CASE REPORT

Treatment of an impacted dilacerated maxillary central incisor

gerc Dimitrios Pavlidis,a Nikolaos Daratsianos,b and Andreas J a Bonn, Germany

The diagnosis of an impacted incisor with dilaceration refers to a dental deformity characterized by an angulation between the crown and the root, causing noneruption of the incisor. In the past, surgical extraction was the rst choice in treating severely dilacerated incisors. The purpose of this case report was to present the correction of a horizontally impacted and dilacerated central incisor through 2-stage crown exposure surgery combined with continuous-force orthodontic traction. The tooth was successfully moved into its proper position. The treatment is discussed, and the orthodontic implications are considered, with a review of the current literature on this topic. (Am J Orthod Dentofacial Orthop 2011;139:378-87)

he abnormality of root dilaceration, which presents itself as the deformed development of a tooth, has been long recognized.1,2 The term refers to an angulation, which can occur anywhere along the length of the toothie, its crown, cementoenamel junction, along the root, or only involving the apex of the root resulting in disruption of the normal axial relationship of the tooth.3 The malformation occurs by displacement of the crown, usually during early tooth development, in a vestibular or, less frequently, palatal direction, while root growth is still progressing in a cranial direction. In the literature, a distinction is also made between vestibular and lateral root bending.4 With continued tooth development, later tooth eruption becomes unlikely, and the tooth remains unerupted. Most frequently, this deformation occurs unilaterally in the maxillary permanent central incisors. It has as also been reported in the maxillary deciduous incisors,5 the mandibular permanent incisors,6 and the maxillary permanent canines and premolars.7 There are also few reports of patients having 2 affected dilacerated teeth (in 1 patient, 11 and 21 were involved; in 2 others, 21 and 22 were simultaneously affected8).
From the Department of Orthodontics, School of Dentistry, University of Bonn, Bonn, Germany. a Resident. b Vice Director. c Professor and head. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Reprint requests to: Andreas J ager, Department of Orthodontics, School of Dentistry, University of Bonn, Welschnonnenstrasse 17, 53111 Bonn, Germany; e-mail, a.jaeger@uni-bonn.de. Submitted, April 2009; revised and accepted, October 2009. 0889-5406/$36.00 Copyright 2011 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2009.10.040

Dilacerations are estimated to occur in 3% of all permanent dentitions. However, the etiology of dilaceration is not yet fully understood. Traumatic injury to the deciduous predecessors8 and ectopic development of the tooth germ9 are the 2 commonly cited causes of this anomaly, so that the entity has continued to present something of a clinical puzzle. The treatment of a dilacerated anterior tooth is challenging for the clinician, because of its difcult position and the abnormality of the root. Treatment often involves surgical removal with subsequent orthodontic methods to either close the space or keep it open until the patient reaches an age when implants or prosthetic treatment can be performed. Both methods have associated problems. Alternatively, surgical exposure followed by orthodontic traction is suggested to save an impacted dilacerated incisor. This article presents a patient with a horizontally impacted and dilacerated maxillary left central incisor. With the help of 2 stages of surgical crown exposure combined with continuous orthodontic traction, the dilacerated incisor was successfully moved into its proper position.
DIAGNOSIS AND ETIOLOGY

A 10-year-old white girl was referred by her general dentist to the orthodontic department of the University of Bonn in Germany for consultation. The chief concern was the noneruption of the maxillary left central incisor; this had resulted in an unesthetic appearance and a psychologic compromise (Figs 1 and 2). The child was physically healthy, and there was no evident history of a traumatic injury in the frontal oral region. However, because of the severely displaced position of 22, with

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Fig 1. Pretreatment extraoral and intraoral photographs.

Fig 2. Dental casts showing noneruption of the maxillary left central incisor.

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Fig 3. A and B, Pretreatment panoramic and maxillary occlusal radiographs disclosing the impacted maxillary incisor.

Fig 4. A, Pretreatment cephalogram showing the dilacerated maxillary incisor; B, cephalometric tracing.

an incisal cant, dental trauma could not be excluded. Examination of the oral cavity showed dental caries in the deciduous teeth and a deep insertion of the maxillary labial frenulum. The patient had a skeletal Class I occlusion with a balanced facial pattern. The analysis of the lateral cephalometric radiograph disclosed normal cephalometric values. Intraoral examination showed an early mixed dentition and an Angle Class I molar relationship. The impaction of the maxillary left central incisor had resulted in drifting of the adjacent teeth with a resultant midline deviation and a 45 mesial rotation of the left lateral incisor. The impacted incisors crown was palpable high in the labial sulcus. There were minor arch length discrepancies in both arches and a crossbite of the rst molar on the right side. The panoramic and maxillary occlusal radiographs demonstrated an impacted maxillary left central incisor

(Fig 3). The tooths morphology and position were easily visible in the lateral cephalometric radiograph (Fig 4), showing a horizontally displaced tooth, with its crown rotated more than 100 from normal, and its incisal tip just below the oor of the nose. The palatal surface of the crown was facing forward like the hand of a trafc policeman,9 and the root was shortened. It was not possible to exactly dene the root apex on the conventional radiographs. Thus, a TC-Dentascan (NewTom, Newtom Deutschland AG, Marburg, Germany) was performed, and evaluation conrmed the presence of the impacted tooth localized in the body of the premaxilla with a bend at the roots apical third (Fig 5). The dilacerated tooth showed complete apex formation. In addition, the tooth had a marked labiopalatal curvature adjacent to the cortical plate of the bone of the palatal vault, and the crown-root angle was judged to be about 45 . The use

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Fig 5. Two records of the TC-Dentascan showing the special anatomy of the tooth.

of TC-Dentascan was essential to show the root dilaceration and to focus on potential problems associated with the orthodontic movement of the tooth.
TREATMENT ALTERNATIVES AND OBJECTIVES

The following treatment options were considered. 1. Surgical extraction of the impacted incisor and restoration with a prothesis or an implant after orthodontic space opening when growth had ceased. Surgical extraction of the impacted incisor, orthodontic space closure, and prosthodontic restoration of the left lateral incisor as the central incisor at a later stage. Orthodontic space opening, uncovering the tooth by using the closed eruption technique and orthodontic traction of the tooth into proper alignment.

2.

Fig 6. Intraoral situation before surgery.

3.

The treatment options were explained to the parents, and it was decided to attempt to bring the tooth into alignment.
TREATMENT PROGRESS

The patient was referred to the general dentist for restoration of the carious deciduous teeth. Subsequently, a xed appliance was placed on the maxillary teeth to create space for the impacted central incisor. Bands with lingual Burstone slots were placed on the maxillary rst molars, and orthodontic brackets were bonded to the 3 anterior permanent teeth. Initially, the posterior crossbite was corrected with an asymmetrically activated transpalatal arch. Afterward, the rotated left lateral incisor was aligned by means of a cantilever, which was fully inserted to the lateral incisors slot and ligated to the left molar band. Leveling was then continued with a 0.0175in multistrand wire, followed by a 0.016 3 0.016-in beta-titanium alloy wire and a 0.016 3 0.022-in stainless steel wire with an open-coil spring in the position of the unerupted central incisor (Fig 6). Once adequate space was achieved, the patient was transferred to the oral surgeon for exposure of the

impacted incisor. Because of the severe displacement, 2 stages of surgical exposure of the crown were recommended. The rst stage was to expose only the lingual surface of the crown and attach a gold chain (Fig 7, A and B). By using local anesthesia, a full thickness mucoperiosteal buccal ap was raised. The incisor crown morphology was normal, with no enamel defects, so that the procedure of bonding the gold chain was carried out without problems. To use the closed-eruption technique, the ap was repositioned and sutured, leaving the gold chain protruding through the mucosa (Fig 7, C).10 The patient returned 8 days later, and orthodontic traction was initiated. Continuous orthodontic force was applied to bring the tooth occlusally into the arch. A force of 60 to 90 g was applied by means of a cantilever from the main archwire via a cross-washer. After 4 months of traction, the tooth was close to eruption buccally. At that point, the patient was referred again to the oral surgeon to place an attachment but, this time, on the buccal surface of the crown. Because the tooth was close to eruption, the surgeon removed only minor overlying tissue and at the same time corrected the deep insertion of the labial frenulum (Fig 8, A). By the ninth month of treatment, the incisor was brought closer to alignment. During the traction, a palatal bulge developed (Fig 8, B). The continuous traction also resulted in infraocclusion of all maxillary incisors, an inevitable side effect. At that time, an orthodontic

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Fig 7. A, B, and C, Surgical exposure of the impacted tooth with the closed-eruption technique.

Fig 8. Documentation of the orthodontic treatment: A, situation 1 week after the second stage of surgical exposure combined with labial frenulum correction; B, after 6 weeks, a signicant palatal bulge was clinically manifest; C-E, leveling and alignment of the arch.

bracket was bonded upside down on the labial surface. In addition, the rest of the permanent dentition was bonded to initiate labial root torque for the incisor and to close the anterior open bite. Leveling was performed with a 0.0175-in multistrand wire, followed by a 0.016 3 0.016-in beta-titanium ally wire and a 0.016 3 0.022-in stainless steel archwire in both arches (Fig 8, C-E). The palatal bulge was completely reduced, and ideal overbite, overjet, and intercuspation were established (Figs 9 and 10). The bands and brackets were removed, and maxillary and mandibular Hawley retainers were placed.

TREATMENT RESULTS

By using of a combination of 2 stages of crown exposure and continuous orthodontic traction, the impacted dilacerated maxillary left central incisor was successfully positioned into proper alignment in the dental arch. During treatment, the patient had compromised oral health, which resulted in cervical decalcication of the maxillary anterior teeth and mild gingival inammation after treatment. The exposed incisor had an acceptable gingival contour, which signicantly improved at the 6-month recall. A slightly

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Fig 9. Records directly after debonding.

longer crown height was noticeable. Radiographically, the previously impacted incisor showed a dilacerated root displaced in the alveolar bone (Figs 11 and 12). This is why the root was not palpable labially underneath the alveolar mucosa. No root resorption was evident, the tooth was asymptomatic, and pulp testing showed a vital pulp. Total treatment time was about 18 months (Fig 13).
DISCUSSION

The authors of most oral surgery textbooks consider surgical removal of a dilacerated, unerupted maxillary incisor the usual course of treatment.11 However, reports of successfully treated dilacerated impacted maxillary anterior teeth have been published.7,12-19 degaard7 presented a patient with 2 horizontally and severely impacted and dilacerated maxillary canines, and indicated that a marked dilacerated tooth could be brought into

correct position. Just as our patient showed, the dilaceration of the root is not a great obstacle, if the case is carefully planned and compliance is good. Most authorities agree that there are 2 possible causes of dilaceration. The most widely accepted cause is trauma.8 However, traumatic injuries cannot account for all cases of dilaceration, especially for those of deciduous teeth. An idiopathic developmental disturbance was proposed as another possible cause in patients with no clear evidence of trauma.9 The treatment of dilacerated anterior teeth is always a clinical dilemma. Failure due to ankylosis, external root resorption, and root exposure after orthodontic traction is possible. Ankylosis can hardly be tested unless orthodontic force is applied to the affected tooth. In case of ankylosis, surgical luxation to allow further orthodontic movement has been used with considerable success.20

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Fig 10. Posttreatment casts.

A dilacerated tooth is said to be more resistant to extrusion than a tooth with a normal root, making the apical area more prone to resorption.21 However, in our patient, no obvious root resorption could be detected, suggesting that, in the case of dilaceration, root resorption can hardly be predicted. Radiographic controls during orthodontic traction would seem to be wise. Depending on the degree of dilaceration, the apical portion of the root can penetrate the labial cortical plate, so that it would be intraorally palpable in the labial sulcus.5 In severe cases, the root apex can even be exposed into the oral cavity, so that surgical endodontics, endodontic treatment, and apicoectomy would be indicated.17 In our patient, although the radiographic examination showed an acute angulation of the tooth, the root apex was not palpable after tooth uprighting, suggesting that the dilaceration was less pronounced than the TC-Dentascan had shown. It can be concluded that the radiographic examination must be considered with caution. Orthodontic tooth traction can be attempted in borderline cases but should be closely monitored. In case of root apex palpation, traction should be stopped, and reevaluation is recommended. In another report, a permanent mandibular incisor was naturally erupted with the root orthoaxially displaced in the alveolar ridge, despite severe root dilaceration, beginning just below the cementoenamel junction.6 In this case, the crown was severely buccally inclined, and for this reason tooth removal was chosen.

Fig 11. Posttreatment panoramic radiograph showing no signs of root resorption of the aligned left central incisor.

The treatment approach for impacted maxillary teeth requires close cooperation of dental specialties such as orthodontics, oral surgery, endodontics, and prosthodontics. Studies have shown that, when more bone is removed during surgical exposure, there is greater bone loss after orthodontic treatment.22,23 Two stages of crown exposure can prevent greater amounts of bone destruction during the rst stage of crown exposure because the placement of the attachment on the labial surface of a severely angulated dilacerated tooth typically requires more bone removal than placement on the lingual surface. Therefore, the attached auxiliaries need to be switched from the lingual surface to the labial surface in the second stage of

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Fig 12. A, Posttreatment cephalogram proving that penetration of the cortical bone from the dilacerated root apex was avoided; B, cephalometric tracing.

crown exposure to facilitate traction and uprighting of the tooth (Fig 8, A). Another issue that the clinician must be aware of when treating a dilacerated impacted anterior tooth is that a gingivo-mucosal palatal bulge might develop as the tooth moves incisally (Fig 8, B). This bulge in our patient was caused by marked curvature of the tooth, which, in the pretreatment position of the tooth, was close to the cortical plate of the palatal vault (Fig 5). Thus, as the tooth erupted, the palatal bulge became more prominent. Singh and Sharma15 were the rst to describe this nding. They stopped traction when the palatal bulge became extremely prominent, since they were afraid of losing tooth vitality. Subsequently, they added labial root torque and a step-up bend in the main archwire. Once the palatal bulge had been reduced, incisor traction was continued. In our patient, a different design of mechanics was used to resolve this problem. The incisor bracket was bonded on the labial surface of the tooth with a rotation of 180 . By placing a fullsize rectangular wire, the tooth was signicantly uprighted, resulting in bulge elimination. There are 2 others options for the treatment of dilacerated incisors cited in the literature: surgical repositioning24 and tooth autotransplantation.25 Prophylaxis of root dilaceration is undoubtedly an important issue. In the management of dilacerated incisors, manipulation of the inherent potential of Hertwigs epithelial root sheath is fundamental to a successful outcome. Therefore, if orthodontic treatment is considered,

it is crucial that the treatment is started early. This permits the epithelial root sheath to be redirected and offers the chance for the developing root to adapt to the correct spatial relationship of the aligned crown. A clinical report conrms root adaptation of dilacerated impacted teeth.24 Moreover, a dilacerated tooth with incomplete root formation should have a better prognosis for orthodontic traction.12 It is strongly recommended that all teeth that have not erupted 6 months after the normal eruption date should be examined radiographically to ascertain any possible cause for the delayed eruption.26,27 Intervention should begin as early as possible, so that normal root development can continue. The longer the tooth is retained, the poorer the prognosis for eruption, axial root growth, and orthodontic traction. Even in a patient with severe dilaceration of the anterior teeth, if extraction of the impacted tooth and restoration with a prosthesis or an implant is necessary, orthodontic traction can be performed initially to improve esthetics and also to achieve and functionally maintain the height of the alveolar process.19
CONCLUSIONS

Treatment of an impacted dilacerated incisor is a clinical challenge, which should be undertaken by the orthodontist following carefully planned procedures. A joint orthodontic, oral surgery, endodontic, and prosthodontic examination and approach are of outmost importance.

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Fig 13. Superimpositions of the lateral cephalograms showing the dental and skeletal changes during orthodontic treatment: A, superimposition on the anterior cranial base (S-N); B, superimposition on the maxillary base (Spa-Spp); and C, superimposition on the mandibular base (Gn-Go).

We thank the surgeons M. Tzoumpas and Yango Pohl for their common treatment of the patient.
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9. Stewart DJ. Dilacerated unerupted maxillary central incisors. Br Dent J 1978;145:229-33. 10. Vermette ME, Kokich VG, Kennedy DB. Uncovering labially impacted teeth: apically positioned ap and closed-eruption techniques. Angle Orthod 1995;65:23-34. 11. Davies PHJ, Lewis DH. Dilacerationa surgical/orthodontic solution. Br Dent J 1984;156:16-8. 12. Lin YTJ. Treatment of an impacted dilacerated maxillary central incisor. Am J Orthod Dentofacial Orthop 1999;115:406-9. 13. Chew MT, Ong MMA. Orthodontic-surgical management of an impacted dilacerated maxillary central incisor: a clinical case report. Pediatr Dent 2004;26:341-4. 14. Mattison GD, Bernstein ML, Fischer JW. Lateral root dilaceration: a multi-disciplinary approach to treatment. Endod Dent Traumtol 1987;3:135-40. 15. Singh GP, Sharma VP. Eruption of an impacted maxillary central incisor with an unusual dilaceration. J Clin Orthod 2006;40:353-6. 16. Cozza P, Marino A, Condo R. Orthodontic treatment of an impacted dilacerated maxillary incisor: a case report. J Clin Pediatr Dent 2005;30:93-8. 17. McNamara T, Woolfe SN, McNamara CM. Orthodontic management of a dilacerated maxillary central incisor with an unusual sequela. J Clin Orthod 1998;32:293-7.

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18. Sandler PJ, Reed RT. Treatment of a dilacerated incisor. J Clin Orthod 1988;22:374-6. 19. Uematsu S, Uematsu T, Furusawa K, Deguchi T, Kurihara S. Orthodontic treatment of an impacted dilacerated maxillary central incisor combined with surgical exposure and apicoectomy. Angle Orthod 2004;74:132-6. 20. Takahashi T, Takagi T, Moriyama K. Orthodontic treatment of traumatically intruded tooth with ankylosis by traction after surgical luxation. Am J Orthod Dentofacial Orthop 2005;127: 233-41. 21. Graber TM, Swain BF. Orthodontics: current principles and techniques. St Louis: C.V. Mosby; 1985. p. 231-4.

22. McDonald F, Yap WL. The surgical exposure and application of direct traction of unerupted teeth. Am J Orthod 1982;89:331-40. 23. Kohavi D, Becker A, Zilbermann Y. Surgical exposure, orthodontic movement and nal position as factors in periodontal breakdown of treated palatally impacted canines. Am J Orthod 1984;85:72-7. 24. Tsai TP. Surgical repositioning of an impacted dilacerated incisor in mixed dentition. J Am Dent Assoc 2002;133:61-6. 25. Filippi A, Pohl Y, Tekin U. Transplantation of displaced and dilacerated anterior teeth. Endod Dent Traumetol 1988;14:93-8. 26. Munns D. Unerupted incisors. Br Dent J 1981;8:39-42. 27. Becker A. Early treatment for impacted maxillary incisors. Am J Orthod Dentofacial Orthop 2002;121:586-7.

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