Drs. Pat Brady, Carina Dabney, and Hilton Israelson helped a patient uncover her smile through orthodontics
Figure 1: Initial photos and panoramic X-ray
On August 20, 2014, a 13-year-old patient presented to our office for orthodontic treatment with this chief complaint: “I don’t want to smile because I don’t have any front teeth.” Her mother further confided that her daughter’s education has been severely impeded as she refused to attend school because of her appearance. The initial examination revealed a Class I posterior occlusion, and teeth Nos. 6, 8, 9, 10, and 11 were impacted, while No. 7 was partially erupted and lying parallel to the floor of the nose (Figure 1).
The treatment plan called for the exposure and bonding of attachments to all of the impacted teeth and bonding the remaining teeth in the maxillary and mandibular arches. Initially, the plan was to use distraction osteogenesis to advance the maxilla and hopefully stimulate growth of alveoli for the impacted teeth. Such surgical distraction proved unnecessary, however, as treatment progressed. Simply uncovering, extrusion, and advancing the teeth with their alveoli eventually provided the much needed support for the upper lip.
A CT scan provided both orthodontist and oral surgeon enough additional data to formulate an eruption plan for the impacted teeth. The surgeon channeled the bone to expedite the eruption of each impacted tooth, while the forced eruption of the exposed teeth was achieved by using as anchorage the inner bow of a maxillary headgear appliance from which the outer bows were removed. The inner bow fitted into the headgear tubes of the molar bands and was tied in place with ligature wires. The anterior part of the adapted headgear bow was notched to accommodate elastic threads that tied to the uncovered, impacted teeth. A continuous edgewise maxillary arch wire consolidated the rest of the maxillary dentition to minimize reciprocal effects from the extrusion of the impacted teeth (Figure 2).
Figure 2: Modified headgear inner bow and exposed impacted teeth
Figure 3: Exposed teeth erupted enough to receive brackets
As treatment progressed and the teeth continued to erupt, brackets were added allowing more control. At this time tooth No. 8 was now discovered to be rotated 180° and possessed a dilacerated root. It was decided by mutual agreement between the orthodontist and oral surgeon to leave the tooth in its unrotated position (Figure 3).
As the teeth erupted, the headgear bow was advanced downward and forward. The headgear bow was discarded once the teeth had sufficiently erupted to use anterior box elastics to the maxillary and mandibular incisors. A vertical elastic was applied to the impacted maxillary canine to aid its eruption. As soon as the maxillary arch had been aligned, anterior box elastics were used to close the bite.
At this point, the patient was referred to a periodontist for sulcus deepening amid concerns regarding the attached gingiva over the maxillary central incisors. Once the periodontal tissue had stabilized, the ortho-dontic therapy was completed, and tooth No. 8, which remained unrotated, was reconstructed by filling in the lingual surface of the tooth with composite to give the appearance of a normal incisor facial surface (Figure 4).
Figure 4: Treatment outcome photographs. Note the temporarily composite-augmented lingual surface of the maxillary left
central incisor that awaits further periodontal and cosmetic intervention
On February 1, 2017, after a period of 2 years and 6 months, treatment was completed, and the patient no longer hesitates to smile, and she attends school regularly. In addition to its general dentists and specialty teams, Bear Creek Family Dentistry of Dallas, Texas, donated their staff, facilities, and services to make this treatment possible.