Ebrahim Al-Awadhi

BDentSc BA MSc (Lond) PhD(Udubl) MFD (RCSI) MOrth(RSC Eng) FFD (RCSI)
 E"ology
•  Skeletal
•  Dental
•  So+ ,ssue
•  Habits
• Increased overjet

• Anterior open bite or

incomplete overbite

• Unilateral crossbite
with displacement

• Proclined upper and

retroclined lower
 Management

n  Encourage patient to stop and discuss the

side effects
n  Adhesive bandage on the finger
n  Nail varnish
n  Thumb guard
n  Removable appliance
n  Fixed ( maxillary lingual arch with cribs)
Removable
•  Late exfoliation of primary teeth

•  Supernumerary



•  Dilaceration
 Unerupted Central Incisors
When are they late ?
(RCS Eng Clinical Guidelines)
1. Erup"on out of sequence



Lateral Incisor erupted
before central
2. Retained deciduous incisor
when contra-lateral tooth fully
erupted
more than 6 months



3. If both 1/1 UE then when
lower incisors erupted
more than 12 months
 Management Overview
Ø H+V Radiographs (Parallax Technique)
Ø Create and Maintain Space
Ø 75 % erupt 55% align
Ø Remove Physical obstruc,on
Ø  Tuberculate ( 1-1 ) worse than conical supernumerary ( 1 -5 )
78% will erupt within 16 months

Ø Exposure Open (R/V a+er 18 months)

Closed (Gold Chain)
Ø Extract Incisor (Rare- Dilacerated)
•  Most common in anterior maxilla
•  2% of the popula,on
•  Cause of unerup,on in 30-60% cases
•  High inverted unlikely cause
•  Palatal most problema,c
 Conical

Complex/
compund
Shape
Tuberculate

Supplemental
Supernumerary
mesodens

Posi,on paramolar

distomolar
 Conical Supernumerary

§  Peg shaped
§  Root formation ahead
§  May be inverted
§  May erupt
§  Mesiodens
§  Do not interfere with the
eruption of the
permanent teeth.
 Tuberculate Supernumerary

§  Barrel shaped
§  Root formed late
§  Usually palatal x2
§  Rarely inverted
§  Rarely erupt
§  Almost always cause
impaction of both centrals
 Effects

•  No effect
•  Displacement
•  Diastema
•  Unerup"on
 Conclusions
n  ¾ of immature incisors will erupt without need for
further surgery when the obstruction is removed and
space maintained

n  Only 1/5 of mature incisors will erupt when the

obstruction is removed and space maintained

n  On the whole exposure and bonding of all un-

erupted incisors at the first surgery is recommend to
avoid a second surgical procedure
n  Max. canine is second only to 8s

n  Incidence of canine impaction 1.7%

Ericson and Kurol, 1986

n  Palatal in 85% and buccal in 15%

Hitchin, 1956

n  Twice as common in females as males

Dachi and Howell, 1961

n  8% of patients have bilateral impactions

 Impacted canines
n  Buccaly and palataly impacted canines have
different aetiology
n  Buccaly:
n  83% of buccaly impacted canines had insufficient space to
erupt
n  Crowding is the main aetiological factor
n  Palataly: 85% of palataly canines had sufficient
space to erupt

n  Two theories
n  A) Genetic Peck and Peck, 1994
n  B) Guidance Becker et al, 1981
 Clinically
Inspect
Angulation
A I

P
Palpate

Colour
C
IMPAC
M
Mobility
Guidelines for the assessment of the impacted maxillary
canine.
Counihan K, Al-Awadhi EA, Butler J.
Dent Update. 2013 Nov;40(9):770-2, 775-7
 Poor
They are intended to Average
assess Good

1. buccal or palatal
2.Vertical Canine height
3. Position of Canine root apex Antero-
Posterior
4. Canine angulations to the midline
5. Canine overlap of adjacent incisor root
6. Resorption

(S"varos and Mandall, 2000)

Category Good Prognosis Average Poor

Overlap of No horizontal overlap Up to half root width Complete overlap

incisor

Vertical CEJ- half way up root >half < full root length > full root length
height

angulation 0-15 deg 16-30 deg >30 deg

Position of Above canine position Above 1st premolar Above 2nd premolar
apex

 Interceptive measures
recommended
n  The patient age is between 10-13yrs

n  The maxillary canine is not palpable and

radiographic examination confirms palatal
position

n  Uncrowded arch

n  Clinical re-evaluation and follow up

radiographs should be taken every 6 mo
•  If the canine overlaps 2 >
half 64%

•  If the canine overlaps 2 <

half 91%

•  Improvement was seen in

50% of cases after 6
months and 28% after 12
months

•  None could be expected

after a year
(Ericson and Kurol
1987)
6-11 year olds
8-14%
 Aetiology

resorp"on

Normal
Loss repair
exfolia"on

resorp"on
 Repair

Infra Resorp"on
Ankylosis
occlusion

Repair
 Causes

•  Mechanical
•  Chemical
•  Iadiopathic
•  1/5 of patients with infraoccluded
teeth have premolar aplasia
(Bjerklin 1992)
•  Other developmental
abnormalities ( impacted canines,
peg laterals, ectopic first molars)
•  Unilateral

•  Early onset

•  Progress faster

•  Maxilla>
Mandible 5 years
Bilateral

Slower
progression

Late onset

Mandible >
Maxilla
Ø Mild ( above the contact
point)

Ø Moderate (at the contact

point)

Ø Severe (below the contact

point)
 Without ManagementWith
Permanent
permanent
successor
successor

Root
Age of PX forma"on

Path of
eruption
Severity
Tipping of
adjacent teeth
 Infraocclusion Primary Molars
Management
•  With permanent successor
Non Extraction
Usually (90%) exfoliate allowing eruption but typically 6 months late but review 6 monthly.
Extraction
If between ½ - 2/3 of premolar root developed
Abnormal path of eruption
severe infraocclusion with risk of complete submergence

•  Without Permanent successor

Extract
If severe infraocclusion and radiographic evidence of ankylosis
extract to prevent lateral open bite and poor bone site for future implant
Orthodontic decision to maintain or close space depending on malocclusion
Non- Extraction (Keep Primary Molar)
Molars that show late infraocclusion with good root form after the age of 12 yrs may be
left with occlusal restorations to maintain occlusal integrity