Multidisciplinary management of an unusual case of multiple developmental defects in lateral incisor followed by intrusive injury to primary incisors
A 14-year-old female patient reported with chief complaint of discoloration and pain in right upper front tooth since 10 days. Pain was dull and intermittent in nature. Past medical history was non-contributory. Past dental history revealed trauma to primary central incisors and right lateral incisor 10 years back, after fall from stairs. On reporting to local dentist, intrusion (grade I) was diagnosed for all 3 mentioned teeth. Patient was kept under observation. Later, these primary teeth exfoliated corresponding to their age.\nThe extra-oral examination of head and neck structures were within normal limits and corresponded to normal growth and development for that age. Intra-oral examination of hard tissues revealed the presence of abnormal, discolored, hypoplastic permanent right maxillary lateral incisor. Labial surface of crown was having notch-like structure in cervical third region of crown []. Palatal view revealed presence of cusp-like structure of 4-5 millimeters extending less than half the distance from CEJ [] and a developmental groove run deep between palatal aspect of lateral incisor and this additional cusp []. Tooth was tender on percussion, and electric pulp testing indicated negative response. The crown of the lateral incisor had normal mesio-distal width and was tilted palatally. Primary right maxillary canine was retained, and the tip of erupting permanent right maxillary canine was observed distal to crown of lateral incisor []. Intra-oral periapical radiograph revealed the presence of an extra root-like structure superimposing right lateral incisor. []. Periapical radiolucency was present with respect to same tooth. Maxillary permanent right canine was seen impacted above the retained right primary canine and distal to permanent right lateral incisor.\nTreatment was planned in order to prevent periodontal disease and development of dental caries on palatal groove and to correct the esthetic status of hypoplastic tooth. To achieve the desired outcome, treatment was done in 3 steps. In the first step, endodontic treatment was performed followed by orthodontic alignment of the tooth and finally, esthetic rehabilitation was done.\nThe tooth was isolated with rubber dam, and access preparation was done. Pulp tissues were removed with barbed broaches. An extra canal was observed palatally to main canal, which was quite smaller in dimension. Canal was negotiated, and pulp tissue was removed with the help of barbed broach. The cleaning and shaping for both the canals were achieved using K files (Mani, Japan) and simultaneously, irrigation with normal saline and 5.2% sodium hypochlorite was done. The final apical file used was 30 size (ISO 0.02 taper) for both the canals. The canals were finally flushed with normal saline and dried with absorbent paper points. The canals were filled with calcium hydroxide powder (Deepashree products, Ratnagiri, India), mixed with saline, and were kept under observation for 4 weeks. The periapical radiolucency remained unchanged after 1 month; however, the tooth was asymptomatic. Final obturation was done using sealer (Endoflux, Ammdent, Mohali, India) with gutta-percha (Dentsply, France, SAS) by lateral compaction technique []. Patient was recalled again after 3 months for check-up. Periapical lesion was healed. Patient was referred to department of orthodontics for correction of malposed canine.\nThe fixed orthodontic treatment was started on patient using MBT (Mclaughlin, Bennett, Trevisi) straight wire appliance with slot size of 0.022 × 0.028˝ dimensions. Brackets were bonded on the upper arch, but the malformed tooth was banded due to its convexity and hypoplasia.\nInitially, alignment was done to mildly de-rotate the canine using 0.016˝ NiTi wire (Libral Traders, USA) for 4 weeks, followed by 0.016˝ stainless steel wire with NiTi coil spring (light force) for distalization of canine. This procedure took 6 months to distalize. During distalization, the posterior anchorage was reinforced with Nance palatal arch. After distalization, a space of 1.5 mm was created between canine and lateral incisor. This space was closed with 0.018 × 0.025˝ stainless steel wire (Libral Traders, USA) using ‘T’ loop mechanics. This took approximately 8 weeks. The remaining distopalatal rotation of canine was finally aligned with NiTi wire (Libral Traders, USA). This alignment took 3 weeks followed by a stabilizing wire (3 months). The total fixed orthodontic procedure took 10 months.\nThe orthodontic treatment was followed by esthetic rehabilitation of lateral incisor by all ceramic crown [].