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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 10  |  Issue : 4  |  Page : 245-249

Surgical repositioning of the impacted permanent maxillary central incisor


Department of Pedodontics and Preventive Dentistry, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India

Date of Submission22-Oct-2019
Date of Acceptance20-Nov-2019
Date of Web Publication22-Jan-2020

Correspondence Address:
Dr. A J Sai Sankar
Department of Pedodontics and Preventive Dentistry, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh
India
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DOI: 10.4103/srmjrds.srmjrds_74_19

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  Abstract 

Clinically missing or unerupted permanent teeth manifest in early childhood itself, yet they may be misdiagnosed or left untreated due to the lack of knowledge or experience, which might have a major impact on facial esthetics and psychological aspect of the individual. Physical obstruction is the primary local cause for delayed tooth eruption. These obstacles can be due to the presence of supernumerary teeth, mucosal barrier, scar tissue, and tumors. The procurement of conventional radiographs is restricted with the advent of cone-beam computed tomography which is considered as a best tool in an localizing impacted tooth in the field of dentistry. The present case report depicts a 2-year follow-up of a horizontally impacted maxillary permanent central incisor associated with odontoma that was surgically reimplanted successfully.

Keywords: Cone-beam computed tomography, impacted teeth, odontoma, plasma-rich fibrin, reimplantation, repositioning


How to cite this article:
Hanisha A, Sai Sankar A J, Sridhar M, S.Krishna V S. Surgical repositioning of the impacted permanent maxillary central incisor. SRM J Res Dent Sci 2019;10:245-9

How to cite this URL:
Hanisha A, Sai Sankar A J, Sridhar M, S.Krishna V S. Surgical repositioning of the impacted permanent maxillary central incisor. SRM J Res Dent Sci [serial online] 2019 [cited 2020 Jul 3];10:245-9. Available from: http://www.srmjrds.in/text.asp?2019/10/4/245/276378


  Introduction Top


Missing/unerupted anterior teeth can have a major impact on dentofacial esthetics which influences the self-esteem and general social interaction of an individual. Delayed tooth eruption can be associated with various hereditary and environmental factors. Hereditary factors include supernumerary teeth, cleft lip and palate, cleidocranial dysostosis, odontomas, abnormal tooth/tissue ratio, and gingival fibromatosis, whereas environmental factors include trauma, early extraction or loss of deciduous teeth, retained deciduous teeth, cystic formation, endocrine abnormalities, and bone diseases. Odontomas occur more often in the permanent dentition than their predecessors.[1],[2] To improve the prognosis, early identification and management of odontoma is vital. The present case emphasizes the successful management of an impacted maxillary permanent central incisor associated with odontoma.


  Case Report Top


A 14-year-old male patient reported to the department of pedodontics and preventive dentistry with a chief complaint of small-sized upper front teeth. Family and medical histories were noncontributory and had no previous history of dental trauma. Intraoral hard-tissue examination revealed retained primary teeth (61 and 62), unerupted 21, and full normal complement of permanent teeth [Figure 1]. Initial intraoral periapical radiograph and orthopantomograph revealed the presence of an opaque calcified mass between the retained primary and the unerupted permanent central incisor. Occlusal radiograph unveiled the horizontal position of the impacted teeth, parallel to the palate with complete root formation. Subsequently, cone-beam computed tomography was advised to evaluate the precise size, location, and extent of the mass in relation to the unerupted permanent tooth [Figure 2]a [Figure 2]b [Figure 2]c [Figure 2]d [Figure 2]e. A provisional diagnosis of calcified mass measuring 22 mm × 13 mm associated with an impacted maxillary left permanent central incisor was made.
Figure 1: Frontal view showing retained and missing teeth

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Figure 2:(a) Intraoral periapical radiograph illustrating radiopaque mass in relation to 61 and 62. (b) Occlusal radiograph showing radiopaque mass with overlying impacted incisor. (c) Orthopantomograph demonstrating radiopaque mass with crown of impacted permanent incisor. (d and e) Cone-beam computed tomography showing calcified mass with overlying horizontally impacted maxillary left central incisor

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Considering the age of the patient and availability of space, extraction of retained deciduous teeth, removal of radiopaque mass followed by surgical reimplantation of the permanent central incisor was planned. After obtaining the parental consent, routine blood investigations were done before performing the procedure under local anesthesia. A trapezoidal mucoperiosteal flap was elevated extending from 11 to 22 and deroofing of the labial cortical plate which was present over the calcified mass was removed [Figure 3]a. Four calcified structures were recovered from the surgical site, and thorough debridement was carried out for the removal of any residue [Figure 3]b. The permanent central incisor was gently luxated and removed, and an intentional root canal therapy was performed by holding the tooth at the cementoenamel junction without damaging the periodontal tissue [Figure 3]c [Figure 3]d [Figure 3]e. Following the removal of retained primary teeth, the area was irrigated with a copious amount of saline and the tooth was gently repositioned into the socket without much manipulation. The large residual bony defect was packed with bone graft (OsteoGen, Impladent Ltd., Holliswood, NY, USA) which was mixed with plasma-rich fibrin (PRF) [Figure 3]f that was prepared from the patient's blood. After achieving hemostasis, the mucoperiosteal flap was sutured back in position and immediate flexible composite wire splint was designed to immobilize the reimplanted tooth [Figure 3]g. The patient was instructed regarding proper oral hygiene maintenance and intake of soft diet and kept under antibiotic coverage. Sutures were removed after 1 week; however, composite wire splint was secured for 3 weeks. Healing was uneventful at periodical recalls with a 2-year follow-up [Figure 4]a [Figure 4]b [Figure 4]c [Figure 4]d [Figure 4]e [Figure 4]f. The excised calcified mass was sent for histopathological examination. These decalcified sections revealed ghost cells along with spherical dystrophic calcification, enamel concretions, sheets of dysplastic dentin, minimal pulp tissue, and focal areas of cementum-like material with a connective tissue capsule similar to that of dental follicle [Figure 5] which was diagnosed as complex odontoma.
Figure 3:(a) Surgical exposure of calcified mass. (b) Excised calcified mass. (c) Surgical exposure of the permanent tooth. (d) Permanent incisor is luxated and extracted. (e) Root canal therapy was performed extraorally. (f) Packing of plasma-rich fibrin with bone graft in the residual bony defect. (g) Suturing and immobilization with composite wire splint

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Figure 4: (a and b) Postoperative clinical and radiographic follow-up after 1 week. (c and d) At 1-year follow-up. (e and f) During 2-year follow-up period

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Figure 5: Histological picture showing dentinoid-like material with minimal pulp tissue and focal areas showing cementum-like structures

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  Discussion Top


Odontomas, a hamartomatous malformation, occur due to abnormal proliferation of both epithelial and mesenchymal components of dental tissues.[3] The etiology of the odontoma is unknown, but it implicates to include a history of trauma during primary dentition, inflammatory/infectious processes, hereditary anomalies, odontoblastic hyperactivity, or alterations of the genetic components that are involved in monitoring tooth development.[4] The dental lamina which persist after tooth development sometimes may lead to formation of extra odontogenic epithelial cells which in turn lead to formation of odontome. Odontomas lead to pathologic alterations in the neighboring teeth such as devitalization, malformation, aplasia, malposition, embedded, or retained deciduous teeth. Ideally, odontomas should be removed with proper curettage of soft tissues enveloping them because they contain various tooth formulations that can predispose to cystic changes which interfere with tooth eruption and may cause considerable bone expansion. However, the possibility of recurrence is less if they are well encapsulated.[3]

Cone-beam computed tomography was preferred to localize impacted teeth in the maxillofacial region as it allows three-dimensional imaging with an undistorted view of the dentition, accurate localization of the impacted tooth, and visualization of associated structures with less imaging time, easy data transfer, and less scattered radiation.[5]

Timely intervention is mandatory in case of unerupted/impacted teeth to avoid complications such as cystic changes, resorption of adjacent teeth, space loss, and poor alignment of teeth. As there was no universal consensus on therapeutic approach for impacted teeth associated with odontomas, the decision depends on various factors such as the position of an impacted tooth, age of the patient, amount of root formation, and available space.[6] Orthodontic extrusion may be preferable to surgical repositioning in case of impacted teeth that lie in a favorable position. In the present case, as the root development was complete and the position of incisor was unfavorable for the placement of bracket to extrude it orthodontically, the option of intentional surgical reimplantation was planned and executed. Any atraumatically extracted tooth can be a potential candidate for intentional reimplantation due to the presence of viable periodontal ligament cells, which is crucial for postsurgical healing.[7] Apart from these, the extra oral time, pH and osmolality of the transporting media and gentle handling during the surgical manipulation are key for success.[6] In this case, the extraoral dry time was very short (15 min) with minimal socket manipulation that ensured the regeneration of its elements as well as healing of the bone and epithelial attachment.

Nonrigid splinting was used to stabilize the tooth, allowing normal physiologic tooth mobility that promotes fibrous instead of the osseous junction with the alveolar socket.[8]

PRF, a dense fibrin network, is osteoconductive and/or osteoinductive in nature, and it promotes angiogenesis as it has low thrombin level optimal for the migration of endothelial cells and fibroblasts. PRF also helps in facilitating adhesion and spreading of cells, regulates the gene expression of growth factors, growth factor receptors, and proteins, and determines the outcome of a cell response to growth factors due to the presence of collagen, fibronectin, elastin, other noncollagenous proteins, and proteoglycan in the extracellular matrix of PRF. It is superior to plasma-rich protein due to more physiologic architecture in bone formation favoring better healing and can be used in conjunction with bone grafts that aid in promoting hemostasis, wound healing, bone growth, and maturation. Clinical trials suggest this combination to enhance the density of the bone.[9],[10]

The positive outcome of this case during the 2-year follow-up can be attributed to the absence of clinical symptoms such as lack of woody dullness on percussion, spontaneous eruption of the reimplanted tooth, and absence of pathological radiographic findings. It was suggested that the risk of root resorption significantly reduces after the first 2 years of reimplantation which adds to the success of the present case.[11] Various factors such as age of the patient (better healing ability), good oral hygiene maintenance, completed root formation, less extraoral time, sufficient space available, minimal manipulation of the reimplanted tooth, and use of PRF with bone graft and splint that allowed physiologic mobility can be credited for the favorable outcome.

Further, to improve the esthetics of the patient, orthodontic intervention for proper alignment of the reimplanted tooth followed by gingival contouring and prosthetic rehabilitation was planned.


  Conclusion Top


Clinical experience and dental literature suggest that radiographic examination should be performed for any pediatric patient who presents with clinical evidence of delayed/unerupted permanent tooth or retained deciduous teeth with or without a previous history of dental trauma. Dentists should be aware and have adequate knowledge about these conditions for early diagnosis and timely management to avoid further complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Yaqoob O, Neill JO, Gregg T. Management of unerupted maxillary incisors. Available from: http://www.rcseng.ac.uk/fds/ publicationsclinicalguidelines/clinicalguidelines/documents/ ManMaxIncisors. 2010.pdf. [Last accessed on 2012 Jun 18].  Back to cited text no. 1
    
2.
Nuvvula S, Pavuluri C, Mohapatra A, Nirmala SV. Atypical presentation of bilateral supplemental maxillary central incisors with unusual talon cusp. J Indian Soc Pedod Prev Dent 2011;29:149-54.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Chaudhari NT, Sharma NK, Kanodia DR, Sethy SK. Compound composite odontoma: Two case reports and its review J Oral Med Oral Surgery Oral Pathol Radiol 2015;1:83-8.  Back to cited text no. 3
    
4.
Satish V, Prabhadevi MC, Sharma R. Odontome: A Brief Overview. Int J Clin Pediatr Dent 2011;4:177-85.  Back to cited text no. 4
    
5.
Nematolahi H, Abadi H, Mohammadzade Z, Soofiani Ghadim M. The use of cone beam computed tomography (CBCT) to determine supernumerary and impacted teeth position in pediatric patients: A case report. J Dent Res Dent Clin Dent Prospects 2013;7:47-50.  Back to cited text no. 5
    
6.
Agrait EM, Levy D, Gil M, Singh GD. Repositioning an inverted maxillary central incisor using a combination of replantation and orthodontic movement: A clinical case report. Pediatr Dent 2003;25:157-60.  Back to cited text no. 6
    
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Narayan GS, Sripal R, Ashok BV, Venkatesan SM, Indra R. Intentional reimplantation of impacted maxillary permanent central incisor associated with compound odontoma – A case report J Sci Dent 2012;2:51-5.  Back to cited text no. 7
    
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Verma SL, Sharma VP, Singh GP. Management of a transmigrated mandibular canine. J Orthod Sci 2012;1:23-8.  Back to cited text no. 8
    
9.
Saluja H, Dehane V, Mahindra U. Platelet-Rich fibrin: A second generation platelet concentrate and a new friend of oral and maxillofacial surgeons. Ann Maxillofac Surg 2011;1:53-7.  Back to cited text no. 9
    
10.
Chandran P, Sivadas A. Platelet rich fibrin: Its role in periodontal regeneration. The Saudi J Dent Res 2014;5:117-22.  Back to cited text no. 10
    
11.
Sardana D, Goyal A, Gauba K. Delayed replantation of avulsed tooth with 15-hours extra-oral time: 3-year follow-up. Singapore Dent J 2014;35:71-6.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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Discussion
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