MANAGEMENT OF

IMPACTED
CANINE

ANMOL GOEL
POST GRADUATE STUDENT
DEPARTMENT OF ORTHODONTICS
V.S DENTAL COLLEGE
CONTENTS

Part I:
 Introduction
 History
 Pattern of tooth eruption
 Frequency And Incidence
 Etiology
 Classification of Canine Impaction
 Theories For Impaction
 General Principles
 Diagnosis

2
Part II:
 Treatment Modalities
 The Surgical Exposure/ Flap Techniques
 Attachments
 Auxiliaries
 Treatment Strategies
 Conclusion
 References.

3
 Introduction

 IMPACTUS (latin origin) = pushed against

 Archer (1975) defines impacted tooth as one which is

completely or partially unerupted and is positioned
against another tooth or bone or soft tissue so that its
further eruption is unlikely.

Archer William H. Oral and Maxillofacial Surgery, Vol. I,ed. 5, Philadelphia, WB Saunders Co. 1975

4
 According to Mason , “An impacted tooth is one whose
eruption is considerably delayed ,and for which there is
clinical or radiographic evidence that further eruption may
not take place”(Eur J Orthod,2001)

 A canine is considered as being impacted if it is interrupted

after complete root development or if the contralateral
tooth is erupted for atleast 6 months with complete root
formation (Lindauer ,Rubenstein J Am Dent Assoc 1992)

5
 TOOTH ERUPTION AND ITS STAGES
 Tooth eruption is defined as the movement of a tooth from
its site of development within the alveolar process to its
functional position in the oral cavity.

6
Stages

7
 When Can A Tooth Be Considered As Impacted

 Under normal conditions, tooth

erupts with a developing root, that
is approximately ¾ of its final root
length. (Proffit, Gron)

 Hence in simple terms, a tooth can

be considered impacted if its root is
completed but still has not erupted.

8
  Applying this concept to maxillary and mandibular canines ,
they generally have their ¾ root completed by 11-12 yrs and
9-10 yrs respectively. (Gron)

• According to Shafer et al: Impacted teeth are those which

are prevented from erupting by some physical barrier in
the eruption path.

Proffit, Fields, Sarver, Ackerman. Contemporary Orthodontics. 4thed:pg 94. 9

FREQUENCY AND INCIDENCE

10
 Incidence

Thilander and Myrberg

Dachi and Howell estimated the cumulative
reported that the prevalence of canine
incidence of impaction in 7 to 13- year-
maxillary canine old children to be 2.2%
(Thilander B, Myrberg N. The
impaction is 0.92% prevalence of malocclusion in
(Dachi SF, Howell FV. A survey of
Swedish school children.
3,874 routine full mouth radiographs.
Oral Surg Oral Med Oral Path Scand J Dent Res 1973;81:12-
1961;14:1165-9.) 20.)

Ericson and Kurol

estimated the incidence at Of all patients with
1.7% Impactions are twice maxillary impacted
as common in females canines, it is
(1.17%) as in males
(0.51%).(Ericson S, Kurol J. estimated that 8%
Radiographic assessment of maxillary
canine eruption in children with clinical
have bilateral
signs of eruption disturbances. Eur J
Orthod 1986;8:133-40.)
impactions

11
 Becker et al. reported that
The incidence of the palatally displaced
permanent canine canines occurred three
impactions was 20 times more frequently
times higher in the than those found
maxilla than in the buccally.
(Becker A, Smith P, Behar R. Theincidence
mandible. (Johnston WD. of anomalous maxillary lateral incisors in
Treatment of palatally impacted canine relation to palatally-displaced cuspids.
teeth. Am J Orthod 1969;56:589-96.) AngleOrthod 1981;51:24-9.)

Johnston reported that the

palatal impactions were
twice as common as the
labial impactions.

12
 History
Author Year of Specimen
publication

Sullivan and 1915 Punin

Hellman Calvarium

Thoma 1917 Ancient

Egyptians

Krogman 1940 Tepe Hissar,

Iran

Iseri and Uzel 1987 Cayonii,

Turkey

1
 Palatal Versus Labial Impactions

 Fournier et al reported a palatal to labial impaction

ratio of 3:1.
 Jacoby reported a palatal to labial impaction ratio
of 12:1.
inclined
 Palatally impacted canines horizontal/
oblique direction

inclined
 Labial impactions vertically

Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofacial Orthop

1992; 101: 159-71. 14
  Jacoby further observed that
roughly 85% of palatally
impacted canines had sufficient
space for eruption into the dental
arch.

 Conversely, 83% labially

impacted maxillary canines
appeared to have arch length
deficiency.

Jacoby H. The etiology of maxillary canine impactions. A J Orthod 1983;84:125-32.

15
 Development and Eruption Pattern
 Broadbent (1941) stated that calcification of the permanent
maxillary canine crown starts at one year old, between the
roots of the first deciduous molar, and is complete at 5-6 years.
By the age of 12 months the crown of the tooth is found
between the roots of the primary molar.
 At 3-4 years of age the canine passes over the line of the
primary incisors to lie on the labial side of the root of the
lateral incisor (Miller, 1963).
 At the age of four years the primary first molar, the first
premolar germ and canine lie in a vertical row. Subsequent
growth on the facial surface of the maxilla provides space for
the forward movement of the canine so that its cusp comes to
lie medial to the root of the deciduous canine
Broadbent BH. Ontogenic development of occlusion. Angle
Orthodontist 1941; 11: 223-41. 16
 The positional changes between 8 and 10
years of age need careful observation for
detection of potential impaction
(Williams, 1981).
 During this stage of development the
canine normally migrates buccally from a
position lingual to the root apex of the
deciduous precursor; however, some
canines do not make the transition from
the palatal to the buccal side of the dental
arch and remain palatally unerupted.

17
• As far as the maxillary canine is concerned, fact is it has a
long and tortuous eruption path, beginning close to the
floor of the orbit. It is considered that this tooth has much
further to travel before it erupts into the mouth and
therefore has a greater chance of ' losing its way'.

• The maxillary canine is the last tooth to erupt in the upper

arch with a deciduous predecessor and therefore is most
susceptible to environmental influences such as crowding.

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19
ETIOLOGY OF MAXILLARY CANINE IMPACTION-A
REVIEW-Becker,AJODO 2015

Local pathology

Local hard tissue obstruction

Departure from or disturbance of

normal development of maxilla

Heredity or genetic factors

20
 Etiology
Local factors Generalized
1) Tooth size-arch length GENERAL
discrepancies PRENATAL
2)Prolonged retention of
the deciduous canine Hereditary
3)Abnormal position of the POSTNATAL
tooth bud Endocrine pathology
4)Ankylosis Irradiation
5)Cystic or neoplastic
formation Febrile diseases
6)Dilaceration of the root Necrosis/ Inflammatory
7)Idiopathic condition with changes in bone due to
no apparent cause. exanthematous diseases.
Malnutrition

Bishara SE. Impacted maxillary canines: a review. Am J

Orthod Dentofacial Orthop
1992; 101: 159-71. 21
Classification of canine impaction
Class I : Impacted canines in the palate
1: Horizontal
2: Vertical
3: Semivertical
Class II: Impacted canines located on the labial surface
1: Horizontal
2: Vertical
3: Semivertical
Class III: Impacted canine located labially and palatally
- crown on one side and the root on the other side
Class IV: Impacted canine located within the alveolar
process - usually vertically between the incisor and first
premolar
Class V: Impacted canine in edentulous maxilla

22
 Classification by ACKERMAN and FIELDS in 1935.

IMPACTED CANINE

Horizontally vertically

Palatal Labial
Above Below
Mid- alveolar
(With respect to the apex)
( With respect to the arch)
(J CO 1979 DEC)
Classification of Palatally impacted canine

 Based on two variables:

1) Transverse relationship of the crown to the line of dental
arch which may be:
(a) Close
(b) Distant
(2) Height of the crown of the teeth in relation to
the occlusal plane which may be:
(a) High
(b) Low

24
Group 1
- Proximity to the line of arch – close.
- Position in the maxilla – low.

Group 2
- Proximity to the line of arch – close.
- Position in the maxilla – forward, low &
mesial to the lateral incisor root.

25
 • Group 3
- Proximity to the line of arch - close.

- Position in the maxilla - high.

• Group 4
- Proximity to the line of arch - distant.
- Position in the maxilla – high.

26
Group 5
- Canine root apex mesial to that of
lateral incisor or distal to that of first
premolar.

Group 6
- Erupting in the line of arch in place and resorbing
the roots of incisors.
- Marginally displaced.
 

27
Level A. The crown of the impacted canine tooth is at the
cervical line of the adjacent teeth.
Level B. The crown of the impacted canine tooth is between
the cervical line and root apices of the adjacent teeth.
Level C. The crown of the impacted canines is beneath the
root apices of the adjacent teeth.

28
Angulation classification of impaction

29
 Theories regarding the causes of displacement

1) Long path of eruption

 Since it had a long and tortuous
eruption path, beginning close to the
floor of the orbit.
 It therefore had a greater chance of
‘losing its way’.

Becker A. The orthodontic treatment of impacted teeth. 2nd ed. Abingdon, Oxon,

England: Informa Healthcare; 2007.
30
 2) Crowding
 Since normal eruption path of the permanent canine is
buccal to the line of the arch

 Also teeth immediately adjacent to the canine, erupts before

the canine.

• Hence it moves buccally in

case of crowding.

31
 In a series of clinical research studies by Jacoby, Becker and
Brin et al, they pointed out that the likelihood of palatal
displacement is much reduced where crowding is present.
 They have shown it to be a far more prevalent occurrence
when there is excessive space in the dental arch.

32
3) Non-resorption of the root of the deciduous canine

 Lappin stated that this causes a

palatal deflection of the eruption
path, leading to impaction.

 Several studies have shown the

spontaneous eruption of impacted
canines, following the extraction of
deciduous canines.

33
 4) Trauma
 Brin et al have illustrated:
1) Trauma may cause movement of the
lateral incisor, or
2) movement of the unerupted canine
itself, or
3) In terms of the guidance theory, that
this could be explained as being due to
the shortness of the lateral incisor root,
whose development ceased as a result
of the trauma.

Brin I, Solomon Y, Zilberman Y. Trauma as a possible etiologic factor in maxillary

canine impaction. Am J Orthod Dentofacial Orthod 1993; 104: 132–137.

34
5) Presence of chronic irritation
 Periapical abscess or periodontitis
itself can deflect the path of a
developing canine.

 This infection may develop into a

radicular cyst or it may initiate cystic
change in the follicle of the canine,
either of which will alter the path of
eruption.

35
 6) Guidance theory

Miller reported that:

- missing laterals causes palatal impaction.
- however small and peg laterals provide the
required guidance for the normal eruption of
adjacent canine.
 Later studies (Becker and Brin et al) showed peg-shaped
incisors were nine times commoner in palatal impaction
cases as compared to the general population.

Becker A. The orthodontic treatment of impacted teeth. 2nd ed. Abingdon, Oxon,

England: Informa Healthcare; 2007.

36
  Hence a hypothesis was presented that at the critical time
when guidance was required the root of the anomalous
lateral incisor is too rudimentarily developed to provide it.

 It was based on the fact that the anomalous small and peg-
shaped lateral incisors develop very much later (3 years)
than normal lateral incisors.

Becker A, Smith P, Behar R. The incidence of anomalous lateral incisors in relation

to palatally-displaced cuspids. Angle Orthod 1981;51: 24–29.

37
  Small, peg-shaped and missing laterals are more frequent
findings among females in the ratio of 2:1 to 3:1.

 Reason given was that:

- the maxillary permanent canine erupts
earlier in females, which could mean that
earlier lateral incisor guidance will be
necessary for its normal eruption.

Becker A. The orthodontic treatment of impacted teeth. 2nd ed. Abingdon, Oxon,

England: Informa Healthcare; 2007.

38
  The ‘guidance theory’ comprises of five elements:
1) Normal eruption: It adopts Broadbent‘s original view that,
given the timely and normal development of a lateral
incisor, guidance for the canine is provided and a buccal
path of eruption is to be expected, with the tooth palpable
early on.
2) First stage Impaction:
 If there is a loss of guidance due to missing or late
developing laterals, canine will displace mesially and
palatally.
 Also if there is no vertical movement of canine, it results in a
more horizontal impaction.

Becker A. The orthodontic treatment of impacted teeth. 2nd ed. Abingdon, Oxon,

England: Informa Healthcare; 2007.
39
3) First stage impaction and secondary correction

 Sometimes, the palatal periosteum may deflect the

developing canine from its first-stage displacement to a
downward and vertical direction.
 Since the alveolar process in the canine region is V-shaped in
cross section, it tends to erupt labially.
 It explains the corrective influence of vertical alveolar
process redirecting canine on a more favourable path

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 4) Second stage Impaction:

 Self-correction is prevented by the

presence of an anomalous and late-
developing lateral incisor, redeflecting
the tooth further palatally.
 Not seen when the lateral incisor is
absent.

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 5) Second stage Impaction and secondary correction

 Extraction of an over-retained deciduous canine or

anomalous lateral incisor, may often lead to spontaneous
eruption of the impacted tooth.

42
 Peck et al have studied maxillary permanent canine/first
premolar transposition and have found a strong hereditary
influence in its etiology.
 They point out that this phenomenon cannot be considered
as deriving guidance from the lateral Incisor.

• They also claim that this represent

that the etiology of palatal impaction
is also under total genetic control.

Peck L, Peck S, Attia Y. Maxillary canine-first premolar transposition, associated

dental anomalies and genetic basis. Angle Orthod 1993;63: 99–109.
43
  However in vast majority of buccally and palatally
displaced canines, the root apex is ideally placed in the
arch.

• Becker stated that extrusion and tipping of

the crown into its place in the arch is usually
sufficient to resolve the malalignment and
little or no root torque being required in
most cases.

Adrian Becker

Becker A. Palatal canine displacement: guidance theory or an anomaly of genetic

origin? Angle Orthod 1995; 65: 95–98.
44
 Alternative cone-beam computed tomography
method for the analysis of bone density
around impacted maxillary canines
 American Journal of Orthodontics and Dentofacial Orthopedics
 Volume 154, Issue 3, September 2018

 The aim of this study was to evaluate the surface

area and fractal dimension of the alveolar bone on
cone-beam computed tomography (CBCT) images of
patients with maxillary impacted canines.
 The maxillary alveolar bone area is increased in the
impacted side compared with the non-impacted side.

45
SEQUELAE OF IMPACTED CANINE

Migration of
Labial or lingual root resorption of
neighbouring teeth
malpositioning of impacted or
and loss of arch neighbouring tooth
impacted tooth
length

Dentigerous cyst Infection particularly

formation associated with Referred pain
partial eruption

Poor esthetics
Late resorption of Loss of vitality of
associated with
unerupted canine incisors
primary canine

46
 Prevalence and risk factors of root resorption of
adjacent teeth in maxillary canine impaction, among

untreated children and adolescents

EJODO,7th December 2018

 The aim of this retrospective study was to assess in

maxillary canine impaction cases both the prevalence of
root resorption of adjacent teeth among untreated
children and adolescents, and its associated risk factors.

 Root resorption of adjacent teeth was detected in more

than two-thirds of a sample of sixty untreated children
and adolescents.

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 IMPACTED MANDIBULAR CANINE
HISTORY
 Old Stone Age, Homo mousteriensis hauseri (period 100000-40000
years BC), showed impaction of a permanent mandibular left canine
and third molar, along with a deciduous canine. (Weinberger, 1948).

 Nodine (1908) mentioned that the oldest human specimen showing

an impacted and unerupted left mandibular canine is that of a
Mousterian youth found in Vezere, France and estimated as being
40,000 years old.

 Aydin et al reported a male to female ratio of

1:1.22

48
 Associated Clinical Features

 Jain et al revealed a trend in mandibular canine

impaction patients, towards:

 Retrognathic mandible.
 Skeletal Class II.
 Retroclined mandibular and maxillary incisors.

Jain S, Prakash A T, Agrawal M. Dento-skeletal characteristics of subjects with

impacted mandibular canine(s). J Indian Orthod Soc 2015;49:19-24 49
Classification

• According to Field and Ackerman(1935)

Labial position Unusual position

(1) Vertical (1) At inferior border
(2) Oblique (2) In mental protuberance
(3) Horizontal (3) Migrated to opposite side

50
 Management
 There are several treatment options proposed for impacted
mandibular canines including:
1) surgical removal,
2) exposure and orthodontic alignment,
3) transplantation and observation.
 If adequate space for alignment of an impacted mandibular
canine exists and it is mechanically possible to reposition it
into proper position, then orthodontic treatment is
indicated.

51
52
 It should be noted orthodontic treatment of impacted
canines started after the conclusion of the pubertal growth
spurt are likely to be protracted.

 If the mandibular incisors are in a normal position, space for

the impacted canine is sufficient, and the patient is symptom
free, then transplantation may be a reasonable treatment
choice.

53
 Some authors believe asymptomatic impacted teeth can be
left in place, but in these patients a series of successive
radiographs should be taken periodically.
 Observation of impacted mandibular canines may be
indicated in the following circumstances:
1) A systemic contraindication to a surgery exists.
2) There is a deeply impacted asymptomatic mandibular
canine with no associated pathology, particularly in an older
patient.
3) Whenever the patient has a satisfactory dental appearance
and does not want surgical intervention.

54
 Surgical extraction is necessary in the following situations:
1) The existence of infection, cyst, or tumour related to the
impacted canine.
2) The impacted tooth causes the periodontal disturbances of the
adjacent teeth.
3) The presence of neuralgic symptoms.
4) Crowding of the mandibular arch requiring therapeutic
extractions to correct crowded incisor teeth.
5) The impacted canine is ankylosed and cannot be transplanted.
6) There is evidence of root resorption affecting the adjacent
teeth.
7) The root of impacted canine is severely dilacerated
8) Patient rejection of orthodontic treatment

55
 Transmigration

 According to Joshi it is defined as “migration of a tooth across

the jaw midline without the influence of any pathological
entity”

• Javid suggested that transmigration

should be considered when half the
length of the crown crosses the midline.

• Mupparapu proposed that if a canine reaches and crosses the

midline lengthwise, it could still be considered a true case of
transmigration irrespective of its eruption status.

56
 History

 Nodine has described the

condition in prehistoric skulls.

• There are currently more than 50

published reports on canine
transmigration with the first being
reported in 1951 by Bluestone.

57
Evidences

1) Morphologic evidence
• Because the teeth are mirror images of
each other.

2) Neurological evidence (Caldwell and Bruszt)

 Surgical removal of the tooth with an inferior dental nerve
block on the migrated side caused pain.
 Once the contralateral side was blocked, pain ceased.
 This confirms the origin of the tooth because it maintained
its nerve supply from the original side.

Camilleri S, Scerri E. Transmigration of mandibular canines—a review of the

literature and a report of five cases. Angle Orthod 2003;73:753–762 58
Occurrence
 Aydin et al reported canine transmigration incidence of
0.31%. Whereas Javid reported 0.1% (1 of 1000 dental
students).
 Most of the cases reported in the literature were unilateral
mandibular canine transmigration and a very few were
cases of bilateral canine transmigration.
 The left canine is more commonly involved than the right
canine.

59
 Aktan et al observed that:
1) The frequency of canine transmigration is more in the mandible than
maxilla.
- Transmigration of maxillary canines is very rare, which may be
due to the shorter distance between the roots of maxillary
incisors and the floor of the nasal fossa and restriction of the
path of tooth movement by the roots of adjacent teeth
2) Women were affected more often than men. (Peck--M:F = 1:1.6)

F. S.Ryan, P. Batra, H. Witherow, M. Calvert. Transmigration of a maxillary canine. A

case report. Primary Dental Care, vol. 12, no. 2, pp. 70–72, 2005. 60
 Classification of mandibular canine
transmigration
 Depending on its path of deviation into five types.
Type 1 (45.6%)
- Canine positioned mesioangularly across the midline within
the jaw bone, labial or lingual to anterior teeth and the crown
portion of the tooth crossing the midline.

Mupparapu M . Patterns of intra-osseous transmigration and ectopic eruption of

mandibular canines: review of literature and report of nine additional cases.
Dentomaxillofacial Radiology 2002;31(6):355–360. 61
Type 2 (20%)
- Canine horizontally impacted near the inferior border of the
mandible below the apices of the incisors
Type 3 (14%)
- Canine erupting either mesial or distal to the opposite canine.

62
Type 4 (17%)
- Canine horizontally impacted near the inferior border of the
mandible below the apices of either premolars or molars on the
opposite side.
Type 5 (1.5%)
- Canine positioned vertically in the midline (the long axis of the
tooth crossing the midline) irrespective of eruption status.

63
 Etiology
 The etiology of this rare
developmental anomaly is not
yet known.
 Contributing factors:
1) Heredity.
2) Abnormal displacement of the
dental lamina in the embryonic
life (Nodine).
3) Small root fragment or an
odontoma (Nodine).
4) Agenesis of permanent lateral
incisors (Ando et al).
5) Association with a cystic lesion
(Al-Waheidi).
Joshi MR. Transmigrant mandibular canines: a record of 28 cases and a retrospective
review of the literature. Angle Orthod 2001;71:12 -22. 64
6) Crowding
7) Spacing
8) Supernumerary teeth
9) Excessive length of the crown of the mandibular
canines.
10) Javid, Joshi and Shetye suggested that the
abnormally strong eruption force, which drives the
canine through the dense symphyses. They also
noted that the conical shape of the tooth aids its
passage through the bone.

S. Peck. On the phenomenon of intraosseous migration of nonerupting teeth. Am J

Orthod and Dentofac Orthop 1998;113( 5):515–517.
65
11) Marks and Schroeder attributed initiation and
control of eruption to the dental follicle at the
molecular level, with the coronal portion
stimulating bone resorption and the apical
portion stimulating deposition.
 They suggested that a regional disturbance in the dental
follicle may lead to local defective osteoclastic function with
an abnormal eruption pathway being formed.
 12) Mitchell and Nixon and Lowley presented reports of
cases in which the probable etiology of the displacement of a
lower canine was a mandibular fracture through the
developing crypt.

Marks SCJ, Schroeder HE. Tooth eruption: theories and facts. Anat Rec. 1996;
245:374–393.
66
Clinical factors associated with
canine transmigration

 Findings by Joshi and Pérez et al suggests that 70.8% and

48% of the sample respectively, had retained deciduous
canines.
 Deviated dental midline.
 Proclination of the lower incisors, increased axial inclination
of the unerupted canine and an enlarged symphyseal cross-
sectional area of the chin. (Vichi and Franchi)

S. Ando, K. Aizaea, T. Nakashima, Y. Sanka, K. Shimbo, and K. Kiyokawa,

“Transmigration process of impacted mandibular cuspid,” The Journal of Nihon University
School of Dentistry, vol. 6, pp. 66–71, 1964.
67
Diagnosis
 When lower permanent canine is clinically absent along with two
or more of previously mentioned factors and the patient is 10 to
13 years old.
 The patient should be evaluated radiographically for impaction
and transmigration.
 It is possible in the routine check up that the intraoral periapical
radiograph may fail to reveal transmigrated canines.

Joshi MR. Transmigrant mandibular canines: a record of 28 cases and a retrospective

review of the literature. Angle Orthod 2001;71:12 -22.

68
 Howard observed the influence of the axial inclination of
impacted canines on its migration.
 Canines with axial inclination between 25° and 30° to the
midsagittal plane represent a group of unerupted canines
that are displaced but not migrating across the mandibular
midline.
 Those impacted canines that are between 30° and 95° are a
group that tends to cross the midline.

69
 An overlap appears to exist between 30° and 50°.
 When this angle exceeds 50°, crossing the midline becomes
a rule.
 Joshi reported the axial inclination to the midsagittal plane
of migratory canine ranged from 45° to 95°.

70
 Ando et al observed the greatest amount of movement of
transmigratory canine is more rapid before the formation of
its root.

 However, Dhooria et al observed a fairly rapid movement

even after completion of the root formation, about 3 to
4mm in one of their patients during 1 year.

71
 Transmigration-treatment options

Atleast half root formed Preferably intraoral approach

• If the crown of such a tooth migrates past the opposite incisor

area or if the root apex have migrated past the root apex of the
adjacent lateral incisor, it might be mechanically impossible to
bring it into place. (Camilleri et al) 72
CLINICAL ASSESSMENT
 Inspection
 Palpation
STUDY MODEL ANALYSIS: Amount of space available in dental arch for
impacted canine is assessed in model.
RADIOGRAPHIC ASSESSMENT
INTRA ORAL
 PERIAPICAL
 OCCLUSAL
EXTRA ORAL
 OPG
 LATERAL CEPHALOGRAM
 POSTERO ANTERIOR VIEW
 CBCT 73
 CLINICAL ASSESSMENT

INSPECTION
 Relationship of maxillary dental midline to
facial midline
 Distal tipping and migration of adjacent
teeth
 Over-retention of the primary teeth
 Delayed eruption of the permanent teeth
 Absence of a labial bulge

74
 Presence of a palatal bulge.
 Kurol and Ericson suggested that
absence of the “canine bulge” when the
child is around 11 years of age is not an
indication of canine impaction. However,
they suggested palpation of the buccal
surface of the alveolar process distal to
the lateral incisor to help determine the
position of the maxillary canine before its
emergence.

75
 PALPATION
 Palpation of the buccal and lingual mucosa,
using the index fingers of both hands
simultaneously, is recommended to assess
the position of the erupting maxillary
canines.
 Eruption time of a maxillary canine varies
from 9.3 to 13.1 years. Canines are palpable
from 1 to 1.5 years before they emerge, the
absence of the canine bulge after the age of
10 years is a good indication that the tooth
is displaced from its normal position, and
ectopic eruption or impaction of the
maxillary cuspids is possible
76
 However, occasionally the bony canine eminence has been
confused with the tooth, and the fact that a canine is
impacted has been missed. The clinician should also
manipulate the deciduous canine to determine if it is mobile.
If it is, this indicates that its root has undergone significant
resorption.

77
RADIOGRAPHIC METHODS RELATED
TO THE DIAGNOSIS OF IMPACTED
TEETH

QUALITATIVE
RADIOGRAPHY

INTRA ORAL EXTRA ORAL

IOP OPG
OCCLUSAL
A LATERAL CEPH

MAX ANT
OCCLUSAL
TRUE VERTEX
OCCLUSAL
MANDIBULAR
OCCLUSAL

78
 INTRA ORAL PERIAPICAL
RADIOGRAPHS (IOPAR)

 The first, simplest and most informative X-ray film is the periapical
view.
 From this film, it will be immediately obvious if there is an impacted
tooth and if its stage of development is similar to that of its erupted
antimere, with at least two-thirds of its root length.
 The presence and size of a follicle will be obvious, and it will be
possible to ascertain crown or root resorption, root pattern and
integrity .
 The presence and description of hard tissue obstruction will be
evident
 Similarly, it will show soft tissue lesions, such as cysts.
79
 Tube-shift technique or
Clark's rule/ PARALLAX
METHOD
 Two periapical films are taken of the
Distal Normal Mesial
same area, with the horizontal angulation angulation angulation
angulation of the cone changed when
the second film is taken. If the
impacted canine in question moves in
the same direction as the cone, it is
lingually positioned. If the canine
moves in the opposite direction, it is
situated closer to the source of
radiation and is therefore buccally
located, so called Same Lingual
Opposite Buccal (SLOB) rule;

80
 Vertical tube shift method

Buccal-object rule - If the vertical angulation of the cone is changed in two

successive periapical films, the buccal object will move in the direction opposite
the source of radiation. On the other hand, the lingual object will move in the
same direction as the source of radiation. The basic principle of this technique deals
with the foreshortening and elongation of the images of the films.
Left canine is highly placed in OPG.
In IOPA left canine moves towards apical 1/3 of lateral incisor.
Left canine is labially placed, as it moves in opposite direction of tube shift.

81
 MANDIBULAR OCCLUSAL: To get a true
occlusal view in the anterior region, the
head is tipped back further & X-ray tube is
angled at 110 degrees to the horizontal
plane at symphysis menti along the long
axis of the incisor teeth.
 MAXILLARY ANTERIOR OCCLUSAL : The
best that can be achieved by positioning
the tube close to the face so that it
becomes high and steeply angled view.
 TRUE VERTEX OCCLUSAL: A true vertex
view is one which passes parallel to the
long axis of central incisors. This is
possible if the cone is placed over the
vertex of the skull to produce vertex
occlusal film. Since the beam has to travel
a great distance there is loss of clarity.

82
OCCLUSAL RADIOGRAPHS

 Occlusal films also help determine the buccolingual position

of the impacted canine in conjunction with the periapical
films.
 The most frequently used projection for the maxillary canine
localization is the true occlusal view.
 In this view the central ray passes through the glabella and
falls perpendicular to the film.

83
 ORTHOPANTOMOGRAPH (OPG)

 Panoramic radiography is a fundamental examination which

gives an overview but does not permit precise localization of
an impacted canine in three-dimensional space .
 Its value lies in giving a panoramic view of the mouth before
starting orthodontic treatment.

84
Lateral cephalogram and PA view
 A true lateral view will give exact information regarding both
the antero-posterior and vertical location of an object,
relative to other structures that may be seen both on that
radiograph and clinically.
 It will not give any clue to the bucco-lingual (transverse-
plane) picture
 True postero-anterior view , defines the height (vertical
plane) and the bucco-lingual relationship only

85
 COMPUTED TOMOGRAPHY (CT)

 CT is known to be superior to other

radiographic methods in showing
bony lesions as well as provides
accurate 3D localization of canines .
 Tomography offers greater
diagnostic yield , but it is difficult to
perform, entails high radiation
exposure, and often fails to
demonstrate minimal root resorption
. The major limitation of CT is
radiation risk which is especially
greater in children . The average
range of radiation exposure for
maxilla is 1,031-1,420 μSv . 86
 CONE BEAM COMPUTED TOMOGRAPHY (CBCT)
 CBCT imaging is precise in determining
not only the labial/lingual relationship but
also a more exact angulation of the
impacted canine.
 These 3D images are beneficial in
determining the proximity of adjacent
incisor and premolar roots, which can be
invaluable in determining the ease of
uncovering and bonding and the vector of
force that should be used to move the
tooth into the arch with a lesser chance of
damage to adjacent tooth.
 It also has the potential of providing clear
images of highly contrasted structures
and is useful in evaluating bone .
87
 Disadvantage:
1) Expensive.
2) Relatively increased radiation exposure when
compared to the conventional radiography.

88
 3-dimensional imaging techniques may be
more sensitive compared with traditional 2-
dimensional approaches and can accurately
pinpoint the:
1) location
2) angulation
3) proximity to lateral roots.
 Also, there is a high correlation between
CBCT diagnosis and direct visual observation
of the roots of extracted teeth. It also has the
potential of providing clear images of highly
contrasted structures and is useful in
evaluating bone .

Mah KJ, Alexandroni S. Cone-beam computed tomography in the management of

impacted canines. Semin Orthod 2010;16:199-204.
89
 Rapid Prototyping

 3D-CT reconstruction images are seen as 2-D on

film and the computer screen.
 This limitation can be overcome with the use of
CT to make a model by means of rapid
prototyping.
 This technique comprises several technologies
that use data from CAD files to produce physical
models and devices by a process of material
addition.

Faber J, Berto M, Quaresmaa M. Rapid prototyping as a tool for diagnosis and treatment
planning for maxillary canine impaction. Am J Orthod Dentofacial Orthop. 2006;129:583-
89.
90
91
STIVAROS AND MANDALL ANALYSIS

Stivaros N, Mandall NA. Radiographic factors affecting the management of

impacted upper permanent canines. J Orthod 2000; 27(2): 169−173.

92
93
94
BAYESIAN NETWORK ANALYSIS Michele Nieri, Aldo Crescini etal .Factors
affecting the clinical approach to impacted maxillary canines: A Bayesian network analysis (Am J Orthod
Dentofacial Orthop2010;137:755-62)

1. Distance from tip of canine

to occlusal plane=d
2. Alpha angle: angle measured
between the long axis of the
impacted canine and the
midline
3. Sector: s-sector: sector where
the cusp of the impacted
canine is located
(sector 1, between the
midline and the axis of the
central incisor
Favourable when sector 2, between the axes
 d=15±1 mm of the central incisor and the
 α angle is≤35 ±13 degrees lateral incisor.
sector 3, between the axes
of the lateral incisor and the
 Sector 3
first premolar
Values beyond this range indicate a
unfavourable impaction. 95
 KPG ANALYSIS
A novel 3D classification system for canine
impactions – the KPG index
Kau, Pan, Gallerano., Int J Med Robotics Comput Assist Surg 2009; 5: 291–296.

 KPG analysis uses a KPG index which is a grid-like scale was

devised of the three different views (x, y and z) in order to grade
the difficulty of impaction and the potential efficacy of treatment
 Depending on its anatomical location, the cusp tip and the root
tip are each given a number on a 0–5 scale on the three separate
images taken before treatment. The sum of both cusp tip and
root tip scores in the three views would decide the anticipated
difficulty of treatment.
 Scores in the range 0–9 fall into the category of easy; 10–14 are
moderate; 15–19 are difficult; and 20 and above are extremely
difficult.

96
 The x axis of locating the canine
0. Canine cusp tip/root tip is in the proper erupted location; no
treatment necessary in this dimension.
1. Cusp tip/root tip is within the width of the alveolus on either side
of the vertical line bisecting the canine.
2. Cusp tip/root tip is in the area between the edge of the alveolus
and a vertical line bisecting the adjacent tooth; either the distal
half of the lateral incisor or the mesial half of the first premolar.

97
3.Cusp tip/root tip is in the further half of the
neighbouring tooth; mesial half of lateral incisor or distal
half of first premolar.
4. Cusp tip/root tip is in the distal half of the central incisor,
or distal to the first premolar but mesial to the midline of the
second premolar.
5. Cusp tip/root tip is in the mesial half of the central incisor
or distal to the midline of the second premolar

98
 The y axis of locating the canine
0. Canine cusp tip is in the proper vertical location.
1. Cusp tip is in the coronal region.
2. Cusp tip lies in a horizontal plane with the cervical
third of the incisor root.
3. Cusp tip lies in a horizontal plane with the middle
third of the incisor root.
4. Cusp tip lies in a horizontal plane with the apical third
of the incisor root.
5. Cusp tip is supraapical to the incisor root.

99
0. Canine root tip is in the proper vertical location.
1. Root tip lies in a horizontal plane with the apical third
of the incisor root.
2. Root tip lies in a horizontal plane with the middle third
of the incisor root.
3. Root tip lies in a horizontal plane with the cervical
third of the incisor root.
4. Root tip is in the coronal region.
5. Root tip is extended past the coronal region.

100
The z axis of locating the canine
0. Canine cusp/root tip is in its proper location
along the occlusal arch.
1. Cusp/root tip is 0–2.0 mm away from the
occlusal arch of the cusp tip or root tip, either
buccally or lingually.
2. Cusp/root tip is located in the area 2.0–4.0 mm
away from the occlusal arch, either buccally or
lingually.
3. Cusp/root tip is located in the area 4.0–6.0 mm
away from the occlusal arch, either buccally or
lingually.
4. Cusp/root tip is located in the area 6.0–8.0 mm
away from the occlusal arch, either buccally or
lingually.
5. Cusp/root tip is more than 8.0 mm away from
the occlusal arch of the normal canine cusp or
root tip, either buccally or lingually. 101
102
Assessment of difficulty

After scoring the cusp tip and root tip in the three
views, the degree of difficulty of treatment is categorized as
simple, moderately difficult and nearly impossible.
These categories are determined by the sum of all
scores for each individual tooth.

Scores in the range

0–9 fall into the category of easy;
10–14 are moderate;
15–19 are difficult; and
20 and above are extremely difficult.
103
 TITLE-ASSESSMENT OF ROOT APEX POSITION OF IMPACTED MAXILLARY
CANINES ON PANORAMIC FILMS
AJODO 2017

 Aim of the study to analyze the root apex positions of

impacted maxillary canines on panoramic films according to
their labiopalatal position on CBCT and to predict position of
impacted maxillary canines.
 Patients CBCT and panoramic radiographs were taken.
 Using CBCT data, each sample was classified according to the
crown location of the impacted canine and specifically with
regard to the labiopalatal relationship to yield the following
groups: group labial, group palatal, and group middle.

104
Group labial included 14 patients. Group middle included 3
patients. Group palatal included 13 patients
The mesiodistal position of the impacted maxillary canine root
apex relative to adjacent teeth was classified into a panoramic
sector..
105
106
 REFERENCES
 Bishara SE. Impacted maxillary canines: a review. Am J Orthod
Dentofacial Orthop
 Orthodontic Treatment of Impacted teeth by Adrian Becker
 Jacoby H. The ballista spring system for impacted teeth. Am J
Orthod 1979;75:143-51
 Bowman, S.J. and Carano, A.: The Monkey Hook: An auxiliary
for impacted, rotated, and displaced teeth, J. Clin. Orthod.
36:375-378, 2002.
 Bowman SJ, Carano A. The Kilroy spring for impacted teeth. J
Clin Orthod. 2003;37:683-688.
 Vardimon Graber et al Rare earth magnets and impaction. Am
J Orthod 1991;100:494-512
 Michele Nieri, Aldo Crescini, Roberto Rotundo,
TizianoBaccetti, PierpaoloCortellini, andGiovan Paolo Pini
Prato.Factors affecting the clinical approach to impacted
107
 A novel 3d classification system for canine impactions – the
kpg index chung how kau philip pan ron l. gallerano int j
med robotics comput assist surg 2009; 5: 291–296.
 Efficient management of unerupted teeth: a time-tested
treatment modality robert l. vanarsdall jr seminars in
orthodontics, vol 16, no 3 (september), 2010: pp 212-221
 Palatally impacted canines: the case for preorthodontic
uncovering and autonomous eruption david p.
mathews ,vincent g. kokich american journal of
orthodontics and dentofacial orthopedics april 2013 vol 143
issue 4
 Palatally impacted canines: the case for closed surgical
exposure and immediate orthodontic traction adrian becker
stella chaushu american journal of orthodontics and
dentofacial orthopedics april 2013 vol 143 issue 1
 maxillary canines: A Bayesian network analysis .Am J
OrthodDentofacialOrthop2010;137:755-62 108
PART -2

109
Part II:
 Treatment Modalities
 The Surgical Exposure/ Flap Techniques
 Attachments
 Auxiliaries
 Treatment Strategies
 Conclusion
 References.

110
 TREATMENT MODALITIES

There are four treatment options for impacted

teeth
Observation and Intervention
Relocation: Orthodontic or Surgical
Surgical Removal
Prosthetic Replacement

111
OBSERVATION AND INTERVENTION
 OBSERVATION :
Observation of the dentition normally begins with
the completion of the deciduous dentition eruption
with the eruption of first permanent molars at
approximately 6 years of age and ends with the
removal or eruption of the impacted tooth.
 INTERVENTION:
If a decision to treat is made, treatment should be as
minimal as needed to facilitate natural eruption.
“The majority of impacted teeth erupt if hard or soft
tissue obstructions are removed from their
eruption paths.”

112
 General Principles Of Impaction
Management

 Orthopaedic or functional treatment

should be done first, aimed at reducing the
skeletal discrepancy, if patient is in his/her
growing period.

• Once incisor root resorption has

been positively identified, the full
focus of treatment should be
directed at distancing the impacted
tooth from the adjacent root as
113 quickly as possible.
 Order of treatment

1. Before surgery, creation of sufficient space for the

unerupted tooth, thereby encouraging and
enhancing the natural eruption process.
2. During surgery, removal of any hard or soft tissue
obstruction and exposure of the unerupted tooth.
3. Placement of attachment on the tooth, either at
surgery or shortly thereafter.
4. Augmentation of the natural eruption process by
providing directional traction.
5. Align the teeth and relocate the roots of the incisors
in the alveolar bone.

114
 General Principles Of Mechanotherapy

 By the time impacted canine is diagnosed

the full permanent dentition is usually
erupted and hence should be dealt in one
full and comprehensive treatment plan.
 Alignment of the impacted canine should be
done only after space has been created for it
in the dental arch.

115
 Methods of Creating Space:
A) By utilizing existing incisor space:
Becker showed incisor spacing was due to
failure of completion of ugly duckling stage of
development.

116
 B) Improving Arch form:
 Maxillary canine erupt more buccally to
deciduous canine and slightly buccally to
premolar and lateral incisors.
 So improving arch form after extraction of
deciduous canine will add 2-3 mm of space.

117
C) Increasing arch length:
 In mild crowding cases distalization of
molar is recommended which increases the
arch length.

118
D) Extraction as means of prevention
a) Deciduous Canine
 Erickson and Kurol concluded that palatal
displacement of canine with apex
confirmed in line of arch requires extraction
of deciduous canine for good prognosis for
eruption of permanent canine.
b) First Premolar
 If its decided to treat the malocclusion by
extraction modality of treatment.    

119
c) Lateral incisor
1) Severe root resorption
2) Peg shaped or severely malformed lateral
incisor (Dens invaginatus) can be extracted
instead of healthy premolars.

120
d) Central incisor
 When there is advanced resorption of
central incisor roots, more than 2\3rd and
canine erupting in a line close to the long
axis of the incisor, extraction of incisor is
indicated.

121
 After the initial alignment rest
of the teeth should be
transformed into a composite
and rigid anchorage unit.
This is done with a heavier
wire, thereby maximizing the
anchorage.

• Using an auxiliary means of traction from

the rigid orthodontic appliance, a gentle
and continuous light force, is applied to
the tooth.

122
And is aimed at erupting the impacted tooth
along a path that is free of obstruction from
neighbouring teeth.
If near the root of adjacent tooth it should
first be diverted in a different direction, to
circumvent the obstruction
only then can it be drawn along a new and
unimpeded path to its place.

123
Treatment Timing

 By the age of 9–10 years, it is usually possible to palpate

a normally developing maxillary permanent canine tooth
on the buccal side of the alveolus, high above its
deciduous predecessor.
 If the tooth is not palpable at this age, radiographs
should be taken to assist in locating the tooth and any
pathology.

124
 SURGICAL INTERVENTION WITH ORTHODONTIC
TREATMENT/ORTHODONTIC RELOCATION

Surgical techniques for exposing impacted canines

1. Circular Incision/ Window approach

2. Apically repositioned flap (ARF)
3. Closed flap eruption technique (FCET)
4. Tunnel traction (TT)
5. Piezoelectric surgery.
  
125
126
 CIRCULAR INCISION
 This may be made in the sulcus mucosa, immediately over
the crown, to expose the bony crypt immediately beneath .
In order to do this, the entire surgical procedure would
inevitably be sited above the attached gingiva.
 On the labial side, the tooth will be invested with the thin
oral mucosa, which offers a poor long term prospect under
conditions of normal function for the fully corrected canine

127
 Advantages:
a) Easy to perform
  b) Suitable access can be provided for bonding
of the attachment
c) Reduction of impaction is rapid.
Disadvantages:
a) Tooth will be invested on labial side with thin oral mucosa
rather than attached gingiva.
b)Typical soft tissue contour aggravates Plaque accumulation
which leads to gingivitis. Inflammation will prevent
regeneration of the Periodontal ligament which leads to
apical movement of the epithelial attachment
128
 APICALLY REPOSITIONED SURGICAL FLAP/
OPEN EXPOSURE TECHNIQUE
 This method was first
described in the context of
surgical and orthodontic
treatment of unerupted teeth
by Vanarsdall and Corn (1977).
 In their method, a
mucogingival flap is raised
from the crest of the ridge that
includes attached gingiva .
 The flap is detached from the
underlying hard tissue some
way up into the sulcus , to
expose the canine.
129
 The flap is then sutured to the labial side of the crown of
the permanent canine, to cover the denuded periosteum
and overlying the cervical portion of the crown, while the
remainder of the crown remains exposed.
 Subsequent eruption of the tooth is accompanied by the
healing gingival tissue, and, when the tooth takes up its
final position in the arch, it will be found to be invested
with a good width of attached gingiva.

130
131
Advantages:
a) Maintain the width of attached gingiva
b) Easy access for bonding of the
attachment
c) Tooth can be visualized from the time of
exposure till it come to occlusion
Disadvantages:
a) Uneven and unesthetic gingival margin
b) Increased Clinical crown length

132
c) Some degree of attachment and bone loss on the labial
surface,which was considered as possibly related to an
increased potential for plaque accumulation.
d) Vertical orthodontic relapse : After apical repositioning the
gingival tissue heals to the adjacent mucosa, producing soft
tissue band of gingival scarring. As the tooth is pulled
incisally this mucosa get stretched down with it,toward the
alveolar crest. Thus it tend to relapse once the force is
released .

133
 FULL FLAP CLOSURE/ CLOSED EXPOSURE
TECHNIQUE
 This was proposed by McBride (1979), and is a procedure
that may be used regardless of the height of the canine.
 A buccal surgical flap is raised as high as is necessary to
expose the unerupted canine.
 An attachment is then bonded to the tooth and the flap is
fully sutured back to its former place.
 A twisted stainless steel ligature wire that has been
threaded through the attachment is then drawn inferiorly
and through the sutured edges of the replaced flap, at the
crest of the ridge, or through the socket vacated by the
extracted deciduous canine.

134
135
Advantages:
a) Tooth can be erupted towards and through the attached
gingiva which maintains the width of the attached gingiva
b) No gingival scarring and good periodontal attachment is
established
c) No vertical relapse
d)  Conservative bone removal
e)   Immediate traction possible
f) Less discomfort and good
post operative Haemostasis

136
 Disadvantage:
a) Placement of the bonding attachment is necessary at the
time of exposure
b)  If there is a bond failure it needs re-exposure
c)  Difficulty in gaining dry field
d) Buttonholing: This occurs because of the buccal prominence
of the tooth, lack of buccal bone and relative tightness of the
replaced flap. The damage to the mucogingival tissue is due
to the bulk of wide and high profile conventional bracket, which
may lead to a breakdown of the overlying tissue to cause a
dehiscence

137
 On comparison

This closed-eruption method compares favourably (Vermette et

al, 1995) when compared with the apically repositioned flap
method.
 no tendency for an apical and uneven gingival position,
 it does not produce a long clinical crown .
 no loss of attachment on the buccal aspects,
 no gingival scarring produced with this method,
 the periodontal attachment is completely normal.
 there was no vertical relapse of the treated canine following
the completion of treatment.
 However, the closure of the flap at the end of the surgical stage
dictates the necessity for the placement of an attachment,
while the tooth is visible and in the surgeon's operatory.
138
 On comparison
FULL FLAP CLOSURE APICALLY REPOSITIONED
CLOSURE

ADVANTAGES • rapid healing • orthodontist's presence

• less discomfort unnecessary
• good post-operative haemostasis • bond failure - needs no
• less impediment to function surgery.
• conservative bone removal • reliability of bonding.
• immediate traction possible

DISADVANTAGES • presence of orthodontist required • wider bone exposure

• bond failure dictates re-exposure • many visits to change packs
• difficulty in gaining dry field . • greater risk of infection
• delayed initiation of traction

139
 TUNNEL TRACTION TECHNIQUE
Modified by Crescini et al 1994

 For aligning deep infraosseous

impacted canines.
 Socket of vacated deciduous canine
can be used as an osseous tunnel for
movement of impacted canine
towards the centre of the alveolar
ridge.
 Orthodontic traction may be
efficiently applied, and the treatment
result shows a good bony profile and
an uncompromised periodontal
result, similar to that seen on
normally erupted teeth.
140
VISTA technique(Vertical incision
subperiosteal tunnel access)

The vertical incision subperiosteal tunnel access procedure is a novel, submucosal

tunneling procedure originally designed to surgically correct gingival recession (a).
Through vertical incisions, the labial mucosa is undermined and repositioned coronally as
shown by the yellow arrow (b). The submucosal space fills with a hematoma (red) that
provides platelet-derived growth factors to promote healing (c). This minimally invasive
approach is utilized to correct soft tissue defects in the maxillary anterior region.

141
(a) The first incision is made in the mucosa covering the crown of the
impacted canine. (b) Periosteal elevators are used to reflect the incision and
expose the crown for bonding the button. (c) A second incision is then made
at the site where the power chain exits the soft tissue (arrow).

142
 An OBS (white arrow) is inserted in the IZC to anchor the three-dimensional
(3D) lever arm. (b) The distal end of the 3D lever arm is inserted in the hole of
the OBS (green arrow). (c) The power chain attached to the UL3 is activated
by the 3D lever arm in the direction of the yellow arrow.

143
The two incisions are then sutured for primary healing. (b) The occlusal
view of the lever arm shows it was contoured away from the cheek to
prevent soft tissue irritation. (c) The buccal view of the mechanics is
illustrated with a drawing superimposed on the post-operative photograph.
Red lines show 1st and 2nd sutured incisions and a gold chain of elastics
show the line of traction.
144
 Piezoelectric surgery

• Gives precise and clean bone cut.

• Used to cut the bone and not for soft tissue flap reflection.

145
146
 Anchor unit:

• When dealing with a malocclusion that

incorporates an impacted tooth, 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.

147
• A heavy & more rigid arch wire is then placed
into

the brackets on all the teeth of aligned & complete

dental arch, the aim is to provide solid anchor base

that will notallow distortion of arch wire to

occur as a resultof forcethat will be applied to the

impacted tooth after exposure.

148
 Attachments
: –
 Lasso wires
 Threaded pins

 Orthodontic bands

 Standard orthodontic bracket

 A simple eyelet

 Elastic ties and modules

 Magnets

149
 {a} Lasso wires:
It is twisted lightly around the neck of the canine.
Disadvantages:
 This results in irritation of the gingiva
Prevents reattachments of the healing tissues in area of
CEJ (cemento-enamel junction).
May produce areas of external resorption & ankylosis in
areas of CEJ.
So, it is rarely used now.

150
(b) Threaded Pins:
Provide the attachment for an
impacted tooth.
Disadvantages
- Dentally invasive.
- Requires a subsequent
restoration.
-Difficult to place along the long axis of the tooth because of
smaller surgical exposure.
-The drilled hole may inadvertently enter the pulp(unerupted
teeth may have large pulp chambers).
151
 {c} Orthodontic
bands: They largely
replace the Lasso wires &
threaded pins.
Advantage:
They are compatible with the health of periodontal tissues.

Disadvantage:
- Large surgical field required.
-Inadequate moisture control may hamper with the
cement-band bond.

152
 {d}Standard orthodontic
brackets:
• Any edge-wise , Begg’s , PEA brackets can be used.

• They are routinely used as direct attachments along with

the composites.

153
 Disadvantages:

- As the bracket base is wide, it is difficult to adapt to

any other tooth surface except for the buccal surface.

- The bracket’s shear bulk creates irritation as the tooth

is drawn the soft tissues.

- Ligature wire or elastic thread tied to bring

the impacted tooth into arch.

154
{e} A simple eyelet:
Advantages:
-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.

155
(f) Elastic ties and

modules
Advantages
- Application of light forces
- Good range of action
- Easier to tie

Disadvantages
- Tends to loosen
- High degree of force decay

156
{f} Magnets:
It is made up of rare earth lanthanide alloys .
• It is rarely
used.
Disadvantage:-
corrosion.

157
 Ballista Spring (Jacoby 1979)

◦ A ballista loop is a simple, convenient, unobtrusive method of applying a

vertical vector of force to a palatally impacted tooth to erupt the crown into
the center of the alveolus.

◦ When the canine crown is displaced mesially and lies over the root of the
permanent lateral incisor, an apically positioned flap is the appropriate
surgical uncovering technique.

◦ Exposure of the crown facilitates attachment of an elastomeric chain

directed toward the center of the edentulous alveolar ridge to gradually
guide the canine crown into the dental arch.

158
• It is made of rectangular wires.
• It proceeds forward until it is opposite to canine space and
bent vertically downwards and terminate into a small loop.
• With slight finger pressure ,spring is tied to pigtail ligature, by
this it
provides an extrusive force for the canine to erupt.
• If the impacted tooth is resistant to movement or if the distance for the tooth to
move is more it will leads to lingual molar root torque leads to loss of anchorage. To
overcome this feature TPA is used.

159
160
 Kilroy spring:
• The Kilroy Spring is a constant force module
that is slid onto a rectangular archwire over
the site of an impacted tooth.

• In the passive state, the vertical loop of the

Kilroy Spring extends perpendicularly from the
occlusal plane (Fig. 2).

• To activate the spring, a stainless steel

ligature is guided through the helix at the apex of
the vertical loop, and the loop is directed toward
the impacted tooth. The ligature is then tied to an
attachment that has been direct-bonded to the
surgically exposed tooth. (Fig. 3)

161
Kilroy II Spring

• The Kilroy II Spring was designed

to produce more vertical than
lateral eruptive forces for eruption
of buccally impacted teeth.
• Its multiple helices increase its
flexibility, but also increase the
likelihood of impingement on the
adjacent soft tissue.
• Consequently, more frequent
progress checks are
recommended with the Kilroy II.

162
 THE K- 9 SPRING
•Varun Kalra (2000)
• Made in 0.017”X 0.025”TMA wire
 Advantages:
• Simple in design
• Low cost
• No patient compliance
•Light continuous eruptive and distalizing
forces
JCO Oct 2000
163
JCO Oct 2000
164
CANTILEVER SPRING

 Lindauer and Isaacson

(1995)
• TMA .017 X .025 wire used

•Force generated was measured

by dontrix guage.
• It should not exceed 70gms.
JCO Feb 1999
165
TMA BOX LOOP

• TMA .017 X .025 wire

used.

•Produce sagittal and

horizontal corrections while
continuing vertical
eruption.
Surendra Patel J C O 1999
166
 THE MONKEY HOOK
S.Jay Bowman (2002)

•It is a simple auxiliary with an open loop on each

end for the attachment of intra oral elastic or
elastomeric chain or for connecting to a bondable
loop button. JCO July 2002 167
 A combination of monkey hooks and bondable loop-
buttons allows the production of a variety of
different direction force such as:

I. Vertical intermaxillay eruptive forces

JCO July 2002

Easy-Way-Coil (EWC) system
The EWC system introduced by Schubert (2008) consists of a Remanium
closed-coil stainless steel spring, 0.010" ligature wire and a bondable lingual
button. The spring has an outer diameter of .047" and an inner diameter
of .030". Each 1mm of activation generates an average force of .158N or
16.1gms. To assemble the system, cut a 1" length of spring with a ligature
cutter. At one end, carefully bend the last few coils of the spring at a 45°
angle to make an eyelet about 1mm in length. Attach the eyelet to the
lingual button with the .010" ligature wire. After twisting and trimming the
ligature wire to a length of 1.5mm, firmly press the end against the stem of
the button with a band adapter. It is important to ensure that the
attachment can still be turned for subsequent activation. The spring should
be reactivated at four week intervals to maintain a constant force. After the
crown will has emerged enough to remove the lingual button and place a
bracket on the tooth. Further alignment can be accomplished with a
“piggyback” arch segment. The EWC system allows the constant application
of force throughout the eruption of impacted teeth. It can be applied either
unilaterally or bilaterally, with secure anchorage and no undesirable side
effects.

169
 AUSTRALIAN HELICAL ARCHWIRE

• Christine Hauser (2000)

•Made in special plus .016”
arch wire
•Force should not exceed
200 gm
•Activation by twisting the
steel ligature wire every two
weeks
170
 Eruption and Alignment of Impacted Teeth with
Multi-Purpose Attachments JCO 2012
 The MPA is a small, P-shaped bonded attachment, only .4mm thick
at its base and 1mm thick at the lumen, with a flat base for incisors
and a curved base for canines, premolars, and molars. A hook can be
formed by passing a strand of ligature wire through the lumen of the
MPA and twisting it

171
Treatment of Ectopic Maxillary Canines Using a
Palatal Implant for Anchorage JCO 2005
The Straumann Orthosystem palatal miniimplant consists of a pure
titanium (grade 4) intraosseous screw with a smooth, transmucosal
neck (2.5mm or 4.5mm long) and an exposed, 2mm head, to which a
healing cap is attached. The self-tapping threads are sandblasted and
acid-etched for optimal primary stability.
The active portion of the ISDS is made in
one of two designs:
Type 1. Two lingual sheaths with rectangular openings are soldered to
a steel cap,which is attached to the palatal implant. An .032“ TMA**
spring is inserted in each lingual sheath for maxillary molar
distalization. Two .040“ stainless steel arms are soldered to the
mesial portion of the steel cap for initial extrusion of the
impacted teeth.

172
Type 2 (Fig. 2B). The .032" TMA springs are inserted in the lingual
sheaths as cantilever arms to produce extrusion of the impacted
teeth in the vertical plane. Further labial movement of the
impacted canines is performed with the cantilever arms activated
in the horizontal plan

173
 U-Flex eruption device
Its base is U-shaped and is exible to fit snugly to an incisal edge.
Has low prole to reduce the risk of dehiscence of overlying soft
tissue flap.It is coated with titanium nitride.

174
An Efficient Technique of Bonding Orthodontic
Attachments to Surgically Exposed Impacted Teeth
JIOS 2012
 Expasyl* is a paste used for gingival retraction that opens the
sulcus, physically displacing the tissue and leaving the field dry,
ready for impression taking or cementation. It contains 15%
aluminium chloride, kaolin and water. The aluminium chloride
present in the paste provides excellent hemostasis and seepage
control which can be taken advantage of, while bonding
orthodontic attachments to surgically exposed impacted teeth.
The mechanism of action of aluminium chloride is mainly due to
its ability to precipitate tissue and blood proteins, causing a
mechanical obstruction to hemorrhage from injured blood
vessels. It also has the capability to extract fluid from the tissues.
Aluminum chloride is highly soluble in water, freely soluble in
alcohol and soluble in glycerin. Aluminum chloride has no
contraindications and minimal side effects
175
176
 RETENTION CONSIDERATIONS

Evaluation of post treatment alignment by Becker et al

• Incidence of rotations and spacings

1. Impacted side- 17.4%

2. Control side 8.7%
•Ideal alignment on control side is twice as often as the
impacted side.

177
 To minimize rotational relapse, options available are

1. Fiberotomy

2. Bonded fixed retainer

This can be done during or after the treatment.

Clark’s suggestion for palatally impacted canine: Lingual

drifting can be prevented by removal of halfmoon-

shaped wedge of tissue from lingual aspect of canine.

178
Case report

◦ ERUPTION OF AN IMPACTED CANINE WITH A SEMI-

FIXED APPLIANCE: - Dr. K. Neelima, Dr. K. Nagaraj , Dr.
Roopa Jatti (The Orthodontic CYBER journal, February
2010)

179
• A 19 1/2 year old female patient presented with an impacted upper left
canine and an over-retained primary upper left canine.. She had a
permanent dentition, with a Class I molar relationship and a proclined
maxillary left lateral incisor. The overjet was 3mm and the overbite was
close to normal. A palpable bulge was present on the buccal side of the
impacted canine region on intraoral examination.

• Intraoral periapical radiographs taken with the slob technique and occlusal
films confirmed that the impacted canine was on the labial side, with its
crown mesially angulated and the tooth almost horizontally impacted. The
crown of the impacted tooth was in close proximity to the root of the
permanent lateral incisor

180
 APPLIANCE
DESIGN:

A semi-fixed appliance was used in the initial phases to achieve

a favorable path of eruption. The appliance, comprised of wires
extending from the maxillary first molar bands palatally into the
Nance button to reinforce the proposed anchorage.
Circumferential Clasps extending from the distal of the lateral
incisor and the mesial of the first premolar were inserted into
the Nance button to maintain space for alignment of the
impacted canine.
181
 SURGICAL
TECHNIQUE:
◦ A labial flap was raised in the maxillary left canine region under local
anesthesia. The crown of the impacted canine was exposed and a bracket
was bonded to an accessible site on the tooth, using a light-cured
adhesive for
◦ maximum strength. A 0.010” stainless steel ligature wire was passed
through the bracket and brought out of the flap.
◦ A tunnel was created through the bone following extraction of the
deciduous canine and the flap was then closed with silk sutures, which
were to be removed one week later. The semi-fixed appliance was
cemented an hour after the surgical procedure. The ligature wire was
loosely ligated to the clasps of the semi-fixed appliance.

182
 CASE
a favorable angulationPROGRESS:
◦ A distally directed force was initially applied to the tooth because of its angulation. Once
was achieved, in approximately 90 days, an incisal eruptive force
was applied, in addition to the distalizing force. Periodic intraoral periapical and occlusal
radiographs were taken to assess the angulation and case progress. Once the tooth was
almost upright, a full 0.022” x 0.028” Roth fixed appliance was bonded.

183
• Once the proper accomplished, the semi-fixed appliance was removed by cutting
the wires extending from the molar bands into the Nance palatal button.

• Molar bands with buccal tubes were retained for further fixed appliance therapy.

• A 0.016” Nickel Titanium archwire was then placed for initial leveling and
alignment followed by 0.017” x 0.025” and 0.019 x 0.025” Nickel Titanium
aligning wires.

• A passive open coil spring was threaded over 0.019” x 0.025” stainless steel
base arch wire for space maintenance in the canine region after which a 0.022” x
0.028” bracket was bonded to the now erupting upper left canine for its
alignment into the arch.

• A 0.016” NiTi auxiliary overlay wire was

placed on stainless steel base arch wire for
further alignment of canine

184
RESUL
T:
◦ Total treatment time was about 14 months, which included an initial 7-8
months of treatment with a semi-fixed appliance, followed by full bonded
fixed mechanotherapy.
◦ A minor amount of gingival recession was observed on the canine along
with a slight amount of apical root resorption with regard to the adjacent
lateral incisor.
◦ Both of these findings were, however, insignificant considering the amount of
tooth movement required in this case and, most importantly, preserving the
vitality of the associated teeth.

185
A retrospective long-term pulpal,periodontal,
and esthetic, follow-up of palatally impacted canines
treated with an open or closed surgical exposure
technique using the Maxillary Canine Aesthetic Index
Am J Orthod Dentofacial Orthop 2020
The primary objective of this study was to compare the aesthetic outcome of
palatally impacted canines treated with an open or closed surgical exposure
technique using the Maxillary Canine Aesthetic Index (MCAI) at least 1 year
after debonding. Secondary objectives were set on the periodontal outcome,
tooth color, pulpal status, and self-reported contentment.
The sample of this retrospective study consisted of 53 patients with an
average age of 20 years and 7 months at the time of the investigation. A total
of 53 canines were investigated. All canines were aesthetically scored with the
MCAI. Other outcome variables were investigated,such as gingival
inflammation, pocket probing depth, vitality, percussion sensitivity, and tooth
color. All patients received a questionnaire to evaluate their appraisal of
different parameters

186
 Conclusions: A closed surgical exposure of palatally
impacted maxillary canines is preferred in terms of
aesthetics when measured with the MCAI. There was
no difference between the 2 techniques in terms of
periodontal outcome. Canines treated with a closed
exposure tended to have a darker color and delayed
response to cold testing.

187
 CANINE IMPACTION: HOW EFFECTIVE IS EARLY
PREVENTION? AN AUDIT OF TREATED CASES
Mew J and Mew M Stoma Edu J 2015
 Introduction: Impacted maxillary canines are a major problem and expense in
orthodontic practice. It seems as though their incidence has risen in recent
years. It had been noticed that fewer canines appeared to be impacted
amongst patients who had been treated by Orthotropics®, a form of treatment
which involves proclining the incisors and expanding the maxilla. The objective
was to compare the influence of Orthotropics on the ratio of impacted canines
with matched averages from other populations. Methodology: Records over a
five year period were taken from a practice specialising in Orthotropics. An
audit of the incidence of impacted canines was taken and compared with
average frequencies. Results: There appeared to be a zero incidence of
impacted canines amongst patients from this practice who started treatment
before the age of ten. This compares with an incidence of 3½ % in the wider
range of older patients from comparative populations. Conclusion: Expansion
coupled with proclination of the incisors in children under nine years old, may
reduce or eliminate the impaction of maxillary canines
188
 CONCLUSION:
 Various surgical and orthodontics
techniques may be used to recover impacted
maxillary canines.Proper management of these
teeth requires appropriate surgical techniques to
apply forces in a favourable direction and to have
complete control for efficient correction, thereby
avoiding damage to the adjacent teeth.
◦ The management of impacted canine is a
complex procedure requiring a multidisciplinary
approach.The clinician should communicate with
each other to provide the patient with an optimal
treatment plan based on scientific rationale.

189
 REFERENCES

 Jerad A. Servais a, Laurence Gaalaas .Alternative cone-

beam computed tomography method for the analysis of
bone density around impacted maxillary canines .
American Journal of Orthodontics and Dentofacial
Orthopedics .Volume 154, Issue 3, September 2018, Pages
442-449
 Becker A. The orthodontic treatment of impacted teeth. 2nd
ed. Abingdon, Oxon, England: Informa Healthcare; 2007.
 Prevalence and risk factors of root resorption of
adjacent teeth in maxillary canine impaction, among
untreated children and adolescents .EJODO,7th December
2018

190
 Alignment of palatally impacted canine with open window
technique and modified k‑9 spring.,dipti shastri, amit
nagar, pradeep tandon contemporary clinical dentistry |
apr-jun 2014 | vol 5 | issue 2
 A new technique for forced eruption of impacted teeth
michael schubert., volume xlii number 3 © 2008 jco, inc.
 Surgical and orthodontic management of impacted
canine., vincent kokich.,american journal of orthodontics
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 Manne r, gandikota c, juvvadi sr, medapati rama h, anche
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 Surgical uncovering and stimulation of physiological
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191
 Australian helical archwire –helping hand for canine
impaction .,amit prakash , shanker dayal gupta , sonali
rai , adit arora and sandeep jain universal journal of
medicine and dentistry(issn:2277-0992) vol. 1(7) pp. 076-
078, october, 2012
 Orthodontic traction of impacted canine using magnet: a
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larry cf li, ricky wk wong and nigel m king
cases journal 2008, 1:382 doi:10.1186/1757-1626-1-382
 Labially Impacted Maxillary Canines Causing Severe Root
Resorption of Maxillary Central Incisors. - Diane J. Milberga
(Angle Orthod 2006;76:173–176.)

192
 ERUPTION OF AN IMPACTED CANINE WITH A SEMI-
FIXED APPLIANCE: - Dr. K. Neelima, Dr. K. Nagaraj , Dr.
Roopa Jatti (The Orthodontic CYBER journal, February
2010)
 Labially Impacted Maxillary Canines Causing Severe Root
Resorption of Maxillary Central Incisors. - Diane J.
Milberga (Angle Orthod 2006;76:173–176.)
 Sung-Hun Kim,Woo-Sung Son, Tetsutaro Yamaguchi.
Assessment of the root apex position of impacted maxillary
canines on panoramic films October 2017 Vol 152 Issue 4
American Journal of Orthodontics and Dentofacial
Orthopedics
193