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Management of Unerupted Lateral Incisor by LASER Assisted Surgical Exposure
Introduction- Maxillary incisors are aesthetically important, parents often notices it first and are troubled (1,2). The children are bullied or teased due to delayed eruption resulting in psychological complications. It is necessary to bring the unerupted incisor into its correct position with proper monitoring and timely surgical orthodontic intervention so as no prosthetic solution is required as nothing is better than tooth itself. LASER have its advantages over conventional scalpel for the surgicalexposureoftheuneruptedincisors.
Diagnosisofuneruptedincisors-
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A)Clinicalevaluation- 1) Firstly patient’s chronological age and dental age should be examined to determine if there is delayederuptionornot. 2) The amount ofspace available for the eruption oftooth, space loss, midline shift, position ofthe adjacentteeth,andcontouroftheboneshouldbeexamined 3) Palpation of the labial bulge on the mucosa if visible and if not visible then evaluation by radiograph 4) The distance from the mucogingival junction - An adequate amount ofkeratinized gingival tissue that is under proper plaque control, is a fundamental requirement for periodontal health. Labially or buccallyerupting teethshowreduceddimensions ofgingiva as abnormal eruptionofpermanentteeth restrictsoreliminatesthekeratinizedtissuebetweentheeruptingcuspandthedeciduoustooth. Alack ofattached gingiva (keratinized gingiva) poses a potential risk for gingival recession in labially or buccally erupted teeth due to the possibility of accumulation of plaque and/or traumatic tooth- brushing.
B) Radiographic evaluation- Theaccuratelocationoftheuneruptedlateralincisorbytheconventional two - dimensional radiographs is done. For the exact estimation ofbuccolingual position a second periodical film is obtained by using a) Clark’s rule b) Buccal-object rule. CBCT (Cone Beam ComputedTomography) canbe usedto avoidmultiple exposure andto knowthe accurate positionof thetooth.
1)Firstlydeterminethepresenceoflateralincisorsandifboneispresentontheeruptingtoothbuds 2)Theamountofrootformed
In this case the patient’s chronological age was 9 years suggesting of delayed eruption of lateral incisor. Palpationofthe painless incompressible labial fibromucosal protuberance orbulge is done to locate the crown. Itis supportedbythe intraoral periapical radiograph. No bone is seenonthe crown ofthe uneruptedlateralincisor. The locationandsize ofwindowto be made duringsurgicalexposure isdeterminedtobe1mmbelowthemucogingivaljunction.
Treatment- PioonS1 blue dentalLASERof450 nmwavelengthwas usedforthe surgical exposure oflateralincisor.
Thisconsistoffollowingsteps: 1)Isolationofareafollowedbyapplicationoftopicalanaestheticagent. 2) Marking the shape, extent and site ofwindow ofexposure by making dots with LASER at lesser powersettingsusing400microntip. (Fig1) 3)Removalofthetissueathigherpowersettingwith400microntipinnon-contactmode.
The complete safety protocols were followed for the patient, operating and assistant stafflike using laser protective eye glasses and use of high vacuum suction. Highly reflective instruments were avoidedwhileusinglasers. (Fig2)
Rationale for the use of LASER- LASER assisted surgical procedure has various advantages. Incision performance, hemostasis, reduced pre and post-operative oedema and pain hence the
In paediatric patient behavioural guidance ofchildren in the operative and perioperative period is a special challenge. Use of topical anaesthetic agent, no scalpel and less blood results in better cooperation from the children. It also aids in patient homecare and allows for better bracket repositioningandfinaldetailing.
Conclusion - When unerupted tooth is not deeply placed, surgical exposure with Pioon LASER at 450nmallowsconservationofattachedgingiva, noinjection, lessbleedingduringsurgery, lessuseof analgesic and anti-inflammatory drugs, minimal postoperative complication and also immediate placement of orthodontic brackets so less appointments as well. Hence LASER represents indispensablemodalitytotreatpaediatricpatientswithease.
References-
1)HuBerK, Suri, TanejaP. Eruptiondisturbances ofthe maxillaryincisors: aliterature review. JClin PediatrDent2008; 32: 221-230. 2) Pavoni C, Mucedero M, laganàG, Paoloni V, CozzaP. Impactedmaxillaryincisors: diagnosis and predictivemeasurements. AnnStom2012; 3: 100-105.
Fig1 -Preoperativeview(PicCourtesy–Dr.SanaFarista)
