Macrodontic maxillary incisor in alagille syndrome
A 10-year-old male was presented to our dental office complaining of delayed eruption of a maxillary central incisor []. His medical history indicated a diagnosis of ALGS with no previous systemic treatment or complication. Clinical examination revealed characteristics ALGS traits: Broad forehead, deep-set eyes with eye-socket, pointed mandible and prominent chin; maxillary hypoplasia, maxillo-mandibular retrusion; and increased vertical facial dimension were also noted. He presented a Class I molar relationship on both side, a correct overjet and a deep overbite (90%). Absence of maxillary right central incisor with no adequate space in the maxillary arch was noted. Crowns of the adjacent teeth had slightly drifted into the unoccupied space. An intra-oral examination revealed the presence of several decalcifications on deciduous teeth with previous conservative treatment on first permanent molars and maxillary first deciduous molar on right side. Panoramic radiograph showed a macrodontic maxillary right central incisor vertically retained.\nCephalometric analysis indicated a Class I skeletal pattern with retrognathic maxilla and mandible, prominent chin, and slight hyperdivergent tendency.\nTreatment objective was to create space in the maxillary arch and allow the eruption of the impacted central incisor. Surgical exposure and orthodontic traction with a fixed appliance was planned.[]\nRisk of increased bleeding, vascular events, and latex hypersensitivity were the major concern, requiring the use of latex-free materials, controlled hemostatic procedure, and antibiotic prophylaxis as recommended by the cardiologist.\nBands on deciduous second molars and Begg's brackets on permanent incisors and deciduous canines were placed. After alignment and levelling were completed using 0.014″ nickel–titanium archwire, a relatively rigid stabilizing wire (0.018″ round Australian wire) was placed, and a coil spring was used to create adequate space between the central incisor and the right lateral incisor. Periodontal surgery was performed to expose the maxillary right central incisor. An access flap was elevated to expose the impacted tooth and a lingual button connected to a ligature wire was bonded to the palatal surface. A closed surgical exposure technique was chosen. An elastic module for applying an apically directed force was applied to the stabilizing wire []. Vertical traction allowed the incisor eruption to be guided along the alveolar ridge. Once crown of the maxillary incisor adequately appeared in the maxillary arch, a Begg bracket was bonded to the vestibular surface and alignment and levelling were completed using 0.014″ nickel titanium wire, and later replaced by 0.018″ round Australian wire []. Active treatment took 9 months.\nThe impacted maxillary right central incisor was brought into proper alignment with the adjacent teeth. Once alignment was achieved, greater height and crown width of the macrodontic incisor caused gingival margin and incisal border alterations []. Conservative treatment and minimal restorative interventions,[] accessory periodontal treatment, and dental reshaping procedures[] may be indicated to re-establish the proper size and dimension of the macrodontic incisor.