Orthodontic Case: Pediatric Low-Positioned Horizontally Inverted Impacted Tooth

This case report investigates the complex treatment of a horizontally inverted impacted maxillary central incisor (tooth 21) with an associated cyst in a 6-year-old male patient. The impacted tooth required sagittal rotation exceeding 90 degrees and extensive movement within the alveolar bone, posing significant clinical challenges. The treatment innovatively combined extraoral traction devices with fixed appliances, utilizing light-force mechanics (60–90g) to guide the tooth’s eruption in stages. Phase I involved cyst enucleation, laser-assisted gingival exposure, and closed traction with precise directional control to avoid adjacent root interference, while dynamically adjusting buccal traction vectors using extraoral devices. Phase II achieved arch alignment, resulting in thickened labial cortical bone, harmonious gingival contouring, and intact periodontal attachment. Three-dimensional radiographic monitoring and biomechanical modulation were emphasized to prevent bone loss and root resorption. Compared to traditional surgical fenestration, laser technology significantly reduced tissue trauma and promoted periodontal recovery. This case breaks through the limitations of conventional traction, demonstrating that high-angle impactions can be resolved through minimally invasive techniques combined with optimized anchorage to achieve both functional and aesthetic goals. It provides a reproducible clinical pathway for managing complex pediatric impactions, highlighting the importance of multidisciplinary strategies and early intervention.