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• W2000735105 abstract "A girl, aged 7 years 11 months, came for treatment with the chief complaint of lack of eruption of her maxillary right central and lateral permanent incisors. The radiographic analysis indicated complete transposition of the maxillary right lateral incisor and canine, and a pseudotransposition of the maxillary right central and lateral incisors. This is a clinical condition of mixed transposition in the same hemi-arcade: the combination of a complete transposition and another incomplete or coronary transposition—a situation that has not been reported in the literature. The patient was treated with surgical exposure and ligation of the 3 teeth, the eruption was properly guided, and the correct order of the 3 teeth was restored in the arch. The diagnosis, appliance design, and treatment sequence are described. A girl, aged 7 years 11 months, came for treatment with the chief complaint of lack of eruption of her maxillary right central and lateral permanent incisors. The radiographic analysis indicated complete transposition of the maxillary right lateral incisor and canine, and a pseudotransposition of the maxillary right central and lateral incisors. This is a clinical condition of mixed transposition in the same hemi-arcade: the combination of a complete transposition and another incomplete or coronary transposition—a situation that has not been reported in the literature. The patient was treated with surgical exposure and ligation of the 3 teeth, the eruption was properly guided, and the correct order of the 3 teeth was restored in the arch. The diagnosis, appliance design, and treatment sequence are described. Dental transposition can be defined as the positional interchange of 2 adjacent teeth, including their roots, or the development or eruption of a tooth in a position normally occupied by a nonadjacent tooth.1Peck S Peck L Classification of maxillary tooth transpositions.Am J Orthod Dentofacial Orthop. 1995; 107: 505-517Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 2Shapira Y Kuftinec MM Tooth transpositions—a review of the literature and treatment considerations.Angle Orthod. 1989; 59: 271-276PubMed Google Scholar A transposition is defined as complete when both the crowns and the roots are affected, or incomplete, also called pseudotransposition, when only the crowns are involved.1Peck S Peck L Classification of maxillary tooth transpositions.Am J Orthod Dentofacial Orthop. 1995; 107: 505-517Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 3Attia Y Les canines transposées: classification et approche thérapeutique.Orthod Fr. 1986; 57: 615-627PubMed Google Scholar, 4Gonzalez-Cuesta FJ Molina A Bossy A Estudio clínico de las transposiciones de los caninos.Rev Esp Ortod. 1995; 25: 47-54Google Scholar It is a rare anomaly and a challenge for the clinician to diagnose and treat.1Peck S Peck L Classification of maxillary tooth transpositions.Am J Orthod Dentofacial Orthop. 1995; 107: 505-517Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 2Shapira Y Kuftinec MM Tooth transpositions—a review of the literature and treatment considerations.Angle Orthod. 1989; 59: 271-276PubMed Google Scholar, 4Gonzalez-Cuesta FJ Molina A Bossy A Estudio clínico de las transposiciones de los caninos.Rev Esp Ortod. 1995; 25: 47-54Google Scholar, 5Thilander B Jakobsson SO Local factors in impaction of maxillary canines.Acta Odontol Scand. 1968; 26: 145-168Crossref PubMed Scopus (184) Google Scholar Trauma is a commonly accepted etiologic factor in the development of a transposition, especially when the permutation involves a maxillary canine and a lateral incisor, or maxillary central and lateral incisors.1Peck S Peck L Classification of maxillary tooth transpositions.Am J Orthod Dentofacial Orthop. 1995; 107: 505-517Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 6Moyers RE Riolo ML Tratamiento temprano.in: Moyers RE Manual de ortodoncia. 4th ed. Editions Médica Panamericana, Buenos Aires, Argentina1992: 343-431Google Scholar, 7Ruprecht A Batniji S El-Neweihi E The incidence of transposition of teeth in dental patients.J Pedod. 1985; 9: 244-249PubMed Google Scholar, 8Laptook T Silling G Canine transposition—approaches to treatment.J Am Dent Assoc. 1983; 107: 746-748PubMed Scopus (44) Google Scholar, 9Attia Y Favot P Les transpositions de canines: traitements interceptifs.Rev Orthod Dento Faciale. 1987; 21: 251-262Google Scholar, 10Bassigny F Les transpositions des canines permanentes et leur traitement: une approche preventive.Rev Orthop Dento Faciale. 1990; 24: 151-164Crossref PubMed Scopus (5) Google Scholar, 11Yaillen DM Early identification and correction of transposed teeth.Angle Orthod. 1990; 60: 73-77PubMed Google Scholar Because of the low prevalence and the variability, limited information is available about the treatment of patients with this disturbance.1Peck S Peck L Classification of maxillary tooth transpositions.Am J Orthod Dentofacial Orthop. 1995; 107: 505-517Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 2Shapira Y Kuftinec MM Tooth transpositions—a review of the literature and treatment considerations.Angle Orthod. 1989; 59: 271-276PubMed Google Scholar, 3Attia Y Les canines transposées: classification et approche thérapeutique.Orthod Fr. 1986; 57: 615-627PubMed Google Scholar, 4Gonzalez-Cuesta FJ Molina A Bossy A Estudio clínico de las transposiciones de los caninos.Rev Esp Ortod. 1995; 25: 47-54Google Scholar, 5Thilander B Jakobsson SO Local factors in impaction of maxillary canines.Acta Odontol Scand. 1968; 26: 145-168Crossref PubMed Scopus (184) Google Scholar, 12Peck L Peck S Attia Y Maxillary canine-first premolar transposition, associated dental anomalies and genetic basis.Angle Orthod. 1993; 63: 99-109PubMed Google Scholar, 13Favot P Attia Y Garcias D Les canines transposées: étilogie-pathogénie.Orthod Fr. 1986; 57: 605-613PubMed Google Scholar Therefore, it is a difficult task to standarize treatment procedures that could be extrapolated to similar clinical situations.1Peck S Peck L Classification of maxillary tooth transpositions.Am J Orthod Dentofacial Orthop. 1995; 107: 505-517Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 2Shapira Y Kuftinec MM Tooth transpositions—a review of the literature and treatment considerations.Angle Orthod. 1989; 59: 271-276PubMed Google Scholar, 3Attia Y Les canines transposées: classification et approche thérapeutique.Orthod Fr. 1986; 57: 615-627PubMed Google Scholar, 4Gonzalez-Cuesta FJ Molina A Bossy A Estudio clínico de las transposiciones de los caninos.Rev Esp Ortod. 1995; 25: 47-54Google Scholar, 5Thilander B Jakobsson SO Local factors in impaction of maxillary canines.Acta Odontol Scand. 1968; 26: 145-168Crossref PubMed Scopus (184) Google Scholar, 12Peck L Peck S Attia Y Maxillary canine-first premolar transposition, associated dental anomalies and genetic basis.Angle Orthod. 1993; 63: 99-109PubMed Google Scholar, 13Favot P Attia Y Garcias D Les canines transposées: étilogie-pathogénie.Orthod Fr. 1986; 57: 605-613PubMed Google Scholar, 14Van Gool AV Injury to the permanent tooth germ after trauma to the deciduous predecessor.Oral Surg Oral Med Oral Pathol. 1973; 35: 2-12Abstract Full Text PDF PubMed Scopus (33) Google Scholar, 15Berlocher WC Schneider PM Transposition of maxillary incisors.Oral Surg Oral Med Oral Pathol. 1983; 55: 639Abstract Full Text PDF PubMed Scopus (8) Google Scholar, 16Shapira Y Kuftinec MM Villagordoa G An unusual transposition of the maxillary central and lateral incisors.J Dent Child. 1982; 49: 443-444PubMed Google Scholar, 17Aguiló L Gandía JL Transposición entre incisivo central y lateral superior: presentación de un caso clínico.Rev Esp Ortod. 1995; 25: 145-149Google Scholar Early identification and proper diagnosis are fundamental in adequate treatment planning and correction of these anomalies.1Peck S Peck L Classification of maxillary tooth transpositions.Am J Orthod Dentofacial Orthop. 1995; 107: 505-517Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 15Berlocher WC Schneider PM Transposition of maxillary incisors.Oral Surg Oral Med Oral Pathol. 1983; 55: 639Abstract Full Text PDF PubMed Scopus (8) Google Scholar, 16Shapira Y Kuftinec MM Villagordoa G An unusual transposition of the maxillary central and lateral incisors.J Dent Child. 1982; 49: 443-444PubMed Google Scholar, 17Aguiló L Gandía JL Transposición entre incisivo central y lateral superior: presentación de un caso clínico.Rev Esp Ortod. 1995; 25: 145-149Google Scholar In this case report, a unique situation of several transposed teeth in a hemi-arcade is presented, and the treatment sequence is described. A girl, aged 7 years 11 months, came for treatment to our office in Seville, Spain, with the chief complaint of lack of eruption of the maxillary right central and lateral permanent incisors (Fig 1, Fig 2, Fig 3, Fig 4). She had a history of a severe contusion to the anterior part of the maxillary dentoalveolus at the age of 1.5 years; it did not, however, result in apparent pulp damage or loss of teeth. She suffered another trauma to the same region when she was 4.5 years old, and this resulted in the loss of the maxillary right central and lateral deciduous incisors.Fig 2Pretreatment study models.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3A, Pretreatment cephalogram; B, tracing.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 4A, Pretreatment panoramic radiograph; B,pretreatment panoramic radiograph with the appliance in place; C, tracing (blue, central incisor; green, lateral incisor; red, canine).View Large Image Figure ViewerDownload Hi-res image Download (PPT) The facial analysis showed an ovoid face, increased lower anterior facial height, and a mild increase of the gingival exposure on smiling (Fig 1). Dentally, the patient exhibited a mild Class III molar relationship in the mixed dentition with a tendency toward an anterior open bite. The maxillary left central and lateral permanent incisors had erupted, but the maxillary right central and lateral permanent incisors had not (Fig 1). In the area corresponding to the right central and lateral incisors, and in the area above the crown of the maxillary right deciduous canine, several prominences were identified by palpation of the mucosa that seemed to correspond to these unerupted teeth. The cephalometric analysis showed a mild skeletal Class III malocclusion, with a growth axis that was predominantly vertical. There were an increase of lower anterior facial height and an open-bite tendency of both skeletal and dental origin (Fig 3, Table). The panoramic radiograph showed 3 impacted teeth in the anterior region of the right side of the maxilla (Fig 4): the right central and lateral permanenet incisors and the canine, in a triple mixed transposition. The crown of the lateral incisor was closer to the midline, whereas the crown of the central incisor occupied a more distal position. The canine was between the 2 incisors, positioned above them. The position of the central incisor was predominantly vertical, although its crown was oriented distally, causing an incomplete transposition with the crown of the lateral incisor. The lateral incisor had a horizontal angulation, with its crown toward the mesial aspect and its apex toward the distal apect. The incisal edge of the lateral incisor was visible through the gingiva (Fig 2). The canine was positioned higher, with both its crown and root mesial to the lateral incisor, resulting in a complete transposition with the lateral incisor. The impaction of the 3 teeth was complete (Fig 4).Tablesummary of cephalometric analysisValueMeanPretreatmentPostreatment phase 1Postreatment phase 2RetentionSagittal relationships Maxillary position SNA (°)82±3.578111177 Mandibular position SNPg (°)80±3.578787878 Sagittal jaw relationship ANPg (°)2±2.50(−1)(−1)(−1)Vertical relationships Maxillary inclination SN/ANS-PNS (°)8±3.0681010 Mandibular inclination SN/GoGn (°)33±2.540373939 ANS-PNS/Go Gn (°)25±6.034292929Dentobasal relationships Maxillary incisor inclination Maxillary incisor/ANS-PNS (°)110±6.0109109110111 Mandibular incisor inclination Mandibular incisor/Go-Gn (°)94±7.088908384 Mandibular incisor compensation Mandibular incisor/A-Pg (mm)2±2.04434Dental relationships Overjet (mm)3.5±2.51111 Overbite (mm)2±2.51111 Interincisal (°)132±6.0129131138136 Open table in a new tab The goals for phase 1 included the following: (1)supervise and treat, if needed, the Class III skeletal tendency, as well as the vertical growth pattern and the open-bite tendency; (2) uncover surgically the 3 unerupted transposed teeth and ligate them; (3) guide the maxillary right central and lateral incisors into their correct positions in the arch; (4) guide the canine into its correct position for the age of the patient, above the root of the deciduous canine; (5) preserve the periodontal health of the 3 teeth; and (6) once corrected, maintain the position of the maxillary right central and lateral incisors during the exchange. Because of the patient's stage of dental development, the few permanent teeth present, and the limited possibilities of anchorage, a removable acrylic plate was selected as the initial appliance to guide the eruption of the 3 teeth. A removable appliance provides a good source of anchorage from both the teeth and the contact of the acrylic against the palate, thereby reducing the side effects on the anchor teeth. In addition, the risk of iatrogenic damage such as decalcification from the prolonged use of fixed appliances is reduced. After the exchange, the patient would be reevaluated, and phase 2 treatment would be started to finish the correction of her malocclusion. The complete correction of these 3 teeth presented considerable difficulties. The most difficult situation was the lateral incisor. Extraction of the lateral incisor would have greatly simplified the treatment, since the eruption guidance of the central incisor would have been easier and faster; similarly, bringing the canine into its normal path of eruption could have been accomplished without major difficulties. On the other hand, this decision implied the need for future replacement of the extracted tooth as well as the need to preserve the space throughout treatment. A second alternative was to maintain the relative positions of the lateral incisor and the canine, avoiding correction of the complete transposition of these 2 teeth. That could be done by extracting the deciduous canine, bringing the lateral incisor distally into the position of the permanent canine, and bringing the central incisor into its correct position. The space between the 2 incisors would be maintained, and the eruption of the permanent canine would be guided into the space during a later stage of treatment. This approach would require prosthetic treatment to modify the crown morphology of the lateral incisor and, probably, the canine also. However, the risk of periodontal damage to the teeth would be diminished, and the mechanics would be simplified. To avoid future replacement of teeth, a decision was made with the patient's parents to attempt to bring all 3 teeth into their normal positions, assuming the risk of potential periodontal damage or eventual loss of someteeth. The appliance was designed to have a large palatal acrylic surface to enhance anchorage and Adams clasps on the maxillary first permanent molars and the maxillary first deciduous molars to provide adequate retention. Three hooks were added in the following locations as points of traction. Hook 1 was placed in the midline, adjacent to the mesial aspect of the maxillary left central permenent incisor. Hook 2 was located close to the mesial surface of the maxillary right deciduous canine, and hook 3 was placed close to the maxillary right second deciduous molar (Fig 4). Because the 3 teeth were close to each other with a limited amount of bone around them, the chance of iatrogenic damage such as root resorption and periodontal damage was considered. It was necessary to create a “safe corridor” for the movement of each tooth. An important decision involved the order in which the teeth should be moved as well as the vector of movement of each tooth. The mesial movement of the crown of the central incisor was undertaken first, by means of light elastic traction with a power tube from the ligature on the incisor to hook 1 (Fig 4). The mesial movement of the crown of the central incisor allowed the crossed interposition with the crown of the lateral incisor to be relieved. Once the crowns of both incisors were separated, it was possible to start the movement of the lateral incisor. Since this tooth was horizontal, with the cusp of the permanent canine lying mesial to the root of the lateral incisor, it was necessary to first move the crown of the lateral incisor mesially without uprighting its root. A power tube with light traction was placed from hook 1 to the ligature of the lateral incisor, resulting in mesial and downward movement of the crown of the lateral incisor (Fig 4). After 5 months of treatment (Fig 5, A), the central incisor had erupted in a reasonable position. The crown of the lateral incisor had erupted close to the central incisor, but the mesial and buccal inclination of its crown was significant. The lateral incisor was still in a fairly horizontal position, with the apex of its root pointing to the distal and palatally located. The canine was located higher, with a moderate mesial inclination, and its cusp pointing near the eruptive pathway of the lateral incisor. At this point, it was necessary to distalize the crown of the canine if the uprighting movement of the lateral incisor's root was to be performed with an acceptable level of certainty. To distalize the crown of the canine, an elastic force was used from hook 3 (Fig 4, Fig 5) to generate a vector of force with a greater horizontal component and a smaller vertical component. Extrusive force on the canine was kept to a minimum so as not to worsen the transposition with the root of the lateral incisor. Once the crown of the canine had been moved to a position more distal and buccal than the root of the lateral incisor, the pathway for uprighting the incisor had no interference. At that point, to complete the eruption of the lateral incisor, an elastic force from hook 2 was used. After 9 months of treatment with the removable appliance, the central and lateral incisors had erupted into acceptable positions. At that time, the right central and lateral incisors were bonded with brackets with 0.022×0.028–in slots (Fig 5, B). The teeth were leveled and aligned with sectional round 0.016–in nickel-titanium archwires, and then the spaces between the incisors were closed by using 0.016–in stainless steel sectional archwires and power chain. Acceptable root positions without evidence of root damage were observed at the end of this treatment phase (Fig 6). It was decided not to correct the torque on the lateral incisor at this stage, but to correct it during phase 2 when more permanent teeth would be available for anchorage. At the end of phase 1, both central and lateral incisors were located in their proper positions and showed good mucogingival health. The panoramic radiograph (Fig 6) showed no root resorption of the teeth involved. In addition, because of the patient's stage of development, the crown of the maxillary right permanent canine had been succesfully moved distally to the root of the lateral incisor. Therefore, the combined transposition was considered successfully corrected, without evidence of major iatrogenic effects. Total treatment time for phase 1 was 20 months: 12 months with the removable appliance and 8 months with fixed appliances. The patient wore a maxillary Hawley retainer and was checked periodically to monitor the eruption of the remaining permanent teeth for 1 year 4 months. At the age of 10 years 9 months, the first pre-molars had erupted, and the second premolars and the maxillary right permanent canine were close to erupting. At that time, the patient started phase 2 treatment (Fig 7, Fig 8, Fig 9). The facial analysis indicated that she still had a dolichofacial pattern with a moderate increase of lower anterior facial height (Fig 7). Dentally, she had a Class I relationship and minimal overbite. Both maxillary right central and lateral incisors were in their correct positions, and the maxillary right permanent canine was between the roots of the right lateral incisor and the deciduous canine (Fig 9). A decision was made to extract the deciduous canine to encourage the eruption of the permanent canine.Fig 8Beginning of phase 2 study models.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 9A, Panoramic radiograph at the beginning of phase 2 (note the crown of the canine between the roots of the lateral incisor and the deciduous canine); B, lateral cephalogram at the beginning of phase 2; C, tracing; D, general superimposition of pretreatment and beginning of phase 2 cephalometric tracings on the anterior cranial base.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The treatment goals for phase 2 included the following: (1) nonextraction; (2) control the tendency for vertical growth; (3) guide the eruption of the maxillary right permanent canine to its proper position; (4) level and align both arches: (5) improve the torque of the maxillary anterior teeth; (6) preserve the periodontal health and root integrity of the teeth involved in the transposition; and (7) achieve a stable functional occlusion with good mucogingival health and pleasing facial balance. Because the transpositions had been corrected in phase 1, the treatment alternatives in phase 2 did not relate to the anterior teeth. However, the patient showed a moderate increase of lower anterior facial height with minimal overbite. Therefore, we considered extracting the maxillary and mandibular second premolars to increase the overbite and reduce the vertical height of the face. Since the patient had been cooperative, the use of high-pull headgear was preferred to control the vertical position of the molars. In addition, other factors considered to prefer the nonextraction option were: shorten the already long treatment time, the amount of crowding present was minimal, avoid further traumatic impact during treatment and the fact that the patient exhibited an acceptable soft tissue profile. A 0.022×0.028–in preadjusted edgewise appliance was used, combined with a high-pull headgear to control the vertical growth pattern. The maxillary right deciduous canine was extracted. Alignment, leveling and arches coordination were accomplished through sequential increases in archwire sizes from 0.016–in nickel-titanium to 0.019×0.025–in nickel-titanium in the maxillary arch, and to a 0.019×0.025–in stainless steel archwire in the mandibular arch. Since the space avilable for the eruption of the maxillary right permanent canine was slightly deficient, a compressed coil spring was placed in the maxillary 0.019×0.025–in nickel-titanium archwire, and the tooth was tractioned with elastic power tube and light forces. Once the permanent caninewas in its correct position into the arch, adequate torque control wasachieved through sequential increases in archwire sizes from 0.019×0.025–in nickel-titanium, 0.019×0.025–in stainless steel, and 0.021×0.025–in stainless steel. The patient was cooperative, and the appliances were removed 22 months after starting phase 2 treatment. After debonding, a maxillary Hawley retainer and a mandibular vacuum-formed retainer were delivered. The patient was instructed to wear them full time for 12 months, when a decision for reducing the wear time would be made. At the end of phase 2 treatment (Fig 10, Fig 11, Fig 12), the patient showed acceptable facial balance, although she had a slight increase of lower anterior facial height. Dentally, she had Class I molar and canine relationships with good occlusion and normal overbite and overjet. The maxillary right central and lateral incisors and the canine were located in their proper positions and showed good mucogingival health (Fig 10). The crowns of the central incisor and the canine were restored with light-cured composite. The final panoramic radiograph showed satisfactory root paralleling with no apical root resorption of the teeth involved in the transposition. The original axial inclination of the roots of the lateral incisor and canine had been slightly overcorrected (Fig 12). The cephalometric analysis showed a Class I skeletal relationship with adequate axial inclination of the maxillary and mandibular incisors (Fig 12, Table). Therefore, the combined transposition was considered successfully corrected, with no major iatrogenic effects. Five years after treatment (Fig 13), the patient showed good facial esthetics and excellent occlusal stability. The periodontal status of the anterior teeth involved in the transposition continues to be healthy.Fig 11Posttreatment study models.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 12A, Posttreatment panoramic radiograph; B, posttreatment lateral cephalogram; C, tracing; D, general superimposition of pretreatment, beginning of phase 2, and posttreatment cephalometric tracings on the anterior cranial base.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 13Postretention facial and intraoral phtographs.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Trauma is a commonly accepted etiologic factor in the development of transpositions, especially when the permutation involves the maxillary incisors.1Peck S Peck L Classification of maxillary tooth transpositions.Am J Orthod Dentofacial Orthop. 1995; 107: 505-517Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 6Moyers RE Riolo ML Tratamiento temprano.in: Moyers RE Manual de ortodoncia. 4th ed. Editions Médica Panamericana, Buenos Aires, Argentina1992: 343-431Google Scholar, 7Ruprecht A Batniji S El-Neweihi E The incidence of transposition of teeth in dental patients.J Pedod. 1985; 9: 244-249PubMed Google Scholar, 8Laptook T Silling G Canine transposition—approaches to treatment.J Am Dent Assoc. 1983; 107: 746-748PubMed Scopus (44) Google Scholar, 9Attia Y Favot P Les transpositions de canines: traitements interceptifs.Rev Orthod Dento Faciale. 1987; 21: 251-262Google Scholar, 10Bassigny F Les transpositions des canines permanentes et leur traitement: une approche preventive.Rev Orthop Dento Faciale. 1990; 24: 151-164Crossref PubMed Scopus (5) Google Scholar, 11Yaillen DM Early identification and correction of transposed teeth.Angle Orthod. 1990; 60: 73-77PubMed Google Scholar In this patient, the 2 episodes of trauma could have been responsible for the transposition of the 3 teeth. However, the trauma could have worsened a previously existing condition of multiple dental malposition. The teeth were exposed, ligated, and erupted by using a closed-eruption technique. This modality of uncovering, rather than the apically positioned flap technique, was preferred for several reasons. The number of teeth involved (3) was too great for an open-eruption technique because of the potential for periodontal damage and the risk of scars after treatment.18Vermette ME Kokich VG Kennedy DB Uncovering labially impacted teeth: apically positioned flap and closed-eruption techniques.Angle Orthod. 1995; 65: 23-32PubMed Google Scholar Also, the lateral incisor was in a labial position, but the central incisor was higher and deeper, and the canine was in a high and deep position in the bone; this eliminated the alternative of an apically positioned flap surgical technique. Furthermore, the closed-eruption technique provided good mucogingival health and no detectable periodontal damage at the end of treatment. Bonded buttons on the surface of the crowns of the impacted teeth are the common way of surgical ligation in our clinical practice. However, a decision was made to use transcoronal ligation of the central incisor and the canine because of the severely abnormal position of the 3 teeth in the transposition, the lack of predictibility of our treatment, and the potential iatrogenic damage to the periodontal condition of these teeth if new surgeries had to be performed in the area because of bonding failure of the buttons. The use of a removable plate during phase 1 allowed us to create different vectors of force for traction of the 3 teeth, with a good source of anchorage and limited adverse side effects on the remaining permanent teeth. Since the plate was constructed with 3 hooks in different positions, it was possible to establish an adequate sequence of traction of the transposed teeth and prevent interferences without modifying the design of the plate. However, this required frequent appointments to change the power-tube ligature, clean the appliance, and allow complete rinsing of the mouth. An alternative to this mechanical approach would have been to use skeletal anchorage (miniscrews or miniplates) in various locations. However, the patient was started 11 years ago, when the use of these mechanical devices was uncommon and not used in our practice. Also, in our opinion, temporary anchorage devices are useful in many clinical situations but do not replace classic mechanical stategies that have worked efficiently for many years. The clinical examination after treatment showed no periodontal damage, and the radiographic evaluation showed no root shortening. However, the root of the lateral incisor was close to the root of the central incisor, and the torque of the lateral incisor was slightly deficient, in spite of the prolonged use of stainless steel rectangular archwires for torque control. This was probably due to the abnormal position of the lateral incisor at the beginning of treatment. In addition, the mesiodistal angulations of the lateral incisor and the canine were slightly overcorrected at the end of treatment, but the follow-up postretention panoramic radiograph showed some spontaneous correction of the roots toward a more parallel relationship. Excellent patient cooperation with the high-pull headgear was important to control the vertical growth tendency. The Class III tendency did not express itself, and the patient has an acceptable facial balance. A good functional occlusion with adequate skeletal balance and facial esthetics were achieved with the 2-phase treatment." @default.
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• W2000735105 title "Mixed unilateral transposition of a maxillary canine, central incisor, and lateral incisor" @default.
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