APICOECTOMY TREATMENT OF AN IMPACTED MAXILLARY CANINE THAT RESISTED ORTHODONTICALLY FORCED ERUPTION
3 . Discussion
Maxillary canine impaction is a well-documented dental condition . Many etiologic factors have been described in the literature . 7 , 8 , 9 Impacted maxillary canines typically require a multidisciplinary approach . A correct diagnosis of the predisposing factors that cause tooth immobility is important for setting up a successful treatment plan 10 . Lack of space is a frequently reported cause of impaction , but palatally impacted maxillary canines have been associated with sufficient space in the dental arch . 5 , 6 This association was consistent with the clinical situation in the present case study ; no crowding was observed at the recipient site , and the remaining space was favorable . With the first orthodontic treatment , the canine was exposed and a bracket was placed to force its eruption . Nevertheless , the impacted canine resisted the orthodontically-induced forces , which raised the suspicion of an ankylosis . However , ankylosis could be ruled out , based on results from mobility tests on the exposed canine crown and radiography ( CBCT scan ) of the periodontal ligament space around the root . We next investigated a probable cause for the lack of mobility by examining reconstructions of the CBCT data in all planes . Finally , we found a morphological discrepancy of the canine that could explain the clinical situation ; that is , we found an apical bend at the canine tip , which passed through the cortex of the nasal floor . Autotransplantation was the first treatment alternative suggested , based on sufficient reports in the literature about successful rates in treating maxillary impacted canines ; 11 , 12 moreover , the recipient site had been opened orthodontically . However , an important factor in the prognosis of an autotransplanted tooth is the competence of the alveolar bone and the surrounding soft tissues in the recipient zone . It is generally assumed that the periodontal ligament will not initiate osteogenesis in the absence of adjacent bone . Furthermore , wound
closure with a gingival flap is a key factor in
successful healing . 13 , 14 In our case , the canine had previously been exposed and had commenced descent towards the alveolar ridge before halting . However , we detected defects in the supporting bone tissue and the mucosa . Due to the lingual localization of these defects , we suspected that the condition of these tissues would deteriorate after the surgical removal of the canine . Moreover , because these types of bony defects do not close optimally , 15 they may potentially persist as periodontal defects after transplantation . Thus , the prognosis of an autotransplanted tooth was considered unfavorable . The key to successful treatment for this patient was a careful assessment of the clinical situation , combined with early identification of the true cause of immobility ( i . e ., the dilaceration of the canine root apex , which anchored the canine to the cortical bone of the nasal floor ). The only alternative treatment option would have been an extraction of the immobile canine . Instead , we hypothesized that the hooked apical root tip had provided resistance to guided eruption . Therefore , we performed an apicoectomy of the anchored portion , after endodontically treating the exposed canine . The follow-up examination performed 14 months postoperatively supported our hypothesis , because removal of the hindering factor allowed the canine to react positively , by promptly descending to its functional position with guided eruption . A second follow-up examination was performed 26 months postoperatively . The treatment outcome was stable , as shown by the absence of mobility , resorption , periapical lesion , or recurrence of impaction .
4 . Conclusion
An apical dilaceration through the cortical bone may immobilize an impacted canine . After treating the tooth endodontically , an apicoectomy of the bent tip can facilitate canine exposure and eruption , with a favorable prognosis .
Acknowledgments
The authors declare no conflict of interest related to this study . There are no conflicts of interest and no financial interests to be disclosed .
REFERENCES
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