A Modified Palatal Appliance for Forced Eruption of Impacted Central Incisor

A Modified Palatal Appliance for Forced Eruption of Impacted

Central Incisor

Kiyoshi Tai*/Je-won Shin**/Jae Hyun Park***/Yasumori Sato****

A 9-year-old female was referred by her general dentist for an evaluation of an impacted maxillary left central
incisor. Her maxillary left primary incisors showed crossbites and her right central incisor showed an edge-
to-edge bite which caused gingival recession on the mandibular right central incisor. After treatment, the
impacted maxillary central incisor erupted successfully. An optimal overbite and overjet were also achieved,
and her gingival recession was improved.

Keywords: Impacted central incisor, a modified palatal appliance, forced eruption

INTRODUCTION

I
mpaction is defined as the condition where a tooth fails to erupt
into the dental arch and where it has no potential to erupt. While
the incidence of permanent tooth impaction in the dental arch
is relatively common, the prevalence of maxillary central incisor
impaction is relatively rare, only from 0.06% to 0.2% in the general
population.1 The etiology of an impacted maxillary central incisor is
multifactorial, involving both hereditary and environmental factors
such as a lack of space, ankylosis, cysts, supernumerary teeth, cleft
palate, and trauma.2 Both missing and impacted maxillary incisors
have a negative impact on dental esthetics and create the potential
for speech difficulties and aberrant tongue posture. Moreover, the
possibility for promoting psychological problems is present, not
* Kiyoshi Tai, DDS, PhD, Visiting adjunct professor, Postgraduate Ortho- only for the patient but for the parents as well. Accordingly, early
dontic Program, Arizona School of Dentistry & Oral Health, Mesa, diagnosis and interceptive treatment is critical to addressing these
AZ, adjunct assistant professor, Graduate School of Dentistry, Kyung issues with optimal esthetic and functional outcomes. The following
Hee University, Seoul, South Korea, and private practice of orthodon- case is of a young girl who had an impacted central incisor that was
tics, Okayama, Japan.
treated with a modified Nance appliance with an extended arm.
**Je-won Shin, DMD, MSD, PhD, Professor and chair, Department of Oral
Anatomy and Developmental Biology, School of Dentistry, Kyung
Hee University, Seoul, Korea.
Clinical Case
***Jae Hyun Park, DMD, MSD, MS, PhD, Professor and chair, Postgrad- A 9-year-old female was referred by her general dentist for an
uate Orthodontic Program, Arizona School of Dentistry & Oral Health, evaluation of an impacted left central incisor. Medical history was
A.T. Still University, Mesa, USA and international scholar, Graduate not remarkable. An intraoral clinical examination exhibited that she
School of Dentistry, Kyung Hee University, Seoul, South Korea. was in the early mixed dentition stage with delayed eruption of her
****Yasumori Sato, DDS, PhD, Private practice of orthodontics, Okayama,
maxillary left central and lateral incisors. She presented a Class I
Japan.
molar relationship on both sides. Her maxillary left primary incisor
Send all correspondence to: exhibited a crossbite and her right central incisor presented an edge
Jae Hyun Park, DMD, MSD, MS, PhD, Postgraduate Orthodontic Program, to edge bite which caused gingival recession on the mandibular
Arizona School of Dentistry & Oral Health, A.T. Still University, 5835 East right central incisor. Her maxillary dental midline was deviated by
Still Circle, Mesa, AZ 85206; approximately 1 mm to the left (Fig. 1).
E-mail: [email protected].

424 doi 10.17796/1053-4625-43.6.11 The Journal of Clinical Pediatric Dentistry Volume 43, Number 6/2019
 A Modified Palatal Appliance for Forced Eruption of Impacted Central Incisor

Fig. 1 Pre-treatment facial and intraoral photographs.

Figure 1.
Figure 1.

A panoramic radiograph showed a supernumerary tooth located maxillary left canine. Cephalometric analysis revealed a skeletal
on the coronal portion of her maxillary left central incisor. The Class I (ANB: 0.9°) with hypodivergent growth pattern (SN-MP:
maxillary left lateral incisor overlapped the left canine. From a 26.5°). Her maxillary right incisor was slightly retroclined (U1 to
cone-beam computed tomography (CBCT) image, the supernu- SN: 102.2°) and mandibular incisors showed proclination (IMPA:
merary tooth was located on the lingual side of the impacted central 105.7°) (Fig. 2 and Table).
incisor and the lateral incisor was located on the palatal side of the

Fig. 2 Pre-treatment radiographs.

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A Modified Palatal Appliance for Forced Eruption of Impacted Central Incisor

Table.1 Cephalometric measurements

Measurement Japanese norm Pre-treatment Post-treatment 2y-Retention

SNA (°) 82.0 79.7 79.2 77.9
SNB (°) 80.0 78.9 78.0 77.1
ANB (°) 2.0 0.9 1.2 0.9
Wits (mm) 1.1 -4.2 -2.8 -1.7
SN–MP (°) 34.0 26.5 28.6 28.4
FH–MP (°) 28.2 22.0 22.7 21.9
LFH(ANS-Me/N-Me)(%) 55.0 58.2 55.0 53.8
U1–SN (°) 104.0 102.2 108.6 107.1
U1–NA (°) 22.0 22.5 29.4 29.2
IMPA (°) 90.0 105.7 97.8 99.9
L1–NB (°) 25.0 31.0 24.4 23.8
U1/L1 (°) 124.0 125.6 125.0 126.2
Upper lip to E-plane (mm) 1.2 -3.0 -3.1 -4.5
Lower lip to E-plane (mm) 2.0 -1.8 -1.9 -2.8

Treatment Progress appliances with a 0.014-in nickel-titanium archwire. After leveling

Early diagnosis is crucial for scheduling the best time to start and aligning, an 0.018-in stainless wire with open coil spring was
treatment to allow for normal eruption of permanent teeth by used to gain space for the lingually displaced maxillary left lateral
extraction with retained primary and supernumerary teeth.3 The incisor. To control the torque, the maxillary left lateral incisor was
treatment objectives in this case were to monitor the eruption of the bonded upside down. To align the maxillary left central and lateral
permanent teeth and extract the supernumerary tooth and remaining incisors and to control the torque of the teeth, an auxiliary wire was
primary teeth in order to facilitate normal eruption of the permanent engaged to the vertical slots of the teeth (Figs. 4-7). After 3 months,
teeth to thus obtain optimal overbite and overjet. the torque was controlled and the fixed orthodontic appliances were
The supernumerary tooth near the central incisor was extracted debonded. Fixed retainers were placed in the mandibular arch from
to clear a path for eruption. To bring the impacted central incisor to canine to canine and in the maxillary arch from lateral incisor to
the occlusal plane, a modified Nance appliance with an extended arm lateral incisor after debonding. Wraparound removable retainers
was used for forced eruption (Fig. 3). Approximately one year later, were delivered in both arches to achieve long-term stability of the
the impacted tooth erupted and tip-edge brackets (TP Orthodon- successful tooth movement. Total treatment time for this patient was
tics, LaPorte, Ind) were bonded with 0.022 X 0.028-in preadjusted 19 months (Fig. 8).

Fig. 3 Progress intraoral photographs showing the modified Nance appliance with an extended arm.

Figure 3.
426 doi 10.17796/1053-4625-43.6.6 The Journal of Clinical Pediatric Dentistry Volume 43, Number 6/2019
Figure 3.
 A Modified Palatal Appliance for Forced Eruption of Impacted Central Incisor

Fig. 4 Progress intraoral photographs showing the lingually displaced maxillary left lateral incisor. The patient’s fixed orthodontic
treatment started when she was 10 years and 5 months old.

Figure 4.

Fig. 5 Progress intraoral photographs after 6 months of treatment.

Figure 4.

Figure 5.

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A Modified Palatal Appliance for Forced Eruption of Impacted Central Incisor

Fig. 6 Progress intraoral photographs after 16 months of treatment.

Figure 6.
Fig. 7 Auxiliary torquing spring (0.016-in Australian wire) to Treatment Results
control the root movements of central and lateral
Post-treatment records revealed that the treatment objec-
incisors.
tives were achieved. Facial photographs showed improved smile
esthetics. The Class I molar relationships were maintained and Class
Figure 6. I canine relationship was accomplished. An optimal overbite and
overjet were also achieved (Fig. 8).
A post-treatment panoramic radiograph showed acceptable root
parallelism except for a dilacerated maxillary left lateral incisor.
There were no significant signs of bone resorption and the anterior
teeth demonstrated no signs of significant apical root resorption.
The patient’s third molars were developing except for the mandib-
ular right third molar. Post-treatment lateral cephalometric analysis
and superimposition revealed no significant skeletal changes (ANB:
1.2°) and her mandibular plane was slightly increased (SN-MP:
28.6°). Compared with pre-treatment, the maxillary incisors were
proclined (U1-SN: 108.6°) and the mandibular incisors were retro-
clined (IMPA: 97.8°). (Figs. 9 and 10, and Table). At the 2-year
follow-up, the patient had stable occlusion and the results of the
Figure 7. orthodontic treatment were maintained (Figs. 11 and 12).

428 doi 10.17796/1053-4625-43.6.6 The Journal of Clinical Pediatric Dentistry Volume 43, Number 6/2019
 A Modified Palatal Appliance for Forced Eruption of Impacted Central Incisor

Fig. 8 Post-treatment facial and intraoral photographs.

Figure 8.
Figure 8.
Fig. 9 Post-treatment radiographs.

Figure 9.

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A Modified Palatal Appliance for Forced Eruption of Impacted Central Incisor

Fig. 10 Cephalometric superimposition. Black, pre-treatment; DISCUSSION

red, post-treatment.
A number of approaches have been reported to correctly position
impacted maxillary incisors into the dental arch. Several authors2,4,5
have suggested surgically exposing impacted incisors and using
fixed expansion appliances including bracketing of both permanent
and primary teeth to serve as anchorage for orthodontic extrusion.
These approaches can prove to be challenging because placing fixed
appliances at an early age can cause compliance and hygiene issues.
In addition, in cases with patterns of generalized delayed eruption, it
is often more prudent to limit the use of fixed appliances, and direct
treatment application specifically to the impacted tooth/teeth to
prevent further root resorption of the adjacent teeth. Therefore, the
treatment of impacted maxillary permanent central incisors poses
a significant clinical challenge and requires particularly skilled
management when it involves very young and anxious parents.
The most commonly reported methods for establishing traction
for extruding impacted maxillary incisors have involved the place-
ment of fixed appliances to create anchorage. This is followed by the
alignment and stabilization of the maxillary arch with fixed appli-
ances and the subsequent surgical exposure of the impacted teeth
with placement of a bonded attachment, secured to the archwire and
adjusted over time.4,6 In our case, the approach was to surgically
expose the impacted maxillary left central incisor and use a modified
Nance appliance with an extended arm to serve both as anchorage
and to provide active forces to extrude the tooth and thus achieve
the principal clinical objective without the need for additional fixed

Fig 11 Post-retention facial and intraoral photographs 24 months after debonding.

Figure 10.

Figure 11.
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Figure 10.
doi 10.17796/1053-4625-43.6.6 The Journal of Clinical Pediatric Dentistry Volume 43, Number 6/2019
 A Modified Palatal Appliance for Forced Eruption of Impacted Central Incisor

Fig 12 Post-retention radiographs 24 months after debonding.

Figure 12.
auxiliary appliances. Following successful extrusion of the central REFERENCES
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the root movements of the central and lateral incisors. 3. Gömleksiz C, Arslan E, Arslan S, Pusat S, Arslan EA. Delayed diagnosis
Figure 11.
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4. Rizzatto SMD, de Menezes LM, Allgayer S, Batista EL, Freitas MPM,
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appliances, specifically using a modified Nance appliance with an 5. Shah SB, Kulkarni GK. Guiding teeth into occlusion: case report. J Can
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CONCLUSION
The impacted maxillary central incisor has been successfully
positioned with a modified palatal appliance. In this case, the
patient’s anterior coupling and gingival recession were significantly
improved in 19 months of treatment.

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