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Forced eruption of impacted maxillary central incisors with severely dilacerated roots

2016; Elsevier BV; Volume: 150; Issue: 4 Linguagem: Inglês

10.1016/j.ajodo.2016.04.018

1097-6752

Na‐Young Chang, Jae Hyun Park, Sang-Cheol Kim, Kyung-Hwa Kang, Jin-Hyoung Cho, Jin-Woo Cho, Hong-Eek Jang, Jong‐Moon Chae,

Dental Trauma and Treatments

•Impacted maxillary central incisor with severely dilacerated root can be forcibly erupted.•In patient 1, the root perforated the labial plate without significant resorption.•In patient 2, the root was resorbed by touching the labial plate during torque control.•Impacted teeth with dilacerated roots might require endodontic therapy.•Long-term follow up might be necessary depending on the appearance of root resorption. Treatment of impacted dilacerated incisors is challenging for clinicians because of the prominent position of the teeth and the abnormality of their roots. We report on 2 patients who had horizontally upward impacted and severely dilacerated maxillary central incisors. The first patient's root perforated the labial plate without significant resorption, and the second patient's root was resorbed. Both patients were treated by a surgical-orthodontic approach, and the crowns of the impacted teeth were brought into the arches by closed forced eruption. Therefore, if impacted teeth have dilacerated roots, patients should be told of the possibility of root resorption. Treatment of impacted dilacerated incisors is challenging for clinicians because of the prominent position of the teeth and the abnormality of their roots. We report on 2 patients who had horizontally upward impacted and severely dilacerated maxillary central incisors. The first patient's root perforated the labial plate without significant resorption, and the second patient's root was resorbed. Both patients were treated by a surgical-orthodontic approach, and the crowns of the impacted teeth were brought into the arches by closed forced eruption. Therefore, if impacted teeth have dilacerated roots, patients should be told of the possibility of root resorption. By virtue of their location, impacted maxillary central incisors in children pose a disturbing esthetic dilemma for parents.1Crawford L.B. Impacted maxillary central incisor in mixed dentition treatment.Am J Orthod Dentofacial Orthop. 1997; 112: 1-7Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Because they are located up front, they are quite obvious when impacted. Space for the incisor tends to close during the delay of eruption, shifting the dental midline.2Tsai T.P. Surgical repositioning of an impacted dilacerated incisor in mixed dentition.J Am Dent Assoc. 2002; 133: 61-66Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Although impaction occurs less frequently in the maxillary incisors than in the maxillary canines, it is more significant in the early mixed dentition in terms of both esthetics and occlusion.3Wei Y.J. Lin Y.C. Kaung S.S. Yang S.F. Lee S.Y. Lai Y.L. Esthetic periodontal surgery for impacted dilacerated maxillary central incisors.Am J Orthod Dentofacial Orthop. 2012; 142: 546-551Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Many factors can affect the prognosis of impacted teeth, such as the position and direction of the tooth, age of the patient, dilaceration, and so on. Of these factors, dilaceration is a primary obstacle to successful alignment. Impacted incisors show various angulations in the crown or root; the most complicated situation is dilaceration with the crown in an inverted orientation. Depending on the direction and angulation of the dilaceration, ankylosis, external root resorption, and root exposure can occur after orthodontic traction.4Sun H. Wang Y. Sun C. Ye Q. Dai W. Wang X. et al.Root morphology and development of labial inversely impacted maxillary central incisors in the mixed dentition: a retrospective cone-beam computed tomography study.Am J Orthod Dentofacial Orthop. 2014; 146: 709-716Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 5Topouzelis N. Tsaousoglou P. Pisoka V. Zouloumis L. Dilaceration of maxillary central incisor: a literature review.Dent Traumatol. 2010; 26: 427-433Crossref PubMed Scopus (55) Google Scholar Maxillary central incisor eruption failure can be the result of trauma-induced dilacerations. Although the cause of root dilaceration is still unclear, studies have documented several potential causes.6Wasserstein A. Tzur B. Brezniak N. Incomplete canine transposition and maxillary central incisor impaction: a case report.Am J Orthod Dentofacial Orthop. 1997; 111: 635-639Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 7Lin Y.T. Treatment of an impacted dilacerated maxillary central incisor.Am J Orthod Dentofacial Orthop. 1999; 115: 406-409Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 8Smith D.M.H. Winter G.B. Root dilaceration of maxillary incisors.Br Dent J. 1981; 150: 125-127Crossref PubMed Scopus (40) Google Scholar, 9Kolokithas G. Karakasis D. Orthodontic movement of dilacerated maxillary central incisor.Am J Orthod. 1979; 76: 310-315Abstract Full Text PDF PubMed Scopus (31) Google Scholar Smith and Winter8Smith D.M.H. Winter G.B. Root dilaceration of maxillary incisors.Br Dent J. 1981; 150: 125-127Crossref PubMed Scopus (40) Google Scholar reported that traumatic injury to the deciduous incisors can lead to dilacerations of the permanent incisors, and Kolokithas and Kawakasis9Kolokithas G. Karakasis D. Orthodontic movement of dilacerated maxillary central incisor.Am J Orthod. 1979; 76: 310-315Abstract Full Text PDF PubMed Scopus (31) Google Scholar found that trauma can cause a change in the axial inclination of an unerupted deciduous incisor. When trauma occurs before the permanent teeth have erupted, the root-forming cells of the unerupted permanent tooth germ can be damaged, thus impairing the growth of the root and also changing the orientation of the tooth in the alveolar process. The outcome is a dilacerated tooth, which usually requires assistance to erupt.10Betts A. Camilleri G.E. A review of 47 cases of unerupted maxillary incisors.Int J Paediatr Dent. 1999; 9: 285-292Crossref PubMed Scopus (36) Google Scholar, 11Becker A. The orthodontic treatment of impacted teeth.3rd ed. Wiley-Blackwell, Oxford, United Kingdom2012Crossref Scopus (3) Google Scholar Other trauma-related clinical problems such as ankylosis and invasive cervical root resorption can cause unerupted teeth.11Becker A. The orthodontic treatment of impacted teeth.3rd ed. Wiley-Blackwell, Oxford, United Kingdom2012Crossref Scopus (3) Google Scholar, 12Becker A. Chaushu G. Chaushu S. Analysis of failure in the treatment of impacted maxillary canines.Am J Orthod Dentofacial Orthop. 2010; 137: 743-754Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 13Bedoya M.M. Park J.H. A review of the diagnosis and management of impacted maxillary canines.J Am Dent Assoc. 2009; 140: 1485-1493Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 14Becker A. Abramovitz I. Chaushu S. Failure of treatment of impacted canines associated with invasive cervical root resorption.Angle Orthod. 2013; 83: 870-876Crossref PubMed Scopus (18) Google Scholar Surgical exposure followed by orthodontic traction is the solution most widely adopted to save impacted dilacerated incisors, but dilacerated roots make the traction complicated and can lead to the need for multiple surgeries not only to enhance effective traction but also to improve gingival esthetics.15Vanarsdall R.L. Corn H. Soft-tissue management of labially positioned unerupted teeth.Am J Orthod. 1977; 72: 53-64Abstract Full Text PDF PubMed Scopus (104) Google Scholar, 16Vermette M.E. Kokich V.G. Kennedy D.B. Uncovering labially impacted teeth: apically positioned flap and closed-eruption techniques.Angle Orthod. 1995; 65: 23-32PubMed Google Scholar, 17Kajiyama K. Kai H. Esthetic management of an unerupted maxillary central incisor with a closed eruption technique.Am J Orthod Dentofacial Orthop. 2000; 118: 224-228Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar The prognosis of the treatment depends on the degree of dilaceration, the position of the tooth, and the root formation of the tooth. A dilacerated tooth with an obtuse inclination angle, a closer position to the alveolar crest, and incomplete root formation has a better prognosis for orthodontic traction.4Sun H. Wang Y. Sun C. Ye Q. Dai W. Wang X. et al.Root morphology and development of labial inversely impacted maxillary central incisors in the mixed dentition: a retrospective cone-beam computed tomography study.Am J Orthod Dentofacial Orthop. 2014; 146: 709-716Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 5Topouzelis N. Tsaousoglou P. Pisoka V. Zouloumis L. Dilaceration of maxillary central incisor: a literature review.Dent Traumatol. 2010; 26: 427-433Crossref PubMed Scopus (55) Google Scholar, 18Topouzelis N. Tsaousoglou P. Gofa A. Management of root dilaceration of an impacted maxillary central incisor following orthodontic treatment: an unusual therapeutic outcome.Dent Traumatol. 2010; 26: 521-526Crossref PubMed Scopus (12) Google Scholar We present 2 young girls with impacted maxillary central incisors and severely dilacerated roots. Patient 1 was a 7-year-old girl with the chief complaint of an impacted maxillary right central incisor. There was nothing relevant in her medical or dental history. She had an impacted maxillary right central incisor, which, along with the left central incisor, was tilted into the open space, and the dental midline of her maxillary arch was deviated by 2.5 mm to the right (Fig 1). Radiographs confirmed that the maxillary right central incisor was impacted with dilaceration on the root (Fig 2). The cone-beam computed tomography (CBCT) images taken for further evaluation showed that the crown of the maxillary right central incisor was just below the nasal floor in the premaxilla, with the palatal surface facing forward. Compared with the maxillary left central incisor, the root of the impacted incisor was short, and the apical third was dilacerated upward (Fig 3).Fig 2Patient 1: pretreatment lateral cephalogram, and periapical and panoramic radiographs.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3Patient 1: pretreatment CBCT images.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Several treatment options were considered. The first was to extract the impacted maxillary right central incisor to gain space for an implant and fixed prosthetics after the patient was fully grown. The second was to extract the impacted maxillary right central incisor and close the space using fixed orthodontic appliances. After space closure, the right lateral incisor and canine could be treated with prosthetic restorations. The third was to gain space for the maxillary right central incisor with an orthodontic appliance while forcing its eruption. Because the parents wished to bring the impacted tooth down rather than extracting it, the third treatment option was chosen. The patient and her parents were informed of the possibility of root resorption and perforation of the labial bone and therefore the subsequent need for canal treatment and apicoectomy.5Topouzelis N. Tsaousoglou P. Pisoka V. Zouloumis L. Dilaceration of maxillary central incisor: a literature review.Dent Traumatol. 2010; 26: 427-433Crossref PubMed Scopus (55) Google Scholar, 7Lin Y.T. Treatment of an impacted dilacerated maxillary central incisor.Am J Orthod Dentofacial Orthop. 1999; 115: 406-409Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 9Kolokithas G. Karakasis D. Orthodontic movement of dilacerated maxillary central incisor.Am J Orthod. 1979; 76: 310-315Abstract Full Text PDF PubMed Scopus (31) Google Scholar Orthodontic treatment using a fixed appliance was initiated to gain space for the maxillary right central incisor. After initial alignment with a 0.014-in nickel-titanium archwire, an 0.018-in stainless steel wire and a nickel-titanium open-coil spring were applied between the maxillary right deciduous canine and left central incisor. After 3 weeks, the impacted maxillary right central incisor was exposed under local anesthesia, and a button was bonded on the lingual surface for forced eruption. The traction of the maxillary right central incisor was started on the day of surgery with elastic thread that was replaced every 4 weeks. After 8 months of treatment, the maxillary right central incisor emerged into the oral cavity, making it possible to bond a bracket on the labial surface of the tooth. Forced eruption continued for 3 more months, but since the deciduous teeth were exfoliating, we decided to remove the appliance and wait (Fig 4). After 11 months of observation, all deciduous teeth were replaced by permanent teeth. Since the patient showed a skeletal Class II relationship with maxillary excess, cervical headgear was used to restrict maxillary growth and distalize the maxillary posterior teeth while at the same time correcting the dental Class II relationship. Seven months later, full fixed orthodontic treatment was started, but only in the maxillary arch because the mandibular arch was already well aligned. Brackets were bonded from the maxillary right second premolar to the left second premolar along with a 0.014-in nickel-titanium archwire. A month later, the teeth were aligned with an 0.018-in stainless steel wire; after 6 months, the archwire was changed to a 0.019 × 0.025-in titanium-molybdenum alloy to control the torque of the maxillary right central incisor. When the torque control was completed, debonding was done after detailing. A fixed retainer and a removable Hawley retainer in the maxillary arch were used for retention (Fig 5, Fig 6, Fig 7).Fig 6Patient 1: posttreatment intraoral photographs.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 7Patient 1: posttreatment lateral cephalogram, and periapical and panoramic radiographs.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The impacted maxillary right central incisor was successfully aligned by gaining additional space in the arch and tracting the tooth. The total treatment took 3 years 9 months, including the 11 months of observation in midprocess. Although there was some vertical discrepancy in the ginigival height between the right and left central incisors, gingivoplasty was not done because the patient and parents did not want any further surgery. The dilacerated root of the maxillary right central incisor was palpable in the mucosa, but there were no symptoms and the tooth was vital. The CBCT scans showed that the root tip was exposed outside the labial bone, but there was no root resorption (Fig 8). The results were still acceptable 15 months after retention (Fig 9, Fig 10).Fig 9Patient 1: intraoral photographs 15 months posttreatment.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 10Patient 1: 15-month posttreatment lateral cephalogram, and periapical and panoramic radiographs.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Patient 2 was an 8-year-old girl with the chief complaint of an unerupted central incisor. There was no specific medical or dental history, and she said that she had never experienced any trauma to her anterior teeth. Before her visit to our hospital, she went to a local dental clinic and was given a space maintainer. Her molar relationships were Class I on both sides with a 2-mm midline deviation to the right in the maxillary arch, but there was no tilting of the adjacent teeth. The panoramic view showed that the maxillary right central incisor was impacted with a dilacerated root. The CBCT scans showed that the crown of the maxillary right central incisor was just below the nasal floor, similar to the previous patient, with the palatal surface facing forward. The incisor root was short, and the apical third was dilacerated upward, adjacent to the cortical bone of the palatal vault (Fig 11, Fig 12).Fig 12Patient 2: pretreatment lateral cephalogram, CBCT image, and panoramic radiograph.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The treatment options were the same as those for patient 1. At first, the parents wanted to have the impacted tooth extracted and replaced with a dental implant, but it was not done. Three years later, they wished to have the tooth moved down and aligned. After rediagnosis, the third treatment option was done. The patient and her parents were informed of the possibility of root resorption and perforation of the labial bone (Fig 13, Fig 14).Fig 14Patient 2: 3 years after the initial visit, lateral cephalogram, CBCT image, and panoramic radiograph.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Fixed orthodontic treatment was initiated only in the maxillary arch because the mandibular arch was already well aligned. After a month of alignment with a 0.014-in nickel-titanium archwire, the wire was replaced by 0.018-in stainless steel. During the process, a nickel-titanium open-coil spring was applied to gain space for the maxillary right central incisor. Three weeks later, the impacted tooth was exposed under local anesthesia, and a button to move the tooth was bonded on the palatal surface. Traction was started using elastic thread that was replaced every 4 weeks. After 7 months, the button was removed from the maxillary right central incisor, and a bracket was bonded on the labial surface. To prevent hindrance to the eruption of the impacted central incisor, a 0.017 × 0.025-in stainless steel wire with a compensating bend was used. Two months later, the maxillary right central incisor was aligned by placing 0.014-in nickel-titanium archwire under the main wire to prevent distortion of the shape of the arch. Two months later, the alignment of the maxillary right central incisor was completed, and a 0.019 × 0.025-in titanium-molybdenum alloy wire was used to control the torque. When the torque control of the maxillary right central incisor was finished, debonding was done after detailing. A fixed retainer and a removable Hawley retainer were used for retention in the maxillary arch (Fig 15, Fig 16).Fig 16Patient 2: posttreatment intraoral photographs.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The impacted maxillary right central incisor was well aligned. The treatment period was15 months. The CBCT scans showed that the exposed part of the root was resorbed (Fig 17), and so the root was not palpable in the mucosa. However, the tooth was vital with no symptoms. The results were still acceptable 6 months after retention. Because impaction occurs only in young patients, any prosthodontic solution would be just temporary after the impacted incisor was extracted, and some sort of provisional treatment would be necessary until a permanent solution could be implemented when the patient is fully grown. In the meantime, there would be severe alveolar bone loss in the extraction site that would degrade the future implant site.19Chaushu S. Becker T. Becker A. Impacted central incisors: factors affecting prognosis and treatment duration.Am J Orthod Dentofacial Orthop. 2015; 147: 355-362Abstract Full Text Full Text PDF Scopus (32) Google Scholar For these reasons, the orthodontic-surgical solution was chosen for our young patients. Chaushu et al19Chaushu S. Becker T. Becker A. Impacted central incisors: factors affecting prognosis and treatment duration.Am J Orthod Dentofacial Orthop. 2015; 147: 355-362Abstract Full Text Full Text PDF Scopus (32) Google Scholar treated 64 impacted incisors with the orthodontic-surgical modality and reported that the overall success rate was 90.0%. Although the prognosis for orthodontic-surgical treatment of impacted incisors is good, it is not so good when the incisors have dilacerated roots. Treatment times were relatively long (up to 2 years) and were significantly affected by the initial height of the impacted tooth. Although the initial height of the impacted tooth in both of our patients was at the level of the apical third of the root of the adjacent erupted central incisor, the orthodontic-surgical treatments were successful. Maxillary incisors with dilacerated roots have long been a challenge to clinicians. Whereas dilaceration in either maxillary deciduous or permanent incisors is typically associated with dental trauma in a young person, causing pathosis from a deciduous predecessor or simply an abnormal position of the tooth germ, there was no evidence of traumatic injury to the dilacerated maxillary incisors of either patient.6Wasserstein A. Tzur B. Brezniak N. Incomplete canine transposition and maxillary central incisor impaction: a case report.Am J Orthod Dentofacial Orthop. 1997; 111: 635-639Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 7Lin Y.T. Treatment of an impacted dilacerated maxillary central incisor.Am J Orthod Dentofacial Orthop. 1999; 115: 406-409Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 8Smith D.M.H. Winter G.B. Root dilaceration of maxillary incisors.Br Dent J. 1981; 150: 125-127Crossref PubMed Scopus (40) Google Scholar, 9Kolokithas G. Karakasis D. Orthodontic movement of dilacerated maxillary central incisor.Am J Orthod. 1979; 76: 310-315Abstract Full Text PDF PubMed Scopus (31) Google Scholar, 10Betts A. Camilleri G.E. A review of 47 cases of unerupted maxillary incisors.Int J Paediatr Dent. 1999; 9: 285-292Crossref PubMed Scopus (36) Google Scholar, 11Becker A. The orthodontic treatment of impacted teeth.3rd ed. Wiley-Blackwell, Oxford, United Kingdom2012Crossref Scopus (3) Google Scholar Surgical management of an impacted tooth is considered the key to achieving desirable esthetic results. There are 3 common techniques for exposing unerupted teeth: window excision of soft tissues, an apically positioned flap, and a closed-eruption technique. The window approach might lead to gingival scarring or increase the clinical crown length.4Sun H. Wang Y. Sun C. Ye Q. Dai W. Wang X. et al.Root morphology and development of labial inversely impacted maxillary central incisors in the mixed dentition: a retrospective cone-beam computed tomography study.Am J Orthod Dentofacial Orthop. 2014; 146: 709-716Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar An apically positioned flap is usually used to preserve keratinized tissue, but it is not applicable for highly impacted cases.15Vanarsdall R.L. Corn H. Soft-tissue management of labially positioned unerupted teeth.Am J Orthod. 1977; 72: 53-64Abstract Full Text PDF PubMed Scopus (104) Google Scholar Becker et al20Becker A. Brin I. Ben-Bassat Y. Zilberman Y. Chaushu S. Closed-eruption surgical technique for impacted maxillary incisors: a postorthodontic periodontal evaluation.Am J Orthod Dentofacial Orthop. 2002; 122: 9-14Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar reported that overall good long-term esthetic results could be achieved by treating impacted maxillary incisors with a closed-eruption orthodontic-surgical technique. The closed-eruption technique with chain and elastic thread from the button on the impacted tooth to the main archwire was therefore adopted for our patients. In patient 1, the CBCT scans showed that the dilacerated root apex of her maxillary right central incisor had perforated the labial plate during the forced eruption and was palpable in the mucosa. We were able to move the impacted tooth in this case, but if it becomes impossible to align it properly because of dilacerations, the alternative strategy would be to perform endodontic therapy followed by an apicoectomy.21Uematsu S. Uematsu T. Furusawa K. Deguchi T. Kurihara S. Orthodontic treatment of an impacted dilacerated maxillary central incisor combined with surgical exposure and apicoectomy.Angle Orthod. 2004; 74: 132-136PubMed Google Scholar Fortunately, this was not necessary, and the patient had no discomfort, and tooth vitality was maintained after aligning, so the only follow-up needed was periodic monitoring. Interestingly, there was no significant root resorption in the dilacerated root after forced eruption with patient 1, whereas the dilacerated root showed severe root resorption compared with the adjacent teeth in patient 2. Therefore, early treatment is recommended to reduce dilaceration of the root and to facilitate future treatment. Although in a systematic review,22Weltman B. Vig K.W. Fields H.W. Shanker S. Kaizar E.E. Root resorption associated with orthodontic tooth movement: a systematic review.Am J Orthod Dentofacial Orthop. 2010; 137: 462-476Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar tooth morphology is not considered to be a causative factor for root resorption during orthodontic movement, Sameshima and Sinclair23Sameshima G.T. Sinclair P.M. Predicting and preventing root resorption: part I. Diagnostic factors.Am J Orthod Dentofacial Orthop. 2001; 119: 505-510Abstract Full Text Full Text PDF PubMed Scopus (234) Google Scholar reported that an abnormal root shape (pipette, pointed, or dilacerated) showed more root resorption during orthodontic movement. If the impacted teeth have dilacerated roots, it would be advisable to inform the patients of the possibility of root resorption because torque control can cause root resorption if the root apices come in contact with the labial plates. It has been suggested that the success rate when moving an impacted tooth with a dilacerated root depends on the degree of dilaceration, the position of the tooth, and the amount of root formation.4Sun H. Wang Y. Sun C. Ye Q. Dai W. Wang X. et al.Root morphology and development of labial inversely impacted maxillary central incisors in the mixed dentition: a retrospective cone-beam computed tomography study.Am J Orthod Dentofacial Orthop. 2014; 146: 709-716Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 5Topouzelis N. Tsaousoglou P. Pisoka V. Zouloumis L. Dilaceration of maxillary central incisor: a literature review.Dent Traumatol. 2010; 26: 427-433Crossref PubMed Scopus (55) Google Scholar, 18Topouzelis N. Tsaousoglou P. Gofa A. Management of root dilaceration of an impacted maxillary central incisor following orthodontic treatment: an unusual therapeutic outcome.Dent Traumatol. 2010; 26: 521-526Crossref PubMed Scopus (12) Google Scholar Our 2 patients had dilacerated roots with acute angles and superior upward positions, and root formation was completed in patient 2 at the start of treatment, so they probably were not the best candidates for the treatment options we selected. Despite these indicators for failure, the impacted maxillary central incisors were successfully aligned in both patients. Although aligning impacted incisors with dilacerated roots can be challenging, it can be done successfully by exposing the crown and moving the tooth with a light force. When the root is dilacerated, its apex can touch the cortical plate and cause root resorption during torque control. However, in some cases, the incisor is still vital even when the dilacerated part of the root is exposed out of the bone. We will continue with long-term monitoring of the dilacerated incisors, something that is essential is such cases.