When a tooth fails to erupt into the arch beyond its chronological age limit is said to be impacted. Impacted teeth do not erupt on its own; they should be brought into occlusion or extracted based on the underlying cause. Even though there are many reasons behind impactions, regularly impacted teeth are seen with insufficient arch length and space into which they erupt. Impaction of third molars, canine and premolars are more common in the maxillary arch whereas central and lateral incisors are seen rarely.\[[@ref1][@ref2]\]

Odontomas generally look like small, solitary or multiple radio-opaque lesions found on routine radiographic examinations.\[[@ref3]\] Odontomes may cause disturbances in the eruption of permanent teeth or retention of primary teeth, which leads to impaction of permanent teeth. Odontomes are associated with permanent teeth mostly and rarely seen with deciduous teeth.

Case Report {#sec1-1}
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An 18-year-male patient by name Vinith came with a complaint of generalized spacing in his upper front teeth.

On clinical examination, the case was diagnosed as Angles class I molar relation on class I skeletal base with retained deciduous lateral incisor 52, with missing right side lateral incisor and spacing in the upper anterior teeth and mild crowding in the lower teeth. Patient had no significant medical and dental history. The central incisor was drifted slightly toward unerupted lateral incisor and lack of space for the lateral incisor to erupt. On palpation, there were no signs of bulge either in the labial vestibule or on palatal vault.

On radiographic examination, odontome and retained deciduous tooth was seen along with horizontally impacted lateral incisor \[[Figure 1](#F1){ref-type="fig"}\]. The central incisor was shifted toward the right side and occupied half of the lateral incisor space. The crown of the lateral incisor was hitting the root of the central incisor. Same side lingual, opposite side buccal technique with two intraoral periapical radiographs confirmed the presence of impacted lateral incisor on the palatal side.

![Pretreatment osteoprotegerin and lateral cephalogram](JPBS-7-728-g001){#F1}

The treatment options available were extraction of impacted lateral incisor and going for a prosthetic implant by creating sufficient space for the implant placement and residual space closure with the help of fixed orthodontic treatment.

Second option was a fixed partial denture by closing the spaces in the upper front teeth, and the third option was to extract the deciduous tooth and bringing the impacted tooth into occlusion, but it is time-consuming. The patient was more interested in saving the tooth instead of going for artificial teeth.

The treatment plan was to bring the impacted lateral incisor into occlusion and close the spaces in the upper arch. Odontome and retained deciduous lateral incisor was surgically excised \[Figures [2](#F2){ref-type="fig"} and [3](#F3){ref-type="fig"}\].

![Pretreatment intra oral view](JPBS-7-728-g002){#F2}

![Smile and buccal view showing missing lateral incisor](JPBS-7-728-g003){#F3}

An McLaughlin, Bennett, Terevisi fixed appliance with 0.022 slot was bonded, 0.016 NiTi was used for initial leveling and aligning. The space was maintained for the impacted lateral incisor with the archwire sleeve. The central incisors were moved to the left side in order to prevent root resorption, as the lateral incisor was lying in closer proximity to the root of central incisor, and to regain the space for lateral incisor. Space closure was done on 0.19 × 0.25 stainless steel wire, and to provide stability for the adjacent tooth while bringing the impacted tooth into occlusion. Once the considerable amount of space obtained for the lateral incisor to bring into occlusion, under local anesthesia surgical exposure was done on palatal side \[[Figure 4](#F4){ref-type="fig"}\]. After elevation of the mucoperiosteal flap, an adequate amount of bone was removed by creating a channel for the tooth to come out with the help of rotary cutting instruments. A lingual button was bonded onto the palatal aspect of the lateral incisor. Ligature wire with bull eye holes were attached to the lingual button and tied to the main arch wire. Mucoperiosteal flap was closed and sutured.

![Surgical exposure of palatally placed impacted lateral incisor](JPBS-7-728-g004){#F4}

Once wound got healed, 0.012 NiTi wire was used as piggyback wire and engaged it to the ligature wire and tightly tied to the rigid stainless steel main archwire. As NiTi has shape memory effect, it started moving the tooth into occlusion, this was seen periodically through radiographs. We have increased the force slightly in further visits by increasing the dimension of the wire to 0.014 and 0.016 NiTi. Once the tooth was seen on the labial aspect, 0.016 × 0.22 TMA wire was used with a coil to bring the tooth into occlusion. Elastic chain was used simultaneously to move the tooth distally.

Once the tooth came closer, 0.016 NiTi was placed directly into the bracket of lateral incisor and brought it into occlusion \[[Figure 5](#F5){ref-type="fig"}\]. It took 18 months to bring the horizontally impacted lateral incisor into occlusion. A panoramic radiograph shows the dilacerated lateral incisor with uprighted teeth and with proper space closure \[[Figure 6](#F6){ref-type="fig"}\]. The stabilized teeth were retained with upper and lower fixed lingual retainer [Figure 5](#F5){ref-type="fig"}. Impacted lateral incisor into occlusion.

![Impacted lateral incisor into occlusion](JPBS-7-728-g005){#F5}

![Posttreatment osteoprotegerin and lateral cephalogram](JPBS-7-728-g006){#F6}

Discussion {#sec1-2}
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The patient wanted to retain the tooth instead of going for extraction and was very much cooperative throughout the treatment. The treatment was done on closed flap technique to control and reduce infection. The tooth was placed deep inside near the root apex of central incisor. The lingual button was bonded onto the palatal side of the impacted tooth because the labial side was facing towards the nasal floor. Many precautions were taken during bonding because the chances of debonding were high on the lingual aspect compared to the labial side, due to its irregular morphology. Lingual button was bonded on blood free field in order to prevent debonding. Controlled amount of force was applied carefully with the help of ligature wire in every visit to prevent from debonding. Stepwise bull eye loops were given and attached to the lingual button. As the tooth gets closer, the ligature wire was cut and the loop adjacent to the tooth was tied to the NiTi wire. The slow continuous force from the NiTi wire brought the tooth into occlusion. Complete space closure and a broad smile was achieved within a span of 18 months \[[Figure 7](#F7){ref-type="fig"}\].

![Posttreatment frontal and smile view](JPBS-7-728-g007){#F7}

Conclusion {#sec1-3}
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Impacted teeth can be treated easily in the mixed dentition with the periodic extraction of retained deciduous tooth. If the impacted tooth was in favorable position and time was not a constraint impacted tooth can be brought into normal occlusion with orthodontic tooth movement.

Financial support and sponsorship {#sec2-1}
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Nil.

Conflicts of interest {#sec2-2}
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There are no conflicts of interest.
