Traction of impacted and stacked maxillary anterior teeth with precise biomechanics followed by torque control using gate spring

Abstract

•Sequential traction of overlapped and impacted teeth prevented root collision.•A gate spring was used to control torque during traction.•Root movement was controlled according to the biomechanical analysis. Impaction of multiple maxillary anterior teeth is a rare condition; when it occurs, it impacts the patient’s chewing function and smile esthetics, and it has always been problematic for clinicians. This case report presents an 11-year-old girl with impaction of 3 adjacent maxillary anterior teeth, including labiopalatally oriented maxillary right central and lateral incisors and a mesially inclined maxillary right canine. These 3 impacted and stacked teeth were sequentially aligned after surgical exposure and orthodontic traction, and the surrounding dentigerous cyst healed simultaneously. Precise and delicate biomechanics will control root movement and prevent root collision. Gate spring, a novel torquing auxiliary, was used for highly efficient root torque movements of the previously impacted incisors. After 32-month treatment, the patient’s occlusion and esthetics greatly improved. Impaction of multiple maxillary anterior teeth is a rare condition; when it occurs, it impacts the patient’s chewing function and smile esthetics, and it has always been problematic for clinicians. This case report presents an 11-year-old girl with impaction of 3 adjacent maxillary anterior teeth, including labiopalatally oriented maxillary right central and lateral incisors and a mesially inclined maxillary right canine. These 3 impacted and stacked teeth were sequentially aligned after surgical exposure and orthodontic traction, and the surrounding dentigerous cyst healed simultaneously. Precise and delicate biomechanics will control root movement and prevent root collision. Gate spring, a novel torquing auxiliary, was used for highly efficient root torque movements of the previously impacted incisors. After 32-month treatment, the patient’s occlusion and esthetics greatly improved. Dental impaction has been reported to precipitate various pathologic conditions, including external root resorption of adjacent teeth, dentigerous cyst, odontogenic tumors, and so on.1Alqerban A. Jacobs R. Lambrechts P. Loozen G. Willems G. Root resorption of the maxillary lateral incisor caused by impacted canine: a literature review.Clin Oral Investig. 2009; 13: 247-255Crossref PubMed Scopus (112) Google Scholar, 2Sarica I. Derindag G. Kurtuldu E. Naralan M.E. Caglayan F. A retrospective study: do all impacted teeth cause pathology?.Niger J Clin Pract. 2019; 22: 527-533Crossref PubMed Scopus (16) Google Scholar, 3Mortazavi H. Baharvand M. Jaw lesions associated with impacted tooth: a radiographic diagnostic guide.Imaging Sci Dent. 2016; 46: 147-157Crossref PubMed Scopus (34) Google Scholar A variety of local factors, including insufficient space, excessive bone or soft tissue resistance, cysts, and tumors might obliterate the eruption path.4Becker A. Chaushu S. Etiology of maxillary canine impaction: a review.Am J Orthod Dentofacial Orthop. 2015; 148: 557-567Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 5Isola G. Cicciù M. Fiorillo L. Matarese G. Association Between odontoma and impacted teeth.J Craniofac Surg. 2017; 28: 755-758Crossref PubMed Scopus (65) Google Scholar, 6Hyomoto M. Kawakami M. Inoue M. Kirita T. Clinical conditions for eruption of maxillary canines and mandibular premolars associated with dentigerous cysts.Am J Orthod Dentofacial Orthop. 2003; 124: 515-520Abstract Full Text Full Text PDF PubMed Google Scholar, 7Agani Z. Hamiti-Krasniqi V. Recica J. Loxha M.P. Kurshumliu F. Rexhepi A. Maxillary unicystic ameloblastoma: a case report.BMC Res Notes. 2016; 9: 469Crossref PubMed Scopus (11) Google Scholar, 8Kim S. Kim J. Song J.S. Choi H.J. Choi B.J. Kim S.O. Continued root development of a surgically repositioned human incisor tooth germ.Oral Surg Oral Med Oral Pathol Oral Radiol. 2013; 115: e11-e15Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar General conditions associated with eruption failures, such as Apert syndrome, osteopetrosis, hypoparathyroidism, and cleidocranial dysplasia, might cause attenuated eruptive force and/or increased resistance.9Tsuji M. Suzuki H. Suzuki S. Moriyama K. Three-dimensional evaluation of morphology and position of impacted supernumerary teeth in cases of cleidocranial dysplasia.Congenit Anom (Kyoto). 2020; 60: 106-114Crossref PubMed Google Scholar, 10Reddy G.S. Chalapathi K.V. Reddy D.S. Rana S. Kalyan M. Kartheeki B. et al.Multiple impacted permanent teeth, an indicator for early detection of hypoparathyroidism: A rare case report.J Family Med Prim Care. 2018; 7: 1096-1099Crossref PubMed Google Scholar, 11Xue Y. Wang W. Mao T. Duan X. Report of two Chinese patients suffering from CLCN7-related osteopetrosis and root dysplasia.J Craniomaxillofac Surg. 2012; 40: 416-420Crossref PubMed Scopus (22) Google Scholar, 12Hohoff A. Joos U. Meyer U. Ehmer U. Stamm T. The spectrum of Apert syndrome: phenotype, particularities in orthodontic treatment, and characteristics of orthognathic surgery.Head Face Med. 2007; 3: 10Crossref PubMed Scopus (16) Google Scholar Impaction of canines is not quite rare, with prevalence just secondary to that of the third molars.13Thilander B. Jakobsson S.O. Local factors in impaction of maxillary canines.Acta Odontol Scand. 1968; 26: 145-168Crossref PubMed Scopus (190) Google Scholar Impaction of maxillary incisors, although less usual, is more noticeable and therefore calls for urgent orthodontic treatment.14Aydin U. Yilmaz H.H. Yildirim D. Incidence of canine impaction and transmigration in a patient population.Dentomaxillofac Radiol. 2004; 33: 164-169Crossref PubMed Scopus (127) Google Scholar, 15Al-Zoubi H. Alharbi A.A. Ferguson D.J. Zafar M.S. Frequency of impacted teeth and categorization of impacted canines: a retrospective radiographic study using orthopantomograms.Eur J Dent. 2017; 11: 117-121Crossref PubMed Scopus (42) Google Scholar, 16Grover P.S. Lorton L. The incidence of unerupted permanent teeth and related clinical cases.Oral Surg Oral Med Oral Pathol. 1985; 59: 420-425Abstract Full Text PDF PubMed Scopus (331) Google Scholar Impaction of multiple maxillary anterior teeth, including incisors and canines, is rare and severely affects the patient’s orofacial function and esthetics. Treatment options for impacted anterior teeth involve (1) extraction of the impacted teeth with subsequent prosthetic treatment,17García B. Boronat A. Larrazabal C. Peñarrocha M. Peñarrocha M. Immediate implants after the removal of maxillary impacted canines: a clinical series of nine patients.Int J Oral Maxillofac Implants. 2009; 24: 348-352PubMed Google Scholar (2) removal of the eruption resistance and space creation for spontaneous eruption,18Lygidakis N.N. Chatzidimitriou K. Theologie-Lygidakis N. Lygidakis N.A. Εvaluation of a treatment protocol for unerupted maxillary central incisors: retrospective clinical study of 46 children.Eur Arch Paediatr Dent. 2015; 16: 153-164Crossref PubMed Scopus (22) Google Scholar (3) surgical exposure and orthodontic traction,19Kim K.A. Hwang H.S. Chung K.R. Kim S.H. Nelson G. Recovery of multiple impacted maxillary teeth in a hyperdivergent Class I patient using temporary skeletal anchorage devices and augmented corticotomy.Angle Orthod. 2018; 88: 107-121Crossref PubMed Scopus (8) Google Scholar,20Jiang Q. Yang R. Mei L. Ma Q. Wu T. Li H. A novel approach of torque control for maxillary displaced incisors.Am J Orthod Dentofacial Orthop. 2019; 155: 860-870Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar and (4) surgical repositioning.8Kim S. Kim J. Song J.S. Choi H.J. Choi B.J. Kim S.O. Continued root development of a surgically repositioned human incisor tooth germ.Oral Surg Oral Med Oral Pathol Oral Radiol. 2013; 115: e11-e15Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Among them, orthodontic traction has the most favorable functional and esthetic results with fewer complications,21Dehis H.M. Fayed M.S. Management of maxillary impacted teeth and complex odontome: a review of literature and case report.Open Access Maced J Med Sci. 2018; 6: 1882-1887Crossref PubMed Scopus (4) Google Scholar,22Gebert T.J. Palma V.C. Borges A.H. Volpato L.E. Dental transposition of canine and lateral incisor and impacted central incisor treatment: a case report.Dental Press J Orthod. 2014; 19: 106-112Crossref PubMed Scopus (14) Google Scholar whereas it is relatively technique demanding and time-consuming compared with other approaches.23Ling K.K. Ho C.T. Kravchuk O. Olive R.J. Comparison of surgical and non-surgical methods of treating palatally impacted canines. II. Aesthetic outcomes.Aust Orthod J. 2007; 23: 8-15PubMed Google Scholar However, torque movement of the impacted teeth after traction makes another challenge.23Ling K.K. Ho C.T. Kravchuk O. Olive R.J. Comparison of surgical and non-surgical methods of treating palatally impacted canines. II. Aesthetic outcomes.Aust Orthod J. 2007; 23: 8-15PubMed Google Scholar Because traction force can only be applied to the crown and rarely to the root (except in the patient reported by Arango et al24Arango E. Plaza S.P. Chaves A.M. Melsen B. Can forces be applied directly to the root for correction of a palatally displaced central incisor with a dilacerated root?.Am J Orthod Dentofacial Orthop. 2019; 156: 275-282Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar), extra torque control is commonly required in impaction patients when the crown has been aligned while the root lags. A plethora of torque control methods have been introduced into the treatment of impacted anterior teeth, including inverted brackets,25Yang S. Yang X. Jin A. Ha N. Dai Q. Zhou S. et al.Sequential traction of a labio-palatal horizontally impacted maxillary canine with a custom three-directional force device in the space of a missing ipsilateral first premolar.Korean J Orthod. 2019; 49: 124-136Crossref PubMed Scopus (3) Google Scholar a high-torque prescription bracket with L-loop,19Kim K.A. Hwang H.S. Chung K.R. Kim S.H. Nelson G. Recovery of multiple impacted maxillary teeth in a hyperdivergent Class I patient using temporary skeletal anchorage devices and augmented corticotomy.Angle Orthod. 2018; 88: 107-121Crossref PubMed Scopus (8) Google Scholar auxiliary brackets bonded on the gingival one third of crowns of the adjacent teeth with a segmental archwire,20Jiang Q. Yang R. Mei L. Ma Q. Wu T. Li H. A novel approach of torque control for maxillary displaced incisors.Am J Orthod Dentofacial Orthop. 2019; 155: 860-870Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Warren Spring,20Jiang Q. Yang R. Mei L. Ma Q. Wu T. Li H. A novel approach of torque control for maxillary displaced incisors.Am J Orthod Dentofacial Orthop. 2019; 155: 860-870Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar temporary anchorage device,24Arango E. Plaza S.P. Chaves A.M. Melsen B. Can forces be applied directly to the root for correction of a palatally displaced central incisor with a dilacerated root?.Am J Orthod Dentofacial Orthop. 2019; 156: 275-282Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar and so on. However, torque discrepancy can scarcely be eradicated. As reported by Jiang et al,20Jiang Q. Yang R. Mei L. Ma Q. Wu T. Li H. A novel approach of torque control for maxillary displaced incisors.Am J Orthod Dentofacial Orthop. 2019; 155: 860-870Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar the torque of the impacted teeth remained incorrigible despite the sequential use of the third-order bend, Warren Spring, and V-bend over the 12-month treatment. In summary, efficient torquing control has remained a daunting task in impaction patients. This case report describes an adolescent girl with impacted and overlapped adjacent maxillary anterior teeth, including the labiopalatally oriented maxillary right central and lateral incisors and the mesially inclined maxillary right canine. The 3 impacted teeth successfully erupted and aligned with a precise biomechanical design. Afterward, a novel auxiliary gate spring was used for highly efficient root torque movement of the previously impacted teeth. An 11-year-old girl came with a chief complaint of missing maxillary anterior teeth. The patient was physically healthy without significant family or medical history related to the unerupted teeth, and no trauma to the anterior region was reported. Pretreatment facial photographs (Fig 1) showed a symmetrical face, normal vertical facial height, and convex profile with a retrusive chin. When she smiled, the maxillary dental midline deviated 1 mm to the right, and the maxillary incisor exposure was insufficient. The intraoral examination indicated a late mixed dentition with unseen maxillary right central incisor, lateral incisor, canine and second premolar, and retained deciduous maxillary right central incisor, canine and second molar (Fig 1). The cast analysis (Fig 2) demonstrated a 6.8 mm space between the deciduous maxillary right central incisor and the deciduous right canine, a mild curve of Spee (3.9 mm), deepbite of degree II, and distal molar relationship.Fig 2Pretreatment dental casts.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Panoramic radiograph and cone-beam computed tomography (CBCT) revealed the stacked condition of the 3 unerupted maxillary teeth. The maxillary right central and lateral incisors lay horizontally behind the root of the mesially inclined maxillary right canine, and the crowns of impacted incisors pointed toward labially and palatally and revealed a of in surrounding the crown of the impacted central incisor (Fig is with dentigerous pathologic examination was of the maxillary anterior and Three-dimensional Large Image Figure ViewerDownload Hi-res image Download (PPT) revealed a skeletal Class with mild mandibular of the maxillary incisors, and a mandibular (Fig and in a The patient was as a hyperdivergent skeletal Class and dental Class impaction of the maxillary right central incisor, lateral incisor and canine, and maxillary dentigerous treatment options were first was the extraction of the impacted anterior teeth and orthodontic space by the patient be without 3 anterior teeth for implants be and the of bone be and space might be to of adjacent teeth and teeth eruption E. Plaza S.P. Chaves A.M. Melsen B. Can forces be applied directly to the root for correction of a palatally displaced central incisor with a dilacerated root?.Am J Orthod Dentofacial Orthop. 2019; 156: 275-282Abstract Full Text Full Text PDF PubMed Scopus (3) Google second was the extraction of the retained deciduous maxillary right central incisor and canine to space with subsequent orthodontic This the patient’s teeth, is to the and the treatment be and was a of traction third was the surgical of the impacted teeth. is an for impacted teeth, in a However, it is associated with including root and of root S. Kim J. Song J.S. Choi H.J. Choi B.J. Kim S.O. Continued root development of a surgically repositioned human incisor tooth germ.Oral Surg Oral Med Oral Pathol Oral Radiol. 2013; 115: e11-e15Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar The family to the impacted teeth by surgical exposure and orthodontic The treatment were to (1) space for the impacted teeth and the maxillary anterior teeth, (2) the dental and (3) functional that the impacted maxillary right canine was to the it was to after and space by the retained deciduous canine. After extraction of the maxillary right canine and brackets were bonded on the maxillary An was used to the canine with a (Fig After the maxillary right canine was with the crown was to the position of the impacted incisors. were to be labiopalatally horizontally impacted and the root of the canine. The impacted central incisor lay the lateral incisor, and were (Fig As surgical exposure was on the to tooth a surgical was on the cyst to the and the between the cyst and A was used to the whereas a the traction force (Fig Because the stacked of the maxillary right central and lateral incisors might during orthodontic tooth sequential traction was distal and movement of the maxillary right lateral incisor was crown from the root of the central root movement of the central incisor was by a force was by forces to and with traction of the impacted central incisor was (Fig photographs exposure was and with were bonded on the maxillary right central and lateral incisors. A as the to the dentition with a traction Large Image Figure ViewerDownload Hi-res image Download traction from to A and The maxillary right lateral incisor and with a were bonded on the maxillary right central incisor to forces and root The maxillary right central incisor the and a force was applied to the root the The maxillary right lateral incisor was not with the the root movement of the impacted central incisor been Large Image Figure ViewerDownload Hi-res image Download (PPT) After sequential traction, all the impacted maxillary anterior teeth were to in the However, the intraoral photographs indicated that the maxillary right lateral and central incisors to and root (Fig that the of the previously impacted lateral and central incisors were and labially and A novel torquing auxiliary, the gate spring was used to and root torque to the lateral and central incisors, and favorable torque correction was after (Fig The gate spring was by the with a to of force and The of torque movement on the of the of the gate that root torque was applied to the lateral incisor with the the whereas root torque was applied to the central incisor with the the were on and were applied in a subsequent to photographs gate been used on the maxillary right central and lateral incisors, and torque was and The the gate spring by the toward the tooth with a Large Image Figure ViewerDownload Hi-res image Download (PPT) facial photographs showed an profile with dental and facial The intraoral examination demonstrated that all impacted teeth were and and Class I canine and molar were with and The gingival of the maxillary right lateral incisor and canine were whereas the gingival of the maxillary right central incisor that of the central incisor and radiograph and showed of the impacted teeth with root resorption the of incisor in the bone in the (Fig Panoramic image showed the of the maxillary right central and lateral incisors were to the of the Three-dimensional image showed of the impacted teeth with root and and Large Image Figure ViewerDownload Hi-res image Download (PPT) The analysis revealed and of the and the of significant in the The of to indicated that the skeletal discrepancy between the and was improved. The maxillary anterior teeth were to normal increased from to intraoral and the favorable torque correction of the maxillary right central and lateral incisors compared with the gate spring treatment, and was with normal teeth as a (Fig and intraoral photographs the in This case report describes the treatment of impacted multiple maxillary anterior teeth, the of the horizontally stacked maxillary central and lateral incisors. The first daunting in patient is to controlled root movement of the impacted right central and lateral incisors over a Precise biomechanical is for the traction of the incisors. After the lateral incisor was only with bracket and to root the root of the central incisor to be when it was were bonded on the central incisor, and the was mesially with on the whereas the tooth was (Fig This a force that root traction with precise biomechanics the of root collision. A of in when the central incisor root the lateral incisor was from the and movement was the central incisor root an space (Fig using a for root increased the force in the force and the vertical of the central incisor (Fig In after the root of the central incisor been the was for movement (Fig the of the central and lateral incisors were a during traction to root collision. The second in patient was torque control of the previously impacted incisors after traction and Because the traction force is applied a on the it is for the crown to be aligned while the root the extra torque M. Suzuki H. Suzuki S. Moriyama K. Three-dimensional evaluation of morphology and position of impacted supernumerary teeth in cases of cleidocranial dysplasia.Congenit Anom (Kyoto). 2020; 60: 106-114Crossref PubMed Google B. Boronat A. Larrazabal C. Peñarrocha M. Peñarrocha M. Immediate implants after the removal of maxillary impacted canines: a clinical series of nine patients.Int J Oral Maxillofac Implants. 2009; 24: 348-352PubMed Google N.N. Chatzidimitriou K. Theologie-Lygidakis N. Lygidakis N.A. Εvaluation of a treatment protocol for unerupted maxillary central incisors: retrospective clinical study of 46 children.Eur Arch Paediatr Dent. 2015; 16: 153-164Crossref PubMed Scopus (22) Google Scholar for torque control of a The first approach on the between the and the bracket including the third-order bend, high-torque and of the bracket K.A. Hwang H.S. Chung K.R. Kim S.H. Nelson G. Recovery of multiple impacted maxillary teeth in a hyperdivergent Class I patient using temporary skeletal anchorage devices and augmented corticotomy.Angle Orthod. 2018; 88: 107-121Crossref PubMed Scopus (8) Google Scholar,20Jiang Q. Yang R. Mei L. Ma Q. Wu T. Li H. A novel approach of torque control for maxillary displaced incisors.Am J Orthod Dentofacial Orthop. 2019; 155: 860-870Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The second is to use such as Warren Q. Yang R. Mei L. Ma Q. Wu T. Li H. A novel approach of torque control for maxillary displaced incisors.Am J Orthod Dentofacial Orthop. 2019; 155: 860-870Abstract Full Text Full Text PDF PubMed Scopus (6) Google L. Root torque with Warren Clin Orthod. Google Scholar and torquing H. S. torque correction for teeth in with Clin 2016; Google Scholar However, the of not be efficient K.A. Hwang H.S. Chung K.R. Kim S.H. Nelson G. Recovery of multiple impacted maxillary teeth in a hyperdivergent Class I patient using temporary skeletal anchorage devices and augmented corticotomy.Angle Orthod. 2018; 88: 107-121Crossref PubMed Scopus (8) Google Scholar,20Jiang Q. Yang R. Mei L. Ma Q. Wu T. Li H. A novel approach of torque control for maxillary displaced incisors.Am J Orthod Dentofacial Orthop. 2019; 155: 860-870Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar In gate were applied to the torque of the previously impacted maxillary right central and lateral incisors (Fig torquing auxiliary of an spring, mm and with with a of and to the gate spring on the by the with a that in a (Fig In the the was by it to of and it was the of the lateral incisor and of the central incisor to or root torque In the torquing of the gate spring, the force is to to the of (Fig that of the third-order torquing is to mm of the of As a the gate spring be more efficient for torque control compared with the third-order The gate spring is an of the Warren spring, and a to the force However, to a in The Warren spring is on the a of the of with the when the torquing In the with of the gate spring a with the in no during no of the torquing In the root torque of the lateral incisor was after a treatment with the gate spring (Fig in torque after root the gingival of the maxillary right central incisor was that of the central However, according to esthetic the gingival of central incisors of canines, whereas lateral incisors be more by 1 and of the maxillary anterior Dent. 2009; PubMed Scopus Google smile and analysis and treatment J Orthod Dentofacial Orthop. 2003; 124: Full Text Full Text PDF PubMed Scopus Google Scholar In the maxillary right central incisor the gingival whereas the central incisor In the clinical crown of the central incisor deviated from the esthetic A. D.S. The of maxillary central incisor on smile J. 2012; PubMed Scopus Google S. H. S. M. of dental in incisor J Oral Sci. PubMed Scopus Google Scholar be that the discrepancy in the gingival position of maxillary central incisors was caused by the insufficient crown of the central the of crown on the central incisor to the gingival (Fig the the gingival esthetics. crown is after of to esthetics. and stacked maxillary anterior teeth to traction with precise biomechanical in root is for is in such patients to the stacked teeth for the exposure and orthodontic traction, and the torque of anterior tooth in and the root deviated from the of the bone while the crown has been extra root torque control is for the previously impacted The gate spring has to be a highly efficient for the torque

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