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CLINICIAN'S CORNER
Esthetic periodontal surgery for impacteddilacerated maxillary central incisors
Yu-Ju Wei,a Yi-Chun Lin,b Shou-Shin Kaung,c Shue-Fen Yang,d Shyh-Yuan Lee,e and Yu-Lin Laif
Tapei, Taiwan
FromTaiwaaFellobSeniocChairdChaiNatioeChairDentifChairNatioReprinGenere-maiSubm0889-Copyrhttp:/
546
Clinicians do not frequently see impacted dilacerated maxillary incisors in their patients. When they do, thereare several diagnostic and management challenges for correcting root dilacerations. An unfavorable estheticoutcome might occur as a result of soft-tissue complications during surgical eruption procedures. We present2 patients with an impacted and dilacerated maxillary central incisor. Computed tomography scans with3-dimensional reformation were used to accurately assess the positions of the dilacerated teeth, the degreeof dilaceration, and the stage of root formation. The therapy primarily involved 2-stage crown exposure surgerycombined with orthodontic traction. An apicoectomy was performed on 1 dilacerated tooth; the other exhibitedpulp vitality. This article highlights the periodontal surgical strategies for the esthetic management of invertedcrowns. Through periodontal plastic surgery and interdisciplinary cooperation, the impacted dilacerated centralincisors were properly aligned, and successful esthetic results were achieved. (Am J Orthod Dentofacial Orthop2012;142:546-51)
Tooth dilaceration is a dental anomaly manifestedby a sharp angulation of the longitudinal axisof a tooth. Maxillary incisor dilaceration is rela-
tively rare and estimated to occur in up to 1% of allpermanent dentitions.1-3 The dilacerated root can curvein a labiolingual or mesiodistal direction. The mostcommon orientation of a dilacerated maxillary incisor iswith the crown directed upward and labially.4,5
Therefore, surgical exposure and orthodontic forcederuption of impacted dilacerated incisors areparticularly challenging because the dilacerated toothcan erupt in an awkward position. Moreover, thecurved root can affect adjacent teeth6 or penetratethe labial cortical plate with sequelae of pulpal andperiapical problems.7
the Department of Stomatology, Taipei Veterans General Hospital, Taipei,n.w, Division of Periodontology.r instructor, Division of Periodontology.person, Division of Orthodontics.rperson, Division of Endodontics; associate professor, School of Dentistry,nal Yang-Ming University, Taipei, Taiwan.person, Division of General Dentistry; professor and dean, School ofstry, National Yang-Ming University, Taipei, Taiwan.person, Division of Periodontology; professor, School of Dentistry,nal Yang-Ming University, Taipei, Taiwan.t requests to: Yu-Lin Lai, Department of Stomatology, Taipei Veteransal Hospital, No 201, Sec 2, Shih-Pai Rd, Shih-Pai, Taipei, Taiwan 11217;l, [email protected], May 2011; revised and accepted, July 2011.5406/$36.00ight � 2012 by the American Association of Orthodontists./dx.doi.org/10.1016/j.ajodo.2011.07.028
Although previous reports showed successful realign-ment of such teeth, unesthetic gingival contours of theexposed incisors might occur if periodontal problemsare not properly managed. However, there is only a lim-ited amount of illustrated literature on the soft-tissuemanagement of impacted dilacerated incisors. The pur-pose of this article is to report the periodontal surgicalstrategies for the esthetic management of 2 patientswith an impacted dilacerated maxillary central incisor.Comprehensive plans and treatment procedures weredeveloped, and successful results were obtained withthe cooperation of various specialists.
CASE REPORTS
Patient 1, an 8-year-old girl with a complaint of de-layed eruption of the maxillary left central permanentincisor, was referred to the Department of Orthodonticsat Taipei Veterans General Hospital in Taiwan. She wasphysically healthy and had no history of dental trauma.She had an Angle Class I occlusion, with an overjet of7 mm and an overbite of 3 mm. The maxillary left centralpermanent incisor was unerupted, and the adjacent teethhad migrated into this unoccupied space (Fig 1, A).The periapical radiograph showed that the maxillaryleft central permanent incisor was impacted, andthe crown edge was directed upward (Fig 1, B). The3-dimensional reformatted computed tomographyimages showed that the dilacerated incisor with thecrown had rotated about 90�, its incisal tip was just
Fig 1. Pretreatment records of an 8-year-old girl with anunerupted maxillary left central incisor: A, intraoral photo-graph; B, periapical radiograph of the tooth.
Fig 2. Computed tomography: A, dilacerated tooth witha crown-root angle of about 90�; B, complete rootformation of the dilacerated tooth (arrow).
Wei et al 547
below the floor of the nasal cavity, and its root formationwas almost complete (Fig 2).
Our treatment plan involved surgical exposure andorthodontic eruption of the dilacerated tooth. Becauseof the severity of the dilacerated incisor root, the pa-tient’s parents were informed that an apicoectomyduring the tooth traction might be needed. After spaceredistribution and recreation of adequate space for thedilacerated incisor, surgical exposure with a closed-eruption technique was performed. An incision wasmade on the labial surface in the maxillary left central in-cisor region, and the flap was raised. A lingual buttonwith a presecured ligature wire was bonded to the palatalsurface of the exposed crown, which faced the oral cavity(Fig 3, A). The flap was repositioned and closed withsutures (Fig 3, B). A ligature wire was tied to the mainarchwire with an elastic thread. The soft tissues healedin 2 weeks, after which traction of the impacted incisorbegan.
The incisal edge of the impacted incisor was extrudedoutside the alveolar mucosa 4 months after tooth erup-tion, resulting in no keratinized tissue on the labial sideof the crown (Fig 4, A). To augment the keratinizedmucosa, periodontal plastic surgery by using a doublepapilla flap from the interdental area of the adjacentteeth was performed (Fig 4, B). In the meantime, the lin-gual button was replaced with a bracket bonded to thelabial side of the crown, and traction was continuedwith an 0.018 3 0.022-in stainless steel wire. The rootapex of the dilacerated incisor could be palpated justunder the alveolar mucosa (Fig 5, A) 3 months after sur-gery, and the patient complained of discomfort in thisarea. This tooth exhibited percussion pain and negativeresponses to the cavity test. The patient was transferredto the endodontist for root canal treatment and anapicoectomy with mineral trioxide aggregate retrogradefilling (Fig 5, B and C). Orthodontic treatment wasrestarted 2 months later, and the impacted incisor was
American Journal of Orthodontics and Dentofacial Orthoped
then moved into a normal position. Total treatmenttime was about 19 months.
Through a 2-stage crown exposure surgery, the im-pacted maxillary left central incisor was successfullyprotracted into proper alignment with an acceptablegingival contour. The width of the keratinized gingivawas 3 mm (Fig 6, A). A posttreatment radiograph1 year later showed no specific pathology of the toothor its periapical tissue (Fig 6, B).
Patient 2, an 8-year-old girl, was referred for ortho-dontic consultation regarding an unerupted maxillaryleft central permanent incisor. She had experiencedtrauma in the maxillary deciduous incisor region at theage of 4 or 5 years.
The clinical examination showed that she had mixeddentition, with an Angle Class II molar relationship anda maxillary dental midline that deviated to the left side.A severe space deficiency in the bimaxillary arch wasalso noted. Overjet was 4 mm, and overbite was 5 mm(Fig 7, A). A periapical radiograph showed that themaxillary left central incisor was impacted (Fig 7, B). Acomputed tomography scan showed that the dilaceratedincisor had a crown-root angle of 120�, with less thanone-third of normal root formation (Fig 8).
The treatment objectives for this patient were toextrude the impacted dilacerated incisor to a proper po-sition and to resume root development of the impactedincisor because its root apex was still open. The patienthad a combined surgical and orthodontic approach toalign the impacted dilacerated incisor after reestablish-ing the space. A crestal incision and 2 vertical incisionswere made to expose the impacted tooth. A labial flapwas raised, and the lingual button with 2 presecuredligature wires was bonded to the palatal surface of thecrown (Fig 9, A). The flap was replaced and sutured(Fig 9, B). The ligature wires were tied to the mainarchwire, and the impacted incisor was extruded afterremoving the stitches.
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Fig 3. Surgical exposure with a closed-eruption technique: A, lingual button placed over the impactedtooth; B, after repositioning and suturing.
Fig 4. A, Incisal edge of the tooth extruded outside the alveolar mucosa 4 months postoperatively; B,a double papilla flap to increase the keratinized gingiva.
Fig 5. A, Apex of the labially protruded dilacerated incisor; B, elevated flap and root apex penetratingthe labial cortical plate; C, apicoectomy and mineral trioxide aggregate retrograde filling.
Fig 6. Posttreatment records: A, intraoral photographshows that the teeth were properly aligned and the gin-giva was harmonious; B, radiograph shows no periapicalpathology of the left central incisor.
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The lingual button placed on the impacted incisorwas extruded outside the alveolar mucosa (Fig 10, A)within 3 months of the operation. An apically positionedflap was used to increase the keratinized gingiva. At thesame time, another lingual button was bonded to thelabial side of the crown (Fig 10, B). A palatal tractionforce was applied after removing the stitches. The im-pacted incisor had smoothly reached its normal level inthe arch by 1 year later. The labial gingival marginwith scar tissue was noted (Fig 10, C), and gingivoplastywith electrosurgery was performed. The second phase oforthodontic treatment for full dentition alignment wascompleted within 3 years.
After finishing the full-mouth orthodontic treatment,the entire dentition was properly aligned with adequate
Journal of Orthodontics and Dentofacial Orthopedics
Fig 7. Pretreatment records of an 8-year-old girl with anunerupted maxillary left central incisor: A, intraoral photo-graph; B, periapical radiograph.
Fig 8. Computed tomography: A, dilacerated tooth witha crown-root angle of about 120�; B, incomplete rootformation (arrow).
Wei et al 549
and harmonious gingivae around the maxillary anteriorarea (Fig 11, A). The radiographic examination showedthe continuation of root development without pulpobliteration or root resorption of the erupted incisor(Fig 11, B).
DISCUSSION
For a critical diagnosis of an impacted dilaceratedtooth, the traditional radiographic examinations (peri-apical, cephalometric, and panoramic) are not alwayssufficient because of the limitations associated withtheir 2-dimensional information. In these 2 patients,computed tomography scans with 3-dimensionalreformations were used to evaluate the positions of theimpacted teeth, the degree of root formation, and the cur-vature and direction of the dilacerated root in 3 dimen-sions.8-10 Clear and detailed images provided importantinformation for diagnosis and comprehensive planningfor delivering excellent care in difficult cases.
Management of an unerupted dilacerated maxillarycentral incisor can include a broad range of options,from passive observation to surgical exposure withorthodontic traction,5,7,11-15 autotransplantation,16,17
or an aggressive decision to extract the tooth.18,19
American Journal of Orthodontics and Dentofacial Orthoped
Surgical exposure followed by orthodontic traction isthe most widely adopted way to save such teeth.However, it is challenging to deal with the forcederuption of a dilacerated tooth, since there is a chanceof failure because of ankylosis, external root resorption,or loss of attachment.20 The curved root tip might perfo-rate the labial cortical plate or touch the adjacent rootsurfaces during tooth movement.5,7 The dilaceratedtooth can erupt in an inappropriate position witha compromised esthetic result. The successful treatmentof an impacted dilacerated tooth is thought to dependon the stage of root formation, the degree ofdilaceration, and the position of the tooth.14,15,20 Bothof these patients were referred at 8 years of age. Theaccessibility of orthodontic traction between the2 patients was not similar because of differences indilaceration and development of the roots. Patient 1had a dilacerated root at a right angle, and rootformation was almost complete. During the toothtraction, the curved apex penetrated the labial corticalplate, resulting in pulpal necrosis. An apicoectomy wastherefore performed. After removing the curved roottip, ideal tooth alignment was subsequently achieved.In patient 2, orthodontic traction of the impactedtooth was initiated at the beginning of root formation;this allowed the tooth to change direction duringgrowth. Root formation continued during orthodontictooth movement, and a proper spatial relationshipwith the newly aligned crown ultimately developed.
Surgical management of an impacted tooth is con-sidered the key to achieving desirable esthetic results.There are 3 common techniques for exposing uneruptedteeth: window excision of soft tissues, an apicallypositioned flap, and a closed-eruption technique. Thewindow approach might lead to gingival scarring or in-crease the clinical crown length.21 An apically positionedflap is usually used to preserve keratinized tissue, but it isnot applicable for highly impacted cases.22 The closed-eruption technique was therefore adopted for thesepatients. However, the incisal edges of the invertedcrowns in both patients were highly located near thefloor of the nasal cavity and outside the alveolarenvelope. It is difficult to erupt such teeth through themidcrestal area by using only lingual button orthodonticattachments.
During orthodontic repositioning of the teeth, thecrown portions of both impacted teeth were exposednear the level of the mucogingival junction, resultingin limited keratinized gingivae around the labial surfacesof the crowns. For esthetic reasons, both patients re-ceived secondary periodontal plastic surgery. Techniquesfor gingival augmentation of the exposed crown includea free gingival graft and various sliding-flap procedures.
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Fig 9. Surgical exposure of the tooth: A, lingual button in place and ligature wires attached; B, the flapafter repositioning and suturing.
Fig 10. Postoperative records after 3months:A, lingual button tracked outside the alveolar mucosa;B,apically positioned flap to increase the keratinized gingiva; C, tooth eruption and gingival scarringnoted.
Fig 11. After the second stage of orthodontic treatment:A, intraoral photo shows that the teeth were properlyaligned;B, radiograph shows that themaxillary left centralincisor had continuous root development.
550 Wei et al
The free gingival graft results in an unesthetic “patch-like” appearance and is contraindicated in the estheticregion, whereas the pedicle-flap technique, consistingof an apically positioned flap, a laterally positionedflap, and a double papilla flap, usually provides idealcolor and texture matches to the adjacent gingivaeand is therefore considered for such patients. Theamount of keratinized gingivae surrounding the ex-posed crown, the location of the incisal edge of theinverted crown, and its relationship to the mucogingivaljunction will determine the appropriate flap technique.Patient 1, with minimal keratinized mucosa coronal to
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the exposed crown, was treated with a double papillaflap elevated from the interdental area of the adjacentteeth, and patient 2 was successfully treated with anadditional apically positioned flap. As a result, bothpatients had adequate and harmonious gingivae at thelabial surfaces of the maxillary anterior teeth.
CONCLUSIONS
Treatment of impacted dilacerated maxillary centralincisors is a clinical challenge. This article highlightsthe importance of soft-tissue management and elabo-rates on the periodontal surgical strategies for theesthetic treatment of inverted dilacerated crowns. Thecase reports show that computed tomography scanswith 3-dimensional reformation offer valuable informa-tion to evaluate root dilaceration in 3 dimensions, andthat multidisciplinary cooperation, with careful assess-ment, early intervention, and appropriate soft-tissuemanagement, secures optimal outcomes.
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