# Eruption Treatment of Impacted Teeth Following Surgical Obstruction Removal
## 2 Treatment Methods and Patients  
The three treatment modalities are presented in the following cases:  
1. Surgery only This conservative approach includes passively waiting for spontaneous impacted tooth eruption following the surgical removal of the obstruction. This is indicated for young patients who have both favourable dental age and tooth position [10], i.e., when the impacted tooth still has the potential to erupt [22]. Figure 1 presents the case of an 8-year-old patient with a supernumerary tooth that blocked the normal eruption of the right permanent central incisor. Extraction of the supernumerary tooth was performed at the age of 7. Because of the central incisor's position and the stage of maturation, the decision was made to wait for spontaneous eruption with no active orthodontic traction. One year later, when the tooth failed to erupt spontaneously (Figure 1A), an orthodontic treatment was initiated, including space opening and repeated surgical exposure combined with orthodontic brace cementation and active traction. 2. Surgery with immediate traction This method of active orthodontic traction following the removal of an obstruction is usually advised when the root apex is almost or totally closed and the tooth is considered to have poor eruption potential [22; 23]. This approach benefits from early impacted tooth eruption, which reduces the psychological impact resulting from a long period of waiting for spontaneous eruption of a missing anterior tooth [24]. Figure 2A presents the case of an 11-year-old patient with a supernumerary tooth that prevented the eruption of the left permanent central incisor. The treatment plan included orthodontic space gaining followed by surgical extraction (Figure 2B) and immediate orthodontic traction of the impacted central incisor (Figure 2C). 3. Surgery with delayed traction This method includes bonding an orthodontic brace (button or eyelet) onto the impacted tooth during the surgical removal of the obstruction, and waiting for spontaneous eruption without applying active orthodontic force [25]. Figure 3 depicts a 7-year-old boy with an impaction of both permanent central maxillary incisors. A panoramic radiograph and a cone beam computer tomography analysis (CBCT) revealed an odontoma lesion, which blocked the left maxillary central incisor area, combined with a large cyst that developed between the right maxillary canine and the central incisor (Figure 3A). The conservative treatment approach included the extraction of the deciduous maxillary incisors and enucleation of the cyst and the odontoma (Figure 3B), followed by cementation of buttons with stainless steel twisted pigtail ligature wires on both central incisors (Figure 3C). The pigtail ligatures were rolled under the gingiva without applying active orthodontic force (Figure 3D). Figure 1: A supernumerary tooth localised at the position of an unerupted right permanent central incisor (tooth 11). (**A**) Eight-year-old boy, post supernumerary extraction (a year ago), demonstrating the failure of the spontaneous eruption of tooth 11. (**B**) Second surgery, including exposure of tooth 11. (**C**) Final result following 15 months of orthodontic traction. Figure 3: Impaction of both permanent central maxillary incisors. (**A**) Seven-year-old boy, intra-oral view validating deficient oral hygiene, carious primary dentition, and labial bone bulging above teeth 61-62 (arrow). Panoramic and CBCT illustrating the odontoma in the second quadrant. (**B**) Odontoma surgical exposure. (**C**) Exposure of the impacted teeth following removal of the odontogenic tumour mass. (**D**) Cementation of orthodontic buttons tied with ligatures. (**E**) Follow-up demonstrating an intra-oral view of the emerging process of the impacted teeth with the attachments (arrows). (**F**) Final location of the permanent incisors in the dental arch following their spontaneous eruption. Figure 2: Obstructive supernumerary tooth that prevented the eruption of the left permanent central incisor (tooth 21).