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The treatment of impacted and unerupted teeth
T I l E T R E A T M E N T OF I M P A ( ' T E D A N D I;NERUPTI~2D T E E T I I ~':: HARRY B. W R I G H T ,
D.D.S.,
P t l I b A D E I A ' H I A , I)A.
I I E d e v e l o p m e n t a l forces of tile h u m a n ol'ganimn, the sum total of which we term Nature, }lave decreed that all the permanent teeth shah be present and in their correct positions if we are to have a normal occlusion, tIowever, it is f r e q u e n t l y noticed that one or several of the teeth fail to erupt and will not do so unless assisted.
T
While e v e r y one will agree t h a t it is easier to e x t r a c t such a tooth than to aid its eruption, the baneful consequences f r o m such e x t r a c t i o n spell ultim a t e distortion to the dental arch with p r o b a b l e i m p a i r m e n t of the normal health and function of the organism. The p u r p o s e of this clinic is to d e m o n s t r a t e methods which have been f o u n d useful in assisting the eruptions of such teeth as require this attention. One must d e t e r m i n e b y r a d i o g r a p h i c diagnosis, definitely and a c c u r a t e l y tile relative position of the crown of the tooth to the s u r r o u n d i n g tissues. This position h a v i n g been found, a circular incision is made about the area of the crown, and the tissue including the bony process overlying the tooth is r e m o v e d by tile use of chisels, in order to expose the crown freely. Styptic gauze is held o v e r this portion until there is some cessation of bleeding. A hole, about 2 ram. deep, is drilled obliquely into the lower t h i r d of the crown of tile tooth, in such a w a y as to aw)id the pulp. An iridio-platinum wire staple 0.020 inch in thickness and one-quarter inch in length is cemented into tile cavity. The s u r r o u n d i n g tissues are b a t h e d with a solution of adrenalin chloride, and the p a t i e n t is dismissed for one week. It is well to a d j u s t regulating appliances to gain the necessary space for the descent of the u n e r u p t e d tooth before the surgical exposure is p e r f o r m e d . On the subsequent visit, a u x i l i a r y wires 0.020 inch in d i a m e t e r can be soldered to the main arch for the direction of stinmlus for eruption. The d i a m e t e r uf the main arch wire is 0.040 inch in thickness. Some examples of eases t r e a t e d follow: Fig. 1 A shows r a d i o g r a p h of Case 1, showing u n e r u p t e d canine in position before t r e a t m e n t . B shows r a d i o g r a p h of same ease t w e n t y - e i g h t months l a t e r with canine in place. Note t h a t a portion of the pin is left in place and acts as an efficient filling' material. Fig. 2 A shows p l a s t e r east of Case 1 before t r e a t m e n t . Note t h a t the left deciduous eanine is unexfoliated. B shows Mershon lingual appliance in position with free end of a u x i l i a r y spring e n g a g i n g staple, cemented in tooth. C shows east m a d e t w e n t y - e i g h t months later, pewnanent canine in position. *Clinic presented at the t h i r t y - f i r s t a n n u a l m e e t i n g of th,~ A me ri c a n Soeiety of Orthodontists, Toronto, Canada, May 20, 1932. 617
Hctrrg It. Wright
618
A.
B. Fi~;. 1.
A.
C'. F i ~ . 2.
Fig'. 3.
C.
A. Fig.
4.
Treatment
o f• I m p a c t e d
aud
Uner~q#ed
6119
7 ee h ~'
Fig. 3 in a radiograph (ff Case 2 showing an mlerupted canine before treatment. Fig. 4 A shows Case 2 with a Mershon lingual arch adjusted with the free eIrd of the r e e u r v e d auxiliary wire engaging the staple for buccal movement of the right maxillary canine. B shows a east made one year later with the labial round wire arch adjusted having an auxiliary wire spring 0.020 inch in thickness e x e r t i n g stimuli for the creati<)n of necessary space. C shows a cast made two months later than that shown in B, with a Mershon lingual arch adjusted. Note the auxiliary spring adjusted for rotation of the maxillary right first premolar and auxiliary spring for the 1)u('(,al movement of the canine, which in now in position. Fig. 5 shows radiooraphs of Case :~ with bilateral maxillary labial (,anine impactions, before treatment.
F i g . 5.
A.
B.
ft.
F i g . 6.
Fig. 6 A sh(~ws cast of Case 3 before tleatment. B shows cast of ease eight months later. The left first:premolar was removed. Note lingual arch adjusted with auxiliary springs for labial movement of incisors and labial arch with auxiliary springs adjusted to stai)les in impacted teeth, these springs having a " s a f e t y pin c o i l " as an aid to posterior movement. (Y shows east made t h i r t y months later with both canines in position. Fig. 7 shows radiographs of Case 4 with impacted mandibular left second premolar, before treatment. Fi~'. S A shows cast of Case 4 with lingual arch adjusted. Note auxiliary wire exerting a n t e r i o r pressm'e on the first premolar for creating space an(l auxiliary wir(~ for the development of the anterior segment of the arch. B shows cast made t w e n t y months later with impression of the lingual arch in position. Note that space in developing for the reception of the second pre-
Harry B. Wright
620
molar which has now e r u p t e d and is in lingual position. C shows cast made six months later than B, with premolar in position. The lingual arch is now adjusted for general rounding out of the mandibnlar arch. Fita'. 9 shows radiographs of Case 5. A shows the impacted maxillary right central incisor before treatment. B made t h i r t y - t h r e e months later shows the central incisor in correct position, with remainder of pin in situ.
:Fig'. 7.
A.
B.
U.
:Fi.~. 8.
.4.
/7. :Fig. 9.
Fig'. 10 shows two views of Case 5 before treatment. Fig'. 11 shows two views of cast of Case 5 made nine months later. Note the lingual arch with auxiliary springs adjusted f o r the creation of necessary space, and the sacrifice of tissue for the exposure of impacted incisor crown. A wire link connects tile staple with the labial arch wire, motive force being obtained by bending the arch wire incisally and spring'ing it cervically for the engagement of the incisal end of the link.
Tre~ttmen! of lmp~wled and l't~,e~'uplcd Teeth
621
Fig. 12 shows two views of east made two years later than that in Fig. 11, showing completed case.
F i g . 10:
Fig. 11.
]~'i g'. 1 2 .
Fig" 13.
Fig. 13 is a photo~'raph laken one year after cessation of t r e a t m e n t show-
ing the teeth in occlusion.
D.D.S.,
P t l I b A D E I A ' H I A , I)A.
I I E d e v e l o p m e n t a l forces of tile h u m a n ol'ganimn, the sum total of which we term Nature, }lave decreed that all the permanent teeth shah be present and in their correct positions if we are to have a normal occlusion, tIowever, it is f r e q u e n t l y noticed that one or several of the teeth fail to erupt and will not do so unless assisted.
T
While e v e r y one will agree t h a t it is easier to e x t r a c t such a tooth than to aid its eruption, the baneful consequences f r o m such e x t r a c t i o n spell ultim a t e distortion to the dental arch with p r o b a b l e i m p a i r m e n t of the normal health and function of the organism. The p u r p o s e of this clinic is to d e m o n s t r a t e methods which have been f o u n d useful in assisting the eruptions of such teeth as require this attention. One must d e t e r m i n e b y r a d i o g r a p h i c diagnosis, definitely and a c c u r a t e l y tile relative position of the crown of the tooth to the s u r r o u n d i n g tissues. This position h a v i n g been found, a circular incision is made about the area of the crown, and the tissue including the bony process overlying the tooth is r e m o v e d by tile use of chisels, in order to expose the crown freely. Styptic gauze is held o v e r this portion until there is some cessation of bleeding. A hole, about 2 ram. deep, is drilled obliquely into the lower t h i r d of the crown of tile tooth, in such a w a y as to aw)id the pulp. An iridio-platinum wire staple 0.020 inch in thickness and one-quarter inch in length is cemented into tile cavity. The s u r r o u n d i n g tissues are b a t h e d with a solution of adrenalin chloride, and the p a t i e n t is dismissed for one week. It is well to a d j u s t regulating appliances to gain the necessary space for the descent of the u n e r u p t e d tooth before the surgical exposure is p e r f o r m e d . On the subsequent visit, a u x i l i a r y wires 0.020 inch in d i a m e t e r can be soldered to the main arch for the direction of stinmlus for eruption. The d i a m e t e r uf the main arch wire is 0.040 inch in thickness. Some examples of eases t r e a t e d follow: Fig. 1 A shows r a d i o g r a p h of Case 1, showing u n e r u p t e d canine in position before t r e a t m e n t . B shows r a d i o g r a p h of same ease t w e n t y - e i g h t months l a t e r with canine in place. Note t h a t a portion of the pin is left in place and acts as an efficient filling' material. Fig. 2 A shows p l a s t e r east of Case 1 before t r e a t m e n t . Note t h a t the left deciduous eanine is unexfoliated. B shows Mershon lingual appliance in position with free end of a u x i l i a r y spring e n g a g i n g staple, cemented in tooth. C shows east m a d e t w e n t y - e i g h t months later, pewnanent canine in position. *Clinic presented at the t h i r t y - f i r s t a n n u a l m e e t i n g of th,~ A me ri c a n Soeiety of Orthodontists, Toronto, Canada, May 20, 1932. 617
Hctrrg It. Wright
618
A.
B. Fi~;. 1.
A.
C'. F i ~ . 2.
Fig'. 3.
C.
A. Fig.
4.
Treatment
o f• I m p a c t e d
aud
Uner~q#ed
6119
7 ee h ~'
Fig. 3 in a radiograph (ff Case 2 showing an mlerupted canine before treatment. Fig. 4 A shows Case 2 with a Mershon lingual arch adjusted with the free eIrd of the r e e u r v e d auxiliary wire engaging the staple for buccal movement of the right maxillary canine. B shows a east made one year later with the labial round wire arch adjusted having an auxiliary wire spring 0.020 inch in thickness e x e r t i n g stimuli for the creati<)n of necessary space. C shows a cast made two months later than that shown in B, with a Mershon lingual arch adjusted. Note the auxiliary spring adjusted for rotation of the maxillary right first premolar and auxiliary spring for the 1)u('(,al movement of the canine, which in now in position. Fig. 5 shows radiooraphs of Case :~ with bilateral maxillary labial (,anine impactions, before treatment.
F i g . 5.
A.
B.
ft.
F i g . 6.
Fig. 6 A sh(~ws cast of Case 3 before tleatment. B shows cast of ease eight months later. The left first:premolar was removed. Note lingual arch adjusted with auxiliary springs for labial movement of incisors and labial arch with auxiliary springs adjusted to stai)les in impacted teeth, these springs having a " s a f e t y pin c o i l " as an aid to posterior movement. (Y shows east made t h i r t y months later with both canines in position. Fig. 7 shows radiographs of Case 4 with impacted mandibular left second premolar, before treatment. Fi~'. S A shows cast of Case 4 with lingual arch adjusted. Note auxiliary wire exerting a n t e r i o r pressm'e on the first premolar for creating space an(l auxiliary wir(~ for the development of the anterior segment of the arch. B shows cast made t w e n t y months later with impression of the lingual arch in position. Note that space in developing for the reception of the second pre-
Harry B. Wright
620
molar which has now e r u p t e d and is in lingual position. C shows cast made six months later than B, with premolar in position. The lingual arch is now adjusted for general rounding out of the mandibnlar arch. Fita'. 9 shows radiographs of Case 5. A shows the impacted maxillary right central incisor before treatment. B made t h i r t y - t h r e e months later shows the central incisor in correct position, with remainder of pin in situ.
:Fig'. 7.
A.
B.
U.
:Fi.~. 8.
.4.
/7. :Fig. 9.
Fig'. 10 shows two views of Case 5 before treatment. Fig'. 11 shows two views of cast of Case 5 made nine months later. Note the lingual arch with auxiliary springs adjusted f o r the creation of necessary space, and the sacrifice of tissue for the exposure of impacted incisor crown. A wire link connects tile staple with the labial arch wire, motive force being obtained by bending the arch wire incisally and spring'ing it cervically for the engagement of the incisal end of the link.
Tre~ttmen! of lmp~wled and l't~,e~'uplcd Teeth
621
Fig. 12 shows two views of east made two years later than that in Fig. 11, showing completed case.
F i g . 10:
Fig. 11.
]~'i g'. 1 2 .
Fig" 13.
Fig. 13 is a photo~'raph laken one year after cessation of t r e a t m e n t show-
ing the teeth in occlusion.