Interdisciplinary approach for bilateral maxillary canine: First premolar transposition with complex problems in an adult patient
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 []. Occlusal examination Showed upper retained deciduous canine with bilateral ectopic eruption of canine buccally between 1st and 2nd premolar teeth []. 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 []. 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 1st premolar tooth. Class I molar relation was seen in the right side. She underwent extraction of left side upper 1st molar, both maxillary 3rd molar and right side lower 3rd molar due to gross decayed condition 5 years back. Further, heavily restored amalgam fillings in relation to the lower left 1st molar and right 2nd 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 [].\nConsidering 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 1st molar region. Graft was placed such that to increase the width of attached gingiva rather than for recession coverage of the lower incisors []. 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 1st premolar brackets were interchanged with 1st 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 2nd molar banding was done []. 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 [Figures -]. Finally, a three unit metal ceramic fixed prosthesis was done in relation to 26 region.