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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 24-28

A Versatile Spring Design for Management of Impacted Teeth in Anterior Arch


Department of Orthodontics, D.Y. Patil University, School of Dentistry, Nerul, Navi Mumbai, Maharashtra, India

Date of Web Publication17-Jun-2015

Correspondence Address:
Neil David Andrade
Department of Orthodontics, Dr. D.Y. Patil University, School of Dentistry, Nerul, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2393-8692.158906

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  Abstract 

A new orthodontic spring design that can be employed in the narrow labial vestibule to provide traction force for movement of impacted teeth in the anterior arch is described. The spring is fabricated at chairside in TMA wire of 0.016 × 0.022″ or 0.017 × 0.025″ size. The method for deployment of this spring design is illustrated with a case report of management of horizontally impacted maxillary central incisor in an 18-year-old patient. The spring design was able to deliver variable force vectors that are customarily required to move impacted teeth from a horizontal to vertical orientation.

Keywords: Disimpaction, impacted incisor, orthodontic spring


How to cite this article:
Sharma S, Andrade ND, Soni VP. A Versatile Spring Design for Management of Impacted Teeth in Anterior Arch. Indian J Oral Health Res 2015;1:24-8

How to cite this URL:
Sharma S, Andrade ND, Soni VP. A Versatile Spring Design for Management of Impacted Teeth in Anterior Arch. Indian J Oral Health Res [serial online] 2015 [cited 2019 Oct 18];1:24-8. Available from: http://www.ijohr.org/text.asp?2015/1/1/24/158906


  Introduction Top


Management of impacted teeth in the anterior arch always poses a considerable challenge to the clinician on account of root crowding that is invariably present in these cases; and lack of adequate space to maneuver the tooth through the narrow confines of alveolar cortical plates in this region. The need for precise management assumes further significance in the socio-developmental context where patients presenting with impacted teeth in the anterior arch belong to a younger age group. In contemporary society perceptions are dominated by esthetics and vital first impressions and the absence of an anterior tooth in a young adolescent demands immediate attention.

There are limited options in managing impacted teeth in the anterior arch; these being passive observation, exposure with traction applied to the tooth for alignment or extraction of tooth with later replacement. For the maxillary incisors, the traction option is often undertaken because of the important role these teeth play in building esthetics. [1],[2]

Anterior teeth are commonly impacted in the vertical orientation and less commonly with angulation in the orbital or alveolar plane. Such impactions respond well to orthodontic traction for alignment. However, anterior teeth may also present with the angulation directed labio-lingually. An impaction of this type is almost always difficult to treat as the orthodontic force vector has to change with sequential movement of the impacted tooth. The impacted tooth in this situation has to be moved through the path of least resistance in two different planes to effect disimpaction and alignment.

Various configurations of elastics and springs are employed for application of desired force vectors. Ballista spring, [3] K-9 spring, [4] universal spring [5] and Kilroy spring (American Orthodontics, Inc., 1714 Cambridge Ave., Sheboygan, WI 53082) [6] are examples of such arrangements. These springs are largely directed towards the goal of managing impacted canines. Treatment for an impacted maxillary central incisor would inevitably require a spring that operates in the narrow labial vestibule and is versatile enough to provide force direction in more than one plane.

The design and application of a new spring configuration for management of impacted teeth in the anterior arch is described with the help of a case report in this article.


  Case Report Top


The 18-year-old female patient reported with chief complaint of an unerupted upper front tooth. The patient was made aware of the existence of an impacted maxillary incisor during a recent dental X-ray examination. Patient was in good health and gave no history of medical concerns or dental trauma.

On clinical examination, the patient had balanced facial proportions, an orthognathic profile and a modified smile in which a conscious effort to cover maxillary anterior teeth was evident and only mandibular anterior teeth were displayed [Figure 1]. Intraoral examination revealed a generally satisfactory dentition with the exception of dental caries in # 36 and # 46 and a grossly decayed # 26 [Figure 2].
Figure 1: Extra-oral photographs

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Figure 2: Intra-oral photographs

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The patient had normal overjet and overbite, class I molar relationship on the right side and a class I canine relationship bilaterally.

Orthopantomogram examination showed an impacted no. 21 and a mesiodens in the same region. The impacted incisor was positioned horizontally with its crown close to the middle third of the root of the maxillary right central incisor, and its root in close relation to the root of the maxillary left lateral incisor. Apical pathology in carious no. 46 was seen [Figure 3]. Patient's dental development was commensurate with her age.

Analysis of the lateral cephalogram revealed an orthognathic hard and soft tissue profile and dental/skeletal cephalometric parameters within normal limits [Figure 4].
Figure 3: Panoramic radiograph showing impacted maxillary central incisor and mesiodens in region of 21

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Figure 4: Lateral cephalogram

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Problem list

Spaces among maxillary anterior teeth, a compromised smile, minor spaces in the mandibular anterior teeth, carious # 36, 46 and a decayed # 26 were salient in the problem list. Maxillary midline deviation was observed due to drifting of adjacent teeth into the unoccupied space at impacted # 21 region. Mandibular midline was also shifted to the right [Figure 2].

Treatment objectives

  • Restorative treatment for carious and decayed teeth.
  • Leveling and alignment of maxillary and mandibular arches and recovering space in the maxillary arch for the impacted left central incisor.
  • Restoration of maxillary left central incisor at recovered space and achieve normal appearance of anterior segment
  • Establish an acceptable and stable, functional occlusion.


Orthodontic treatment options

  • Extraction of the impacted maxillary central incisor, creation of space with orthodontic therapy, and restoration with an implant or a fixed partial denture.
  • Extraction of impacted maxillary central incisor, orthodontically substituting the lateral incisor for the central incisor, followed by a prosthetic restoration.
  • Surgical exposure of the impacted maxillary central incisor, recovery of necessary space and application of orthodontic traction to move incisor into alignment.


Orthodontic treatment plan

Treatment options were explained to the patient and her parents, and it was decided that the impacted tooth be salvaged and brought into occlusion with orthodontic movement. Taking into consideration the position of the impacted central incisor and its vicinity to the root of the lateral incisor, treatment was decided to be conducted in two phases.

Phase I included extraction of the mesiodens in relation to 11 and 21, leveling and aligning of maxillary and mandibular arches with fixed orthodontic appliance and space regain for the impacted maxillary incisor. Phase II included surgical exposure of the crown of an impacted tooth, uprighting it from a horizontal to a vertical position, followed by subsequent orthodontic traction to bring it into occlusion.

Orthodontic treatment progress

An MBT prescription, 0.022 slot bracket system was placed with bands on teeth nos. 17, 26, 37, 46 and initial leveling was completed with a 0.016" NiTi wire. With a relatively rigid stabilizing wire (0.017 × 0.025″ stainless steel) on the maxillary arch, a NiTi Open Coil Spring was used between 11 and 22 to create adequate space for the impacted incisor.

Once the required space was achieved [Figure 5], exposure of the impacted central incisor was performed, and the exposure site was allowed a short healing period before further treatment was carried out.
Figure 5: Leveling of maxillary arch with adequate space for impacted incisor before its surgical exposure

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A maxillary central incisor bracket was bonded onto the available labial surface of the crown of the incisor with its horizontal slot as parallel as possible with the incisal edge of the tooth [Figure 6].
Figure 6: Bracket bonded on labial surface of tooth no. 21 after surgical exposure and healing period

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Initial traction on the impacted tooth was applied with a 0.016″ NiTi wire riding piggyback on a 0.017 × 0.025″ SS main archwire. The auxiliary wire was ligated loosely to the impacted tooth [Figure 7]. This initial procedure made adequate surface of the crown available for application of uprighting spring.
Figure 7: Orthodontic traction applied with 0.016" NiTi wire over 0.017 0.025? stainless steel main archwire

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The impacted tooth needed to be uprighted to a vertical orientation to allow for further orthodontic traction. This was done by the use of an auxiliary spring constructed from a 0.016 × 0.022″ TMA archwire [Figure 8]. The spring was designed in a manner so as to upright the impacted incisor while simultaneously continuing application of orthodontic traction to bring the tooth into occlusion. One end of the spring was ligated to the main archwire through all teeth in the first quadrant while the free end was engaged as possible to the horizontal slot of the bracket bonded on the impacted incisor. The design of the spring allowed for application of force to bring the tooth downward and provide a labial root torque to upright it.
Figure 8: Auxiliary spring design-constructed with 0.016 × 0.022″ TMA wire to upright horizontally impacted maxillary central incisor

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As the tooth gradually uprighted and progressed towards occlusion [Figure 9], modifications were made in the spring with third order bends to continue traction in the same direction and exerting root torque on the tooth [Figure 10]. The spring was discontinued after the tooth was close to the occlusal plane, at which point it was tied to the main arch wire with an elastic chain [Figure 11].
Figure 9: Partial uprighting of impacted maxillary central incisor

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Figure 10: Modification in spring to continue uprighting

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Figure 11: Bracket engaged to main archwire with elastomeric chain

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Progressive changes in the bracket placement were made as and when possible and elastic traction was continued [Figure 12].
Figure 12: Bracket position correction and continued alignment

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At this stage, it was possible to engage a 0.016″ NiTi wire in the bracket slot, and regular alignment mechanics could be used [Figure 13]. Archwires were upgraded sequentially to a 0.019 × 0.025″ NiTi archwire for final alignment of the tooth [Figure 14].
Figure 13: 0.016″ NiTi wire engaged in bracket

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Figure 14: 0.019 0.025″ NiTi wire engaged in bracket

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Treatment result

The impacted maxillary central incisor was brought from a horizontal and embedded position into arch and alignment after 10 months of treatment. The patient was happy with her improved smile and there was a perceptible gain in patient's confidence.

Restorative management of carious teeth has been carried out in respective departments.

Spring design

The versatile spring was used in this case for management of impacted maxillary central incisor [Figure 8], though the uniplaner design of its active component permits operation in labial vestibule in both maxillary and mandibular anterior arches. It is constructed using commonly available TMA wire of 0.016 × 0.022″ or 0.017 × 0.025″″ dimensions. It can be easily activated at various bends [Figure 10] to direct force in the desirable direction or to impart root torque. The passive and retentive component of the spring is the archform segment that rides piggyback to main archwire or can be ligated with main archwire or under tie-wings.


  Discussion Top


Maxillary central incisor is probably the most prominent among dental esthetic components. [1],[2] Rarely missing and normally erupting at 6-8 years of age, an impacted maxillary central incisor is easily diagnosed when it fails to erupt. However, in a different socioeconomic environment, partly because of a lack of adequate knowledge; an unerupted anterior tooth may not be reported well into adolescence and in some cases even adulthood. Patients who present with impacted teeth are generally young, and as far as possible, an attempt should always be made to salvage an impacted tooth since it can serve its function for its lifetime.

Proffit [7] has considered problems in treating impacted teeth in three distinct areas: Surgical exposure for access, placement of a utilitarian attachment and orthodontic force application. The first two areas have common solutions. Exposure can be performed in 3 accepted ways: 1. Circular excision of the oral mucosa immediately overlying the impacted tooth; 2. Apically repositioning the raised flap that incorporates attached gingiva overlying the impacted tooth and 3. The closed-eruption technique in which the raised flap that incorporates attached gingiva is fully replaced in its former position, after the attachment has been bonded to the impacted tooth. [8]

While orthodontic traction for treatment of impacted teeth that are vertically oriented in the alveolar bone requires only time and patience, challenges are different when the tooth is impacted horizontally. In the present case, a new design for an auxiliary spring was used that was capable of exerting force in variable directions with suitable activations. The spring was successfully used to meet treatment objectives.

Ideally, an orthodontic spring should be unobtrusive to occlusion, be nonirritating to surrounding soft tissues, provide adequate force and have a long range of action. [9],[10] The spring configuration used and presented in this case met all these criteria. In addition, it can be activated to provide force direction in different planes with suitable modifications. Chairside fabrication of this spring for easy customization is recommended.

 
  References Top

1.
Xubair A, Graber TM, Vanarsdall R, Vig KW. Orthodontics: Current Principles and Techniques. 5 th ed. Philadelphia, PA, USA: Mosby; 2012.  Back to cited text no. 1
    
2.
Becker A. The Orthodontic Treatment of Impacted Teeth. London: Martin Dunitz; 2007.  Back to cited text no. 2
    
3.
Jacoby H. The ′ballista spring" system for impacted teeth. Am J Orthod 1979;75:143-51.  Back to cited text no. 3
    
4.
Kalra V. The K-9 spring for alignment of impacted canines. J Clin Orthod 2000;34:606-10.  Back to cited text no. 4
    
5.
Vibhute PV. Versatile auxilliary orthodontic spring for orthodontic correction of impacted teeth. J Indian Orthod Soc 2011;45:40-7.  Back to cited text no. 5
    
6.
Bowman SJ, Carano A. The Kilroy Spring for impacted teeth. J Clin Orthod 2003;37:683-8.  Back to cited text no. 6
    
7.
Proffit WR. Contemporary Orthodontics. 4 th ed. St Louis: Mosby; 2007. p. 564-6.  Back to cited text no. 7
    
8.
Lundberg M, Wennström JL. Development of gingiva following surgical exposure of a facially positioned unerupted incisor. J Periodontol 1988;59:652-5.  Back to cited text no. 8
    
9.
Burstone CJ, Lawless DT. The application of continuous forces to orthodontics. Angle Orthod 1961;31:1-14.  Back to cited text no. 9
    
10.
Tulley WJ, Campbell AC. A Manual of Practical Orthodontics. 3 rd ed. Bristol, UK: John Wright and Sons Ltd.; 1970. p. 524-64.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]



 

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