European Archives of Paediatric Dentistry

, Volume 16, Issue 2, pp 153–164 | Cite as

Εvaluation of a treatment protocol for unerupted maxillary central incisors: retrospective clinical study of 46 children

  • N. N. Lygidakis
  • K. Chatzidimitriou
  • N. Theologie-Lygidakis
  • N. A. LygidakisEmail author
Original Scientific Article



To evaluate the clinical outcome of a treatment protocol performed in children with unerupted permanent maxillary central incisors, including surgical removal of any related obstruction and traction initiation in one stage, under fully repositioned flap, combined with pre- and post-operative orthodontics for space creation and final alignment.


Forty-six patients aged 7.3–12.7 years (mean = 9.44 ± 1.36) having 54 impacted maxillary central incisors were reviewed. The study group included 37 patients fully treated by us and nine referrals with eruption failure of impacted incisors following previous surgical removal of various obstructions. Detailed patient’s clinical and radiographic data were recorded.


Aetiology of unerupted incisors included 9 patients with odontomas, 24 with supernumerary teeth, 1 with skeletal lack of space, 1 with a dentigerous cyst, 4 with dilaceration, 1 with severe incisor MIH, 5 with luxation injuries to primary predecessors and 1 with coexisting dilaceration and odontoma. The total treatment time following the standardised protocol ranged from 5 to 21 months (mean 9.88 ± 3.10), while the time needed using different approaches (no pre-operative orthodontics or obstruction removal and then to wait over an assessment period) ranged from 12 to 18 months (mean 15 ± 2.12) and 17 to 30 months (mean 23.73 ± 5.14), respectively (p < 0.05). The time needed for full alignment depended on the inclination, the height of the impacted tooth (p = 0.001) and the patient’s age (p = 0.002). Additionally, the absence of pre-operative orthodontics for space creation dramatically increased treatment time (p = 0.018). In contrast, the maturity of the impacted tooth and the developmental stage of the anterior teeth did not affect treatment time. Finally, when the location of the impacted tooth and the space availability allowed waiting for spontaneous eruption, treatment time was not statistically different from that of the main treatment protocol (p = 0.545).


The studied treatment protocol appears ideal for successful results and minimum treatment time. Space creation followed by surgical removal of any obstruction together with orthodontic traction initiation produces excellent results, while waiting for spontaneous eruption is indicated only in cases of favourable patient’s age and tooth location. Treatment initiation with operation in the absence of the required eruption space is not recommended, whereas in unfavourable cases obstruction removal without simultaneous orthodontic traction increases dramatically the total treatment time and requires an unnecessary second operation for traction.


Treatment Impacted Unerupted Maxillary central incisors 



The authors wish to thank Mrs Eirini Stamatopoulou, MSc, Biostatistician, for performing the statistical analyses. Dr K. Chatzidimitriou is a Hellenic State Scholarships Foundation scholar.

Ethical standard

The authors state that the study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Also, the presented patients and their parents had given their informed consent prior to the inclusion in the study.


  1. Altun C, Cehreli ZC, Güven G, Acikel C. Traumatic intrusion of primary teeth and its effects on the permanent successors: a clinical follow-up study. Oral Surg Oral Med OralPathol Oral Radiol Endod. 2009;107(4):493–8.CrossRefGoogle Scholar
  2. Becker A, Brin I, Ben-Bassat Y, Zilberman Y, Chaushu S. Closed-eruption surgical technique for impacted maxillary incisors: a postorthodontic periodontal evaluation. Am J Orthod Dentofac Orthop. 2002;122:9–14.CrossRefGoogle Scholar
  3. Becker A. Early treatment for impacted maxillary incisors. Am J Orthod Dentofac Orthop. 2002;121:586–7.CrossRefGoogle Scholar
  4. Betts A, Camilleri GE. A review of 47 cases of unerupted maxillary incisors. Int J Paediatr Dent. 1999;9(4):285–92.CrossRefPubMedGoogle Scholar
  5. Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofac Orthop. 1992;101:159–71.CrossRefGoogle Scholar
  6. Bishara SE. Treatment of unerupted incisors. Am J Orthod. 1971;59:443–7.CrossRefPubMedGoogle Scholar
  7. Bodenham RS. The treatment and prognosis of unerupted maxillary incisors associated with the presence of supernumerary teeth. Brit Dent J. 1967;123:173–7.PubMedGoogle Scholar
  8. Brin I, Zilberman Y, Azaz B. The unerupted maxillary central incisor: review of its etiology and treatment. J Dent Child. 1982;5:352–6.Google Scholar
  9. Brin I, Ben Bassat Y, Zilberman Y, Fuks A. Effect of trauma to the primary incisors on the alignment of their permanent successors in Israelis. Community Dent Oral Epidemiol. 1988;16:104–8.CrossRefPubMedGoogle Scholar
  10. Bryan RA, Cole BO, Welbury RR. Retrospective analysis of factors influencing the eruption of delayed permanent incisors after supernumerary tooth removal. Eur J Paediatr Dent. 2005;6(2):84–9.PubMedGoogle Scholar
  11. Buchanan S, Jenkins CR. Riga-Fedes syndrome: natal or neonatal teeth associated with tongue ulceration. Case report. Aust Dent J. 1997;42:225–7.CrossRefPubMedGoogle Scholar
  12. Chaushu S, Zilberman Y, Becker A. Maxillary incisor impaction and its relationship to canine displacement. Am J Orthod Dentofac Orthop. 2003;124:144–50.CrossRefGoogle Scholar
  13. Chaushu S, Dykstein N, Ben-Bassat Y, Becker A. Periodontal status of impacted maxillary incisors uncovered by 2 different surgical techniques. J Oral Maxillofac Surg. 2009;67(1):120–4.CrossRefPubMedGoogle Scholar
  14. Christen A, Segrest V. Distortion and artifacts encountered in panorex radiography. J Am Dent Assoc. 1968;77:1096–101.CrossRefPubMedGoogle Scholar
  15. Cole BO, Shaw AJ, Hobson RS, et al. The role of magnets in the management of unerupted teeth in children and adolescents. Int J Paediatr Dent. 2003;13(3):204–7.CrossRefPubMedGoogle Scholar
  16. Crawford LB. Impacted maxillary central incisor in mixed dentition treatment. Am J Orthod Dentofac Orthop. 1997;112:1–7.CrossRefGoogle Scholar
  17. Cvek M. Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with gutta-percha. A retrospective clinical study. Endod Dent Traumatol. 1992;8(2):45–55.CrossRefPubMedGoogle Scholar
  18. Di Biase DD. The effects of variations in tooth morphology and position on eruption. Dent Pract Dent Record. 1971;22:95–108.Google Scholar
  19. Duncan WK, Ashrafi MH. Management of the nonerupted maxillary anterior tooth. JADA. 1983;106:640–4.PubMedGoogle Scholar
  20. Ferguson JW. Management of the unerupted maxillary canine. Br Dent J. 1990;169:11–7.CrossRefPubMedGoogle Scholar
  21. Foley J. Surgical removal of supernumerary teeth and the fate of incisor eruption. Eur J Paediatr Dent. 2004;5(1):35–40.PubMedGoogle Scholar
  22. Grover PS, Lorton L. The incidence of unerupted permanent teeth and related clinical cases. Oral Surg Oral Med Oral Pathol. 1985;59:420–5.CrossRefPubMedGoogle Scholar
  23. Huber KL, Suri L, Taneja P. Eruption disturbances of the maxillary incisors: a literature review. J ClinPediatr Dent. 2008;32(3):221–30.Google Scholar
  24. Iramaneerat S, Cunningham SJ, Horrocks EN. The effect of two alternative methods of canine exposure upon subsequent duration of orthodontic treatment. Inter J Paed Dent. 1998;8:123–9.CrossRefGoogle Scholar
  25. Jacobs SG. Radiographic localization of unerupted maxillary anterior teeth using the vertical tube shift technique: the history and application of the method with some case reports. Am J Orthod Dentofac Orthop. 1999;116(4):415–23.CrossRefGoogle Scholar
  26. Kluemper GT, Beeman CS, Hicks EP. Early orthodontic treatment: what are the imperatives? JADA. 2000;131(5):613–20.PubMedGoogle Scholar
  27. Kohavi D, Zilberman Y, Becker A. Periodontal status following the alignment of buccally ectopic maxillary canine teeth. Am J Orthod. 1984;85:78.CrossRefPubMedGoogle Scholar
  28. Leyland L, Batra P, Wong F, Llewelyn R. A retrospective evaluation of the eruption of impacted permanent incisors after extraction of supernumerary teeth. J ClinPediatr Dent. 2006;30(3):225–31.Google Scholar
  29. Lin YTJ. Treatment of an impacted dilacerated maxillary central incisor. Am J Orthod Dentofac Orthop. 1999;115:406–9.CrossRefGoogle Scholar
  30. Lygidakis NA, Theologie-Lygidakis N, Dimopoulos AS. Orhtodontic-surgical management of unerupted permanent teeth using the fully repositioned flap technique. Part 1. Results, treatment time and post-treatment stability in 90 cases. Eur J Paediatr Dent. 2001;2(3):119–27.Google Scholar
  31. Lygidakis NA, Wong F, Jälevik B, et al. Best Clinical Practice Guidance for clinicians dealing with children presenting with Molar-Incisor-Hypomineralisation (MIH). Eur Arch Paediatr Dent. 2010;11(2):75–81.CrossRefPubMedGoogle Scholar
  32. Macias E, Carlos F, Cobo J. Posttraumatic impaction of both maxillary central incisors. Am J Orthod Dentofac Orthop. 2003;124:331–8.CrossRefGoogle Scholar
  33. Mason C, Azam N, Holt RD, Rule DC. A retrospective study of unerupted maxillary incisors associated with supernumerary teeth. Br J Oral Maxillofac Surg. 2000;38(1):62–5.CrossRefPubMedGoogle Scholar
  34. Mead SV. Incidence of impacted teeth. Int Orthod. 1930;16:885–90.Google Scholar
  35. Mitchell L, Bennett TG. Supernumerary teeth causing delayed eruption— a retrospective study. Br J Orthod. 1992;19:41–6.CrossRefPubMedGoogle Scholar
  36. Munns D. Unerupted incisors. Br J Orthod. 1981;8:39–42.CrossRefPubMedGoogle Scholar
  37. Patchett CL, Crawford PJ, Cameron AC, Stephens CD. The management of supernumerary teeth in childhood–a retrospective study of practice in Bristol Dental Hospital, England and Westmead Dental Hospital, Sydney, Australia. Int J Paediatr Dent. 2001;11(4):259–65.CrossRefPubMedGoogle Scholar
  38. Stramotas S, Geenty JP, Darendeliler MA, et al. The reliability of crown-root ratio, linear and angular measurements on panoramic radiographs. Clin Orthod Res. 2000;3:182–91.CrossRefPubMedGoogle Scholar
  39. Suri L, Gagari E, Vastardis H. Delayed tooth eruption: pathogenesis, diagnosis, and treatment. A literature review. Am J Orthod Dentofac Orthop. 2004;126(4):432–45.CrossRefGoogle Scholar
  40. Tanaka E, Watanabe M, Nagaoka K, Yamaguchi K, Tanne K. Orthodontic traction of an impacted maxillary central incisor. J Clin Orthod. 2001;35:375–8.PubMedGoogle Scholar
  41. ValladaresNeto J, Silva FA, Kaadi OB. Delayed eruption of permanent incisor associated to prolonged retention of deciduous predecessor: obstructive, traumatic, developmental or idiopathic? Rev Odontol Bras Cent. 1995;5:4–10.Google Scholar
  42. Vanarsdall RL, Corn H. Soft-tissue management of labially positioned unerupted teeth. Am J Orthod. 1977;72:53–64.CrossRefPubMedGoogle Scholar

Copyright information

© European Academy of Paediatric Dentistry 2014

Authors and Affiliations

  • N. N. Lygidakis
    • 1
  • K. Chatzidimitriou
    • 1
  • N. Theologie-Lygidakis
    • 1
  • N. A. Lygidakis
    • 1
    Email author
  1. 1.Private Paediatric Dental ClinicAthensGreece

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