APICOECTOMY TREATMENT OF AN IMPACTED MAXILLARY CANINE THAT RESISTED ORTHODONTICALLY FORCED ERUPTION
3. Discussion
Maxillary canine impaction is a well-documented dental condition. Many etiologic factors have been described in the literature. 7, 8, 9 Impacted maxillary canines typically require a multidisciplinary approach. A correct diagnosis of the predisposing factors that cause tooth immobility is important for setting up a successful treatment plan 10. Lack of space is a frequently reported cause of impaction, but palatally impacted maxillary canines have been associated with sufficient space in the dental arch. 5, 6 This association was consistent with the clinical situation in the present case study; no crowding was observed at the recipient site, and the remaining space was favorable. With the first orthodontic treatment, the canine was exposed and a bracket was placed to force its eruption. Nevertheless, the impacted canine resisted the orthodontically-induced forces, which raised the suspicion of an ankylosis. However, ankylosis could be ruled out, based on results from mobility tests on the exposed canine crown and radiography( CBCT scan) of the periodontal ligament space around the root. We next investigated a probable cause for the lack of mobility by examining reconstructions of the CBCT data in all planes. Finally, we found a morphological discrepancy of the canine that could explain the clinical situation; that is, we found an apical bend at the canine tip, which passed through the cortex of the nasal floor. Autotransplantation was the first treatment alternative suggested, based on sufficient reports in the literature about successful rates in treating maxillary impacted canines; 11, 12 moreover, the recipient site had been opened orthodontically. However, an important factor in the prognosis of an autotransplanted tooth is the competence of the alveolar bone and the surrounding soft tissues in the recipient zone. It is generally assumed that the periodontal ligament will not initiate osteogenesis in the absence of adjacent bone. Furthermore, wound
closure with a gingival flap is a key factor in
successful healing. 13, 14 In our case, the canine had previously been exposed and had commenced descent towards the alveolar ridge before halting. However, we detected defects in the supporting bone tissue and the mucosa. Due to the lingual localization of these defects, we suspected that the condition of these tissues would deteriorate after the surgical removal of the canine. Moreover, because these types of bony defects do not close optimally, 15 they may potentially persist as periodontal defects after transplantation. Thus, the prognosis of an autotransplanted tooth was considered unfavorable. The key to successful treatment for this patient was a careful assessment of the clinical situation, combined with early identification of the true cause of immobility( i. e., the dilaceration of the canine root apex, which anchored the canine to the cortical bone of the nasal floor). The only alternative treatment option would have been an extraction of the immobile canine. Instead, we hypothesized that the hooked apical root tip had provided resistance to guided eruption. Therefore, we performed an apicoectomy of the anchored portion, after endodontically treating the exposed canine. The follow-up examination performed 14 months postoperatively supported our hypothesis, because removal of the hindering factor allowed the canine to react positively, by promptly descending to its functional position with guided eruption. A second follow-up examination was performed 26 months postoperatively. The treatment outcome was stable, as shown by the absence of mobility, resorption, periapical lesion, or recurrence of impaction.
4. Conclusion
An apical dilaceration through the cortical bone may immobilize an impacted canine. After treating the tooth endodontically, an apicoectomy of the bent tip can facilitate canine exposure and eruption, with a favorable prognosis.
Acknowledgments
The authors declare no conflict of interest related to this study. There are no conflicts of interest and no financial interests to be disclosed.
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