Monday, April 27, 2015

Correction of an Impacted and Severely Displaced Central Incisor in an 8 Year Old Patient

This patient (8 years old) presented to our practice after referral from their dentist after it was discovered that his upper left central incisor was displaced severely and would not erupt due to the presence of two supernumerary teeth (extra teeth) in the same region.

The initial panoramic radiograph shows the central incisor crown tipped up toward the nose and one of the developing supernumerary teeth is circled. The other had already been removed previously. Supernumerary incisors in the maxilla (upper jaw) are actually fairly common and are called mesiodens if in the region of the central incisors.

The initial cephalometric radiograph cleary shows just how far the extra tooth's development pushed the central incisor out of position.

To correct this problem and bring the impacted central incisor into position, we placed limited braces along with a transpalatal arch bar and referred him to an oral surgeon to attach a button and gold chain to the impacted incisor. The button and chain allow the orthodontist to gradually guide the tooth in by applying orthodontic traction in desired directions periodically. The surgeon determined that the extra tooth was too close to the incisor needing to be moved so he wanted to perform a second surgery later to remove the extra tooth once there would be minimal risk of damage to adjacent teeth.

The following photo is following the surgery with our orthodontic appliances in place:

We started seeing him once per month to apply orthodontic traction with an elastic thread usually and gradually bring the tooth in. The discomfort associated with activation is usually minimal and lasts for just a few minutes. The patient did great at every appointment.

This panoramic radiograph shows the attachment of the gold chain to the lingual (backside of the tooth):

The next progress panoramic radiograph shows the position of the central incisor after 6 months of activation. The supernumerary tooth is much more visible also, so it was decided that it was time for a second visit to the oral surgeon to now remove the extra tooth safely now that the central was not so close and move the button from the underside of the tooth to the more ideal position on the front side of the tooth:

Here is the tooth 10 months after starting traction with the button now on the facial but still a lot of root movement needed to get the tooth into the right angulation:

And finally here is the final photo and panoramic radiograph. The central incisor has good root form and is fully vital making the case a great success. We are currently giving him a little break and will start his comprehensive orthodontic treatment with full braces once the rest of his permanent teeth finish erupting to ideally align all teeth, even the vertical position of the central incisors a little better and perfect his bite. Needless to say he was very excited to have that front tooth finally!