SUMMARY In the present paper the management or anterior impacted teeth is reviewed. Techniques regarding the surgical as well as the orthodontic aspect of their management are described. Mainly the 3 surgical techniques for the exposure of anterior impacted teeth are presented, which should be chosen in regards on the site of impaction; namely, they are the gingivecto- my, the apically positioned flap, and the closed eruption technique. The basic principles of the orthodontic treatment of anterior impacted teeth are also presented, by which teeth could be properly aligned in the dental arch. This orthodontic treatment comprises 2 phases, the pre-surgical and the post-sur- gical phase. The biological rules for the protection of the periodontium and for the safe alignment of anterior impacted teeth are finally described. Keywords: Anterior Impacted Teeth; Surgery; Orthodontics Dimitrios Hatziemmanuil 1 , Labros Zouloumis 2 , Nikolaos Topouzelis 3 Aristotle University, Faculty of Dentistry Thessaloniki, Greece 1 Private Dentist 2 Department of Oral and Maxillofacial Surgery 3 Department of Orthodontics REVIEW PAPER (RP) Balk J Stom, 2006; 10: BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141 Surgical and Orthodontic Management of Impacted Anterior Teeth T U P N B U P M P H J D B M T P D J F U Z Introduction Impacted are the permanent teeth which stay within the jaw bone after their normal eruption time and are surrounded by the dental follicle, which has no com- munication with the oral cavity 1,2 . The causes for anterior teeth impaction can be local and/or systemic. An important role plays the multigenetic and multifactorial heritability 3,4 . Studies have shown that about 1-2% of occlusal problems correlate to impacted anterior teeth 5,6 . More frequent are the palatally impacted teeth with a frequency double that of the labially impacted anterior teeth. The alignment of the anterior impacted teeth is essential, because otherwise complications occur, such as ankylosis, external root resorption, recession, bone loss and risk for the health of the adjacent teeth 7 . There are, though, cases for which the ideal treatment is not feasible and in such cases the outcome may be tooth extraction 8,9 . The possible causes, the impaction frequency and the location of the impacted anterior teeth are important for the clinical practice. Of particular interest are the surgical and orthodontic techniques used for the exposure and subsequent alignment of the anterior impacted teeth. Treatment of anterior impacted teeth may require the cooperation of various dental disciplines, mainly radio- logy, oral surgery and orthodontics. In radiology, whose main role is to identify the impacted tooth location, the various techniques used are panoramic radiographs, intraoral periapical radiographs (using Clark’s technique for the identification of the labio-palatal location of the impacted tooth), bite-wing radiographs and tomography, individually modified for the requirements of each case 10 . For the surgical phase of the treatment of impacted teeth many techniques have been developed. Among them, the most important are the closed eruption technique (CE), the apically positioned flap (APF), being the most conservative, and the open technique with a transmucosal “window” - gingivectomy (GE). Different methods have been used for the orthodontic force application from time to time, for the proper alignment of these teeth, such as brackets placed in holes opened in the crown of the exposed teeth, cervical wire loops, gold or silver teeth veneers equipped with brackets or hooks, hoods directly bonded to the teeth, etc 11 . Frequency and Location of Anterior Teeth Impaction The anterior teeth most frequently impacted are upper canines, followed by upper lateral incisors, upper central incisors, lower canines, and lower incisors 12 . The
Surgical and Orthodontic Management of Impacted Anterior Teeth
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hatziemmanuil.inddSUMMARY In the present paper the management or anterior impacted teeth is
reviewed. Techniques regarding the surgical as well as the orthodontic aspect of their management are described. Mainly the 3 surgical techniques for the exposure of anterior impacted teeth are presented, which should be chosen in regards on the site of impaction; namely, they are the gingivecto- my, the apically positioned flap, and the closed eruption technique. The basic principles of the orthodontic treatment of anterior impacted teeth are also presented, by which teeth could be properly aligned in the dental arch. This orthodontic treatment comprises 2 phases, the pre-surgical and the post-sur- gical phase. The biological rules for the protection of the periodontium and for the safe alignment of anterior impacted teeth are finally described. Keywords: Anterior Impacted Teeth; Surgery; Orthodontics
Dimitrios Hatziemmanuil1, Labros Zouloumis2, Nikolaos Topouzelis3
Aristotle University, Faculty of Dentistry Thessaloniki, Greece 1Private Dentist 2Department of Oral and Maxillofacial Surgery 3Department of Orthodontics
REVIEW PAPER (RP) Balk J Stom, 2006; 10:
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141
Surgical and Orthodontic Management of Impacted Anterior Teeth
TUPNB UP
HJ D B M! !T P D JF U Z
Introduction
Impacted are the permanent teeth which stay within the jaw bone after their normal eruption time and are surrounded by the dental follicle, which has no com- munication with the oral cavity1,2. The causes for anterior teeth impaction can be local and/or systemic. An important role plays the multigenetic and multifactorial heritability3,4. Studies have shown that about 1-2% of occlusal problems correlate to impacted anterior teeth5,6. More frequent are the palatally impacted teeth with a frequency double that of the labially impacted anterior teeth.
The alignment of the anterior impacted teeth is essential, because otherwise complications occur, such as ankylo sis, external root resorption, recession, bone loss and risk for the health of the adjacent teeth7. There are, though, cases for which the ideal treatment is not feasible and in such cases the outcome may be tooth extraction8,9.
The possible causes, the impaction frequency and the location of the impacted anterior teeth are important for the clinical practice. Of particular interest are the surgical and orthodontic techniques used for the exposure and subsequent alignment of the anterior impacted teeth.
Treatment of anterior impacted teeth may require the cooperation of various dental disciplines, mainly radio- logy, oral surgery and orthodontics. In radiology, whose main role is to identify the impacted tooth location, the
various techniques used are panoramic radiographs, intraoral periapical radiographs (using Clark’s technique for the identification of the labio-palatal location of the impacted tooth), bite-wing radiographs and tomography, individually modified for the requirements of each case10. For the surgical phase of the treatment of impacted teeth many techniques have been developed. Among them, the most important are the closed eruption technique (CE), the apically positioned flap (APF), being the most conservative, and the open technique with a transmucosal “window” - gingivectomy (GE). Different methods have been used for the orthodontic force application from time to time, for the proper alignment of these teeth, such as brackets placed in holes opened in the crown of the exposed teeth, cervical wire loops, gold or silver teeth veneers equipped with brackets or hooks, hoods directly bonded to the teeth, etc11.
Frequency and Location of Anterior Teeth Impaction
The anterior teeth most frequently impacted are upper canines, followed by upper lateral incisors, upper central incisors, lower canines, and lower incisors12. The
2 Dimitrios Hatziemmanuil et al. Balk J Stom, Vol 10, 2006
location of the anterior impacted teeth and their respective frequencies were studied by many researchers, with results not always agreeing with each other. It is reported that the impaction frequency for the upper canines is 0.92% according to Dachi and Howell13 and 1.7% according to Thilander and Jacobsson14, and that it more often appears in Caucasians and, according to others, more frequently in women than in men15. More frequent is, finally, the palatal impaction of the canine (80%)16. Fournier17 agrees that the palatally impacted teeth are more frequent than the labially impacted, with a proportion of 2:1. According to the same author, the palatally impacted teeth are located closely to the roots of the adjacent incisors and the nasal cavity.
Others differentiate the location frequency according to the geographical latitude, reporting that the upper central incisors are the third most frequently impacted teeth in the Caucasians, while in Asians it is even more frequent18. In a more generalized report5-6, it is argued that about 1-2% of the occlusal problems concern the labially impacted anterior teeth and their categorization was as follows:
Category A D < 12 mm Category B 12 mm < D < 15 mm Category C D > 15 mm (D: the distance of the incisal edge from the occlusal
plane of the anterior teeth measured on the panoramic radiography).
Reasons of Impaction
The causes of impaction are local and systemic. Heredity also plays an important role. Systemic causes inclu de cleft palate, cleidocranial dysostosis, osteopetrosis, various syndromes, etc12. Local factors are equally important. The usual eruption time for the canines is 11-12 years for the upper and 9-11 for the lower19. The eruption of the upper canine sometimes delays. This is attributed to the longer formation period, simultaneously to the longer eruption path20. Some authors21,22 refer to the role the anterior crowding plays in relation to the impacted canines, arguing that, since the canine is the last tooth that erupts in the dentition, a bit more labially to the arch line (and slightly more labially to the deciduous canine), when anterior crowding exists, for the permanent canine may remain unerupted. The prolonged presence of the predecessor primary tooth in the dental arch, due to trauma or advanced caries, also plays an important role. In the latter situation, the development of post-trauma or post- extraction healing tissue may weaken the eruption force. Another challenging situation exists when pathological tissue is located near the dental germs of the erupting teeth and hinders their emergence in the dental arch. Such situations are odontomas12, as well as odontogenic cysts9.
Many cases with impacted teeth are caused by super- numerary teeth due to hereditary influence. This view has
been documented by various researchers. Specifically, Sta fne23, in a sample of 200 cases with supernumerary teeth, found genetic influence in 90% of the sample. Also, Brook24 found an even greater frequency of super- numerary teeth in first-degree relatives of patients with supernumerary teeth, compared to the general population. Carton and Rees25 found twins with exactly the same dental anomalies, including supernumerary teeth.
Surgical Management of Impacted Anterior Teeth and Orthodontic Placement of Bracket
Many surgical techniques have been reported in the international literature for the management of anterior impacted teeth. The most frequent in the past were the radical technique with gingivectomy (trans-mucosal win- dow), and the apically positioned flap (APF) 8,26-28. Less frequent was the closed eruption (CE) technique17,29-34. The latter 2 belong to conservative techniques.
Gingivectomy35
This technique, according to Vanarsdall and Corn8, is called trans-mucosal window or simple complete exposure and is described as follows: after radiographic examination and identification of the crown position, an incision is made and the crown is exposed without flap creation, with the creation of a “window”, until the crown is visible (Fig. 1). The “window” is created with the layered excision of the overlying tissues (mucosa, periosteum, part of the dental follicle), separately or in toto, depending on the distance from the alveolar ridge and tooth location. This detail is significant, bearing in mind that this soft tissue will eventually become the attached gingiva in the normal dental arch; performing a bevelled incision will result in periodontal problems12. Special attention must be paid to the direction of soft tissue removal (mucosa), which must be bevelled to the impacted tooth cervix.
The incision design used plays an important role to the treatment outcome. Usually, in labially impacted anterior teeth the semilunar incision is preferred, while in palatally impacted teeth the options are the semilunar incision, the cruciform incision or even the intra-sulcular marginal incision (including the interdental papillae) or the para- marginal incision (excluding the interdental papillae) 36. It is up to the discretion of the surgeon to place a bracket (or any other kind of attachment) to the incisal third of the tooth at the same day. Yet, if the bracket is not placed during surgery and the trans-mucosal window is post- surgically covered by epithelial cells, then a second surgery is needed37. For this reason, and also for the control of the peripheral capillary bleeding, it is better to cover the crown with surgical cement for a week and then to uncover it.
Balk J Stom, Vol 10, 2006 Management of Anterior Impacted Teeth 3
Figure 1. A and B: clinical and radiographic view of the impacted tooth 13, while the tooth 53 remains in the dental arch; C: “Window” opening, extraction of the tooth 53 and segmental arch-wire insertion for the tooth 13 traction; D: alignment of the tooth 13 by means of a continuous upper
arch-wire; E: clinical view of the tooth 13 after the orthodontic appliance removal
Figure 2. A: clinical view of the impacted tooth 33, while the tooth 73 remains in the dental arch; B: Initial incision for the tooth 33 exposure; C: exposure of the tooth 33, with a flap reflection and extraction of the tooth 73; D: suturing of the apically repositioned flap
4 Dimitrios Hatziemmanuil et al. Balk J Stom, Vol 10, 2006
Apically positioned flap38
According to this technique, previously mentioned as Kincaid’s technique8,11,39-41, after local anaesthesia a flap is raised from the edentulous area or from the area of the impacted tooth, protecting as much as possible the attached gingiva (Fig. 2). In special cases, usually of impacted canines which have a more vertical direction and lie above their normal anatomical position, the surgery is performed both labially and palatally, in order to free the tooth from its bony crypt17. The bone covering the crown is removed. The two thirds of the crown are exposed and the dental follicle is removed from the margins of the exposed crown.
Vanarsdall and Corn8 stress that surgical manipulation must avoid areas apically to the cemento-enamel junction (CEJ) because in this area new attachment formation is anticipated. The flap is sutured with the periosteum and one half to two thirds of the crown are left exposed. Surgical cement is placed over enamel, to avoid soft tissue swelling. A week later, the cement is removed and the patient is instructed to keep this area of the crown clean. 2 weeks after surgery or 7-10 days after surgery, along with suture removal8, a bracket is bonded on the exposed tooth. The more horizontal is the position of the tooth the more incisally the bracket is placed, in order to achieve orthodontic traction with the desirable tooth inclination.
Figure 3. A: radiographic view of the highly-impacted 13; B: initial incision for the exposure of 13 by means of the closed technique; C: tooth 13 exposure, bracket bonding and wire ligation for the traction of tooth; D: flap sutured in its initial position, while the ligation wire emerges through the
incision to be attached to the arch-wire of the fixed orthodontic appliance
Closed eruption38
According to this technique, after local anaesthesia a full-thickness flap is raised, a bracket is placed on the tooth and the flap29,30 is sutured to its initial position (Fig. 3). If the impacted tooth lies in the middle of the alveolar bone, the incision is made on the crest of the alveolar ridge, which bisects the soft tissues of the edentulous area. Surgical burs are used and bone is removed over the incisal portion of the crown so as the placement of the bracket to be facilitated. A ligation wire or a 0.01″
gold chain connects the bracket with the arch wire of the lateral segment of the orthodontic appliance and flaps are fully repositioned. The arch wire or the chain emerges through the flaps from the middle incision. A week later the clinician activates the device, creating the desired direction for the proper eruption of the tooth. Levine and Scope42, moreover, suggested the excision of an ellipsoid segment of keratinized mucosa from the position of the horizontal incision, where tooth eruption is anticipated - this is where the arch wire that connects the impacted tooth with the rest orthodontic appliance emerges.
Balk J Stom, Vol 10, 2006 Management of Anterior Impacted Teeth 5
Indications and contraindications for the technique Whichever technique is used, 2 parameters are of
paramount importance. First, a number of general surgical rules are to be implemented, strictly following the surgical protocol and, second, the technique selection must be based on sound criteria. In detail, as general rules for the surgical exposure of impacted teeth, the following are mentioned:
Before surgery, space must have been created in the dental arch for the proper alignment of the impacted tooth. This space must be marginally larger than the width of the impacted tooth and allow the development of attached gingiva. Pre-surgical space recovery is also important, because it allows the tooth to erupt in a normal fashion, which is considered ideal43,44; The incision design must aim at preserving the attached gingiva7; For successful bracket bonding, sufficient access to the impacted tooth enamel must be obtained27; The least possible amount of epithelial tissue must be removed, for the bonding to be performed in conditions void of saliva and blood. As much as possible dental follicle must be maintained, which later helps in the epithelial attachment formation7; The proper orientation of the orthodontic traction of the impacted tooth must be facilitated, so as to erupt through gingiva and not through oral mucosa19; Post-surgically, conditions for health maintenance of the previously impacted tooth and its surrounding tissues must be provided8,34,35,41; No intervention, mechanical or chemical, must be performed apically to the CEJ of the impacted tooth. Animal experiments have shown a close relation between the injury of this area and recession45. Flap must extend 2-3 mm coronally to the CEJ, as this helps the connective tissue attachment to the bone and cementum and avoids epithelial obstruction from the labial mucosa. This is an important detail because, during tooth movement and due to tension, apical displacement of the attached gingiva that surrounds the erupting tooth takes place, and not abiding by it leads to recession and unacceptable aesthetic outcome8; The wound will be much smaller if the bracket placement is performed simultaneously with the surgery; The etchant used for bracket bonding must not come to contact with the root and the soft tissues; Suturing must be performed with silk sutures, which must be removed 7-10 days after surgery. Also, to pre- vent epithelial tissues to cover the exposed tooth, if the bracket is to be bonded in a later appointment, surgical cement usage is recommended.
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-
-
-
-
-
-
-
-
-
Proper tissue repositioning; Absence of inflammation (which may result, among other things, to bone loss, which is even greater when ortho dontic tooth movement coexists); Mild forces usage; Atraumatical surgery and minimal bone loss, something that other researchers also emphasize34,35,41. Factors influencing method selection may be: Labial or palatal tooth impaction30 and tooth inclination; Width of the bone that covers the impacted tooth crown; Oral hygiene and especially the periodontal tissues healthy condition and the amount that can be involved in surgery30.
The gingivectomy technique is mainly indicated in impacted teeth with palatal, superficial crown position and in a limited number of other cases, in which the extents of the incision are limited to the keratinized epithelium. In all other cases the method is contraindicated, and so the “trans-mucosal window” technique is seldom used.
In contrast to the previous method, APF is mostly used in canines with labial17,39, superficial location, with a short distance from the gingival margin34. It is also common in cases of anterior impacted teeth where more attached gingiva is needed, or the impacted tooth is late- rally positioned to the edentulous area38. APF limitations include cases where the impaction is too high near the ves- tibule or too deep in the jaw bone30,31,34.
In cases where the impacted tooth is located deep in the jaw bone and/or near the nasal spine, the CE technique is usually indicated17,34. Fournier17 reports he always uses this technique in cases with palatally impacted teeth.
Advantages and disadvantages of the methods Much research has been devoted to the surgical pha-
se of the anterior impacted teeth management, with the results of the comparison of the various surgical techni- ques not always in agreement.
The gingivectomy technique has the advantage of not requiring the presence of the orthodontist during surgery, since the bracket can be placed at a later time37. Another important fact is that, in relation to the other techniques, it is much easier. Yet, this technique does not respect the soft tissues much (simple complete exposure)8, leading, in the recent years, in a declining support for this method. It has also been observed that the aligned teeth, which have been exposed with gingivectomy, later present deficient attached gingiva and marginal gingival overgrowth47, situations that compromise the periodontal support of these teeth.
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6 Dimitrios Hatziemmanuil et al. Balk J Stom, Vol 10, 2006
hygiene with the better resistance of the tooth to physi- cal trauma from brushing48. This happens because the ap propriate width of attached gingiva is created around the erupting tooth. Additional advantages are the much less stressing and almost non-destructive handling of the perio- dontal tissues of the adjacent teeth, and minimal alveolar bone excision around the crown of the impacted tooth. Furthermore, no periodontal tissues apically to the CEJ are removed, thus preventing gingival recession and bone loss47. Scientific research has revealed some disadvan- tages of this method, such as the increased risk for attach- ment loss in labially impacted teeth with a thin labial bony wall38. Also, with the APF technique, gingival scars have been observed around the aligned teeth due to the ortho- dontic movement. Another study reported that 61% of the teeth treated with APF relapsed and submerged after treat- ment, possibly because of the tension applied from the mucosa in deep impactions, whose action is released after the orthodontic appliance has been removed38.
Finally, as an advantage for the increasingly used CE technique is mentioned that the tooth maintains the neces- sary attached gingiva width during eruption and no stress is applied to the soft tissues around this and the adjacent teeth47. Also, healing is facilitated, while the bonded bracket is found to be well tolerated by the tissues, without significant signs of soft tissue inflammation34,49. In addi- tion, this treatment modality simulates better the normal tooth eruption31, because together with the tooth move- ment a slow migration of the gingiva takes part, which results in a better aesthetic outcome. Its shortcoming is that bone removal, besides osseous support problems, bears the risk of ankylosis of the impacted tooth when it is extended beyond their anatomical crown27,50. There is also the risk of a second surgery, in case of an undesirable bracket de-bonding during traction and before eruption.
Orthodontic Management of Impacted Anterior Teeth
Orthodontics occupies a great part of the manage- ment of the anterior impacted teeth, since before surgery (pre-surgical orthodontic treatment) it creates the precon- ditions necessary for the impacted tooth alignment, and after surgery (post-surgical orthodontic treatment) relo- cates the tooth to its proper position in the dental arch. In the rare occasions where no orthodontic treatment is used in the management of such problems, significant disadvan- tages…
reviewed. Techniques regarding the surgical as well as the orthodontic aspect of their management are described. Mainly the 3 surgical techniques for the exposure of anterior impacted teeth are presented, which should be chosen in regards on the site of impaction; namely, they are the gingivecto- my, the apically positioned flap, and the closed eruption technique. The basic principles of the orthodontic treatment of anterior impacted teeth are also presented, by which teeth could be properly aligned in the dental arch. This orthodontic treatment comprises 2 phases, the pre-surgical and the post-sur- gical phase. The biological rules for the protection of the periodontium and for the safe alignment of anterior impacted teeth are finally described. Keywords: Anterior Impacted Teeth; Surgery; Orthodontics
Dimitrios Hatziemmanuil1, Labros Zouloumis2, Nikolaos Topouzelis3
Aristotle University, Faculty of Dentistry Thessaloniki, Greece 1Private Dentist 2Department of Oral and Maxillofacial Surgery 3Department of Orthodontics
REVIEW PAPER (RP) Balk J Stom, 2006; 10:
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141
Surgical and Orthodontic Management of Impacted Anterior Teeth
TUPNB UP
HJ D B M! !T P D JF U Z
Introduction
Impacted are the permanent teeth which stay within the jaw bone after their normal eruption time and are surrounded by the dental follicle, which has no com- munication with the oral cavity1,2. The causes for anterior teeth impaction can be local and/or systemic. An important role plays the multigenetic and multifactorial heritability3,4. Studies have shown that about 1-2% of occlusal problems correlate to impacted anterior teeth5,6. More frequent are the palatally impacted teeth with a frequency double that of the labially impacted anterior teeth.
The alignment of the anterior impacted teeth is essential, because otherwise complications occur, such as ankylo sis, external root resorption, recession, bone loss and risk for the health of the adjacent teeth7. There are, though, cases for which the ideal treatment is not feasible and in such cases the outcome may be tooth extraction8,9.
The possible causes, the impaction frequency and the location of the impacted anterior teeth are important for the clinical practice. Of particular interest are the surgical and orthodontic techniques used for the exposure and subsequent alignment of the anterior impacted teeth.
Treatment of anterior impacted teeth may require the cooperation of various dental disciplines, mainly radio- logy, oral surgery and orthodontics. In radiology, whose main role is to identify the impacted tooth location, the
various techniques used are panoramic radiographs, intraoral periapical radiographs (using Clark’s technique for the identification of the labio-palatal location of the impacted tooth), bite-wing radiographs and tomography, individually modified for the requirements of each case10. For the surgical phase of the treatment of impacted teeth many techniques have been developed. Among them, the most important are the closed eruption technique (CE), the apically positioned flap (APF), being the most conservative, and the open technique with a transmucosal “window” - gingivectomy (GE). Different methods have been used for the orthodontic force application from time to time, for the proper alignment of these teeth, such as brackets placed in holes opened in the crown of the exposed teeth, cervical wire loops, gold or silver teeth veneers equipped with brackets or hooks, hoods directly bonded to the teeth, etc11.
Frequency and Location of Anterior Teeth Impaction
The anterior teeth most frequently impacted are upper canines, followed by upper lateral incisors, upper central incisors, lower canines, and lower incisors12. The
2 Dimitrios Hatziemmanuil et al. Balk J Stom, Vol 10, 2006
location of the anterior impacted teeth and their respective frequencies were studied by many researchers, with results not always agreeing with each other. It is reported that the impaction frequency for the upper canines is 0.92% according to Dachi and Howell13 and 1.7% according to Thilander and Jacobsson14, and that it more often appears in Caucasians and, according to others, more frequently in women than in men15. More frequent is, finally, the palatal impaction of the canine (80%)16. Fournier17 agrees that the palatally impacted teeth are more frequent than the labially impacted, with a proportion of 2:1. According to the same author, the palatally impacted teeth are located closely to the roots of the adjacent incisors and the nasal cavity.
Others differentiate the location frequency according to the geographical latitude, reporting that the upper central incisors are the third most frequently impacted teeth in the Caucasians, while in Asians it is even more frequent18. In a more generalized report5-6, it is argued that about 1-2% of the occlusal problems concern the labially impacted anterior teeth and their categorization was as follows:
Category A D < 12 mm Category B 12 mm < D < 15 mm Category C D > 15 mm (D: the distance of the incisal edge from the occlusal
plane of the anterior teeth measured on the panoramic radiography).
Reasons of Impaction
The causes of impaction are local and systemic. Heredity also plays an important role. Systemic causes inclu de cleft palate, cleidocranial dysostosis, osteopetrosis, various syndromes, etc12. Local factors are equally important. The usual eruption time for the canines is 11-12 years for the upper and 9-11 for the lower19. The eruption of the upper canine sometimes delays. This is attributed to the longer formation period, simultaneously to the longer eruption path20. Some authors21,22 refer to the role the anterior crowding plays in relation to the impacted canines, arguing that, since the canine is the last tooth that erupts in the dentition, a bit more labially to the arch line (and slightly more labially to the deciduous canine), when anterior crowding exists, for the permanent canine may remain unerupted. The prolonged presence of the predecessor primary tooth in the dental arch, due to trauma or advanced caries, also plays an important role. In the latter situation, the development of post-trauma or post- extraction healing tissue may weaken the eruption force. Another challenging situation exists when pathological tissue is located near the dental germs of the erupting teeth and hinders their emergence in the dental arch. Such situations are odontomas12, as well as odontogenic cysts9.
Many cases with impacted teeth are caused by super- numerary teeth due to hereditary influence. This view has
been documented by various researchers. Specifically, Sta fne23, in a sample of 200 cases with supernumerary teeth, found genetic influence in 90% of the sample. Also, Brook24 found an even greater frequency of super- numerary teeth in first-degree relatives of patients with supernumerary teeth, compared to the general population. Carton and Rees25 found twins with exactly the same dental anomalies, including supernumerary teeth.
Surgical Management of Impacted Anterior Teeth and Orthodontic Placement of Bracket
Many surgical techniques have been reported in the international literature for the management of anterior impacted teeth. The most frequent in the past were the radical technique with gingivectomy (trans-mucosal win- dow), and the apically positioned flap (APF) 8,26-28. Less frequent was the closed eruption (CE) technique17,29-34. The latter 2 belong to conservative techniques.
Gingivectomy35
This technique, according to Vanarsdall and Corn8, is called trans-mucosal window or simple complete exposure and is described as follows: after radiographic examination and identification of the crown position, an incision is made and the crown is exposed without flap creation, with the creation of a “window”, until the crown is visible (Fig. 1). The “window” is created with the layered excision of the overlying tissues (mucosa, periosteum, part of the dental follicle), separately or in toto, depending on the distance from the alveolar ridge and tooth location. This detail is significant, bearing in mind that this soft tissue will eventually become the attached gingiva in the normal dental arch; performing a bevelled incision will result in periodontal problems12. Special attention must be paid to the direction of soft tissue removal (mucosa), which must be bevelled to the impacted tooth cervix.
The incision design used plays an important role to the treatment outcome. Usually, in labially impacted anterior teeth the semilunar incision is preferred, while in palatally impacted teeth the options are the semilunar incision, the cruciform incision or even the intra-sulcular marginal incision (including the interdental papillae) or the para- marginal incision (excluding the interdental papillae) 36. It is up to the discretion of the surgeon to place a bracket (or any other kind of attachment) to the incisal third of the tooth at the same day. Yet, if the bracket is not placed during surgery and the trans-mucosal window is post- surgically covered by epithelial cells, then a second surgery is needed37. For this reason, and also for the control of the peripheral capillary bleeding, it is better to cover the crown with surgical cement for a week and then to uncover it.
Balk J Stom, Vol 10, 2006 Management of Anterior Impacted Teeth 3
Figure 1. A and B: clinical and radiographic view of the impacted tooth 13, while the tooth 53 remains in the dental arch; C: “Window” opening, extraction of the tooth 53 and segmental arch-wire insertion for the tooth 13 traction; D: alignment of the tooth 13 by means of a continuous upper
arch-wire; E: clinical view of the tooth 13 after the orthodontic appliance removal
Figure 2. A: clinical view of the impacted tooth 33, while the tooth 73 remains in the dental arch; B: Initial incision for the tooth 33 exposure; C: exposure of the tooth 33, with a flap reflection and extraction of the tooth 73; D: suturing of the apically repositioned flap
4 Dimitrios Hatziemmanuil et al. Balk J Stom, Vol 10, 2006
Apically positioned flap38
According to this technique, previously mentioned as Kincaid’s technique8,11,39-41, after local anaesthesia a flap is raised from the edentulous area or from the area of the impacted tooth, protecting as much as possible the attached gingiva (Fig. 2). In special cases, usually of impacted canines which have a more vertical direction and lie above their normal anatomical position, the surgery is performed both labially and palatally, in order to free the tooth from its bony crypt17. The bone covering the crown is removed. The two thirds of the crown are exposed and the dental follicle is removed from the margins of the exposed crown.
Vanarsdall and Corn8 stress that surgical manipulation must avoid areas apically to the cemento-enamel junction (CEJ) because in this area new attachment formation is anticipated. The flap is sutured with the periosteum and one half to two thirds of the crown are left exposed. Surgical cement is placed over enamel, to avoid soft tissue swelling. A week later, the cement is removed and the patient is instructed to keep this area of the crown clean. 2 weeks after surgery or 7-10 days after surgery, along with suture removal8, a bracket is bonded on the exposed tooth. The more horizontal is the position of the tooth the more incisally the bracket is placed, in order to achieve orthodontic traction with the desirable tooth inclination.
Figure 3. A: radiographic view of the highly-impacted 13; B: initial incision for the exposure of 13 by means of the closed technique; C: tooth 13 exposure, bracket bonding and wire ligation for the traction of tooth; D: flap sutured in its initial position, while the ligation wire emerges through the
incision to be attached to the arch-wire of the fixed orthodontic appliance
Closed eruption38
According to this technique, after local anaesthesia a full-thickness flap is raised, a bracket is placed on the tooth and the flap29,30 is sutured to its initial position (Fig. 3). If the impacted tooth lies in the middle of the alveolar bone, the incision is made on the crest of the alveolar ridge, which bisects the soft tissues of the edentulous area. Surgical burs are used and bone is removed over the incisal portion of the crown so as the placement of the bracket to be facilitated. A ligation wire or a 0.01″
gold chain connects the bracket with the arch wire of the lateral segment of the orthodontic appliance and flaps are fully repositioned. The arch wire or the chain emerges through the flaps from the middle incision. A week later the clinician activates the device, creating the desired direction for the proper eruption of the tooth. Levine and Scope42, moreover, suggested the excision of an ellipsoid segment of keratinized mucosa from the position of the horizontal incision, where tooth eruption is anticipated - this is where the arch wire that connects the impacted tooth with the rest orthodontic appliance emerges.
Balk J Stom, Vol 10, 2006 Management of Anterior Impacted Teeth 5
Indications and contraindications for the technique Whichever technique is used, 2 parameters are of
paramount importance. First, a number of general surgical rules are to be implemented, strictly following the surgical protocol and, second, the technique selection must be based on sound criteria. In detail, as general rules for the surgical exposure of impacted teeth, the following are mentioned:
Before surgery, space must have been created in the dental arch for the proper alignment of the impacted tooth. This space must be marginally larger than the width of the impacted tooth and allow the development of attached gingiva. Pre-surgical space recovery is also important, because it allows the tooth to erupt in a normal fashion, which is considered ideal43,44; The incision design must aim at preserving the attached gingiva7; For successful bracket bonding, sufficient access to the impacted tooth enamel must be obtained27; The least possible amount of epithelial tissue must be removed, for the bonding to be performed in conditions void of saliva and blood. As much as possible dental follicle must be maintained, which later helps in the epithelial attachment formation7; The proper orientation of the orthodontic traction of the impacted tooth must be facilitated, so as to erupt through gingiva and not through oral mucosa19; Post-surgically, conditions for health maintenance of the previously impacted tooth and its surrounding tissues must be provided8,34,35,41; No intervention, mechanical or chemical, must be performed apically to the CEJ of the impacted tooth. Animal experiments have shown a close relation between the injury of this area and recession45. Flap must extend 2-3 mm coronally to the CEJ, as this helps the connective tissue attachment to the bone and cementum and avoids epithelial obstruction from the labial mucosa. This is an important detail because, during tooth movement and due to tension, apical displacement of the attached gingiva that surrounds the erupting tooth takes place, and not abiding by it leads to recession and unacceptable aesthetic outcome8; The wound will be much smaller if the bracket placement is performed simultaneously with the surgery; The etchant used for bracket bonding must not come to contact with the root and the soft tissues; Suturing must be performed with silk sutures, which must be removed 7-10 days after surgery. Also, to pre- vent epithelial tissues to cover the exposed tooth, if the bracket is to be bonded in a later appointment, surgical cement usage is recommended.
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Proper tissue repositioning; Absence of inflammation (which may result, among other things, to bone loss, which is even greater when ortho dontic tooth movement coexists); Mild forces usage; Atraumatical surgery and minimal bone loss, something that other researchers also emphasize34,35,41. Factors influencing method selection may be: Labial or palatal tooth impaction30 and tooth inclination; Width of the bone that covers the impacted tooth crown; Oral hygiene and especially the periodontal tissues healthy condition and the amount that can be involved in surgery30.
The gingivectomy technique is mainly indicated in impacted teeth with palatal, superficial crown position and in a limited number of other cases, in which the extents of the incision are limited to the keratinized epithelium. In all other cases the method is contraindicated, and so the “trans-mucosal window” technique is seldom used.
In contrast to the previous method, APF is mostly used in canines with labial17,39, superficial location, with a short distance from the gingival margin34. It is also common in cases of anterior impacted teeth where more attached gingiva is needed, or the impacted tooth is late- rally positioned to the edentulous area38. APF limitations include cases where the impaction is too high near the ves- tibule or too deep in the jaw bone30,31,34.
In cases where the impacted tooth is located deep in the jaw bone and/or near the nasal spine, the CE technique is usually indicated17,34. Fournier17 reports he always uses this technique in cases with palatally impacted teeth.
Advantages and disadvantages of the methods Much research has been devoted to the surgical pha-
se of the anterior impacted teeth management, with the results of the comparison of the various surgical techni- ques not always in agreement.
The gingivectomy technique has the advantage of not requiring the presence of the orthodontist during surgery, since the bracket can be placed at a later time37. Another important fact is that, in relation to the other techniques, it is much easier. Yet, this technique does not respect the soft tissues much (simple complete exposure)8, leading, in the recent years, in a declining support for this method. It has also been observed that the aligned teeth, which have been exposed with gingivectomy, later present deficient attached gingiva and marginal gingival overgrowth47, situations that compromise the periodontal support of these teeth.
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6 Dimitrios Hatziemmanuil et al. Balk J Stom, Vol 10, 2006
hygiene with the better resistance of the tooth to physi- cal trauma from brushing48. This happens because the ap propriate width of attached gingiva is created around the erupting tooth. Additional advantages are the much less stressing and almost non-destructive handling of the perio- dontal tissues of the adjacent teeth, and minimal alveolar bone excision around the crown of the impacted tooth. Furthermore, no periodontal tissues apically to the CEJ are removed, thus preventing gingival recession and bone loss47. Scientific research has revealed some disadvan- tages of this method, such as the increased risk for attach- ment loss in labially impacted teeth with a thin labial bony wall38. Also, with the APF technique, gingival scars have been observed around the aligned teeth due to the ortho- dontic movement. Another study reported that 61% of the teeth treated with APF relapsed and submerged after treat- ment, possibly because of the tension applied from the mucosa in deep impactions, whose action is released after the orthodontic appliance has been removed38.
Finally, as an advantage for the increasingly used CE technique is mentioned that the tooth maintains the neces- sary attached gingiva width during eruption and no stress is applied to the soft tissues around this and the adjacent teeth47. Also, healing is facilitated, while the bonded bracket is found to be well tolerated by the tissues, without significant signs of soft tissue inflammation34,49. In addi- tion, this treatment modality simulates better the normal tooth eruption31, because together with the tooth move- ment a slow migration of the gingiva takes part, which results in a better aesthetic outcome. Its shortcoming is that bone removal, besides osseous support problems, bears the risk of ankylosis of the impacted tooth when it is extended beyond their anatomical crown27,50. There is also the risk of a second surgery, in case of an undesirable bracket de-bonding during traction and before eruption.
Orthodontic Management of Impacted Anterior Teeth
Orthodontics occupies a great part of the manage- ment of the anterior impacted teeth, since before surgery (pre-surgical orthodontic treatment) it creates the precon- ditions necessary for the impacted tooth alignment, and after surgery (post-surgical orthodontic treatment) relo- cates the tooth to its proper position in the dental arch. In the rare occasions where no orthodontic treatment is used in the management of such problems, significant disadvan- tages…
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