Combined orthodontic-surgical treatment of impacted teeth

Extra-oral examination: mesocephalic, round symmetric face, pupils equally round, pupillary line horizontal, competent lips with average tonicity.

Examination of TMJ: Maximum mouth opening – 51mm, no displacement or deviation on closure, without pain, pathological sounds and path of closure.

Intra-oral examination: Average oral hygiene, low cariosity, pink gingiva, oral mucous membrane with no pathological signs, good periodontal condition, upper labial frenulum inserts to the incisive papilla.

Cast analysis: Mixed dentition, AI with signs of AII/2, overjet=0.5mm, overbite=4mm, diastema 11-21, nonocclusion 14, impaction of 13 and 23, distally rotated 33, 43, 12, mesially rotated 16, 26, space diskrepancy in maxilla -2mm, in mandible 0mm, Tonn’s index – 76,7%.

Cephalometric analysis before therapy: SNA: 83°, SNB: 80.5°, SNPo: 81°, ANB: 2.5°, Wits: 2mm, NS-ML: 31°, S-Go:N-Me: 65%, Mx 1-NS: 104°, Mx 1-NPo: 5mm, Interincisal: 132°, Mn 1-ML: 92.5°, Mn 1-Apo: 1mm.

AI with signs of AII/2; Overjet: 0.5mm; Overbite: 4mm; Class I skeletal base; Average growth pattern; Buccal nonocclusion 14; Diastema 11-21; Impaction of 13, 23; Distally rotated 12, 33, 43; Mesially rotated 16, 26; upper labial frenulum inserts to the incisive papilla.

Treatment objectives:
1st orthodontic phase: To level upper dental arch, to close the diastema, to derotate and align individual teeth, to enlarge the space for 13 and 23.
surgical phase: Surgical exposure of crowns of impacted teeth, adaptation of extrusion chains.
2nd orthodontic phase: Teeth 13 and 23 firstly pull by tying elastic thread distally to the transpalatal arch. Then apply Kilroy spring and pull impacted teeth to the continuous archwire. Relevelling of upper dental arch. Lower dental appliance is optional.

Treatment plan and appliances:
Preadjusted edgewise appliance – slot .022, preskription Roth, low-profile metal brackets
Orthodontic bands 16, 26
Orthodontic brackets 15-25
Plan of occlusion - AI

Maxilla:
1. Levelling and aligning (NiTi .014)
2. .016x.022 NiTi
3. .017x:025 SS with open coil springs for 13,23
4. Modified transpalatal arch (TPA)
5. Surgical exposure and orthodontic traction to the TPA
6. Kilroy spring and traction to the archwire
7. Relevelling with NiTi archwires
8. Retention (ESSIX)
9. Gingivectomy recommended - dd.13 a 23

The success of the treatment of impacted teeth depends on the correct diagnosis and treatment plan. It’s essential to know precise position of impacted teeth and to plan exact movement of the teeth. If this is not the case, there is a risk of causing resorption of adjacent roots when pulling impacted teeth to their location, which is iatrogenic harming of the patient. In palatal position of impacted canines right behind the roots of upper incisors, there is usually need to pull them away from incisors first using a pull distally to the transpalatal arch. When the tooth is uprighted and in the safe distance from upper incisors, it can be pulled to the continuous archwire. After creating enough space for buccaly impacted teeth, they often erupt by themselves.