pulp revascularization after repositioning of impacted incisor … · 2015-07-23 · [6]), surgical...

Case Report/Clinical Techniques

Pulp Revascularization after Repositioning of ImpactedIncisor with a Dilacerated Root and a Detached ApexPawe1 Plakwicz, DDS, PhD,* Agnieszka Kapu�sci�nska, DDS,† Krzysztof Kuku1a, DDS, PhD,‡

and Ewa Monika Czochrowska, DDS, PhD§

Abstract
Severely impacted and dilacerated incisors are rarelyconsidered for surgical exposure because they may notrespond favorably to orthodontic extrusion. These inci-sors are often extracted, resulting in the need for toothreplacement; however, prosthetic solutions are limitedin growing patients. Transalveolar autotransplantationof an impacted incisor may be the only method to pre-serve the natural tooth and maintain the shape of thealveolus. The severely impacted upper central incisor(#9) with a developing root was diagnosed in a 9-year-old girl. The unfavorable tooth position and dilacer-ation of its root made orthodontic extrusion of theimpacted incisor impossible. Initial orthodontic spaceopening at the recipient site was performed before thesurgery. Transalveolar transplantation of the impactedincisor to its normal position was performed to avoidtooth extraction. The incisor was later aligned usingfixed orthodontic appliances. At the 5-year follow-up,the transplanted incisor presented features that weretypical of a revascularized tooth (ie, obliteration ofroot canal but a positive response to vitality tests).Healthy periodontal tissues and continued root develop-ment were also noted. However, the root apex, whichseparated from the transplant at the time of the surgery,continued formation in its initial position. Transalveolartransplantation of an unfavorably impacted upper cen-tral incisor with a dilacerated root is a successful treat-ment, which stands the test of time. The early stage ofroot development allowed revascularization of the toothdespite dilaceration of the root and detachment of itsapex. (J Endod 2015;41:974–979)
Key WordsCentral incisor, impacted tooth, revascularization, rootdilaceration, tooth autotransplantation

From the Departments of *Periodontology, ‡Oral Surgery, and §OMazowieckie Centre of Dentistry, Warsaw, Poland.

Address requests for reprints to Dr Pawe1 Plakwicz, ul Miodowa0099-2399/$ - see front matter

Copyright ª 2015 American Association of Endodontists.http://dx.doi.org/10.1016/j.joen.2015.01.034

974 Plakwicz et al.

The incidence of impaction of upper central incisors was reported to be 0.06%–0.2%.Most impacted central incisors have crown or root dilacerations (1). Steward (2)

reported that more than 70% of dilacerated incisors had a developmental etiology, 22%could result from trauma, and <10% were accompanied by supernumerary teeth orfollicular cysts. Topouzelis et al (3) considered dilacerations of upper central incisorsas a direct result of damage from traumatized primary incisors. However, Andreasenet al (1) stated that most of the root angulations of impacted incisors are not directlyrelated to trauma but rather the change of their eruption path because of the presence ofan obstacle.

Systematic studies (2) and literature reviews (3, 4) describing the management ofimpacted central incisors with dilacerated roots are very rare. Available treatmentoptions include removal of an obstruction (ie, odontomas [5] or supernumerary teeth[6]), surgical exposure followed by orthodontic traction (7–12), tooth extraction(13), or seldom transalveolar transplantation usually followed with root canal treat-ment (surgical uprighting) (14–16).

In the present report, we have described a viable treatment option for a severelyimpacted, dilacerated upper central incisor in a growing patient. The main objective ofthe treatment was to perform early autotransplantation of the impacted incisor beforecompletion of its root development to promote pulp revascularization. This aimed topreserve the tooth vitality and additionally the functional and esthetic integrity of thedental arch in a young child.

Case ReportA 9-year-old girl with a missing upper left central incisor and negative overjet at-

tended an orthodontic consultation in July 2008. The panoramic radiograph revealedimpaction of tooth #9. The long axis of the crown was tilted mesially and labially about150� (Fig. 1A). The developing root of the impacted incisor (#9) was located palatallyto the root of the left lateral incisor (#10) and deflected in a labial dilaceration. Thepatient had a history of trauma to the deciduous incisors at the age of 6 years. An un-successful attempt of orthodontic extrusion of the impacted incisor had been per-formed a year earlier. The alternative treatment plan included space opening at thesite of the impacted incisor and transalveolar autotransplantation (surgical uprighting)of the developing impacted incisor to its normal position.

Two months after bonding of fixed orthodontic appliances, the patient experi-enced further trauma at the swimming pool and hit her upper right central incisor(#8) against the floor. The patient and parents considered the accident insignificantbecause of the presence of an intact crown and the absence of tooth displacement.For that reason, they did not report this episode to a dentist or the orthodontistproviding treatment.

rthodontics, Medical University of Warsaw, Warsaw, Poland; and †Department of Orthodontics, The

18, 00-246 Warsaw, Poland. E-mail address: [email protected]

JOE — Volume 41, Number 6, June 2015

Delta:1_given name

Delta:1_surname

Delta:1_given name

Delta:1_surname

mailto:[email protected]

http://dx.doi.org/10.1016/j.joen.2015.01.034

It took 12months before the surgery to provide adequate width for
performing the transalveolar transplantation. During orthodontic treat-ment, no spontaneous eruption or change in the position of theimpacted tooth (#9) was observed. Additionally, a lack of furtherroot development and apex completion of the contralateral right centralincisor (#8) was noted before the surgery (Fig. 1B). Tooth #8 did notrespond to the electric and thermal pulp tests. Only at the presurgicalexamination did the patient’s parents confirm the second trauma,and tooth #8 was identified as nonvital. Complete debridement of thepulp chamber and root canal was performed followed by temporaryfilling with calcium hydroxide. It was decided to complete the root canaltreatment of tooth #8 after the transplantation of the impacted leftincisor (#9).

Surgical ProcedureSurgery was performed under general anesthesia in November

2009. A midcrestal incision was made within the keratinized gingivaat the edentulous ridge, which corresponded to the impacted incisor’sarea. This incision extended to intrasulcular incisions along the vestib-ular side of teeth #8 and #9. A full-thickness flap was then raised labiallyto gain access to the impaction site (Fig. 2A and B). The labial corticalplate was carefully removed using surgical burs and elevators to avoidany damage to the periodontal ligament and the developing root of theimpacted incisor (Fig. 2C). Tooth #9 was gently removed from its initialposition using forceps applied only to its crown. Great effort was madeto avoid any damage whatsoever to the periodontal ligament and the

Figure 1. Panoramic radiographs: (A) before treatment (July 2008) and (B) afte


root cementum during tooth removal. The soft tissues of the follicle con-nected to the cervical margin were kept intact. After removal, the toothwas kept in a saline solution for 2 minutes. The bone defect was in-spected for the presence of any sharp edges, and it was reshaped toaccommodate the incisor in its normal position (Fig. 2D). There wasno initial stability when the transplant (#9) was placed within thebone defect with its developing apex facing the labial aspect of the crypt(Fig. 2E); therefore, an orthodontic bracket was bonded to the labialsurface of the crown. A steel ligature, which connected the bracket tothe orthodontic wire, provided semirigid stabilization for the trans-planted incisor during healing (Fig. 2F). Nonresorbable sutures wereplaced to seal the flap around the tooth.

Treatment OutcomesThe transplanted incisor was examined clinically (mobility, pocket

probing, and electric pulp testing) and radiographically (intraoral ra-diographs) at 1, 3, 6, 12, and 18 months and then every year after au-totransplantation. The endodontic treatment of the right central incisor(#8) was successfully completed 1 month after transplantation of tooth#9. Orthodontic treatment was completed 3 years after the surgery. Anormal overjet and overbite were obtained, and the transplanted toothwas well aligned in the upper arch. The occlusion was stable during theobservation period.

Five years after the transplantation, the final clinical and radiologicexaminations were performed. Tooth #9 presented stage 1 mobility as-sessed according to the M€uhlemann Index (17) and responded to

r orthodontic space reopening before the surgery (August 2009).

Pulp Revascularization and Impacted Incisor 975

Figure 2. The surgery (August 2009): (A) the front maxilla before flap preparation, (B) the bone covering the impacted tooth (#9) after flap elevation and beforeremoval of labial cortical plate, (C) the impacted incisor in its initial position after removal of the labial plate, (D) the bone defect after removal of the labial plateand the impacted incisor, (E) the incisor after positioning within the bone defect with its dilacerated root directed labially, the sutured flap, and (F) the transplantedincisor with orthodontic attachment bonded to the labial surface of the crown and stabilized using steel ligature.


thermal and electric pulp testing (Electric Pulp Tester; Denjoy DentalCo, Ltd, Hunan, China). A clinical examination revealed normal peri-odontal tissues at the transplanted and adjacent teeth (probingdepths <3 mm) and an adequate width of the attached gingiva(Fig. 3A). No loss of clinical attachment was detected, and the inter-

Figure 3. The dental arches at the final follow-up: the (A) labial and (B) palatal vwhich had a root canal treatment.

976 Plakwicz et al.

dental papillae were normal. A slight asymmetry of the incisive papillawas found (Fig. 3B).

Radiographic examinations were performed at follow-up visits tomonitor both central incisors. The progressive obliteration of the rootcanal of the transplanted incisor was present on intraoral radiographs

iew of the transplanted left central incisor (#9) and right central incisor (#8),


Figure 4. The radiographic examination. Intraoral radiographs of maxillary incisors: the transplanted dilacerated incisor (#9) 3 weeks after the surgery.(A) There are no radiologic signs of the mineralized apex of the tooth; 18 months after the surgery, partial obliteration of the pulp of the transplanted incisor.(B) Contralateral incisor (#8) had a root canal treatment completed 1 month after transplantation of tooth #9; (C) 5 years after the surgery, the completeobliteration of the pulp of transplanted incisor is visible; and (D and E) the CBCT scans (March 2014) show the apex formation a few millimeters away fromthe transplant.


(Fig. 4B). No signs of pathology of the transplanted incisor (#9), thetraumatized incisor (#8), or adjacent alveolar bone were detected onradiographs. The presence of lamina dura surrounding the entire toothsocket of the transplant was identified on intraoral radiographs3 months after the surgery and did not change during the observationtime (Fig. 4B and C). The cone-beam computed tomographic (CBCT)scans performed at the 4-year follow-up to evaluate the volume of thealveolar bone in the anterior maxilla confirmed the continuity of thealveolar process. The dilacerated root of transplanted tooth #9 waslocated within the alveolus and was completely covered with the labialcortical plate (Fig. 4D and E). Additionally, the CBCT examination (per-formed in March 2014) revealed apex completion of the transplantedtooth, which was found at its initial position (ie, some distance fromthe final position of the transplanted incisor) (Fig. 4E).

DiscussionTreatment of incisor impaction is challenging, especially if the

impacted tooth has root dilaceration. Missing anterior teeth are a majorconcern for orthodontic patients. Early initiation of the treatment ad-dresses potential psychological concerns related to the absence of frontteeth. The initial diagnosis of impaction is usually confirmed using con-ventional panoramic radiographs. Impacted incisors can be furtherlocalized using the vertical or horizontal parallax or lateral cephalo-metric radiography. CBCT imaging offers greater possibilities for diag-nosing the impaction and recognizing the extent of dilaceration and thestage of root development.


Treatment possibilities include orthodontic or surgical uprightingof an affected incisor or its extraction. The decision depends on the po-sition of the impacted tooth, its angulation, the stage of root develop-ment, the presence of root dilaceration, and the experience of thedental team.

Forced orthodontic eruption of a dilacerated central incisor is thetreatment of choice. Closed orthodontic exposure (7, 8, 10–12) oropen exposure and tooth alignment (9) are recommended in mostcases. Esthetic problems associated with orthodontic eruption of anectopic incisor (eg, lack of keratinized tissue) can be solved usingvarious mucogingival procedures (11). In severe cases of impactionwith root dilaceration, root canal treatment or apicoectomy is necessaryto complete treatment during orthodontic alignment (11, 18).

Transalveolar transplantation, which is a surgical uprighting of animpacted tooth, seems to be an attractive option to save the affectedincisor and shorten the treatment time. The protocol for autotransplan-tation of developing teeth, especially premolars, was introduced inScandinavia (19–21) and proved to be predictable in long-term studies(22). Autotransplanted developing teeth underwent pulp revasculariza-tion, preserved normal periodontal tissues, and continued root growthafter surgery (23–25). Additionally, normal periodontal healing anderuption promoted alveolar bone development at the recipient site(26, 27). Despite difficult surgical access, transalveolartransplantation of developing impacted premolars has proven to be apredictable method to preserve the natural teeth (28). However, teethwith dilacerated roots may not be optimal candidates for autotransplan-tation because of even more difficult surgical access and a higherrisk of complications including progressive inflammatory root


resorption, ankylosis, and arrested root development. Transalveolartransplantation of impacted, dilacerated incisors followed by root canaltreatment has been previously described (15). However, Choi (16)questioned routine endodontic treatment because of the risk of rootperforation (29). The severity and direction of root dilacerations playan important role in planning the surgery. Lateral dilaceration maycomplicate accommodation of the incisor between the adjacent teeth.Labial dilaceration can cause the apical part of the root to extend labiallyout of the alveolar process after surgical uprighting.
If extraction of the impacted incisor is inevitable, the treatment op-tions to replace the missing tooth include orthodontic space closure(30, 31), autotransplantation of a tooth from another part of themouth, or prosthetic replacements (13). Dental implants are generallycontraindicated in growing patients because of their negative effects onalveolar bone development and progressive infraposition of implant-supported crowns related to the passive eruption of adjacent teeth(32). However, the major concern regarding extraction of an impactedtooth is the alveolar bone deficiency at the extraction sites. If alveolarbone defects develop in children, they usually become more pro-nounced with time and eventually may even preclude treatment withdental implant and jeopardize the periodontal status of adjacent teethin adulthood.

The presented case involved the multidisciplinary approach of anorthodontist, a pedodontist, an oral surgeon, and an endodontist as wellas previous consultations of a speech therapist and a psychologist. Inthis case, orthodontic space closure in the anterior maxilla was contra-indicated because of existing class III malocclusion. Therefore, theobjective of the treatment was to avoid tooth extraction in the upperarch and to preserve the dilacerated tooth (#9). The autotransplanta-tion of the impacted incisor was scheduled before completion of rootdevelopment to promote pulp revascularization after the surgery. Con-cerns regarding patient’s cooperation and complexity of the procedurewere the main reason to perform the surgery under general anesthesia.Root dilaceration and severe impaction of the incisor resulted in diffi-cult surgical access. As a consequence, the developing apex of the root(which at that time mainly comprised soft tissues) was unintentionallydetached and thus left undetected in its initial position.

The 5-year follow-up of the transplanted incisor revealed success-ful healing. Tooth #9 was considered to be vital because, despite pro-gressive pulp obliteration, there were no signs of periapicalpathology and it responded to electric and thermal pulp testing. Revas-cularization of the pulp is a typical sequela after autotransplantation ofdeveloping teeth. Skoglund et al (23) described the ingrowth of the newvessels from the apical bone through the apex of the transplanted devel-oping tooth (33). Pulp obliteration is regarded as scar tissue, whichaccompanies revascularization and indicates successful healing of thepulp (34, 35).

The periodontal tissues of the transplanted incisor healed nor-mally. Ankylosis (replacement resorption), which was a potentialcomplication of periodontal healing, was not present because the tootherupted into occlusion, responded to the orthodontic treatment, andpresented normal mobility. The root of the transplanted incisor accom-modated well within the alveolar bone. The detached developing apexcontinued its development and mineralization at its initial position.

ConclusionsIn the presented case, the transalveolar transplantation of the

impacted incisor resulted in saving the natural tooth. The incisor pre-served vitality despite root dilaceration and detachment of its developingapex during the surgery. Normal periodontal healing and assisted or-thodontic forced eruption allowed alignment of the tooth within the

978 Plakwicz et al.

dental arch. This observation adds a valid option to the treatment ofgrowing patients with severe impaction of incisors with dilaceratedroots.

AcknowledgmentsThe authors deny any conflicts of interest related to this study.

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