Post-trauma complex orthodontic approach: the impact of psychological issues of bullying on treatment decision

ABSTRACT Objective: This article aims to discuss the multidisciplinary approach required in the treatment of cases of impaction and ankylosis of permanent teeth, associated with a history of trauma, considering the psychological state of the child and family when faced with a traumatic case of bullying, by reporting the complex treatment of a central incisor needing to be orthodontically moved across the midline. Conclusion: This clinical case was a major challenge, which included complex multidisciplinary procedures. Results and stability after 26 months of retention indicated successful orthodontic space closure of two maxillary teeth, without the use of implants or prostheses, in an adolescent patient who had a history of dental trauma, alveolar bone loss, and an uncertain initial prognosis.


INTRODUCTION
The deciduous incisors are the teeth most commonly affected by dental trauma. 1 There is a close anatomic relationship between the apexes of deciduous incisors and the buds of succeeding teeth: the hard tissue barrier between them has a thickness of less than 3 mm and it might consist of only connective fibrous tissue. 2 Frequent consequences for the permanent dentition after an intrusion trauma to the deciduous dentition are impaction of succeeding teeth, which can be explained by the physical displacement of the permanent tooth bud, with or without dilaceration at the time of injury; root resorption disorders 1,3,4 and ankylosis. 5 Impacted teeth have the potential to cause serious problems such as development of pathologies and other complications, due to their proximity to the anatomical structures. 5 Impacted teeth can induce resorption of adjacent teeth, periodontal disease, marginal bone loss at the root surface of adjacent teeth, and cysts or tumors. 5,6 In addition, the impaction of permanent maxillary incisors may impair the physical, psychological and social development of the child, 7 since these teeth are in frontal and centered position in the oral cavity, playing an essential role in facial aesthetics and oral function. 8 The treatment options for impacted maxillary incisors usually include space creation Feu D, Carvalho FAR -Post-trauma complex orthodontic approach: the impact of psychological issues of bullying on treatment decision 5 for spontaneous eruption, 9 surgical exposure and orthodontic traction 7 , or extraction of the impacted incisor followed by prosthodontic rehabilitation. 10 Treatment by orthodontic traction of impacted central incisors has been reported to have the most favorable outcomes, both esthetically and functionally. 11 However, there is a risk of traction failure and bone loss. 10,12,13 Besides, many authors state that after diagnosis of impaction, the therapeutic decision should prioritize tooth eruption. 3,7,8,11,[14][15][16][17] But it is important to emphasize that there is no standard protocol for the assessment of impacted teeth, and the decision should be taken according to each situation. 5 In addition, the child may be the target of bullying at school, generating a negative impact on their emotional development and requiring a solution that meets the demands generated by this situation.
It is also worth mentioning that multiple dental impactions involving maxillary incisors and canines cause aesthetic, functional, psychosocial and financial burdens for affected individuals. They can cause irreparable dental harm during or after treatment, and even years after the trauma, due to sequelae. [18][19][20][21][22][23][24] Considering all these points, it is crucial to intercept complex cases of impaction as soon as possible, to establish the proper therapy. Thus, this article aims to discuss the multidisciplinary approach needed in the treatment of cases of impaction and ankylosis of permanent teeth associated with a history of trauma.

DIAGNOSIS AND ETIOLOGY
A 13-year-old girl of African descent presented to the private orthodontic office for orthodontic treatment eight years after suffering a facial trauma with traumatic dental injury (TDI), with the main complaint of "missing front tooth and ugly smile".
This trauma induced the avulsion of deciduous maxillary right central incisor and left lateral incisor, and intrusion of the deciduous maxillary left central incisor. After that, she attended regular preventive visits with the pediatric dentist, who detected several eruption disorders in the permanent dentition, including impaction of the maxillary left central incisor and both right and left canines. The pediatric dentist tried to use a removable appliance to move the maxillary left lateral incisor for almost a year without success, and suggested that it should be clinically diagnosed with ankylosis, due to the impossibility of induced movement.
The patient had vertical facial pattern with a convex profile, absence of passive lip sealing and an asymmetric smile, with minimal exposure of maxillary teeth, and evidence of anterior projection of the tongue at rest and during swallowing (Fig 1). Intraoral clinical examination revealed an altered sequence of the permanent teeth eruption. There was significant positive discrepancy in the maxillary arch due to missing teeth (+9.7mm), and moderate dental crowding in the mandibular arch (-7.2mm). Occlusal analysis revealed a The maxillary left central incisor presented severe displacement, with an angulation greater than 90º in relation to the sagittal plane (Fig 2).
Cone beam tomographic images (CBCT) evaluation defined the exact place of the impacted maxillary left central incisor: the tooth was horizontally positioned, and its crown was close to the nasal floor and anterior nasal spine, across the midline, while the root was palatally displaced. The distance from the cementoenamel junction to the root apex of this tooth was also 5.6mm shorter than that of the maxillary right central incisor, characterizing root shortening. The maxillary left canine root was in close relationship with the maxillary sinus (Fig 3).

TREATMENT PLAN
The treatment plan included the use of: high-pull headgear to correct Class II and help with anchorage; Hyrax-type palatal expander, to transversely expand the maxillary arch; and extraction of the maxillary left central incisor, which had a very poor prognosis for orthodontic traction, and the maxillary left lateral incisor, with probable ankylosis. A fixed appliance was After the end of orthodontic treatment, the patient would be referred for aesthetic rehabilitation. This type of approach is rarely indicated, but it was considered the best solution for the presented situation, with lower risks and better prognosis, to meet the psychosocial, financial and aesthetic needs of the patient. However, due to the young age of the patient, options 1 and 2 were not considered, due to the long waiting period until implant placement (growth completed) and/or subsequent restoration work. They were also considered impractical due to the chances of additional alveolar bone loss at the extraction site, as this region already had significant bone deficiency. In addition, the patient's financial and psychological conditions also did not favor these two options.      The cephalometric analysis (Fig 8, Tab 1 The panoramic radiograph (Fig. 9) showed good root parallelism, except for the maxillary left canine and the right cen- The patient reported excellent dental function, absence of muscle pain or joint problems, satisfaction with dental and facial aesthetics, and improved quality of life.  the maxillary left canine was moved to (Fig 10).  After a 26-month retention period, the facial aesthetics and occlusion achieved were maintained, and a good improvement in periodontal support and clinical health was also observed in the maxillary left canine (Fig 11). Panoramic (Fig 12) and cephalometric (Fig 13, Tab 1) radiographs did not reveal significant changes, in comparison to the end of treatment.

MEASURES
Based on the CBCT, the midpalatal suture moved together with the right central incisor, and the connective tissue of the suture was pushed to the left, apparently becoming incorporated into the periodontal ligament, appearing as a radiolucent image distal to the maxillary right central incisor (Fig 14). CBCT also revealed that the tooth movement had little or no effect on the position of the incisive foramen.      the alveolar bone condition of vertically impacted teeth was better than that of horizontally impacted teeth. 3,7,8,11,[14][15][16][17] The available literature also shows that suitable treatment timing is critical for treating malpositioned impacted maxillary central incisors. 7,27,20 In the clinical case presented, however, this 13-year-old patient, in addition to having an CBCT showed that tooth movement had little or no effect on the position of the incisive foramen. In addition, axial views on CBCT showed that the spatial course of the nasopalatine canal was relatively unchanged. Therefore, it appeared that the orthodontic correction included the teeth, periodontal tissues and related attached buccal mucosa, but did not affect the processes of the hard palate 22 , which is similar to the clinical results achieved in the present case. McCollum 37 stated that this stretched frenum and gingival tissue appear to play little or no role in the relapse of these incisors, as in this case they remained stable for nearly 9 years after retention -similar to the results found in the present case after more than 2 years of retention. The presence of fixed lingual retainer is a factor that makes cleaning even more difficult, so the patient was emphatically instructed about the need to use dental floss, and is being followed up with biannual periodontal control visits.
Feu D, Carvalho FAR -Post-trauma complex orthodontic approach: the impact of psychological issues of bullying on treatment decision 35 The treatment of TDIs is often complex and requires interdisciplinary approach, and should be directed to avoid sequelae. 18 Then, the therapy of an impacted maxillary central incisor and an ankylosed lateral incisor in the same quadrant due to trauma requires a multidisciplinary approach: Orthodontics, Surgery, Periodontics, Prosthetics and Esthetic Dentistry are essential for successful treatment. 44 The present patient reported satisfactory dental function, absence of muscle pain or joint alterations, satisfaction with dental and facial aesthetics, and improved quality of life. No significant root resorption was observed as a consequence of the major tooth movement. Moreover, we believe that the long-term stability of results observed in the present case likely had a strong influence on the correction of tongue function and position.