Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 51166

AbstractCase ReportDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case report
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : ZD10 - ZD13 Full Version

Transnasal Extraction of Mesiodens and Guided Eruption of Unusual Impacted Central Incisor: A Case Report and Review of Literature


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/50514.16122
Senthil Kumar, Arun Kumar, Prasad, Davidson Rajiah, Deepa

1. Senior Assistant Professor, Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Chennai, Tamil Nadu, India. 2. Associate Professor, Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Chennai, Tamil Nadu, India. 3. Professor, Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Chennai, Tamil Nadu, India. 4. Senior Assistant Professor, Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Chennai, Tamil Nadu, India. 5. Postgraduate Student, Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Chennai, Tamil Nadu, India.

Correspondence Address :
Dr. Senthil Kumar,
No. 3, First Floor, Rajiv Gandhi Nagar, South Mada Street Extention, Villivakkam,
Chennai, Tamil Nadu, India.
E-mail: drsenthilkumaromfs@gmail.com

Abstract

Mesiodens is one of the developmental problems in children and adolescents. Mesiodens is a supernumerary tooth in the midline between two central incisors which eventually causes poor aesthetics, food impaction, malocclusion and cyst formation. Here, authors presents a rare case of a 13-year-old male with unusual impacted inverted permanent maxillary left central incisor and horizontally placed mesiodens lying palatal to the permanent maxillary left central incisor. The patient presented with unerupted permanent upper left central incisor. Although most unerupted teeth require surgical removal, surgical-orthodontic treatment may be needed when maxillary incisors are involved due to the aesthetic impact. Surgical-orthodontic treatment aims at the complete alignment of natural teeth and does not require prosthetic intervention. This case report also reviews current literature on the treatment and multidisciplinary management of this problem. Early diagnosis and treatment are recommended to prevent any orthodontic and pathological complications.

Keywords

Inverted central incisor, Juxta nasal tooth, Platelet rich fibrin, Surgical-orthodontic treatment

Case Report


Surgical Procedure

Fixed orthodontic appliance with orthodontic brackets of McLaughlin, Bennett and Triversi (MBT) type and arch wires were placed prior to the surgery.

Firstly under local anesthesia with vasoconstrictor (2% lidocaine with 1:2,00,000 epinephrine) palatal approach was tried for removal of the horizontally lying palatally placed mesiodens, but as the root was facing palatally and the crown was lying just 2 mm inferior to the nasal floor, the palatal approach was deferred due to anticipated slippage of the mesiodens during removal and transnasal approach under General Anesthesia (GA), considering the proximity of the mesiodens to the nasal floor.

Oral intubation was decided as transnasal approach was to be performed. After infiltration with local anesthetic with vasoconstrictor (2% lidocaine with 1:2,00,000 epinephrine), crestal incision was placed inside the gingival sulcus from 14 to 24 on the labial side and a full thickness mucoperiosteal flap was elevated on the labial side exposing the anterior nasal spine. Nasal mucosa was gently elevated and protected with Howarth periosteal elevator to prevent postoperative epistaxis as a complication.

Nasal floor was identified. Deroofing of the mesiodens was done on the nasal floor with the round Tungsten Carbide (TC) bur (Waldent) and the crown of the mesiodens was exposed. Bone guttering around the mesiodens was done and using a purchase point between the mesiodens and central incisor 21, the mesiodens was elevated and removed while the central incisor 21 was stabilised with fingers. Bone guttering was done around the incisal edge and labial, palatal side of upper left central incisor with a round TC bur and the left maxillary central incisor was exposed (Table/Fig 7).

After the extraction of the mesiodens, there was less than 1 mm of inter-radicular bone between impacted 21 tooth and empty tooth socket which consequently lead to grade I mobility of the central incisor 21 intraoperatively. Hence, Platelet Rich Fibrin (PRF) (Table/Fig 8) was prepared to regenerate the alveolar bone support between unusual impacted central incisor and the extraction socket of extracted mesiodens to guide the eruption of impacted 21. Intraoperatively a bur hole was placed distal to the 21 impacted tooth 2 mm from incisal edge for guided orthodontic eruption. Pretwisted ligature wires were passed through the bur hole and twisted and secured to the brackets on 11, 12, 13 (Table/Fig 9)a,b. The surgical site was irrigated with copious amount of betadine and saline. Then PRF was prepared to be placed over the inter-radicular bone between unusual impacted central incisor and the extraction socket of extracted mesiodens before closure.

Preparation of platelet rich fibrin: Firstly, 20 mL of blood sample was collected from patient via 18G needle from the superficial veins of the lower limb and was placed in the centrifuge [REMI PRP Centrifuge machine, Dermacell Private Limited, Mumbai] and was allowed to spin immediately (approximately within 2 minutes of blood collection) at 3000 rpm for 10 minutes (1). The blood sample settled in three layers, the lower fraction of Red Blood Cell (RBC), middle fraction of fibrin clot and upper fraction of straw coloured acellular plasma. The upper fraction of the acellular plasma was removed. The resulting PRF preparation was picked up with forceps and the red thrombus (RBC fraction) was eliminated with scissors (Table/Fig 8) (2). The PRF was compressed by dry gauze and it was placed near the root of impacted central incisors labially on the thin bone covering the 21 impacted tooth and palatally in the extraction socket of mesiodens for regeneration of bone to help guided eruption of the impacted 21 tooth (Table/Fig 9)a,b. Closure was done with 3-0 vicryl (Healthium Medtech Private Limited).

On subsequent follow-up visits, postoperative IOPA (Table/Fig 10)a and image (Table/Fig 10)b, and OPG (Table/Fig 11) taken around 9 months postoperatively showing bone formation near the central incisor 21 and after 1 year 5 months clinical examination revealed no mobility of the 21 tooth and guided eruption of the central incisor 21 into the oral cavity (Table/Fig 12).

Discussion

Mesiodens is a frequent disorder of odontogenesis which features the presence of a tooth in addition to the normal series in the midline between the central incisors. The most common type of supernumerary tooth is mesiodens (3). Most unerupted teeth require surgical removal, but surgical-orthodontic treatment may be needed in case of maxillary incisors due to the aesthetic impact (4),(5),(6). Surgical-orthodontic treatment aims to bring complete alignment of natural teeth and does not require prosthetic intervention (4),(5),(6).

In 1917, Balk coined the term mesiodens and mentioned as supernumerary teeth located mesial to both central incisors appeared as peg-shaped crown. The prevalence of mesiodens is 0.15-1.9%. It is more frequently found in males than females in the proportion of 2:1 to 6:1 (5),(6). Mesiodens account for about 80% of all supernumerary teeth which can occur individually or as multiples [mesiodentes], may appear unilaterally or bilaterally, and often remain unerupted. Supernumerary teeth result due to changes occurring in the process of normal epithelial-mesenchymal interactions of tooth development (6). The theories of formation of supernumerary tooth include the tooth germ dichotomy, overgrowth, or dental lamina hyperactivity, where the pressure induced by the rest of the dentition leads to the proliferation of epithelial rests of dental lamina eventually resulting in outbreaks of supplemental supernumerary teeth (5),(6).

Ectopic tooth or intranasal tooth erupts into nasal cavity is a rare occurrence with only 0.1 to 1% patients affected in our community (7). It appears that mesiodens develops from the floor of the nasal cavity with different aetiologies such as injury, rhino maxillary sinusitis, dental diseases, maxillary blisters, blockage of dental eruption, damage to formative tissue, for example “palatine gap”. Intranasal tooth also cause septal perforation, aspergillosis, naso-oral fistula (8),(9),(10). The possible dental complications include eruption delay of the permanent incisors [38.8%], upper midline diastema [17.6%], axial rotation or inclination of the erupted permanent incisors [16.4%], resorption of the adjacent teeth [4.7%], cyst formation [4-9%] and infection (10). Impacted mesiodens remain clinically silent or diagnosed as an accidental finding during the radiographic examination or they cause complications and require an immediate treatment. Hyperactivity of the dental lamina is the most widely supported theory to explain the cause of mesiodens (10).

CBCT is an essential investigation as it provides a high resolution 3D representation of the maxillofacial region. It may help in selecting the right surgical treatment option as it mainly depends on the type and location of impacted teeth and its relation to the adjacent vital structures. Consequently, CBCT aids in minimising trauma to the adjacent hard and soft tissues (11).

A cystic alteration is observed in 4-9% of the mesiodens cases, with the anterior maxilla being affected in 90% cases.This indicates surgical removal of the mesiodens (8). Extraction is indicated for nasally erupting teeth to relieve symptoms and to prevent complications. The ideal time of removal of such teeth should be after the complete formation of permanent teeth roots to prevent any damage during their development (8),(9),(10),(12).

Treatment options like surgical management of mesiodens or keeping under observation depends on factors such as the child’s age concerned with the ability to cope up with a surgical procedure. Early management avoids unpleasant experience that may have psychological impact on the patient (5). Second is the proximity of the mesiodens to the incisors and the developing dental structures (5). Developing roots are prone to surgical trauma which may damage the future dental growth. In these cases treatment may be delayed (13). Finally it is prudent to assess whether mesiodens is labially or palatally positioned. The surgical access to the mesiodens must be considered depending on the amount of bone removal and damage to the incisors (5). In children, mesiodens mostly partially erupts and complete eruption of mesiodens seldom occurs, and therefore more favorable surgical approach may be decided with time (5).

The literature mentioned in (Table/Fig 13) suggests that those palatally placed impacted inverted mesiodens were removed by palatal approach and those which were near the nasal floor were removed by transnasal approach. Similarly in the present case, for the horizontally lying palatally placed mesiodens, palatal approach was tried first, but as the root was facing palatally and the crown was lying just 2 mm inferior to the nasal floor, the palatal approach was deferred due to root apex of the mesiodens faced palatally and its crown was faced towards nasal floor. transnasal approach was done considering the proximity of the mesiodens to the nasal floor.

Acharya S reported inverted impacted supernumerary tooth between two central incisor blocking the path of eruption of the maxillary left permanent central incisor which had caused delayed eruption. Similarly in this case, the unusual position of the mesiodens had caused the delayed eruption of 21 which presented clinically as missing 21 and also caused abnormal axial rotation or inclination and unusual inverted position of the impacted 21 tooth (13).

Sujlana A et al., reported transnasal approach in a case of inverted impacted mesiodens and Hauer L et al., in 2018 reported modified maxillary vestibular approach with intranasal dissection in a case of inverted impacted mesiodens positioned near the nasal floor (14),(15). Similarly in the present case, authors have selected the transnasal approach to remove the impacted mesiodens positioned mesiolaterally behind the impacted left permanent central incisor 21 because authors could not approach the mesiodens palatally due to its inverted abnormal anatomic position as the the crown was positioned near nasal floor and the root was towards palatal side.

Mesiodens was an accidental finding after taking an OPG. As per literature evidence, mesiodens occurs most commonly in the midline (15),(16) and it was the same in the present case, so it was advised for extraction of mesiodens followed by guided eruption of 21 was planned. CBCT for this particular case was a very useful tool for determining the tooth position of the 21 and abnormal position of mesiodens and selecting the right surgical approach. As per the literature available, the ideal time for mesiodens removal is after complete root formation of permanent central incisor (8),(9),(10),(12). In the present case, the patient age was 13 years suggesting complete root formation of 21, so that during extraction any injury to the developing root of the 21 tooth could be avoided.

Alzahrani AA et al., demonstrated that the use of PRF accelerates socket wound healing after tooth extraction as noticed by increased bone fill and reduced alveolar bone width resorption using clinical and radiographic methods (17). In this case Platelet rich Fibrin [PRF] was used at the surgical site which is a gel like biomaterial that contains high concentration of growth factors like platelet derived growth factor, transforming growth factor, vascular endothelial growth factor and endothelial growth factor; all of which are secreted by platelets. PRF stimulates and accelerates tissue healing and bone regeneration, decreases postoperative pain, oedema and prevents infection (18).

In the present case, after the extraction of the mesiodens, there was less than 1 mm of inter radicular bone between impacted 21 tooth and empty tooth socket which consequently led to grade I mobility of the central incisor 21 intraoperatively. Hence, PRF was placed on the labial and the palatal aspects of the impacted 21 tooth for bone regeneration for the purpose of guided tooth eruption which needs proper periodontal ligament formation, alveolar bone support for successful guided eruption. At the end of 1 year and 5 months of follow-up the central incisor 21 was successfully guided to erupt with good bone support.

Conclusion

The abnormal nasal position of the impacted mesiodens and the unusual impacted left permanent maxillary central incisor makes this case a peculiar and a challenging one. CBCT proved to be a useful diagnostic tool in determining the relationship of the unusual impacted 21 teeth to the vital structures and the amount of available bone and position of mesiodens there by deciding best surgical approach for tooth removal. Transnasal approach was used for the removal of impacted supernumerary teeth proximal to the nasal floor. The use of Platelet Rich Fibrin as a bone regenerating agent at the surgical site has shown best results for guided impacted tooth eruption which is suggested by the absence of mobility of the central incisor 1 year 5 months postoperatively after erupting into the oral cavity. Hence, early diagnosis, relevant investigations, multidisciplinary approach are vital for framing the treatment plan and also to prevent complications.

References

1.
Kobayashi M, Kawase T, Horimizu M, Okuda K, Wolff LF, Yoshie H. A proposed protocol for the standardized preparation of PRF membranes for clinical use. Biologicals. 2012;40(5):323-29. [crossref] [PubMed]
2.
Everts PA, Zundert AV, Schonberger JP, Devilee RJ, Knape JT. What do we use: Platelet-rich plasma or platelet-leukocyte gel? J Biomed Mater Res. 2008;85:1135-36. [crossref] [PubMed]
3.
Jindal R, Sharma S, Gupta K. Clinical and surgical considerations for impacted mesiodens in young children: An update. Indian J Oral Sci. 2012;3:94-98. [crossref]
4.
Cosme-Silva L, Costa E Silva LL, Junqueira MA, de Oliveira Dias NN, da Silveira Moretti AB, Sakai VT. Combined Surgical Removal of a Supernumerary Tooth and Orthodontic Traction of an Impacted Maxillary Central Incisor. J Dent Child (Chic). 2016;83(3):167-72. PMID: 28327268.
5.
Sachin AG, Anand LS, Anil TP. Management of Palatally Positioned Impacted Mesiodens: 2 Case Reports. J Orthod Endod. 2017;3:01.
6.
Jayakaran TG, Vishnu RC, Annamalai S, Baghkomeh PN. Surgical Removal of an Impacted Supernumerary Tooth Located in a Unique Position. J Dent Oral Biol. 2017;2(2):1027.
7.
Henrique Fernandes de Oliveir et. Al Intl. Arch. Otorhinolaryngol., São Paulo, 2009;13(2):201-03.
8.
Noleto JW, Prado R, Rocha JF, DaCosta MF, Barbosa CG, Toscano MG. Intranasal inverted tooth: A rare cause of a persistent rhinosinusitis. Indian J Dent Res. 2013;24:762-64. [crossref] [PubMed]
9.
Pham TT, Chau SM, Ifegwu IO, Wang BY, Wong BJF Endoscopic Removal of Intranasal Supernumerary Tooth Presenting as Nasal Obstruction and Epistaxis. J ClinRadiol Case Rep. 2018;2(1):04.
10.
Saleh B and Philip R. An Inverted Impacted Mesiodens Perforating the Nasal Floor with an Impacted Canine. Int J Oral Dent Health. 2019. Doi: 10.23937/2469-5734/1510082. [crossref]
11.
Reza S, Shafiei S, Moslemi H, Hamidreza & Khah MM. Intraoral transnasal approach for surgical extraction of bilateral deeply impacted mesiodens: A case report. Authorea. 2021;11(9). Doi: 0.22541/au.162912444.49431614/v1. [crossref]
12.
KumarK A, Bharathi R, Masthan K, Jacobina J. Nasal eruption. Indian J Multidiscip Dent. 2015;5;40-41. [crossref]
13.
Acharya S. Supernumerary tooth-case report- International Journal of Scientific Study. 2015:3(3).
14.
Sujlana A, Pannu P, Bhangu J. Double mesiodens: A review and report of 2 cases. Gen Dent. 2017;65(5):61-65. PMID: 28862591.
15.
Hauer L, Hrusak D, Jambura J, Gencur J, Hosticka L, Andrle P, et al. Modified maxillary vestibular approach with subperiostal intranasal dissection for surgical extractions of mesiodentes impacted in the floor of the nasal cavity. J Craniomaxillofac Surg. 2019;47(1):01-05. Doi: 10.1016/j.jcms.2018.05.032. Epub 2018 May 18. PMID: 30522795. [crossref] [PubMed]
16.
Sammartino G, Trosino O, Perillo L, Cioffi A, Marenzi G, Mortellaro C. Alternative transoral approach for intranasal tooth extraction. J Craniofac Surg. 2011;22(5):1944-46. Doi: 10.1097/SCS.0b013e31821151ba. PMID: 21959476. [crossref] [PubMed]
17.
Alzahrani AA, Murriky A, Shafik S. Influence of platelet rich fibrin on post-extraction socket healing: A clinical and radiographic study. Saudi Dent J. 2017;29(4):149-55. Doi: 10.1016/j.sdentj.2017.07.003. [crossref] [PubMed]
18.
Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, et al. Platelet-rich fibrin [PRF]: a second-generation platelet concentrate. Part V: Histologic evaluations of PRF effects on bone allograft maturation in sinus lift. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(19):299-303. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/50514.16122

Date of Submission: May 24, 2021
Date of Peer Review: Jul 28, 2021
Date of Acceptance: Feb 21, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 26, 2021
• Manual Googling: Feb 07, 2022
• iThenticate Software: Feb 26, 2022 (15%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com