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Combined Surgical and Orthodontic Treatment of Impacted Maxillary Canines

Combined Surgical and Orthodontic Treatment of Impacted Maxillary Canines

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Wissam Marzouk, BDS, MSc, PhD*; K.M. Ragai ElMostehy, BDS, FDSRCS**; Abdullah Al-Qurashi, BDS, MS***

Positional variations of the maxillary cuspid are frequently encountered in dental practice. In such cases, because of its devious path to reach its position in the arch, it often gets impacted and becomes difficult to bring into occlusion. Both the orthodontist and surgeon should aim at early diagnose, schedule a plan, surgically expose the cuspid and use all acceptable orthodontic mechanics to bring it into occlusion. Sixty-six cases of unerupted maxillary canines were treated by two different surgical exposures and methods (window and open-closed flap techniques) and were orthodontically moved into occlusion. The etiology, diagnosis and evaluation of the impaction, as well as the possible orthomechanics used to arrange the canine's position, need a clear understanding to plan a final treatment. The findings of this study showed that buccally-impacted canines are more common and to reach occlusion more quickly than palatally-impacted canines. The axial inclination of the palatally impacted canines with the Frankfort horizontal plane has a direct effect upon the rapidity of treatment. The window surgical technique was found to be more convenient to the surgeon, orthodontist and patient.

The positional variations that the maxillary cuspid adopts are frequently encountered in orthodontic practice. While bringing the unerupted maxillary canine into the dental arch could be difficult, the therapist's diagnostic and treatment plan should be in the best interest of the patient. Incidence of impaction of the maxillary canine rank second 1 2 to that of third molar impaction. ' In any orthodontic practice the anticipation of problems related to maxillary canine impaction should be kept in consideration by early diagnosis. Early referral to the proper specialist is mandatory where

certain interceptive measures could be instituted so as to diminish further
4 5






resorption ' or cystic degeneration . In reviewing the etiological factors that lead to maxillary canine impaction, it is generally accepted that the devious path it follows during its eruption and the long period of its development play a great role in its impaction. ' Although crowding has been implicated, this factor has been neglected by several authors. Among other causes of canine impaction is heredity where several members of the same family are affected. Cystic degeneration around unerupted canines might cause their impaction.
10 14 3 27

Received 16/01/96; revised 06/08/96 and 29/11/96, accepted 18/12/96 * Consultant Orthodontist, Dental Department, King Fahd National Guard Hospital ** Professor of Periodontics & Consultant, Dental Department, King Fahd National Guard Hospital *** Oral & Maxillofacial Surgeon and Consultant, King Fahd National Guard Hospital, Jeddah, Saudi Arabia Address reprint requests to : Dr. A. Al-Qurashi

Bishara and Isiekwe et al listed the most common cause that participate in maxillary canine impaction such as tooth-size, arch length discrepancy, prolonged retention or early loss of deciduous canines, ankylosis of the developping canine, presence of alveolar clefts, root dilaceration of the develoipng canine, cystic degeneration of the enamel organ of


The Saudi Dental Journal, Volume 9 Number 2, May - August 1997.

radiographically and cephalometrically evaluated and findings were documented. which some authors consider superior to cephalostats in locating the impacted canine.August 1997. Not all the patients came for orthodontic treatment but have been referred for other dental problems. scaling and oral hygiene instructions and extractions of premolars for the first group. Moreover. Patients were clinically. is the parallax technique.2]. 3]. the cross-sectional occlusal radiographs as well as cephalostat technique yielded the best localization of impacted canine. Another method used. May . Their ages ranged from 13 to 19 years. Hence. The Saudi Dental Journal.SURGICAL AND ORTHODONTIC TREATMENT the canine during its eruption. Two or more periapical radiographs were taken in the same area. 1. 91 Clinical photographs were taken and study models were made on each patient. the patients were divided orthodontically into two groups. Once the line of etreatment was reached. All impacted maxillary canines were accidentally discovered through the routine clinical and radiographic investigations. Patients space establishment were referred to have restorations. the palatally impacted canines were traced and the angle formed by its long axis and Frankfort horizontal plane was measured in an attempt to find a relation between the axial inclination of the impacted canine and the period it would take to descend to occlusion [Figs. The position of the impacted canine was determined by either palpation or location on lateral cephalometric as well as intraoral occlusal radiogprahs [Figs. The lateral cephalometric radiographs were traced and the skeletal and dental cephalometric angles were measured to decide whether a case would require extraction mechanics or not. shifting the tube horizontally between exposures. The patients were scheduled for bracketing and bonding to start the active orthodontic tooth movement. In this investigation. Volume 9 Number 2. upper and lower alginate impressions were taken and poured in stone to serve as primary and study models for each use. Kingdom of Saudi Arabia. This study was to review the causes of maxillary canine impaction and to present 66 cases treated surgically by two different surgical approaches and orthodontically moved into their respective positions in the arch. Jeddah. iatrogenic etiology and idiopathic maxillary canine impaction. such cases were referred to the Orthodontic Unit for further investigations and treatment. . To complete orthodontic records. The first group was the extraction cases for which the maxillary first premolars were to be extracted and the second group were the non-extraction cases for which repositioning of the impacted canines was the only procedure performed after its surgical exposure. The brackets were Materials and Methods This study comprises 66 patients who sought dental treatment in King Fahd General Hospital Dental Department.

0. Volume 9 Number 2. a ligature wire was tied to it and twisted to form a long pig tail tie with an eyelet at its free end [Fig. A cervical face bow was used over the first molar until enough space was created bilaterally [Fig. A round 0. The created flap was raised by blunt dissection to expose the tooth around its great circumference and to expose as much of the clinical crown as possible just short of the amelo-cemental junction. In the case with bilateral canine impaction. The first method was the open-closed flap technique and the second was the Window technique. the cervical round tube for extra-oral force application if required and the other rectangular tube for the arch wire. Bonding the orthodontic brackets was done during surgery after drying the exposed tooth surface from blood as best as possible.018" stainless steel wire was then placed with first order bend to complete alignment. Before bonding the bracket. This extension was to dangle down into the oral cavity through the flap that is replaced to cover the tooth with its bracket bonded to its crown [Fig. Osseous surgery was done with Ochschenbein chisels so as to avoid any heat production from rotating instruments. a flap was raised and the crown of the unerupted canine was exposed and surgical osteotomy was performed around the greatest circumference of the tooth taking in consideration not to expose the amelo-cemental junction. . Surgical Procedure Surgical exposure of the impacted canine was done in either of two ways without any criteria of selection. A semilunar incision was performed along the tip of the located cusp and extended for 0.018"x0.b.92 standard stainless steel Edgewise brackets with 0. Finally. 6].c.August 1997. In cases of Class I subdivision malocclusion where there was a unilateral mesial shift of posterior teeth. The bands used were double tubed bands. Treatment for both groups was started by aligning and levelling the teeth by nickle titanium arch wires starting by round 0. the tooth was pulled to its destined position in the arch. Class II elastics (1/4" medium pull) were used on that side over the maxillary first premolar and mandibular first molar with a lower lingual arch for maximum anchorage. MARZOUK ET AL First Group : In 33 cases. the patients were ready for surgical interference.5 cm on both sides of the tooth [Figs.014" followed by 0. an elastic chain over a rectangular 0. 5]. This was to allow viewing the position of the embedded crown. A graduated periodontal probe was used to perforate the anaesthetized oral mucosa to give a general idea as to the position of the unerupted canine for determing the line of The Saudi Dental Journal. In the first group (extraction cases). incision. spaces were created for the impacted canines. 4a. In the second group (non-extraction). 7a.022" stainless steel wire and/or push coil between lateral incisor and first premolar was used until a suitable space was created. Second Group : This group comprised 33 patients. May . the patients were scheduled for surgical exposure of the canines by either procedure mentioned below.016" then by 0.18". The bracket was then bonded according to the accessibility obtained.c]. In those instances where there was retained deciduous canines and some spaces between teeth. there was absolutely no space for ethem and the molars were in Class II malocclusion. At times the teeth were so irregular that to commence treatment.022" slot.b.012" round nickle titanium wire was used. By emeans of this wire.].

Periodontal pack was applied to burrow itself under and around the window and left for one week [Figs. This would allow a proper co-aptation of the dentogingival interface and secure a knife-like pattern of marginal gingiva. Thirty-six (54. none came seeking treatment for the impacted canine as all patients were not aware of the presence of any abnormality. adjusting the position of the brackets was done by rebonding. Accidental discovery of the impaction was through routine screening in the Dental Department. To commence active orthodontic movement. Finally.018" and 0.016".5%) cases had the canines bucally situated while thirty (45.018"x 0. The edges of the flap have been bluntly undermined and then The Saudi Dental Journal. .5%) were palatally impacted.g]. was ligated to the brackets. 0. Forty cases (60. 0.6%) showed retained deciduous canines. As a prominent clinical finding. Intraoral examination revealed that 65 cases were unilaterally impacted while bilateral impaction was present in only one case.SURGICAL AND ORTHODONTIC TREATMENT 93 sutured all around the window with any soft tissue immediately surrounding the crown.022" rectangular stainless steel arch wire with a hellicle between the lateral incisor and the tooth distal to the created space. 7e. It should be noted that. approximately. The time required to have the impacted canine come actually into the oral cavity was recorded for each case taking the time of commencement of force applicatioon as a zero hour. Volume 9 Number 2.018"x0.022" nickle titanium wires as deemed necessary. a 0. May . it was ascertained that the crown surface was totally dry of any fluid. there was a bulge of the mucosa either labial or palatal that determined the position of the Osseous surgery was done in a way that did not leave any bulbous or bony projections that could hinder the path of canine eruption. Results Of the 66 cases treated in this study. Teeth on either side of the canine space were ligated together by stainless steel ligature wire to secure anchorage and to prevent any loss of the created space. At the time of bonding brackets after one week. By means of the elastic threads that were tied to the hellicle in the arch wire and to the stainless steel extension in the first method or the brackets in the second method.August 1997.014". 2 mm of bone was left coronal to the amelo-cemental junction. Once the crown was fully exposed into the oral cavity.f. the canine was positioned in the dental arch by using 0. gradual pulling forces were achieved until the canine reached a convenient position.

August 1997. . May . Volume 9 Number 2.94 MARZOUK ET AL The Saudi Dental Journal.

while one case showed loosening of the bracket twice. . Although this was not a common finding. 10 cases showed loosening of the bonded brackets under the flap once.August 1997. May . Re-entry surgeries were performed in those 11 cases to rebond the brackets. Volume 9 Number 2. more often than not. it was. The Saudi Dental Journal. The bucally impacted canines reached occlusion at a faster rate than the palatally presenting as indicated in Tables 1.SURGICAL AND ORTHODONTIC TREATMENT 95 impaction. A significant difference in the treatment time was noticed in the bucally impacted canines compared to those presenting palatally in both surgical procedures. In those cases which could not be detected by palpation or by the presence of a bulge. lateral cephalometrics helped in locating the impacted canine [Fig. 3 and 4 treated by either the Window or the Open-closed method. accurately determined radiographically. 1]. Intraoral occlusal films were merely confirmatory to the cephalometrics. 2. Out of the 33 cases treated by the open-closed flap.

9 0. for 12 cases with an angle ranging from 95 to 110. the teeth reached occlusion in nine months of treatment.D. of Cases 7 6 5 Time to Reach Occlusion 3 months 4 months 5 months No. Seven cases with angles ranging from 120 to 135 reached occlusion after 10 months irrespective of the surgical technique used to expose them. Time required for maxillary impacted canines to reach occlusion (both bucally and palatally impacted) in the open-clos flap technique. Distribution of mean time to reach occlusion in months for bucally and labially impacted canines in the window technique.99. Buccally Impacted Time Range Mean S. It was shown that the more acute the angle was.August 1997. Buccally Impacted Time Range Mean S. of Cases 4 5 6 3 Time to Reach Occlusion 3 4 5 6 months months months months No.1 0. In 11 cases with angles ranging between 110 and 120.78 Palatally Impacted (N = 15) 8-11 months 9. T= (N = 8) 3-6 months 4. T= (N = 8) 3 . of Cases 7 7 1 Palatally Impacted Time to Reach Occlusion 8 months 9 months 10 months Table 4. the longer the period taken by the impacted canine to reach occlusion. No. Buccally Impacted No. Both types SD = Standard Deviation P < 0.05 There is a significant difference Table 3.96 MARZOUK ET AL Table 1. Angles formed by the long axis of impacted canines and the Frankfort horizontal plane. Fifteen palatally impacted cuspids reached occlusion during a period of 8-11 months with a mean time distribution of mean time of 9.1.120 120.9 months with a SD = +0. the faster the impacted canine reached occlusion and the more obtuse the angle was. Thus. Buccally Impacted No. Both types of impactions were surgically exposed by the open-closed flap techniques. The complexity of diagnosis and treatment plan using taxes the orthodntist's and . Volume 9 Number 2. Tables 3 and 4 indicate that 18 cases of bucally impacted cuspids erupted and reached occlusion during a period of 3-5 months with a distribution mean time of 3.1 months = 0.D. It was also found that four of the cases treated by the Window technique showed active tooth eruption without any ortho-mechanics applied.46 Palatally Impacted (N = 15) 8.63 Table 5. Table 5 illustrates the effect of angulation of the long axis of palatally impacted canines with Frankfort horizontal plane on the time taken by the impacted canine to arrive to occlusion. of Cases 12 11 7 Range of Angle 95.05 There is a significant difference of impactions were surgically exposed by the Window technique.110 110. May .6 0.4 months +1. Time required for maxillary impacted canines to reach occlusion (both bucally and palatally impacted) in the window technique. P < 0. the time of The Saudi Dental Journal.10 months 8. Distribution of mean time to reach occlusion in months for bucally and labially impacted canines in open-close flap technique.63.and 2 show that 18 cases of bucally impacted maxillary canines reached occlusion during a period ranging from 3-6 months with a mean time distribution of 4.8 while 15 palatally impacted canines reached occlusion within a period of 8-10 months with a SD = +0.8 T = 18.4 1.135 Treatment Time 8 months 9 months 10 months treatment was 8 months. Discussion Impaction of the maxillary canine is a problem frequently encountered in orthodontic practice. of Cases 5 4 5 1 Palatally Impacted Time to Reach Occlusion 8 9 10 11 months months months months Table 2. as depicted from this table.1 T = 12.99 Tables 1.5 months 3.

This does not coincides with the findings of Fergusson who concluded that displacement from normal path of eruption most commonly occurs in a palatal direction. there are several modalities in treating impacted maxillary canines dictated by several parameters. which in itself is traumatic both to the patient and the gingival tissues. The extrusion of a peg-tail extention from under the raised flap in the open-closed technique method was reported by several patients in this study to be very irritating. Dent Pract Dent Rec 1972. Fergusson JW. did not gain acceptance. Comparing the two surgical techniques of exposing the impacted maxillary canine. The impactions reported in this study were discovered accidentally in patients who came for other dental consultations. Brin et al and Jacoby" Surgical management of impacted canine for orthodontic mechanics has been a subject of controversy. On the other hand. ' 2 12 Proponents of the open-closed technique concluded that the risk of attachment loss is reduced if a flap is raised and then replaced over the exposed crown of the impacted canine after attaching a suitable means with which traction of the impacted canine is applied. This is in agreement with the findings of Moss . Richardson and McKay 4 8 3 questioned the validity of this concept as applied to many maxillary displaced canines. congenitally missing laterals and retained deciduous canines..22:241-48. Anterior segment crowding has been considered as a cause in maxillary canine impaction yet some cases presented in this report showed the presence of enough spaces to accommodate normal eruption of the impacted tooth to its destined position. 3. 1. Observation on the misplaced upper canine. References Bass TP. 1213 In this study. Fearne et al correlated impaction of maxillary canine and cystic formation around the unerupted canine. 5. 7. Although heredity has been implicated as a cause in maxillary canine impaction yet. The available spaces resulted from the presence of peg-shaped laterals. Indeed. May . . the following conclusions are drawn : 1. only one patient exhibited a cystic formation around an impacted canine. The suturing procedure adopted in the Window technique allowed the soft tissues to heal in a knife-like edge with the tooth surface resulting in proper co-aptation of the marginal gingiva of the finally erupted tooth. a third surgical re-entry procedure should be performed to re-bond a loose bracket. Part II. Br Dent J 1990. the orthodontist as well as to the patient himself. the angle existing between the long axis of the impacted canine and Frankfort horizontal plane could affect the period taken by the impacted maxillary canine to reach occlusion irrespective of the technique performed to expose it.169:11-17. the Window technique gave better clinical results when compared to the open-closed technique for several reasons. Volume 9 Number 2. 2.13:13-23. Delayed eruption of maxillary canine teeth. no familial background has been detected. Treatment. 3. Moss JP. 4. Finally. 6. It should be added in this respect that the Window technique allowed the impacted canine to reach its destined position at a The Saudi Dental Journal. performed by several authors. Dent Pract Dent Rec 1976. Management of unerupted maxillary canine. Impaction of the maxillary canine was found to be more common buccally than palatally.August 1997. It was found indeed that such a procedure is more convenient to the surgeon. at times. in the present study. ' 3 6 2 10 3 9 4 Conclusion Based on the results of this study. Proc Br Pedodont Soc 1983. surgeon's intelligence. A significant difference was found between bucally and palatally treatment 4. impacted time. it was found that the most favorable angle is from 95 to 100 degrees. Orton et al asserted that most ectopic canines are palatally impacted. In this respect.18:25-33. McKay C. Bonding of the impacted exposed canine could be easily performed in "open air" after controlling the fluid contamination of the tooth surface if it is bonded during surgery. In the cases presented in this report. The angulation of the palatally impacted canine in relation to Frankfort horizontal plane had a direct effect on the period of treatment taken by the orthodontically moving canine to reach occlusion. In this report. Greater number of cases should be treated by the Window technique in future studies to validate our conclusion that the Window technique was superior to the Open-closed flap technique. The Window technique. rather than moving the hidden canine under a flap which is indeed unpredictable. maxillary canines in terms of Bucally impacted canines reached occlusion faster than palatally impacted canines. the Window technique was more advantageous than the Open-closed flap technique in our hands and more promising in bringing the tooth into occlusion. Another advantage of the Window technique is that it enables the orthodontist to observe all professional tooth movements during the treatment period. A second and. Also. Richardson A. 2. crowding could not be a major factor in maxillary canine impaction.SURGICAL AND ORTHODONTIC TREATMENT 97 faster rate than impacted canines exposed by the open-closed technique. The unerupted canine. Opponents to this technique advocated that removal of a tissue from an impacted canine might result in a "pathological" dento-gingival junction of the finally erupted tooth. The devious path and the late development of the maxillary canine seemed to be the most acceptable cause of its impaction. The results obtained from this study showed that labial maxillary canine impaction is more common than palatal impaction.

Br J Orthodont 1988. 8.34:53-57. Odontol Scan 1976. Position of the maxillar Odontostomatol Trop 1987. Am J Orthod Dentofac Orthop 1938.154:294-96. Treatment of the unerupted maxillary canine. orthodontic Acta correction of Orthod Dentofac Orthop 1992. 15: 93.12:189-92. Fearne severely J. Orton HS.84:159-71. Bishara SE. Extrusion of the ectopic maxillary canine using a lower removable appliance. Brim I. Jacoby H. . 13.84:125-32. Boe OE. Isiekwe MC. The upper cuspid. displaced associated follicular disturbance. Impacted maxillary canine: A review. Am J Orthod Dentofac Orthop 1995. The Saudi Dental Journal. 9. Gravey MT. Lee RT. Br J Orthod 1985. Nwoku AL. Comparison of two surgical methods impacted in combined maxillary surgical canines.10:17-20. Shalhay M. 7. MARZOUK ET AL y permanent canine in relation to anomalies or missing lateral incisor. Hunter SB. when Maintaining eexposing an and ideal tooth an relationship aligning impacted tooth. Its development and impaction. May .98 5. 10. Wisth PJ. Eur J Orthod 1986. Becker A. Pearson MH. Dewel BF. Favorable maxillary spontaneous canines with eruption of 14. Preliminary consideration and surgical methods. 12.19:79-90. Surgery as an adjunct in the orthodontic management of impacted maxillary canine.8:245-55. Nodeval K. 6.August 1997. Am J 11. Wong-Lee gingiva TK. Wong FCK. Angle Orthodont 1949. Br Dent J 1983.98. The etiology of maxillary canine impaction. Volume 9 Number 2. A population study.107:349-59.

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