Case Report

Forced eruption of impacted and dilacerated premolar

Sanjeev Datana1, Saugat Ray2, Dinesh Chaudhry3, Prasanna Kumar4

Abstract
Management of an unfavorably impacted tooth, especially with a dilacerated root is a challenge in orthodontic practice. This article
discusses the successful management of one such tooth. A 9‑year‑old girl reported for orthodontic treatment and was diagnosed as Class I
malocclusion with impacted tooth unfavorably positioned and dilacerated root. The case was conservatively managed, and impacted
tooth with 20° dilaceration and 70° deviation from normal axis was successfully guided into occlusion without jeopardizing its vitality
or morphology.

Key words: Dilaceration, forced eruption, impaction

Introduction On examination, the patient had mild convex profile and

bilaterally symmetrical face. Intraoral examination revealed
An impacted tooth is one that is prevented from erupting to
that the patient is in mixed dentition stage and little ahead
its normal functional position after root development. The
of her chronological milestone with the premature eruption
obstruction can be because of bone, tooth, fibrous tissue or its
of first premolars [Figure 1]. Orthopantomogram (OPG)
abnormal position. Mandibular second premolar is the third
revealed erupting permanent canines and second premolars
most common impaction after third molars and maxillary
in all quadrants. All developing teeth were normally
canine with an incidence of approximately 24%. An impacted
positioned except for left lower second premolar. There
tooth may pose esthetic, masticatory, hygienic and/or potential
was no history of trauma or premature loss of any tooth
problems for adjacent teeth and structures. The treatment
in the arch. The long axis of this tooth was at an angle of
of impacted premolars can be challenging in orthodontic
70° to the long axis of adjacent teeth with crown directed
practice and more so for an unfavorably impacted tooth with
distally approximating middle 1/3 of root of first permanent
dilaceration. The present case report elucidates conservative
molar and root apex in approximation to apex of the first
management of developing horizontally impacted mandibular
premolar. In addition, the impacted premolar had prominent
second premolar with dilaceration and significant deviation
dilaceration at the level of middle 1/3 of root at an angle of
from normal axis.
20° [Figure 2].
The primary treatment objective for the patient was a
Case Report correction of impacted premolar. No skeletal correction was
A 9‑year‑old girl was referred to the tertiary care dental planned, as the clinical feature of the patient was suggestive
center for the management of developing malocclusion. of skeletal Class I. Keeping in view of the above, cost factor
and unnecessary radiographic exposure involved with the
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radiographs lateral cephalogram was not taken.
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Keeping in view, the above positional and morphological
considerations and dental developmental status it was decided
DOI:
to take up the case for early treatment. Fixed mechanotherapy
10.4103/0301-5742.199255

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4
Department of Dental Surgery, AFMC, Pune, Maharashtra, India
For reprints contact: reprints@medknow.com
Address for correspondence: Dr. Saugat Ray,
12 Corps Dental Unit, 659 SS Enclave, Jodhpur ‑ 342 010, Rajasthan, India.
E‑mail: saugatray80@gmail.com How to cite this article: Datana S, Ray S, Chaudhry D, Kumar P. Forced
eruption of impacted and dilacerated premolar. J Indian Orthod Soc
Received: 20‑04‑2016, Accepted with Revisions: 30‑09‑2016 2017;51:43-5.

© 2017 Journal of Indian Orthodontic Society | Published by Wolters Kluwer - Medknow 43

 Datana, et al.: Forced eruption of impacted premolar
was planned for guided eruption of impacted premolar tooth
and its integration into the arch.
Treatment progress
Both maxillary and mandibular arch were bonded with
Roth 0.018″ preadjusted edgewise appliance (PEA). After
extraction of the deciduous molar and initial alignment with
0.016 NiTi was achieved, 0.016″ × 0.022″ stainless steel (SS)
arch wire was engaged in the lower arch. Simultaneously
an attachment was bonded on the impacted tooth after
surgical exposure through the extraction socket. Closed
eruption technique was followed, and an SS ligature from
the attachment was ligated to the base arch wire [Figure 3].
The patient was monitored at regular interval of 4 weeks,
and forced and controlled eruption tie was activated. The
tooth was made to erupt in its predetermined position in
5 months. Lingual button was replaced with a PEA bracket
followed by satisfactory alignment of the premolar in all
three planes [Figure 4].
Results
The impacted tooth was guided successfully without
jeopardizing its vitality, gingival, and periodontal
health [Figure 5]. The posttreatment OPG [Figure 6]
and intraoral peri‑apical radiograph [Figure 7] revealed
good periodontal support with no evidence of apical root
resorption.
Figure 1: Pretreatment
Figure 3: Mid‑treatment orthopantomogram
44 Journal of Indian Orthodontic Society | Vol 51 | Issue 1 | January‑March 2017
Discussion
The prevalence of impacted permanent teeth ranges from 5.6%
to 18.8% of the population with mandibular second premolar
being the third most commonly impacted permanent tooth
after third molars and maxillary canine.[1‑3] The prevalence of
mandibular premolar impaction is approximately 24% of all
the impactions and ranges from 0.2% to 0.3% in adults.[4] The
mandibular second premolar also shows great variation in its
development pattern; being one of the last permanent tooth to
develop and erupt.[5]
Various factors which can be attributed to the impaction of
mandibular premolar includes local factors like premature
loss of deciduous predecessor with mesial migration of
permanent first molar, ectopic position of tooth, pathologies
such as dentigerous cyst, ankylosed deciduous molar, and
syndromes like cleidocranial dysostosis.[6,7] The tooth bud
for mandibular second premolar is normally located between
the roots of deciduous second molar and any abnormality in
position results in deviated eruptive path and impaction. If
left untreated it may cause damage to neighboring teeth and
loss of ach integrity.[8] The present case seems to have an
ectopic position of developing 35 leading to its deviated path
of the eruption and its proximity to root apex of developing
34 may have contributed to its dilaceration in the absence of
any external trauma.
A dilacerated impacted tooth poses a great challenge to
orthodontist in diagnosis, treatment planning, and deciding the
prognosis.[9] In young patients, every attempt should be made
to save the dilacerated impacted tooth with a multidisciplinary
approach.[10] There are different opinions on therapeutic choices
for cases of impacted teeth with dilacerated roots. Literature
Figure 2: Pretreatment orthopantomogram
Figure 4: Orthopantomogram after complete eruption of premolars
 Datana, et al.: Forced eruption of impacted premolar
Figure 5: Posttreatment
Figure 6: Posttreatment orthopantomogram
Figure 7: Posttreatment intraoral periapical of the fully erupted premolar
reveals the success of orthodontic guidance of an impacted
tooth is best if deviation of impacted tooth long axis is <45°
from its normal position.[11] In the present case, the distal incline
of impacted tooth was 70° from its normal axis which was
managed successfully by orthodontic guidance of the tooth
to normal occlusion.
Although various treatment options are available, orthodontic
guidance of the impacted tooth is the best treatment option
and should be considered in young patients to achieve better
functional, esthetic, and biocompatible results.[12,13]
Journal of Indian Orthodontic Society | Vol 51 | Issue 1 | January‑March 2017
Closed eruption technique offers an advantage of better esthetic
outcome with good gingival contour and periodontal health and
more so for deeply impacted teeth. In the present case, closed
eruption technique was appropriately used keeping in view the
depth of impaction and dilacerated root to achieve adequate
periodontal support and gingival attachment.[14]
Conclusion
The present case report is a vivid example of how timely
diagnosis and treatment made the difference to the fate of
abnormally developing tooth, which was likely to remain
impacted, had the proactive intervention not been adopted.
Although initially the position and morphological aberrations
of impacted premolar in the present case had a poor prognosis
for forced‑guided eruption but meticulous planning and clinical
control could able to bring the impacted tooth in occlusion
and turned down any requirement of prosthetic rehabilitation
in future.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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