2020, Number 3
Impacted maxillary centrals associated with supernumeraries orthodontic management with dental-type anchorage
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Language: English/Spanish [Versi?n en espa?ol]
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Page: 186-192
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ABSTRACT
One of the oral complications of supernumerary teeth is the impact of adjacent teeth, including crowding, diastema formation, rotation, tooth displacement, occlusal interference, cavities, periodontal problems, difficulty chewing and compromised aesthetics. The association with multiple supernumerarios, the formation of a toothpaste with bone destruction, root reabsorption and oronasal fistula. It presents the management of a patient of 11 years of age diagnosed as skeletal class II with divergent norm growth, class I bilateral molar and class II bilateral canine, with dental organs 11 and 21 retained, right posterior cross bite, lower crowding, presence of unrupted supernumerary teeth between canine and premolar, as well as anterosuperior sector. For the treatment was performed alignment, leveling, extraction of supernumerary teeth, surgery for the traction of the central incisors, stripping. In the detail and retention were used: prescription brackets Roth 0.022" × 0.028", bondable tubes in 6's and 7's higher, bands with dotted tubes in 6's in buttons on dental organs 11 and 21 bondeable in 6's and 7's superiores. Active treatment time one year and six months. Hawley retention with upper and lower vestibular belt.INTRODUCTION
Tooth impaction is a challenge for the orthodontist, the prevalence of these is increasing and can cause major problems.1 The absence of central teeth and the canine are the most seen in the smile and when speaking, this is one of the most common causes of consultation to the professional because it is considered to affect self-esteem and social interaction of children in general which will be important to detect to solve the problem at an early age.2 On the other hand, different conditions can affect normal dental eruption, which can be divided into primary etiological factors such as failures in the resorption process, trauma, and infections, among others, and secondary factors such as abnormal muscular pressure, febrile diseases, and endocrine alterations.3 Other possible causes are an ectopic position of the dental germ, non-vital or ankylosed primary teeth, extraction or an early loss of deciduous teeth, mucosal barriers in the eruption pathway that act as a physical barrier, and bone diseases.4 Generally, the most affected tooth is the canine, in less than 2% of the general population, followed by the central incisor with 0.06 to 0.2%5,6 in the maxilla. The origin of this impaction phenomenon according to Becker and Chaushu can be: obstructive at least by the presence of mesiodens or supernumerary teeth and traumatic,6 Brook refers to a frequency of 1.5 to 3.5% in random populations and only between 28 and 60% of these patients presented impaction for the incisor group for these causes, in the same sense they refer that odontomas can cause obstruction and impediment of the eruption of the incisors.7,8 Common complications of supernumerary teeth are impaction of adjacent teeth, crowding, diastema formation, rotation, displacement of teeth, occlusal interference, caries, periodontal problems, difficulty in chewing, and compromised esthetics.8-10 Another factor that can condition dental eruption is the formation of cysts, such as the case of the dentigerous cyst that can be present in supernumerary teeth and some cases can present with associated bone destruction, root resorption, and oronasal fistula.5,11,12 Children are frequently exposed to falls or trauma to the face or mouth, and when this involves the primary teeth, damage to the germ-forming cells of the permanent tooth will occur, not only in the crown but also in producing root dilaceration of the permanent tooth.12 The degree of damage to the permanent tooth depends on the stage of development of the tooth, as well as the type and direction of the trauma inflicted, which will affect the eruption orientation line of the permanent tooth.8,13
CASE REPORT
We report the case of an 11-year-old patient whose reason for consultation was "central teeth surgery", referred by the mother, clinically a normo divergent growth is observed, as well as the absence of dental organs 11 and 21 and radiographically skeletal class II (Figure 1A and B). Initial studies were performed using intraoral photographs in the intraoral analysis of the molar relations class I molar and canine class II bilateral, the absence of the dental organs OD 11 and 21, right posterior crossbite, and moderate anteroinferior crowding was observed. The dental midlines cannot be determined due to the absence of the same upper centrals. In the occlusal view the upper arch forms square and the lower arch with moderate crowding (Figure 1C-G). Additionally, CBCT was used as a diagnostic tool, where the presence of impacted teeth 11 and 21 and supernumeraries of these same teeth in palatal as well as another at the level of the roots of the OD 34 and 35 can be observed (Figure 2).
The treatment consisted of three phases. The first phase focused on alignment, leveling and detailing with prescription Roth brackets 0.022" × 0.028" with a sequence of NiTi archwires 0.014", 0.016", 0.018" upper and lower, steel 0.018", 0.020" and 0.018" × 0.025" upper and lower. In the second phase, surgical extractions of the supernumerary teeth were performed, placing the bondable buttons, with metal ligature to begin the incorporation of the OD 11 and 12 using traction to the arch (Figure 3A and B). The lifting and uncrossing of the crossbite of the dental organs 17 and 16 were carried out employing bite turbos in 36 and 46. Besides the use of cross elastics from the palatal bonded button in 16 and 17 to the vestibular tube of 46 and bonded button in 47, the brackets of the OD 12 and 22 were bonded in the head to correct the torque of these teeth. Vertical and horizontal overbite (overjet and overbite), dental midlines, and bilateral canine class II were corrected by stripping, intramaxillary chains, and elastics.
In the intraoral photographs of progress, the patient's progress can be observed by dental alignment and leveling and the OD 11 and 21 already incorporated (Figure 3C- E). In the final studies, a bilateral class I molar and canine can be identified, as well as the adequate overjet and overbite, and the lower midline 1 mm deviated to the left concerning the upper dental midline. In the occlusal view the correction of mild anteroinferior crowding the appropriate arch forms (Figure 4A-E). Finally, the recommended Hawley retainers with the vestibular belt for the upper and lower jaw indicated continued treatment (Figure 4F-G). In the extraoral smile photograph and the initial cephalometric overlay identified with the black line and the red line, growth is observed (Figure 5A and B). The orthopantomography shows the correct root parallelism and 28 permanent teeth present with third molars in formation (Figure 5C). The treatment time was one year and six months, the treatment objectives were met, which consisted of correcting the facial profile of the soft tissues. With the traction of central 11 and 12 the bilateral class I molar was maintained. Exodontia of supernumeraries, ameloplasty of incisors 12, 21, and 22, correct intercuspidation, canine disocclusion guide, as well as incisor guide and generalized gingivoplasty were performed.
DISCUSSION
Bradley14 points out that the management of impacted permanent incisors will depend on the type of supernumerary teeth, as well as the number, whether impacted or erupted, unilateral or bilateral and the stage of development of the tooth, the direction, and space available in the arch for unerupted teeth and the displacement of adjacent teeth.15 Regarding the prognosis of these teeth, Becker and Stewart say that it will depend on whether or not there is ankylosis, external root resorption, and exposure after traction.5,16 The age at which treatment is started, the position of the impaction palatally or vestibular, and the distance of the tooth from the occlusal plane are factors reported by Lin that will increase treatment time and complexity.15 At CESO, the problem was solved in a multidisciplinary way with surgery for the incorporation of the canine into the dental arches, which was an excellent alternative, achieving the objectives at this age of 11 years, which, with the adequate positioning of the teeth, improved the bone infrastructure and by correcting the malpositions the occlusal trauma was reduced.
CONCLUSION
To prevent this, it is best to diagnose retained teeth at an early age, as they can cause complex situations that with the passage of time can affect the patient's self-esteem. The orthodontist upon receiving the patient, should make good clinical analysis with the support of diagnostic images 2D or 3D to rule out any discrepancy and thus have a follow-up. Retained teeth present a great dilemma, incorporating them into the arch represents a challenge. When this is achieved, esthetic and functional changes are obtained, improving skeletal and occlusal relations.
REFERENCES
AFFILIATIONS
1 Residente del primer año de la maestría Ortodoncia y Ortopedia Maxilofacial en el CESO. Centro de Estudios Superiores en Ortodoncia (CESO).
2 Profesor de la maestría del CESO y profesor de tiempo completo Titular "C" de la Carrera de Cirujano Dentista de la Facultad de Estudios Superiores Zaragoza, Universidad Nacional Autónoma de México (UNAM). Centro de Estudios Superiores en Ortodoncia (CESO).
3 Director del CESO. Centro de Estudios Superiores en Ortodoncia (CESO).
CORRESPONDENCE
Beatriz Gurrola Martínez. E-mail: beatgurrola@gmail.comReceived: Agosto 2020. Accepted: Noviembre 2020.