Impacted tooth is defined as an unerupted or partially erupted tooth so positioned that complete eruption is unlikely.1
The most commonly impacted teeth after the third molars are the maxillary canines with a prevalence of about 1.5%. Canines are most often impacted on the palatal aspect instead of buccally.2
The etiology of the impacted permanent teeth is multifactorial including polygenic causes as well. It is mostly associated with retained deciduous teeth, absent, malformed or diminutive lateral incisors, late developing dentition, tooth size/arch length discrepancy, ankylosis, dilacerations of roots and last but not the least, systemic causes.3,4,5
Impacted teeth may present multifaceted problems for the patient. The sequale of an impacted tooth may lead to root resorption of the adjacent teeth thereby jeopardizing the prognosis of the adjoining teeth. (14 %)5, cystic changes around the impacted tooth, dentigerous cyst for example.6 esthetic concerns, since the space in the dental arch will be unesthetic6, loss of arch length which further ahead might lead to occlusal disturbances7, mucosal perforation underneath a denture8, local infections9 and in some cases referred pain, etc.10
Orthodontist, Periodontist and the Pedodontist are the stake holders in the management of impacted teeth. The various steps of the treatment involves firstly the pedodontist giving an early diagnosis of impacted teeth. The orthodontist intervenes presurgically for creation of space and the periodontist for the surgical exposure of the tooth.
On history & clinical examination the teeth are usually palpable in the buccal vestibule 1-2 years before their eruption time.11,12 After the age of 10-11 years absence of palpable canines or other teeth accordingly in the sulcus should direct the clinician towards radiographic assessment. The radiographic examination12,13 include anterior occlusal and periapical radiographs, two periapicals, anterior occlusal (70-75 degree) and optical projection tomography (OPT).The advancement in the technology gives the clinician another option of a CBCT which would locate an impacted tooth precisely.13
This case series presents the cases of three patients undergoing surgical exposure of impacted maxillary central incisor and canine to facilitate the orthodontic treatment.
Case Report 1
A female patient aged 22 years was referred from the department of Orthodontics to the department of Periodontics, I.T.S Dental College, Hospital & Research Centre, Greater Noida for the surgical exposure of impacted maxillary right central incisor (11). The over retained primary tooth was extracted before intiating the orthodontic treatment.
On clinical examination, a bulge was palpable in the vestibule area mesial to the maxillary right lateral incisor. On radiographic examination i.e intraoral periapical view and occlusal view of the maxilla, an impacted maxillary central incisor could be noted on the right side.
After thorough clinical and radiographic examination, an apically positioned flap with ostectomy procedure was decided. The procedure was carried out by reflecting a full thickness flap which was displaced apically and sutured using 4-0 silk sutures. Suture removal was done 10 days post-operatively and an orthodontic bracket was placed on the exposed tooth. Initially a lingual button was bonded on the exposed tooth surface and ligated to archwire. Once the tooth started erupting and the 2/3rd of the crown was visible in the oral cavity, the MBT bracket was bonded at the ideal position. A light arch wire was fully ligated. On 6 months post-operativeexamination, the tooth had erupted completely into the oral cavity(Figures 1-6).
Figure 1 (A,B,C): Pre-operative view depicting the bulge of the impacted maxillary right central incisor (Case-1)
Figure 2: IOPA depicting the impacted maxillary right central incisor (Case 1)
Figure 3: Occlusal view radiograph (maxillary) depicting the impacted maxillary right central incisor (Case 1)
Figure 4: Immediate post-operative view of the exposed impacted tooth (Case 1)
Figure 5: Three months post-operative view showing partial extrusion of maxillaryright central incisor (Case 1)
Figure 6: Six months post-operative view showing erupted maxillary right central incisor (Case 1)
Case Report 2
A male patient aged 24 years was referred from the department of Orthodontics to the department of Periodontics, I.T.S Dental College, Hospital & Research Centre, Greater Noida for the surgical exposure of impacted canine (23). On clinical and radiographic examination, the maxillary left canine was found to be palatally impacted. On bone sounding, the crown of the tooth was found to be overlaid with bone plate. The treatment protocol decided was to reflect a full thickness flap along with osteoctomy for sufficient exposure of tooth surface. A soft tissue window was created using electrocautery (ART E 1 Electrosurge, BonART Co. Ltd, US) for exposure of the crown. The flap was sutured back into position. Ball attachment was placed on the exposed crown immediately after the surgery for applying the orthodontic forces (Figures 7-11).
Figure 7: Pre-operative view depicting the bulge of the impacted maxillary left canine(Case 2)
Figure 8: IOPA depicting the bulge of the impacted maxillary left canine (Case 2)
Figure 9: Mucoperiosteal flap reflected(Case 2)
Figure 10: Soft tissue window created using Electrocautery to expose the impacted teeth
Figure 11: 3 Months post-operative view showing partial extrusion of maxillary left canine (Case 2)
Case Report 3
A female patient aged 23 years was referred from the department of Orthodontics to the department of Periodontics, I.T.S Dental College, Hospital & Research Centre, Greater Noida for the surgical exposure of impacted maxillary and mandibular canines. On clinical examination, the bulge of the maxillaryand mandibular canines were palpable on the labial aspect. On radiographic examination, the patients CBCT revealed the soft tissue impaction of all the four canines. Accordingly a treatment plan was formulated and it was decided to create soft tissue window using diode laser. The laser (Dental diode laser-photon plus 10 watt, ZolarTM Technology &Mfg Co. Inc, Ontario, Canada) was set at a power setting of 1 Watt. Laser was used in pulsed, contact mode. The Orthodontic bracket was bonded immediately to the exposed tooth surface so as to prevent the soft tissue overgrowth. Active forces were applied 2 weeks postoperatively (Figures 12-15).
Figure 12: Pre operative view depicting the bulge of the impacted maxillary and mandibular canines (Case 3)
Figure 13: CBCT showing the exact position of the impacted maxillary and mandibular canines(Case 3)
Figure 14: Soft tissue window created using Diode Laser to expose the impacted maxillary right canine (Case 3)
Figure 15: Bracket attached for orthodontic therapy immediately after surgery(Case 3)