Dilacerated inverted horizontally impacted central incisor

Dilacerated impacted maxillary central incisor
Tejraj Kale1, Akhilesh Verma2,Anish luke

1. Associate Professor
2. Postgraduate Student
3. Clinician

Affiliation: Department of oral & maxillofacial surgery KLE dental college & research centre

ABSTRACT
Impacted incisor with dilaceration refers to a dental deformity characterized by an angulation between crown and root causing noneruption of the incisor.Treatment of the impacted teeth is always done in consultation with orthodontist. In this article, a horizontally impacted and dilacerated inverted maxillary central incisor was diagnosed radiographically and surgical extraction was done for this case as orthodontically it was difficult to get into alignment.

Introduction
By definition1, an impacted tooth is one that is embedded in the alveolus so that its eruption is prevented or the tooth is locked in position by bone or the adjacent tooth/teeth. Impaction of maxillary permanent incisors is not a frequent case in dental practice, but its treatment is challenging because of the importance of these teeth to facial esthetics2. Because of its rare occurrence, it may not be diagnosed during routine dental check up. Radiographs tend to play an important role in their detection.
Dilaceration is a developmental distortion of tooth form found in permanent incisors and caused by trauma to the primary teeth whose apices lie close to the permanent tooth germ.
This article presents a rare case of a horizontally impacted and dilacerated inverted maxillary left central incisor in 20 year male.

Case report
A 20 year male reported to a private dental clinic with a complaint of missing central incisor. Patient had class 1 molar relation & had healthy dentition except for the few carious teeth and Ellis class 2 fracture of right cental incisor. On palpation no bulge was felt over the buccal sulcus or on the palatal surface. Radiographic examination revealed a horizontally impacted left central incisor in between the roots of adjacent teeth (Fig1). Orthodontic opinion was sought. Due to position of the tooth the surgical extraction was planned as the orthodontic alignment had poor prognosis for this particular case. Crevicular incision was given over the labial aspect extending from the 12 to 22 region. Flap was raised and tip of the impacted central incisor visualized. The crown portion of the impacted central incisor was exposed till cemento-enamel junction using bur under continuous irrigation, which revealed inverted positioning of the central incisor. Elevation was done with great difficulty, after creating a purchase point, owing probably to severely dilacerated root, and extraction was done (Fig2). After control of the hemorrhage, the flap was closed using 3-0 silk suture and pressure pack was given. Patient was recalled for suture removal after 7 days, healing was fine.

Fig1:IOPA showing inverted impacted 21	Fig2:Extracted tooth

DISCUSSION
Literature has little mention of central incisor impaction. Here we have reported a case of an inverted, dilacerated, horizontally impacted central incisor. 56-60% of incisor impactions result from supernumerary teeth as against impaction of permanent incisors3. Other etiology such as inadequate spacing in arch, genetic makeup, trauma may also be responsible for impacted incisors4. In our case the cause tends to be trauma which the patient reported. Some cases of impacted canines or incisors may be properly positioned with the aid of direct orthodontic traction instead of surgical extraction5. However, a horizontally inverted impacted incisor with dilaceration, characterized by an angulation between crown and root, still poses a clinical dilemma6. There is increased risk of failure due to ankylosis , external root resorption, and root exposure after orthodontic traction.7 Rarely, impacted maxillary central incisor may be found associated with dentigerous cyst. The involvement of the central incisor by Daley8 & Wysocki 9reported 0.1-0.6% and 1.5% by shear respectively. Even the adenomatoid odontogenic tumour had been found in association with the impacted teeth11.
So a prophylactic removal of the impacted teeth which have poor orthodontic prognosis is advisable, so as to avoid pathologic changes in them at a later stage.
Even the successful cases probably have an unesthetic gingiva of the exposed incisor and need to have periodontal surgeries7. Proper treatment planning is of utmost importance to yield good outcome.

Treatment Alternatives4
The following are three possible treatment alternatives:
1. Extraction of the impacted central incisor and restoration with a bridge or an implant later when growth had ceased.
2. Extraction of the impacted central incisor and closure of the space, substituting the lateral incisor for the central incisor with subsequent prosthetic restoration.
3. Surgical exposure, orthodontic space opening and traction of the impacted dilacerated central incisor into proper position.

After being explained the possible treatment alternatives along with the risks involved, the parents chose disimpaction of that tooth. They were unwilling to undergo orthodontic treatment due to long span of treatment and economic problems.
Conclusion
Impacted teeth fails to erupt into normal occlusion once their eruption potential is lost, it is here that a oral surgeon comes into picture. These tend to create trouble at the later stage of life which can be in form of pain, crowding of teeth, cyst formation. Decision to surgically extract the teeth is to be taken only after thorough orthodontic consultation12 and also the opinion of the patient have to be kept in mind.

References
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