|DENTAL SCIENCE - CASE REPORT
|Year : 2013 | Volume
| Issue : 6 | Page : 190-194
Interdisciplinary approach for bilateral maxillary canine: First premolar transposition with complex problems in an adult patient
Dhivakar Selvaraj1, Jhonson Raja2, Somasundaram Prasath3
1 Department of Orthodontics, Rajas Dental College, Kavalkinaru, Tirunelveli, Tamil Nadu, India
2 Department of Periodontics, Rajas Dental College, Kavalkinaru, Tirunelveli, Tamil Nadu, India
3 Department of Prosthodontics, Rajas Dental College, Kavalkinaru, Tirunelveli, Tamil Nadu, India
|Date of Web Publication||1-Jul-2013|
Department of Orthodontics, Rajas Dental College, Kavalkinaru, Tirunelveli, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Adult patients seeking orthodontic care were increased nowadays not only on esthetic need but also on functional demand. But problems with adult patients were not only malocclusions but also dental caries, pulpal pathology, missing teeth, muco-gingival problems and loss of supporting structures. We report here a case of 35-year-old female with complete transposition referred as a positional interchange of two permanent teeth within the same quadrant of the dental arch along with gingival recession of the lower anteriors and missing molars. Gingival health was improved by free gingival graft in lower anteriors followed by fixed orthodontic procedure to correct transposition. Based on transposition crown recontouring and restoration was done along with replacement of missing molars with fixed prosthesis. Thus, proper treatment planning with interdisciplinary management improves not only the esthetics and occlusal relationship but also with stable results.
Keywords: Complete transposition, free gingival graft, gingival recession, missing tooth, maxillary canine and premolar transposition
|How to cite this article:|
Selvaraj D, Raja J, Prasath S. Interdisciplinary approach for bilateral maxillary canine: First premolar transposition with complex problems in an adult patient. J Pharm Bioall Sci 2013;5, Suppl S2:190-4
|How to cite this URL:|
Selvaraj D, Raja J, Prasath S. Interdisciplinary approach for bilateral maxillary canine: First premolar transposition with complex problems in an adult patient. J Pharm Bioall Sci [serial online] 2013 [cited 2019 Aug 24];5, Suppl S2:190-4. Available from: http://www.jpbsonline.org/text.asp?2013/5/6/190/114319
Maxillary canine was very unique in its self-cleaning shape, corner stone location and alar base support for esthetics. Its pointed cusp shape helps for tearing food and long root allows distribution of occlusal load. But because of the long path of eruption canine tooth often get deflected either buccaly or palatally, impacted or transposed. Of the above mentioned transposition, a rare dental anomaly referred as a positional interchange in the position of two permanent teeth within the same quadrant of the dental arch.  Chattopadhyay and srinivas,  showed 0.4% of prevalence of transposition in Indian population. Joshi and Bhatt,  showed a higher incidence of maxillary canine and premolar transposition. Transposition needs intervention with orthodontic procedure to alleviate crowding which improve esthetics, smile characteristics and occlusal relation which indirectly improves the oral hygiene maintenance and self-confidence of the individual.
Adult patients seeking orthodontic care were increased nowadays not only on esthetic need but also on functional demand. But problems with adult patients were missing teeth, muco-gingival problems, dental caries, attrition and loss of supporting structures.
Following case report describes interdisciplinary management of bilateral maxillary canine and premolar complete transposition in adult female with periodontal problems and missing teeth treated with combined fixed orthodontic tooth movement, restorative and crown recontouring, periodontal surgical procedure and prosthetic replacement.
| Case Report|| |
A 36 years, 10 month old female patient presented to Department of Orthodontics with a chief complaint of generalized spacing in upper and lower front region of the teeth and irregular arrangement in posteriors of the upper arch. Extra oral examination revealed the patient with an average facial form with symmetrical face, mild convex profile, posterior divergence and competent lips. During smile, both upper and lower incisors were visible within her age limits [Figure 1]. Occlusal examination Showed upper retained deciduous canine with bilateral ectopic eruption of canine buccally between 1 st and 2 nd premolar teeth [Figure 2]. Clinical and radiographic evaluation show it's a case of complete transposition,  where crown and root of the respective teeth are found parallel in their transposed position [Figure 3]. Interestingly she doesn't have any other dental anomaly or developmental missing tooth except bilateral occurrence of complete canine transposition. Root morphology was altered with external root resorption in the distal aspect of the mid root section was seen in the upper left 1 st premolar tooth. Class I molar relation was seen in the right side. She underwent extraction of left side upper 1 st molar, both maxillary 3 rd molar and right side lower 3 rd molar due to gross decayed condition 5 years back. Further, heavily restored amalgam fillings in relation to the lower left 1 st molar and right 2 nd molar. Grade II mobility  and class III gingival recession,  was seen in both lower central incisors. Cephalometric analysis showed a class I skeletal pattern with proclination of both upper and lower incisors with 0.5 mm over jet and overbite relationship [Table 1].
|Table 1: Cephalometric measurements for pre-treatment, post-treatment and post-retention changes |
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Treatment plan and progress
Considering the class III gingival recession of both the lower central incisors, free gingival graft was planned initially before orthodontic treatment to improve the periodontal status. Free gingival graft of 8 mm × 5 mm was taken from the donor site of palatal tissue in relation to upper left 1 st molar region. Graft was placed such that to increase the width of attached gingiva rather than for recession coverage of the lower incisors [Figure 4]. Fixed orthodontic treatment was started with extraction of both retained deciduous canines in the upper arch with 022 Roth prescription along 0.012 niti wire. Since it's a case of complete transposition, maxillary canine and 1 st premolar brackets were interchanged with 1 st premolar moved mesially in the deciduous canine position. First premolar was recontoured as canine and canine as premolar respectively. After 3 months, brackets were fixed in the lower arch. Leveling and aligning was done up to 0.019 SS × 0.025 SS in both arches. Orthopantamogram was taken and bracket was repositioned in relation to 14, 21, 23, 24 and 2 nd molar banding was done [Figure 5]. Recontouring and restoration was done in relation to 11, 13 and 23. Occlusal settling was completed and space in the 26 region was maintained for prosthesis replacement. After final debonding fixed bonded retainer was placed in both upper and lower arch. A removable Hawley type retainer was also placed in the upper arch [Figure 6], [Figure 7] and [Figure 8]. Finally, a three unit metal ceramic fixed prosthesis was done in relation to 26 region.
|Figure 4: Graft in situ relation to lower incisors for recession coverage|
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|Figure 5: Orthopantamogram showing teeth angulations and position before 2nd molar banding|
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|Figure 6: Post-debonding intra oral view with lingual bonded retainers in upper and lower arch|
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| Discussion|| |
When tooth was fully erupted it was difficult to move the completely transposed teeth to their normal position compared to incomplete transposition and erupting canine tooth in young adolescence because the bucco-lingual width of the alveolar bone was not sufficient to support two adjacent teeth moving in different directions. If an attempt was made to correct the tooth position there would be possibilities for compression and friction which leads to iatrogenic damage to teeth (e.g., root resorption) and periodontal tissues (e.g., clefting and recession of gingival tissue).  So considering the functional integrity of the periodontium to prevent the development of attachment loss and root resorption, treatment was planned to maintain canine and premolar in their respective position.
Periodontal need to improve the width of attached gingiva in relation to both lower central incisors was done with free gingival graft. Free gingival graft was taken from the donor site of palatal tissue in relation to upper left molar region to improve the periodontal health and to prevent further soft-tissue recession during orthodontic tooth movement. Further orthodontic movement of the lower incisor was mostly lingual rather facial helps to maintain the restored gingival level without further recession. Any recession of the labial gingival margins due to normal aging or other reasons (mechanical, including overzealous tooth brushing or periodontal) will take on natural look. 
Premolar was rotated mesially to increase the mesial incline by placing the bracket 1 mm distally to normal position,  and care was taken to prevent fenestration of the premolar buccal roots. Torquing of the upper premolars to simulate canine was not performed considering the root morphology, root length and existing external root resorption.  Though torquing of premolars and canine was not performed, inclination of both the teeth was favorable which provide an esthetic frontal smile. Gingival line would be better if gingival recontouring was done in premolar to simulate canine, but patient was satisfied with the existing results.
Functionally group function was established instead of canine guided occlusion because of the tendency for interference of the lingual cusp of the premolar during lateral movement. Selective occlusal grinding was done on the lingual cusp of 1 st premolar during each appointment to prevent the development of sensitivity and allow development of reparative dentin till interference was relieved.
After 20 months of active treatment, appliance was debonded. Prosthetic replacement of the missing maxillary 1 st molar tooth was planned rather than orthodontic space closure because of lack of third molar. Further metal ceramic restoration was advised to patient rather than implant prosthesis considering the bone density and width which was not favorable for implant placement. Follow-up records were taken 2 years after debonding shows excellent esthetics, occlusal stability with marked improvement in her self-confidence and self-esteem [Figure 9], [Figure 10] and [Figure 11].
| Conclusion|| |
Adult patients with complex malocclusion like complete canine and premolar teeth transposition with periodontal problems and missing tooth should be best managed with interdisciplinary management procedures. The risk benefit ratio in terms of cost, duration, occlusion, periodontal health, esthetics and stability parameters and limitation from diagnosis, treatment and maintenance phase should be considered. If these parameters and limitations were not seriously considered, final treatment outcome would be questionable.
| References|| |
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|2.||Chattopadhyay A, Srinivas K. Transposition of teeth and genetic etiology. Angle Orthod 1996;66:147-52. |
|3.||Joshi MR, Bhatt NA. Canine transposition. Oral Surg Oral Med Oral Pathol 1971;31:49-54. |
|4.||Shapira Y, Kuftinec MM, Stom D. Maxillary canine-lateral incisor transposition: Orthodontic management. Am J Orthod Dentofacial Orthop 1989;95:439-44. |
|5.||Carranza FA, Takei HH. Clinical diagnosis. In: Carranza FA, editor. Clinical periodontology. 10 th ed. St. Louis: Saunders; 2006. p. 546. |
|6.||Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13. |
|7.||Ciarlantini R, Melsen B. Maxillary tooth transposition: Correct or accept? Am J Orthod Dentofacial Orthop 2007;132:385-94. |
|8.||Rosa M, Zachrisson BU. Integrating esthetic dentistry and space closure in patients with missing maxillary lateral incisors. J Clin Orthod 2001;35:221-34. |
|9.||Krishnan V. Critical issues concerning root resorption: A contemporary review. World J Orthod 2005;6:30-40. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]