Surgical management of AN inverted AND impacted maxillary central incisor - case report

Abstract

Impacted maxillary permanent central incisor is not a frequently reported case in our dental practice. Dilaceration is one of the causes of failure of eruption of permanent maxillary incisor. It is a developmental anomaly of the form of a tooth that commonly occurs in permanent incisors .We report a case of a 14-year-old boy with an impacted central incisor in the maxillary region managed at Dr.H.Gordon Roberts’s hospital, Meghalaya, India. The tooth was completely upside down with the crown facing towards the nasal floor and the root towards the alveolar process with severe dilaceration. Surgical removal of the impacted central incisor was performed under local anesthesia without disturbing the floor of the nose.

Introduction

Impacted maxillary central incisors have a major effect on the dental and facial aesthetics of an individual. The impaction of the maxillary central incisor is uncommon and only few cases have been reported 1.The order of frequency of the impacted teeth are mandibular 3rd molar, maxillary 3rd molar, maxillary cuspid, mandibular cuspid, mandibular premolar, maxillary premolar and maxillary central and lateral incisors 2 .The impaction of maxillary incisors can be classified into labially impacted incisors, palatally impacted incisors and vertically impacted incisors3. The subdivisions under labially impacted incisors are labially inclined, labially horizontal and labially inverted. The subdivisions under impacted palatal incisors are palatally inclined and palatally horizontal 3. The treatment for impacted maxillary central incisors is surgical removal followed by a bridge or implant, surgical exposure and orthodontic traction of the impacted central incisor into proper position4. The objective of this case report is to highlight an uncommon condition.

Case Reports

A 14-year old boy reported to our maxillofacial surgery outpatient department with the complaint of painful swelling in the upper anterior front teeth region. Intra oral examination showed that the permanent central incisor on the right side was missing with no history of previous extraction. The swelling was firm, tender and measured 2x1cm and extending from the left central incisor to the right lateral incisor. An intra-oral periapical radiograph showed an impacted right central incisor [Figure2]. A panoramic radiograph revealed the presence of an inverted and impacted maxillary right central incisor with the crown facing the floor of the nose while the root was facing the alveolar process and there were multiple unerupted permanent teeth [Figure1]. Orthodontic management was difficult to perform because of the unusual pattern and the morphology of the impacted central incisor, so surgical removal of the tooth was prescribed. Surgical removal of the impacted central incisor after informed consent was done under local anesthesia without disturbing the floor of the nose [Figure3, Figure4, Figure5]. The dilaceration of the impacted tooth was not noticed in the panoramic radiograph. The reflected mucoperiosteal flap was then closed with 3-0 vicryl and there was no oronasal communication.

Figure 2. localized radiograph showing inverted and impacted maxillary central incisor.

Figure 1. Panoramic radiograph showing multiple unerupted teeth.

Figure 3. Intraoperative photograph.

Figure 4. Exposed central incisor.

Figure 5. Surgically removed dilacerated tooth.

Discussion

The occurrence of impacted maxillary incisors can be associated with hereditary and environmental factors. The maxillary incisors have a major role on dental and facial aesthetics of an individual. The impacted maxillary permanent central incisor with dilacerations is uncommon. Nevill 5 conducted a review of 1166 randomly selected patients; among these patients, 176 dilacerated teeth were identified. The most commonly affected teeth were mandibular third molars, followed by maxillary second premolars and mandibular second molars. Of these teeth, maxillary and mandibular central and lateral incisors are the least frequently affected representing approximately 1% of the series5. Depending on the type of impaction and degree of dilaceration, a number of treatment options had been recommended. The treatment of an unerupted tooth will depend on its position, morphology and presence of enough space in the dental arch6. Surgical exposure and moving the impacted tooth into normal occlusion with light force orthodontic traction is well accepted with good outcome; the other treatment option is surgical removal followed by bridge or implants.

If the trauma occurs while the crown of the permanent tooth is forming, enamel formation will be disturbed and there will be a defect in the crown of the permanent tooth7. However, if the trauma occurred after the crown formation, the crown could be displaced relative to the root. Root formation might stop, leaving a permanently shortened root. More frequently, however, root formation continues, but the remaining portion of the root then forms at an angle to the traumatically displaced crown. If distortion of root position was severe enough, it would be difficult for the crown to assume its proper position7. The crown is usually dislocated forward with the palatal surface facing the vestibular site; the incisor border is turned up towards the anterior nasal bone while the root remains in its normal position. The curve or bend could occur anywhere along the length of root, depending on the amount of root formed when the injury occurred8.

Surgical exposure followed by orthodontic treatment is the treatment of choice in many cases9 ; however an inverted and impacted tooth with severe dilacerated root as in the index case was better removed surgically. Surgical exposure followed by orthodontic treatment is associated with technical difficulties especially in exposure and orthodontic alignment of such malformed teeth10. Severely dilacerated root is a surgical challenge for maxillofacial surgeons as the risk of root fracture is high. In our present case, surgical removal of the impacted maxillary central incisor was done under local anaesthesia. Utmost care was given during bone removal and elevation of the tooth. The tooth was not sectioned to prevent risk of root displacement during elevation of crown portion.

Conclusions

In conclusion, the surgical management of an inverted impacted tooth pose clear challenges to the maxillofacial surgeon and the simple alternative with good outcome is tooth extraction.