Clinical Success

in

Surgical and
Orthodontic Treatment
of Impacted Teeth

Jean-Marie Korbendau, DDS, MS

Associate Professor
Faculty of Dentistry
University Paris V, France

Antonio Patti, MDS, DUO

Director
The International Center for the Study of Clinical Orthodontics
Verona, Italy

English Translation by

Jay K. Weiss, DMD

Former Adjunct Associate Professor
Department of Human Behavior
Columbia Dental School
New York, New York

Paris, Chicago, Berlin, Tokyo, London, Milan,

Barcelona, Istanbul, São Paulo, Mumbai, Moscow,
Prague, and Warsaw
First published in French in 2005 by Quintessence International, Paris
Le Traitement orthodontique et chirurgical des dents incluses

© 2006 Quintessence International

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Printed in France
Acknowledgments

The authors extend their thanks to:

Jean-François Andréani
Guy Chaumanet
Robert Chatagnon
Thierry Chatagnon
Jean-Louis Giovannoli
Laurent Glas
François Guyomard
Gérard Motto
Franck Renouard
Jean-Claude Talmant
Pierre Vion
Preface

This book addresses the problems associated with impacted teeth in

children and adolescents from both orthodontic and surgical
perspectives. Emphasis is placed on a prophylactic approach to
reduce or, when possible, eliminate the need for surgery. However,
there are cases for which surgery is unavoidable; therefore, this text
describes strategies for designing intervention in specific anatomic
situations. Above all, its goal is to help orthodontists plan treatment to
meet the needs of their patients.
Many individuals have contributed to the successful completion of
this volume. My collaboration with Professor of orthodontics François
Guyomard, on Chirurgie parodontale orthodontique (Edition CdP,
1999), allowed me to adapt the principles of mucogingival surgery for
use in orthodontic surgery. Professor Frans P. G. M. van der Linden
kindly gave his permission to use images from his atlas, Development
of the Human Dentition (Harper & Row, 1976), to illustrate specific
problems that children may endure during tooth eruption. The
knowledge I gained in preparing to publish a number of articles with
Danielle Pajoni, an authority in computerized tomography, proved
invaluable in helping me to visualize the exact anatomic locations of
ectopic teeth. Finally, I have worked closely over the last few years
with Xavier Korbendau, who has contributed his clinical skills to the
surgical treatment of a number of patients with complex problems.

Jean-Marie Korbendau, DDS, MS

Table of Contents

Cover
Table of Contents
Acknowledgments
Preface

1 Stages of Eruption of Permanent Teeth

Components of Eruption
Bony crypts
Dental follicle
Localization of the Bony Crypts of the Maxillary Permanent
Teeth
Incisors
Canines
Intraosseous Eruptive Pathways
Eruption of the incisors
Eruption of the canines
Relationship of canines and lateral incisors
Relationship of Malpositioned Tooth Buds to Anatomic
Structures
Incisors
Canines
Orthodontic and Radiographic Assessment of Impacted
2 Teeth
Orthodontic Assessment
Eruption and dental age
Impaction of teeth
Impacted central incisor
 Impacted maxillary canine
Radiographic Assessment
Conventional radiography
Periapical radiographs
Occlusal radiographs
Computerized tomography
Prescriptions for supplementary examinations
Extraction of Impacted Teeth
Orientation of the tooth bud and the eruptive trajectory
Malformation of roots
Ankylosis
Dentigerous cysts

3 Preventive Treatment of Impactions

Supernumerary Teeth and Odontomas
Impacted Maxillary Primary Canines
Overretention of primary canines
Palatally positioned permanent canines
Labially positioned permanent canines
Providing Eruptive Guidance
Expansion of the anterior maxilla
Advancement of the anterior segment
Distalization of the buccal segments
Extraction of permanent teeth

4 Criteria for Choosing Orthodontic and Surgical Protocols

Stages of Orthodontic Treatment
Impacted canines
Impacted central incisors
Impacted premolars
Impacted molars
Surgical Approaches to Impacted Teeth
Replaced and displaced flaps
Palatal approach
Buccal approach
5 Impacted Maxillary Canines: Palatal Approach

Classification of Palatally Impacted Canines

Class 1 Impaction
Impacted tooth near palatal mucosa
Deep bony impaction
Class 2 Impaction
Superficial impaction
Class 3 Impaction
Deep bony impaction

6 Impacted Maxillary Canines: Buccal Approach

Superficial Impactions
Direct access flap
Apically displaced flap
Apically and laterally retracted flaps
Palatal Impactions
Apically retracted buccal flaps
Deep Bony Impactions
Replaced mucoperiosteal flap

7 Impacted Mandibular Teeth

Eruption of Mandibular Incisors
Eruption of Mandibular Canines
Ectopic trajectories of emerging canines
Transmigration of mandibular canines
Eruption of Mandibular Premolars
Bibliography
Stages of Eruption
of Permanent Teeth
Components of Eruption
At the embryonic bell stage, the dental bud is made up of three parts:
the dental organ, the dental papilla, and the dental follicle (Fig 1-1).
Embryonic tissue derived from the dental lamina organizes itself
around this group, adapting to growth of the tooth bud; lamellar bone
then gradually begins to replace it, forming an encasement of bone
known as the bony crypt. Inside this casement, calcification of the
crown and formation of the root both begin.
Generally, when one quarter of the root has developed, the tooth
will start to erupt (van der Linden 1983). This is a complex process of
many stages, none of which has been completely elucidated.
However, it is clear that this mechanism ensures that root formation
will be coordinated with development of the tooth’s periodontal
environment, the dental bud’s osseous journey, the emergence of the
crown into the oral cavity, and its eventual arrival at the occlusal
plane.

Bony crypts
As this pre-eruptive tooth bud choreography proceeds, the bony crypts
enact parallel movements; their ceilings, or cell walls, oriented toward
the occlusal plane, form an opening that provides access to the
gubernacular canal. This tunnel through bone, which contains a
fibrous cord where epithelial remnants of the dental lamina persist,
connects the crypt to the cortical plate and sometimes to the alveolar
wall of the primary tooth. This collective voyage makes a profound
impression on the tooth as it erupts (Fig 1-2).

Dental follicle
When the crown is completely calcified, cells of the follicular envelope
exert primary control on the two active poles of the dental bud (Cahill
and Marks 1980) (see Figs 1-1 and 1-3).
 Fig 1-1 Dental bud. Follicular tissue envelops the dental organ and the dental papilla of the
dental bud, which has two poles, apical (PA) and coronal (PC).

Fig 1-2 Bony crypt of mandibular right first premolar, viewed at the center of the vault of the
coronary pole. The orifice of the gubernacular canal connects the bony crypt to the bifurcation
of the primary molar; resorption has joined it to the curved wall sculpted by the dental follicle.
 The apical pole serves as the site for the formation of the supporting
dental tissues, cementum, periodontal ligament, and surrounding
alveolus. Bone formed by apposition organizes around the roof of the
crypt in relation to the walls of the developing root, which partially
invests the space that the crown had occupied (Figs 1-4a and 1-4b).
As a result, the architecture of the crypt changes as it keeps pace with
the progress of tooth eruption. The coronary pole of the follicle
continues to adhere to the crown until it fuses with the buccal
epithelium before the tooth emerges into the arch.
It is this portion of the follicle that provides the osseous cleft through
which the tooth passes along the gubernacular canal. Mononuclear
cells that are the precursors of osteoclasts and osteoblasts are stored
within the follicle before eruption begins (Craddock and Youngson
2004). The osteoclasts are then liberated to assist in preparing a path
for migration of the permanent tooth’s crown by creating an opening in
the vault of the crypt and by initiating resorption of the primary tooth’s
root (Kawakami et al 2000).

Fig 1-3 This portion of the dental follicle completely envelops the tooth crown while the root
is forming. The remains of its epithelium fuse with gingival epithelium when the tooth
emerges.
 Fig 1-4a Eruption of the mandibular left canine modifies the bony crypt. The root forms in
the site that the crown occupied near the lower border of the mandible, as alveolar bone
adapts to it.

Fig 1-4b Orifices of the gubernacular canals (arrows), located at the center of the crypt
roofs. The canal of the mandibular left canine opens into the periodontal ligament of the
primary canine, while the premolar canals engage the bifurcations of the primary molars.

At the same time, a cleft in the bone, several millimeters deep at the
alveolar border of the single-rooted primary teeth, will ease the
eruption of their successors (Fig 1-5). But the extent of this resorption
varies according to the type of tooth. Premolars migrate into
substantial alveolar craters, but canines, whose coronal dimensions
are substantially larger than those of their primary predecessors,
require even larger openings through which to move successfully.
These two resorption processes, of bone and primary tooth roots, join
to create space for passage of the permanent teeth.
The location of the opening of the gubernacular canal indicates the
site in the lingual cortical plate where the permanent successor will
emerge behind the primary tooth, although sometimes it will emerge
directly into the primary tooth’s pulp cavity. In the first instance the
gubernacular fibers bind into the gingival lamina propria; in the second
they intersperse with the primary tooth’s periodontal membrane (Figs
1-6 and 1-7).

Fig 1-5 Dentition of a 4-year-old child. Resorption of the alveolar processes of the primary
teeth is already well advanced, as the child has begun the very first stage of eruption of the
permanent teeth. (From van der Linden and Duterloo 1976).
 Fig 1-6 Long axes of the mandibular permanent anterior teeth are lingually inclined as they
emerge behind the primary teeth.

Fig 1-7 Gubernacular canal of the mandibular left canine opens directly lingual to its
primary predecessor, lending a beveled edge to its resorption.

Not all of the mechanisms that govern the initiation of the eruption of
permanent teeth are as yet understood, but many experiments have
shown the important role that the dental follicle plays in this process.
Accordingly, dental practitioners should adhere to well-established
anatomic and physiologic operative protocols for freeing, or
extricating, permanent teeth whose eruption has been delayed.
 In surgical interventions, practitioners should be careful not to
remove all of the follicular tissue that still envelops the crown of a
tooth before its emergence, because in early stages of eruption, it is
imperative that the portion of the root adjacent to the
cementoenamel junction be protected by its follicle. Supracrestal
fibers can only develop after the tooth emerges into the mouth,
either by the normal physiologic means or with surgical assistance.
Furthermore, the coronal portion of the follicle is responsible for
the bone resorption that enables the tooth to migrate. Therefore, the
surgeon, after removing enough soft tissue to bond an attachment,
should then remove bone lying in the tooth’s eruption pathway.

Localization of the Bony Crypts of the Maxillary

Permanent Teeth
Incisors
While the bony crypts that surround most of the buds of the
permanent teeth are interconnected, the intermaxillary suture
separates the two maxillary permanent central incisors (as it did their
primary predecessors), usually generating a characteristic
posteruptive diastema (see Figs 1-5 and 1-11).
The crowns of the central incisors calcify under the floor of the nasal
cavity and stimulate resorption, with a lingual bevel, of their primary
predecessors, behind which they are forming. The crypts of the
maxillary lateral incisors are located more lingually behind those of the
central incisors so that, viewed frontally in 4-year-olds, half of their
crowns would be masked by the central incisors. This backward
positioning of the lateral incisor places it in the same plane as the
canine, for whose eruption it will later serve as a guide. At this stage of
calcification, which occurs in a constricted space, the developing
permanent teeth are normally quite crowded.
The lateral incisor crypts are closer to the occlusal plane than those
of the other teeth in the arch; calcification proceeds at varying rates in
the maxilla as a function of the length of the tooth roots (van der
Linden 1976).
Canines
The bony crypts of the canines are located near the external border of
the nasal fossae anterior to the sinuses, from which they are
separated only by a thin lamina of bone (Figs 1-8 and 1-9).
Taken together, the maxillary teeth have a conical appearance. As a
result, the bony crypts of the canines, which are placed higher than
the others, are the most internal. Their buds develop behind the roots
of the primary teeth and behind the buds of the other permanent teeth.

In a view of a skeletal specimen of a 4-year-old child, the primary

first molar, the bud of the first premolar, and the bud of the
permanent canine have the appearance of three steps of an
ascending stairway tipped toward the anteroexternal angle of the
opening of the nasal cavity (see Fig 1-8).

Fig 1-8 Crypt of the permanent canine. In a 4-year-old, the primary first molar, the bud of
the first premolar, and the bud of the permanent canine (13) form three steps (arrows) of an
ascending stairway. The ensemble of the maxillary teeth can be compared to a conical trunk;
consequently, the buds of the most elevated teeth are also the most internal.
 Fig 1-9 Intercanine distance. This distance is equivalent to the width of the nares. (A)
Where the nasal fossae are broad, the intercanine distance is correspondingly wide and is not
associated with a convergence of the roots of the incisor teeth. (B) Where the nasal fossae
are narrow, the intercanine distance is similarly reduced, and the incisor roots converge fairly
closely.

Intraosseous Eruptive Pathways

Eruption of the incisors
The central incisors migrate labially to emerge in the arch in a position
somewhat labial to that occupied by the primary teeth. After the
central incisors have assumed their places, the lateral incisors begin
their voyage labially through a narrow passageway alongside the roots
of the central incisors. As the lateral incisors take their places in the
arch, they reduce the size of the initial midline diastema.
During the labial migration of the lateral incisors, their roots begin
developing with a mesiopalatal tilt in the crypts in which the crowns
formed. The positioning of the bony crypts determines the orientation
of the emerging lateral incisors. At this stage, the roots of the incisal
teeth tend to converge, and the extent to which they occupy space in
the maxilla will sculpt the eruptive pathways of the canines. If
crowding develops in the mixed dentition, there will not be enough
room for the lateral incisors to migrate labially between the roots of the
central incisors and the primary canines, and the corridors for the
canines will not be defined.
Eruption of the canines
By the time children are 6 to 7 years old, calcification of canine crowns
has been completed and, as root formation proceeds along the nasal
border in the crypt that the crowns had occupied, the teeth are ready
to begin erupting. They maintain their spatial relationships with the
nasal and antral cavities as well as with the other teeth in the arch
during calcification (Figs 1-10 and 1-11). As they move along the
lower third of the lateral incisor roots, the canines erupt almost
vertically within the dental arch, usually with a mesial inclination of
several degrees (Fig 1-12).
Still moving at the side of the lateral incisors, the canines continue
their journey until they reach the occlusal plane. After passing the
centers of resistance of the lateral incisors, the emerging canines
begin to exert a mesial pressure on the lateral incisor roots and then
on their crowns, which straightens the anterior dentition. The long
axes of these teeth progressively lose their apical convergence as the
midline diastema completes its closure (Figs 1-13a and 1-13b).
During the 3 or 4 years that precede the eruption of the maxillary
canines, their proper position can be confirmed by palpating the labial
region distal to the lateral incisors.

Fig 1-10 Locations of the canine crypts, viewed horizontally. An axial section above the
maxillary palatine processes shows the bony crypts of the canines still situated in the frontal
maxillary processes. In a horizontal plane, this region of spongy bone tissue takes the form of
a triangle, bordered on three sides by cortical bone: (1) the cortical plate of the nasal cavity,
(2) the anteromedial wall of the sinus, and (3) the anteroexternal wall of the frontal process.
 Fig 1-11 Dentition of a 6-year-old child. The crypts of the central incisors, separated by the
intermaxillary suture, occupy the full extent of the nasal orifice. The neighboring crypts of the
lateral incisors (12, 22) are lingual to and half obscured by them.

Fig 1-12 Dentition of an 8-year-old child. The vertical center of the canine crypts is located
at the nasal floor. When eruption begins, the canine crowns often have a slight mesial
inclination. By the time the child is 9 years old, the crowns reach the distal surfaces of the
lateral roots, which tends to produce more vertical movement.

Age Position of maxillary canines

8 to 9 years: Canine bulge at the apex of the primary
tooth
10 to 11 years: Lower and more pronounced bulge
11 to 12 years: Primary canine becomes mobile
 Relationship of canines and lateral incisors
When children are 8 to 9 years old, the roots of the lateral incisors are,
in theory, sufficiently well formed to sustain the contact of the mesial
angles of the canine crowns and to guide canine eruption. Moving
thus along the walls of the lateral incisor roots, the canines upright the
incisors and establish good proximal contacts (Becker 1998). If the
crowns of the canines and the roots of the lateral incisors do not meet
in the same plane, the canines will pass across the roots either inside
or outside the dental arch, and their eruptive paths will be secondarily
modified.
When the nasal cavity is narrow, the intercanine distance will be too
small for the canine to establish contact with the distal wall of the
lateral incisor root, and the canine will slide along the root’s labial
surface (Fig 1-14).
The canine cannot be described at this stage as being
malpositioned because its eruptive trajectory has not yet changed and
the greater part of its root still lies palatally (Figs 1-15a and 1-15b). If
the lateral incisor is congenitally absent, the canine will descend
directly into the palatal aspect of the arch and will frequently erupt into
the position of the missing lateral incisor (Fig 1-15c).
Even if the distance between the canines is wide enough to allow
them to erupt into good alignment, they may still go astray if:

• The lateral incisors cannot provide the needed guidance because they
are congenitally absent; their root development is delayed; or their
configuration, size, or positioning makes them inadequate for the task.

• The tooth bud’s orientation is disturbed, which can lead to the tooth’s
eventual eruption going off course, most often in a medial oblique
way. If this happens, the tooth will be impacted if the crown breeches
the vertical line extending alongside the external wall of the nasal
cavity (see chapter 2; Williams 1981).
 Fig 1-13a Computerized tomography scan. The crown of the maxillary left canine contacts
the apical third of the root of the neighboring lateral incisor.

Fig 1-13b Eruptive corridor of the canine is bounded mesially by the distal surface of the
lateral incisor root. Both of these teeth become progressively upright as the canine proceeds
past the lateral incisor’s center of resistance (CR). At the same time, the interincisive septum
develops (third radiograph).
 Fig 1-14 Size of the nasal cavity governs the relationships of the maxillary canines and
lateral incisors. In the photograph on the right, note the distobuccal inclination of the lateral
incisors (more marked on the left lateral incisor) caused by insufficient intercanine distance
(van der Linden and Duterloo, 1976).

Fig 1-15a Insufficient intercanine distance. The eruption paths of the incisors and canines
are still normal at this stage, but as the canines continue to descend, the insufficient distance
will cause a mesial orientation, forcing the malposition of the incisors.
 Fig 1-15b Axes of the lateral incisor roots conform to the position of their bony crypts,
behind the central incisors.

Fig 1-15c In this case of agenesis of a lateral incisor, the canine’s eruptive course would
not change. The canine would move directly down and take the place of the lateral incisor.

Relationship of Malpositioned Tooth Buds to

Anatomic Structures
Contact with certain anatomic structures can alter the morphology of
erupting maxillary anterior teeth. Malposition of a tooth bud can be
primary (genetic) or secondary (as a result of trauma). In cases of
primary dystopia, the bud will be normal in formation but
malpositioned, a situation that occurs most often with central incisors
and canines.

Incisors
A thorough analysis of the medical and dental history helps to
determine whether the ectopic placement of a tooth is genetic or the
result of a blow to anterior primary teeth that could have been
transmitted to the dental follicles of the central incisors. Central incisor
follicles begin to stimulate the resorption of the roots of their primary
predecessors when children are 4 years old. If trauma occurs at an
early stage when the permanent crowns are calcifying, it could cause
development of follicular lesions known as dilacerations, or sharp
angulations of roots. When children are older and crown calcification
has been completed, trauma to a primary tooth can displace the
calcified portion of the crown itself as well as cause a sharp angulation
of the root; but this rarely occurs. A number of authors (Howe 1971;
Stewart 1978) question the reasons for lesion development, partly
because it is always unilateral, but also because it seems unlikely that
the effects of a traumatic accident could be limited to a single tooth.

Intermaxillary suture
If the maxillary central incisor erupts in a mesial direction, it will
eventually encounter the cortical wall of the intermaxillary suture, a
shock that will block its migration and change its morphology but will
not cause it to resorb. Returning the wandering tooth to its proper
eruptive path creates a secondary change in the shape of the tooth’s
root (Figs 1-16a to 1-16c).
But if the tooth is oriented outward, its root will be unable to develop
in the same axis as the crown while it grows against the osseous wall
and will remain markedly angulated (Figs 1-17a to 1-17d).
 Figs 1-16a to 1-16c (a, left) Deformation of the intermaxillary suture in a 9-year-old boy.
The maxillary left central incisor is migrating in a way that puts its crown in severe
mesioversion. (b, center) Palatally positioned crown is still blocked against the cortical wall of
the suture, which it is deforming. (c, right) Radiograph taken 2 years after the beginning of
treatment. The malformation of the maxillary left central incisor’s root resulted from a vagary in
the eruption path during its formation.

Fig 1-17a Intermaxillary suture and root malformation. The left central incisor of this 10-
year-old girl is erupting near the suture, but the lateral incisor has drifted into the space
originally designated for the central incisor.
 Fig 1-17b Abnormal orientation of the tooth bud in relation to the cortical wall eventually
resulted in angulation of the maxillary left central incisor root.

Fig 1-17c Failure of the lateral incisor to come into occlusion 1 year after it was surgically
disengaged indicates the gravity of the root distortion of the adjacent central incisor, whose
apex is twisted at a 90-degree angle.
 Fig 1-17d Despite the severity of the root malformation, the maxillary left central incisor
was brought into good alignment in the arch.

Hard palate
When a tooth bud is rotated 90 degrees, its crown faces the nasal
floor and its immature root makes abrupt contact with the cortical
palatal plate. For the root to continue to develop in this environment, it
must embrace the palatal contour (Figs 1-18a to 1-18c). The upper
border of the palate, which is also the floor of the nasal cavity,
constitutes another anatomic limit for the teeth. An untreated traumatic
event occurred before the tooth’s root formation was complete. The
damages suffered by the cementum and periodontal membrane
resulted in secondary severe ankylosis. Following tooth extraction, the
sharp deviation in root shape caused by the impact with the palatal
cortical plate is visible (Figs 1-19a to 1-19d).

Canines
Ectopic canines develop in the alveolus or in the hard palate.
 Fig 1-18a Hard palate and root malformations. The crown of this 8-year-old girl’s maxillary
left central incisor is oriented toward the floor of the nasal fossae, as is apparent from the
direct view of the pulp chamber.

Fig 1-18b Contour of the hard palate explains the shape and direction of the tooth root.
 Fig 1-18c Three-dimensional reconstruction, taken from a CT section, showing how the
root development of the maxillary left central incisor changes direction as it comes into contact
with the hard palate.

Fig 1-19a Orthodontic treatment was not sought soon enough after the traumatic intrusion
of this maxillary left central incisor. Later, because the ankylosis was too entrenched, the tooth
could not be moved at all.
Fig 1-19b Axial radiograph at the level of the hard palate. The distortion of the maxillary left
central incisor’s root is evident a few months after the traumatic accident.

Fig 1-19c Extent of the ankylosis, which was confirmed in a CT scan, made the extraction
of the tooth imperative.
 Fig 1-19d Advanced dissolution of dentin and pronounced angulation of the root’s tip.

Alveolar process
To move an unerupted canine tooth that is stalled and not proceeding
toward the alveolar crest, the orthodontist must first bond an
attachment to the tooth’s crown after uncovering it in either a palatal or
a buccal approach, depending on its relationship to the adjoining
lateral incisor. The need to select a surgical pathway has led
practitioners to describe these teeth as being palatally or buccally
impacted, a qualification that has resulted in erroneous spatial
conceptualizations and, consequently, miscalculated eruptive paths
(Korbendau and Pajoni 1999). While the maxillary canine tooth always
occupies a palatal position, it is possible for its crown to move across
the labial root surface of the lateral incisor and emerge into the arch
labially. But the osseous palatal wall and its fibromucosal covering
always prevent a dystopic lingual emergence (Fig 1-20).

Hard palate
The hard palate is an osseous plate lying perpendicular to the alveolar
process that separates the oral cavity from the nasal cavity. When a
canine tooth in its bony crypt is not oriented vertically toward the
alveolar crest, it may develop within the spongy palatal bone and
begin to move horizontally.
The growing tooth, maintaining the orientation of the bud, may
continue parallel to the nasal wall toward the apices of the incisors
(Figs 1-21 and 1-22). An errant canine might equally stray from the
median sagittal plane to encounter the premolar roots, sometimes
provoking them to resorb. Generally, canines that lie horizontally do
not have curved roots and will continue to develop within the confines
of the hard palate (Fig 1-23).
Canines may develop above the roots of maxillary teeth in the upper
part of the hard palate, where the space narrows progressively as it
becomes more distant from the floor of the nasal cavity. The triangular
space, corresponding to the upper half of the bony crypt, is bounded
by the nasal cavities and the sinuses (see Fig 1-10). Usually these
teeth move labially; other trajectories are rare (see Fig 1-23).

Fig 1-20 Ectopic canines developing in the alveolar process. These maxillary canines are
developing in the lingual section of the alveolus and moving toward the median sagittal plane.
 Fig 1-21 Ectopic canines developing in the hard palate. These maxillary canines are
developing perpendicular to the long axes of the teeth that have already taken their places in
the arch. The right canine is moving toward the median sagittal plane, while the left canine is
heading away from it.

Fig 1-22a Maxillary right canine of a 15-year-old boy developing in the hard palate parallel
to the nasal wall. In this horizontal position, it can complete its development entirely within a
structure of spongy bone without risking malformation of its root.
 Fig 1-22b The long axis of this maxillary right canine, which is horizontally impacted in the
upper portion of the alveolus, is oriented toward the median sagittal plane, its cusp passing
above the apex of the central incisor. This scenario, genetic in origin, is often accompanied by
agenesis of one or more teeth.

Fig 1-22c Oblique coronal reconstructions show the relationship between the maxillary
right canine and the nasal and antral cavities as well as the canine’s proximity to the apices of
the first premolar and the central incisor. The middle schema also shows the gubernacular
canal (outlined by red arrows) of this ectopic canine.
 Fig 1-23 Positions of ectopic canines in the hard palate. (A) The crown of this canine,
which lies at the border between the alveolar process and the hard palate, closely approaches
the roots of the maxillary left lateral and central incisors. (B) The tooth can be seen lying at the
angle of the hard palate and the frontal process. (C) The long axis of the maxillary left canine
angle of the hard palate and the frontal process. (C) The long axis of the maxillary left canine
is perpendicular to the dental arch. Its root is developing in the spongy portion of the hard
palate, while its crown lies above the alveolar process at the level of the apices of the
premolars.
Orthodontic and
Radiographic
Assessment of
Impacted Teeth
Orthodontic Assessment
Eruption and dental age
Van der Linden and Duterloo (1976) described eruption as the journey
of a tooth from its bony crypt to its assigned place in the dental arch
and emergence as the point when a tooth emerges through the
gingival and mucosal tissues that envelope it into the oral cavity.
As a general rule, a tooth begins eruption when one third of its root
is formed. Whenever clinical examination reveals that a tooth is late in
erupting, practitioners should estimate the time and probability of
eruption through radiographic assessment before preparing a
therapeutic plan that might include extraction of its primary
predecessor or surgical exposure.
Clinicians should be careful not to confuse chronologic age with
dental age. It takes about 3 years for a tooth’s apex to close after it
has emerged into the arch. By examining dental roots in panoramic
radiographs, clinicians can compare the dental age of a patient with
the chronologic age. However, in children younger than 9 years,
clinicians must base their estimations on root formation because no
apical closure of permanent teeth will have occurred (Becker 1998).

Orthodontists can use this data to evaluate the dental age of patients
with problems of tooth eruption and decide whether to monitor
progress or initiate prophylactic treatment.
 Three situations are possible:

• When root development is within the normal range but slow—a gap
between dental and chronologic age—no action should be taken.

• When dental and chronologic age coincide but one or more teeth are
late in erupting after root formation is complete, extraction of primary
teeth is indicated (Fig 2-1).

• When dental and chronologic age coincide but the root formation of
one or more teeth remains incomplete, progress should be monitored
and no immediate action should be taken.

Impaction of teeth
By the time two thirds of a tooth’s root is formed, it should have
emerged into the arch. If the crown remains at some distance from the
alveolar crest after its scheduled eruption time because of insufficient
room or an ectopic eruption pattern, it is said to be impacted.

• A tooth is impacted if its periodontal membrane is not connected to the

oral cavity.

• A tooth that is blocked from full entry into the dental arch but whose
follicular envelope is partially or fully open to the oral cavity is said to
be partially erupted.
 Fig 2-1 This panoramic radiograph shows that this 11-year-old girl, whose dental and
chronologic age coincide, has impacted mandibular left premolars. A reading of a
supplementary computerized tomography (CT) scan will confirm whether or not they can
successfully be brought into the arch.

Therefore, a blocked tooth may be completely enclosed in its bony

crypt, or may have fenestrated the roof of that crypt. In such
instances, the crown and its follicular covering come into contact with
the internal surface of the mucosa that covers cortical bone. But this
submucosal tooth remains impacted until its follicular envelope is
perforated.
The many authors who have recorded the frequency, prevalence,
and percentages of impacted teeth agree that third molars, especially
in the mandible, have the most problems erupting. Usually,
practitioners solve these difficulties by removing third molar buds or
the mature teeth (Korbendau and Korbendau 2001).
Other impacted teeth are usually preserved, especially the incisors
and canines, because of their importance to esthetics, occlusal
function, and proper alveolar growth. When a tooth’s eruption is
interrupted, the walls of its follicle usually thicken (Ericson and Bjerklin
2001). The teeth most likely to develop dentigerous cysts—mandibular
third molars (50%), maxillary canines, and mandibular second
premolars, in that order—share a common denominator: Their
emergence into the dental arch is often impeded by lack of space in
the dental arch (Shear 1992).

Pathologic etiology of impactions

While we cannot enumerate all of the factors that can interrupt
eruptive movement or lead to a deviation in its path, we can note that
the factors may be systemic or local or a combination of the two.
Heredity certainly plays a role in families where ectopic positioning of
canines occurs frequently. Similarly, familial patterns in dental
agenesis, or the formation of peg-shaped lateral incisors, contribute to
faulty eruption of canines because these anomalies of neighboring
teeth deprive the canines of the guidance they need in reaching the
alveolar crest (Pirinen et al 1996).
At the initial examination, orthodontists should check carefully for
anomalies that might cause difficulties in eruption of susceptible teeth.
If assessment reveals an impacted tooth, practitioners should prepare
a treatment plan that will take into account the primary causes of tooth
impaction, whether systemic or local in origin:

• Incorrect orientation of the tooth bud in its bony crypt, a defect that
may affect any permanent tooth but is most frequently seen in
maxillary canines and central incisors.

• An ectopic eruption trajectory of a permanent tooth, most likely

genetic in origin, frequently affects maxillary canines (Peck et al
1994) and is often a consequence of an ectopic gubernacular
canal.

• An eruptive pathway whose dimensions are too small is associated

with underdevelopment of the anterior maxilla or with other
dentomaxillary discrepancies that ultimately cause shortened arch
length.

• The presence of an obstacle, such as a supernumerary tooth or an

odontoma, constitutes an impediment to eruptive thrust. These
usually develop in the anterior maxilla and are the principal cause
of impaction of maxillary central incisors.

• Ankylosis following trauma or surgical intervention.

Clinical observations
Orthodontists should gather as much information as possible about
 their patients, no matter what their age, including thorough medical
and dental histories, clinical examinations, and appropriate
radiographs, so that they can establish the most effective treatment
plans.

Impacted central incisor

Even when an anterior tooth, such as a central incisor, fails to appear
on time, patients and parents do not always note its absence (Fig 2-2).
Not infrequently, the general dentist, the pedodontist, or the
orthodontist is the first to make the discovery. When the possibility of
an impaction is recognized, orthodontists must establish a precise
diagnosis and prognosis based on clinical examination of the dentition
and periodontium, study casts, and appropriate radiographs. They
should answer these relevant questions: What are the chances of the
problem resolving itself with no intervention? What risks, such as root
resorption, does it pose for neighboring teeth? Should its primary
predecessor be extracted? If a supernumerary tooth is present, should
it be removed? Should the anterior maxilla be expanded? Will the
tooth need surgical and orthodontic assistance to emerge into the
arch?

Examination of the dentition

• Determination of the patient’s dental age

• Assessment of primary teeth: their presence or absence, coloration,

mobility, extent of root resorption

• Evaluation of the available space and determination of the space that

the unerupted tooth will need to take its place in the arch, using the
size of the contralateral tooth as a guide.
 Fig 2-2 Initial examination. The parents waited until their child was 9 years old before
inquiring why the primary right central incisor was still in place and the left permanent central
incisor fully erupted.

Examination of the periodontium

• Attached gingiva: condition, height, and thickness.

• Edentulous crest: mesiodistal width of the labial gingiva.

• Alveolar mucosa: location and morphology of the mucogingival line

and its relationship to the impacted tooth.

• Labial frenum: size and level of its insertion.

• Bony contour: morphology and thickness and the presence or absence

of a labial canine bulge. Orthodontists should use firm palpation to try
to locate the tooth.

Examination of the occlusion

Orthodontists should not only evaluate the immediate, local problem
completely but also determine whether it will develop into a
malocclusion; sufficient space for the impacted incisor must be
available or made available before surgical intervention can begin.

Examination of study casts

Orthodontists can examine maxillary and mandibular study casts to
 understand arch shape; transverse and sagittal symmetry; intercanine
distance; morphology and position of the lateral incisors; tooth or
dentomaxillary disharmonies; tooth dimensions; and any lack of
harmony between tooth size and arch size, both anteriorly and
posteriorly.

Impacted maxillary canine

For 80% of 12-year-old girls and 13-year-old boys, maxillary canines
have already taken their places in the arch. However, diagnostic
examinations should take place much earlier in order to detect
possibilities of ectopic eruption trajectories. When canines are
emerging normally, orthodontists can discern them by labial palpation
(see chapter 1).

Age Position of maxillary canines

8 to 9 years: Canine bulge at the apex of the
primary tooth
10 to 11 years: Lower and more pronounced bulge
11 to 12 years: Primary canine becomes mobile

We have already reviewed the relationships of the permanent canine

bony crypts with the primary dentition in chapter 1. Canines begin to
develop in the palatal alveolar process, which accounts for the high
percentage of palatal trajectories when canines erupt ectopically,
usually toward the median sagittal plane. Jacoby (1983) states that in
85% of cases of palatal canine impaction, arch length would have
been sufficient to accept the tooth, but the tooth’s trajectory had gone
awry because there was no guidance from the lateral root.

An adjacent lateral incisor fails to provide the needed guidance as a

result of one or more of the following characteristics:

• Insufficient root length

• Oval or conical shape, a quality that incites “drifting” (Oliver et al

1989)
• Axial rotation that can provoke palatal or, in some cases, labial
migration of the canine

• Delayed development (Becker et al 1984)

Practitioners should be alert for indications of canine malplacement,

by examining the labial mucosa carefully, checking the long axes of
the primary canines, and regularly comparing the two halves of the
dental arch. Most canines that can be discerned by palpation will erupt
normally (Ericson and Kurol 1987), but, on the other hand,
orthodontists should not assume that the absence of a labial canine
bulge in very young patients is pathognomonic of impaction; however,
with older children such a deficiency becomes more significant.
When crowding is present, the root of the lateral incisor usually
causes the eruptive pathway of the maxillary canine to deviate toward
the labial cortical plate. This situation is evident in the early mixed
dentition if the maxillary lateral incisor is blocked between the
permanent central incisor and the primary canine. If the intercanine
distance is reduced, there will be greater distal inclination of the lateral
incisor crowns, which will thrust their roots more palatally than those of
the central incisors. In such cases, the erupting canines, being unable
to emerge palatally, will move labially across the surface of the lateral
roots (Van der Linden and Duterloo 1976).
But orthodontists should not assume that an impacted tooth is
erupting buccally just because they have been able to palpate it,
especially if it is high in the maxilla and its crown lies near the apical
third of the lateral incisor root. Only a radiographic examination will
provide a precise localization of the canine crown. Furthermore, it is
often the lateral incisor, not the canine, that is malpositioned.

Radiographic Assessment
Conventional radiography
Panoramic radiograph
 The panoramic radiograph is the basic radiograph for detecting
impacted teeth because it provides an overall view of the maxilla,
mandible, alveolar processes, dentition, and nasal fossae.
Orthodontists can use it to assess the entire dental system; look for
anomalies in morphology and status of teeth (eg, dilacerations, root
curvatures, or hooked apices); inspect eruptive trajectories; check for
congenitally absent teeth, supernumerary teeth, impactions, and
dystopias; assess dental age; review the status of restorations,
including root canal fillings; and examine nearby skeletal structures for
granulomas or cysts (Fig 2-3).
If impactions are present, a panoramic radiograph will show:

• Tooth position, whether deep or shallow

• General orientation, horizontal or inclined mesially or distally

• Relationships with neighboring teeth

• Risk of their transposition

• Presence or absence of apical resorption of the roots of adjacent teeth

This simple, relatively inexpensive examination has some

limitations. Its tendency to deform and superimpose some structures
makes it inadequate for a precise localization of impacted teeth either
buccally or lingually and in relation to the dental arch in the horizontal
plane. Furthermore, it does not show the exact inclination of canine
teeth. In a panoramic radiograph, incisors are seen in a direct frontal
view, but canines, which are situated where the arch curves distally,
present an inclination, which is a product of an averaging of the film’s
frontal and lateral projections (Figs 2-4 and 2-5).

Lateral cephalometric radiograph

This routine radiographic examination allows orthodontists to visualize
the sagittal and vertical positions of impacted central incisors as well
as to determine the likelihood of agenesis of canines (extremely rare).
It also furnishes information about the sagittal and vertical positions of
canines that are present along with their relation to the floor of the
nasal cavity. For children 8 to 9 years old, this radiograph is especially
useful because it clearly displays canines at a time when their crowns
should be in close proximity to the root tips of the primary canines and
angulated mesially. The long axes of the canines should be nearly
parallel to the long axes of the incisors (see Fig 2-5a). Nevertheless,
the superimposition of right and left sides in lateral headfilms limits
their reliability.

Fig 2-3 Panoramic radiograph permits evaluation of the entire dental system. The canines
have begun to erupt, their long axes aligned with the distal surfaces of the lateral incisors as
they move coronally from the floor of the nasal fossae. Note the bony crypt of the maxillary left
permanent canine (blue arrow).

Fig 2-4 The apparent mesial inclination of the maxillary canines of this 12-year-old boy, as
shown on this panoramic radiograph, should be interpreted with caution because it is not a
frontal view but instead a pictorial average of lateral and frontal radiographic projections.
Fig 2-5a Lateral cephalometric radiograph of the patient shown in Fig 2-4. This sagittal
projection shows a mesial inclination of the long axis of the maxillary canine.
 Fig 2-5b Frontal cephalometric radiograph of the same patient depicts the maxillary
canines as perfectly vertical.

Frontal cephalometric radiograph

This film shows the patient in a transverse view (see Fig 2-5b).

• Mandibular molars develop buccally in the bony crypts and upright as

they erupt. The maxillary molars, on the other hand, are relatively
upright in the bony crypts and move buccally as they erupt to contact
their antagonists in the occlusal plane.

Maxillary canines start eruption in a palatal direction, while mandibular

canines begin in a lingual direction. Both switch to a labial trajectory
as they emerge into the arch.

• First premolars erupt vertically.

To understand these eruptive patterns in the transverse occlusal

sense, the molars, canines, and premolars can serve as references
(Vion 1997) for:
• Measuring the width of the nasal fossae and the size of the maxilla and
the mandible, and evaluating the relationships among them.

• Measuring the intercanine distance, the sizes of the maxillary and

mandibular molars, and the relationships among them.

• Visualizing the abnormal position of the canine tooth buds and

estimating the likelihood of impaction. Erupting canines should be
inclined mesially, their crowns lying below the level of the apices of the
lateral incisors on the lateral border of the nasal cavity. Ricketts (1995)
strongly advocated understanding this normal posture of canines in 8-
year-old children, in order to recognize teeth that occupy faulty
positions and devise prophylactic strategies to prevent aberrant
eruption.

The routine radiographs used by orthodontists are useful for

detecting possible problems of impaction but cannot serve as a basis
for a definitive diagnosis. For that, orthodontists have to prescribe
more exhaustive examination procedures.

Periapical radiographs
In conventional radiography, periapical films give the most useful
information about impacted teeth. By taking two or more periapical
films of the same region with different angulations of the central ray
and a long-cone technique that assures tooth-film parallelism,
orthodontists can determine tooth position.

Clark’s rule: If three objects are aligned on the axis of the central
ray, their images will be superimposed on the film. If the X-ray
source is moved laterally but remains aimed at the three objects,
individual images of each will appear on the radiograph. The object
closest to the film will appear to have moved in the same direction
as that of the X-ray source.

Using Clark’s rule to interpret periapical radiographs, orthodontists

can determine if a tooth is impacted labially, lingually, or palatally. It is
highly useful for selecting a surgical approach to supernumerary or
impacted teeth, and in the absence of CT scan it is the method of
choice for pinpointing the location of the crown of an impacted
maxillary canine.
To determine the location of an impacted maxillary canine crown,
the first film taken is a right-angle view of the crown as aligned by the
long-cone film holder (Figs 2-6a and 2-6b). With the next film placed in
the same position, the X-ray head is kept in the same horizontal plane
and moved distally about 20 degrees. Structures that were
superimposed on the first, orthogonal radiograph are now seen
individually (Figs 2-6c and 2-6d). If the canine crown moves distally, in
the same direction as the X-ray source, it is lying palatally (Figs 2-6e
and 2-6f).
This technique is particularly valuable when a deeply impacted
canine appears to be superimposed on the apex of a lateral incisor.
The orthodontic-surgical team can determine with confidence whether
it lies buccally or palatally and select a surgical approach without
undertaking more complicated examinations (Figs 2-7a to 2-7h).
When a canine is labially impacted, orthodontists must determine
how closely its crown straddles the apex of the neighboring lateral
incisor by taking a right-angle periapical film. If the canine does not
reach the midline axis of the lateral incisor, it can be uncovered with a
simple, apically directed gingival flap. If the canine–lateral incisor
relationship is more intimate, the flap has to be lateral as well as
apical (see chapter 6).
 Figs 2-6a and 2-6b First periapical film, taken at a right angle to the crown, shows the
maxillary right canine superimposed over the roots of the incisors.

Figs 2-6c and 2-6d When the second radiograph is placed in the same position as the first
but the X-ray beam is moved about 20 degrees distal, the canine crown seems to move with it
because it is closer to the film than the other teeth in the arch.
Figs 2-6e and 2-6f Examination of both the skeletal specimen and CT scan confirm the
palatal position of the maxillary right canine, just as Clark’s rule indicated.

Fig 2-6 Clark’s rule for locating the crown of an impacted canine.

Fig 2-7a Both canines in this 13-year-old girl are impacted, and no buccal bulges can be
palpated on either side.
Fig 2-7b This occlusal film shows the maxillary canines within the dental arch, so it would
be easy to conclude that they are palatally impacted.

Fig 2-7c This occlusal film, taken from a lateral distal perspective, shows the crown of the
maxillary right canine lying over the apical third of the maxillary right lateral incisor.
 Figs 2-7d to 2-7f The first periapical film (d, left) was taken at a right angle to the crown, as
shown in diagram A. The second film (e, center) was taken with the X-ray beam moved
distally, as shown in diagram B. The crown appears to have moved mesially, not distally,
which indicates that it is farther away from the film than the root of the lateral incisor and must
be, therefore, lying buccally.

Fig 2-7g Using a buccal approach, the labially impacted maxillary right canine was
uncovered and a button bonded to it.
 Fig 2-7h With a full-banded orthodontic appliance, both maxillary canines were moved to
their proper positions in the arch.

When a canine is palatally impacted and does not pass the midline
axis of the lateral incisor, extraction of the primary canine will
encourage the permanent canine to move into the correct eruption
trajectory 78% of the time over an 18-month period (Ericson and Kurol
1988a).

Occlusal radiographs
Orthodontists will find these 57 × 76-mm radiographic films relatively
easy to use with young children whose palates are frequently too
narrow for proper placement of periapical films. They are useful
supplements to other radiologic examinations, providing a third,
horizontal dimension by which to assess the size of the maxilla.

Disto-occlusal upper median film

The central ray of the X-ray beam is placed on the median sagittal
plane and then adjusted to an angle of 60 to 70 degrees to the long
axis of the erupted maxillary permanent incisor. This position will
provide a good view of the incisors, similar to that from a periapical
film taken with the bisecting technique; it also provides a topographic
depiction of the palatal vault, aiding in localization of a palatally
impacted tooth (see Fig 2-7b).

Ortho-occlusal 90-degree view

This radiograph will, in theory, show the relationships of
supernumerary teeth or the crowns of impacted canines with the roots
of the incisors, but the X-ray power generator must be 90 kV to obtain
a transcranial view.

Lateral disto-occlusal 60-degree view

The long, 76-mm side of the film is lined up with the portion of the arch
being examined, with the central ray pointed to the center of the film at
a 60-degree angulation, 2 cm below the external canthus of the eye
(Figs 2-8 and 2-9). This film furnishes an extremely helpful view of the
impacted canine and its relationship to the incisors.

Fig 2-8 Radiographic examination of the maxillary right canine via a 60-degree lateral
disto-occlusal film. The long (76-mm) side of the film is placed parallel to the portion of the
arch being examined.
 Fig 2-9 Maxillary right permanent canine enveloped in a dentigerous cyst. The root of the
first premolar is partially resorbed even though the canine is some distance from it.

Computerized tomography
Orthodontists should obtain a scanning film, or CT scan, for severely
impacted teeth, especially in the case of maxillary canines.

This type of radiographic examination can:

• Establish the precise position of any tooth

• Establish the exact relationship of the tooth to neighboring skeletal

structures

• Establish the location of possible obstacles, such as supernumerary

teeth or odontomas

• Reveal complications, such as cysts

• Reveal any root resorption caused by the canine

Orthodontists can also use three-dimensional CT reconstructions to

improve the clarity and didactic aspects of communication.
Locating an impacted tooth
By studying the axial sections furnished by CT scans orthodontists
can locate an impacted tooth with regard to skeletal structures and
neighboring teeth. In the maxilla, thin 1- to 2-mm sectional CT views
are generally oriented parallel to the hard palate (Figs 2-10a to 2-10f).
The reference film is taken at the level of the apices or the apical
third of the maxillary teeth. Practitioners use a cursor to trace a curve
located midway between and parallel to the cortical plates of the arch
(see Fig 2-12e). Additional curved lines, parallel to the central line, can
be traced to vary the depth of the curvilinear panoramic
reconstruction, with spacing ranging from 1 to 5 mm (average 2 mm).
For visualization of erupting canines, three sectors are examined
(see Fig 2-10).

Suprapalatal region
Axial CT sections taken just above the hard palate allow orthodontists
to locate the bony crypts of the canines adjacent to the nasal cavity.
As the canine crowns complete their calcification in 7- to 8-year-old
children, their roots begin to form in this narrow sector of cancellous
bone, from which all teeth begin their eruption trajectory. Maxillary
canine roots are always lingual to the dental arch even if their crowns
lie buccal to it (see Figs 2-10a and 2-10b).

Figs 2-10a and 2-10b Suprapalatal level, where maxillary canine tooth buds are located.
 Figs 2-10c and 2-10d Palatal level, where the centers of the canine crypts are located.

Figs 2-10e and 2-10f Subpalatal level. Transverse axial sections of the alveolar processes
show the relationship of the impacted teeth to the roots of adjacent teeth.

Palatal region
In axial CT sections of this region, the nasal and sinus cavities can no
longer be seen. Canines, whose buds are oriented horizontally, find
sufficient room for their roots to develop completely in spongy bone
without deformation. In this view the apices of the maxillary central
incisors may first appear when children are 10 to 11 years old (see
Figs 2-10c and 2-10d).

Subpalatal region
Infrapalatal CT sections, which pass through the alveolar processes,
provide well-defined views of the palatal cortical plates as well as the
 lingual limits of alveolar bone (see Figs 2-10e and 2-10f). The more
occlusal these axial sections are placed, the better they depict the
position of the canine teeth in relation to the median sagittal plane.
Accordingly, when a canine’s eruptive path is angled mesio-obliquely,
a practitioner can clearly evaluate the impact of its crown on the roots
of the maxillary incisors.

• When the canine’s eruption path is normal, the crown’s axis coincides
with the axes of already erupted teeth as it proceeds along the distal
surface of the lateral incisor root (Figs 2-11a to 2-11h). The buccal
cortical plate is often distended around the bulge of the canine crown
below its apex, where it can be readily palpated in 9- to 10-year-old
children but it is not distended at the tip of the canine, which is
obscured by the root of the primary canine.

• If the eruption trajectory is directed buccally, the crown passes in front

of the lateral incisor root (see chapter 6, Figs 6-2 and 6-3). But when
the lateral incisor’s root formation is delayed, the canine may erupt
more mesially than usual, a development that should not be
interpreted as resorption of the permanent lateral incisor root (see Fig
2-11b).

• If the eruption trajectory is directed palatally, successive axial CT

sections of the alveolus will display the relationship of the canine
crown to the roots of the lateral and central incisor teeth as the canine
continues along its ectopic path (see Fig 2-16).

Estimating size and shape of the dental follicle

The follicles of ectopic teeth are, in general, larger than those of teeth
that erupt normally. In a 2001 study by Ericson and Bjerklin, axial CT
sections were used to show that the size of the follicles, which varied
from 0.5 to 7.0 mm as measured around the crown periphery, was a
function of local anatomic conditions.
These follicles usually expand within spongy bone, which offers little
resistance, but follicle expansion can also occur when the tooth is in a
labial position because there the thin cortical plate is easily
fenestrated (Figs 2-12b and 2-12g).
Local anatomic conditions also govern the shape of dental follicles.
Usually the follicle assumes a spherical form. If the tooth becomes
impacted, however, it can become asymmetric if (as often happens)
the ectopic canine resorbs alveolar bone and the periodontal
membranes of adjacent teeth whose roots it engages (see Fig 2-15d).
Cystic degeneration of dental follicles in children 10 years of age or
older with mixed or early adult dentitions is usually discovered in
routine radiographic assessment.
While dentigerous cysts of maxillary canines only rarely grow large
in size, when they do they may encompass the crown of the lateral
incisor as well as that of the canine. When the tooth erupts, either
physiologically or with surgical and orthodontic assistance, the
degeneration caused by the cyst disappears.

Detecting root resorption

Impacted canines can cause or be associated with infections, tumors,
and neurologic or mechanical problems. Root resorption, which is
asymptomatic in the majority of cases, is the most common of these
disorders; canine impaction can lead to the loss of the affected teeth—
usually the maxillary lateral incisors, and sometimes the maxillary
central incisors and first premolars as well (Pajoni et al 2003) (Figs 2-
13 and 2-14).

Fig 2-11a Unerupted maxillary left lateral incisor and canine in a 12-year-old girl.
 Fig 2-11b Lateral incisor crown just beneath the mucosa; its root appears to have been
resorbed by the markedly enlarged follicle of the unerupted canine.

Fig 2-11c Three-dimensional CT scan, apparently confirming the diagnosis of severe root
resorption of the maxillary left lateral incisor by the canine.

Fig 2-11f Located lingual to the canine, the maxillary left lateral incisor root (22) can be
clearly seen in this more occlusal section. It is not being resorbed but is late in developing,
which is common in maxillary lateral incisors.
 Figs 2-11d and 2-11e (d, left) The first infrapalatal CT section shows the apical third of the
maxillary central incisors. (e, right) On a lower section, the root of the maxillary right lateral
incisor (12) contacts the mesial surface of the right canine. The root of the left lateral incisor is
suggested by the radiolucent area between the left canine and the palatal cortical plate.

Fig 2-11g The maxillary left lateral incisor has taken its place in the arch. Its fully formed
root was 4 years late in developing, and its apex does not yet appear to be closed.
Figs 2-12a and 2-12b Ectopic maxillary right and left canines in a 12-year-old girl.
Comparison of the suprapalatal and the palatal CT sections shows the horizontal,
coronoapical orientation of these impacted teeth.

Fig 2-12c Three-dimensional CT reconstruction confirming the location and axial

positioning of the maxillary canines.
 Fig 2-12d Composite planar CT reconstructions clarify the relationship of the canines to
the adjacent teeth.

Fig 2-12e Axial reference section. By superimposing oblique CT scans of the crowns on a
measurement grid, practitioners can precisely locate the teeth in the alveolar process.
 Fig 2-12f The precision attained through comprehensive radiologic examination makes the
surgical and orthodontic protocols more effective and simple.

Fig 2-12g CT scans of the crowns of the mandibular right central and lateral incisors can
be reset in the measurement grid of the axial reference section.

When clinical examination reveals that a maxillary canine is not

present in the dental arch, orthodontists must undertake further
radiographic studies to assess the eruption trajectory and detect
possible complications.
If the crown of the unerupted tooth appears to be superimposed on
the roots of adjacent teeth, orthodontists can use Clark’s technique to
establish whether the errant tooth is buccal or lingual, but they cannot
determine if any neighboring teeth are being resorbed unless the
entire thickness of the root has been compromised (see Fig 2-13a).
In 1987, Ericson and Kurol demonstrated that 12.5% of ectopic
maxillary canines provoked resorption of adjacent teeth. In 2002, the
same authors used CT scans to show that the resorption rate of
maxillary incisors is actually much higher, recorded at 48% in their
study.
If the trajectory of an erupting canine is normal, its crown will
encounter and be guided by the root of the adjacent lateral incisor.
The contacting enamel of the canine sometimes temporarily breaches
the lamina dura of the lateral incisor, but this structure usually repairs
itself as the canine crown continues its eruption. In the majority of
normal canine eruption patterns no root damage occurs; however,
moderate dentinal resorption persists in 3% of cases (Ericson et al
2002).
Contrary to the opinion of some authors (Ericson et al 2002),
contact between enamel and dentin does not seem to be necessary
for root lesions to develop. Axial CT sections clearly show that
substantial root resorption can reach as far as the pulp in an adjacent
tooth provided it is in contact with the wall of the canine’s dental
follicle, even if the canine crown itself remains several millimeters from
the root surface (Figs 2-15d and 2-16d).
The follicular tissues of erupting permanent teeth orchestrate the
resorption of the roots of primary teeth as the cells of their walls
secrete prostaglandins to encourage the production of the osteoclasts
that create passageways through bone (Matejka et al 1985).
Mechanical stimulation, such as compression of the follicle by the
emerging tooth, can stimulate secretion. Such an intrafollicular
initiation, gone somewhat awry, could explain the occasional
development of a voluminous dentigerous cyst.
 Figs 2-13a and 2-13b Root resorption of the maxillary central incisor is often more severe
in cases of canine encroachment than that caused by encroachment of the lateral incisor.

Fig 2-14a Root resorption of a maxillary right first premolar, resulting from contact with the
crown and follicle of the maxillary right canine.
 Fig 2-14b Composite planar CT reconstructions show the maxillary canines in a high
position with a mesiobuccal orientation perpendicular to the first premolars, which appear to
be blocking the canine eruption.

Fig 2-14c Root resorption of the maxillary left first premolar.

Fig 2-15a The primary canines of a 15-year-old boy remain in place and show no signs of
mobility. Their permanent successors cannot be located by palpation.

Fig 2-15b The crown of the maxillary left canine has moved mesially, seriously resorbing
the root of the central incisor. Note the thickness of the canine’s follicle.
 Fig 2-15c Using a buccal approach, an attachment was bonded to the maxillary left canine.
This periapical radiograph also clearly depicts the resorption of the lateral incisor root.

Fig 2-15d Several months after initiation of treatment, a CT examination showed the
lingual position of the crown of the maxillary left canine (23), the size of its follicle, and the
severity of the root resorption of the left central and lateral incisors. The enlarged follicle of the
right canine envelops the distal wall of the root of the maxillary right lateral incisor without
affecting it, while causing root resorption of the maxillary primary right canine.
 Fig 2-15e Three-dimensional CT reconstruction showing the severe lingual inclination of
the crown of the maxillary left canine. Palatal access to the tooth was created to change the
orientation of the applied orthodontic force.

Figs 2-16a and 2-16b (a, left) Palatal surgical approach to an impacted canine reveals the
fenestration (arrow) of the cortical plate in this 15-year-old boy. (b, right) The maxillary left
canine crown has been partially uncovered so that an attachment can be bonded to it. The
alveolar borders of the adjoining left central and lateral incisors were preserved.
 Figs 2-16c to 2-16e (c, left) Three-dimensional CT reconstruction showing the position of
the crown relative to the alveolar crest. At this time, not enough space in the arch had been
prepared for it. (d, center) Coronal reconstruction in the region of the left lateral incisor. The
crown of the canine is somewhat distant from it, but the bulging follicle has modeled the
resorption of the lateral incisor. (e, right) Three-dimensional CT view clearly showing that the
maxillary left canine’s crown is not in contact with the roots of the left lateral and central
incisors, which nevertheless have suffered severe root resorption.

Fig 2-16f Panoramic view demonstrating the orientation of the maxillary left canine.
 Fig 2-16g The crown of the maxillary left canine and its follicle occupy the entire width of
the alveolar process.

Fig 2-16h Axial section passing through the tip of the cusp of the maxillary left canine. A
zone of resorption in the maxillary left lateral incisor lies at some distance from the canine
enamel itself.

Because most canines erupting ectopically move mesially through

the alveolus, their crowns might contact lateral incisors (38% of the
time) or central incisors (9%) (Ericson and Kurol 1988b). Root
resorption could be found on the apical third of the roots of the
affected teeth, but it could also be found laterally, on the distal, palatal,
or buccal surfaces depending on the trajectory of the malerupting
canine.

Prescriptions for supplementary examinations

While conventional radiography is an indispensable tool in the
detection of impacted teeth, only computerized tomography can
establish their precise relationships with neighboring teeth.
Computerized tomography should be employed whenever there is
doubt about the integrity of any dental structures in their vicinity. CT
scans have demonstrated that the “mechanical” accidents provoked
by impacted teeth are far from rare and can lead to serious
consequences.
Impacted canines cause other less severe mechanical accidents,
including unnatural root curvature and displacement of adjacent teeth,
usually first premolars. The maxillary lateral incisor is not the only
victim of impacted canines; adjacent first premolars are almost
invariably displaced or bent.
CT scans of impacted teeth, especially canines, also provide critical
information for choosing an effective trajectory for orthodontic traction.
In this area of treatment, techniques have greatly improved since the
days when the impacted tooth was lassoed with a ligature wire. Once
reliable bonding methods became available, impacted teeth could be
moved without risk by placing an attachment directly on the palatal or
buccal surface of the tooth, depending on the surgical approach.

Today, computerized tomography continues to aid orthodontists in

devising better ways to apply force; they can locate impacted teeth
precisely in space and make angular and linear measurements
directly on the films, thus allowing them to choose axes of traction
that will not aggravate the impacted tooth’s contacts with other
teeth. This is especially important in cases of deep bony impaction,
where the canine lies in contact with the apices of neighboring
teeth; any inaccurate course of movement could prove more
harmful to the dentition than extraction of the errant tooth.

Extraction of Impacted Teeth

Based on clinical and radiographic assessment of adolescent and
young adult patients, orthodontists can usually propose a treatment
plan to successfully bring their impacted teeth, whose eruptive
trajectories have been ectopic, into the arch.
 Occasionally, because of factors such as patients’ age, state of
general health, or socioeconomic status, orthodontists may have to
propose extraction of the impacted tooth. In such cases, all possible
risks should be scrupulously explained to parents and patients so that
consent to or refusal of treatment will be truly informed.
For prospective adult patients, who are often concerned about the
duration and difficulties associated with treatment, orthodontists
should present alternatives to mechanotherapy for bringing impacted
teeth into place. Potential growth cannot be counted on to aid
therapeutic progress, and the chances for success in the surgical-
orthodontic treatment of impaction are lower than for younger patients.
Should an adult conclude that prosthetic replacement is the best
solution, the practitioner must decide whether to extract the impacted
tooth or leave it in place. This decision must take into account the
length of time the tooth has been impacted, whether the appearance
of its ligament suggests the possibility of ankylosis, the depth of the
impaction, the size of the follicle, and the evolving characteristics of
the radiolucent area shown in a pericoronal radiographic film. All
things considered, it is usually best not to extract an impacted tooth
that has been asymptomatic for many years (see Chapter 7, Fig 7-10).
There are some circumstances in which extraction is required.
These are primarily associated with the orientation of the tooth bud
and eruptive trajectory, certain malformations, resorptions that could
lead to ankylosis, or cysts related to the tooth’s eruption.

Orientation of the tooth bud and the eruptive

trajectory
Any departure from the normal eruptive pathway is considered an
ectopic trajectory. These abnormal routes are often caused by the
tooth bud position in its bony crypt at the time of crown calcification.
Sometimes an erupting tooth may wander off course even though its
initial orientation was good. Traumatic accidents, especially to
maxillary incisors, can cause such deviations.
Ectopic positioning of a tooth does not usually constitute an
indication for extraction, except in those rare instances when a tooth
bud is rotated 180 degrees in its crypt (Figs 2-17a and 2-17b).
Horizontally impacted maxillary canines developing in the hard palate,
for example, do not need to be extracted; they can be successfully
brought into the arch orthodontically (see Fig 6-8).

Fig 2-17a Orientation of the tooth bud and the eruptive trajectory. The maxillary right
canine developed normally in the frontal process, but its tooth bud had been rotated 180
degrees.

Fig 2-17b Extraction of maxillary right canine in sections.

Malformation of roots
Root malformation alone is not an indication for extraction. An
impacted tooth with a curvature in the apical third of its root can be
moved owing to the continual remodeling of bone that is stimulated by
orthodontic force (see Fig 4-24b). If the entire root is curved and
traumainduced dilaceration was not the cause, appropriate
mechanotherapy should be applied to bring it into the arch so that
development of the sector of the alveolar process that depends on it
can terminate correctly (see Fig 1-17c).

Ankylosis
Ankylosis of impacted permanent teeth is defined as a fusion of the
root’s cementum with alveolar bone. Maxillary canines in individuals
40 years of age and older are particularly susceptible to this
complication (Stafne and Austin 1945), but ankylosis can also affect
impacted teeth of younger patients after they have been uncovered
surgically and are being treated orthodontically. Extraction is rarely
indicated for ankylosed teeth in older patients, but when movement of
an impacted tooth has stopped because of ankylosis in an adolescent,
extraction is almost always required.
Dental ankylosis is often regarded as a failure of the articulation of a
tooth root with its surrounding tissues, as typified by the union of
cementum with alveolar bone. Actually, two dental zones can
encounter bone and resorb: the tooth’s crown as well as its root.

Coronal ankylosis
The epithelial membrane that protects the coronal enamel of an
unerupted tooth from contact with connective tissue also isolates it
from follicular tissue. The partial or complete disintegration of the
coronal reduced epithelium, which occurs when it fuses with oral
epithelium as the tooth emerges into the oral cavity, may be
responsible for the asymptomatic resorptive lacunae that are
sometimes seen in enamel (Azaz and Schteyer 1978; Schulz and
Donath 1992). In 1958, Blackwood observed on histologic sections
that resorptive enamel lacunae formed in regions where reduced
epithelium was absent. Dentin can be affected secondarily. New
osseous tissue invariably invades these lacunae (Stafne and Austin
1945), establishing a solid union between dentin and bone and thus
depriving the tooth of movement (Fig 2-18).

Fig 2-18 Ankylosis of a crown. This axial section shows the substantial resorption and
subsequent ankylosis of the crown of the maxillary right canine, which required extraction.

For many years the protocol for uncovering impacted teeth for
orthodontic treatment consisted of developing a flap; completely
removing follicular tissue, which was believed to prevent it from
degenerating into a cyst; encircling the cervical region of the tooth with
a ligature wire; then suturing the flap in its original position. This
technique encouraged ankylosis in two ways: (1) by removing follicular
tissue and, with it, reduced epithelium, thus allowing direct contact
between the blood clot and enamel, and (2) by clearing bone from the
impacted tooth up to the dentoenamel junction, thus provoking enamel
and cemental lesions.

Radicular ankylosis
If ligamentary tissue disappears, ankylosis follows. The alveolar
surface fuses with the surface of the cementum, and all tooth
movement comes to a halt. Resorptive cemental and dentinal lacunae
develop, and these tissues decalcify and are progressively invaded by
cells originating in bone marrow.
 After an original traumatic event, a tooth that has not been
immediately stabilized by orthodontic or surgical intervention will
suffer, secondarily, from crushing of its periodontal membrane and
resorption of root tissues, which will quickly be replaced by bone cells
(Andreasen and Andreasen 1994).
Orthodontists can rarely make a definitive diagnosis of ankylosis on
the basis of clinical and conventional radiographic examinations. The
periodontal space that is depicted on radiographic film represents only
a portion of the proximal surface of the root. A CT scan, on the other
hand, displays the entire root surface through its axial sections;
nonetheless, its resolution of 0.5 to 1.0 mm is insufficient to discern
minute resorptions. When evidence of tissue resorption can be seen
clearly on a radiographic film, the practitioner must seriously consider
extracting the affected tooth (Fig 2-19).

Dentigerous cysts
A dentigerous cyst is a type of odontogenic cyst that occurs with
relative frequency and coincides with the cessation of a permanent
tooth’s eruptive migration through bone. The teeth most often affected
are, in decreasing order, the mandibular third molars, the maxillary
canines, and the mandibular premolars. These lesions are most often
revealed on routine radiographs of 10- to 20-year-old patients whose
teeth are in the mixed or young adult dentition stage (Shear 1992).
 Fig 2-19 Root ankylosis. This three-dimensional reconstruction shows extensive cemental
and dentinal resorption in a maxillary right second premolar (arrow) as well as invasion of
osseous cells.

The dental follicles of ectopic maxillary canines often appear

thickened on radiographs, but they do not require any adjustment in
protocol for uncovering impactions. However, when a cyst becomes
too voluminous or develops a suspicious polylobed extension, the
enclosed tooth must be extracted and the tumor excised (Korbendau
and Guyomard 1998) (Figs 2-20a and 2-20b; see also Fig 7-11).
When these lesions develop around mandibular premolars, they
often expand rapidly and extensively. Sometimes the precipitating
cause of a follicular cyst is a pulpal infection of a primary molar. If
there is no disharmony between tooth and jaw size, a conservative
approach may be adopted (see Fig 7-13); the tooth may be allowed to
erupt normally after the tumor has been excised, but only if sufficient
space has been prepared in the arch.
Fig 2-20a Dentigerous cyst. This ectopic maxillary canine is enveloped by an invasive
cystic tumor.

Fig 2-20b The tumor around the maxillary canine occupies virtually all of the maxillary
sinus and extends into the hard palate.
Preventive
Treatment of
Impactions
 Fig 3-1 Locations of maxillary supernumerary teeth. (Pp) Hard palate; (Pap) labial alveolar
process; (Pav) palatal alveolar process.

When orthodontists discern early indications of an ectopic eruptive

trajectory, especially of a maxillary canine, they can attempt to correct
the aberration and avoid unfavorable consequences. The means for
accomplishing these changes include:

• Extraction of supernumerary teeth and odontomas that may block

eruption

• Extraction of primary canines to change the orientation of the

permanent canines

• Improvement of the eruptive pathway when there is a risk of impaction,

by expanding the anterior maxilla, advancing the anterior teeth,
moving the buccal segments distally, or extracting selected permanent
teeth

Supernumerary Teeth and Odontomas

An aberrant tooth bud from a proliferation of the dental lamina can
create one or more supernumerary teeth, a phenomenon known as
hyperdontia. Only 25% of supernumerary teeth emerge into the oral
cavity; the rest remain impacted and often block the normal eruption of
 permanent teeth through bone. In the mandible, supernumerary teeth
are usually found in the premolar region and occasionally in the incisor
sector. However, more than 80% of supernumerary teeth are found in
the maxilla and, of these, 90% are found in the anterior region (Rajab
et al 2002), where embryologic modifications are most prevalent.
Malformed supernumerary teeth can develop within three regions
where sufficient spongy bone is available (Fig 3-1):

1. Hard palate: Conventional radiographs or computerized tomography

(CT) scans can reveal impacted supernumerary teeth in this elevated
area, where they pose no threat to the erupting permanent dentition
(Figs 3-2a and 3-2b).

2. Labial alveolar process: Supernumerary teeth are found in this area

only rarely (Figs 3-3a to 3-3c).

3. Palatal alveolar process: Supernumerary teeth are most likely to be

found in this sector and can become obstacles to the eruption of
maxillary incisors and even canines (Figs 3-4 and 3-5). These low-
lying impactions, which are known as mesiodentes when they erupt in
the midline, can also appear as conical or riziform structures (two or
three in number) posterior and inferior to the unerupted permanent
tooth.

Figs 3-2a and 3-2b This supernumerary tooth, impacted in an elevated position in the hard
palate, has not interfered with the eruption of permanent teeth.
Fig 3-3a The presence of two supernumerary teeth in the labial alveolar process did not
prevent the eruption of the maxillary permanent central incisors but did cause their
malposition.

Fig 3-3b A mucoperiosteal flap has been retracted from the gingival margin so that the
supernumerary teeth can be extracted.
 Fig 3-3c The marginal bony crest has been left undisturbed; the minor malposition of the
central incisors does not pose a risk for future malalignment.

Clinicians should perform exploratory radiographic examinations

when they suspect children have unerupted supernumerary teeth or
when they have noted a delay in eruption of permanent teeth during
the early stages of transition to the mixed dentition (around 9 years
of age). It is best to extract supernumerary teeth before problems
develop.

The longer extraction of supernumerary teeth is delayed, the greater

the risk that the affected permanent teeth will not erupt spontaneously.
By the time children are 10 years old, the apices of their central
incisors are almost fully formed and eruptive forces have diminished.
After this time, impacted teeth have to be uncovered surgically and
orthodontically repositioned. To make matters worse, space in the
arch may already have been lost if erupted incisors have drifted into a
midline deviation (Russell et al 2003).
 Fig 3-4a One year after the extraction of the maxillary right primary central and lateral
incisors, their permanent successors are still impacted in the palatal alveolar process.

Fig 3-4b The maxillary right central and lateral incisors are impacted in a high position.
Root formation of the central incisor is delayed.
 Fig 3-4c Limits of a planned mucoperiosteal flap.The incision line is marked close to the
alveolar crest and extended into the lingual sulci of the left permanent central incisor and the
right primary canine.

Fig 3-5a Labial approach for a palatally positioned supernumerary tooth. The maxillary
right primary central incisor of this 9-year-old child has not exfoliated. Because the mesially
inclined crown of the permanent successor was blocked against the intermaxillary suture, it
had to be moved to allow for unencumbered eruption.
 Fig 3-5b The impacted central incisor is uncovered and the supernumerary tooth removed
from a labial approach. At the same visit, an attachment is bonded to the central incisor.

Fig 3-6 Compound odontoma. Every dental tissue is represented in this tumor, which was
blocking the eruption of two incisors. Perfectly developed odontoid structures are seen amid
other irregular tissue masses (see Fig 4-24).

Odontomas, which are the most widespread “tumors” of dental

origin, are more accurately described as malformations. They are
composed of abnormal or imperfectly differentiated odontogenic
tissues that never achieved harmonious morphodifferentiation
(Chomette et al 1986) (Fig 3-6). The clinical signs of odontomas are
as imperceptible as those of supernumerary teeth. Clinicians should
suspect the impaction of permanent teeth when they note the
continued presence in the arch of one or more primary teeth in
children over the age of 10. Odontomas can impinge on the bony crypt
of a tooth bud or impede the eruption of a developing permanent
tooth, but only cause slight deformation of the cortical plate and no
accompanying signs of inflammation (Figs 3-7a to 3-7d). When
orthodontists palpate in the area of an odontoma, patients will report
no pain.

Fig 3-7a Odontoma and impacted canine. The tumor is inferior to the crown of the
maxillary right permanent canine and superior to the root of the maxillary right primary canine.

Fig 3-7b This axial CT scan shows the odontoma, which is developing in the center of the
alveolar process, displacing the permanent canine lingually, and causing a fenestration of the
palatal cortical plate.
 Fig 3-7c Axial sections of the crown, perpendicular to the axis of the arch, show that the
odontoma is adjacent to the labial surface of the impacted canine.

Fig 3-7d Extracted primary canine placed alongside the odontoma, which consists of small
odontoid structures whose odontogenesis has proceeded normally.

Impacted Maxillary Canines

The most opportune time to observe the maxillary canines beginning
their eruption and detect an eventual impaction is when children are
around 8 years of age. Orthodontists should be especially vigilant
during this critical period when maxillary canines migrate labially.

Overretention of primary canines

Permanent canines emerge when children are between 11 and 13
years of age. If a primary canine has not exfoliated at this stage,
orthodontists should consider this overretention as a result of, not a
 cause of, an ectopic position of its successor (Lappin 1951).
By taking conventional radiographs, orthodontists might find that:

• The permanent canine has not precipitated vertical resorption of the

primary tooth’s root.

• The canine crown is inclined too far mesially.

• The canine crown, having slipped over the root of the permanent
lateral incisor, is deprived of the eruptive guidance of the lateral
incisor’s distal surface.

Unerupted canines may be positioned palatally or labially.

Preventive treatment for an unerupted canine should be based on its
position relative to the lateral incisor, which can be verified by
additional periapical radiographs or CT scans (see chapter 2).

Palatally positioned permanent canines

A panoramic radiograph will reveal the pathway and impaction depth
of the unerupted canine.

Direction of the path of eruption

If the crown of the impacted canine is inclined mesially, the angle that
its long axis forms with the medial sagittal plane can be discerned on
a panoramic radiograph and measured on a frontal cephalogram.
When that angle is greater than 10 degrees, the crown will breach the
vertical reference line, which is an extension of the external surface of
the nasal fossae (Williams 1981) (Figs 3-8a to 3-8d). The greater the
angle, the worse the prognosis for the eventual entry of the impacted
tooth in the dental arch. When the canine crown appears
superimposed over the lateral incisor root, its path of eruption can be
deemed ectopic (Figs 3-9a and 3-9b).
 Fig 3-8a Spontaneous changes in the path of eruption of permanent canines. The long
axes of this 11-year-old boy’s unerupted maxillary permanent canines, which are mesially
inclined, form an angle with the median sagittal plane that is greater than 10 degrees, with the
tips of their cusps extending past the vertical nasal wall reference line. Their distance from the
occlusal plane can be measured on this panoramic film.

Fig 3-8b By the time this patient reached 17 years of age, his maxillary right primary
canine had exfoliated normally and the permanent successor had erupted into the arch and
reached the plane of occlusion. The left permanent canine, however, having embarked on a
different trajectory, was now at a 45-degree angle with the median sagittal plane, its crown
lying posterior to the root of the central incisor.
 Fig 3-8c The crown of the impacted left canine has been partially uncovered and a button
bonded to its palatal surface, leaving an opening in the mucosa. The right canine achieved
alignment unassisted.

Fig 3-8d Using orthodontic force, the maxillary left canine has been moved into the arch
without disturbing the integrity of the surrounding periodontium.
 Fig 3-9a Changes in eruptive pathways after extraction of maxillary primary canines. This
9-year-old boy’s unerupted maxillary permanent canines were mesially inclined about 30
degrees. As their crowns migrated toward the median sagittal plane, they completely covered
the roots of the peg-shaped lateral incisors. The maxillary primary canines were extracted.
 Fig 3-9b Two years later, both canines had uprighted and reached their correct positions in
the arch.

Impaction depth
By periodically measuring the depth of a tooth’s impaction from the tip
of its cusp to the occlusal plane, orthodontists can measure its
progression on panoramic radiographs as the patient ages from 8 to
13 years. A canine passes across the apical third of the root of the
lateral incisor as it traverses the alveolar process diagonally. Near the
midsagittal plane, the canine ends its trajectory lying over the
cementoenamel junction of the central incisor.
Radiographs taken every 6 months show that some canines will
upright their long axes spontaneously, while the position of others will
worsen as their angles of eruption open still further. In the 11-year-old
patient shown in Figs 3-8a and 3-8b, the two maxillary canines initially
had identical angulations. Over time, however, the long axis of the
right tooth progressively approached a vertical angle, while the long
axis of the left canine steadily became more horizontal.

Extraction of primary canines

Canines begin to deviate from a normal eruptive position in patients
 9 years of age. Orthodontists should monitor errant canines and, if
they do not emerge into the arch, extract the primary canines when
the patient reaches the age of 10.

Since Lappin’s 1951 article, many authors have reported that such
extractions often improve the eruptive position of permanent canines.
The teeth take the path of least resistance, to the area of new bone
formation in the site formerly occupied by the primary canine.
Extraction of primary canines should take place when the patient is 10
to 13 years old: Before age 10 unerupted canine teeth may align
themselves with no intervention, but after age 13 it may be too late for
extraction to help. Improvement in the status of the unerupted tooth
should become evident within 6 to 18 months. If no positive change is
seen, more complex strategies should be undertaken.
The extent to which an impacted tooth has moved horizontally plays
an important role in its capacity to change direction. A longitudinal
study of 46 canines (Ericson and Kurol 1988a) showed that 78%
changed their angulation in the 18 months that followed the extraction
of the primary canine. But the figure rose to 91% when the tip of the
canine’s cusp had not passed the midline of the lateral root (see Fig 3-
9a).
For unerupted canines to emerge properly into the arch, space for
them must be maintained or even increased after extraction of the
primary teeth (Power and Short 1993; Jacobs 1998; Leonardi et al
2004).

Labially positioned permanent canines

A correlation exists between labially positioned ectopic maxillary
canines and anterior crowding (Jacoby 1983). When the orifices of the
nasal fossae are narrow, intercanine width is reduced, and the lateral
incisors tend to be more distally inclined than usual. The lateral incisor
roots often assume a more palatal orientation than the roots of the
central incisors. As a result, the crowns of the canines do not have the
eruption guidance normally provided by the distal surfaces of the
lateral incisor roots and therefore move into labial malpositions, often
inducing the crowns of the lateral incisors to tilt labially as well.
Preventive treatment for this condition consists of increasing the
intercanine width to provide suitable eruptive guidance for the
maxillary canines.

Providing Eruptive Guidance

While preventive treatment against possible impaction can be
undertaken for any permanent tooth, the maxillary canines become
impacted more frequently than any other teeth. Initial treatment
prepares the dental arch so that there will be adequate room for the
erupting tooth or focuses on making basal bone, especially in the
anterior maxilla, more capable of accepting the tooth. Maxillary
canines erupt bilaterally where the anterior and posterior regions of
the maxillary arch intersect. These osseous structures have different
embryologic origins: The anterior maxilla derives from the anterior
nasal bud, while the posterior maxillary segments are formed by a
fusion of the maxillary buds.
The follicles of the maxillary canines are located at the mesial
extremity of the premaxillary suture during periods of active growth
(Fig 3-10). Any deviation in or disturbance of that osseous growth can
provoke a change in the orientation of canine tooth buds.
 Fig 3-10 Anterior maxilla of a 4-year-old child. The follicles of the maxillary canines are
located at the mesial extremity of the premaxillary suture, behind the orifices of gubernacular
canals of the lateral incisors. These relatively major fenestrations appear because the bony
crypts of the lateral incisors are closer to the occlusal plane than are those of the central
incisors.

Four factors govern the eruption of permanent canines into normal

position in the arch:

• Position of the tooth bud in its bony crypt

• Path of eruption

• Shape and position of the lateral incisors

• Amount of space available for the canines in the arch

When interceptive measures are necessary to provide eruptive

guidance for a maxillary canine, treatment must begin in the mixed
dentition. If there is a lack of space for teeth other than canines to
erupt into, the mechanical factors (eg, an interfering structure or
abnormal tooth inclination) can be treated by orthodontic realignment
of the arch. Because canines have far longer paths of eruption than
the other teeth, the eruptive pathways between the lateral incisors and
the first premolars must be free from obstacles to ensure an
unencumbered eruption. If the bud of the maxillary canine lies under
the apex of the root of an adjacent permanent tooth, the orthodontist
should not extract the interfering tooth, but rather make room for the
canine to migrate into the arch (Figs 3-11a to 3-11d).
Lack of space for eruption of maxillary canines may be due to:
underdevelopment of the anterior maxilla, perhaps owing to a mouth-
breathing habit; migration of neighboring teeth into space needed for
the canine; forward movement of the entire buccal segment; or a lack
of harmony between tooth size and jaw size.
When arch-length discrepancy in the mandible is severe enough to
necessitate premolar extraction, premolars will often have to be
removed in the maxilla as well. When extractions are not indicated,
treatment relies on expansion, distalization of the buccal segments,
and/or advancement of the anterior teeth to provide eruptive guidance
for the canines.
Orthodontists use cephalometric analyses to formulate differential
diagnoses in deciding whether to advance the incisal group, retract
the buccal segments, or extract premolars to correct the malocclusion.

However, no technique providing eruptive guidance can overcome

faulty tooth bud orientation of genetic origin.

In attempts to provide eruptive guidance in young patients,

orthodontists should remember that it is dangerous to close
diastemata between lateral and central incisors by correcting a distally
inclined lateral incisor crown (Figs 3-12a to 3-12b). Broadbent (1941)
warned that such a procedure risks impaction of the canines and
resorption of lateral incisor roots.

Expansion of the anterior maxilla

There is a close relationship between soft and hard tissues in the
anterior maxillary region. Orthodontists should not disregard the
reciprocal actions that the facial tissues and the transitional zones of
the dental arches can exert upon each other. The cheeks and the lips,
for example, exert functional forces in the area around the nose.
Sometimes symmetric or asymmetric pathologic constraints can be a
factor, as they are for children with obstructions in one or both nostrils.
Any change in the size of the choanae affects the distance between
their neighboring structures, the maxillary canines (Talmant et al
2003).
The extraperiosteal width of the base of the piriform orifice is
approximately equal to the size of the bony crypts of the central
incisors (Figs 3-13a and 3-13b). During the growth period, the piriform
orifice’s relationship with the width of the maxillary incisal block
remains linked to the amount of space occupied by the apices of the
maxillary incisors, while the canines remain symmetrically positioned
on each side of the nasal fossae. Movement and alignment of the
maxillary incisor follicles play an important role in the enlargement of
the intercanine arch in the transverse growth and physiology of the
anterior maxilla (Delaire 1974).

Fig 3-11a Providing eruptive guidance. Serious crowding on a Vshaped maxilla is a sign of
deficient bone growth. Note the rotated right lateral incisor and the lingual position of the left
lateral incisor. Clinical examination suggested that successful treatment without extraction
could occur by moving the maxillary molars distally into a Class I relationship.
 Fig 3-11b The maxillary canines, which are positioned high above the apices of the lateral
incisors, do not have sufficient room to erupt. Note the 30-degree angulation of the maxillary
left canine.

Fig 3-11c After a 6-month expansion with a Quad-helix, the buccal segments were moved
distally with a Hilgers pendulum. The maxillary primary canines are ready to be extracted.
 Fig 3-11d Panoramic film taken 2 years after the beginning of treatment showing all the
teeth in their correct positions. The maxillary canines did not require surgical uncovering.

Fig 3-12a Risks associated with changing the axial inclination of lateral incisors. The
crowns of the unerupted maxillary canines of this 9.5-year-old boy, which were overangulated
mesially by about 15 degrees, had come into contact with the apices of the lateral incisors.
Fig 3-12b After widening the maxilla with a rapid maxillary expansion device, a Quad-helix
was used for retention, and a full-banded appliance closed the midline diastema and
uprighted the lateral incisors; this was, perhaps, the iatrogenic cause of the extensive root
resorption.

Fig 3-13a Frontal section of the premaxilla of a 24.5-week-old human fetus. (Photo
courtesy of Dr J Talmant.)
 Fig 3-13b The extraperiosteal width of the base of the piriform orifice is approximately
equal to that of the bony crypts of the maxillary primary central incisor tooth buds.

This widening of the maxilla enlarges the base of the piriform orifice
and develops the associated soft facial tissues of the nasal floor and
the nasal passages. The shape of the nostrils is an important factor in
nasal function (Talmant et al 2003). Orthodontists frequently
encounter underdevelopment of one side of the nasal pyramid and its
nostril owing to the absence of a lateral incisor, the presence of a
diminutive lateral incisor, or the excessive crowding of the incisors,
each of which reduces the amount of associated maxillary bone that
would have constituted part of the nasal floor.

The chain of events can be summed up in this way:

• Deficiency of dental substance

• Deficiency in transverse growth of the anterior maxilla

• Deficiency in the mechanical support required for optimal nasal

function

Orthodontists can perform an early expansion of the anterior maxilla

during maxillary incisor eruption to ensure correct and stable dental
alignment as well as to enlarge, indirectly, the nasal floor. This will
also ensure good support from the facial tissues and the enhanced
piriform orifice as well as position the canine tooth buds to prevent
impaction.
Expansion in the anterior part of the intermaxillary suture should
take place before children reach the age of 12 years, while it is
possible to distalize the canines as well as the central incisors. This
expansion improves the tone of the facial tissues, widens the piriform
orifice, and may benefit the mandible: intercanine width can increase if
maxillary expansion is accomplished before eruption of the mandibular
canines.
Once mechanotherapy is concluded, a course of myotherapy to
improve and stabilize proper breathing and tongue function could
improve retention of the orthodontic and orthopedic corrections
(Talmant et al 2003; Chauvois et al 1991).

Mechanics of maxillary expansion

Expansion techniques must respect the anatomic integrity of the
growing membranous suture, especially the collagenous fibers of the
osteogenic zone. To be effective, an orthopedic mechanism must
apply tension to collagenous fibers on the osseous borders without
breaking them. Expansion should be carried out slowly, with forces
gentler than those delivered by rapid maxillary expansion devices. A
few months after the midline suture has been expanded, the
orthodontist can begin aligning the incisors distally on either side of
the suture. The gingiva will prevent diastemata as the central incisors
begin to move toward the median sagittal plane. This is preferable to
rapid maxillary expansion, during which central incisors are forcibly
separated (Talmant et al 2003). The Quad-helix is the best appliance
for maxillary expansion because of its gentle force; in the mixed
dentition it can be used for situations indicated for rapid maxillary
expansion (Henry, 1993). When cemented in place, the Quad-helix
should be fully activated to maximize orthopedic expansion and
minimize tooth movement.
The Quad-helix, unlike the rapid maxillary expander, can operate
selectively to allow:
• Correction of molar rotation, which adds 2 mm of available space on
each side of the arch (Figs 3-14a and 3-14b)

• Expansion of the anterior sector and, if necessary, the posterior sector

The Quad-helix exerts slow and continuous forces on the midline

suture and maxillary dentition. Bell and Lecompte (1981) studied the
expansion of the intermaxillary suture through radiographic
examination just 2 weeks after beginning the active phase of
treatment. Displacement of the maxillae using Quad-helix expansion
was linear, asymmetric, or angular (Bell 1982).

Fig 3-14a Severe crowding of anterior dentition in a 9-year-old girl. Unerupted maxillary
canines were normally inclined, but the incomplete development of the maxilla and palatal
position of the incisors made the space insufficient for proper canine emergence. The eruptive
pathways were reconstituted by expanding the maxilla with a Quad-helix appliance and
moving the incisors anteriorly with an advancement arch.
 Fig 3-14b Panoramic radiograph of the patient at 11.5 years. The canines are migrating
into the restored eruption pathways. The patient was treated without extractions because
tooth size and size of the mandible were in harmony.

The orthopedic separation of the maxillary segments is linked to the

distance from the supranasal area (Fig 3-15). The further an area is
from this point, the greater the displacement can be; the teeth and
alveoli that are more distant from the supranasal area can undergo
more dramatic movement than tissues adjacent to the midline suture.
From an occlusal view (Fig 3-16), the separation of the maxillary
segments is angular—wider anteriorly and more narrow posteriorly. As
the primary teeth are carried buccally, the permanent tooth buds
follow, thus altering the eruption sites of the permanent dentition (Bell
1982).
 Fig 3-15 Frontal view of orthopedic separation of the intermaxillary suture with the lateral
inclination of the maxillae and the teeth. (After Bell 1982.)

Fig 3-16 Occlusal view of orthopedic separation of the intermaxillary suture. The structure
of the gap, greater anteriorly than posteriorly, provokes a lateral and posterior rotation of the
maxillae. (After Bell 1982.)
Advancement of the anterior segment
Orthodontists can treat insufficient anterior arch length resulting from
lateral underdevelopment of the maxillae (revealed by a frontal
cephalogram) by moving the anterior teeth forward with an
advancement arch.

Fig 3-17a This 10.5-year-old girl’s unerupted canines were inclined mesially about 30
degrees, the tips of their cusps lying 15 mm from the occlusal plane.

Fig 3-17b A Hilgers pendulum was placed in the maxillary arch.

 Fig 3-17c In 6 months the appliance has achieved significant changes. The Hilgers
pendulum was replaced with a Gosgharian-Nance, or a Quad-helix.

Fig 3-17d Quad-helix in place. The treatment has provided enough space for unimpeded
eruption of the canines.

Distalization of the buccal segments

For treatment of Class II molar relationships that have resulted from
mesial drift of the maxillary buccal segments, orthodontists have a
variety of mechanisms at their disposal (eg, transpalatal bar, Quad-
helix, Hilgers pendulum, distal jet, and extraoral force) (Figs 3-17a to
3-17d).

Extraction of permanent teeth

When a serious discrepancy between the size of the teeth and that of
the jaw requires extraction of premolars, early removal of the teeth
allows unerupted canines that are correctly positioned vertically to
migrate into the extraction sites and avoid drifting into ectopic labial
locations.
Criteria for
Choosing Orthodontic
and Surgical
Protocols
 If measures taken to prevent the impaction of teeth have been
ineffective or if orthodontic consultation has been delayed too long, a
combined surgical-orthodontic treatment can be implemented to help
impacted teeth emerge into the arch.

Stages of Orthodontic Treatment

Impacted canines
For patients with impacted canines, orthodontists must consider a
number of parameters before discussing a treatment plan. After
clinical and radiographic analyses, patients and parents can be
presented with the advantages and disadvantages of three options:

1. No treatment for the impaction. If a patient decides to have neither

surgical nor orthodontic treatment, the orthodontist should monitor the
impacted tooth by radiographic examination, looking for the
development of pathologic changes such as root resorption of
adjacent teeth. The patient must be informed of all associated risks,
including the poor prognosis for long-term retention of the relatively
unesthetic, short-rooted primary canines.

Extraction of the impacted tooth. Once it is extracted, the canine must

be replaced. Provided that sufficient space is available, an implant or
a fixed partial denture can be planned for when the adult dentition has
fully matured (see chapter 2). Another solution is to move the distal
teeth forward, replacing the missing canine with the first premolar.
However, the first premolar is usually an unsuitable replacement for
the canine in terms of esthetics, volume, and function.

3. Combined surgical and orthodontic treatment. This option would be

the most satisfactory solution. If sufficient room is available for the
canine, all teeth can be preserved. In cases of crowding, orthodontic
treatment can create additional space, which sometimes necessitates
surgical extractions of permanent teeth.

When orthodontic treatment is indicated for an impacted canine, the

orthodontist must determine if there is sufficient space in the arch for
proper alignment of all teeth. Insufficient space requires extraction,
usually of the first premolars. Orthodontists, patients, and parents
should evaluate all pertinent factors (eg, probability of success,
anticipated length of treatment, and motivation and cooperation of the
patient). Extraction is frequently necessary when treatment is delayed
or when there are major discrepancies in arch length.
In treating impactions, orthodontists should first level the teeth
already in the arch and correct any rotations or malpositions before
opening the space for the emergence of the unerupted canines.

Opening space in the dental arch

This treatment stage should follow a series of steps formulated during
orthodontic assessment.

Closing diastemata
If diastemata are present between incisors, orthodontists may be able
to recover the missing millimeters simply by closing them (Figs 4-1a
and 4-1b). Room can be created by placing an active open-coil spring
between the lateral incisor and the premolar. Before applying mesial
pressure to the lateral incisor crown, orthodontists should be certain
that this movement will not thrust the tooth’s root into a position where
contact with the unerupted canine will provoke resorption.
If it has not exfoliated, the primary canine can be preserved to
maintain space in the dental arch (see Fig 5-2a) until the permanent
canine is uncovered and bonded to an attachment. The primary
canine can be extracted at the same appointment.
 Fig 4-1a The diastema between the maxillary right central and lateral incisors was closed
with an active open-coil spring, which acted more on the crowns than on the roots because its
force application was distant from the center of resistance. An uprighting spring was then
used to move the lateral incisor root out of the space into which the crown of the erupting
canine was being directed.

Fig 4-1b Components of the space-opening appliance: (1) full heavy steel archwire, (2)
open-coil spring to create space, (3) bonded attachment loop, and (4) 0.012-inch twisted
metal ligature wire with loop.

Moving buccal segments distally

The treatment plan may include distal movement of buccal segments
 using extraoral force, a transpalatal arch, a Quad-helix, a Hilgers
pendulum, or a distal jet (see Figs 3-17b and 3-17d).

Advancing anterior teeth

For this procedure an advancement arch, a Quad-helix-Crozat, or a
variety of other appliances can be used (Patti and Perrier 2003).

Increasing arch length

An arch-length deficiency frequently creates problems in the anterior
sector with inadequate intercanine width. Orthodontists can increase
space using a Quad-helix or an ideal nickeltitaniun archwire that
produces 1 mm of available arch space for each millimeter of
expansion in the canine region. Expansion of 2 mm in the premolar
region and 4 mm in the molar region will add 1 mm of useable arch
length to the dentition.

Extractions
When extractions are required, first premolars are usually selected
because they are close to the impacted canines, where the additional
room is required. However, this procedure is elected only when a
severe discrepancy between tooth and jaw size cannot be corrected
by any other means to recover the necessary space.

Orthodontists should create the required space before the impaction

is uncovered. Obtaining more room than required in the treatment
plan can compensate for any anchorage loss when full archwire
tension is applied to the emerging canine.

Preparing anchorage and the active unit

The second step in treating impaction cases is preparing the
anchorage teeth and the active unit, which includes the appliance and
the teeth that need to be moved. There are four types of anchorage
that orthodontists can employ for activation forces:

1. Removable appliances. The disadvantage of the removable acrylic

appliance is that it requires cooperation from patients, some of whom
find it uncomfortable to wear. Less cumbersome chrome-cobalt
 appliances may be more acceptable. Orthodontists can insert
appliances at the start of treatment if there is sufficient space in the
arch and the teeth are in good alignment. They are recommended for
determining whether the impacted tooth is ankylosed or capable of
movement; the applied traction will not create adverse effects in the
anchorage unit. If traction is accurately calibrated and the canine is
not ankylosed, the orthodontic appliance can draw the impacted tooth
into position in the arch. In these situations, some authors suggest
using a magnet strategically embedded in the appliance to attract a
reciprocal magnet bonded to the tooth crown, but there has not yet
been wide acceptance of this technique.

2. Anchored teeth. After leveling, alignment, and space creation have

been completed, orthodontists may bind the anchorage teeth together
as a unit, using a rigid 0.018 × 0.022-inch steel archwire.

3. Steel archwire. Before highly elastic nickel-titanium archwires were

available, orthodontists sometimes used a steel archwire to move
teeth by bending appropriate loops into it.

Transpalatal bar. When it is cemented to the maxillary first molars, this

appliance can supply transverse support to the anchored teeth for the
force applied to the impacted canine (see Fig 4-24g).

Fig 4-2 Components of a bonded eyelet.

 Fig 4-3 Eyelet bonded near the tip of the impacted canine.

Once preparation is complete, the impacted tooth can be uncovered

and the active unit put in place.
The active unit is the appliance that moves the impacted tooth via
force applied to its bonded attachment. A number of small
attachments, composed of a base with a steel mesh surface and an
exterior button, ring, or eyelet, are available for bonding to the
impacted tooth at the time it is uncovered (Figs 4-2 and 4-3).
Orthodontists place an attachment in the most strategic position on
the crown to bring the tooth into the appropriate position in the arch.
Depending on access, the surgeon will bond the attachment on one
of three surfaces:

• Buccal—this is usually the best location (see Fig 4-3)

• Distal

• Palatal—this often provokes rotation that could extend treatment time

unless correct preplanned mechanics are used to prevent it (see Fig
5-10j)

Preoperative protocol for bonding the attachment

Orthodontic bonding materials

There are four families of orthodontic bonding agents:

• Traditional hydrophobic
• Hydrophilic

• Self-etching

• Glass-ionomer cements modified with resin composite

The first three agents consist of an adhesive and a composite, and

the fourth is a type of cement that does not need an additional
adhesive (Hitmi et al 2002).
A successful bond is particularly important in surgical orthodontics;
after uncovering the impacted tooth and bonding an attachment with
its ligature, the practitioner must sometimes re-cover the crown with a
mucoperiosteal flap sutured in its original position.

Preparing the enamel surface

A 5- to 6-mm-diameter section of the crown’s enamel surface must be
uncovered for the 4-mm attachment.
The enamel is cleansed with a small pumice-impregnated brush and
then carefully rinsed. However, the abrasive pumice is unnecessary
when preparing a newly uncovered tooth because it takes 2 hours for
the glycoproteins in saliva to form an acid-resistant film on newly
exposed enamel (Nielsen et al 1975). After rinsing, a brush is passed
over the tooth, and then the tooth is carefully dried. Any saliva or
blood will contaminate the enamel surface.

Enamel etching
Before bonding with traditional hydrophobic or hydrophilic agents,
orthodontists must etch the enamel with phosphoric acid to enhance
bond strength.
For the desired chalky white “bond-friendly” enamel surface, the
acid concentration must be at least 20%. Most orthodontists use a
35% solution and follow the 30-second application recommended by
numerous studies. By incorporating phosphoric acid in a colored gel,
application can be restricted to the area of enamel receiving the
attachment (Hitmi et al 2002).

When bonding immediately follows surgery, orthodontists should not

 blast air on the prepared area because it can dry the enamel
excessively, compromise hemostasis, and result in a fine spray of
blood on the enamel surface. Instead, an aspirator is placed on the
bonding region and held in place until the enamel turns the
characteristic chalky white.

Positioning the attachment on the enamel

Using a twisted 0.14- or 0.355-mm ligature wire that has been fixed
through the eyelet or around the button, the authors prepare the
metallic attachments under sterile conditions. Before bonding, the
ligature wire is adjusted to conform to the site of the impaction. The
end of this ligature is bent into a loop (Fig 4-4).
The resin composite bonding agent will polymerize either chemically
or photochemically and should be hydrophilic. The essential
component of such agents (eg, Transbond MIP, 3M Unitek; Ortho
Solo, Ormco) is an adhesive that does not react poorly to humidity and
can be used with any photopolymerizing resin composite. Even when
using these more forgiving products, orthodontists should not neglect
the preliminary stage of drying the enamel. However, even if the
drying process is not entirely successful, these agents, unlike the
hydrophobic types, often demonstrate great tolerance and good
performance (Hitmi et al 2002). After applying the bonding agent to
the chalky enamel, the surface must be rapidly dried with the
aspiration nozzle to evaporate the solvent in the adhesive. Both the
adhesive and the resin composite are then polymerized:

1. Place a small amount of resin composite on the base of the

attachment (Fig 4-5).

2. After removing the aspiration nozzle and any excess resin composite,
immediately place the attachment.

3. Photopolymerize the resin composite from four different positions,

always being careful to place the lamp as close as possible to the
attachment, especially when access to the site is difficult.

Self-polymerizing bonding agents

 These bonding materials (eg, Prompt L Pop, 3M ESPE; Transbond
Plus, 3M Unitek) are self-etching because they decalcify the enamel
while introducing the adhesive. With these products enamel
preparation is less complex, requiring only a simple cleaning and
surface drying. The attachment is placed as follows:

1. Clean and dry the canine surface.

2. Apply the self-polymerizing adhesive for 15 seconds, while carefully

protecting the enamel surface against contamination by blood or
saliva.

3. Lightly dry the adhesive to evaporate the solvent.

4. Place the attachment, with the resin composite on its base, on the
enamel surface and polymerize the resin composite.

Fig 4-4 Metal button with attached twisted ligature ending in a 0.012-inch loop. The ligature
length is adjusted to the depth of the impaction when the tooth crown is uncovered.
 Fig 4-5 Limited amount of resin composite placed on the base of the attachment to
minimize afterbonding.

Resin-modified glass-ionomer cements

Resin-modified glass-ionomer cements (eg, Fuji Ortho,
photopolymerizing type, GC) can be used with a self-etching adhesive
(Altounian 2000; Hitmi et al 2002). This protocol eliminates the rinsing
required when a polyacrylic or phosphoric acid is used in enamel
preparation—a step that can provoke seepage and weaken bond
strength. An additional advantage of using these products together is
that they strengthen the mechanical bond and cause less alteration to
the enamel surface.
The orthodontist and oral surgeon should determine which
attachment position on the exposed crown will best serve the desired
tooth movement. For example, the orthodontist might want it placed
mesially or distally to simplify rotation control, even during the initial
stage of vertical tooth movement. For certain clinical situations, the
orthodontist might even request the placement of attachments on both
the buccal and lingual surfaces, to better guide tooth movement. New
radiographic techniques, particularly computerized tomography, have
improved the visualization of an impacted tooth’s position and its
relation to adjacent teeth and have facilitated this collaboration.
The orthodontic goal is to move the impacted tooth as efficiently as
possible, because unnecessary detours not only prolong treatment but
also risk damaging the roots, especially in adults.

Moving the impacted tooth

Orthodontists begin moving an impacted tooth toward its place in the
arch using an elastic band, an elastic chain, or a closed nickel-titanium
spring that is attached to the ligature wire with a terminal loop secured
to the bonded attachment (see Fig 4-22c).
As the canine moves toward its assigned position, the attached
ligature wire can be shortened and its terminal loop re-formed. When
the tooth is close enough, its attachment can be tied directly to the
archwire. To avoid soft tissue inflammation and injury, elastic ligatures
or chains should not be used when an attachment is covered by
mucosa. They can be used, however, once the attachment becomes
visible.
Force can be applied to impacted teeth from a sectional archwire
inserted in the apical tube of a double buccal tube (see Fig 5-8c). This
sectional archwire offers better directional control of force, thanks to
the bends and loops that are created to increase its elasticity, and a
gentle, continuous force that can be easily adjusted. This type of
appliance offers the additional benefit of not deriving anchorage from
teeth adjacent to the impaction, an arrangement that could provoke
unwelcome reciprocal movements (Fig 4-6).
Orthodontists should perform a biomechanical evaluation of the
clinical situation to select a mechanotherapy using gentle force that
can bring the tooth efficaciously into its final position in the arch.
Fruitless back and forth movements not only subject the tooth’s root to
possible resorption but also risk frictional contact with neighboring
teeth.

The forces employed for moving impacted teeth should be gentle

and continuous, and not strong enough to cause an overly rapid
movement that would impair the periodontal tissues. Recommended
force levels, which can be applied as soon as bonding is completed,
are 30 g for vertical, extrusive movements, and 50 g for horizontal
movements.

Because of lack of precision, the authors do not recommend applying

force via elastic bands from the mandible. Although some practitioners
suggest using this method, there is no way of controlling the direction
 or the amount of pressure that will be delivered every time patients
open their mouths.

Vertical, extrusive movement

Orthodontists can assist natural vertical movement with gentle force,
but it is often unnecessary; the horizontal force applied to the
uncovered canine usually stimulates emergence as well. Many
systems have been proposed to accomplish this goal, including the
following:

• Ballista sectional (see Fig 5-7f).

• Multipurpose sectional. The authors recommend this system because

orthodontists can control all movements called for in the treatment
plan to guide the tooth toward the prepared site in the arch. It is made
of 0.016 × 0.022-inch steel titanium-molybdenum alloy (TMA) archwire
with two horizontal loops, one just mesial to the molar tube and one at
the site the impacted canine is destined to occupy (see Fig 4-6a). The
distal loop is used to activate the anterior, buccal sector of the
sectional wire and applies force to move the tooth buccally; the loop
mesial to the molar tube allows orthodontists to activate the anterior
palatal component of the sectional to move the tooth distally. For
palatal movement, orthodontists should ligate the sectional over the
full archwire in the premolar region, but for buccal movement the
sectional should be free, not ligated.

Buccal movement
Orthodontists can obtain buccal movement by tying the impacted tooth
directly to the rigid full archwire using an elastic ligature or chain.
Space for the tooth can be maintained by placing an open-coil spring
or a tube on the full archwire between the brackets of the lateral
incisor and the first premolar. Without such measures, especially if a
small-diameter archwire is used, the lateral incisor and premolar may
be drawn together palatally as the canine is moved buccally (see Fig
4-6b). Accordingly, when a palatally impacted canine has to be moved
a considerable distance, orthodontists should select a sectional
archwire such as the one shown in Fig 4-6a.
When the impacted canine nears its final position, orthodontists
should replace the bonded button or eyelet with a bracket with
negative or buccal root torque; simply inverting a normal bracket with
palatal root torque (+22 degrees) converts it to a bracket with strong
buccal torque (–22 degrees). By this means, orthodontists can bring
the root of the impacted canine, which would otherwise have remained
too palatal, into correct position while the crown assumes its place in
the arch.
Final alignment is achieved with full archwires.

Fig 4-6a Patti multipurpose sectional archwire with posterior (b1) and anterior (b2) loops.

Fig 4-6b Movement from archwire traction. The maxillary right lateral incisor and first
premolar are drawn together (blue arrows), while the lateral incisor is moved palatally (black
arrow).
 Orthodontists should study the directional mechanics of tooth
movement with as much attention as they devote to planning the
intensity of force. A sound choice of vectors can maintain the health
of the periodontal tissues surrounding the impacted tooth, while a
poor choice could cause soft tissue deterioration and lengthen
treatment time.

The types of force applied to palatally and buccally positioned

canines are discussed in chapters 5 and 6, respectively. To clarify
how the different appliances are constructed, they have been mounted
on typodonts in simulated clinical conditions.

Final detailing and retention

Alignment of the once-impacted canine in the arch is perfected with a
series of full nickel-titanium or steel archwires that increase in
diameter. At the completion of active treatment, traditional retention
devices are used.

Integrating the canine into functional occlusion

A formerly impacted canine that has reached its correct position in the
arch with a healthy periodontium should assume the same role as
those of normally erupting canines. To be considered correctly
positioned:

• Vertically: The canine should be more occlusal than the lateral incisor
and at the same level as the central incisors.

• Mesiodistally: The canine should be inclined mesially with its root more
distal than the crown.

• Buccolingually: The canine should be inclined to the same angle as the

mandibular antagonist so that, on average, the intercanine angle is
136 degrees. The triangle that their crowns form allows free function
and prevents mandibular locking, which limits excursive masticatory
movements, overloads the tooth and the periodontium, and risks
repercussions in the neuromuscular and articular systems (Slavicek
2000; Patti and Cardonnet 1998).
Impacted central incisors
When a maxillary primary central incisor remains too long in the arch,
parents usually notice it and arrange for an orthodontic consultation.
The same is true when the primary tooth has been lost and adjacent
permanent teeth have drifted into the space. In other instances
impaction is not discovered until a practitioner takes radiographs.
Local factors, such as follicular cysts, are responsible for the
majority of impacted incisors. Thickening of the pericoronal follicular
membrane, which is a frequent consequence of impaction, can lead to
pulp necrosis of the overretained primary tooth, which in turn causes
infection of the impacted tooth’s follicle. As the cyst develops, it may
not only block eruptive progress but even begin to move the central
incisor deeper into the maxilla. The first step to treating this problem is
extraction of the overlying primary tooth and creation of an opening in
the mucosa to restimulate emergence of the blocked permanent tooth.
When a primary incisor is lost prematurely, modified keratinized
tissue frequently grows into the space. If the unerupted permanent
successor lies immediately apical to this barrier, a simple incision in
the mucosa is often all that is needed to stimulate spontaneous
emergence. If the central incisor occupies a deeper position, the
surgeon should retract a flap apically to expose the crown and bond
an attachment. Orthodontic force can then be applied to assist the
tooth in resuming its eruption into the arch.
Treatment for an impacted permanent tooth usually begins in the
mixed dentition when room for it in the arch has not yet been entirely
lost. Orthodontists can restore lost space by placing a sectional 0.016
× 0.022- or 0.018 × 0.025-inch steel archwire with an open-coil spring
placed between the brackets on the adjacent lateral and central
incisors. In most cases, this allows the unerupted tooth to find its way
into position unaided. If additional help is required, orthodontists can
tie a light elastic ligature from the arch to an attachment on the tooth’s
crown without risking a reciprocal effect on the two anchorage teeth
(see Fig 4-19). When more secure anchorage is needed to support
advancement or intrusion, a utility archwire can be used with an open-
coil spring placed between the central and lateral incisors. When the
crown lies primarily horizontally and buccally, the lingual force should
be applied from a lingual hook placed between the central and lateral
 incisors.

Impacted premolars
When a primary second molar is lost prematurely, the permanent first
molar may drift mesially and impede eruption of the second premolar.
Orthodontists can use a variety of appliances to assist in uprighting
the molar (Patti and Perrier 2003):

• Removable appliance equipped with a spring

• Lip bumper

• Utility arch, if incisors need to be intruded (a tip-back bent mesial to the

molar will help to upright it)

• Sectional uprighting archwire

• Full archwire with an open nickel-titanium coil spring between the

molar tube and the first premolar bracket

Impacted molars
On the rare occasions when premolars and molars—other than third
molars—become impacted, some physical impediment like a
dentigerous cyst or a malpositioned tooth is usually responsible. When
such teeth are ankylosed, they must almost always be extracted. But if
they are merely blocked as a result of errant tooth movement,
orthodontists can treat them successfully.
A primary second molar can overhang a permanent first molar and
impede its eruption (Fig 4-7). If the obstruction is minor, orthodontists
can free the blocked tooth by placing a brass separating wire between
the primary and permanent molars and tightening it every 2 weeks.
This treatment occasionally needs to be accompanied by local
anesthetic.
Permanent second molars can also be impacted, but much less
frequently than third molars. Etiologic factors include insufficient space
owing to a disharmony between tooth size and jaw size, ankylosis, or
an iatrogenic complication of badly planned orthodontic treatment.
Injudicious distalizing mechanics applied to maxillary first molars, via
extraoral or intraoral forces, can transfer the anterior space deficit to
the posterior region and cause impaction of second molars (Raberin
2004). A poorly conceived plan of mechanotherapy that would include
strong tip-back bends in a utility arch to intrude the mandibular
anterior teeth in a strap-up with inadequate molar stabilization could
impart an undesirable distal inclination to the anchor teeth, blocking
out the second molars.
After part of the crown of an impacted second molar has been
surgically exposed, an attachment can be bonded to the distal portion
of its occlusal surface. Orthodontists can then cement an appliance in
place to upright and extrude the second molar distally. A U-shaped
0.036-inch steel wire distal loop must extend far enough distally from
the impacted tooth that elastic traction can effect the desired
movements. Orthodontists can stabilize this process by ligating a
sectional archwire to the first molar, the premolars, and eventually the
canine. As soon as the second molar emerges sufficiently into the
arch, orthodontists can bond a tube and place a new sectional
archwire to complete the uprighting process (Figs 4-8 and 4-9).

Surgical Approaches to Impacted Teeth

Replaced and displaced flaps
Replaced flaps are mucoperiosteal flaps that provide direct access to
the cortical plate and allow surgeons to uncover impacted or
supernumerary teeth as well as to treat cystic lesions. In each case,
surgeons replace the flap and suture it into position (Fig 4-10).
Displaced flaps, which can be of full or partial thickness, are used to
encourage an impacted tooth’s eruption by surgical exposure in the
oral cavity. Surgeons will move the gingival flap apically so that at
least part of the impacted tooth will remain uncovered (Fig 4-11).
 Fig 4-7 Impacted maxillary right first molar. The tooth is unable to erupt because of the
forward movement created by resorption in the primary second molar.

Figs 4-8a and 4-8b Orthodontic force applied to an impacted second molar. (a, left) A
button has been bonded to the surgically uncovered occlusal surface. A fixed 0.036-inch blue
Elgiloy lingual archwire cemented to the first molars carries a U-shaped extension lingual to
the mandibular right first and second molars. An elastic ligature can be tied from the
extension’s distal, closed loop on the midline of the arch to the button on the second molar. (b,
right) Close-up of the elastic ligature, tied between the lingual archwire’s terminal eyelet and
the second molar’s bonded button, which exerts distal extrusive force on the tooth.
 Fig 4-9a After extraction of the second molars, both mandibular third molars of this 18-
year-old patient became impacted.

Fig 4-9b After 3.5 months, orthodontic treatment freed the crowns of the third molars and
allowed them to erupt, although they still need to upright.

Palatal approach
Surgeons use palatal flaps, which are always replaced, to remove
most supernumerary teeth and odontomas found in the anterior
maxilla and to provide an eruption path for impacted canines confined
within the maxilla.
Impacted maxillary canines are the only permanent teeth that can
be brought into the arch through either a palatal or a buccal route,
depending on their location (see chapters 5 and 6).

Preparing the palatal flap

An incision is made following the neck of the tooth within the gingival
 sulcus and, if the primary tooth is absent, continuing across the middle
of the gingival crest. The incision is then extended across the arch to
the region of the other canine. A no. 12 blade is useful for making
interdental incisions to free the crests of the papillae (Figs 4-12a to 4-
12c).
The palatal mucosa is disengaged by lifting the papillary gingiva as
well as the median papilla, if necessary, to uncover the orifice of the
nasopalatine canal, a process that poses no risk to the neurovascular
bundle. Next, the mucosa is carefully detached from front to back with
a periosteal elevator, keeping the instrument in constant contact with
the bone. The extent of the uncovering depends on the tooth’s
position; the closer the impacted tooth lies to the midline of the
intermaxillary suture, the greater the area that will be uncovered (Fig
4-13a).

Exposing the crown

If the impacted canine is to be extracted, the crown is exposed to its
neck for sectioning (Fig 4-13b). The root can then be removed by
luxation without much affront to the enveloping bone. A conservative
surgical-orthodontic treatment plan for the impacted tooth will provide
for the eventual eruption of the tooth, although it begins with the same
operative protocol. The treatment plan must include four essential
elements to ensure a successful outcome.

1. Preparation of the bony window must commence at a safe distance

from the neck of the incisor. While surgeons should also follow this
principle when the canine is to be extracted, it may be impossible to
do so when the impacted canine lies superficially and is separated
from the incisors by only a thin bridge of bone (Fig 4-14a).

2. The size of the bony window should be as limited in size as possible;

instead of uncovering the crown completely in preparation for its
extraction, surgeons need only expose enough crown surface without
approaching the dentinoenamel junction to bond an attachment.
Surgeons should preserve as much of the follicular envelope as
possible because it separates tooth enamel from bone, thus reducing
the risk of ankylosis (Fig 4-14b).
3. After bonding the attachment, surgeons should remove part of the
osseous tissue still separating the crown from the edentulous crest.
Because uncovering the crown necessarily destroys a portion of the
follicular envelope and thus reduces the eruptive potential for bone
resorption, this precaution will accelerate the tooth’s migration (Fig 4-
14c).

4. In the last step in the uncovering process, surgeons should cut a 5 ×

5-mm opening in the mucosa around the attachment through which
the ligature passes before replacing and suturing the flap in its original
position (Fig 4-14d).

Fig 4-10 Replaced flap. A mucoperiosteal flap was retracted so that an attachment could
be bonded to the crown of the maxillary right canine. A twisted steel ligature was tied to the
attachment and left lying against the bone. The flap was returned to its original position and
sutured around the exposed loop of the ligature.
 Fig 4-11 Displaced flap. This partial-thickness flap was raised from the gingival crest. It
was then displaced apically and mesially so that a portion of the blocked-out tooth’s crown,
with its bonded steel button and attached ligature, remained exposed to the oral cavity.

Fig 4-12a Dotted line showing design of potential incision. It will be made at some distance
from the marginal gingiva through the mucoperiosteum overlying the impacted maxillary right
canine.
 Fig 4-12b This type of incision makes uncovering the impacted tooth’s crown more difficult
because a narrow band of marginal and papillary gingiva is isolated from its vascular support,
but must be left in place.

Fig 4-12c Sulcular incision to raise the palatal mucosa and, if necessary, the median
papilla. The flap will be kept in place by sutures attached to other teeth in the dental arch.
 Fig 4-13a Mucoperiosteal flap retracted across the midline to extract the palatally impacted
maxillary left canine in a 50-year-old man.

Fig 4-13b Sectioning the impacted tooth preserved the bone as well as the osseous border
of the other teeth.

This window aids treatment in three ways:

• If the attachment becomes dislodged, replacement can be bonded in

its place without surgical intervention.

• A mucosal barrier will not slow movement of the tooth. The follicular
tissue facilitates emergence, particularly during the fusion of epithelia.
When a tooth’s crown has been surgically uncovered, the absence of
follicular tissue leaves enamel in direct contact with the chorion of the
palatal mucosa, thus impeding rapid lysis of the covering tissues. The
 surgically created window compensates for this deficiency and
accelerates the emergence of the impacted tooth (Öhman and Öhman
1980), which sometimes completes its eruption in only a few days
(Figs 4-15a and 4-15b).

• Access to canine crowns that are erupting toward the median sagittal
plane posterior to a lateral or central incisor can frequently be
achieved only through a palatal approach. Orthodontic treatment must
sometimes work simultaneously to guide the tooth to the alveolar crest
and correct a rotation. Orthodontists are better able to perform these
manipulations when the tooth erupts rapidly, assisted by a window.

Buccal approach
Buccal flaps can be replaced or displaced. Before uncovering a
buccally impacted canine or incisor, practitioners should carefully
examine the dental arch for indications of its precise location. A
palpable bulge or the tilting of an adjacent tooth caused by the
eruptive force of the malpositioned tooth may betray the presence of
an impacted canine. The clinical exam should be supplemented by
radiographic assessment to locate the impacted tooth in all three
spatial planes.
In the mesiodistal aspect, orthodontists should correlate the eruptive
path of the tooth with the amount of space prepared for it in the arch,
which should always be greater than the width of the crown. Simply by
preparing space for it, orthodontists may stimulate spontaneous
eruption of an impacted tooth.
It is essential that orthodontists carefully study the relationship of
the crown of an impacted canine with its neighboring lateral incisor to
determine the most appropriate operative protocol.
In the buccolingual aspect, orthodontists cannot always determine
that the impacted tooth is in a buccal position by palpation alone,
especially when the impaction is high in the maxilla. Vertically,
orthodontists should evaluate the height of the gingival tissue not only
in the edentulous region where the tooth belongs but also in adjacent
areas. Orthodontists should use the relationship of the gingiva to the
impacted incisors as well as to the canines in selecting an operative
protocol. Orthodontists are strongly advised to launch intervention
before the malpositioned tooth can spontaneously erupt in an
inappropriate position through the alveolar mucosa or near the
mucogingival line (Figs 4-16a and 4-16b) (Levin and Amico 1974;
Vanarsdall and Corn 1977). Depending on the tooth’s location,
operators can select one of three methods for uncovering the crown: a
direct access flap, an apically displaced flap, or a mucoperiosteal
replaced flap.

Fig 4-14a Crowns of maxillary right and left canines, close to the apical thirds of the
incisors near the midline intermaxillary suture.

Fig 4-14b Attachments bonded to the exposed enamel of the lingual surface near the
cusps of the impacted teeth. As much of the follicle as possible has been preserved.
 Fig 4-14c Removal of bony tissue between the crowns and the alveolar crest.

Fig 4-14d Mucosal windows over impacted teeth. Windows are cut through the mucosa
with a no. 15 blade or an electrosurgical scalpel before the flap is replaced and sutured.
 Fig 4-15a Opening of the windows using an electrosurgical scalpel to control bleeding.
Surgeons must be careful not to bring this instrument into contact with bone.

Fig 4-15b Surgical dressing over the exposed tooth. The dressing may be left in place for 3
or 4 days.

Direct access flap

A simple gingival incision is sometimes indicated when the impacted
tooth has been located by clinical and radiographic examination, has
already emerged through the bone, is covered only by dense
collagenous fibers, is palpable, and is located near the space in the
arch prepared for it. Oral surgeons should use this simple incision
when the unerupted tooth is located at least 5 mm from the
mucogingival line of an adjacent tooth but should never risk
compromising its future periodontal integrity by cutting across alveolar
 mucosa (Fig 4-17).

Apically displaced flap

Advantages

• Assists a physiologic process by allowing for surgical emergence of the

tooth

• Allows for orthodontic control of the tooth’s movement and long axis

• Allows for placement, replacement, or removal of a bonded attachment

without additional surgery

Indications

• Available space must be a little greater than the width of the unerupted
tooth, as measured on the contralateral tooth.

• Tip of the crown must be near the mucogingival line of the lateral
incisor. To ensure a satisfactory esthetic result, the gingival
displacement should not exceed a few millimeters. If the tooth is
impacted in a higher position, a replaceable flap should be used.

• The apically displaced flap can also be set laterally for buccally
impacted canines that are lying across the roots of lateral incisors and
could compromise the periodontal health of adjacent teeth.

Operative protocol (Figs 4-18 and 4-19)

1. The flap is outlined with two parallel vertical incisions and one
horizontal incision (see Fig 4-19a). For a central incisor, an incision is
made along the labial frenum. To facilitate an incision through the
alveolar mucosa, surgeons should use a no. 15 blade and tighten the
coronal buccal tissues by exerting finger pressure in the edentulous
area.
A location is selected for the incision that will make the width of the
flap equal to or greater than the mesiodistal dimension of the crown of
the impacted tooth.
Fig 4-16a Impacted maxillary left canine directly beneath the alveolar mucosa, near the
mucogingival line of the lateral incisor.

Fig 4-16b Result with no preventive intervention. Unfortunately the tooth spontaneously
erupted within the mucosal tissue.
 Fig 4-17a Direct access flap. The tip of the cusp of this impacted maxillary left canine,
which can be located easily by palpation, is slightly mesial to the adjacent lateral incisor and
about 5 or 6 mm above its mucogingival line.

Fig 4-17b Space made by extraction of the primary canine. A simple semilunar incision
over the tip of the unerupted canine accelerates its emergence.
 Fig 4-17c Three days after the procedure, the tooth has started to erupt.

2. The inferior edge of the flap has an internal bevel in harmony with the
height and thickness of the gingiva (Fig 4-19b). Surgeons should
fashion the gingival incision in such a way that, when the impacted
tooth takes its place in the arch, the gingival border will match that of
adjacent teeth. If cuts are made at the gingival crest, the excess
gingiva should be retracted by an apical gap at the mucogingival line.
The angulation at which surgeons place the scalpel will determine the
thickness of the flap, which should be identical to that of adjacent
sectors. This incision reaches the full depth of the gingiva at the level
of the future mucogingival line (see Fig 4-19b).

3. The flap will comprise as many as three layers (see Fig 4-18b):

• From its pedicle to where it contacts bone, the flap is at partial

thickness.

• In its middle section, the flap achieves full thickness. When the
blade comes into contact with bone, surgeons should carefully
scrape the surface about 1 cm apically. If there has been no
fenestration, the thin remaining osseous layer can be removed with
a sharp-edged periosteal elevator. The amount of enamel surface
thus uncovered should suffice for bonding the attachment.

• After the attachment has been bonded, the flap will be freed by
 dissection of the subperiosteum with a no. 15 blade in the thick
part of the alveolar mucosa, near the base of the buccal vestibule.

Fig 4-18a Apically displaced flap. (1) The inferior border of the flap is prepared by making
an incision with an internal bevel in harmony with the height and thickness of the gingiva.
 Fig 4-18b Flap constructed in three stages. (1) A partial cut reveals the thickness of the
gingiva. (2) A complete cut uncovers the crown’s enamel surface. (3) Another partial cut frees
the flap at the point of its attachment.

4. The flap is positioned apically. If the tooth is impacted superficially, an

incision will be made to place the gingival border just above the
attachment. The gingival tissue is laterally stabilized by two sutures.
When the impacted tooth is located beneath the alveolar mucosa, at
the level of the mucogingival line, the flap is not replaced over the
attachment and the attachment should be placed at the level of the
mucogingival line. Initially, gingiva will cover the attachment, but if
there is no obstacle the tooth will soon spontaneously continue its
eruption. A surgical dressing is placed after covering the ligature with
a thin sheet of self-adhering tinfoil. In a few days a layer of junctional
epithelium will form over the enamel, and the orthodontist can begin
applying force to the unerupted tooth.

5. The results depend, to a large extent, on the quality of the surgical and
orthodontic protocols selected:

• Vertical incisions must be precise and extend into the gingival

papillae (Fig 4-20).
• Orthodontists must always prepare space for the unerupted tooth
before the start of the surgical procedure so that sufficient
mesiodistal keratinized gingiva will eventually be available (Fig 4-
21).

• Orthodontists must move the unerupted tooth into its correct

eruptive path to encourage development of healthy periodontal
tissues (Fig 4-22).

Fig 4-19a Flap outlined laterally with two parallel incisions (a,b). A horizontal incision must
conform to the gingival height of the contralateral tooth (blue arrow).

Fig 4-19b Incision with an internal bevel. The no. 15 blade is held parallel to the external
surface of the flap.
 Fig 4-19c Thin gingival portion of the flap (blue arrow).

Fig 4-19d Impaction high in the maxilla. The flap is placed over the crown at the level of
the mucogingival line.

With this type of surgical protocol, the exposed crown can be clearly
seen and, if necessary, an attachment correctly rebonded to it. The
point of anchorage can be moved in the weeks following the
surgery. Orthodontic force can direct the tooth toward its proper
eruptive path. Because the crown is accessible, orthodontists can
begin correcting rotations before resistant supracrestal fibers attach
themselves to the cementum (Korbendau and Guyomard 1983,
1998).
 Impacted teeth usually begin to emerge spontaneously after they
have been surgically exposed and do so more rapidly than if the flap
has been replaced.

Fig 4-20a Incorrect incision in the alveolar mucosa.

Fig 4-20b When the tissues are held taut and pulled toward the buccal, a perfectly clean
vertical incision can be made.
Fig 4-21a Poorly conceived orthodontic and surgical protocols. The impacted maxillary
right central incisor is inclined mesially, and there is a supernumerary tooth.

Fig 4-21b Insufficient space in the arch between the maxillary right lateral and the left
central incisors.
Fig 4-21c Mucoperiosteal flap raised to uncover the incisor and the supernumerary tooth.

Fig 4-21d The inferior edge of the flap has been positioned above the attachment, too far
apically, at some distance from the mucogingival line.
Fig 4-21e Two years after uncovering of the impacted crown. The esthetics and the
gingival architecture are unsatisfactory.

Fig 4-22a The crown of the unerupted maxillary right central incisor, which is lying
horizontal, has made a window through the cortical bone.
Fig 4-22b Uprighting of the tooth. An attachment has been bonded to the palatal surface of
the central incisor, and a ligature has been passed through the ring.

Fig 4-22c The tooth has been uprighted enough for an attachment to be bonded to its
labial surface.
 Fig 4-22d Seven years after the uncovering of the unerupted maxillary right central incisor,
the periodontal architecture is satisfactory.

Replaced mucoperiosteal flap

Characteristics and advantages

• The complete mucoperiosteal flap can be rectangular with two

reflecting incisions or triangular with one detaching incision. It is
always located at some distance from where the bony window will be
made.

• It provides surgeons with a generous operating field and a good view

of the obstacle that is impeding eruption of a permanent tooth and
needs to be removed (eg, a supernumerary tooth or an odontoma) or
excised (eg, a follicular cyst) (Fig 4-23).

• The surgical field is suitable for uncovering a tooth impacted in a high

position in the maxilla and for controlling bleeding when an attachment
is bonded to the exposed crown (Fig 4-24).

Difficulties and caveats

• Because the attachment must be bonded immediately following

surgery, surgeons must prevent blood from interfering with the etching
process.
• The 0.014-inch twisted ligature wire, which is attached to the bonded
button or eyelet under the replaced flap and extends to the gingival
crest, must have the proper rigidity so operators can adjust and bend
a loop in its end when necessary.

• It is difficult for orthodontists to monitor the force being applied to an

impacted tooth that has been re-covered by the flap and is hidden
from view. If the attachment is bonded to the crown’s palatal surface,
which is often necessary for horizontally impacted teeth, the tooth
cannot be brought completely into its assigned location in the arch
after several months of applying force. A second intervention may be
required, perhaps to bond a more favorably situated attachment and
to assure that the tooth’s periodontal tissues will be healthy.

Operative protocol
The size of the flap should not be determined by the width of the
edentulous space in the arch but by the size of the bony window that
provides access to the impacted tooth’s crown. The sutures used to
replace the flap must rest on bone to seal the wound off hermetically
and encourage clot formation. That is why retracting incisions must be
some distance away from the opening in the bone (see Fig 4-23). For
uncovering ectopic teeth, a generous flap allows surgeons to ensure
hemostasis for bonding an attachment (see Fig 4-18).

Many studies have compared the results obtained with each of

these procedures (Vermette et al 1995; Lawton and Sandler 1999;
Kokich 2004), which are in fact complementary. A replaced flap
often serves as a first operatory procedure that will be followed by
another surgical intervention. The quality of the connective tissue
reattachment and the final esthetics depend on the efficacy of the
surgical and associated orthodontic protocols. The clinical
examination, the preparation of space in the dental arch, the
dissection of gingival tissue, the limited uncovering of the crown,
and the respect for follicular tissue are all essential factors that
govern the short- and long-term results.
 Fig 4-23a Replaced mucoperiosteal flap for extraction of supernumerary teeth. In the
mixed dentition, attachment of the junctional epithelium remains high on the teeth (blue lines).
Releasing incisions begin in the gingival papilla (white arrow) to ensure that the scalpel will
encounter interdental bone, not the avascular dental cementum (red arrow).

Fig 4-23b Replaced flap for the removal of two supernumerary teeth. Two vertically angled
incisions, AB and CD, and a sulcular incision are outlined. The base will be wider than the free
edge so that lateral incisions will be some distance from the planned opening and will rest on
solid bone.
 Fig 4-23c Access to the supernumerary teeth should not be encumbered by adjacent
covering tissues.

Fig 4-23d Edges of the flap rest on bone.

Fig 4-23e Covering tissues have been replaced in their original position and sutured, thus
hermetically sealing the cavities in the bone.
 Fig 4-24a Replaced mucoperiosteal flap for an ectopic incisor in a 14-year-old boy. The
maxillary right primary lateral incisor and canine are still in place. The firm bulge overlying
their roots can be palpated; the color of the overlying gingiva is normal.

Fig 4-24b Laterally tilted occlusal radiograph revealing a pathologic mass about 17 mm in
diameter. This odontoma, made up of small misshapen supernumerary teeth, is blocking the
canine as well as the lateral incisor, whose root it has deformed.
 Fig 4-24c A broad rectangular mucoperiosteal flap will be retracted to provide access to
remove the odontoma. Vertical incisions will be made at a safe distance from the borders of
the odontoma, whose bulging contour is evident.

Fig 4-24d A periosteal elevator has been used to elevate the flap and to remove the very
thin cortical plate covering the growth. The thin follicular envelope facilitated the splitting and
excision of the tumor from its bony crypt.
 Fig 4-24e Crown of the maxillary right lateral incisor at the base of its crypt. After the
enamel surface has been prepared, an attachment carrying a metal ligature will be bonded to
the tooth.

Fig 4-24f The flap has been sutured back into place to hermetically seal the cavity, thus
protecting the blood clot. The attached ligature, with its end bent into a hook, is long enough
to extend past the inferior edge of the flap. The orthodontist can use the ligature to apply
orthodontic force and guide the tooth toward the site through which it should emerge. The
correctly oriented canine will erupt spontaneously.
 Fig 4-24g Eight months postoperative. Both the maxillary right lateral incisor and canine
have assumed their places in the arch. The root of the lateral incisor, whose tip had been
twisted at a right angle, shows no evidence of resorption.

Fig 4-24h Periodontal tissue 8 months postoperative.

Impacted Maxillary
Canines: Palatal
Approach
Classification of Palatally Impacted Canines
Palatally impacted canines are divided into three categories.

Class The canine crown lies within the arch near its customary
1: position.
Class The entire canine crown lies across the root of the lateral
2: incisor.
Class The canine crown is near the median palatine suture
3: posterior to the lateral incisor root.

The classification of impacted canines within the maxillary arch is

based primarily on crown position (Figs 5-1a to 5-1d). In the majority
of cases, canine roots are located where the bony crypts of these
teeth were formed, in a narrow region of spongy bone near the
external border of the nasal cavity. As a result, the closer the tip of a
canine’s cusp is to the median palatine suture posterior to the central
incisors, the more oblique its path of eruption will be. Very rarely, a 90-
degree or even a 180-degree rotation of the tooth bud will cause the
root to develop in a horizontal or inverted position.
Oral surgeons and orthodontists should answer two questions when
preparing a treatment plan: Which approach should be selected for
uncovering a portion of the crown and bonding an attachment, and
where on the crown should the eyelet, hook, or bracket be placed?
Answers vary according to the location and position of the impacted
tooth within the arch.

Class 1 Impaction

When the canine is located near its customary position, the

attachment is bonded labially.

Impacted tooth near palatal mucosa: 17-year-old

 patient
Clinical examination

• The maxillary left primary canine has not yet exfoliated.

• Sufficient space has been prepared for the impacted canine (Fig 5-2a).

• The slight palatal bulge made by the unerupted tooth is firm to

palpation (Fig 5-2b).

Periapical radiography examination

Periapical radiographs reveal the precise vertical and mesiodistal
position of the tooth (Figs 5-2c and 5-2d). When the crown of a Class
1 impacted tooth is actually located within the arch, the oral surgeon
needs only to remove the overlying palatal mucosa to bond an
attachment.

Anteroposterior relationships
The crown of the impacted tooth should overlay only a small portion of
the neighboring lateral incisor or not at all. A frontal radiograph can
verify the canine’s proximity to the lateral incisor. Before attempting a
surgical protocol, orthodontists must be sure that they have prepared
sufficient room in the arch for the tooth.

Vertical relationships
Surgeons and orthodontists must determine how deeply the tooth is
impacted within bone. If the tooth’s crown lies at a considerable
distance from the alveolar crest, a buccal approach that would require
extensive bone removal is not practical and could jeopardize the
periodontal health of adjacent teeth.
 Fig 5-1a Classification of palatally impacted canines. The position of impacted canines with
respect to the lingual surfaces of the adjacent incisors determines how much tissue to remove
when uncovering crowns and where to place the bonded attachment.

Fig 5-1b Class 1 palatal impaction. The canine is located near the space into which it will
eventually be moved. The attachment can be bonded to the buccal surface.
Fig 5-1c Class 2 palatal impaction. The canine is located over the root of the lateral incisor.
The attachment can be bonded to either the palatal or the distal surface of the crown.

Fig 5-1d Class 3 palatal impaction. The canine is located over the root of the central
incisor. The attachment must be placed on the palatal surface.
Fig 5-2a Class 1 superficial impaction of a maxillary left canine. The orthodontic appliance
prepares space for the permanent canine of a 17-year-old girl, while the primary canine
remains in the arch.

Fig 5-2b During clinical examination a slight, firm bulge was palpated posterior to the
maxillary left primary canine, which showed no mobility.
 Fig 5-2c Periapical radiograph of the maxillary left permanent lateral incisor. The crown of
the unerupted permanent canine appears to lie over a small portion of the lateral incisor root.

Fig 5-2d Confirmation of the palatal position of the tooth. The canine seems to move
distally when the X-ray beam is moved distally in another periapical film.
Fig 5-2e By retracting a small section of palatal mucosa, the surgeon uncovered the tip of
the cusp of the maxillary left permanent canine.

Fig 5-2f When the primary canine was extracted, enough enamel surface of the permanent
canine crown was exposed to bond an attachment.
 Fig 5-3a Acrylic plate designed by Vion (2000) to move a palatally positioned tooth. Tubes
are bonded to the Adams clasps where needed. The annealed distal end of the wire is bent
around the molar band, and the mesial hook of the activated spring is engaged in the eyelet
bonded to the canine.

Fig 5-3b Spring made of extra-hard 0.020-inch Australian wire. (1) The distal end is
tempered to a red color and bent around the back of the tube. (2) The buccal tube is bonded
to the Adams clasp. (3) A horizontal loop regulates tooth movement on the horizontal plane. It
is bent in the opposite direction of that movement. (4) The arm of the spring. (5) Before
activation, the terminal hook of the spring lies at the canine’s ultimate position in the arch.

Orthodontic and surgical treatment plan

1. Level the teeth and, if needed, prepare space with a nickel-titanium

open-coil spring or one of the other methods described in chapter 4.
2. Maintain arch space by slipping a closed coil or crimping a section of
tubing over the archwire.

3. Uncover a portion of the impacted tooth’s crown to bond an

attachment (Figs 5-2e and 5-2f).

4. Apply force to move the tooth buccally toward its position in the arch.

• Force can be applied using elastic stretched between the

attachment on the tooth and the archwire, which must be rigid and
at least 0.018 × 0.022 inches in diameter. As an alternative, Patti’s
multipurpose sectional archwire, described in greater detail in the
Class 2 Impaction section, also can be used. Because this device
exerts reciprocal force against the first molar, anchorage must be
buttressed with a transpalatal archwire. If sufficient space is
available and the rest of the teeth are in good alignment, the
orthodontist can use an acrylic plate to move the tooth buccally
into the arch (Figs 5-3a and 5-3b).

• As soon as the tooth nears the alveolar crest, the bonded bracket
or loop replacing the original eyelet can be tied directly to a full
nickel-titanium archwire ligated to the other teeth.

5. Movement is finished using a series of rectangular archwires of

increasing diameter.

6. A Hawley retainer is used for retention.

Deep bony impaction: 15-year-old girl

Clinical examination

• The maxillary right primary canine has not exfoliated, and there is
insufficient arch space for the permanent successor (Fig 5-4a).

• The maxillary right lateral incisor is tilted distally and separated from
the central incisor by a diastema.
• A palatal bulge is firm to palpation (Fig 5-4b).

• The maxillary dental arch is in good alignment.

Fig 5-4a Class 1 bony impaction. The right primary canine is still present in the maxilla of
this 15-year-old girl. The distal inclination of the maxillary right permanent lateral incisor
suggests that the unerupted canine is exerting mesial pressure on its root.

Fig 5-4b The palatal bulge is firm to palpation.

 Fig 5-4c Periapical film giving the impression that an odontoma is located between the
maxillary right permanent and primary canine teeth. In addition, this film shows that the
impacted canine is not touching the lateral incisor root.

Fig 5-4d Axial section of an infrapalatal CT scan. Part of the odontoma is located in the
same axial sector as the crown of the maxillary right canine, at the level of the canine position.
 Fig 5-4e Three-dimensional reconstruction of a CT scan. The maxillary right canine is
displaced palatally and erupting toward the intermaxillary suture.

Fig 5-4f Three-dimensional view showing the inclination of the long axis of the maxillary
right permanent canine. Its root still seems to be located in the tooth’s original bony crypt.
 Fig 5-4g Palatal view of the reconstruction.

Fig 5-4h A palatal approach uncovered a limited portion of the tooth’s crown. A button was
bonded to its buccal surface.

Periapical radiography examination

There is a bony impaction of the maxillary right canine. Its enlarged
follicle seems to be fused to a calcified tumerous dental mass that lies
inferior to it. In addition, a compound composite odontoma lies along
its long axis, between the crown of the unerupted maxillary right
permanent canine and the primary canine (Fig 5-4c).
The diastema between the maxillary right lateral and central incisors
suggests that the crown of the impacted maxillary right canine is
exerting pressure against the apical third of the lateral incisor root.
However, a periapical radiograph shows that there is no actual
 contact. The inclination of the lateral incisor’s long axis and its eruptive
path can be explained by the palatal position of its bony crypt posterior
to the central incisors. The diastema is therefore physiologic in origin.

Computerized tomography examination

Axial infrapalatal sections (Fig 5-4d) reveal that a portion of the
odontoma is located at the level of the impacted crown, parallel to the
axes of the erupted teeth in the arch. The crown of the maxillary right
canine occupies a dystopic position in the palate, where its eruptive
force has deformed and fenestrated the cortical plate.
Three-dimensional reconstructions show the long axis of the
maxillary right canine and the orientation of its crown (Figs 5-4e to 5-
4g).
The conclusion drawn from the computerized tomography (CT)
scans is that the canine is in a quasi-normal path of eruption even
though it occupies a mesial Class 1 palatal position with its root placed
distally. The surgeon will be able to bond an attachment to its buccal
surface.

Orthodontic and surgical treatment plan

1. Recover arch space via an open-coil spring.

2. Maintain space with a closed-coil spring or a section of tubing on the

archwire.

3. Surgical intervention:
• Uncover the smallest section of the tooth’s crown that will permit
effective bonding of an attachment.

• Extract the primary canine and remove the odontoma.

• Bond an attachment to the tooth’s buccal surface (Fig 5-4h).

4. Apply force to the canine to bring it into position in the arch:
• This can be achieved by stretching an elastic band or chain from
the attachment on the tooth to a full archwire, or by inserting a
sectional archwire in the molar tube that is ligated to a bracket on
 the canine to exert spring force. The anchor molar is stabilized with
a transpalatal arch.

• As soon as the tooth nears the appropriate position in the arch, the
orthodontist can tie a full nickel-titanium 0.016-inch round archwire
into place and directly ligate the canine. A series of rectangular
archwires of increasing diameter can then be ligated in place.
5. Completed orthodontic movement is followed by retention.

Because its root is already in a correct mesial position, this case

also could have been treated with a removable appliance carrying a
spring wire distal to the lateral incisor to tilt its crown mesially and
close the diastema. A long spring arm extending from a tube on the
Adams clasp on the molar can effect the desired movement of the
impacted canine buccally into the arch (see Figs 5-3a and 5-3b).

Class 2 Impaction

When the canine is located near its customary site, the attachment
is bonded labially.

In Class 2 cases neither a clinical nor a radiographic examination will

reveal a palpable palatal bulge. Still, when the tooth lies near the
lateral root, practitioners must ensure that the impaction is palatal by
carefully reviewing these elements:

• A palatal inclination of the lateral incisor’s axis

• The orientation of the palatal alveolar wall with regard to the depth of
the palatal vault

Maxillary canines erupt between the root of the lateral incisor and
the cortical plate. These two structures resist eruptive pressure better
than spongy bone, but tooth migration sometimes results in root
resorption of the lateral incisor or fenestration of the cortical plate.
If the eruptive path through the alveolar process is oblique in
 relation to the medial sagittal plane, the crown of the impacted tooth
can reach the apical third of the lateral incisor and still emerge
palatally through the cortical plate at a considerable distance from the
alveolar crest (Figs 5-5a to 5-5c).
If the path of eruption approaches a vertical inclination, the crown of
the canine will lie near the cementoenamel junction of the lateral
incisor. In this case a bony window will leave a very narrow bridge,
making it difficult for surgeons to preserve the periodontal tissue of the
lateral incisor. Incisions have to be made through the mucosa to
uncover the enamel surface at a safe distance from the lateral incisor,
either toward the gingival crest of the edentulous area or toward the
midline of the maxilla (Figs 5-6a to 5-6c).

Superficial impaction: 13-year-old boy

Clinical examination

• Both maxillary canines are impacted.

• The maxillary right primary canine has exfoliated (Fig 5-7a).

• Sufficient space is available in the arch for the unerupted permanent

canines.

• The cortical plates are not deformed.

Periapical radiography examination

The frontal periapical view shows the orientation of the unerupted
maxillary right canine as well as how it relates horizontally and
vertically to the roots of the adjacent incisors (Fig 5-7b). While it
appears to lie in close proximity to the incisors, the right canine has
not yet caused root resorption, and there is no abnormal thickening of
its dental follicle.
Fig 5-5a Class 2 deep bony impaction. This frontal periapical film shows the vertical depth
of the impaction. The canine crown lies across the root of the lateral incisor.

Fig 5-5b Crown of the maxillary right canine located at some distance from the edge of the
cortical plate (blue arrow). The surgeon has no difficulty in preserving the bony bridge.
 Fig 5-5c If the impaction is deep, ie, at a distance from the plane of occlusion, the layer of
covering bone may, nevertheless, be thin. Surgeons must take the curvature of the palate,
which is parallel to the axes of the alveoli, into account. d = distance between the bony
window and the edge of the cortical plate.

Fig 5-6a Class 2 superficial impaction in the same patient shown in Fig 5-5. A periapical
radiograph of the maxillary left canine shows that it is impacted at a more shallow level than
the contralateral tooth. The crown is located near the neck of the lateral incisor, and it also lies
across the root of the adjacent lateral incisor.
 Fig 5-6b Because of the narrowness of the bony bridge, the surgeon must exercise great
care to uncover the impacted tooth’s crown and still protect the periodontal integrity of the
lateral incisor.

Fig 5-6c Even though the cortical plate overlying the impacted left canine is as thick as the
bone covering the right canine, the impaction is less profound vertically.
 Fig 5-7a Class 2 superficial impaction. Both maxillary permanent canines are impacted in
this 13-year-old boy. The orthodontist has already made room in the arch for these teeth,
which have not created palatal bulges.

Fig 5-7b Periapical film showing the crown of the maxillary right canine in contact with the
roots of the neighboring lateral and central incisors. The tip of its cusp is close to the
cementoenamel junction of the central incisor. Note the thickened follicle.
Fig 5-7c The erupting tooth has already emerged through the cortical plate against the root
of the lateral incisor.

Fig 5-7d The surgeon has removed a portion of the dental follicle to bond an attachment to
the canine’s only accessible surface, its palatal aspect.
 Fig 5-7e The surgeon has fashioned a window in the mucosa far from the edge of the flap
to interfere as little as possible with repair of the lateral incisor’s periodontal tissues.

Fig 5-7f A ballista sectional archwire is being used to move the maxillary right canine in a
posterior direction, away from the lateral root, and to encourage the health and recovery of the
alveolar gingiva.
 Fig 5-7g The once-impacted canine has reached the alveolar crest without extruding any
further. A sectional lingual arch with a loop soldered to the molar band is applying buccal and
distal rotation force to its mesial angle.

Orthodontic and surgical treatment plan

1. Virtually no arch space needs to be recovered, and only minor leveling

is required of other teeth in the arch.

2. Surgical intervention:

• The maxillary right and left first premolars and the maxillary right
and left primary canines are extracted.

• After making a mesiodistal incision in the alveolar crest, the

surgeon retracts a palatal flap beginning near the palatal gingival
margin of the lateral incisor to uncover a portion of the impacted
canine’s crown (Fig 5-7c).

• The attachment is bonded on the distopalatal surface of the canine

(Fig 5-7d).

• The surgeon cuts a window for emergence of the tooth through the
mucosa at some distance from the lateral incisor’s gingival border
(Fig 5-7e).

3. The planned posterior movement of the canine has two objectives:

 • To place the crown of the unerupted tooth directly palatal to its
eventual position in the arch

• To ensure reconstruction of the palatal periodontal margins of the

incisors

By moving the palatally impacted canine posteriorly, away from the

palatal curvature, the orthodontist is able to sufficiently disengage
the buccal surface from overlying tissue to bond an attachment
without having to apply any extrusive force.

The orthodontist moves the canine posteriorly using a buccal

sectional archwire with a loop hooked to an elastic coming from the
palatal button on the maxillary right canine (Figs 5-7f and 5-7g).
4. When the crown of the canine nears its destined position, a 0.016 ×
0.016–inch nickel-titanium archwire will be tied directly into a bracket
bonded to the tooth’s buccal surface to complete its placement in the
arch.

5. Placement will be finished with a 0.018 × 0.022–inch rectangular steel

archwire.

6. Retention is necessary once orthodontic movement is complete.

 Fig 5-8a Patti’s multipurpose sectional archwire, made of 0.016 × 0.022–inch titanium
molybdenum alloy (TMA) wire. This appliance can be used to treat Class 2 and 3 palatally
impacted canines by inserting it into the molar’s buccal tube and bending its distal extremity
around the tube. The sectional archwire lies over the full archwire (not shown) and is tied into
the slots of the premolar brackets.

Fig 5-8b Activation of the anterior loop should yield a distalizing force of about 50 g.
 Fig 5-8c The hook at the mesial end of the multipurpose sectional archwire can be ligated
to the bonded attachment with an elastic or steel ligature.

Fig 5-8d When the first attachment is bonded to the crown’s palatal surface just after it has
been uncovered, the tooth is usually rotated mesially around the center of rotation (CR). The
force applied (F1) will aid in correcting this malposition if the eyelet (A1) is bonded mesially. If
it were bonded toward the distal (A2), applied force (F2) would aggravate the existing rotation.
 Fig 5-9a To complete the second stage in moving a palatally impacted tooth into the arch,
the orthodontist shortens the sectional and again bends a closed loop into its mesial end.

Fig 5-9b Once more, the orthodontist ties the sectional archwire to the attachment on the
canine with an elastic or steel ligature.

Patti’s multipurpose sectional archwire

This sectional archwire has two active loops and a terminal hook:

• The orthodontist can ligate the hook directly into the bonded bracket on
the labial surface of the canine or tie an elastic ligature between the
two (Figs 5-8a and 5-8b).

• The mesial loop, placed in the middle of the canine position, moves the
tooth’s crown distally (Fig 5-8c). If the crown is rotated mesially, for
 example, ligating the mesial loop to the eyelets can either correct or
accentuate the rotation, depending upon the mesial or distal
placement of eyelets, because the line of force will not pass through
the tooth’s center of rotation (Fig 5-8d).

• The distal loop, with a palatal orientation, can impart a horizontal force
when activated buccally.

In the second stage, the orthodontist continues moving the tooth

into its final position by shortening the sectional archwire to its anterior
loop and converting the end into a hook that can be affixed to the
attachment on the crown’s buccal surface (Figs 5-9a and 5-9b).

Class 3 Impaction

When the canine lies near the central incisor, the attachment is
bonded palatally.

When an impaction is superficial, the practitioner can discern distinct

palatal deformations. In these cases, the orthodontic and surgical
protocols follow those outlined for the treatment of Class 2 palatal
impactions. Sometimes, however, in cases of deep bony impactions,
the canines can become transposed with lateral incisors, which can
cause root resorption of the adjacent teeth or tilt the roots distally. CT
scans in axial sections are frequently needed to verify the exact
relationships of the ectopic teeth with the adjacent teeth.

Deep bony impaction: 15-year-old boy

Clinical examination

• The area of the maxillary right canine is edentulous.

• The maxillary right lateral incisor is tilted mesiobuccally (Fig 5-10a).

• A slight palatal deformation is firm to palpation (Fig 5-10b).

Fig 5-10a Class 3 deep bony impaction. Although the maxillary right primary canine has
exfoliated in this 15-year-old boy, the permanent canine has not erupted.

Fig 5-10b Slight bulge in the palate posterior to the maxillary right incisors. Considerable
space is available in the arch to receive the canine.
 Figs 5-10c to 5-10e (c, left) Having transposed itself with the lateral incisor, the crown of
the canine is superimposed over the root of the central incisor. It appears to be occupying the
space between the roots of the central and lateral incisors. (d, center) Periapical view taken
from a distal angulation. The tip of the canine’s cusp has moved distally, in the same direction
as that of the X-ray beam, which confirms that the tooth’s crown has passed lingually over the
lateral incisor root. (e, right) This suprapalatal axial section shows the position of the maxillary
right canine’s root within the spongy bone of its bony crypt. The wall of the nasal cavity is
thickened.

Fig 5-10f Panoramic CT scan depicting the eruptive trajectory of the maxillary right canine.
Note the deformation of the nasal floor. CA = the level of the preceding suprapalatal axial
section.
 Fig 5-10g An axial infrapalatal section showing the transposition of the maxillary right
lateral incisor and canine. Note the irregular shape of the bony crypt around the canine crown.

Fig 5-10h A more occlusal axial section reveals that the roots of the lateral and central
incisors are in contact with the canine’s follicular envelope. There is no evidence of resorption.
The wall of the palatal alveolar process is very thin.
 Fig 5-10i A section of mucosa has been retracted to uncover the palatal surface of the
impacted maxillary right canine and bond an attachment.

Fig 5-10j Elastic force applied from the buccal anchorage of a full arch-wire to the crown’s
palatal surface may encourage rotation.

Periapical radiography examination

In the frontal view, the tip of the canine appears to overlap the pulp
chamber of the central incisor (Fig 5-10c). In the distally angulated
view, the tip of the canine seems to have moved only slightly distally,
indicating that it is very close to the root of the central incisor (Fig 5-
10d). These two films demonstrate, together, that the crown of the
maxillary right canine is located palatally. Vertically, its cusp lies
across the apical two-thirds of the central incisor’s root.
 Computerized tomography examination
In the suprapalatal axial section (Fig 5-10e), the apex of the maxillary
right canine occupies a normal position in the frontal process, but the
nasal floor seems to be pushed upward (Fig 5-10f).
In the infrapalatal axial sections (Figs 5-10g and 5-10h) at the crown
level, the follicular cavity is irregular where it abuts a dehiscence of
palatal bone. Although the crown lies against the root of the right
central incisor, it does not seem to have precipitated any root
resorption. The maxillary right canine also lies in close proximity to the
maxillary right lateral incisor, whose root has tilted distally and whose
periodontal membrane is no longer intact.
A panoramic reconstruction depicts the axial inclination of the
canine’s long axis and the displacement of its crown toward the
midsagittal plane, which confirms the data provided by the axial and
alveolar sections. A Class 3 palatal impaction can be diagnosed.

Orthodontic and surgical treatment plan

1. Sufficient space is available for the canine.

2. After the leveling stage, a 0.016 × 0.022–inch or a 0.018 × 0.025–inch

heavy stabilizing archwire can be ligated into place.

3. Surgical intervention from a palatal approach:

• An incision is made on the alveolar crest between the maxillary

right lateral incisor and first premolar.

• A sulcular incision is extended at the right canine.

• A mucoperiosteal flap is retracted (Fig 5-10i).

4. An attachment to which a metallic ligature is affixed is bonded to the

palatal surface of the impacted canine.

5. The surgeon opens a window through which the canine can emerge.

6. Orthodontic procedures:
• Since its root is already in the correct position, the canine crown will
be tipped distally. A transpalatal arch will reinforce anchorage,
while the multipurpose sectional arch will move the canine buccally
and distally as previously described, thus distancing it from the root
of the lateral incisor. A palatal force system consisting of a tube
soldered to the lingual surface of the first molar band can also be
used with a Bollender (1993) sectional Barrière arch to aid in
distalizing and eventually correcting the canine’s rotation. The
orthodontist must not engage the lateral incisor in any appliance
until the canine has moved to a safe distance. Distalizing the
canine with palatal traction avoids aggravating its rotation. In fact,
correct activation of the palatal sectional archwire can rotate the
emerging canine distally without provoking unwanted reciprocal
movements of adjacent teeth.

• Correction of the rotation must be completed before full emergence

of the crown and attachment of the supracrestal periodontal fibers.

• A buccal bracket providing negative torque to the crown is bonded

at an early stage in the extrusion and distalization of the canine.
The final positioning of the tooth in the arch is completed with the
multipurpose sectional archwire described for the preceding clinical
cases. The orthodontist must remember that force applied to a
palatally impacted tooth from buccal anchorage may cause rotation
or aggravate a preexisting rotation (Fig 5-10j).
Impacted Maxillary
Canines: Buccal
Approach
 In the majority of cases, using a buccal approach to uncover an
impacted canine facilitates bonding a bracket to the buccal surface.
Only when the tooth’s eruptive pathway is horizontal, or nearly so, is
the palatal surface more accessible than the buccal surface.
Surgeons may select a buccal approach to treating impacted
maxillary canines if they fall into one of these categories:

1. An ectopically erupting canine in the interior of the arch, facing its

appropriate position in the alveolar ridge. While this is also considered
a Class 1 palatal impaction (see chapter 5), the surgeon can consider
uncovering the canine from a buccal approach if it is not tilted palatally
and if its path of eruption passes near the space prepared for it in the
arch.

2. A canine midway between the two cortical plates and abutting the root
of the lateral incisor or premolar.

3. A buccally erupting canine, outside the arch. Orthodontists can discern

the problem before children are 13 years old by a tilting of the lateral
incisor or a pathognomonic buccal bulge near the site in which it
should be erupting.

The specific surgical protocol depends on whether the impaction is

superficial, palatal, or deep bony.

Superficial Impactions
Superficial impactions can be treated using a direct access flap, an
apically displaced flap, or apically and laterally retracted flaps.

Direct access flap

The surgeon makes a direct access flap in the space prepared for the
canine (Figs 6-1a and 6-1b) by removing mucosal tissue that has
blocked emergence of the tooth and clearing an area on its crown for
bonding an attachment.

Surgical protocol
• A horizontal incision is made perpendicular to the plane of the bone,
following the summit of the edentulous crest between the lateral
incisor and the first premolar.

• A second, vertical incision is made at the distal edge of the first

incision, pressing the no. 15 blade completely through gingiva to bone.
These two incisions delimit a mucoperiosteal flap, which is triangular
and just large enough when retracted to uncover a portion of the
canine crown for bonding an attachment (Figs 6-1c and 6-1d).

• A window is prepared in the palatal mucosa through which the canine

can emerge. This semicircular window usually allows the canine to
make an unassisted emergence into the oral cavity within a few days
(Figs 6-1e and 6-1f).

The direct access flap is indicated only for superficial impactions,

when the impacted canine lies near the gingival crest and there are
no mucogingival problems.

Apically displaced flap

When the crown of the canine has strayed from its normal path of
eruption to lie across the lateral incisor’s root buccally, the surgeon
must clarify the clinical situation to determine the proper surgical
protocol:

• The canine crown lies across only a small portion of the lateral incisor
(Figs 6-2a to 6-2c). By retracting an apical flap from the gingival crest
over the crown, enough of the distobuccal surface will be uncovered to
bond an attachment. The steps of the protocol are the same as those
presented for the uncovering of incisors (see chapter 4, Figs 4-19a to
4-19d).

• The canine crown lies across the entire root of the lateral incisor (Figs
6-3a and 6-3c), hiding it from view on the periapical film. Sometimes
unerupted canines can drift so far mesially that they become
transposed with the adjacent lateral incisor root (Figs 6-4a and 6-4b).
As in the preceding case, a partial flap is prepared from the
edentulous space in the arch, this time laterally, and retracted to
uncover the canine crown.

Fig 6-1a Space prepared for the maxillary right canine of a 16-year-old boy. A thick layer of
mucosa has prevented eruption.

Fig 6-1b Periapical film showing the slight distal inclination of the tooth.
 Fig 6-1c Retraction of a direct access flap with two incisions. The first incision was made
along the gingival crest; the vertical incision meets the first incision at the distal border of the
canine space.

Fig 6-1d A button bonded near the tip of the canine’s cusp.
Fig 6-1e Palatal mucosa removed from the canine’s tip with a no. 15 blade. An electric
scalpel should never be used near bone.

Fig 6-1f Five days postoperative, the tooth has begun to emerge into the oral cavity.
 Figs 6-2a to 6-2c Partial superimposition of the canine crown over the lateral incisor. The
canine has not drifted past the midline of the lateral incisor.

Figs 6-3a to 6-3c Complete superimposition of the canine over the lateral incisor. The
canine’s ectopic path of eruption may have greatly reduced the height of the lateral incisor’s
attached gingiva.
 Figs 6-4a and 6-4b Transposition of the maxillary left permanent canine and lateral incisor.
The lateral incisor root is positioned lingually. Crowding contributed to the canine’s buccal
position.

Apically and laterally retracted flaps

If the canine crown is completely superimposed over the lateral
incisor’s root, the canine cusp often lies near the lateral incisor’s
cementoenamel junction, and the residual height of its attached
gingiva may, as a result, be considerably reduced (see Figs 6-3a to 6-
3c). In such cases, uncovering the canine crown may compromise the
periodontal integrity of the lateral incisor. Surgeons should, therefore,
gain access to the canine by creating a triangular window in the
alveolar mucosa superior to the lateral incisor’s mucogingival line. An
attachment can then be bonded to an accessible spot on the canine’s
crown for the application of corrective orthodontic force.

Surgical protocol
The surgeon uncovers the impacted tooth in three steps: preparing a
laterally retracted apical flap, uncovering enough space on the crown’s
enamel for bonding an attachment, and replacing the gingival flap over
the uncovered tooth.

• The apically retracted flap is prepared with two parallel vertical

incisions. Placement of the inferior incision establishes the gingival
thickness and height of the flap, which should be relatively thin. The
mobility of the flap is ensured by a deep debridement of the
periosteum layer in a buccal direction inferior to the base of the flap
 (Figs 6-5a to 6-5c).

• A triangular fenestration is cut in the alveolar mucosa; its three sides

consist of a horizontal incision near the canine’s cusp the length of the
lateral incisor’s mucogingival line, an oblique incision joining the base
of the mesial vertical incision, and the vertical incision (Figs 6-5d to 6-
5f). Usually the impacted tooth’s crown is covered only by mucosa, but
if it also is covered by the cortical plate, the bone is fenestrated using
the cutting edge of a periosteal elevator.

• The free edge of the flap is replaced over the bonded attachment on
the crown’s enamel (Fig 6-5g). Depending on how far the lateral
incisor has been displaced, the flap may be sutured to marginal
gingiva or directly to the periosteum left in place over cortical bone.

Orthodontic protocol

• The uncovered tooth is moved toward its proper path of eruption, away
from the lateral incisor’s root. The orthodontist must protect the lateral
incisor’s periodontal membrane by delaying stimulation of the canine’s
actual eruption.

• When the canine is at a safe distance from the lateral incisor the
orthodontist can use gentle force to guide the once-impacted tooth
toward the occlusal plane.

If the other teeth in the arch are well aligned, the orthodontist can
use a removable appliance carrying a spring wire anchored in a tube
soldered to the Adams clasp first to distalize and then extrude the
canine (Figs 6-5h and 6-5i).
However, the orthodontist may decide that the situation requires a
fixed appliance.

• A transpalatal arch is soldered to the molar bands.

• A heavy archwire is placed in the molar’s extraoral-force buccal tube

with a hook at the mesial end that should be distal to and at the same
level as the canine’s crown (Fig 6-6).
• The elastic force between the hook and the canine’s bonded
attachment creates a purely horizontal movement.

• As soon as the canine has reached its normal eruptive pathway, a

sectional archwire with a loop can guide its vertical eruption.

Other devices, such as sectional archwires with loops between the

molar and the canine, can also be used to distalize or extrude the
emerging tooth.

Fig 6-5a The maxillary left lateral incisor of a 12-year-old girl is inclined buccally. In the
absence of the canine, a diastema has opened between the maxillary left lateral and central
incisors.

Fig 6-5b The first step in uncovering the impacted canine is to create a simple, apically
retracted flap using two parallel incisions, AB and CD. Deep debridement is performed inferior
to the base of the flap (AC).
Fig 6-5c The surgeon uses a scalpel with an internal bevel to make the initial incisions in
the tissue to be retracted (see chapter 4).

Fig 6-5d Horizontal incision over the tip of the impacted canine down to bone. (See Fig 6-
5f, XY.)

Fig 6-5e Oblique incision to bone. (See Fig 6-5f, BX.)

 Fig 6-5f Points B, X, and Y define a triangular section of gingiva for excision to open a
window over the tip of the canine’s cusp.

Fig 6-5g After bonding a button attached to a twisted ligature wire to the canine crown, the
surgeon replaces the flap.
Fig 6-5h The crown is moved distally then guided into the alveolar ridge by a sectional
spring wire soldered to the buccal tube on the Adams clasp of the removable plate.

Fig 6-5i Two years following the end of the retention period.
 Fig 6-6 A fixed appliance for moving the canine crown distally. This heavy 0.040-inch steel
sectional archwire has an anterior hook placed distal to and at the same horizontal level as
the canine, just mesial to the first premolar. It moves the canine crown away from the lateral
incisor’s root in a purely horizontal direction to place it within its normal path of eruption.

Palatal Impactions
Apically retracted buccal flap
Indications
Literature dealing with canine impactions has shown that a palatal
positon is much more common for the canine than a buccal position.
However, this observation cannot determine the appropriate operative
protocol. The evidence suggests that in normal unencumbered
eruption, canines maintain a palatal position as they move from their
bony crypt to their appropriate places in the dental arch. When
canines become buccally positioned, they have usually been guided
by the root inclination of the lateral incisor.
Most Class 1 palatally impacted canines (see chapter 5) can be
uncovered using a buccal approach. The only situation that prevents a
buccal approach is when the crown of the canine is too intimately
involved with the root of the lateral incisor, from both the mesiodistal
and vertical perspectives. The prerequisites for a safe and effective
 use of the buccal approach are:

• In the mesiodistal sense, rapid buccal movement can only be

accomplished if the impacted canine has not drifted past the midline of
the lateral incisor’s root. The surgeon must also make a bony window
that is larger than the canine’s crown, through which the tooth can
readily emerge.

• In the vertical sense, the canine crown must lie close enough to the
gingival crest that bone removal will not compromise the bony support
of adjacent teeth.

The buccal approach is especially indicated when the planned

orthodontic treatment will include a full-banded lingual appliance.

Fig 6-7a A 35-year-old woman to be treated with a lingual orthodontic appliance. The
maxillary right canine is impacted palatally posterior to the right lateral incisor.
 Fig 6-7b These incisions outline the rectangular buccal access flap.

Fig 6-7c No attempt should be made to uncover the crown of an impacted tooth without
knowing its precise location.
Fig 6-7d Opening a generous window through the mucosa facilitates finding the tip of the
canine’s cusp.

Fig 6-7e Part of the canine crown is uncovered to bond an attachment. Note the thickness
of the alveolar bone.
 Fig 6-7f The flap is replaced inferior to the attachment, on the edge of the bone.

Fig 6-8a Disto-occlusal radiograph showing the orientation and depth of a maxillary right
canine in a 15-year-old boy.

Fig 6-8b Midline occlusal film showing the buccolingual position of the canine’s crown.
 Fig 6-8c The orthodontic appliance used to prepare space for the unerupted canine.

Fig 6-8d Outline of the planned rectangular mucoperiosteal flap.

Figs 6-8e to 6-8g Procedural sequence taken from a video. (e, left) After removing the
overlying mucosa from the gingival crest, the surgeon cuts a window in the bone. (f, center)
Bonding of the attachment. (g, right) The surgeon positions the flap at the edge of the bone.
 Fig 6-8h A 7-year postoperative view of the gingiva.

Fig 6-8i The canine in its correct position in the arch.

Surgical protocol
Surgeons can make a few adjustments in the operative protocol when
using an apically retracted buccal flap to gain access to a palatally
impacted canine (Figs 6-7 and 6-8).

• If a considerable amount of bone covers the tooth on the buccal

aspect, it would be risky to search out the impacted canine by trial and
error.

• After retracting the flap, a large quantity of the mucosa covering the
alveolar crest should be removed so that the tip of the canine’s cusp
can be located.

• After an attachment is bonded, the flap should be replaced just inferior

to it on bone; when an impacted canine is in a palatal position, gingiva
 cannot be placed directly over the enamel (see Figs 6-7f and 6-8g).

Advantages of a buccal approach

• This approach avoids any cutting through heavy palatal mucosa and
provides more direct access to the crown of the impacted canine.

• The attachment can be placed on the buccal surface of the impacted

canine near the tip of its cusp, or near its distobuccal border. During
orthodontic force, these positions eliminate the risk of rotating the
canine into a malposition; the correction of such a rotation is lengthy
and likely to relapse.

• If the canine is already rotated, a well-placed attachment can aid in

correcting this defect before supracrestal gingival fibers imbed in the
tooth’s cementum.

Orthodontic protocol
When the canine crown is in a completely palatal position within the
maxillary arch, the first stage of the buccal displacement must be
exclusively horizontal. The canine’s enamel must be in contact with
the gingiva to ensure an immediate adhesion so that when extrusive
force is finally applied, the gingiva will correctly accompany the
emerging tooth. Orthodontists can use elastic force stretched between
the attachment on the tooth and either a heavy buccal archwire if the
tooth was impacted superficially, or a sectional archwire if it was a
deep bony impaction. After horizontal displacement is complete, the
same sectional archwire can be used to extrude the tooth.
When vertical, or even oblique, traction is applied to the canine first,
apically displaced gingival tissue will remain apically positioned.
Another benefit derived from first moving impacted canines
horizontally is that orthodontists can avoid having to open the bite to
prevent interference from occluding teeth.

Deep Bony Impactions

Replaced mucoperiosteal flap
In cases of deep bony impaction, where the canine lies superior to the
mucogingival line of the lateral incisor, the surgeon cannot suture a
flap buccally. Once the attachment is bonded, the flap should instead
be replaced in its original position. The covered tooth can be moved
by applying force to the ligature tied to the attachment, and its
progress can be checked frequently with radiographs. Following this
protocol can provide excellent esthetics (see chapter 4, Figs 4-24a to
4-24h).
Ectopic teeth erupting in the palatal process (Figs 6-9a and 6-9b)
can only by accessed by a buccal approach. These situations require
the preparation of a large and extended mucoperiosteal flap. In deep
bony impactions, the impacted teeth have drifted on a nearly
horizontal plane, but they can sometimes be located superior to the
roots of the incisors or, very rarely, the premolars (see chapter 1, Fig
1-23).

Fig 6-9a Axial section showing the ectopic trajectories of the maxillary right and left
permanent canines in a 12-year-old girl. A computerized tomography film of this same patient
is presented in Fig 2-12.
Fig 6-9b A three-dimensional reconstruction showing the orientation of the maxillary right
and left canines, as well as their relationships with the roots of the lateral incisors.

Fig 6-9c Triangular mucoperiosteal flap limited mesially by an incision made at some
distance from the canine space.

Fig 6-9d Attachment bonded to the canine’s palatal surface. An attached steel ligature is
oriented lingually so that traction will correct the tooth’s eruptive pathway.
 Fig 6-9e The flap has been replaced, and the attached ligature wire is emerging from the
alveolar socket of the primary canine.

Figs 6-9f to 6-9g (f, left) Two-year postoperative view of the once-impacted canine,
adjacent teeth, and periodontium. (g, right) Septal crest is close to the cementoenamel
junction of the maxillary left permanent canine.

Surgical protocol
Because of the horizontal orientation of canines in a deep bony
impaction, the oral surgeon must make generous flaps to locate the
crowns, replace them with properly placed sutures, and maintain
hemostasis. A triangular flap with a sulcular and a releasing incision
ensures both sufficient access to the impacted canine and a hermetic
seal to the surgical opening (Fig 6-9c).
The attachment is bonded to the palatal surface of the tooth, and
the ligature twisted around the attachment remains in the alveolar
socket of the primary canine so that lingual traction can be applied
(Fig 6-9d). The oral surgeon then replaces the soft tissues in their
 original position with individual sutures (Figs 6-9e to 6-9g).

Orthodontic protocol
Treatment objectives for deep bony impactions of canines lying
horizontally over the roots of the incisors are as follows:

• Change the eruptive inclination of the canines, making sure that the
teeth do not emerge buccally.

• Guide their crowns into a lingual trajectory to correct their path of

eruption.

The vectors of the force should be applied coronally and lingually. A

heavy rectangular archwire with a palatal hook between the lateral
incisor and the first premolar can move the tooth toward the gingival
crest and tilt it into a normal path of eruption.
Impacted
MandibularTeeth
Eruption of Mandibular Incisors
Crown calcification of permanent incisors is completed at
approximately the same time in both the mandible and the maxilla,
when children are 4 to 5 years of age. Within their lingually inclined
gubernacular canals, the mandibular incisors lie in bony crypts that
are connected to the bony crypts of all the other mandibular teeth
(Figs 7-1 and 7-2). Unlike the situation in the maxillary dentition, the
mandibular central incisors are not separated by a bridge of bone, and
the lateral incisors are not located posterior to the central incisors. The
mandibular permanent incisors initially emerge with a lingual
inclination, but tongue pressure moves them labially into proper
alignment.
These teeth become impacted far less frequently than the maxillary
incisors because of anatomic conditions, such as a favorable
intercanine distance, that differ considerably from those of the maxilla.
However, the presence of a supernumerary tooth may block the
eruption of a mandibular incisor (Fig 7-3).

Fig 7-1 Positions of the mandibular incisors in children about 6 years of age. The crowns of
the four permanent incisors are lingual to the roots of the primary teeth (From van der Linden
and Duterloo 1976).
 Fig 7-2 Dentition of a child about 7 years of age. The crowns of the unerupted canines
normally abut the roots of the adjacent lateral incisors.

Fig 7-3 Supernumerary mandibular teeth. Two odontomas block the eruption of the
mandibular left central incisor. Note the thickening of the follicular wall.

Eruption of Mandibular Canines

The crowns of the mandibular canines, like maxillary canine crowns,
complete their calcification when children are about 6 years of age.
Because canine roots will become the longest mandibular roots, their
bony crypts are located farthest from the occlusal plane along the
inferior cortical border of the mandible.
The eruption of mandibular canines is of relatively short duration;
 they emerge into the arch when children are 9 to 10 years of age, a
full 2 years earlier than the maxillary canines. Since they erupt at a
slight lingual inclination, they usually cause the primary canines and
incisors to resorb with a lingual bevel (see Figs 7-2 and 7-7).

Ectopic trajectories of emerging canines

As it begins its formation, the mandibular canine’s root remains in
contact with the floor of the bony crypt. By the time it emerges into the
oral cavity, the root has finished two thirds of its development, and
when the crown reaches the occlusal plane, the tooth has almost
completely uprighted.
The area within which the mandibular canines erupt in the
mandibular arch is often much larger than what is available to their
maxillary counterparts. In the presence of crowding, the mandibular
canine crowns tend to deviate mesially and buccally. The tooth buds
that eventually become impacted will usually have an abnormal
orientation with rotated long axes and mesially inclined or, less
frequently, distally inclined crowns (Figs 7-4a and 7-4b).

• When the crown of an unerupted mandibular canine is inclined more

than 30 degrees to the median sagittal plane, orthodontic treatment
may be necessary to correct the inclination (see Fig 7-4a). To uncover
a bonding surface on the crowns, an apically and laterally retracted
flap must be created (Figs 7-5a to 7-5g) without damaging the
periodontal integrity of the adjacent lateral incisor. Once an
attachment is bonded, the orthodontist can begin to move the
impacted canine distally to correct its path of eruption. When
insufficient space is available in the arch, the treatment plan may need
to include extraction of premolars (see Fig 7-5e).

• When the unerupted mandibular canine has an inclination of more than

45 degrees, conservative treatment will be risky (see Fig 7-4b);
uprighting the tooth into correct position will probably cause
dehiscence of enveloping bone and serious periodontal defects.
 Fig 7-4a Angulation of the canine tooth bud. When the crypt of the canine is out of
alignment with those of the incisors, an excessive mesial slant (arrow) will keep the canine
from making contact with the distal surface of the lateral incisor and therefore prevent it from
uprighting.

Fig 7-4b Inclination of the mandibular right canine is greater than 45 degrees (arrow).
Orthodontic treatment will be risky.
 Figs 7-5a to 7-5c Surgical and orthodontic treatment of a mandibular canine. (a, left) This
frontal periapical radiograph shows the extent to which the unerupted mandibular left canine
overlies the root of the adjacent lateral incisor. Because its angulation is less than 30 degrees,
it can be brought into position safely through combined surgical and orthodontic treatment. (b,
center) This film shows how well the surrounding osseous septa have developed after the
canine assumed its correct place in the arch. (c, right) The surgeon must be careful not to
damage the periodontal margin of the mandibular left lateral incisor. Note the distance (arrow)
from the gingival margin to the tip of the unerupted canine cusp. GA = attached gingiva.

Fig 7-5d Preparation of the mucoperiosteal flap. The surgeon makes two parallel vertical
incisions, AB and CD, and a horizontal incision, AC. An incision XY follows the mucogingival
line and forms, with the AB incision, a triangle of mucosal tissue to be removed for placing the
gingival flap over the crown of the unerupted mandibular left canine.
 Fig 7-5e Because the treatment plan called for germectomy of all four first premolar buds,
the surgeon removed the mandibular left first premolar at the same time the impacted canine
was uncovered.

Fig 7-5f Two years postoperative. The canine is in place in the arch with healthy gingiva.
 Fig 7-5g Five years postoperative. Note how well the canine’s periodontal margin has fused
with the gingiva of adjacent teeth.

Transmigration of mandibular canines

If the long axis of a mandibular canine bud is inclined at an angle
between 50 and 90 degrees to the midsagittal plane in children aged 7
to 8 years, the canine will begin to drift toward the symphysis. As the
root develops, the canine may even pass the midline and continue to
erupt, asymptomatically, in the contralateral hemimandible. Because
such teeth usually remain impacted (Figs 7-6 to 7-8), they are rarely
discovered before children reach 10 years of age (Joshi 2001). Often,
when a periapical radiograph of an overretained mandibular primary
canine shows only bone where the successor ought to be,
practitioners initially think that the permanent tooth is congenitally
absent. A panoramic radiograph clarifies the clinical situation and
shows how far afield the tooth has strayed. When such dramatic
transmigrations occur, a number of anatomic factors are present:

• The tooth bud is angulated more than 30 degrees (Howard 1976).

• The incisors are tilted labially.

• The alveolar process in the region of the mandibular symphysis is

large enough to allow the tooth to migrate between the roots of the
incisors and the external cortical plate (Vichi and Franchi 1991).

Practitioners must not assume that the incisors were tilted labially
prior to the canine’s transmigration; the canine’s ectopic migration
may cause the labial inclination. Depending on the patient’s age and
the severity of the impaction, the operator will decide whether to
extract the tooth immediately or monitor it using periodic radiologic
checkups (Figs 7-9 and 7-10).

Fig 7-6 Mupparapu’s classification of canine transmigration (2002). (1) The canine is lying
at an oblique angle in the region of the symphysis with the tip of its cusp across the midline.
(2) The canine is lying horizontally near the inferior border of the mandible. (3) The crown of
the impacted tooth is close to the contralateral canine. (4) A horizontally impacted canine lies
under the apices of the premolars and molars of the contralateral hemimandible. (5) The
canine is positioned vertically on the midline between the two mandibular central incisors. 83
= mandibular primary canine.

Fig 7-7 Reconstruction of the most frequent oblique angulation of impacted mandibular
canines. The ectopic trajectory of mandibular canines is not related to an eventual crowding in
the mandible.
 Fig 7-8a and 7-8b Class 1 transmigration of impacted mandibular canines in a 12-year-old
boy. (a, left) Although precise measurements are not possible on panoramic radiographs, the
long axes of the impacted mandibular canines appear to be angulated at more than 45
degrees. (b, right) By the time the patient reached 14 years of age, the left canine had
spontaneously uprighted and emerged into the arch, and the impacted right canine had drifted
as far as the midline.

Fig 7-8c Reconstruction of a panoramic computerized tomography film.

Fig 7-8d Reconstruction of mandibular incisor crowns with considerable labial inclination.
Fig 7-8e Axial section demonstrating the thickness of the mandible and the relationship of
the canine with the roots of the incisors.

Fig 7-8f The root of the mandibular right lateral incisor (arrow) has been forced into the
mandible’s thick lingual cortical plate by the migration of the impacted canine.
 Fig 7-9a Class 3 transmigration of impacted mandibular canines in a 25-year-old woman.
The mandibular right canine has drifted so far that it lies over the root of the contralateral
canine. Even though the mandibular right canine is asymptomatic, the thickness of its follicle
on radiographic examination suggests the possibility of cystic degeneration and indicates its
removal.

Fig 7-9b The oral surgeon removes the mandibular right canine by sectioning its completely
formed root. An extensive gingival flap has been retracted to facilitate the creation of a bony
window and to make it possible for the area to be hermetically sealed after completing the
procedure.
Fig 7-10a Class 2 transmigration of impacted mandibular canines in a 40-year-old woman.
The impacted mandibular left canine lay near the inferior border of the mandible and has
drifted across the midline. Extraction is not indicated.

Fig 7-10b The missing canine will be replaced with an implant.

 Figs 7-11a to 7-11c A dentigerous cyst around a canine. (a, left) An oblique coronal
scanning reconstruction in the region of the mandibular right canine shows the extent of the
growth and how much it has distended and weakened the cortical mandibular bone. (b,
center) Note its bilobular anterior extension. (c, right) This three-dimensional tomographic
reconstruction shows the tumor extending distally to the mental foramen and displacing the
mandibular right first premolar.

Fig 7-11d Retracted triangular mucoperiosteal flap between the mandibular central incisors
with a sulcular incision and a perpendicular releasing incision.
Fig 7-11e Bony window created in the cortical plate over the tumor’s bulge. A marginal
bony bridge is left to ensure that the alveolus will not collapse as the wound heals.

Fig 7-11f Sectioning the canine to facilitate removal.

 Fig 7-11g The surgeon carefully enucleates any remaining extensions of the cyst before
hermetically sealing the cavity with the flap to protect the blood clot. No filling material is
added to the cavity.

The development of a dentigerous cyst around the follicle of an

impacted mandibular canine may require its immediate removal. Such
a decision depends on the tumor’s size, its potential for continued
growth, and the mechanical risks it poses for the mandible and
adjacent teeth (Figs 7-11a to 7-11g).

Eruption of Mandibular Premolars

In the maxilla, premolars usually emerge into the oral cavity before the
canines do, but the reverse is true for the mandibular dentition. Before
they begin their eruptive migration, premolars lie in their bony crypts
between the roots of the primary molars. As the premolar crowns
finish calcifying, they start to move coronally deeper into the furcations
of the primary molars, which quickly begin to resorb (Fig 7-12).
Any crowding of the anterior dentition has little effect on the eruption
of premolars, especially in the mandible, because posterior permanent
teeth are narrower than the primary predecessors. In addition, the
bony crypts of premolars in all four quadrants are separated from each
other by a thick alveolar wall.
The mandibular second premolar is the last tooth to erupt mesial to
the first molar. It usually emerges in a vertical path, but its trajectory
can be disturbed by either the loss of the permanent first molar or the
premature loss of a primary second molar, especially if a space
maintainer is not put in place.
The impaction of premolars is more frequent in the mandible than in
the maxilla and most often involves the second premolars. The
premature loss of primary teeth or an arch-length discrepancy can
impede the eruption of second premolars, which account for 23% of all
impactions and are the third most frequently impacted teeth, following
third molars and maxillary canines.
Fibrous scar tissue requiring surgical removal can also delay
premolar eruption. Slow tooth bud development, which may persist for
years, is another possible factor that is difficult to resolve.
Dentigerous cysts develop fairly frequently in the mixed dentition in
the mandibular premolar area, comprising 77% of follicular lesions
(Shibata et al 2004). A high percentage of the primary premolars with
impacted successors have diseased pulps. Chronic periapical
infection may provoke the development of a periodontal cyst and,
secondarily, a follicular cyst around the unerupted permanent
premolar (Figs 7-13a to 7-13c). Bacteria can penetrate into the tooth
directly during root canal treatment or indirectly through the
gubernacular canal, which lies open at the summit of the impacted
premolar’s bony crypt.
After the surgeon has excised or marsupialized the cysts, the
impacted tooth usually erupts spontaneously (Hyomoto et al 2003).
Cystic pockets must be detached from the tooth in order to be
extirpated, but care must be taken to preserve insertions into the root
because they will form the follicular tissue the tooth will need to
emerge. The wall of the cyst is excised after a circumferential incision
is made through follicular tissue midway up the height of the crown. A
window is created in the gingival crest over the crown through which
the tooth can emerge. Finally the cavity in the bone is closed off with a
small pad of iodoform-impregnated gauze to protect the blood clot.
This dressing is periodically replaced with increasingly smaller
dressings until the crown emerges into the oral cavity.
Orthodontic treatment for these problems requires that space be
maintained for the eruption of permanent teeth and, in some cases,
other teeth in the arch are realigned. However, successful preventive
strategies, which consist of good dental care during the mixed
dentition and regularly scheduled radiographic examinations, is
always preferable to corrective treatment. With proper attention to the
developing dentition of young patients, practitioners can greatly
reduce the occurrence of impaction in permanent teeth.

Fig 7-12 Dentition of a 9-year-old child. At this age, two thirds of a child’s premolar roots
have finished formation, and as the teeth begin to erupt, their crowns rise into the bifurcations
of their primary predecessors. If the pulp tissues of the primary molars are inflamed, infection
can spread to the follicles of the emerging premolars. (From van der Linden and Duterloo
1976).
 Fig 7-13a A dentigerous cyst of a second premolar. The radiolucent area in this radiograph
extends from the inferior border of the mandible to the alveolar crest. The cyst has caused the
erupting mandibular right second premolar to tilt distally.

Fig 7-13b and 7-13c (b, left) The second premolar uprighted completely as it emerged into
the arch, but cystic pressure had left its root misshapen. Crestal bone height relates nicely to
the cementoenamel junctions of the premolars. (c, right) Five-year postoperative view
showing healthy periodontal tissue in the premolar area.
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