|Year : 2013 | Volume
| Issue : 3 | Page : 102-105
Interceptive management of winged maxillary central incisors
Mamta Dali1, Parajeeta Dikshit2, Nitin Kumar Agarwal3, Archana Shrestha4
1 Department of Pedodontics and Preventive Dentistry, Nobel Medical College and Teaching Hospital, CODS, Kathmandu, Nepal
2 Department of Pedodontics and Preventive Dentistry, Kantipur Dental College, Kathmandu, Nepal
3 Department of Dentistry, Institute of Medicine, Kathmandu, Nepal
4 Dental surgeon, Prakash Dental Clinic, Bangalore, Karnataka, India
|Date of Web Publication||8-Aug-2013|
Nobel Medical College and Teaching Hospital, CODS, Biratnagar
Source of Support: None, Conflict of Interest: None
Introduction: Winged maxillary incisors are a well-recognized clinical finding, which can result in psychological trauma to children at growing age. Interceptive treatment is usually carried out in mixed dentition period in order to reduce the severity of a developing malocclusion in future. Case Report: This paper reports a case of 6-years-old female patient with winged maxillary central incisor being treated with derotation technique using the beggs brackets along with nance palatal arch space maintainer. Discussion: The major advantages in carrying out this treatment with fixed brackets are the ease with which the force magnitude and vector can be controlled much more precisely than with a removable appliance, minimal discomfort to the patient and reduces the need for patient co-operation.
Keywords: Early derotation, interceptive management, winged maxillary central incisor
|How to cite this article:|
Dali M, Dikshit P, Agarwal NK, Shrestha A. Interceptive management of winged maxillary central incisors. Dent Hypotheses 2013;4:102-5
| Introduction|| |
Interceptive treatment is usually carried out in order to reduce the severity of a developing malocclusion. This type of treatment is very often indicated and carried out in the mixed dentition, and brings with it unique challenges. 
Winged incisors are a well-recognized clinical finding. Maxillary central incisors typically are situated in their sockets in such a way that their occlusal contour follows the normal arc of the maxillary dentition. However, in some reported cases, the distal margins of the incisors are rotated in a labial or lingual direction. Lingual rotation has been termed counter winging by Dahlberg, whereas labial rotation is simply winging. On occasion, incisor rotation is an obvious function of anterior tooth crowding, especially in cases of counter winging. However, instances are also seen of unilateral and bilateral counter winging and winging, which clearly are not functions of tooth crowding. 
The maxillary central incisor may show a wide range of variability,  particularly with regard to the : l0 abial outline, labial lobe grooves, labial profile curvature, mamelons, cingulum, root size.  It has been found that abnormal dental features were the most common reason for causing psychological trauma in children especially in the 9-10 year age group. 
Evidences suggest that a short course of orthodontic treatment in the mixed dentition may results in improved function and aesthetics thereby reduces the psychological trauma and remains relatively stable in future. 
This paper reports a case of 6-years-old female patient presented with winged maxillary central incisor being treated with derotation technique using beggs brackets along with nance palatal arch space maintainer.
| Case Report|| |
A 6-year-old female child reported to the Department of Pedodontics and Preventive Dentistry with the chief complains of rotated upper front tooth. On intraoral examination, maxillary left central incisor (11) was found to be erupting in a rotated position, whereas 21 erupted with normal pattern [Figure 1]. She presented with a class I molar relationship in the mixed dentition period. Grossly, decayed deciduous first molar (54, 64) were present bilaterally on maxillary arch [Figure 2]. Deep carious lesions were seen on mandibular right and left second molars (75, 85) [Figure 3].
The derotation technique for winged maxillary right central incisor was planned followed by nance palatal arch space maintainer. Pulp therapy followed by stainless steel crowns (3M ESPE, California, US) for mandibular second molars was planned (75, 85).
Nance palatal arch space maintainer was fabricated after extraction of 54 and 64 with molar tubes welded on molar bands. The derotation procedure was carried out by bonding beggs bracket on labial and palatal aspect of 11. Two separate cross elastics (3M Unitek, California, USA) were placed on brackets on labial and palatal aspects, which were engaged to the respective molar tubes of each side of the space maintainer [Figure 4].
|Figure 4: Beggs brackets placed on labial and palatal aspects i.r.t 11 and cross elastics engaged to molar tubes welded to molar bands.|
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Debonding of the brackets were carried out once positive over jet and overbite established followed by the placement of composite ribbond fiber on the palatal aspects of 11 and 21 as a retainer [Figure 5]a and b and continuation of the nance palatal arch space maintainer was planned as there were premature extraction of deciduous first molar bilaterally due to caries [Figure 6]. Pulp therapy followed by stainless steel crown was carried out in 75 and 85 [Figure 7]. Total orthodontic treatment time taken was 7 weeks. Patient was informed to follow up in every 3 months.
| Discussion|| |
Various cases of rotated or winged and atypically formed teeth have been reported previously in the literature. , This patient did not have any orofacial deformities such as cleft lip and palate, where such variations may be expected. Winged or rotated and malformed teeth have often been found to be accompanied by other dental anomalies such as malpositions of adjacent teeth, retained deciduous teeth, dilacerations, supernumeraries, and malformation of several teeth in the same patient. , Although winging could be attributed to the mild crowding present in the anterior region, no definite explanation was present for the atypical morphology of the central incisors because there was no evidence of any other associated dental anomaly.
Knowledge of the biomechanical principles of tooth movement is essential for the orthodontist to execute an individualized treatment plan. If the location of the center of resistance of a tooth or group of teeth is known, the correct moment-to-force ratio can be applied at the brackets to obtain specific centers of rotation-in other words, controlled movement. The studies have shown that the location of the center of resistance of the maxillary central incisor depends on the palatal bone level and is at approximately two-thirds of the palatal alveolar bone height, measured from the root apex. A greater moment-to-force ratio is needed for any controlled movement of the maxillary incisors during the retraction in patients with reduced palatal alveolar bone height.
Treatment may start as soon as sufficient permanent teeth have erupted and the child should be co-operative enough to have bands cemented and brackets bonded. Placement of the fixed appliance usually only takes a little longer time than the required to fit a removable appliance and may be even carried out at a single visit. Although there needs to be patient co-operation for the placement, adjustment and removal of the appliance, the importance of compliance during active treatment is usually less than that for a removable appliance. 
Treatment carried out in mixed dentition stage may take as little as a couple of weeks, but in the more difficult cases it can be longer. In the majority of cases, the end result can be more effectively and efficiently achieved than if a removable appliance was used. In this case, the treatment was started in early mixed dentition period, but however, definitive treatment may probably require in the permanent dentition, but the complexity and duration of the further treatment may be significantly reduced in future.
The major advantages in carrying out this treatment with fixed brackets are the ease with which the force magnitude and vector can be controlled much more precisely than with a removable appliance, minimal discomfort to the patient and reduces need for patient co-operation.
Although rotations can be treated at various stages of root development, an early correction of rotated teeth before root completion is conducive to better retention. Early, derotation of the central incisors was planned and achieved to reduce any possible psychological trauma. 
| Conclusion|| |
Even though, there may be slightly more chair side time required to fit the appliance, there is no laboratory cost involved. The functional improvement coupled with the obvious psychological benefit gives this simple and easily placed appliance a significant advantage over the traditional method of treating these potentially challenging mixed dentition problems.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]