APICOECTOMY TREATMENT OF AN IMPACTED MAXILLARY CANINE THAT RESISTED ORTHODONTICALLY FORCED ERUPTION
Figure 1 . Panoramic radiograph of the impacted right upper canine at its initial location
2 . Case Report
A 26-year-old male was referred to the polyclinic for dental treatment . The clinical investigation revealed agenesis of the lower second premolars with residual space at location 45 and a retained tooth 75 . Additionally , impactions were present at positions 15 and 13 , with residual space at position 15 and a retained tooth 53 , respectively ( Fig . 1 ). The dental arches were not crowded ; spaces between the teeth were observed in both the upper and lower jaws . The suggested starting orthodontic treatment was to place a fixed appliance in the upper jaw to open the pathways for normal eruptions of teeth 15 and 13 . We decided to treat the edentulous space at position 45 with an implant at a later date . The patient ’ s consent was received , and the treatment plan commenced . After 6 months , tooth 38 was extracted , due to recurrent pericoronitis , and tooth 53 was removed in the same session . The linguallylocated , impacted canine ( tooth 13 ) was exposed with a high degree of complexity , due to its deep impaction behind the root of tooth 12 . A bracket was placed on the disto-palatal surface of tooth 13 . Twelve months after the canine was exposed surgically , its downward movement had halted , despite the well-prepared exposure , the firm attachment of the bracket , the sufficient space , and the favorable eruption orientation . The canine was tested for ankylosis with the PerioTest Classic ( MedizinTechnik Gulden e . K , Modautal , Germany ). The test result indicated normal mobility , with no suspicion of ankylosis . A radiographic examination with panoramic radiography ( Orthophos XG Plus , Sirona , Germany ) revealed that the canine was bent in the apical region . The apex was curved towards the cortical bone that forms the floor of the nasal cavity , and it anchored the canine in an impacted position . Further examination with cone beam computed tomography CBCT ( Galileos , Sirona , Germany ) and visualization of planar reconstructions
confirmed that the bent apical region was hooked into the cortical border of the nasal floor ( Fig . 2 ). This morphologic characteristic of the canine apex was suspected to be the primary reason that the effort to force the tooth to its functional position was unsuccessful . Next , the recipient site of tooth eruption was examined both clinically and with CBCT reconstructions . The results revealed bone incompetence at the alveolar ridge and a palatal mucosal defect . Therefore , autotransplantation of the canine was not considered feasible . The last alternative treatment option suggested for this case was the endodontic treatment of the exposed canine , followed by apicoectomy of the bent apical portion , which was anchored to the cortex . The decision was based on the assumption that the downward movement of the canine along its normal eruption path was hindered by the anchoring of the bent apical portion in the dense bone . This anchor would not allow tooth advancement , regardless of the amount of force applied . The patient was informed and agreed to the treatment plan , and the operation was scheduled . The endodontic treatment was performed 18 months after exposure of the impacted canine . The root canal was prepared and filled to the apical bend . An apicoectomy followed , under local anesthesia , essentially to remove the hooked apical portion of the tooth from the compact floor of the nasal cavity ( Fig . 3 ). An initial post-operative control follow-up was performed a week after the operation . Normal healing was observed , and the patient was asked to return for another follow-up appointment after the orthodontic treatment . The first recall took place 14 months after the operation . The canine had positively reacted to the treatment . During the post-operative period , force was applied on the bracket , and the canine had descended to its functional occlusion position . At the next recall , 20 months postoperatively , no
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