105
Impacted maxillary incisors: diagnosis and predictive measurements


into proper position. The final appearance of the tooth was          6.    Huber KL, Suri L, Taneja P. Eruption disturbances of the max-
esthetically pleasing, with gingival margins at the same                   illary incisors: a literature review 1: J Clin Pediatr Dent 2008;
level with similar clinical crowns sizes. The tooth re-                    32(3): 221-230.
sponded well to vitality and did not show abnormalities in           7.    Cozza P, Marino A, Laganà G. Interceptive managment of
                                                                           eruption disturbances: case report. J Clin Pediatr Dent 2004;
crown shape. From a periodontal point of view a band of
                                                                           29(1): 1-4.




                                                                                                         li
labial keratinized gingival measuring 4 mm was present,              8.    Chokron A, Reveret S, Salmon B. Vermelin L. Strategies for
and pocket depth ranged from 1 to 2 mm.                                    treating an impacted maxillary central incisor. Int Orthod




                                                                                                      na
The final radiographs indicated intact roots, proper root                  2010 Jun; 8(2): 152-176.
alignment, and no root disease.                                      9.    Smailiene D, Sidlauskas A, Bucinskiene J. Impaction of the
A skeletal class I (ANB T1:3°, T2:3°) was mantained. An                    central maxillary incisor associated with supernumerary
ideal overbite (T1: 3mm, T2: 2mm) and overjet (T1: 2mm,                    teeth: initial position and spontaneous eruption timing. Stom-
                                                                           atologija 2006; 8(4): 103-107.




                                                                                                   io
T2: 2mm) were established and a Class I molar and ca-
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                                                                           Child 1982 Sep-Oct; 49(5): 352-356.
T1: 108°, T2: 113°).




                                                                                                az
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                                                                                n
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                                                                             er
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                                               nt
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                                                                           tions in managing teeth exhibiting significant delay in erup-
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                                           on

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©




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Annali di Stomatologia 2012; III (3/4): 100-105                                                                                        105
