1

* Second Midterm Exam *

Management of Impacted Teeth

Musab Abed
Saleh Mutlaq
14 - 12 - 2015
 ..Management of Impacted teeth other than 3rd molars..
 Un-erupted Vs. Impacted..
.We should know the difference between Un-erupted V.SImpacted, when we call it impacted or un-
erupted?
.When the time of eruption has been reached and the tooth didnot erupt because there is something
impeding the process of eruption,then we call itimpacted. But if the tooth is still forming and non-
eruptedyet, then it'scalled un-erupted.
 Impacted tooth is a tooth that cannot, or will not, erupt into its normal functional
position by bone, tooth, or fibrous tissue…
 Most common impactions are:Lower 3rdmolars, Upper 3rdmolars, maxillary canines,
mandibular second premolars..
 Other teeth are less common as: upper central incisor, upper premolars, lower
canine, lower molars ..
 Supernumerary tooth might get impacted (like:Mesodens)..

..Impacted canines..
.The most common impacted tooth after wisdoms
.The general principles that is applied in impacted canines, can be applied to other impacted teeth
 Chronology of canine eruption
 Maxilla: 11-12 years. (the Dr. said it is from 11-13 years)
(Should be palpable in the buccal sulcus by 10 years old(canine bulge))
 Mandible: 9-10 year.

1
  Incidence
 Most commonly impacted tooth after
Maxillary and mandibular third molar.
 2% (so it is a high percentage)
 3:1 (palatal : labial)
 4: 1 (Unilateral : Bilateral )
 Female: Male (70% : 30% )
 Maxillary impactions are 20X more common than mandibular

 Etiology
.Why upper canines have high incidence of impaction?
1) Long Path of Eruption
 Canine germ is found very high up around the infraorbital foramen then starts
movingfrom the orbit to the alveolus.

2) Sequence of Eruption
 Lateral incisors and 1st premolars erupt before canines, so it’s the last tooth to erupt
in the anterior zone.
3) Space Deficiency
.Premature loss of the deciduous canine >>> no space left >>>the canine will be impacted.
4) Missing, Small or Anomalous Lateral Incisors (Guidance Theory)
.The crown of upper canine has an intimate relationship with the
distal aspect of the root of lateral incisor so there is theory said
"The lateral incisor especially the superiolateralsurfaceguides the
eruption of upper canine into itsnormalplace" .
.The crown of upper canine must lay over the distal surface of
lateralincisor , So if there is missing, small or anomalous lateral
incisors , we will loosethe guidance and the canine will be impacted ,
mainlypalatal.

2
 The ugly duckling stage
.When you do clinical examination and see the flaring of crowns, this will give you a hint about
the location of impaction
.If the canine is impacted buccally , the crown of lateral and central incisors will flare buccally ,
and visaversa . Why? Because of the effect of canine on lateral incisor (Guidance theory).

 If the impaction come from space deficiency , the canine will be impacted
buccally
 If the impaction come from a problem in lateral incisor , the canine will be
impacted palatally

5) Thick Palatal Mucosa

.In which the tooth cannot penetrate it
6) Retained Cs
.The cause is mostly ankyloses , which impedes
thepermenant canine from eruption .
7) Supernumerary Teeth
8) Cysts and tumors
.Like dentigerous cyst or ameloblastoma

3
9) Trauma (it will causeDilecerationof the root, so there will failure of eruption)
10) Systemic Conditions:
a. Endocrine Deficiencies
(Hypothyroidism – Hypopituitarism)
b. Febrile Disease
11) Syndromes
a. Cleidocranial Dysplasia
b.Gardner’s Syndrome (multiple impactions)
c. Down Syndrome
12) CLAP..(Cleft Lip And Palate)
.Because the cleft will be between premaxilla and maxilla , and it is the area of lateral incisor and canine !
so they are susceptible to impaction or ectopic eruption .

 CLINICAL ASSESMENT :
 No signs of maxillary canines by the age of 12
 Presence of retained deciduous canines
 Symmetry :(the most important thing in clinical assessment)
Compare left side to right side, if more than 6 months then take further
investigations.
.If a child come to you with right canine erupted and left canine is not erupted , ishould monitorfor 6
months , after that if no spontaneous eruption happen , then i should intervene , take X-rays to see if it is
impactedor missing or something impeding its eruption ... This rule is applied to ALL teeth .
 Palpate Alveolus (bulge present 1 year before eruption)
.Remember: the bulge of canine must be palpated buccallyat age of 10
.If the canine is impacted palatally, you can feel the bulge palatally, so sometimes you can know the
location of canine from clinical examination alone.
 Angulation of adjacent teeth.
.If the lateralincisor angulatedpalatally ..the canine is impacted palataly
.If the lateral incisor angulated buccally ..the canine is impacted buccally
 Space Availability
.You should see if there is space or not, or this space is enough or not
 Color of adjacent tooth
 Pressure on the roots of adjacent teethmight cause root resorptionso there will beloss of
vitality (become necrotic)and change in color (become grayish or darker)!!
 Also we should asses the restorability and mobility of the lateral incisors, if it is indicated for
extraction, we have to tract the canine in order to close the space.

4
  Radiographic Assessment
 Plain Radiographs:P.A, Occlusal,OPG..
 Parallax Technique (Tube shift) Occl
 CT scan or CBCT … usal

OPG P.A CBCT

 Radiographic findings:
 Presence or absence of 3s
 Shape and position of 3, angulation ,root configuration
 Condition of adjacent structures
 Resorption of lateral,central..
 Restorability of adjacent teeth
 Presence of supernumerary or odontome
 Presence of pathology or cyst..

We will talk now about Parallax technique (Tube shift):

 Getting two radiographic views with cone shiftto localize the impacted canine if it’s buccal
or lingual /palatal by Parallax Technique ((TubeShift)).
 (SLOB :same lingual opposite buccal)
 Two radiographs with cone shift :
 2 P.As orOPG+P.A orOPG+Occlusal
 Either it isHorizontal tube shift (mesial/distal)or vertical parallax(up/down).

5
.This is an example of Horizontal parallax:
Fig.2a: conventional P.A
Fig.2b: P.A with distal shift
.The impacted canine is palatal because whenwe move the tube distally,the tooth movesdistally also
(apply the SLOB rule).

.This is an example of vertical parallax:

OPG and Occlusal radiographs
.The two impacted canine in theseradiographs are impacted palatallybecausewhen we take occlusal
radiograph wemove the tube upwards , and thetwo canines moves upwards also (towards the apical
3rd of the centrals) .

 Management :
1) Ortho. Consultation (always it is advisable to consult with the orthodontist to formulate the
treatment plan)
2) No treatment (leave in situ and follow up)
 C (deciduous canine)in good position, shape, and good contacts
 According to the patient’s concern, expectations and attitude.
 Review with radiographs every 6 months.

6
  Inform the patient that the tooth in bone might cause problems(cysts).
3) Interceptive treatment
.If a10-13 years old patient came to you for regular check-up , you
examine him and see that there is no canine bulge(and you know that
canine bulge should be palpated at age of 10) , then you should take
anOPG, if the permanent canine is in proper angulation , then you just
have to extract the C , this is called interceptive orthodontic treatment ,
it's simple treatment and more than 91% of impacted canine will erupt
in normal position if the crown on OPG is not crossing the midline of
lateral incisor , but if it is crossing the midline of the lateral , the
percentage of eruptions in normal position will be 2/3 (64%)

4) Extraction of the impacted canine

 If associated pathology with the canine i.e cyst
 Good contact between the lateral incisor and the first premolar.
 Orthodontic decision of canine extraction: if good prognosis of lateral incisor,
or closure of the space intended.
 (Ortho. Tx. either open the space ore close it !)
 If space closed  reshaping of bicuspid into cuspid.
 If space opened  Implant Vs FPD.

The Procedure :
 Labial flap Or Palatal flap Or Combined..
 Anasthesia..
 Incision..
 Flap reflection..

7
 Ex.1 : Labial Impaction

.So you will make the flap and reflect it , this a two-releasing flap

.Then you will remove the bone by the bur

8
.Then you will do crown sectioning and removing the tooth .

Ex.2 :Palatal impaction

9
Then you will do
 Irrigation
 Suturing…

10
 5) Surgical Exposure of the canine
 With/out orthodontic traction
.So sometimes the orthodontist decision will be
expose and leave OR expose and tract
 Labial Vs. Palatal
 Open Vs. Closed
 Exposure& packing Vs. Traction

 Open technique (Window)

.See how we open the flap , remove the bone ,place a gold chain or bracket on the canine ,
make a window in the palatal mucosa , so we can see the canine and the gold chain after
closing the flap

.At the end , it will look like this :

11
  Closed technique
.See how we open the flap , remove the bone ,place a gold chain or bracket on the canine ,
then we close the flap ! so we will pull the canine from under the flap .

.When to do the closed technique and When to do the open technique ?

.If the canine is very high , the surgeons prefers to do the closed technique
.The decision is based on the surgeon, orthodontist and the patient’s situation

.These two pictures demonstrates the Tractionby Goldchain

12
.This is an example ofclosed technique ,but in thelabial aspect :

13
.In the labialexposure, when we open a window in the labial aspect, we might harm all the attached
gingiva! So recession will occur. That’s why there is something called apically repositioned flap. We
make it apically so it will go down as the tooth erupts and it is more esthetic. See the pictures:

E.x: This patient came with missing central incisor , we waited it

for 6 months to see if it will erupt spontaneously , but it doesn’t ,
so we took an OPG , and we saw a small odontome impeding the
tooth from eruption , so what is the procedure now ?

14
.The same thing:anesthesia,flap, removing the odontome, removing the bone all over the crown, attach a
bracket and we close it back.
.This is a closed technique for traction, because we close the flap and not see the tooth anymore, we will
pull the it from under the flap.

6) Auto-transplantation :
.We do it for:
 mature patients older than 17 years
 patient unwilling to have lengthy orthodontic treatment
.We do it when:
 available space
 tooth can be extracted intact with minimal damage to its PDL

15
  The Procedure
.Some patients have impacted canine and retained C , so we will do the following :
 reflect a flap
 extract the tooth and store in blood, or HBS (to keep the tooth vital)
 create socket surgically (C- extraction socket)
 insert tooth into the socket
 Make sure tooth is out of occlusion
 splint for 2-6weeks
 root filling only if pathological changes occur (not in the first 2-6weeks)

 Prognosis
.Auto-Transplantationmay lead to ankylosis or replacement resorption and the prognosis isnot good!
So we should discuss with the patient the possibilityof dental implant which is a better optionwith very
good prognosis.

Test Your-self
.We have an OPG, then we are taking occlusal x- .If a maxillary canine is impacted it is present
ray for bilateral maxillary impacted canines. the palatally in:
right one appear higher compared to root apex of
central, the left one appear lower compared to root <C>0.5% of the cases
apex of central. which one is true?
<C+>85% of the cases
<C+>right is palatally impacted, left is buccally <C>50% of the cases
impacted
<C>15% of the cases
<C>right is buccally impacted, left is palatally
impacted <C>35% of the cases

<C>both are palatally impacted

<C>both are buccally impacted

<C>we need periapical radiograph to determine it

16
.Buccally impacted canines:
<C>are commoner than palatally impacted
canines
<C+>exposed using an apically repositioned flap
<C>occur as a result group function occlusion on
the epsilateral side
<C>the first and third answer
<C>all of the above
.One of the following statements is correct:
<C>All impacted teeth are considered totally
unerupted
<C>All unerupted teeth are considered impacted
<C+>An unerupted tooth may or may not be
impacted
<C>An impacted tooth is likely to erupt if it is
given enough time
<C>The lower canines and upper wisdom teeth
are the most commonly impacted teeth

One day ,
people who did not believe in youwill tell everyone how they met you ..

Done By: Saleh Mutlaq

Corrected By: Omar Diab

17