ATYPICAL DISLOCATION OF IMPACTED PERMANENT TEETH IN CHILDREN. OWN EXPERIENCE*

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1 IMiD, Wydawnictwo Aluna Developmental Period Medicine, 2015;XIX,3(II) 383 Anna Janas, Rafał Stelmach, Piotr Osica ATYPICAL DISLOCATION OF IMPACTED PERMANENT TEETH IN CHILDREN. OWN EXPERIENCE* NIETYPOWE PRZEMIESZCZENIE ZATRZYMANYCH STAŁYCH ZĘBÓW U DZIECI. BADANIA WŁASNE Zakład Chirurgii Stomatologicznej UM w Łodzi, Poland Abstract Introduction: Disturbances in forming of the hard tissue of teeth and bones can be a cause of their malformation and translocation. The impact of permanent teeth is one of them. It can occur with translocation of the tooth germ. The aim of the study was to present an atypical translocation of impacted permanent teeth in children. Material and methods: 3.5 year clinical observation was carried out in 14 children (5 girls and 9 boys), aged between 9 and 12 years old. Patients were referred to our Department by orthodontists, paedodontists and General Dental Practitioners, due to impacted permanent teeth. According to the interview, in 8 cases children suffered from a trauma of a facial part of the skull, caused by a fall. On admitance patients were generally healthy. Basing on the clinical and radiological examination, translocation of the impacted permanent teeth has been diagnosed. In 9 cases it concerned medial maxillary incisors, whereas in remaining children maxillary premolars. The extraction of such teeth has been performed as a part of the one day surgery procedures. Conclusion: In the cases where basing on the radiogram, the position of the tooth allows to predict the latter translocation, the germ has to be extracted. Key words: retained tooth, dislocation, treatment Streszczenie Wstęp: Zaburzenia dotyczące tworzenia się twardych tkanek zęba i kości, mogą być przyczyną wad rozwojowych zębów i ich przemieszczeń. Jedną z nich jest zatrzymanie zębów stałych, które może przebiegać z przemieszczeniem zawiązka zęba. Celem pracy było przedstawienie nietypowego przemieszczenia zatrzymanych stałych zębów u dzieci. Materiał i metody: Badaniem objęto 14 dzieci (5 dziewczynek i 9 chłopców), w wieku od 9 do 12 lat. Pacjenci byli kierowani do naszego zakładu przez lekarzy ortodontów, pedodontów i stomatologów, z powodu zatrzymanych stałych zębów. Z wywiadu wynikało, że w 8 przypadkach dzieci doznały urazu twarzowej części czaszki, na skutek upadku. W chwili zgłoszenia się do naszego zakładu stan zdrowia wszystkich pacjentów był dobry. Wyniki: Na podstawie badania klinicznego i radiologicznego rozpoznano przemieszczenie zatrzymanych zębów stałych u dzieci. Dotyczyły one w 9 przypadkach przyśrodkowych siekaczy w szczęce, zaś u pozostałych dzieci zębów przedtrzonowych górnych. W procedurach chirurgii jednego dnia wykonano usunięcie zębów. Usunięte zęby miały żółtobiałe zabarwienie. Posiadały koronę i ukształtowane korzenie, wokół których zlokalizowana była torbiel zawiązkowa. Korzenie zębów siecznych były zakrzywione. Wniosek: W przypadkach, gdy na podstawie zdjęcia radiologicznego położenie zawiązka zęba pozwala przewidzieć późniejsze jego przemieszczenie, należy zawiązek usunąć. Słowa kluczowe: zatrzymanie zęba, przemieszczenie, leczenie DEV PERIOD MED. 2015;XIX,3,II: *The work is financed by the Medical University in Łódź, in the status frame work nr 503/ /

2 384 Anna Janas et al. INTRODUCTION Impaction of a permanent tooth can be an issue in development of teeth in children. In certain cases, where the tooth is positioned according to its axis, but it is not erupted, we diagnose a partial or total impact. In contrast, when the axis diverges from the direction of the eruption, translocation is diagnosed. The disturbances of development of hard tissues and bones can be a cause of teeth malformations and their translocation. The following factors can affect those kinds of defects: hypopituitarism, hypothyroidism, hypothymia. However it is more frequent for the local factors, such as lack of space for the erupting tooth, pathological processes that are under way in direct proximity, for example cysts or benign tumors, odontomas, healing of the alveolus after premature extraction of primary tooth, persistent primary teeth, also infections and consequences of traumas, to play a role in such condition [1, 2]. Fig. 2. Children referred for treatment by various dental prac oners. Ryc. 2. Dzieci kierowane do leczenia przez różnych lekarzy. THE AIM The aim of the study was to present an atypical translocation of impacted permanent teeth in children. MATERIAL AND METHODS Clinical observation was carried out in 14 children (5 girls and 9 boys), aged between 8 and 12 y.o. (fig. 1). Patients were referred to our Department by orthodontists in 8 cases, paedodontists in 4 and the rest by General Dental Practitioners (fig. 2), due to translocated, impacted permanent teeth. According to the interview, in 8 cases children suffered from trauma. These were all falls, in 3 cases from a swing, in 2 patients a bike, whereas in remaining group sled (fig. 3). On the day of the trauma dental, who did not diagnose any injuries of the facial part of the skull, consulted the children. Upon admittance patients were generally healthy. In all children OPGs have been performed, and in 4 cases also a CT scan (fig. 4, 5). Fig. 3. Sustained trauma. Ryc. 3. Przebyte urazy przez dzieci. Fig. 1. Pa ents age in years. Ryc. 1. Wiek chorych w latach. Fig. 4. The OPG showing the translocated, impacted central incisor 11, deeply posi oned. Ryc. 4. Na zdjęciu pantomograficznym widoczny przemieszczony, zatrzymany ząb sieczny przyśrodkowy 11, z głębokim położeniem.

3 Atypical dislocation of impacted permanent teeth in children 385 Fig. 5. The CT scan showing deep posi on of tooth 11. Ryc. 5. Na zdjęciu CT głęboko położony ząb 11. Fig. 6. Incisal edge of erup ng tooth 22. Ryc. 6. Wyrzynający się brzegiem siecznym ząb 22. Fig. 7. Visible persistent teeth 53, 54, 55 and lack of tooth 15 in the dental arch. Ryc. 7. Widoczne przetrwałe zęby mleczne 53, 54, 55, brak zęba 15 w łuku zębowym. RESULTS The extra oral examination showed no aberration from the normal condition. Whereas the intra oral examination showed an erupting incisal edge of the 21 tooth and lack of tooth 11 (fig. 6) or 21 in 9 children, and in 5 cases persistent primary teeth: 53, 54, 55 (fig. 7) or 64, 65 and lack of tooth 15 or 25. Basing on the radiological examination (fig. 8), the position of translocated, impacted permanent teeth was assessed and the lack of possibility of their bringing into the arch determined. It was a cause of their extraction in the procedures of 1 day surgery. In general anaesthesia with the use of Propofol, in 9 boys the flap was cut and prepared in the vestibule of the oral cavity. Next, with the use of a bur, the cortical layer of the bone was removed, which exposed the crown of the impacted, translocated tooth 11. Using the side Bein elevator tooth 11 was extracted (fig. 9). The postoperative wound was rinsed with Ringer s solution and surgically sutured. Whereas in 5 girls with translocated and impacted premolars, the treatment began with the extraction of persistent teeth 53, 54, 55 (fig. 10). Following by cutting and preparing angular flap, exposing the crown of impacted, translocated tooth 15 (fig. 11). Also with the use of side Bein elevator, the crown was elevated, thus changing its position from horizontal to vertical, which allowed the extraction of tooth 15 (fig. 12). The postoperative wound was surgically treated. After performed surgery, the children were referred to the recovery room, where a physician monitored

4 386 Anna Janas et al. Fig. 8. The OPG showing the translocated tooth 15 and horizontal posi on of the impacted tooth. Ryc. 8. Na zdjęciu pantomograficznym widoczny przemieszczony ząb 15 i poziome ustawienie zęba zatrzymanego. Fig. 11. Exposed crown of impacted 15 tooth. Ryc. 11. Uwidoczniono koronę zatrzymanego zęba 15. Fig. 9. Tooth 11 extracted with the use of a side Bein elevator. Ryc. 9. Z wykorzystaniem dźwigni bocznej Beina, wywarzono i usunięto ząb 11. Fig. 12. Changing the posi on of tooth 15 from horizontal to ver cal with the use of a side Bein elevator. Ryc. 12. Z wykorzystaniem dźwigni bocznej Beina wywarzono koronę zęba 15 i zmieniono jej położenie z poziomego na pionowe i usunięto zatrzymany ząb 15. Fig. 10. Surgically removed permanent teeth 53, 54 and 55. Ryc. 10. Usunięto przetrwałe zęby mleczne 53, 54, 55. Fig. 13. Chisel shaped crowns of central incisors. Ryc. 13. Korony zębów przyśrodkowych siecznych miały kształt dłuta.

5 Atypical dislocation of impacted permanent teeth in children 387 Table I. Numerical colla on of translocated, impacted secondary teeth in children. Tabela I. Zestawienie liczbowe przemieszczonych, zatrzymanych zębów stałych u dzieci. Type of tooth Rodzaj zęba Impacted upper central incisor, right or le side Zatrzymany ząb przyśrodkowy sieczny, górny, strona prawa lub lewa Impacted upper first premolar, le side Zatrzymany ząb przedtrzonowy górny pierwszy, strona lewa Impacted upper second premolar, right side Zatrzymany ząb przedtrzonowy górny drugi, strona prawa 11 or lub or lub or lub 25 Number of children Liczba dzieci Total/Razem Fig. 14. Follicular cyst visible around the root. Ryc. 14. Wokół korzenia widoczna była torbiel zawiązkowa. them. Special attention was paid to breathing issues, impaired coordination and balance, nausea and vomiting. Observation and examinations excluding the abovementioned symptoms, allowed for the children to be discharged home, under the care of their parents. Among 14 children, translocation of impacted permanent teeth concerned maxillary teeth. In 9 boys upper permanent incisors, whereas in 5 girls first and second premolars (tab. I). The crowns of the incisors were chisel-shaped (fig. 13). Labial surfaces were convex, and palatal concave. The roots were angled, with a follicular cyst. In 5 girls, by contrast, in extracted translocated upper premolars, weaker development of buccal cusp was observed. The root was single, with deep sulcuses. Follicular cyst was visible along the root (fig. 14). Extracted teeth were of yellowish white colour. DISCUSSION The prevalence of impacted upper incisors is of 9 % when compared to all cases of impaction. That is why it is on the third place of incidence of impacted teeth, just after the canines and second lower premolars [3]. The ground for the diagnosis of translocated impacted teeth is a thorough clinical and radiological examination, such as panoramic radiograph, which is sufficient for planning the treatment. That kind of radiological imaging was performed in 14 treated children. In 4 cases, by contrast, referring practitioners recommended the patients to perform a CT scan. In our opinion such imaging was unnecessary, because of already performed OPG. At the same time the fact of exposing the children to double ionizing radiation and causing additional costs, needs to be underlined. Kopirova is of opinion that potential diagnosis of atypical protuberance of soft tissues suggests initial evaluation of impacted tooth location [4]. We agree with the above mentioned statement, because we often practice palpation of the maxillary alveolus and alveolar part of the mandible, depending on the location of impacted tooth. Such procedure is correct in case of a superficially impacted tooth. But in 9 children, the translocation of impacted central upper incisors was deep, that is why the palpation was useless and would not contribute any new information on the impacted tooth. In evaluating the location of impacted tooth in the vertical plane, for many years we use and recommend the classification of Mlosek et alia [5], which determines the superficial, middle and deep position. Superficial position is when the crown of impacted tooth projects on the radiogram at the level of the necks of adjacent teeth. Middle position, is diagnosed when the crown of impacted tooth is visible between the neck and apex of the adjacent teeth. Deep position, by contrast, is when the crown projects above the apex or in its area. Because the above-mentioned classification evaluates the position of impacted tooth in the vertical plane, it was not used in 5 cases with horizontally impacted upper first and second premolars. In those cases, the provided OPGs allowed the estimation of impacted tooth location, its relation to the adjacent teeth structures, the maturity stage of the root, indications and contraindications for its introduction to the arch. In own material, there were no indications for introduction those teeth to the arch, which was dictated by the lack of space in the arch, because the tooth 12 took place of the impacted upper central incisors. Furthermore, in the area of roots of those teeth, deep angulation with follicular cyst was observed. Likewise, in the horizontal impaction of premolars, their extraction was advisable.

6 388 Anna Janas et al. As results from our longstanding experience, impacted and translocated teeth are found by accident [6, 7]. That is why, in our opinion, because of the possibility of complications such as teeth and occlusion disturbances and pathological lesions follicular cysts, which were observed in children treated by us, all fully shaped translocated and impacted teeth should be extracted on prophylactic basis as early as possible. Also in the cases of explicit disproportion in tooth size, the number of teeth and existing space, and also in order to eliminate the factors that could disturb the development of correct occlusion, extraction should be planned. The article of Zabel [8], who included in the 5 year clinical study, 7 children (5 boys and 2 children) aged between 9 and 12 years old, deserves special attention. Basing on clinical and radiological examination, 6 patients were diagnosed with one central upper incisor, and in one case impaction of both those teeth. The causes of impaction were supernumerary teeth, persistent premolars and mesiodens. In 6 cases, the extraction of above-mentioned dental anomalies, following with exposing the crowns of impacted teeth and fixing a metal grip and fixed orthodontic appliance, which positively affected the introduction of those teeth into the arch. In a 12 year old girl, by contrast, the extraction of a mesiodens resulted in spontaneous eruption of the impacted tooth 12. Those findings are in accordance with many of our reports [9], concerning such anomalies, because direct elimination of the factor causing the impaction and implementation of surgical-orthodontic treatment, influences positively on the alignment of the tooth in the arch. In presented clinical material, translocated, impacted teeth in 5 children were caused by persistent premolars. Whereas in the majority of cases, it is to be supposed that sustained trauma of the jaws influenced on the translocation of upper central incisors germs and their impaction. In available references, Polish as well as foreign, no articles discussing the translocation and impaction of permanent teeth in children were found. The authors [10, 11] discuss only individual cases of teeth impaction, caused by supernumerary teeth and mesiodenses. In such cases, they practice surgical treatment, to allow the eruption of impacted permanent teeth. This pattern of treatment raises no reservations and is performed in daily dental practice. Whereas in case of translocated, impacted permanent teeth in children, many dentists of various specialties stand before a problem of choosing the right therapeutic method. Due to this fact, the developing of treatment pattern in those cases, needs to be widely spread. In summary, it needs to be underlined, that in the cases where basing on the position of the tooth germ, its latter translocation and impaction can be predicted, the germ needs to be extracted. CONCLUSIONS In cases, where basing on radiological examination, the position of the tooth germ allows to predict its latter translocation, the tooth germ should be extracted. REFERENCES 1. Janas A. Ząb przetrwały, zębiak, torbiel zawiązkowa i zatrzymany stały kieł górny u 13-letniego chłopca. Por Stomat. 2009;5: Janas A. Zatrzymany ząb 21 u 13-letniego chłopca z niedoczynnością przysadki mózgowej. Por Stomat. 2009;10: Grzesiak-Janas G, Janas A, Sikorska I. Zęby zatrzymane. Mag Stomat. 2006;3: Koprivova J. Etiology and treatment of unerupted upper central permanent incisors. Part I Etiology and diagnostics. Ortodoncie. 2001;10: Mlosek K, Kozłowski J, Thun-Szretter K, Piekarczyk B. Zdjęcie pantomograficzne a postępowanie w diagnostyce radiologicznej zębów zatrzymanych. Czas Stomat. 1986;39: Janas A, Ratajek-Gruda M. Zatrzymany ząb mądrości w zachyłku jarzmowym zatoki szczękowej. TPS. 2006;10: Janas A. Całkowicie zatrzymane i zrośnięte zęby trzonowe w szczęce. Por Stomat. 2007;9: Zabel M. Problemy kliniczne związane z leczeniem zatrzymanych przyśrodkowych siekaczy górnych stałych (długotrwałe obserwacje własne). Stomat Wsp. 2003;10: Janas A, Grzesiak-Janas G, Olszewski D. Dwa zęby nadliczbowe przyczyną zatrzymania zębów. Por Stomat. 2009;3: Nogami S, Miayamoto I, Yamauchi K, et al. Supernumerary deciduous teeth with multiple maxillary impacted mesiodens: a case report. Pediatr Dental J. 2012;22: Jafri S, Kaur Pannu P, Galhotra V, et al. Management of an inverted impacted mesiodens, associated with a partially erupted supplemental tooth a case report. Indian J Dent. 2011;2: Author s contributions/wkład Autorów According to the order of the Authorship/Według kolejności Conflicts of interest/konflikt interesu The Authors declare no conflict of interest. Autorzy pracy nie zgłaszają konfliktu interesów. Received/Nadesłano: r. Accepted/Zaakceptowano: r. Published online/dostępne online Address for correspondence: Piotr Osica Zakład Chirurgii Stomatologicznej UM w Łodzi ul. Pomorska 251, Łódź, Poland pioosica@interia.pl