Case presentation

Case 1

A 17-year-old female patient was referred from the Department of Orthodontics to the Department of Periodontology with a chief complaint of pain in the right maxillary posterior region. The patient reported discomfort during mastication, speech, and mouth movements. Clinical examination revealed erythematous and inflamed alveolar mucosa in relation to the maxillary right second premolar region (Figure 1, Panel A). The patient’s oral hygiene status was fair.

Figure 1: Management of a submerged orthodontic mini-implant.(A) Preoperative clinical view showing inflamed overgrown buccal mucosa. (B) Intraoral periapical radiograph showing the mini-implant without evidence of bony changes. (C) Surgical exposure of the submerged mini-implant after flap elevation. (D) Wound closure with 4-0 black silk sutures.

Dental history revealed placement of an orthodontic mini-implant (FORESTADENT Bernhard Förster GmbH, Pforzheim, Germany) in the same region three months earlier. An intraoral periapical radiograph confirmed the presence of a mini-implant adjacent to the root of the maxillary right second premolar (Figure 1, Panel B). Clinical and radiographic findings suggested soft-tissue overgrowth resulting in complete mucosal coverage of the mini-implant, leading to localized inflammation and pain.

Following informed consent, surgical exposure of the submerged mini-implant was performed under local anesthesia using 2% lignocaine hydrochloride with 1:80,000 adrenaline (Lignospan Special, Septodont, Saint-Maur-des-Fossés, France). A mucoperiosteal flap was raised using a No. 12 Bard-Parker blade (Western Surgical, Ahmedabad, Gujarat, India), exposing the embedded mini-implant (Figure 1, Panel C). Granulation tissue surrounding the implant was debrided, and the surgical site was irrigated with sterile saline. The flap was repositioned and secured using 4-0 silk sutures (Ethicon, Johnson & Johnson Private Limited, Mumbai, India) (Figure 1, Panel D).

Postoperatively, the patient was prescribed diclofenac sodium (50 mg) with serratiopeptidase (15 mg) every eight hours for three days, amoxicillin 500 mg three times daily for five days, and 0.2% chlorhexidine mouthwash (Hexidine, ICPA Health Products Ltd., Mumbai, India) twice daily.

At the 15-day follow-up visit, clinical examination demonstrated satisfactory healing with complete resolution of inflammation and symptoms (Figure 2). The patient reported no discomfort and was subsequently referred back to the Department of Orthodontics for continuation of orthodontic treatment.

Figure 2: Postoperative clinical view at 15 days showing satisfactory healing around the orthodontic mini-implant.

Case 2

A 22-year-old female patient was referred from the Department of Orthodontics to the Department of Periodontology for removal of a TPA. Intraoral examination revealed partial embedding of the U-shaped loop of the TPA (Round stainless steel wire; Metro Orthodontics, Hyderabad, Telangana, India) within the palatal mucosa (Figure 3, Panel A). Mild inflammation of the surrounding soft tissue was evident, and palpation confirmed the presence of the embedded loop beneath the mucosal surface.

Figure 3: Surgical retrieval of an embedded transpalatal arch.(A) Preoperative clinical view showing embedding of the U-shaped loop of the transpalatal arch within the palatal mucosa. (B) Incision made in the palatal mucosa to expose the embedded loop. (C) Retrieval of the embedded portion of the appliance using the blunt end of a periosteal elevator. (D) Removal of the transpalatal arch appliance following complete exposure.

Based on the clinical findings, surgical retrieval of the embedded TPA was planned. Written informed consent was obtained before the procedure. Local anesthesia was administered using 2% lignocaine hydrochloride with 1:80,000 adrenaline (Lignospan Special, Septodont, Saint-Maur-des-Fossés, France). A releasing incision was made around the margins of the embedded TPA loop using a No. 11 Bard-Parker blade (Western Surgical, Ahmedabad, Gujarat, India) (Figure 3, Panel B). The embedded segment of the appliance was carefully exposed and retrieved with minimal trauma to the surrounding tissues (Figure 3, Panel C).

Following exposure, the TPA was sectioned into two halves to facilitate atraumatic removal from the palatal tubes of the orthodontic bands (Ormco, Brea, California, USA) (Figure 3, Panel D). After complete removal of the appliance, the surgical site was irrigated with sterile saline, and hemostasis was achieved using gentle pressure with sterile gauze (Figure 4, Panel A). The wound was left to heal by secondary intention.

Figure 4: Postoperative views following removal of the embedded transpalatal arch.(A) Immediate postoperative clinical view. (B) Ten-day follow-up showing complete soft-tissue healing.

Postoperative instructions were provided, and the patient was prescribed diclofenac sodium (50 mg) combined with serratiopeptidase (15 mg) every eight hours for three days for pain and inflammation control. At the 10-day follow-up visit, uneventful healing with complete epithelialization of the surgical site was observed (Figure 4, Panel B). The patient reported no discomfort and was subsequently referred back to the Department of Orthodontics for treatment continuation.