Discussion
Evidence shows that complications occur
in approximately one-half of patients with mesiodens. These
complications may include delayed eruption of the adjacent permanent
teeth usually central incisors, persistent midline diastema, root
resorption of the adjacent teeth, cyst formation such as dentigerous
cyst even in the nasal cavity, eruption into the nasal cavity,
persistent rhinosinusitis, and pain [3, 7, 8]. Different types of
impactions and orientations of mesiodens require different surgical
access and approaches. Deeply impacted inverted mesiodens with palatal
position relative to the roots of the central incisors is traditionally
extracted via a palatal or vestibular approach that obviously needs
excessive bone removal, and is associated with high risk of injury to
the adjacent structures such as permanent teeth or their blood supply.
Nasal mucosal perforation, and more difficult extraction because of the
crown orientation, lack of a good grip for the elevator or forceps, and
poor visibility are other problems encountered in use of traditional
surgical approaches. The intraoral transnasal approach employed for our
case provides much better visibility and has fewer complications with
regard to traumatization of the adjacent structures [5, 9-11].
Another important point is to perform the surgical intervention at a
right time before the emergence of dental developmental problems or
malocclusion. Thus, most patients are younger than 12 years of age at
the time of surgical procedure. Also, the surgeon should ensure a
painless procedure and patient comfort. For this reason, most clinicians
prefer general anesthesia or deep sedation, which require
hospitalization and administration of anesthetic agents. This can cause
financial problems for the patients. Also, deep sedation may have some
adverse effects such as snoring, crying, vomiting, intravenous site
pain, and aspiration [6, 12]. Contrary to the reports that proposed
general anesthesia or had recommendations regarding sedation [9,
12], our experience showed that our suggested modified nasal approach
under local anesthesia created a painless and comfortable experience for
the patient. The most important issue here is detailed and thorough
evaluation of the position of mesiodens that leads to thoughtful
planning of the surgical approach and estimation of the required amount
of nasal floor deflection and the level of discomfort it may cause
during local anesthesia, which was made perfectly clear before surgery
in our study by using CBCT.
.