IMPACTED MAXILLARY CANINE

DR JUNAID HAMZA
 IMPACTION:

 A tooth that fails to erupt and will not attain its anatomical
position beyond the chronological eruption date even after its root
completion.

 Impaction of maxillary and mandibular canines is a frequently

encountered clinical problem.
 Maxillary canines are the most commonly impacted teeth, second
only to 3rd molars.
  IMPACTED CANINE:

 Maxillary permanent canine normally erupts at age of 11-12

years
 Following features have been frequently seen with maxillary
canines
 Congenital absence
 Impaction (unilateral or bilateral)
 Resorption of upper incisors by impaction
 Transposition (with lateral incisor or 1st PM)
  NORMAL PATHWAY:

 It lies first buccal & mesial to the apex of deciduous canine

 It then pushes the root of lateral incisor in the mesial direction,
leads to flaring & spacing in the incisors (Ugly Duckling
Stage)
 Ultimately it moves distally & occlusally & normalize the
flaring & spacing in incisors
 INCIDENCE:

 Maximum canine impaction occurs in approximately 2-3%

of the population.

 Twice as common in females as it is in males.

 The incidence of canine impaction in maxilla is more than

twice that in the mandible.

 Of all patients who have impacted maxillary canines, 8%

have bilateral impaction.
 ETIOLOGY:

 Localized

 Systemic

 Genetic
 LOCALIZED CAUSES:

 Tooth size arch length discrepancy.

 Early loss of primary canine or
prolonged retention of primary canine.
 Ankylosis of primary canine.
 Cysts or neoplasm.
 Absence of lateral incisor(permanent)
 Idiopathic causes
 SYSTEMIC CAUSES:

 Endocrine deficiences

 Febrile diseases

 Irradiations
 GENETIC CAUSES:

 Hereditary

 Malposed tooth germ

 Presence of alveolar cleft

CLASSIFICATION OF
CANINE IMPACTION
  ARCHERS CLASSIFICATION:

 Class I:
Palatally Impacted canines.
Horizontal, Vertical, Semi vertical.

 Class II:
Buccally Impacted canines.
Horizontal, Vertical, Semi vertical.

 Class III:
Between palatal and buccal surface area.
 Class IV:
Located in the alveolar process.

 Class V:
Located in edentulous area.

 Class VI:
Located in aberrant position i.e: sinus.
 ERIKSON AND KUROL
CLASSIFICATION:
 THEORIES OF CANINE IMPACTION:

 Guidance Theory

 Genetic Theory
 EVALUATION:

 If displacement is suspected, the position of an un-erupted

canine, should initially be assessed, clinically followed by
radiographic examination
 Clinically it is possible to locate the canine by palpation in the
buccal vestibule, or palatally & may also seen by the inclination
of lateral incisors
 EVALUATION:
  RADIOGRAPHIC ASSESSMENT:

 Common views are :

1. OPG
2. Periapical
3. Vertex occlusal
4. Standard upper occlusal
5. Lateral ceph
6. Parallax technique ( tube shift technique )
7. CBCT
 RADIOGRAPHIC ASSESSMENT:

The radiographic assessment of a displaced canine should include

following;
 Canine angulation to the midline
 Vertical height of the canine crown
 Antero-posterior position of the canine root apex
 Canine –crown overlap of the adjacent incisor
 Root resorption of the adjacent incisor
 Labio-palatal position of the canine crown
 Labio-palatal position of the canine apex
 CONVENTIONAL WAY OF CANINE
LOCALIZATION:

SLOB RULE:

Same lingual opposite buccal

 Take 1st radiograph at 90 degree

Take 2nd radiograph at 45 degree

Either move mesially or distally slightly

 Determining the Prognosis:

 Age of Patient.

 Availability of space.

 Favorable position of canine.

 Angulation of impacted canine

 VERTICAL HEIGHT OF IMPACTED
CANINE:
MANAGEMENT:
 GENERAL TREATMENT OPTIONS:

1. Interceptive removal of deciduous canine

2. Surgical removal and prosthetic replacement of impacted canine
3. Surgical exposure and orthodontic alignment of impacted canine
4. Auto-transplantation of canine
5. No treatment
 1. INTERCEPTIVE REMOVAL OF
IMPACTED DECIDUOUS CANINE:
 Early detection & presence of crowding may guide for the
extractions of adjacent teeth (PM) & relieve of crowding
 Patients or their guardians may be warned for the possibility of
surgical exposure of ectopic canine & orthodontic traction
 Timely removal of deciduous canine as early as 8-9 years age may
let normal eruption of the permanent canine.
 2. SURGICAL MANAGEMENT:

 Surgical removal of the canine is considered under following

conditions;
 If retained deciduous canine is acceptable in appearance, & patient
is satisfied about the future fate of it, or its prosthetic replacement
 If the impacted tooth is in unfavourable position so we will remove
the tooth and put an implant or resin based bridge
 Extraction of permanent canine can be considered when lateral
and 1st premolar are in contact and midline is on with good
appearance
USE OF LASER FOR SURGICAL
EXPOSURE

 A new innovation is the surgical exposure of impacted canine

 This can then be followed by traction of the canine

 Laser surgery offers a more accurate, bloodless and a

somewhat painless substitute to the conventional surgery.
 Surgical
exposure of
canine using
lasers
3. EXPOSURE AND ORTHODONTIC ALIGNMENT:

 This is the treatment of choice for well motivated patient if

impaction is under these limits

A. Canine crown overlapping no more than half width of

central incisor root
B. Canine crown no higher than the apex of adjacent incisor
root
C. Canine apex in line of arch
 3. EXPOSURE AND ORTHODONTIC
ALIGNMENT:

 The tooth can either be exposed into the mouth & wound packed open, or a
bracket attached to gold chain / lace back wire can be bonded & wound
closed then,
 Orthodontic traction can be done by fixed orthodontic mechanics
 Exposure works well for palatally impacted canines, but buccally impacted
canines usually have a poor gingival contour following exposure
 So, operators prefer to attach a chain to buccally impacted canines & to
close the wound, so that the un-erupted canine is brought down to erupt thru
attached rather than free gingiva
 A) BUCCAL DISPLACEMENT:

 Usually associated with crowding

 More likely to erupt than palatal displacement
 Managed by :
Relief of crowding
Buccal canine retractors (mesial inclination)
Fixed appliance (distal inclination)
 Severe crowding cases may require extractions
 Rarely may require surgical exposure and orthodontic traction
 B) PALATAL DISPLACEMENT:

 Option 1 : surgical removal of canine

 Option 2 : surgical exposure and orthodontic alignment

 Space creation by preliminary orthodontics

 Either allow the tooth to erupt for 3 months
 Or start traction at the time of surgery
 Or start traction 2 days after pack removal
 APPLYING TRACTION:

 Ligature wires.
 Rubber bands.
 Power chain.
 Mini implants.
 RUBBER BAND TRACTION:
 POWER CHAIN TRACTION:
MINI-IMPLANTS TRACTION:
 4. AUTO-
TRANSPLANTATION:

 It is selected, when orthodontic treatment has to be avoided &

of course the long duration, the criteria for the auto-
transplantation are;
 There must be adequate space for the canine in the arch
 Canine should be removed intact with a minimum of root
handling
 The major cause of failure of the transplant is the root
resorption, but it may be reduced, if the surgical technique
is a-traumatic & transplanted tooth is root filled with
calcium hydroxide shortly after surgery
 The success rate is appropriate in few of the cases (about 70
% for 5 yrs)
5. Leaving un-erupted canine in situ

 The primary cuspid can be left in situ, also prognosis is

unpredictable ( a canine with a good root may last for many yrs)
 When eventually primary cuspid is lost, a prosthesis may be
needed
 Extraction of permanent canine may also be considered, where
lateral incisor & 1st PM are in contact, & mid line is on, with
good appearance
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YOU