Treatment of impacted teeth
Introduction :
This relatively common pathology ( 15% of the population according to LANGLADE and up to 20% for others) can affect all teeth, whether deciduous, permanent or even supernumerary.
Our goal as orthodontists is to implement an effective strategy to restore the functional and aesthetic value of this or these teeth by correctly placing them back on the arch.
We will therefore try to answer certain relevant questions that the orthodontist is confronted with in the presence of dental inclusion(s), namely:
• Decision-making clinical signs that should attract our attention
• Weight of radiographic investigations in the diagnosis
• Choice of therapeutic alternative
Definition :
All teeth go through a stage of physiological inclusion . Pathology is considered present when the tooth remains trapped in the bone and soft tissues beyond the normal eruption date, taking into account the patient’s dental age .
The French Standards Association proposes the following definitions:
Retention :
“It is a generic term for any tooth that remains stuck in the maxilla beyond its normal eruption date.”
Inclusion:
“An impacted tooth is a tooth retained in the maxilla beyond the normal date of its eruption and surrounded by a pericoronal sac without communication with the oral cavity.
Treatment of impacted teeth
Epidemiology :
•According to LANGLADE (1986) the frequency of teeth included in an orthodontic population is 15% , including 1% for mandibular teeth .
• It is the permanent teeth that are most commonly subject to inclusions and the rare discovery of included deciduous teeth is rather described as an accompanying sign of major syndrome and exceptionally as an isolated anomaly ( BIANCHI and ROCCUZZU have identified 10 cases in the literature over the last 20 years, and most often of the 2nd deciduous molar).
The mandibular DDS are the most affected followed by their maxillary counterparts, the upper canines , the upper central incisors , the lower premolars , the mandibular canines and finally the 1st and 2nd molars ; the other teeth are more rarely affected.
•In the mandible, the 1st premolars are twice as often included as the canines: (1st PM : 0.48%, 2nd PM : 0.24% Vs Canines: 0.22%). In the maxilla, with the exception of the 3rd molars , the canines are most often included: 2.84%.
• The upper canine is 20 times more included in the maxilla than in the mandible, palatal in 50% to 85% of cases against 30% in the vestibular while it is in an intermediate situation in 20% of cases, unilateral (80%) rather on the right than on the left.
•The retention of the central incisor is more often unilateral and isolated , however, it can be associated with that of its counterpart, that of the lateral and even that of the canine.
• Variability according to sex shows a slight prevalence in girls 60% , according to ROHRER 1929.
• Finally, 90% of the inclusions are covered mainly by soft tissues .
Diagnosis:
•The diagnosis of any impacted tooth must be made as early as possible in order to monitor its development and implement appropriate treatment at the appropriate time.
• Note that in the absence of the incisor , especially the upper central incisor, parents consult early, as soon as the lateral one appears, which reduces the median space and creates an unsightly asymmetrical situation .
• In contrast, in the case of other teeth , generally no functional clinical sign leads the patient to consult early; their discovery is almost always fortuitous during a screening examination .
Clinical examination:
• Clinical examination allows screening of the anomaly. However, only radiographic examination can confirm a positive diagnosis of dental retention.
A. Exoral examination:
• The exoral signs of inclusion are rare and relatively discreet, they mainly concern the support of soft tissues, especially the upper lip.
• Examination of the temporomandibular joints is necessary to look for various palpation disorders related to mandibular kinetics disturbed by the absence of canine protection or correct incisal guide.
Intraoral examination:
Inspection:
• Absence of the permanent tooth after its normal date of eruption.
• Late persistence of the temporary tooth.
• Reduction in the space on the arch required for eruption.
• DDM.
• Signs of QUINTERO and DUFRECHE.
• Versions of adjacent teeth.
• Importance at the level of insertion of the upper labial frenulum.
Palpation:
• Search for a painless, incompressible, fibro-mucous arch, palatine or vestibular.
• Painful palpation, inflamed, red, edematous mucosa, often indicates the presence of an infectious complication.
• Study of the mobility of the temporary tooth and adjacent permanent teeth in search of possible rhizalysis.
➢Retention of incisors:
Examination of the teeth:
✓Absence of an incisor on the arch while the other has evolved for more than six months:
The anomaly is often detected early by parents worried about not seeing the “tooth come out”; the dental formula and age must be determined.
✓Abnormal persistence of the deciduous incisor:
Its mobility and coloration must be examined.
✓ Presence of the lateral incisor:
• The absence of a central incisor, the permanent lateral has evolved, is very significant ( EINHOLTZ) .
✓Examination of adjacent teeth:
• The vitality, mobility and position of adjacent teeth are examined.
Examination of the alveolar region:
• Reduction or closing of the space intended for the tooth in question.
• Painless and incompressible vestibular or palatal fibromucous arch opposite or close to the site of the impacted tooth.
• Look for a fistula if palpation is painful on an inflamed mucosa.
• Deviation of the intermaxillary suture under pressure of the included incisor when it is palatal and oriented towards the PSM
Occlusal examination:
• Deviation of the inter-incisal media towards the inclusion side.
• Mesiogression of the posterior sectors.
• Opening of diastemas.
➢ Retention of canines:
• By the age of 12 years for girls and 13 years for boys, 80% of the maxillary canines have appeared on the arch. This suggests that an examination should be conducted much earlier in order to diagnose a possible ectopic eruption.
Treatment of impacted teeth
Examination of the teeth
✓At the canine level:
• Either persistence of the temporary canine on the arch after 13 years or 6 months after the evolution of the contralateral canine and in this case it is appropriate to test its mobility in order to evaluate the degree of rhizalysis.
• Either absence of the temporary canine not replaced by the permanent canine. Sometimes only a diastema remains between the lateral incisor and the premolar.
✓At the level of the lateral incisor:
• DUFRECHE sign : axial rotation of the lateral incisor.
• QUINTERO sign : vestibulo-coronal position and mesio-vestibular rotation (pathognomonic sign of canine inclusion). The crown of the lateral incisor will be moved in the opposite direction to the pressure exerted on its root.
•Possibility of mobility by rhizalysis
• The absence or microdontia of one or two lateral incisors should be noted due to the modification or disappearance of the canine eruption guide.
✓At the level of the first premolar:
• Mesiolingual rotation favoring palatal inclusion (BASSIGNY) .
Examination of the alveolar region:
• Abnormal, hard, painless and non-depressible fibro-mucosa arch, either in the retro-incisive palatal region most often, or vestibularly at the level of the apex of the lateral incisor.
• Palpation of the arch gives an idea of the thickness of the covering tissues and the depth of the inclusion.
• Possibility of fistula due to pulpal mortification of the lateral incisor.
• Possibility in adults of pain linked to the lysis of neighboring teeth with pulp damage or infectious accidents such as pericoronitis.
Occlusal examination:
• Deviation of the inter-incisal media towards the inclusion side.
• Mesiogression or version of the posterior sectors.
• Opening of diastemas.
• Loss of canine guidance.
• Appearance of wear surfaces, interferences and prematurities.
• Anterior occlusal trauma in the absence of compensatory group protection.
➢ Retention of premolars:
The most affected is the 2nd lower premolar; we can have:
• Persistence of deciduous molars without mobility.
• Premature loss of primary molars accompanied by mesial development of the first molars.
• Absence or reduction of the space for their evolution on the arch.
the most affected is the 2nd lower premolar; we can have:
• Possibility of resorption of the roots of neighboring teeth.
• Appearance of anterior diastemas.
• Distal version of the mesial adjacent tooth by coronal pressure of the impacted tooth on the root.
In summary, disruption of intra and inter arch relationships.
➢ Retention of molars:
Impaction of molars is uncommon with the exception of the 3rd molars; however, when it occurs it causes considerable damage. Clinical signs include:
• Absence of the tooth on the arch revealing a diastema opposite the inclusion site.
• Disruption of inter-arch molar relationships.
• Version of the posterior sectors source of prematurity and interferences.
• Collapse of the vertical dimension.
• Possibility of very painful distal coronal or even root caries on neighboring teeth.
• Frequent infectious, tumoral and painful accidents such as pericoronitis, cysts, etc.
Treatment of impacted teeth
First -line radiological investigations :
Panoramic radiography:
➢ Either the tooth is visible on the image:
• Position in the vertical plane is then provided (inclusion height).
• More or less oblique general axis of the tooth.
• Relationships with neighboring teeth (resorptions?).
• Possible presence of odontomas and additional germs.
• On the other hand, the vestibular or palatal position cannot be formally specified.
Profile teleradiography or Norma Lateralis:
• This examination removes any possible doubt of agenesis and provides us with information in the vertical plane and in the anteroposterior plane, however, the superposition of the teeth of the right and left hemi-jaws limits the precision of the images.
Retro-alveolar:
➢ The advantages of the retro-alveolar image are to specify:
• The shape and anatomy of the canine (volume, apical closure, root curvature).
• The condition of the dental follicle and the desmodontal space.
• The existence or presumption of ankylosis.
• Neighborhood reports (root resorptions: ERICKSON and KUROL ( CHAMBAS , 1993) estimate the damage to permanent incisors in 10-13 year olds at 0.71%)
• The appearance of surrounding tissues (cysts, odontomas, etc.)
Additional radiological investigations (2nd intention ):
Dentascan and 3D reconstruction:
Uses X-rays like traditional radiology and relies on the differential absorption of radiation by various structures.
It consists of creating a stack of 1mm thick sections in the axial plane which are very precise and serve as raw data for the computer production of various reconstructions in the three directions of space.
The documents are provided in actual size, which allows for direct study and measurements on the images:
•Very precise localization and clear morphology of the included tooth.
•Detailed visualization of reports with neighborhood structures.
•Location of obstacles (odontomas, supernumerary teeth, etc.).
•Suspicion of sequelae on adjacent teeth (rhizalysis).
•Establishment of bone assessment and associated anomalies (cysts).
Treatment of impacted teeth
Treatment :
Determining parameters and decision factors:
The therapeutic strategy to adopt when faced with an inclusion depends a lot on the patient, whose orthodontist will have to evaluate:
• Age: this is a fundamental factor in the choice of therapeutic strategy, the younger the patient, the better the prognosis. However, orthodontic treatments are commonly undertaken in adults except the physiological conditions for regeneration and healing are less good.
• Motivation: the patient and his parents must be informed of the sensitivity of the treatment, which may involve several surgeries and may therefore be lengthy.
So request dialogue and information to avoid weariness of the patient, worry of the parents and impatience of the practitioner.
Also, never impose a deinclusion on a patient and never undertake treatment without their commitment and consent.
• Condition of the periodontium: the presence of any periodontal disease at the level of the included tooth or its recipient site (recession, gingivitis, loss of attachment or bone lysis) greatly influences the choice of therapy to be implemented.
The height of the attached gum in relation to the site must also be assessed because certain operations depend on it.
• Aesthetic and functional value of the tooth: do everything to save a central incisor and/or a canine.
• Position of the tooth: carefully examine the position of the tooth in the three spatial directions and its relationships with the surrounding structures (tooth too high, between the apices, horizontal, antral, etc.)
•Ankylosis: according to GLICKMAN it is the fusion of the alveolar bone to the cementum with disappearance of the alveolar ligament leading to the welding of the tooth to the bone thus preventing any orthodontic movement and any traction would cause the movement of the anchor teeth or even the entire arch. In addition, the crestal bone destroys and replaces the root tissues, which can lead to the loss of the tooth.
• Bend or laceration: any abnormality in shape must be taken into account, especially root bends; a laceration will certainly lead to the loss of the tooth, but you can still try to place it on the arch to preserve the bone capital for a possible implant-supported prosthesis.
NB: mortification hardly prevents disinclusion.
Treatment of impacted teeth
Options and alternatives:
Preventive treatment:
1. Elimination of obstacles:
Extra teeth:
If these teeth remain included, they frequently become obstacles to the intraosseous migration of a permanent tooth.
They are common in the maxillary 80-90% of supernumerary teeth. (+++premaxilla)
In the mandible, the supernumerary teeth are located in the premolar sector and more rarely in the incisor sector.
In order to reduce the risk of dental inclusion, a screening radiological examination should be carried out around the age of 9 years ; during the first period of transition of mixed dentition. If a supernumerary tooth is found, extraction should be carried out early before the onset of problems, as soon as a delay in eruption is observed.
Odontomas:
These are the most common tumors of dental origin. The presence of an odontoma can modify the position of a germ or modify the eruption path of a permanent tooth. Its incomplete excision leads to recurrences. ” The earlier the extraction of supernumerary teeth is done, the greater the chances of spontaneous evolution of the permanent tooth increase.”
2. Extraction of the temporary tooth:
•Referring to the study by ERICSSON and KUROL in 1988 , we can now advise extracting the temporary canine as soon as the diagnosis of palatal dystopia of a canine is established.
• The age of 8 years is the appropriate time to observe the intraosseous eruption of the maxillary canine and to screen for possible inclusion. This is when the tooth leaves its palatal position to migrate vestibularly.
•A delay in the loss of temporary teeth should be considered as a consequence of the dystopia of the succedential tooth rather than the cause.
3. Development of an eruption corridor:
❑Anterior expansion of the premaxilla:
Sagittal premaxillary underdevelopment of the premaxilla decreases the anterior length of the arch. This can be resolved by performing anterior expansion by incisor advancement using a Ricketts expansion base arch .
Different means can be used to achieve this expansion:
Quad’helix;
Circuit breaker ;
Palatal plate with medial jack.
❑Distalization of the lateral sectors:
In case of mesialization of the lateral sectors due to early extraction of temporary teeth, the orthodontist has different means at his disposal to move the mesialized teeth back and arrange the eruption corridor.
Hilgers Pendulum,
Distal Jet,
extraoral forces…. .
❑Extraction and germectomy of permanent teeth:
In cases of severe DDM requiring premolar extractions, it is sometimes useful to perform a germectomy or to extract the first premolars early, provided that the permanent canines are in a good axis and in correspondence with the first premolars. This intervention frees the eruption corridor and allows the canines to descend into the extraction site, avoiding a possible dystopia.
Curative treatment:
Abstention:
•The reasons for abstention may come from the patient who refuses orthodontic treatment even though the impacted tooth, due to its position, presents no threat to its environment.
• This decision may also be linked to the impossibility of placing the included tooth, due to its position or its ankylosis and the desire to avoid an avulsion that would be too damaging at bone level or in adjacent teeth (tooth too high, close to the sinus or dental nerve, between the apices, etc.)
Extraction of the impacted tooth (indications):
It is indicated when the included tooth is:
✓ Associated with nervous, infectious, mechanical, tumor complications.
✓ Stiff and uncomfortable.
✓ Deformed with significant coronal-radicular angulation.
✓ Represents a danger for an adjacent tooth (resorption, mobility, caries, etc.).
Treatment of impacted teeth
Surgical-orthodontic treatment:
- Indications and contraindications for surgical release:
Indications:
Surgical release and orthodontic placement are indicated:
• In children up to the age of 14, when the removal of obstacles to eruption and simple orthodontic techniques prove insufficient for the spontaneous establishment of the tooth.
• In adolescents between 14 and 20 years of age, unless the available space is equal to or greater than the space required and a non-impacted tooth is only ectopic.
• In adults, the surgical-orthodontic procedure is most often indicated because the physiological conditions for spontaneous development are less favorable compared to children and adolescents.
Contraindications:
➢From an included tooth that is ankylosed;
➢A tooth included in a horizontal position;
➢When there is a risk of mortification of the tooth or a neighboring tooth;
➢If the included tooth has a significant corono-radicular angulation. A root bend does not constitute a contraindication to orthodontic traction;
➢If the clearance appears too mutilating, particularly in the case of very high inclusion;
➢An uncooperative patient.
2. Different phases
Orthodontic preparation:
After correction of these dysmorphoses, the evaluation of the available space is necessary.
Two situations may arise:
➢Either the available space is sufficient for the placement of the included tooth, so extractions of the permanent teeth are not necessary.
➢Either there is insufficient space, so permanent teeth must be extracted.
Space saving in the incisor sector can be achieved by:
➢Stripping;
➢ leveling (correction of rotations and versions);
➢closure of incisive diastemas;
➢lifting of the supraclusion by ingression of the incisors;
➢anterior expansion using a RICKETTS expansion arch
If the temporary canine is present on the arch, it may be retained for aesthetic and biomechanical reasons (maintaining the mesio-distal space and the vestibulo-lingual width of the alveolar crest).
If the milk canine is absent or if its extraction is indicated to create sufficient space, space will be gained either at the level of the incisal sector or at the level of the lateral sectors or by combined action (in the case of canine inclusion).
Action on the premolar sector will be indicated in the event of:
➢Growth of anterior rotation type, skeletal breakage II;
➢Molar mesioversion;
➢Incisive overbite;
The therapy in this case consists of distalizing the molars (and the pemolars in the event of canine inclusion) using different devices: removable plate with jack, extraoral forces, pendulum, Distal Jet, Gianelly, etc.
Extractions of permanent teeth are especially necessary in cases of:
➢Too much mesialization of the lateral sectors.
➢Posterior rotation type facial growth where any attempt at distalization will increase the vertical dimension;
➢Late processing;
➢If the conservation of the present teeth is random (teeth with severe decay), particularly the 6-year-old teeth.
➢In case of severe DDM.
Surgical release and bonding technique :
The surgical approach is determined by the position of the vestibular or palatal tooth . After the crown has been released, a traction button will be glued to the tooth.
Collage technique :
Setting up the attachment and polymerizing the glue:
✓A small amount of adhesive is deposited both on the fastener and on the previously prepared surface;
✓Rapid drying using a suction cannula ensures evaporation of the solvent contained in the adhesive;
✓A small amount of composite resin is deposited on the base of the attachment;
✓Positioning of the attachment is carried out without difficulty using tweezers when access to the enamel site is easy; on the other hand, for a deeply included tooth, the use of fine diamond tweezers or the JPL guide optimizes this delicate moment.
✓Excess material is removed with a probe;
✓Polymerization of the adhesive and the composite.
Postoperative orthodontic time:
Elastic traction :
The traction can be intra- or inter-arch by a wire, an elastic, a power, or a chain, the main arch can serve as an anchor for this traction; it is a simple means but the intensity of the force it generates is inconstant and requires frequent activations inducing discontinuous forces. However, the use of closed NiTi spring generates light and continuous forces .
Treatment of impacted teeth
Conclusion :
The phenomenon of dental inclusion is far from rare and not restrictive, it therefore deserves our greatest attention.
At the age of 9, a panoramic screening remains essential and must be routine to diagnose any possible presumptive sign of inclusion and thus intercept in time, parents must be aware and informed.
Treatment of impacted teeth
Wisdom teeth can be painful if they are misplaced.
Composite fillings are aesthetic and durable.
Bleeding gums can be a sign of gingivitis.
Orthodontic treatments correct misaligned teeth.
Dental implants provide a permanent solution for missing teeth.
Scaling removes tartar and prevents gum disease.
Good dental hygiene starts with brushing twice a day.