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20 Dental Tribune Middle East & Africa Edition | July-August 2015paediatric tribune Advancing the future of education Hamdan Bin Mohammed College of Dental Medicine, an institution of the Mohammed Bin Rashid Academic Medical Center, is a dental institution launched to support the community with the finest quality of dental education. The postgraduate college offers residents a three year Master of Science Degree in the following six specialisations: • Endodontics • Oral Surgery • Orthodontics • Paediatric Dentistry • Periodontology • Prosthodontics For more information on admissions, please call the Student Affairs Office at +971 4 424 8612 or visit our website at www.hbmcdm.ac.ae. * Applies within the United Arab Emirates only. HAMDAN BIN MOHAMMED COLLEGE OF DENTAL MEDICINE Phone +971 4 424 8777 | Fax +971 4 424 8686 P.O. Box 505097, Dubai Healthcare City, Dubai, United Arab Emirates 800-DENTAL * FORMORE INFORMATION CALLUSON www.hbmcdm.ac.ae > Page 21 Paediatric Dentistry: A Case of the Unerupted Maxillary Permanent Central Incisor and its Multi-Faceted Management By Dr. Ghada Hussain, UAE & Dr. Iyad Hussein, UAE I ntroduction Monitoring the developing dentition is part and parcel of a general dental practitioner’s (GDP) routine and this relies on the basic knowledge of tooth exfoliation and eruption times. Delayed eruption of maxillary central incisors can be a reason that parents/carers bring their child in for a dental assessment. Nevertheless, detecting this anomaly by a GDP by chance on routine examination can occur. According to Yacoob et al (2010)1 intervention for the delayed eruption of maxillary incisors, beyond the normal eruption dates, is needed in many cases. For example, if the eruption of the antimere incisor tooth oc- curred greater than six months previously; or if both central in- cisors remained unerupted and the lower incisors have erupted greater than one year previ- ously or there is deviation from the normal sequence of erup- tion (e.g. lateral incisors erupt- ing prior to the central incisor). This issue is important from the interceptive orthodontic point of view and it may have an effect on the facial aesthetics and psy- chology of the child2 , in addition to some difficulties in pronounc- ing some letters for example ”S” which will lessen the patient’s self-esteem and social interac- tions.3,4 We report a case of an unerupted permanent maxillary central incisor and its multifac- eted treatment in a child patient. Causes of the unerupted maxil- lary permanent central incisor • Heredity (cleft lip and palate, cleidocranial dysostosis, super- numerary teeth, hypodontia, ectopic tooth germ, gingival fibromatosis, tissue scar, od- ontomes, generalised delayed eruption). • Environmental (trauma, re- tained primary teeth, cystic for- mation, early extraction or loss of primary teeth+/-space loss, endocrine abnormalities)5 . Figs. 1 (a, b & c). An 8 ½ year old girl presented with delayed eruption of 21 and a palpable palatal swelling. Lower teeth were carious; see bitewings in Figure 4 Fig. 2. A previously taken DPT of 8 ½ year old (LT) when she was 7 showed the presence of a supernumerary tooth ($) (arrow) in the maxillary midline. This was accidently omitted at the time indicating the importance of a comprehensive report every time an x-ray is taken. Figs. 3 (a & b). Periapical xrays show the presence of an inverted conical su- pernumerary tooth present palatally to 21 (parallax). Figs. 4 (a & b). Patient LT, who was dentally anxious, also had dental caries which the above bitewings show. • The incidence of unerupted maxillary central incisor in 5-12 year old children is 0.13% and the prevalence is 2.6%.6,7 Investigations When an unerupted maxillary incisor is suspected, a full set of investigations should be car- ried out including a medical and dentalhistory,familyhistory,his- tory of dental trauma. A clinical investigation and examination should include direct palpation of the alveolus, assessing if buc- cal or palatal swellings are pre- sent, if a retained primary inci- sor is present, carrying out space analysis and dental charting. Special tests may be required like sensibility tests but most im- portantly radiographs (DPT, up- per anterior occlusal, periapical) to assess if the unerupted tooth is present or not, if it is malformed (e.g dilaceration), if an obstruct- ing feature is present (like a su- pernumerary or odontome) and to locate its correct position by parallax (i.e. buccal or palatal). Management depends on the findings • Remove retained deciduous tooth • Create and maintain sufficient mesial and distal space ortho- dontically • Remove any physical obstruc- tion (eg: supernumerary teeth) •Exposure(openorclosederup- tion technique) with or without a gold chain/attachment • Incisor removal (e.g.: unfa- vourable root formation, anky- losed maxillary incisor) • Osteotomy of segment and re- positioning of the dentoalveolar structure in some cases • Autotransplantation A Case Report An eight and half year-old girl (LT) attended the paediatric dentistry department of Ham- dan Bin Mohammed College of Dental Medicine (HBMCDM) in Dubai Healthcare City for an opinion. The patient’s mother was concerned about the de- layed eruption of an upper front tooth (21) that was affecting her child’s appearance (Figs. 1 a, b & c). LT was medically fit and healthy with no history of previ- ous dental trauma. She was in the mixed dentition stage. Tooth 11 had erupted 4 months ago in cross bite but 21 had not erupted yet. Its eruption was much de- layed(usuallyeruptsat7½years ofage).Lookingbackatprevious x-rays, a DPT was taken a year ago and it was noticed that an important feature was missed. Retrospectively, the presence of a supernumerary tooth ($) in the area of 21 and congenital missing 47 was confirmed (Fig. 2). Two new x-rays, namely up- per intra oral periapicals and the parallax technique (distal shift) showed a supernumerary tooth (conical and inverted) in a pal- atal position (Figs. 3 a & b). LT also had dental caries of her pri- mary teeth (Figs. 4 a & b), had a pronounced gag reflex and was dentally anxious. The patient had a Class I skel- etal and molar relationship, with a slight rotation and ante- rior crossbite of 11. Due to the complex nature of this case, re- quiring a multidisciplinary ap- proach, a joint orthodontic-pae- diatric dentistry case conference was arranged, and a diagnostic list and treatment plan was for- mulated. Diagnostic Summary • 8 ½ year old anxious girl • Delayed eruption of 21 & an inverted conical supernumerary mesiodens palatal to 21 at +97144248612 or visit our website at www.hbmcdm.ac.ae. Phone +97144248777 | Fax +97144248686