CASE PRESENTATIONOrthodontic correction prior to autotransplantation of

impacted permanent maxillary lateral incisor and canine

Name : AAge : 19 years oldRace : MalaySex : Male

Identification Data

The patient was a 19-years-old Malaysian boy whose chief complaints were missing of the upper front teeth since 5 years ago.

History

His mother claimed that there were no tooth erupted at that area since primary teeth exfoliated.

Patient defaulted dental check up several times since 2009 but presented back to HUSM with same complaint since 3 years ago.

One year ago, OPG and periapical radiograph for tooth 22 and 23 were taken showed impacted teeth.

Now, he was on regular appointment with orthodontist for treatment.

Past medical history: No known medical illness Past dental history:

– Done extraction, filling and scaling during primary school

Clinical Examination

Problem list :1. Missing left maxillary lateral incisor and canine2. Median diastema 3. Rotated tooth 24 mesio-bucally4. Upper midline shift 2mm to the left5. Mandibular incisor crowding

Fig 2: Pretreatment intraoral photograph

Fig 3: Pretreatment dental cast

Fig 4: Pretreatment Orthopantomogram

OPG showed impacted maxillary left lateral incisor and canine with minimal space available for both teeth eruption.

Fig 5: Pretreatment lateral cephalograph

Table. Cephalometric measurementsVariable Pretreatment

(0)Normal

(0)

SNA 88 82 (+/-3)SNB 84 79 (+/-3)ANB 4 3 (+/-1)Maxillary incisor to maxillary plane angle

115 108 (+/-5)

Mandibular incisor to mandibular plane angle

94 92 (+/-5)

Interincisal angle 120 133 (+/-10)Maxillary-mandibular angle

28 27 (+/-5)

Upper anterior facial height

46.5 % 45 %

Lower anterior facial height

53.5 % 55 %

The cephalometric analysis showed protrusive maxilla and mandible noted with class I skeletal relationship. Maxillary incisor protruded but normal inclination of mandibular incisor. Class 1 Bimax protrusion.

Treatment objectives

The objectives of the orthodontic treatment were to

(1) close the median diastema

(2) derotate tooth 24

(3) reduce lower anterior teeth crowding

(4) correct midline shift

(5) create space for the impacted teeth (ectopic maxillary left lateral incisor and canine)

(6) replace missing teeth.

Removable appliance

Orthodontic traction

Extraction– Removable partial denture– Fixed prosthodontic appliance (bridge)– Implants – Autotransplantation

Treatment alternatives

Selection of treatment options were explained to patient – extraction and autotransplantation.

However, the amount of space available estimated from dental cast and radiograph was not sufficient to replace the missing teeth.

Thus, fixed appliance was use for orthodontic correction and space management prior to teeth substitutions.

Both the alignment and space acquired provides good outcome for further management of teeth transplantation.

Fig 7. Fixed appliance on upper and lower teeth with open coil spring between left upper central insicor and first premolar

Treatment Progress

Median diastema corrected

Derotated tooth 24

Upper midline corrected

Mandibular incisor was aligned

Sufficient space for autotransplantation

Treatment results

Discussion Impaction of permanent teeth is a relatively common

occurrence that can involve any tooth in the dental arch. Highest frequency of impaction is mandibular and maxillary third molars, followed by maxillary canines and mandibular second molars.

(Aitasalo K, Lehtinen R, Oksala E. 1972)

About one third of impacted maxillary canines are positioned labially or within the alveolus, and two thirds are located palatally in dental arch.

(Johnston WD. 1969)

Studies found that if a patient had a small or peg lateral incisor there was approximately a one-in-ten probability that the canine would be palatally placed; and if the patient had a missing lateral incisor a one-in-twenty probability.

(Jacobs SG.1996)

This findings suggested that anomalous or missing lateral incisors contributed towards palatal displacement of canines initially by absence of guidance for the erupting canine, and later by obstructing the misplaced canine's attempt to rectify its position.

(Becker A, Smith P, Behar R. 1981)

However, this case demonstrated impacted both lateral incisor and canine which was a rare case that requires better orthodontic and surgical approaches.

Treatment modalities in this patient include orthodontic alignment and surgical repositioning.

Space analysis done on dental cast showed minimal space available in the arch compared to space required for autotransplatation of lateral incisor and canine

Thus, more spaces to be acquired in order to placed the missing teeth back into position. The following alternatives were considered for the space management: (1) close median diastema (2) derotate tooth 24 distobucally (3) using open-coil spring between central incisor and first premolar(4) correct midline shift and alignment of maxillary and mandibular teeth which provide more spaces

In considering these treatment outcome,fixed appliance was taken into account.

Removable appliance

Orthodontic traction

Extraction– Removable partial denture– Fixed prosthodontic appliance (bridge)– Implants – Autotransplantation

Discussion : Treatment options

Treatment options : Removable Appliance

Eg. Upper removable appliance with palatal finger spring to close median diastema

Removable appliance Fixed appliance

Only simple tipping movement and few teeth can be moved at a time; complex cases, tx is prolonged.

Many types of tooth movements can be produced and performed simultaneously.

Lower removable appliances are not well tolerated.

Well tolerated because not interfere with tongue.

Uncooperative patients are difficult to be managed because they can removed the appliance by them.

No need cooperation as the appliance is rigidly attached to the teeth.

Impacted teeth can be properly positioned with orthodontic traction.

(Lin, Y. T. J. 1999) However, several factors should be considered when making a

surgical procedure and orthodontic treatment plan for impacted teeth.

In orthodontic traction treatment, consideration on the position, direction and number of missing teeth are crucial.

OPG form this patient demonstrated rotated teeth position with misplaced direction and a total of two impacted teeth presence.

This problems increase the difficulty in these treatment modalities which indicate that the treatment is not effective

Treatment options : Orthodontic Traction

Eg. Orthodontic traction of tooth 13

Many patients with impacted teeth are treated by extraction and the teeth were replaced by implant, fixed or removable partial denture.

In view of the patient's age, autotransplantation of the maxillary lateral incisor and canine was thought to be a good alternative compared to prosthodontic appliances.

Autotransplantation may provide a simplified and faster treatment option or patient with ectopic teeth.

This is especially the case for adult who often reject the idea of wearing the appliance to align the ectopic teeth, yet would benefit from this teeth in the line of the arch.

(Thomas S, Turner SR, Sandy JR.1998)

Treatment options : Extraction

Eg. Autotransplantation

Autotransplantation has its applications in the repositioning of malpositioned teeth and in substitution for missing teeth

(Slagsvold O, Bjercke B 1978)

Autotransplantation is defined as the transplantation of teeth from one site to another in the same individual into extraction sockets or surgically prepared sites.

(Natiella JR, Armitage JE, Greene GW. 1970)

Success rate of autotransplantation is influenced by a number of preoperative and postoperative factors including root development, position of the tooth and surgical technique.

(Schwartz O, Bergmann P, Klausen B 1985)

At present, autotransplantation is advised for a suitable alternative to conventional prosthetic rehabilitation or implant treatment.

(Mejare B, Wannfors K, Jansson L. 2004)

Treatment options : Autotransplantation

This case demonstrates the successful alignment of maxillary and mandibular teeth prior to autotransplantation while maintaining Angle class 1 occlusion that was successfully achieved in less than a year.

The patient's compliance, esthetics, function, and age should all be considered when deciding treatment options.

A diagnostic setup model and radiograpgh were effective and important in determining the appropriate treatment plan for our patient's impacted teeth.

Although many orthodontic treatment mechanics encompassing different levels of complexity have been described in the literature, autotransplatation was presented here are a useful alternative.

Conclusion

Aitasalo K, Lehtinen R, Oksala E. An orthopantomographic study of prevalence of impacted teeth. Int J Oral Surg 1972;1:117-20.Johnston WD. Treatment of palatally impacted canine teeth. Am J Orthod 1969;56:589-96. Jacobs SG. The impacted maxillary canine. Further observations on aetiology, radiographic localization, prevention/interception of impaction, and when to suspect impaction. Australian Dental Journal 1996;41:(5):310-16 Becker A, Smith P, Behar R. The incidence of anomalous maxillary lateral incisors in relation to palatally-displaced cuspids. Angle Orthod 1981;51:24-9. Lin, Y. T. J. Treatment of an impacted dilacerated maxillary central incisor. Am J Orthod Dentofacial Orthop 1999;115:406–409. Slagsvold O, Bjercke B. Applicability of autotransplantation in cases of missing upper anterior teeth. American Journal of Orthodontics 1978;74: 410–21. Natiella JR, Armitage JE, Greene GW. The replantation and transplantation of teeth. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology 1970;29:397–419 Schwartz O, Bergmann P, Klausen B.Autotransplantation of human teeth. International Journal of Oral Surgery 1985;14: 245–58. Mejare B, Wannfors K, Jansson L. A prospective study on transplantation of third molars with complete root formation. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 2004;97:231–38.

References

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