Case Reports CASE MANAGEMENT MATTHEW
OF AN UPPER LOZIER,
HE principal reasons for reporting this case are the consideration of the factor of localization employed in the diagnosis and the conservative surgical approach resorted to in the removal of a deeply impacted canine tooth situated in close proximity to some of the other teeth in the jaw. A girl, about 20 years old, in apparently good health, presented herself for diagnosis and treatment of an upper impacted right canine. The clinical examination revealed a full complement of teeth with a normal occlusion, with the upper right cuspid missing and with the corresponding temporary cuspid still in position. The radiographic examination disclosed a deeply impacted right upper canine lying diagonally, with its crown inclined downward over the roots of the adjoining central and lateral incisors. Though the tooth was entirely symptomless, its removal was deemed advisable because of the observed existing rarefaction around its crown, suggesting a follicular cyst, which would, it was thought, within time, affect and destroy the incisors. Localization.-The problem of determining the location of t.he impacted tooth was not as simple as it is ordinarily. The bite-film approach, so often completely relied upon in locating impacted upper anterior teeth, has never been a favorite with me, in spite of frequently heard declarations as to its usefulness. The case on hand, as can be readily observed from the presented bite films obtained by overhead angulation, again conclusively showed the difficulty in determining the relative position of the impacted tooth to the alveolar plates as well as to the roots of the adjoining teeth, when this mct,hod of localization was used. As a matter of fact, if one is to attempt to decide upon the location of the impacted tooth from this radiograph alone, it could be readily assumed that the crown of the tooth lies here palatally while its root portion, which cannot be clearly discerned, is apparently situated more anteriorly, toward the labial aspect. However, when the Clark method of localization was employed (a technique based upon the principle that the more distant object from the observer moved in the same direction that the observer moves, and vice versa), it was decided that, in all probability, the reverse is true here. The complete soundness of this diagnosis was substantiated later through the surgical findings. It can also be added that there was absolutely no indication in tl,e contour of the arch as to just where the tooth was situated, because the *~~me~ly
‘‘movement ’’ of the crown of the impacted tooth during the employment of t,he Clark method of localization, as evidenced by the radiographs, is very slight here. Impactions found on labial and buccal aspects of tlke upper maxilla are decidedly uncommon and, in this case, the preservation of the patient’s incisors was greatly desired; therefore the approach to the removal of the tooth was undertaken with a ccrtuin degree of anxiety and hesitancy.
Surgical Procedure.-Before proceeding with anesthesia, all of the adjoining teeth, including the temporary cuspid, were tested for vitality and found entirely normal. X mucopcriosteal flap extendin, 0’from the center of the crown of the left central to the distal of the crown of the right temporary cuspid was raised and the bone well exposed to view. A small narrow section of bone located exactly between the dist,al aspect of the right central a.nd mesial aspect of the right lateral incisor was carefully removed and the neck of the impacted canine exposed to view. This exposed portion was then sectioned with an engine-driven surgical mallet. The crown, that is, half of the tooth, was then
moved a bit distally into the space created during the sectioning of the bone and tooth. With the aid of small curved instruments, it was dislocated out of its bed and the cystic membrane enucleated. The root portion of the tooth was then engaged mesially into the space previously occupied by the crown and after several trials was liberated out of the bone. With the employment of this technique, which consumed about thirty minutes, none of the patient’s teeth were traumatized. Examination of the bone overlying the central and lateral roots disclosed neither evidence of their exposure nor any involvement of the bone structure itself. After the field of operation was dbbrided, the flap was brought back into position and retained with several sutures. Except for postoperative edema, which is usually observed after an invasion ot’ loose cellular tissues, the patient was quite comfortable and made an uneventful recovery. Six weeks after the operation, all of the teeth were again tested for vitality, examined for firmness and color, and were found normal. The patient uses her anterior teeth in mastication and is completely comfortable in every other respect. 369 EAST