Guide Dr. Chandralekha B Prof & HOD Dept Of Orthodontics And Dentofacial Orthopedics By : Dr.

Nilofer Vevai

Contents
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Introduction. Impaction….. Normal development of anteriors Theories Regarding Impaction of teeth. Radiographic Diagnosis. Classification of Impacted Canines . Surgical Exposure Of Impacted Teeth Treatment Options. Impacted Canines And Incisor root resorption Maxillary Central Incisors Traumatic Impaction & Impaction Of Single Teeth. Conclusion

Introduction
 A perfect set of 32 is something desired by all.
 However it is not uncommon to find a case wherein

individuals come forth with the sole complaint of not having the normal number of teeth in the oral cavity.

 Mainly this situation arises when there is this lack in

the anterior area & can be a great source of embarrassment to the patient … who may feel socially inferior to his counterparts ...
 2 situations when patients seek treatment :

Class 2 div 2. Impacted teeth in anterior region.

 In general 3rd molars are the most commonly

impacted teeth followed by maxillary canines and mandibular second premolars.
 In cases of maxillary impacted canines palatal canine

impaction is found to be more common than buccal canine impaction.
 In cases of maxillary canine impaction Females

affected more than males and buccal has higher incidence.

 A Brief recap

Nolla’s Stages Of Tooth Development

According to Macdonald a tooth erupts when the root is 2/3 formed.
According to Gron a tooth erupts when the root is ¾ developed.

Dental Age .Morphological Age.Impaction …  Terms which are important : .Chronological Age . .

 Eruption time is generally an indication for dental age is a wrong concept.  Dental age must be assessed depending on the root development of the teeth that should be in the oral cavity irrespective of its eruption status.  A tooth may have delayed eruption due to various local causes. .

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 Over Retained Deciduous Tooth: A term used to describe an unshed deciduous tooth with an underlying tooth with root lengths in excess of three –quarters of the full length. . Retained Deciduous tooth : A term having positive connotation and which maybe defined as a tooth which remains in place due to the absence or retarded development of the permanent successor.

 A permanent tooth with delayed eruption : Is one whose root length is developed in excess of this length and whose spontaneous eruption is expected. .

 An impacted tooth is a tooth that is all the way or partially below the gum line and is not able to erupt properly. bone.An Impacted tooth:  A disorder in which a tooth is so crowded in its socket that it cannot erupt normally. . or another tooth.  An impacted tooth is any tooth that is prevented from reaching its normal position in the mouth by tissue.

Mandibular canines and first premolars 12. While assessing dental Age … a base age of 9 yrs is taken and assessment made.if mandibular central incisor roots are complete means pt is at least 9 yrs old). . .Normally developing maxillary canines and 2nd premolars 14-15 yrs.First molars 9-9. .Maxillary lateral incisors 11 yrs.maxillary first premolars 13-14 yrs. .13 yrs. . . .5 yrs .Mandibular lateral incisors 9.5 yrs.

 Supernumerary teeth coniform premolars and peg laterals excluded. . Factors which must also be considered while assessing dental age : Crown formation Root formation. Root resorption.

 A Late developing dentition : Typically dental age lags behind chronological age and radiographically less root formation Extraction is contraindicated. .

.  Why so ? .Lateral incisor palatal irt both.Canines sited higher up vertically. .Centrals and canines same Anteroposterior level. .Normal Development  A periapical view of a 5 yr old child would give the impression of severe crowding .

 The Eruption Sequence and development of Ugly Duckling Stage and its resolution . .

 Thickened ligament post trauma .Causes Of Impaction  Inadequate resorption of deciduous root.  A supernumerary tooth.  Impactions due to space loss.  Disturbance in the eruption mechanism of teeth.  Early loss of deciduous tooth.  An abnormal eruptive path.  Dental Crowding. .

Tooth size – arch length discrepancies. 10. Prolonged retention or early loss of deciduous canine. 12. 3. Abnormal position of the tooth bud (rotation of tooth buds). 4. 11. Disturbances in the tooth eruption sequence. 8.ETIOLOGY OF MAXILLARY CANINE IMPACTION (MULTIFACTORIAL)  Bishara and associates summarized Moyer’s theory that impacted canine is caused by  Primary (Localized) 1. 6. Trauma of the deciduous tooth bud. Ankylosis. 5. 7. 9. Cystic or neoplastic formation Dilaceration of the root Premature root closure Iatrogenic Idiopathic . Presence of an alveolar cleft. 2.

 Secondary (Generalised )  Abnormal muscle pressure  Febrile diseases  Endocrine disturbances  Vitamin D deficiency  Irradiation .

” A canine in its buccally placed area can be palpated at 1113 yrs of age. Dewel once said : “ No tooth is more interesting than the maxillary canine from the development point of view than the maxillary canine…. .

.  High placement in the maxilla.  Crowding( Hitchins).  Non resorption of the roots of the deciduous canine(Lappin.palatal deflection).Additional reasons for canine impactions:  Long Path of eruption(Broadbent).

Short lateral incisor root due to development stunting by trauma leading to loss of guidance to canine. Trauma : Brin I. Movement of unerupted canine y itself. “Unharmed” adjacent teeth should be also evaluated 4. Soloman Y & Zilberman Y “ Trauma as a possible factor in maxillary canine impaction “ AJO DO 1993 Vol 104: 132-137 Case report … Result : 1. 2. . 3. Trauma causing abnormal path of eruption.

associated dental anomalies and genetic basis” Peck L.63. Soft tissue pathology. “ Maxillary canine first premolar transposition. Attia Y Angle Orthod 1993.  Heredity  Contentious issue   Studies show high positive correlation and spotaneous reslution when local factor is removed.Peck S.99-109  Primary tooth germ displacement .

 The Guidance theory: Miller (1963) & Bass (1967)  Noticed that congenitally missing lateral incisors also had a high instance of palatally impacted canines.  Thus the canine follows a mesial and palatal path since the lateral incisor is now missing to guide it to its correct position.  Hypothesized this due to the lack of guidance generally being given by the lateral incisor during eruption. .

3. . May or may not reach its desired position spontaneously. 1. The Guidance Theory Comprises OF 5 elements: Normal Eruption: 2. First Stage Impaction: Occurs when there is absence of lateral incisors or lateral incisors/peg shaped laterals … due to this there is lack of guidance and the canines shift palatally or are horizontally impacted. First Stage impaction with Secondary correction: A corrective process of the vertical maxillary process redirecting the canine in a more favorable downward path.

5. . Second Stage Impaction with secondary correction: Extraction of the over retained deciduous canine or the anomalous lateral incisor itself leading to the resolution of the problem.Second Stage Impaction: Self correction hampered by an anomalous late developing lateral. An etiologic factor not seen if the lateral incisor is present. redeflecting the tooth palatally. Aka Second Stage Displacement. 4.

. Miller : PEG SHAPED LATERALS AND ANOMALOUS LATERALS . They agree with the Guidance theory but raise questions over the anomalous lateral incisors. However Becker and co workers in their studies claim the opposite.

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.  An undiagnosed & severely resorbed tooth with a poor long term prognosis may be mistakenly included as an integral part of a final outcome dentition in a projected treatment plan but actually is a weak link can actually hamper your treatment plan.Importance……. .

 Clinical Examination : Inspection Palpation  Radiodiagnosis : Radiographic methods of diagnosis recognition of pathologic entities as well as localization and recognition of impacted tooth. .

Vertical Shift + Orthopantamographs 6. IOPAR 2. Radio diagnosis: 1. Occlusal Radiographs. Orthopantamographs + Lateral Cephalograms 7. Vertical Shift Technique 4. CT & CBCT . Orthopantamographs 5. Postero-Antero Cephalogram 10. Lateral Shift Technique 3. 8. Tangential View 9.

Type of Obstruction a) Soft tissue. . High clarity levels Disadvantage : Two dimensional. Shows the type of supernumerary tooth. Intraoral Periapical Radiographs: The first simplest and most informative view. Only Mandibular posterior area is what we call “ True Lateral” since all other areas the beam is angulated hence height assessment not very dependable. b) Hard Tissue.

Should depict the buccolingual placement of structures. In the lower canine premolar area the occlusal view is a true occlusal view and should depict all the posterior standing teeth in cross section. True occlusal view of the anterior area of the mandibular arch – 110 deg True occlusal view of the molar area 90 deg to the horizontal + 15 deg medial tilt of the tooth ……. . Occlusal Radiographs : Methodology.

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Anterior maxillary occlusal Periapical view. A high mesially placed canine seems similar to a high palatally placed canine this is avoided in true vertex view. . True vertex occlusal is the best but clarity low.In the maxilla we have : True Vertex Occlusal.

 In general mandibular occlusal film clarity is generally low due to dense cortical tissue. .

Parallax method . 3D diagnosis of tooth position…. Given by Clark CA in “ A method of ascertaining ethe relative position of unerupted teeth by mrans of film radiographs in 1910. 1. .

. It is of 2 types : The Lateral Tube Shift . The Vertical Tube Shift.

A popular technique. The Lateral Tube Shift : Uses the parallax method. SLOB Rule .

 Can be used with 2 IOPAR’s Lateral Cephalogram And OPG .

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 Vertical parallax: When the canine is in an extremely high position this can be utilised as an alternative. Incisor area impaction with incisor mesiodens this is difficult to discern. SLOB rule. . Reliability is low.

 Orthopantamograph+ IOPAR . Can be used with two IOPAR’s.

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Best for Dilacerated Central Incisor. Tangential View : Taken in the lateral ceph format with an occlusal radiograph. . Helpful for canine impaction Not useful for maxillary central incisor impaction. However during the course of resolution of central incisor impaction best view.

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Large doses Only exceptional cases Resorption of roots of incisor teeth also checked. . CT Scan Late 1980’s used fro the first time for identifying exact position of palatally impacted canines.

Low radiation doses . Xray source and image intensifier. CBCT Digital volume tomographic machines. Slicing. Reconstruction in every direction. 360 deg rotation Panaromic and transaxial view.

123:91-7. Rubenstein LK. .Lindauer SJ.  They modified Kurol & Ericson model for predicting eruption after deciduous canine extraction.  He determined the probability for impaction based on the canine cusp tip location in 1 of 4 sectors. Canine impaction identified early with panoramic radiographs.  Lindauer et al reported that this method identifies up to 78% of the canines that are destined to become impacted. Hang WM.  Lindauer’s method used the location of the cusp tip of the canine in question and its relationship to the adjacent lateral incisor. Isaacson RJ. J Am Dent Assoc 1992. Anderson WC.

 Sector IV includes all areas mesial to sector III.  Sector III is mesial to sector II. but distal to mesial heights of contour of lateral incisor crown and root. but distal to bisector of lateral incisor’s long axis.  Sector II is mesial to sector I. Sector I represents area distal to line tangent to distal heights of contour of lateral incisor crown and root. .

. State that an Angulation of more than 310 would hamper a spontaneous eruption of the canine once the deciduous tooth is extracted.20:215-23.Power SM. Short MB “ An investigation into the response of palatally displaced canines to the removal of deciduous canines and an assessment of factors contributing to a favourable eruption”. Br J Orthod 1993.

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91 0.25 0.38 0.75 0. R Grandhi.98 85–99 0.33 0.98 70–84 0.96 Angle not 0.06 0.87 0. Ajo Do 2003 vol 124  For every unit of change in sector. Probability of canine impaction based on sector and angle measurements Sector I II III IV Angle (deg) 40–54 0.87 0.53 0.04 0.08 0. the odds of indication of impaction increase by a factor of 8.Prediction Of Maxillary Canine Impaction Using Sectors & Angular Measurements  Article By J Warford.81 0.05 0.99 55–69 0.11 0.43 0.7.99 considered .

Secondary . The Surgical Elimination Of Pathology Soft Tissue Lesions Hard Tissue Obstruction .Primary .  Exposure with pack.Surgical Exposure Of Impacted teeth  Surgical intervention without Orthodontic treatment  Exposure Only with spontaneous eruption.

First done for a labially impacted canine by Vanarsdall & Corn. 2 Basic approaches to surgically exposing impacted teeth: The Open Eruption Technique a) The Window Technique b) The apically repositioned flap. .

 Modification by Crescini et al published in “Tunnel traction of intraosseus impacted maxillary canines A a 3 yr follow up” Ajo-do 1994.The Closed Eruption Technique : First described by Hunt & McBride. 105: 61-72 .

.Orthodontic Management Creation Of An Anchor Unit: Modification must be made for anchor unit. A fully multi-bracketed appliance should normally be placed & the entire dentition treated through the stages of leveling & opening of adequate space in the arch for impacted tooth.

.  Magnets.  Orthodontic bands.Devices to help:  Lasso wires  Threaded pins.  Simple Eyelet.  Standard Orthodontic Bracket.  Elastic ties And modules.

Disadvantages: This results in irritation of the gingiva   Prevents reattachments of the healing tissues in area of CEJ (cemento-enamel junction). It is rarely used now.Lasso wires: It is twisted lightly around the neck of the canine. .  May produce areas of external resorption & ankylosis in areas of CEJ.

. Rarely used. Disadvantages: .Threaded Pins: Provide the attachment for an impacted tooth.Difficult to place along the long axis of the tooth because of smaller surgical exposure.Dentally invasive. . . .Requires a subsequent restoration.The drilled hole may inadvertently enter the pulp(unerupted teeth may have large pulp chambers).

Disadvantage: Large surgical field required.Orthodontic bands: They largely replace the Lasso wires & threaded pins. .Inadequate moisture control may hamper with the cement-band bond. Advantage: They are compatible with the health of periodontal tissues. .

. Begg’s .Standard orthodontic brackets: Any edge-wise . PAE brackets can be used. They are routinely used as direct attachments along with the composites.

. it is difficult to adapt to any other tooth surface except for the buccal surface.As the bracket base is wide.Ligature wire or elastic thread tied to bring the impacted tooth into arch.The bracket’s shear bulk creates irritation as the tooth is drawn the soft tissues.Disadvantages: . . .

. As the impacted tooth advances into the arch the exuberant gingival tissues bunches in front of it & causes punching between the bracket & tissues.Interferes with the investing tissues & leads to inflammation & periodontal damage.

An eyelet welded to band material with a mesh backing is soft & easy to contour making its adaptation to bonding surface more accurate which makes for superior retentive properties. .Because of small size they can be placed in more awkwardly placed teeth.It is less irritating to the surrounding tissues. .A Simple Eyelet . .

Easier to tie Disadvantages .Application of light forces .Good range of action .High degree of force decay .Elastic ties and modules Advantages .Tends to loosen .

Disadvantage: Distance.Magnets : Rare earth magnets . One Magnet placed on the appliance. One on the displaced tooth. . They can corrode hence covered with a coating of parylene. Forces generated along the line of magnetic plane. Made Of Lanthanum alloys.

Classification Of Impacted Canine  Maxillary or Mandibular Canine may be impacted a) Bucally. . b) Palatally.

High Low .Classification Of Palatally Impacted Canines :  Transverse Relationship: Close to the midline Away from the midline.  Height Of the Crown of the tooth in relation to the tooth .

 Based On The Above Group I : Transverse : Close Height : Low Group II : Transverse : Close Height : Forward Low and Mesial to lateral incisor root. Group III : Transverse : Close Height : High Group IV: Transverse : Distant Height : High .

.  Group VI : Erupting in the line of arch in place of and resorbing the roots of the incisors. Group V : Canine root apex mesial to that of lateral incisor or distal to that of first premolar.

Root movement rarely necessary. Removal of eggshell thin bone.1. Position : Low Prognosis : Good Most common form of palatal impaction. Group I Transverse : Close to the arch. Surgery : minimally invasive. .

 Complications : Rotation: a) Auxiliary Niti Wire. b) Slingshot elastic. Mesial Crown displacement : Palatal root displacement : .

. Canine crown tilted mesially in close association with the palatal aspect of the root of the lateral incisor. Root apex correct position . Group II Transverse : Close Height : Forward low and mesial to the lateral incisor root.

 Surgery: Lateral Incisor roots may pose a risk. Ligature pigtail made to pass through a electrocauterised slit. Careful Bone removal advised. Flap replaced entirely. Minimum required tooth exposure for bonding. Hurdle : 180 degree rotation .

. Prevention : Vertical traction followed by alignment into desired positioned. b) The active palatal Arch. 3 types of spring auxiliaries may be used : a) The Ballista. c) The Light Auxiliary labial Arch.

. Support for force.  Problems that may be encountered: Thick palatal tissues. Delay may cause adjacent teeth to intrude instead of canine erupting. In all the 3 a heavy base archwire should be present to: a) b) c) Keep space regained open. Resist secondary distortion of the occlusal plane.

Thick And Resistant Palatal Tissue. . Risk Of Exposing and Damaging roots of adjacent teeth. Palatally displaced root. Group II Complications : Rotation.

d) Mesio-distal uprighting. b) Buccal Tipping of the crown. c) Derotation. In All 5 types of tooth movements can be seen in Aligning a Group II impacted canine… a) Vertical Extrusion. e) Buccal root torque .

Group III Transverse : Close Vertical : High Treatment Strategy : Buccal Approach: The Apically repositioned flap. Full Flap reflection & Partial Replacement. Two Stage Traction . Palatal Approach The tunnel Approach.

 Group IV Transverse : Distant Height : High The crowns of impacted canines in this case are placed medially and may even cross the mid-palatal suture. Treatment : Two stage traction approach. Normal Positioning of root apex. .

. Difficult Mechanics.  High relapse rates with the canines being in an edge to edge/ Cross.bite relationship with the lower teeth.

 Group 5 Canine root apex mesial to that of lateral incisor or distal to that of first premolar. Transposed tooth. . May be partially erupted.

  To extract the tooth ( Canine. Four possible lines of treatment:   To resolve the transposition to ideal relationship. To move the premolar mesially or incisor laterally and align the canine into position. . To use the canine for autotransplantation into a prepared socket in its ideal site. incisor/premolar) with least prognosis and leave the deciduous canine intact.

 Complications: Root dehiscence. Group VI Erupting in the line of the arch In place of and resorbing the roots of the lateral incisors. .

. difficult to diagnose correct position.

 Australian Helical Archwire  Tunnel Traction.  Cantilever Spring & TMA Box Loop. .Devices Generating Extruding Forces  Ballista Spring by Jacoby.  K9 Spring  Mandibular Anchorage.  Two Arch wire technique  The monkey hook.  Nickel Titanium Closed Coil Spring.

 Harry Jacoby Ajo Do Feb 1979. is allowed to rotate in the premolar bracket acting like a hinge.016 or 0.  It is an 0.014. .018 inch round wire which accumulates its energy by being twisted around its long axis.  Horizontal part of this wire accumulates the energy. Ballista Spring :  Ballista : An Ancient And Heavy Engine Of Warfare Used To Hurl Heavy Objects.0.

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the horizontal part accumulates the energy into the twisted metal.” .  When the vertical section is released.  When the vertical portion of the spring is raised toward the impacted tooth. it bumps down like a “ballista. The last part of the spring is bent down vertically and ends in a loop shape to which a ligature elastomeric thread can be attached.

 Creates a torsion on the molars hence a TPA must be given. .  Aesthetic.  Can be used for both Unilateral or bilaterally impacted canines.

Diameter 0.018 Force 60-100g of force 120-150 g Best to start with 0.018 inch wire after 2 months and if required force increased by using double wires. .016 inch wire and proceed to 0.016 0.

.  Minimal trauma during surgery.  Can also be used for impacted upper incisors. vestibular upper and lower canines and premolars and molars.  Aesthetic.  Ease of operating and changing the spring. Advantages :  No impinging of roots.

. Cantilever Spring & TMA BOX Loop Given by Lindauer And Isaacson.VITTORIO CACCIAFESTA.017 x 0. Stiff posterior archwire segments And TPA required.025 TMA wire. Auxillary tube one point contact.CARLES BOSCH 0. Statically determinate forces.  Alignment of Impacted Canines with Cantilevers and Box Loops VOLUME 33 : NUMBER 02 : PAGES (82-85) 1999  SURENDRA PATEL.

C. canine has erupted with proper tip. B. allowing engagement in continuous rectangular archwire. Within four months. Cantilever for mesial and vertical eruption of impacted canine. .A. Full-size rectangular archwire and transpalatal arch used for anchorage and space maintenance. Angulation of ligature between cantilever and attachment on canine corresponds to line of force.

 Magnitude of force should not exceed 70gms.  The line of action of the force exerted by the

cantilever on the canine can be adjusted according to the situation. For a buccally impacted canine, the choice would be either to extrude and mesialize the canine or to extrude and distalize it. A palatal push-force component or a buccal pull-force component can be added if necessary.

A Cantilever Spring For Extrusion Canine needs distal tipping

 TMA Box loop :

Statically indeterminate system. Constructed from 0.017x 0.025 TMA The desired activation depends on the postion

Sagittal plane: box loop activated by inserting it into canine bracket; distal tipping and extrusion achieved in one month.

Horizontal plane: box loop activated for correcting canine rotation; mesial rotation achieved in one month.

. Elastics pulling the canine generally have a decay of forces.  TMA Advantageous.  Effectiveness high.

A NiTi Closed Coil Spring .

JH Park. NiTi Closed Coil Spring A Review Of the Diagnosis & Management of Impacted Maxillary canines By MariselaM. No 12. . 1485-1493. J Am Dent Assoc. Bedoya. Vol 140.

Nickel Titanium Closed-Coil Spring for Extrusion of Impacted Canines VOLUME 33 : NUMBER 02 : PAGES (99-100) 1999 LORING L.009”X 0.041” spring Provides 80 gm of force when stretched to twice its resting length . ROSS 0.

unwrap.b. and wrap several links around a stable rectangular archwire with an occlusal step. reactivate. Slip the hook through the link of elastomeric chain (from the impacted canine) nearest the gingiva. At the next visit. and twist it a couple of times. c. d. Be sure to leave a "tail" of chain for reactivation. Activate the spring. and rewrap the spring .

H.A (1997) • 0. Gold links removed for activation.014” nickel titanium arch wire • Gold chain is preferable because of flexibility and biocompatibility.R. Tied to the 0. 3 Pg 183-187 1997 Gold Chain fixed to the active component .Two Arch Wire Technique for Alignment Of Impacted Teeth: Samuels & Rudge Vol 31 No.014 Niti Archwire Which is deflected towards the tooth by 3-4 mm. •Samuels. .

and Displaced Teeth VOLUME 36 : NUMBER 07 : PAGES (375-378) 2002  S. ALDO CARANO  The Monkey Hook is a simple auxiliary with an open loop on each end for the attachment of intraoral elastics or elastomeric chain. JAY BOWMAN.  Inspired by the children's game. .The Monkey Hook: An Auxiliary for Impacted.  A combination of Monkey Hooks and bondable loop-buttons allows the production of a variety of different directional forces to assist in the correction of impacted. Rotated. or for connecting to a bondable loop-button. rotated. "Barrel of Monkeys". since more than one Monkey Hook can be linked together to form a chain. The hook can be closed with a plier to prevent disengagement. or displaced teeth.

 Vertical Eruptive Intermaxillary Force… A small area of the crown needs to be surgically exposed for direct bonding of a loop-button with attached Monkey Hook. The loop should be positioned parallel to the roots of the adjacent teeth to allow subsequent attachment of more hooks for production of a variety of forces. .

The Monkey Hook can extend through the gingival tissue after surgical exposure. a second Monkey Hook can be linked to the first. Best use when used in conjunction with super-elastic archwire. . The Hooks give a more rigid support. If the tooth is deeply impacted.

Elastomeric chain or superelastic coil springs can be attached to these hooks to direct forces laterally. . Can also be used as a rotational couple and a retraction hook. Lateral Directional Forces More than one Monkey Hook can be added to a loopbutton attachment. creating a slingshot effect. much like keys on a key ring.

 The K-9 Spring for Alignment of Impacted Canines Varun Kalra JCO Vol 34 (Oct) pg 606-611 2000. 0.017x0.025 TMA wire.  Advantages • Simple in design • Low cost • No patient compliance • Light continuous eruptive and distalizing forces .

Spring held just distal to vertical arm with plier. Spring bent 90° downward about 7mm mesial to premolar bracket to form vertical arm.Horizontal arm inserted into first molar buccal tube and premolar brackets. and vertical arm bent about 20° inward. . which is about 11mm long and ends in helix. toward palate.

. No. Ajodo Vol 115. Management Of Impacted Maxillary Canines using Mandibular Anchorage. 3 . A mandibular impression is made to fabricate a mandibular lingual arch with o. 255-259. The mandibular lingual arch is cemented in place after fabrication. After adequate space is opened. it is maintained with a closed/open coil spring.036 mm SS wire to be soldered from the first molar band on one side to the first molar band on the other side.

The elastic size can vary to ensure the delivery of forces that range from 40 to 60 g based on the movements of the mandible. . An orthodontic bracket should be bonded on the labial surface of this tooth as soon as possible. and a proficiency check is done a week after the surgical procedure.Elastic traction applied to bonded attachments. The canine is guided vertically toward the occlusal plane. Traction with light forces is applied via directional elastics. The elastic application is demonstrated to the patient.

The need for stiff main archwires to avoid side effects on the adjacent teeth. and archform can become distorted. If a superelastic nickel titanium wire is inserted directly into the canine bracket. the wire must be deflected. but delays the forced eruption of the impacted canine. canting of the occlusal plane. The stiff primary archwire prevents the flexible nickel titanium archwire from sliding freely through the brackets. . since the rest of the dentition must be fully aligned before a sufficiently rigid main archwire can be placed. An overlay or piggyback wire avoids these side effects. and a consequent lateral or anterior open bite.Elastic force modules have the disadvantages of rapid force decay. This can result in tipping or intrusion of adjacent teeth.

 Eruption of Impacted

Canines with an Australian Helical Archwire Christine Hauser,Yon H. Lai, Elina Karamaliki. Volume 34 : Number 09 : Pages (538-541) 2000  O.o16 Australian Archwire special plus, Straight length.  The force should not exceed 200g.  Activation by twisting the steel
ligature wire every two weeks

 Tunnel Traction of Infra-osseus Canines.

Aldo Crescini AjoDo 1994, 115,61-72.

Nagaraj.o10” SS ligature wire placed thru flap. Flap raised o. . Jatti. ERUPTION OF AN IMPACTED      CANINE WITH A SEMI-FIXED APPLIANCE: A CASE REPORT by Dr. Priyanka Sethi. Tunnel created thru the bone.Dr. Dr. A semi fixed appliance used to create a favourable path of eruption. Neelima K. Tied to the clasps. Pigtail lig. Dr.

 Because of the angulation a distally directed force was applied.  Latero incisal + Distal force. .022 Prescription placed .  Roth 0.

. a third molar that might have inadvertently been pushed into the cavity during the removal of a tooth.  Rapid prototyping makes a 3D model with/ without the help of CT Images. Eg. it can reproduce the maxilla with the maxillary sinus and. inside this cavity.Rapid Prototyping  3D CT images are seen as 2D on film and computer screen. It is capable of reproducing complex designs that are unthinkable by any other method.

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Berto.  Rapid prototyping technology made possible the fabrication of an attachment for forced canine eruption. Dental modeling by means of rapid prototyping was an efficient auxiliary method in diagnosis. and communication with this patient and the orofacial surgeon. orthodontic treatment planning. and Quaresma .  Rapid prototyping dental modeling might become the diagnostic procedure of choice in the evaluation of impacted maxillary canines.  American Journal of Orthodontics and Dentofacial OrthopedicsApril 2006 129 583-89 Faber.

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Indeterminate Right/left designation. Congenitally missing Central Incisor extremely rare…  Patients appearance is abnormal and reminiscent of a “Dental Cyclops”…. “ Square” anatomy of incisor .  Associated with : Absence of philtrum. . Absence of dental midline.

.Etiology Trauma Displacement Of tooth bud itself. Displacement may cause normally placed adjacent teeth to cause an obstruction to eruption.

 Traumatic Causes: Obstruction Due to Soft Tissue Repair. . Dilacertation.

however the adjacent teeth continue to develop and eventually erupt leading to the development of the alveolar bone in the area. Acute traumatic intrusion. vertical and with under-developed bone around it leading to narrow alveolar bone immediately around it. however at a later date when the concerned tooth refuses to erupt and investigations are made the tooth is found to be found in the normal position.   The Jerusalem Hypothesis.   .-- Arrested Root Development When a preschool child suffers a trauma the root might get arrested immediately. (intrusive luxation) Actually an advantage since the tooth not allowed to dry.

 Treatment Time : Reported at 7-8 yrs of age. Best treated at this age (4 yrs before canines erupt) Follow up to be done till the canines erupt. .

Supernumerary tooth. c) Alignment . b) Elimination of cause eg. Results : Quite disappointing a) 54-78% cases non eruption. A standard protocol of treatment available followed in Europe… a) Prepare space. b) Delay in Eruption.

b) Loss of labial bony plate. . Why they hesitate doing active mechanotherapy : Mills : Exposure of the crown of the permanent tooth during the procedure to remove the supernumerary tooth. Also : a) Spontaneous eruption chances are high. since periodontal result of the final result is compromised. c) Poor gingival margin and less attached gingiva d) Gingival level discrepancy.

. Final finishing without changing to another appliance. Treatment Protocol: An Orthodontic Appliance in the Early mixed Dentition Space : The Qualities Required : Leveling and derotation. Acheivement of good periodontal prognosis. Light and controlled extrusive forces.

020” Int dm) tubes slide freely in the o. Long and narrow gauge ( 0.018/0. This was extended upto the canine area.o36” dm buccal tube.Johnson’s (Modified) Twin Wire Arch  Given in Int J Of Ortho 1934 Vol 20 946-963.016 NiTi or 0.020 SS. Initial alignment with 0.  Appliance based on fixed molar bands connected by a      soldered Palatal Arch.0175 Niti Post Alignment switch to plain round 0. Place tubing for added retension thius rigidity .

.

 Best method … With e-chain. Now ready for Surgical Intervention.  When it reaches occlusal level reassessment . .

Root Torquing of Impacted Canines
 According to Becker buccal root torque of the treated

impacted canine required may be quite substantial. This may cause a reactive force on the adjacent teeth as well.  Planning must be done in such a way so as to minimize the effects on the anchor units.  Heavy base arch should be used and its form compensated to compensate for the expected movements.

 Intermaxillary S- elastics may be used.

On the side of cross-bite tendency: Buccal of lower molar to lingual of upper molar. v/v on the opposite side.
 A case of bilaterally impacted canine does not have

loss of anchorage since the 2 sides are pitted against one another.

Retention
 Group 4 and 5 cases require maximum retention as

the relapse tendencies are high.  These 2 groups require permanent retainers.
 Acc. To Wilbur Johnston “Palatally Impacted

Canines” Dec 1969 Ajodo A Class I malocclusion case requires no retention.

17. Impacted side.7% Ideal alignment on control side is twice as often as the impacted side. .4% 2. Evaluation of Post treatment Alignment by Becker et al: Incidence of rotations and spacings 1. Control side 8.

shaped wedge of tissue from lingual aspect of canine. It has been suggested for palatally impacted canine: Lingual drifting can be prevented by removal of half-moon. . To minimize rotational relapse. Bonded fixed retainer This can be done during or after the treatment. options available are 1. Fiberotomy 2.

 Angle Orthod 1995. . CE simulates natural eruption pattern. scarring levels).Vermette ME. Mentions another method of Impaction assessment. Periodontal status was similar in both. and pulp status with the closed-eruption technique. Uncovering labially impacted teeth: apically positioned flap and closed eruption techniques.65:23-32. Kennedy DB. Compared the apically positioned flap with the closed eruption technique and found much superior results in terms of gingival( height. Kokich VG.

Yocheved Ben-Bassat. Yerucham Zilberman.  This study demonstrates that overall good long-term esthetic results can be achieved by treating impacted maxillary incisors with a closed-eruption orthodontic surgical technique. .Closed-eruption surgical technique for impacted maxillary incisors: A postorthodontic periodontal evaluation Adrian Becker. and Stella Chaushu. Ilana Brin.

Delayed bonding/banding. Vanarsdall.Soft-tissue management of labially positioned unerupted teeth  Robert L. and Herman Corn. 4. Am J Orthod Dentofacial Orthop 2004. Tooth movement faster. Availability of Attached Gingiva. Attached gingiva restricts the regrowth of soft tissues. 3. . 2.125:284-93 Advantages of Surgical exposure thru Apically repositioned flap: 1.

 A careful treatment approach to this is required as it is of great esthetic concern to us. .Conclusion…  A versatile chapter in orthodontics showing the versatility of our branch in general.

Attached gingiva restricts the regrowth of soft tissues. Tooth movement faster. 4. Availability of Attached Gingiva. 2. 3. Vanarsdall. Delayed bonding/banding.125:284-93 Advantages of Surgical exposure thru Apically repositioned flap: 1. Am J Orthod Dentofacial Orthop 2004. . and Herman Corn.References  Robert L.

Prediction Of Maxillary Canine Impaction Using Sectors & Angular Measurements.20:215-23. Ajo Do 2003 vol 124. J Am Dent Assoc 1992.5. An investigation into the response of palatally displaced canines to the removal of deciduous canines and an assessment of factors contributing to a favourable eruption. Lindauer SJ. 6. Canine impaction identified early with panoramic radiographs. Isaacson. 105: 61-72.123:91-7. 8. Hang WM. R Grandhi. Rubenstein LK. Power And Short Br J Orthod 1993. Article By J Warford. 7. . Tunnel traction of intraosseus impacted maxillary canines A a 3 yr follow up” Ajo-do 1994. Anderson WC.

Volume 33 : Number 02 : Pages (82-85) 1999.vittorio Cacciafesta. Ross Volume 33 : Number 02 : Pages (99-100) 1999. Nickel Titanium Closed-coil Spring For Extrusion Of Impacted Canines. Bedoya. 3 Pg 183-187 1997 12. Ballista Spring Harry Jacoby Ajo Do Feb 1979. 1485-1493. No 12. Two Arch Wire Technique for Alignment Of Impacted Teeth: Samuels & Rudge JcoVol 31 No. . 11. Vol 140. Carles Bosch. 10. 13.9. Alignment of Impacted Canines with Cantilevers and Box Loops. Loring L. JH Park J Am Dent Assoc. Surendra Patel. A Review Of the Diagnosis & Management of Impacted Maxillary canines By MariselaM.

Elina Karamaliki. Management Of Impacted Maxillary Canines using Mandibular Anchorage. Eruption of Impacted Canines with an Australian Helical Archwire Christine Hauser. Volume 36 : Number 07 : Pages (375-378) 2002. 15. The K-9 Spring for Alignment of Impacted Canines Varun Kalra JCO Vol 34 (Oct) pg 606-611 2000. And Displaced Teeth. Yon H. 17. No. Lai. 16. . S.14. 3 . Ajodo Vol 115. The Monkey Hook: An Auxiliary For Impacted. Volume 34 : Number 09 : Pages (538-541) 2000. Aldo Carano. 255-259. Jay Bowman. Rotated.

Priyanka Sethi.18. Faber. American Journal of Orthodontics and Dentofacial Orthopedics. Dr.Dr. Johnson’s Modified Twin Wire Arch. Berto. Int J Of Ortho 1934 Vol 20 946-963. Nagaraj. . Neelima K. Dr. Jatti. Eruption Of An Impacted Canine With A Semifixed Appliance: A Case Report by Dr. Cyberjournal 19. and Quaresma April 2006 129 583-89 20.

Adrian Becker. Angle Orthod 1995. 24. Soft-tissue management of labially positioned unerupted teeth.65:23-32. Vanarsdall. Wilbur Johnston Dec 1969 Ajodo. Ilana Brin.125:284-93. 22. Yerucham Zilberman. . Kennedy DB. Closed-eruption surgical technique for impacted maxillary incisors: A postorthodontic periodontal evaluation. Vermette ME. Palatally Impacted Canines.21. Am J Orthod Dentofacial Orthop 2004. 23. Kokich VG. Uncovering labially impacted teeth: apically positioned flap and closed eruption techniques. and Stella Chaushu. Corn. Ben-Bassat.

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