Treatment of dental inclusion
Introduction :
- Dental inclusions of the incisors and especially of the maxillary canines confront the orthodontist with a complex but relatively frequent situation.
- Their therapeutic approach involves multidisciplinary collaboration where the surgical-orthodontic protocol is carried out in close collaboration with periodontal surgery.
1. Therapeutic decisions:
Is done after an analysis of clinical and radiological data:
a- Placement of impacted teeth (surgical or surgical-orthodontic).
b – Abstention: in the event of:
– Impossible to set up.
– Difficult extraction: damage to neighboring teeth, significant bone decay.
-Patient refusal
c- Extraction: in case of:
– Impossible to set up.
– Accidents due to inclusion (mechanical, infectious, tumoral, nervous, etc.)
- Decision factors:
– Patient-related factors:
- Motivation: duration, possibility of multiple interventions, modification of equipment.
- Patient’s possibilities: financial, professional, distance.
- Age of patient: Possibilities of eruption and cellular activity are more favorable in young people
– Factors related to surgical possibilities:
– General condition of the patient: Bone or blood diseases contraindicate surgery.
– Position of the tooth: Highly placed tooth, horizontal position, risk of decay, damage to neighboring teeth, sinuses, etc.
– Factors related to orthodontic possibilities:
- Practitioner related: have a TQ controlling tooth movement.
- Associated dysmorphoses: implementation undertaken if it provides an aesthetic and/or functional result.
2. Exclusive surgical procedures:
In the event of an obstacle in the path of eruption, surgery alone can prevent inclusion if the procedure is performed before the normal date of eruption or hope for a spontaneous eruption if it is not old at the date of eruption.
- Conductive alveolectomy: allows:
- Free the eruption path
- Remove any obstacles
- Remove the bone surrounding the tooth by exposing 2/3 of the root.
- Take advantage of the natural eruptive potential.
- Induction alveolectomy: allows
– Remove the pericoronal sac (denudation limited to the crown)
– Trigger spontaneous eruption by periapical bone apposition.
- Reimplantation (self transplantation):
– Carried out in the event that functional implementation is not possible, before the constitution of the apical 1/3
– Consists of extracting the impacted tooth and placing it in a new position in a prepared socket on the arch.
– 3-week stabilization.
– Carrying out a root canal treatment.
– Immediate result in a single intervention but presents the risk of rhizalysis.
- Immediate surgical correction:
– Allows you to correct the position of the tooth without moving its apex.
– Indicated in case of canine in high position, apex close to its normal place.
– Mobilization to the syndesmotome.
– Quick method but presents the risk of ankylosis.
3. Orthodontic solutions: (Combined surgical-orthodontic treatment)
Combining the advantages of surgery with orthodontic possibilities increases the chances of functional placement on the arch, a better result and long-term sustainability.
It is a long technique and possible at any age, but requires impeccable motivation on the part of the patient. It goes through the following stages:
- Pre-surgical orthodontic preparation: consists of:
- Arrange the future site of the impacted tooth by creating sufficient space on the arch, this can be:
- Without extraction: correction of malpositions and closure of diastemas.
- With extraction: In case of DDM or Cl II (exo of the first premolars).
- The installation of an anchor for the traction of the tooth as soon as it is released: can be ensured by:
– fixed multi-attachment device: the anchoring concerns the entire arch
– Implants or mini-implants: have the advantage of:
– Can be installed in a low-height area (reduced size).
– Immediate charging
– Resistant to orthodontic forces and without parasitic effects on the entire arch.
– Easy removal without after-effects.
- Surgical phase of disinclusion :
- Surgical approach:
– Canine in low vestibular position :
The crown is released using a simple apical translation flap via the vestibular approach with two parallel vertical incisions and a third which delimits the lower edge of the flap.
– Canine in high vestibular position:
- To release a portion of the crown of the impacted tooth, extensive detachment of the covering tissues is necessary by a repositioned flap:
- A horizontal incision to release all of the attached gingiva.
- A vertical discharging incision in front of the central incisor.
- The tooth will be pulled through the fibromucosa curtain.
– Canine in palatal position:
- Palatal flap: Incision at the level of the gingival sulcus of the 2nd premolar up to the central incisor
- Orthodontic traction aims firstly to move the canine away from the lateral root
- Once the tooth is exposed, the traction will, in a second stage, be vestibular and occlusal.
– Incisors:
- Always vestibular approach.
- The flap is made by two vertical incisions and one horizontal one at the level of the attached gingiva.
- Anchoring techniques:
– Intracoronal anchoring: mutilating the crown with a risk of pulp necrosis.
– Pericoronary anchoring: Ligature at the neck, significant coronary clearance, ankylosis phenomenon.
– Sealed caps and rings: significant clearance, periodontal disease.
– Bonded attachments: reduced dimensions, limited bone clearance.
3-3 Post-surgical orthodontic phase:
– This is the placement on the arch of the included tooth.
– Consists of connecting the force transmitters to the force generators.
– Force transmitters: means of anchoring the included tooth
– Force generators: Elastic tractions.
The forces must be light (50g) and continuous, which helps to avoid parasitic movements and preserve the periodontium .
Treatment of dental inclusion
4. Therapeutic failures:
– Immediate total failure: extraction.
– Potential short-term failure: mucogingival problems, tooth mobility, loosening of the anchor.
– Long-term failure: at the level of other teeth (rhizalignment of the roots of the lateral incisors and first premolars, parasitic movements, pulp mortification).
Conclusion
- The placement of the impacted tooth is rarely a simple process, the patient should be warned of the duration and risks involved.
- This multidisciplinary procedure now offers a more favorable prognosis thanks to developments in imaging, materials and consideration of the periodontal environment.
Treatment of dental inclusion
Deep cavities may require root canal treatment.
Interdental brushes effectively clean between teeth.
Misaligned teeth can cause chewing problems.
Untreated dental infections can spread to other parts of the body.
Whitening trays are used for gradual results.
Cracked teeth can be repaired with composite resins.
Proper hydration helps maintain a healthy mouth.