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.
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