Impacted incisors can pose significant esthetic and functional challenges for patients. Various treatment approaches have been proposed. The 2x4 orthodontic appliance is one of the most effective treatment plans for aligning the teeth. This article presents two cases showing surgical traction's effectiveness using the 2x4 orthodontic appliance in managing impacted incisors. The results of this case series demonstrated successful outcomes in terms of impacted incisor alignment and overall occlusion. Patients exhibited improved esthetics and function. Therefore, Surgical traction of impacted incisors using the 2x4 orthodontic appliance can be a viable and effective treatment approach.&nbsp

Gumro, Menia

Gupta, Sonal

ISHA, SIMRAN

English

International Journal of Medical Research & Review (IJMRR)

International Journal of MedicalResearch and Review2023 Volume 11 Number 5 September-OctoberE-ISSN:2320-8686P-ISSN:2321-127XCase ReportImpacted Incisor TractionPublisherwww.medresearch.inOrthodontic Marvel: 2x4 Appliance for Impacted Incisor Traction - ACase SeriesIsha S1*, Gupta S2, Gumro M3DOI: https://doi.org/10.17511/ijmrr.2023.i05.041* Simran Isha, Junior Resident, Department of Pediatric And Preventive Dentistry, Kd Dental College And Hospital, Mathura, Uttar Pradesh,India.2 Sonal Gupta, Professor and Head, Department of Pediatric and Preventive Dentistry, KD Dental College and Hospital, Mathura, UttarPradesh, India.3 Menia Gumro, Junior Resident, Department of Pediatric and Preventive Dentistry, KD Dental College and Hospital, Mathura, Uttar Pradesh,India.Impacted incisors can pose significant esthetic and functional challenges for patients. Varioustreatment approaches have been proposed. The 2x4 orthodontic appliance is one of the mosteffective treatment plans for aligning the teeth.7 This article presents two cases showing surgicaltraction's effectiveness using the 2x4 orthodontic appliance in managing impacted incisors. Theresults of this case series demonstrated successful outcomes in terms of impacted incisor alignmentand overall occlusion. Patients exhibited improved esthetics and function. Therefore, Surgicaltraction of impacted incisors using the 2x4 orthodontic appliance can be a viable and effectivetreatment approach.Keywords: Impacted incisors, Orthodontic Marvel, Unerupted teethCorresponding Author How to Cite this Article To BrowseSimran Isha, Junior Resident, Department ofPediatric And Preventive Dentistry, Kd Dental CollegeAnd Hospital, Mathura, Uttar Pradesh, India.Email: Isha S, Gupta S, Gumro M, Orthodontic Marvel: 2x4Appliance for Impacted Incisor Traction - A CaseSeries. Int J Med Res Rev. 2023;11(5):123-129.Available Fromhttps://ijmrr.medresearch.in/index.php/ijmrr/article/view/1442Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted2023-09-16 2023-09-18 2023-09-25 2023-10-02 2023-10-09Conflict of Interest Funding Ethical Approval Plagiarism X-checker NoteNil Nil Yes 16%© 2023by Isha S, Gupta S, Gumro Mand Published by Siddharth Health Research and Social Welfare Society. This is an OpenAccess article licensed under a Creative Commons Attribution 4.0 International Licensehttps://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].Int J Med Res Rev 2023;11(5) 123IntroductionImpaction is a condition in which complete tootheruption is hampered by its contact with anothertooth. It is characterized by the absence of a toothin the arch after its usual period of eruption.Unerrupted teeth are often encountered in themixed dentition stage. Maxillary central incisorsnormally erupt between the ages of 8 to 10 years,and delayed eruption adversely affects esthetic,function, and speech.[1] It may result in adjacenttooth migration, space loss, and midline deviation.Primary causes of central incisor impaction can betrauma to the primary teeth, and mechanicalobstruction which might be due to the presence ofsupernumerary tooth, mesiodens, odontomas, orcysts developed within the eruptive path of thetooth. The prevalence of impacted maxillary centralincisors in the age group of 5 to 12 years old is13%. [2]Eruption of the maxillary incisor is delayed if theeruption of the contralateral incisor occurred 6months earlier, the lower incisors have erupted >1year earlier or there is a deviation from the normalsequence of eruption. Diagnosis of impacted incisorscomprises of clinical examination to identify retaineddeciduous teeth and palpation of the alveolarregion.3 The clinician may encounter a painless,incompressible, palatal, or vestibular fibro mucosalprotuberance. Early diagnosis of transposition intooth development and impaction is essential andgreatly influences the prognosis. Intraoralradiographs can confirm a diagnosis. Periapicalviews and/or an upper standard occlusal radiographdetermine the presence and position of maxillaryincisor teeth and any underlying developmentalanomalies or pathology.[5]The fixed appliance 2x4 comprises four bracketsbonded onto the erupted maxillary permanentincisors, two tubes bonded on the first permanentmolars, and a continuous archwire to provide a goodarch form. This appliance's versatility permitsresolving various problems affecting the upperincisors in a simple and short period.7 A 2x4sectional fixed appliance offers more effective andefficient tooth positioning as it allows 3-dimensionalcontrol of involved teeth during the correction ofaligning impacted incisors. Thus this case reportdocuments 2 cases of management of impactedcentral incisors using 2x4 orthodontic appliances.Case 1HistoryA 10-year-old male patient reported to theDepartment of Pediatric and Preventive Dentistrywith a chief complaint of missing teeth in the upperfront tooth region.The patient was healthy and did not have any dentalor medical conditions. Extra-oral examinationrevealed a bilaterally symmetrical face with aconcave profile.Intra-oral examination revealed the angle’s class 1malocclusion bilaterally with the absence ofmaxillary permanent central incisors.Radiographic ExaminationAn occlusal radiograph was advised to determinethe position of the impacted central incisors. Itrevealed the presence of an impactedsupernumerary tooth concerning the impactedcentral incisors. It demonstrated that the maxillarycentral incisors were impacted due to the presenceof the impacted supernumerary tooth which wascausing hindrance in the eruption of these teeth.The position of the supernumerary tooth was palataland in between the central incisors.Diagnosis:Treatment PlanThe treatment was planned in 2 stages; The firststage consisted of surgical extraction of theimpacted supernumerary tooth. In the secondstage, surgical exposure and traction of theimpacted central incisors with the fixed 2x4orthodontic appliance was planned.TreatmentIn the first stage of treatment, Infraorbital andnasopalatine nerve blocks were administered.Palatal incisions were given and the flap was raisedwith a periosteal elevator. Bone cutting was done toexpose the embedded supernumerary tooth. Thesupernumerary tooth was then extracted. Theextracted site was irrigated with betadine andsutures were placed.Isha S et al: Orthodontic Marvel 2x4 Appliance for Impacted Incisor TractionImpacted supernumerary tooth irt 11, 21Impacted central incisors irt 11, 21Int J Med Res Rev 2023;11(5)124Post-operative instructions were given and thepatient was prescribed antibiotics, analgesics, andmouthwash. The patient was then recalled after 10days for suture removal.PRE-OPERATIVESURGICAL EXPOSURE OF IMPACTED INCISORSBRACKETS PLACED ON IMPACTED CENTRALINCISORNITI 0.12 WIRE PLACEDNITI 0.14 WIRE PLACEDNITI 0.16 WIRE PLACEDPOST OPERATIVEIsha S et al: Orthodontic Marvel 2x4 Appliance for Impacted Incisor TractionInt J Med Res Rev 2023;11(5) 125In the second stage of treatment, a nasopalatinenerve block was administered and the labial flapwas raised to expose the impacted incisors.Brackets were placed on the labial surface of theimpacted incisors and lateral incisors, molar tubeswere placed concerning the maxillary 1st molars.The patient was recalled after 48 hours andplacement of 0.12NiTi wire was done. Loose sutureswere placed irt 11, and 21. After 1 month thepatient was recalled, and the wire was changed to0.14 NiTi wire. The patient was recalled after 3months. The wire was changed from 0.14 to 0.16NiTi wire. The central incisors had erupted at thisstage (8 months). After one 1-month patient wasrecalled and the brackets were removed. A lingualretainer was given from the maxillary left canine tothe maxillary right canine. A satisfactory result wasachieved after a total active orthodontic time of 1year.Case 2History And DiagnosisA 10-year-old female patient reported to theDepartment of Pediatric and Preventive Dentistry,with a chief complaint of missing tooth in the upperfront teeth region for 2 years. The patient had norelevant dental or medical history. Both theextraoral and intraoral examinations were done. Inthe extra-oral examination, no abnormalities weredetected while intraoral examination revealed theabsence of the left maxillary central incisor with theangle’s class-I molar relationship bilaterally.Radiographic ExaminationAn Intraoral periapical radiograph was advised todetermine the position of the left maxillary centralincisor. It revealed the presence of an impaction ofthe same tooth. The largest width of the crown ofthe erupted permanent right maxillary centralincisor was 8 mm. The space available for theunerupted right permanent central incisor in themaxilla was 6 mm. Diagnosis:Treatment PlanThe treatment was planned in 2 stages: The firststage consist of maxillary arch expansion with ajack screw expansion appliance, to create a spacefor the unerupted tooth.In the second stage, exposure and traction of theimpacted tooth with the 2x4 orthodontic appliancewere planned. Treatment: The removable Maxillary lateralexpansion appliance was made extra orally.Appliance design: A simple removable plate wasdevised as the mode for expansion. An appliancewas constructed with the jackscrew placed at thedeepest part of the vault along with two well-fittingAdam’s clasps (permanent 1st molars) and ball endclasps ( on between primary 1st and 2nd molars.The acrylic plate allowed for easier expansion.Expansion protocolThe rate and rhythm of screw activation was 1/8thturn 6 days a week. The appliance was given for onemonth, once the crown of the impacted tootherupted further stage of treatment was done. Theremaining crown exposure was done withelectrocautery w.r.t 21 and then the bracket wasbonded on the labial surface of the tooth.MBT brackets were bonded on permanent maxillarycentral and lateral incisors bilaterally and 0.012 Nitiwire of supreme grade was used to align the leftcentral incisor.The patient was recalled after a month, initial wirewas removed and replaced with 0.014 NiTi wire. Inthe 3 months desired result was achieved. Thepatient showed normal clinical crown length withacceptable gingival contour and width. The patientwas satisfied with the esthetic results.Pre-OperativeIsha S et al: Orthodontic Marvel 2x4 Appliance for Impacted Incisor TractionImpacted central incisor w.r.t 21Int J Med Res Rev 2023;11(5)126Maxillary ExpansionCrown exposure with ElectrocauteryMBT braket placed w.r.t 12,11,21,22.0.012 Niti wire placed0.014 Niti wire placedPost-Operative After 3 monthsDiscussionThe occurrence of unerupted maxillary incisors canbe associated with hereditary and environmentalfactors. Often the position of the impacted incisori.e., distance from the alveolar crest, rotation,angulation, and inclination determineIsha S et al: Orthodontic Marvel 2x4 Appliance for Impacted Incisor TractionInt J Med Res Rev 2023;11(5) 127The successful alignment of the impacted teeth.1The timing of intervention has been suggested asbeing important, the younger the age, the quickerthe tooth erupts. To avoid unnecessarycomplications the intervention should not bedelayed. [2]According to some studies, the prevalence ofimpacted central incisors has been estimated at2.6%. In about 0.42-2.1% of the patients withimpacted central incisors, the etiology of theimpaction was the presence of supernumeraryteeth. [3] This was similar to case 1 of this casereport.There are various treatment options for impactedcentral incisors which include, 1) extraction of animpacted tooth, 2) extraction of an adjacent tooth,or 3) non-extraction treatment involving orthodonticspace opening and surgical exposure Thespontaneous eruption has been reported in manycases after space creation. [5] The non-extractionor surgical exposure and orthodontic traction ofimpacted teeth is the treatment of choice in themajority of the cases. Often orthodontic spaceopening is carried out before the surgical exposureas done in Case 2 of our case series. This was doneto create a space to enhance the natural eruption ofteeth.Following supernumerary tooth/teeth extraction,various retrospective clinical studies have foundsuccess rates for the spontaneous eruption of thepermanent incisors to be 42 % (Omer et al. 2010),50 % (67.8 % when the supernumerary was amesiodens) (Patchett et al. 2001), and 75 %. [4]Pavoni et al. (2013) conducted a study that reportedthat rapid maxillary expansion followed by surgicalremoval of an obstacle in the eruption pathway(supernumerary or odontoma) may increase thelikelihood of spontaneous eruption of the impactedincisor. These results indicate that interceptiveorthodontic treatment increases spontaneouseruption in the management of impacted teeth.When the permanent central incisor does not eruptafter mesiodens removal, surgical exposure of teethis done. [1]There are two types of surgical approaches forexposure of the impacted teeth namely open andclosed approaches. Open or the apically positionedflap technique, consists of apically repositioning aflap that will incorporate the attached gingiva whichOverlies the impacted teeth. Another technique isthe closed-eruption technique, a flap is raised thatwill incorporate the attached gingiva over theimpacted teeth. This is followed by attaching anorthodontic bracket to the teeth, and then fullyreplacing the tissue over the tooth and bracket.Both techniques offer certain advantages during theforced eruption of impacted teeth.6 The opentechnique permits easy reattachment of a bracket ifdebonding occurs. However, the closed-eruptiontechnique is believed to provide the most aestheticresults. In the above-mentioned cases closederuption technique was used. The treatment optionwas because this technique provides a betteraesthetic result and good periodontal health.Bayram L.et al. (2006) stated in their article thatforced eruption of impacted teeth must always beconsidered in young patients because this techniquecan lead to suitable results from a periodontal,occlusal, and esthetic perspective at an earlier stagebetter than with other treatment options.[3]In both cases, the successful eruption of impactedincisors took place. An appropriate gingival contourand attached gingiva were seen towards the end ofboth cases. Satisfactory esthetics were achieved. Nofurther Treatment Was Required.ConclusionTreatment of impacted central incisors can be achallenging task. Early diagnosis and interventionsare required for a successful result. Appropriatesurgical treatment followed by orthodontic tractionis usually the most common treatment option.References1. Ayers E, Kennedy D, Wiebe C. Clinicalrecommendations for management of mesiodensand unerupted permanent maxillary central incisors.Eur Arch Paediatr Dent. 2014;15(6):421-428.doi:10.1007/s40368-014-0132-1 [Crossref][PubMed][Google Scholar]2. Barman, D. , Hossain, P. , Rekhade, R. , Biswas,S. , Agarwal, V., Jana, D. and Trainee, P. (2022).Orthodontic Assisted Eruption of PermanentMaxillary Central Incisor. European Journal ofPharmaceutical and Medical Research, [online] 9(1).Available at: [Accessed 23 May 2023] [Article][Crossref][PubMed][Google Scholar]Isha S et al: Orthodontic Marvel 2x4 Appliance for Impacted Incisor TractionInt J Med Res Rev 2023;11(5)1283. Bayram M, Özer M, S¸ener I. Bilaterally ImpactedMaxillary Central Incisors: Surgical Exposure andOrthodontic Treatment: A Case Report. J ContempDent Pract 2006 September;(7)4:098-105. .[Crossref][PubMed][Google Scholar]4. Chandhoke TK, Agarwal S, Feldman J, Shah RA,Upadhyay M, Nanda R. An efficient biomechanicalapproach for the management of an impactedmaxillary central incisor. Am J Orthod DentofacialOrthop. 2014 Aug;146(2):249-54.doi:.1016/j.ajodo.2013.09.017 [Crossref][PubMed][Google Scholar]5. Pinho T, Neves M, Alves C. Impacted maxillarycentral incisor: surgical exposure and orthodontictreatment. Am J Orthod Dentofacial Orthop. 2011Aug;140(2):256-65. doi:10.1016/j.ajodo.2009.11.018 [Crossref][PubMed][Google Scholar]6. Pavlidis D, Daratsianos N, Jäger A. Treatment ofan impacted dilacerated maxillary central incisor.Am J Orthod Dentofacial Orthop. 2011Mar;139(3):378-87. doi:10.1016/j.ajodo.2009.10.040 [Crossref][PubMed][Google Scholar]7. Kannan PK, Palanisamy SK, Kumar TS. A case ofimpacted maxillary central incisor and itsmanagement. J Pharm Bioallied Sci. 2012Aug;4(Suppl 2):S174-6. doi:10.4103/0975-7406.100263 [Crossref][PubMed][Google Scholar]Isha S et al: Orthodontic Marvel 2x4 Appliance for Impacted Incisor TractionInt J Med Res Rev 2023;11(5) 129

ORTHODONTIC MARVEL: 2X4 APPLIANCE FOR IMPACTED INCISOR TRACTION - A CASE SERIES

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ORTHODONTIC MARVEL: 2X4 APPLIANCE FOR IMPACTED INCISOR TRACTION - A CASE SERIES

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