Retrieval of unerupted teeth in pedodontics

Abstract

Introduction
The retrieval of unerupted teeth in pedodontics is always significant to preserve the
trophism of adjacent tissues, establish the correct space, provide adequate function
and maintain good esthetics for the patient. The treatment plan is based on
radiographic examinations and measurements, and on an accurate clinical
evaluation; it aims to achieve the best treatment possible depending on the
complexity of the specific case.

In the most difficult clinical cases it is very important to have an early diagnosis,
which is essential to plan the treatment and achieve success. In these cases, the
pediatrician is in a strategic position to give an early diagnosis through a child’s
medical history and by counting the child’s teeth.

Case presentation
This article presents two different difficult clinical cases of impacted teeth diagnosed
during pediatric age, with a radiological analysis, and successfully treated with
orthodontic devices designed for these specific cases. Clinical case 1 describes a 13-
year-old Italian girl; clinical case 2 describes a 9-year-old Italian girl. The use of
these devices achieved the desired treatment goals. The problems associated with
impacted teeth and the biomechanical interventions used for these patients are
discussed.

Conclusions
An early and careful diagnosis followed by an accurate treatment plan for the
individual cases can lead to retrieval of the impacted teeth without affecting other
anatomic structures and adjacent teeth. In these cases, the pediatrician is in a
strategic position to give an early diagnosis through a child’s medical history and by
counting the child’s teeth.

Introduction

The eruption of permanent teeth in the dental arch is regulated by a significant

genetic control [1] and this guides the correct formation of tooth buds and their
eruption in the dental arch in their right positions.

Certain anatomical conditions or previous traumas or affections of the corresponding

deciduous tooth, may lead to eruption anomalies in terms of time or position, or in
some cases can arrest completely the physiological eruption of the permanent tooth
(dental inclusion).

The pediatrician is certainly the first physician to visit young patients and, as such,
may be able to intercept all oral diseases. The pediatrician must provide general
information to prevent the onset of caries, through proper nutrition and proper use
of fluoride. The pediatrician may ask parents to make a dental visit and then
implement all the measures of prevention as ambulatory care (for example, the
sealing of the first permanent molars) [2].

It is important that pediatricians know the importance of normal oral growth and
development. Often the parents of a young patient ask their pediatrician to assess
which is the right time to refer their child to a dental visit, or even orthodontics. This
is the reason why it is better that the pediatrician is aware of complications that arise
from the inclusion of permanent teeth, which can be prevented and cured when the
patient is a child. In the most difficult clinical cases of impacted teeth it is very
important to have an early diagnosis, which is essential to plan the treatment and
achieve success. The pediatrician is in a strategic position to give an early diagnosis
through a child’s medical history and by counting the child’s teeth.

A tooth is referred to as “retained” when it has not erupted in the dental arch within
its physiological time but still shows radiographic evidence of eruptive capacity and
has no anatomic obstruction on its eruptive path [3, 4]. A tooth is referred to as
“impacted” if it is completely or partially unerupted many years after normal
eruption time or if it is positioned against another tooth, bone or soft tissue, so that
its further eruption is unlikely [3, 4]. The position of these teeth can often show a
very marked ectopy [3, 4].

Some studies demonstrated that the incidence of dental impactions ranges from
5.6% to 18.8% with a higher frequency among women [5].

Teeth that most frequently face impactions are the lower and upper third molars (20
to 30%). Third molars, in order of frequency, are followed by upper canines (85%
with palatal dislocation) which first face retention and then impaction. Upper
canines are followed by lower second premolars (0.3%) that usually face the
impaction because of the premature eruption of the first molar and the first premolar
[6, 7]. Upper central incisors (0.1%) represent the rarest case of impacted teeth [7, 8].

To formulate a prognosis and a treatment plan it is necessary to consider the

different aspects of impactions.

Depending on the grade of impaction there can be a distinction between complete or

partial impaction. Partial impaction occurs when at least a portion of the crown is
visible in the dental arch. Complete impaction occurs when the crown is not visible;
it may be: endosteal, where the tooth is impacted completely within the bone;
osteomucosal, where the tooth is completely covered by mucosa and partially by
bone and mucosal, where the tooth is covered only by mucosa [9].

Depending on the number of impacted teeth there is a distinction between single

impaction and multiple impactions [9].

Based on the duration the impaction of a tooth can be defined as temporarily

impacted or permanently impacted [10]. Temporary impaction relates to a retained
tooth caused by an obstacle (odontoma, cyst or supernumerary) that, as the
obstruction is removed, erupts spontaneously in the dental arch [10]. By contrast, the
impaction is permanent when surgical-orthodontic treatment is necessary to obtain
eruption although the obstacle has been removed.

Finally, impaction can be primary or secondary depending on its cause [11]. Primary
impaction is due to dental intrinsic factors (such as anatomy, inclination), whereas
secondary impaction is caused by external factors such as cystic pathologies,
supernumerary or neoformations [11].

The etiopathogenesis of impactions is very broad and causes are divided into general,
local and structural.

• General causes can be: hereditary, hypofunctional endocrine disorders

(hypothyroidism, pituitary cretinism), hyperfunctional disorders
(hyperthyroidism), dysmetabolic conditions (hypovitaminosis and rachitis)
and infectious diseases (congenital syphilis, rubella, scarlet fever) [12].

• Local causes can be related to the deciduous tooth (persistence, ankylosis,

premature loss, chronic periapical inflammation) or associated with the
permanent tooth (radicular ankylosis, coronal or radicular morphological
alterations, position anomalies, eruption pattern anomalies) [13].

• Structural causes are maxillary hypoplasia, severe hyperdivergence, skeletal

open bite [13, 14] and congenital disorders of the maxillofacial apparatus such
as labiopalatoschisis, cleidocranial dysostosis, cranial stenosis and Down’s
syndrome [4, 15, 16].

The suspect of impaction or retention of one or more teeth can be derived from an
accurate clinical examination, and family and personal medical history.

Inspection and palpation by a dentist may complete the clinical examination. The
final diagnosis and prognosis can be done by an orthodontist with the support of an
X-ray examination that shows the presence and the position of one or more
unerupted teeth [4, 17, 18].

Useful radiographs in the diagnosis of impaction are panoramic, occlusal or

periapical X-ray, or for high accuracy or surgical planning conventional computed
tomography (CT) scans or cone beam CT scans. The orthopanoramic radiograph
provides diagnostic certainty of the impacted tooth, giving an idea of its position and
inclination and its relations with adjacent anatomical structures but it lacks the third
dimension in understanding the precise position of the impacted tooth. In adjunct to
the panoramic examination, an occlusal projection allows a more accurate
determination of the position of the impacted tooth. Currently, the most precise X-
ray examinations to reveal the position of the impacted tooth and of the other nearby
anatomical structures, are conventional CT scans and low-radiation cone beam CT
scans [19].
There are many different types of treatment options: classic orthodontic treatment;
combined surgical-orthodontic treatment; preservative-surgical treatment; and
radical surgical treatment [13]. When the tooth is retained for a matter of space, only
a classic orthodontic interceptive treatment is performed. When the tooth is
impacted and shows abnormal inclination and position, or has a particular coronal-
radicular morphology a combined surgical-orthodontic procedure is required. When
tooth eruption is blocked by a pathological condition (such as cysts, odontomas, and
so on), its eruption in the dental arch depends on the removal of the obstacle; this is
the preservative-surgical procedure (removal of the obstacle). Only in extreme
situations, and in the presence of severe anatomical or positional anomalies, a radical
surgical treatment may be chosen (removal of the impacted tooth) with the
agreement of the patient.

The interceptive retrieval of an impacted tooth gains in importance particularly

during the developmental age to guarantee the trophism of adjacent tissues, to
maintain space, for esthetic and functional reasons. Even in the case that the
retrieved tooth does not guarantee a long-term result, the procedure is advisable
within limits. In that case the retrieved tooth with no long-term prognosis will
perform its function until the patient reaches the age for prosthetic substitution of
the tooth.

To prevent impactions different types of dental extraction can be performed such as,
serial extractions, extractions of unexfoliated or ankylosed deciduous teeth and
extraction of supernumeraries.

Complications that might occur after dental impactions can be distinguished

between mechanical (resorption of the adjacent tooth roots, decubitus), nervous,
infective (lower third molar pericoronitis, periodontal diseases, root resorptions of
the adjacent tooth) [10, 20] and dysplastic (follicular cysts, keratocysts,
ameloblastoma) [4, 9, 11, 21].

Thus, the choice of the optimal treatment strategy depends on a correct diagnosis
and the pedodontic-orthodontic approach.

As stated above, there are prevention methods against impactions that, however, are
to be promptly carried out.

A radiographic screening at an early age is able to intercept dental retention allowing

prompt treatment.

The more an impacted tooth is situated far from its correct position or with a
seriously tilted axis the gentler and more time consuming will be the orthodontic
movement to reposition it. Maximum care will be necessary to avoid damage to
adjacent teeth. Connecting the traction device directly to the orthodontic arch will
produce an excessive force on the teeth adjacent to the impacted one leading to
unwilled traumas or movements [4]. In these cases the use of auxiliary devices
working with maximum anchorage to unload the teeth from traction counterforce is
indicated [4].
Assessing the position and path of eruption of an unerupted tooth from a true lateral
skull, orthopantomograph or a standard occlusal radiograph is considered clinically
important for developing a comprehensive treatment plan. Several studies have
recommended many radiological parameters of practicability to bring about speedy
treatment and its effective resolution. For the lower impacted canine, a problem
exists with the transmigration of the impacted tooth. Howard observed that those
unerupted canines that lie between 25° and 30° in the midsagittal plane do not
migrate across the mandibular midline. Those canines that lie between 30° and 95°
tend to cross the midline. An overlap appears to exist between 30° and 50°. When
the angle exceeds 50°, crossing the midline becomes a rule [22]. For the
transmigrated canine, extraction or transplantation can be proposed.

It was stated that if the apex of the lower canine is seen to have migrated past the
apex of the adjacent lateral incisor, it might be mechanically impossible to bring it
into place [23].

Among radiological parameters, it was also suggested that it may be impossible to

bring the impacted lower canine to its correct position in the presence of an overly
mesially angulated unerupted canine that has begun to migrate labially across the
incisors [24].

For the impacted first permanent molar, there is no clear standard solution for how
to treat retained or impacted first molars, as treatment depends on several local
factors such as the angulations/inclination of the impacted/retained tooth [25].

Although these previous articles mentioned and discussed various principles for
treating practicable impacted teeth, the treatment of impacted teeth out of
recommended radiological parameters of practicability has rarely been reported.

In this report, two clinical cases are described in which impacted teeth out of
recommended radiological parameters of practicability were treated orthodontically
with new purposely conceived orthodontic devices, which achieved the desired
treatment goals.

Case presentation

Clinical case 1
A 13-year-old Italian girl was referred by her pediatrician because of a retained
deciduous canine in her right mandible. During an earlier visit to the pediatrician,
the doctor, considering the age of the patient, asked her about the exchange of
deciduous teeth, and she reported that the tooth had not yet changed. She was not
alarmed, neither was her mother, but the pediatrician insisted that the tooth would
probably have already dropped. The pediatrician therefore encouraged her to contact
her dentist.

The girl was in good health, and her dental and medical history was unremarkable
with only the usual childhood maladies.
An extraoral clinical examination disclosed a symmetrical face with balanced vertical
thirds.She shows a dental-skeletal class I with normal mandibular divergence, with
no bad habits, and her cephalometric values are all normal; even her lower and upper
incisors are normal-inclined. Her profile is standard for Italian people. An intraoral
examination revealed that her dental midlines were concordant with each other and
with her face, and no mandibular shift was detected on closure. Except for some
lower incisor crowding the overall occlusion was fair with acceptable overjet and
overbite. Her clinical periodontal parameters were normal. A radiographic
examination revealed that the mandibular right canine was in an oblique position
with its crown tip near the apex of the lower right first incisor root (Figure 1). An
occlusal radiograph confirmed that the crown of the impacted canine was vestibular
(Figure 2). The canine angulation to the midline was 55° (Figure 3). This value
suggested a very difficult problem, which might not be orthodontically treatable.
After careful evaluation of this case, in view of the age of the patient, the clinical
decision was to treat this impacted tooth orthodontically. Full mouth orthodontic
treatment was suggested.

Figure 1

Pretreatment records. (a) Pretreatment

panoramic radiograph. (b) The unerupted canine
is going to migrate across the mandibular midline,
and its crown tip is near the apex of the lower right
first incisor root.

Figure 2

The occlusal radiograph confirms that

the crown of the impacted canine is
vestibular.

Figure 3
The canine angulation to the midline is 55°.
It was our goal to treat this case with a non-extraction orthodontic approach using
upper and lower jaw appliances, while doing our best to correct the impacted tooth,
to maintain the profile and reaching as good a final occlusion as possible. The
objectives of orthodontic treatment for this patient were to bring the impacted
mandibular right canine into her dental arch, level and align the arches, maintain the
normal overjet and overbite, and achieve a bilateral Class I canine and molar
occlusion. First, the oral surgeon had to eliminate the retained mandibular deciduous
canine. At the same time, a vestibular repositioned, full thickness mucoperiosteal
flap was elevated, and the crown of the canine was exposed (Figure 4). In the same
session a fishing-rod (it is a lingual arch of bands positioned on the first permanent
molar with the addition of an arm in titanium-molybdenum alloy wire with a trend
from the lingual to the buccal side; it is used for traction on canines) was cemented
(Figure 5); this appliance is fixed, and previously prepared by the technician; the
appliance was used to tie up and drive into the canine’s eruption (Figure 6). After 5 to
8 months, the cusp of the canine was visible in her mouth (Figures 7 and 8), so the
fishing rod was replaced with a vestibular rigid arch, welded on the band, to continue
the orthodontic traction. Pre-informed brackets and straight archwires were used;
for the first 15 days a 0.356mm (0.014 inch) nickel-titanium alloy (NiTi) archwire
was used; then it was replaced with a 0.016×0.022 inch NiTi archwire (Figure 8).
When the canine was present in the oral cavity, a bracket was added to it and linked
directly to the arch by an elastic ligation. To keep the space in the arch for the canine,
since it was not aligned, we used an open coil spring (Figure 9). Finally after
approximately 18 months, the canine was well positioned in the arch (Figure 10). At
this time, she was advised that she needed an attached gingiva graft on her restored
tooth to improve esthetics and the periodontal health compromised by the treatment
(Figure 11).

Figure 4
 Surgical outbreak; a vestibular
repositioned, full thickness
mucoperiosteal flap is elevated,
and the crown of the canine is
exposed.

Figure 5

The orthodontic devices: the

Fishing-rod. (a) Fishing-rod in occlusal
view. (b) Fishing-rod in lateral view. The
lever arm of the device allows for a push
in the occlusal-distal direction of the

Figure 6
 Intraoral photographs with
fishing-rod; the appliance
is used to tie up and drive
into the canine’s eruption.

Figure 7

After 5 months, the cusp of

the canine was visible in
the mouth.

Figure 8

After 8 months; pre-

informed brackets and
straight archwires are
used.
Figure 9
After 12 months. When the canine was present
in the oral cavity (a), a bracket was bonded to it
and linked directly to the arch by an elastic
ligation. To keep the space in the arch for the
canine, since it was not aligned, an open coil
spring (b) was used.

Figure 10

After 18 months the canine is well

positioned in the arch.

Figure 11

After 18 months the patient was advised that

she needed an attached gingiva graft on the
restored tooth to improve esthetics and the
periodontal health compromised by the
treatment.
The last step to improve the intercuspidation was the use of criss-cross elastics
between her upper right first molar and her lower right first molar (Figure 12). When
an acceptable occlusion with adequate root angulation had been achieved, the fixed
appliance was removed.Retention was established with removable appliances
(Figure 13). Then, here is the smile of the girl (Figure 14).The post-treatment
radiographic view (Figure 15) showed that the roots of her teeth in her upper arch
were well angulated and aligned. No apical root resorption was evident on the
radiograph. The midline as well as the overjet and overbite had been maintained
during the treatment. Periodontal health was not compromised. One year after
treatment follow-up there was no obvious relapse. Her midline, overjet, and overbite
are still in good position. No tooth morbidity is evident. One year after debonding,
only a partial recurrence was observed in the position of the upper first right molar,
as she had not observed the restraint protocol (Figure 16). Also the periodontal
problem (the lack of attached gengiva) at the level of the lower right canine was
confirmed. Her gums are healthy, and although the lack of attached gengiva in the
canine region is intact, she is satisfied with the treatment results.

Figure 12

Criss-cross elastic to improve

the intercuspidation between
the upper right first molar and
the lower right first molar.

Figure 13

Retention was established with removable appliances on the upper arch

(a) and the lower arch (b), to maintain the obtained result (c). After
orthodontic treatment finished and the canine positioned in an acceptable way in the
dental arch, the patient was advised that she needed an attached gingiva graft on the
restored tooth to improve esthetics and the periodontal health compromised by the
treatment.
Figure 14

Post-treatment photograph
of the smile.

Figure 15

Figure 16

Post-treatment intraoral
photographs: (a) frontal view;
(b) upper occlusal view; (c)
lower occlusal view. One year
after, only a partial recurrence was
observed in the position of the
upper first right molar, as the
patient had not observed the
restraint protocol. The periodontal
surgery (attached gengiva graft of
the lower right canine) has not been performed as requested by the same
patient. The need for an attached gingiva graft on the restored tooth
remained.
SOURCE: https://jmedicalcasereports.biomedcentral.com/articles/10.1186/1752-1947-8-334