Treatment of dental inclusion
INTRODUCTION :
The refinement of clinical and radiological diagnostic techniques now makes it possible to precisely locate the retained teeth and guide the practitioner towards a rigorous and reasoned surgical protocol, which is best adapted to the functional and aesthetic requirements.
Various therapeutic attitudes can be adopted, ranging from abstention to extraction, including orthodontic-surgical disinclusion.
- Definition :
“An impacted tooth is a tooth retained in the maxilla, absent from the arch beyond the normal date of its eruption and surrounded by a pericoronal sac without communication with the oral cavity.”
“An impacted tooth is a tooth retained in the maxilla beyond the normal date of its eruption and whose pericoronal sac is partially or totally open into the oral cavity.”
- Epidemiology :
Dental inclusion can affect all permanent teeth, at varying frequencies. The most affected teeth are, in order of frequency:
(1) The mandibular wisdom teeth which are by far the most affected followed by their maxillary counterparts.
(2) The upper canines
(3) Upper and lower premolars : especially the lower second PM.
(4) Upper central incisors : Lower incisors are very rarely affected.
(5) Mandibular canines : having an inclusion frequency 10 to 20 times lower than the upper canine.
(6) The mandibular incisors .
The 1st and 2nd molars .
- Treatment :
- Decision factors:
- The patient’s general condition:
- Patient psychology:
- The patient’s age:
- Patient hygiene
- The study of dysmorphosis or global malocclusion,
- The study of teeth:
- Analysis of the periodontal state
- Detection of dysfunctions
- Preventive and interceptive treatments:
- Avulsion of the temporary tooth :
In order to modify the path of eruption of the permanent tooth, because an evolving tooth moves “in the path of least resistance”. However, the space should be kept clear in order to avoid mesialization of the posterior sector.
- Maintaining the space allocated to the included tooth:
Premature loss of the temporary tooth requires the possible placement of a space maintainer.
- Avulsion of supernumerary teeth:
Supernumerary germs and odontomas must be diagnosed and avulsed early, in order to prevent the risk of inclusions.
- Therapeutic closure of an interincisal diastema:
After resection of a hypertrophic labial frenum with low insertion, or avulsion of a mesiodens.
- Transverse expansion of the maxilla:
Increasing the available space by orthopedic devices (disjunctor, palatal expander or quad’helix).
- Orthodontic rearrangement of the necessary space:
It is made possible by the distalization devices of the lateral sectors.
- Germectomy or extraction of permanent teeth: in the presence of severe DDM: mainly concerns premolars, but also lay molars (piloted extractions).
- Care of temporary molars to avoid their extraction, and therefore the loss of space reserved for the successor tooth. These teeth serve as natural space maintainers.
- Curative treatment:
- Extraction of the impacted tooth:
This exceptional therapeutic decision is indicated when the included tooth is associated with nervous complications (pain), infections, mechanical complications, tumor complications , significant coronoradicular angulation or when it represents a danger for an adjacent tooth.
- Abstention:
Patient who refuses orthodontic treatment and the impacted tooth presents no threat to the environment.
The impossibility of putting the included tooth in place (its position, ankylosis, avoid an avulsion that is too damaging.
Regular monitoring will be necessary in order to detect any progressive pathology of the tooth left in place.
- Exclusive surgery:
- Induction alveolectomy:
It surgically creates an eruption pathway by removing any bony obstacles that cover the crown and eliminating the pericoronal periodontal fibrous tissue.
- Autotransplantation
It is the reimplantation in a newly formed alveolus at the level of the physiological eruption site of the extracted included tooth. The major risk of this intervention is the process of ankylosis-rhizalysis.
- Orthodontic-surgical treatment:
If the means of prophylaxis of inclusion have not been implemented in time, have failed or if the patient came to consult too late, orthodontic and surgical therapy is undertaken.
Surgical-orthodontic placement of the impacted tooth sometimes has limitations. It is contraindicated when the impacted tooth has:
- Ankylosis
- Wrong orientation (horizontal).
- A risk of mortification or resorption of the neighboring tooth.
- A coronal or radicular anomaly.
- A very ectopic situation, very far from the arch, which could make the surgical procedure mutilating.
- Pre-surgical orthodontic preparation:
The objective of this phase is to
- make an anchor unit to pull the included tooth,
- develop its future site by reserving or creating a place for it after removing the obstacles.
Different stages:
- Alignment of teeth.
- Maintaining and/or opening the necessary space:
- Preparing the anchor unit
Anchoring methods:
- Miniscrews and mini implants
- Removable or mixed device (fixed and removable)
- Multi-attachment device with anchoring auxiliaries (transpalatal arch, lingual arch, etc.)
- Surgical time:
As before any surgical intervention, an assessment of the patient’s general condition will be carried out.
The surgical phase is divided into 3 stages:
- The mucosal time, which corresponds to the preparation of the flap access
- The bone time, which corresponds to the release of the bone table;
- The dental time which corresponds to the positioning and fixing of the coronal anchoring means (traction device).
The type of dental inclusion and its location will determine the surgical approach (which can be vestibular or palatal), and the choice of the appropriate technique for its removal which best respects the tooth and its periodontal environment.
Selection and bonding of the traction device:
” Glued fasteners” constitute a process of choice combining both the preservation of periodontal tissues and dental tissue integrity.
The positioning of the bracket can be determined based on the clinical situation of the tooth and the direction of orthodontic traction to guide it into its previously prepared alveolar site.
Treatment of dental inclusion
- Post-surgical orthodontic phase:
Its purpose is to place it on the arch of the included tooth. The force transmitters must be connected to the “force generators” in an ideal position in order to guide the eruption of the tooth.
The choice of traction method is up to the orthodontist who intervenes two weeks after the disinclusion. It is essential to apply a reasoned mechanics while being particularly attentive:
- To the means generating force;
- To the intensity of the forces involved;
- To the traction direction
It is indeed necessary to be able to prevent the appearance of periodontal lesions.
Treatment of dental inclusion
CONCLUSION :
In the management of patients with dental inclusion(s), the best approach remains early diagnosis, to limit the complications caused by the delayed eruption of the impacted tooth.
Guided extractions of deciduous teeth and removal of eruption obstacles can alter certain orientations in the eruption path.
When the indication for surgical release is established, only an excellent preoperative study taking into account the position of the retained tooth, its relationship with adjacent teeth, the importance and height of the dystopia, the surrounding muco-gingival context, will allow the most appropriate surgical technique to be chosen.
Treatment of dental inclusion
Untreated cavities can damage the pulp.
Orthodontics aligns teeth and jaws.
Implants replace missing teeth permanently.
Dental floss removes debris between teeth.
A visit to the dentist every 6 months is recommended.
Fixed bridges replace one or more missing teeth.
Treatment of dental inclusionTreatment of dental inclusion
INTRODUCTION :
The refinement of clinical and radiological diagnostic techniques now makes it possible to precisely locate the retained teeth and guide the practitioner towards a rigorous and reasoned surgical protocol, which is best adapted to the functional and aesthetic requirements.
Various therapeutic attitudes can be adopted, ranging from abstention to extraction, including orthodontic-surgical disinclusion.
- Definition :
“An impacted tooth is a tooth retained in the maxilla, absent from the arch beyond the normal date of its eruption and surrounded by a pericoronal sac without communication with the oral cavity.”
“An impacted tooth is a tooth retained in the maxilla beyond the normal date of its eruption and whose pericoronal sac is partially or totally open into the oral cavity.”
- Epidemiology :
Dental inclusion can affect all permanent teeth, at varying frequencies. The most affected teeth are, in order of frequency:
(1) The mandibular wisdom teeth which are by far the most affected followed by their maxillary counterparts.
(2) The upper canines
(3) Upper and lower premolars : especially the lower second PM.
(4) Upper central incisors : Lower incisors are very rarely affected.
(5) Mandibular canines : having an inclusion frequency 10 to 20 times lower than the upper canine.
(6) The mandibular incisors .
The 1st and 2nd molars .
- Treatment :
- Decision factors:
- The patient’s general condition:
- Patient psychology:
- The patient’s age:
- Patient hygiene
- The study of dysmorphosis or global malocclusion,
- The study of teeth:
- Analysis of the periodontal state
- Detection of dysfunctions
- Preventive and interceptive treatments:
- Avulsion of the temporary tooth :
In order to modify the path of eruption of the permanent tooth, because an evolving tooth moves “in the path of least resistance”. However, the space should be kept clear in order to avoid mesialization of the posterior sector.
- Maintaining the space allocated to the included tooth:
Premature loss of the temporary tooth requires the possible placement of a space maintainer.
- Avulsion of supernumerary teeth:
Supernumerary germs and odontomas must be diagnosed and avulsed early, in order to prevent the risk of inclusions.
- Therapeutic closure of an interincisal diastema:
After resection of a hypertrophic labial frenum with low insertion, or avulsion of a mesiodens.
- Transverse expansion of the maxilla:
Increasing the available space by orthopedic devices (disjunctor, palatal expander or quad’helix).
- Orthodontic rearrangement of the necessary space:
It is made possible by the distalization devices of the lateral sectors.
- Germectomy or extraction of permanent teeth: in the presence of severe DDM: mainly concerns premolars, but also lay molars (piloted extractions).
- Care of temporary molars to avoid their extraction, and therefore the loss of space reserved for the successor tooth. These teeth serve as natural space maintainers.
- Curative treatment:
- Extraction of the impacted tooth:
This exceptional therapeutic decision is indicated when the included tooth is associated with nervous complications (pain), infections, mechanical complications, tumor complications , significant coronoradicular angulation or when it represents a danger for an adjacent tooth.
- Abstention:
Patient who refuses orthodontic treatment and the impacted tooth presents no threat to the environment.
The impossibility of putting the included tooth in place (its position, ankylosis, avoid an avulsion that is too damaging.
Regular monitoring will be necessary in order to detect any progressive pathology of the tooth left in place.
- Exclusive surgery:
- Induction alveolectomy:
It surgically creates an eruption pathway by removing any bony obstacles that cover the crown and eliminating the pericoronal periodontal fibrous tissue.
- Autotransplantation
It is the reimplantation in a newly formed alveolus at the level of the physiological eruption site of the extracted included tooth. The major risk of this intervention is the process of ankylosis-rhizalysis.
- Orthodontic-surgical treatment:
If the means of prophylaxis of inclusion have not been implemented in time, have failed or if the patient came to consult too late, orthodontic and surgical therapy is undertaken.
Surgical-orthodontic placement of the impacted tooth sometimes has limitations. It is contraindicated when the impacted tooth has:
- Ankylosis
- Wrong orientation (horizontal).
- A risk of mortification or resorption of the neighboring tooth.
- A coronal or radicular anomaly.
- A very ectopic situation, very far from the arch, which could make the surgical procedure mutilating.
- Pre-surgical orthodontic preparation:
The objective of this phase is to
- make an anchor unit to pull the included tooth,
- develop its future site by reserving or creating a place for it after removing the obstacles.
Different stages:
- Alignment of teeth.
- Maintaining and/or opening the necessary space:
- Preparing the anchor unit
Anchoring methods:
- Miniscrews and mini implants
- Removable or mixed device (fixed and removable)
- Multi-attachment device with anchoring auxiliaries (transpalatal arch, lingual arch, etc.)
- Surgical time:
As before any surgical intervention, an assessment of the patient’s general condition will be carried out.
The surgical phase is divided into 3 stages:
- The mucosal time, which corresponds to the preparation of the flap access
- The bone time, which corresponds to the release of the bone table;
- The dental time which corresponds to the positioning and fixing of the coronal anchoring means (traction device).
The type of dental inclusion and its location will determine the surgical approach (which can be vestibular or palatal), and the choice of the appropriate technique for its removal which best respects the tooth and its periodontal environment.
Selection and bonding of the traction device:
” Glued fasteners” constitute a process of choice combining both the preservation of periodontal tissues and dental tissue integrity.
The positioning of the bracket can be determined based on the clinical situation of the tooth and the direction of orthodontic traction to guide it into its previously prepared alveolar site.
Treatment of dental inclusion
- Post-surgical orthodontic phase:
Its purpose is to place it on the arch of the included tooth. The force transmitters must be connected to the “force generators” in an ideal position in order to guide the eruption of the tooth.
The choice of traction method is up to the orthodontist who intervenes two weeks after the disinclusion. It is essential to apply a reasoned mechanics while being particularly attentive:
- To the means generating force;
- To the intensity of the forces involved;
- To the traction direction
It is indeed necessary to be able to prevent the appearance of periodontal lesions.
Treatment of dental inclusion
CONCLUSION :
In the management of patients with dental inclusion(s), the best approach remains early diagnosis, to limit the complications caused by the delayed eruption of the impacted tooth.
Guided extractions of deciduous teeth and removal of eruption obstacles can alter certain orientations in the eruption path.
When the indication for surgical release is established, only an excellent preoperative study taking into account the position of the retained tooth, its relationship with adjacent teeth, the importance and height of the dystopia, the surrounding muco-gingival context, will allow the most appropriate surgical technique to be chosen.
Treatment of dental inclusion
Untreated cavities can damage the pulp.
Orthodontics aligns teeth and jaws.
Implants replace missing teeth permanently.
Dental floss removes debris between teeth.
A visit to the dentist every 6 months is recommended.
Fixed bridges replace one or more missing teeth.
Treatment of dental inclusion