ORTHODONTIC

CONSIDERATIONS OF
IMPACTED TEETH

DR. DIVYA SONI

JR3
CONTENTS
• FAVOURABILITY OF IMPACTED TEETH BY ORTHODONTIC TREATMENT
• FACTORS INFLUENCING THE TREATMENT
• TRATMENT ALTERNATIVES
• GENERAL STEPS IN MECHANOTHERAPY
• ASSESSMENT OF SPACE RQUIREMENT
• ANCHORAGE CONSIDERATIONS
• ATTACHMENTS AND APPLIANCES USED
• LINGUAL APPLIANCES IMPACTED TEETH
• CLEAR ALIGNERS IN THE TREAATMENT OF IMPACTED TEETH
• TUNNEL TRACTION METHOD
• FINISHING
• RETENTION
• CONCLUSION
• REFERANCES
 FAVOURABILITY OF IMPACTED TEETH
Age of patient( Young age or growing age patients show better prognosis than that of adult patients)

BY ORTHODONTIC TREATMENT
A tooth in an intractable position may be granted a good, but false, treatment prognosis.

A lack of appreciation of the considerable anchorage requirements of the case and the need to exploit all available
means of enhancing those requirements will inevitably lead to inefficient mechano- therapy and unnecessarily lengthy
treatment.

Ankylosis might have afflicted the impacted tooth either a prior or as the result of the earlier surgical or orthodontic
manoeuvres.
Factors Patient dependent
Radiologist-
influencing
factors
º Age
:
dependent factors:
Incorrect positional diagnosis
the
º
º Medication
º Abnormal morphology of º Root resorption of impacted
impacted and adjacent teeth or adjacent tooth

treatment
º Pathology affecting the
impacted tooth
º Supernumerary
teeth/odontoma/Sclerotic
bone
º Grossly ectopic teeth º Pathology
º Lack of compliance

Orthodontist- dependent
factors:
º Incorrect positional diagnosis
º Negligent examination of clinical
and/or radiographic features
º Resorption of the root of an
adjacent tooth º Poor anchorage
º Inefficient and poorly designed
appliances
º Iatrogenic causes of failure
Surgeon- dependent
factors:
º Poor surgical planning and
mistaken positional diagnosis
º Surgical exposure without prior
orthodontic planning
º Unnecessarily excessive/botched
surgery
Treatment alternatives
1. No treatment, if the patient does not desire it. Since the long term
prognosis of deciduous canine is poor as its root may eventually resorb , it
should be periodically evaluated.
2. Auto transplantation of the canine.
3. Extraction of impacted canine and moving premolar in its position.
4. Extraction of the canine & posterior segmental osteotomy to move the
buccal segment mesially to close the residual space.
5. Prosthetic replacement of the canine, not amendable for juvenile cases.
6. Most desirable approach is surgical exposure of the canine followed by
orthodontic treatment.
 PRE SURGICAL SURGICAL POST SURGICAL
General Steps in Mechanotherapy
• Leveling and • Surgical exposure • Application of low
Alignment of the of the crown of force (60gm)
erupted teeth. the impacted traction from rigid
• Creating enough canine and anchorage unit.
space for the attachment • Mechanical
impacted canine bonding. alignment.
and maintaining • Stabilization.
it.
• Conversion of the
arch into a rigid
anchorage unit.
 ASSESSMENT OF SPACE
REQUIREMENT
A) Existing incisor space
Becker showed incisor spacing was due to failure of completion of
ugly duckling stage of development. During final stage these existing
space will be closed by mesial movement of lateral incisor.
B) Improving arch form
 The achievement of good arch form is an important initial goal in
the maxillary arch in non extraction cases.
 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.
• C) Increasing arch length
•In mild crowding cases distalization of molar is
recommended which increases the arch length.
•D) Extraction as means of prevention (Mixed
dentition period)
• deciduous canine
•Erickson and Kurol concluded that patient with age of 10-13
years preferably withdelayeddental age,palatal displacement
of canine with apex confirmed in line of arch requires
extraction of deciduous canine for good prognosis for
eruption of permanent canine.
•First Premolar
I) Crowding Of Maxillary Arch
II) Bimaxillary Protrusion
III) Class II Relation
Lateral Incisor
Peg Shaped Or Severely Malformed Lateral Incisor (Dens
Invaginatus) Can Be Extracted Instead Of Healthy Premolars.
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.
 ANCHORAGE CONSIDERATIONS
• Use of full dimension stainless steel rectangular wire in edgewise
brackets.
• Use of 0.022 / 0.020 wires with uprighting springs or torquing springs
to act as brakes if necessary in beggs and tip-edge appliance.
• Micro implant anchorage
The microscrew should be placed in the labial
cortical alveolar bone, at an angle of 10-20° to
the bone surface and as parallel to the tooth's
long axis as possible.
• This keeps the apex of the microscrew on
the buccal side and reduces the likelihood
• of
Theitshead
contacting
of the the root. should be
microscrew
located as incisally
the vertical as possible
component of force.to maximize

In lingual treatment, the smaller arches

that are required for the shorter
interbracket distances and smaller
bracket slots may not be able to resist
distortion.
 The impacted canine needs to pass over
the archwire during buccal movement.
 These considerations make skeletal
anchorage for eruption of impacted
canines even more appealing in lingual.

Micro-Implant Anchorage for Forced Eruption of Impacted Canines, PARK et al, JCO 2004; 38; 297-302.
• Mandibular Anchorage
• Lingual arch is fabricated with
•0.036 inch SS wire
• Vertical hooks (5-6mm in length)

•Elastic force should not exceed 40-60 gm

•Advantages
• Simplicity in appliance design and application
• Reduced overall treatment time

Management of impacted maxillary canines using mandibular anchorage.

Pramod K. Sinha, and Ram S. Nanda; AJODO March 1999
ATTACHMENTS AND APPLIANCES
USED
• Attachments for canine
A.Lasso wire – Shapira and Kuftinec
1)poor control over direction of extrusion
2)risk of external root resorption near CEJ
3)risk of alveolar crestal bone
4)loss and loss of attachment epithelium.

B. Orthodontic bands
1)Requires extensive bone removal.

C. Threaded Pins – Becker and Zilberman

1)Chances for non vitality of the tooth
2)Needs restoration of the tooth at the end of treatment
Shapira Y, Kuftinec MM. Treatment of impacted cuspids: the hazard lasso. Angle Orthod 1981; 51: 203–207.
D. Standard Orthodontic Brackets – Jacobi, Nielson
1) easy to perform
more reliable method
E. 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.

•E. 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

Treatment of an impacted canine with magnets. Darendelier et al; JCO 1994;28:6

F. Magnets G
• Surgical exposure of the impacted tooth and applying .

S
an attachment of small high energy magnets to provide
the traction force so as to aid the eruption of an impacted A
maxillary canine has been described by Sandler (1991)
and Darendeliler and Freidle (1994) s
i
• Small neodymium-iron-boron magnets (3 x 3 x 1 mm) m
• Larger magnet(5x5x2 mm )-removable appliance. p
l
e
Advantages;
• Rapid, safe, and sure eruption of teeth in much less e
time than conventional methods y
• No chains, lassos, or ligatures penetrating the palatal e
tissue reduces chances of inflammation, infection, l
potential ankylosis, e
• The attachment is less likely to be knocked and t
dislodged from the tooth.
• A
• Magnets produce constant physiological forces (40 to n
60Gms) over long periods of time and the direction of the
force can be chosen by the clinician e
y
Force Generating Devices
• Active palatal arch(Becker1978)
• It consist of fine 0.020 inch removable palatal arch wire carrying an
omega loop on each side.
• End of the wire is doubled for Frictionless fit in lingual sheath.
• It is activated by elevating downward activated palatal arch wire and
hooking the pigtail ligature around it.
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.
• 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 provide an extrusive force for the
canine to erupt.
 • Light Auxiliary Labial Arch
• (Kornhauser 1996)
• This loop has a small helix.
• Wire is tied with the basal arch wire in piggyback fashion.
• If basal arch wire is not used it will leads to extrusion of adjacent
tooth and cause alteration of occlusal plane.

 Australian Helical Archwire

• Made in special plus .016” arch wire

• Force should not exceed 200 gm

• Activation by twisting the steel ligature wire every

two weeks
• TMA Box Loop
• TMA .017 X .025 wire used.

• Produce sagittal and horizontal

corrections while continuing vertical
eruption.

Cantilever Spring
• Initial extrusion mechanics with a cantilever.

• Use of a box loop to continue canine extrusion and to

make 1st- and 2nd-order corrections.
• Incorporation of the canine into a continuous archwire
for finishing.
• TMA .017 X .025 wire used
•K-9 Spring
• Made in 0.017”X 0.025”TMA
• wire
• Simple in design

• Low cost

• No patient compliance

• Light continuous eruptive and

distalizing forces
• 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.

• A combination of monkey hooks and bondable loop-buttons allows the

production of a variety of different direction force.

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 .
• 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.
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
• U-FLEX Eruption Device
• Its base is U-shaped and is flexible to fit snugly to an incisal edge.
• It is coated with titanium nitride.
 TADS
• An indirect anchorage system.

• act as a ‘stake in the ground’, against which to tie elastic modules and chains for the
horizontal movement of teeth in various directions .
• Using a TAD in the opposite jaw as a direct anchor, in the absence of an orthodontic
appliance, has the obvious advantage that there can be no adverse, particularly intrusive,
movement of teeth adjacent to the impacted tooth, since these are not included as anchor
units.
• . (a) Extra-oral view to show tipped occlusal plane due to anchorage loss during the attempted
active eruption of the left maxillary canine.
• (b) Intra-oral view of the same case shows the exposed canine ligated with elastic ligature to
the first premolar. The space is held open by a steel tube tied between the incisor and
premolar brackets. The extrusive force has resulted in the lateral open bite and cant in the
occlusal plane.
• (c) Vertical inter-maxillary bite-closing elastics (blue) are used to support the anchorage of the
maxillary arch. A titanium screw TAD is tied to the mandibular canine bracket with an elastic
zygomatic plate

(a) Panoramic view of bilateral infra-occluded first permanent mandibular molars. These teeth are almost
certainly ankylosed and require to be subluxated if they may be made to erupt.

(b) Initial mandibular aligning appliance.

(c) The zygomatic plate affixed firmly with titanium screws to the inferior surface of the zygomatic process of
the maxilla. The free end of the plate is drawn through a separate cut in the attached gingiva, while the larger
flap will be fully replaced and sutured.

(d) The mandibular dentition has been realigned, anterior spaces closed and space created in the molar
region. The patient places the latex elastic between an attachment on the molar band and the hooked end of
the zygomatic plate.
Lingual Appliances, Implants
and Impacted Teeth
(a) Elastic thread tied between the buccal eyelet of the impacted canine and
a loop in the buccal offset of the lingual archwire.

(b) Elastic thread tied between the buccal eyelet of the impacted canine and
an attachment bonded on the buccal aspect of the first molar. A palatal
offset is inserted in the lingual archwire.

(c)Canine auxiliary ligated under main lingual arch and to tooth eyelet.

(d)Nickel–titanium archwire inserted through the palatal eyelet.

(e)Elastic traction from the eyelet bonded on the palatal aspect of the
impacted canine crown to a micro screw inserted between the second
premolar and the first molar.

(f)Ballista spring tied into mini screw.

(a) Passive state.
(b) Activated by ligation to pigtail ligature, applying traction to the
unerupted teeth.
Clear Aligners in the Treatment
of Impacted Teeth
(a) Mandibular occlusal view revealed over- retained lower right deciduous canine and interdental spaces
between the incisors and the lower left canine.

(b, c) Cone beam computed tomography 3D buccal and occlusal images presenting buccally impacted lower right
canine in a disto- angular inclination, towards the opposite side (left side).

(d) Surgical exposure and button cementation on the impacted canine as a preliminary step before orthodontic
tooth movement begins.

(e) Intra- arch impacted canine traction, first towards the right side to enable quick emergence.

(f) then towards its final position on the right side. Impacted tooth traction was performed using 6 oz intra- oral
elastics along with space gaining, which included closure of anterior inter- incisor spaces and lower left canine
distalization.
(g) Nine months after surgical exposure and elastic traction using Invisalign, the
tooth erupted.
(h) Combined inter- and intra- arch traction was continued to guide the
impacted canine from the opposite side of the arch.
(i) Inter- arch elastic traction (open- mouth picture).
(j) Intra- arch elastic traction may cause gingival tissue decubitus.
(k) Intra- arch elastic traction wrapping around the aligner aimed to prevent
pressure ulcer.
 f)Guiding tooth to the line of arch
Tunnel Traction Method  Once the tooth is moved to the oral environment, bonding
attachment is placed on the midbuccal aspect to prevent
iatrogenic rotation of canine and guided to the line of arch.
• Crescini approached a method called as TUNNEL  If the root apex of canine is close to the line of arch and crown
TRACTION(1994). related to the roots of incisors, pure buccal tipping will bring the
• Procedure: crown to desirable position and inclination.
 If the root apex is distant to the line of arch and crown not
• a) Extract deciduous canine
related to the roots of the incisors, usually it will be impacted
• b) Full thickness mucoperiosteal flap is elevated to deep and may even cross the mid palatal suture.
expose the cortical plate.  If there is an horizontal impaction, downward tipping should be
• c) Drill with bur until exposing crown of canine cautiously applied. Force application should be like the fulcrum of
the canine to be at the root end, so that root apex don’t alter
• d) Tooth was bonded and ligature wire tied
following the canine tipping movement.
• e) Traction force given after 1week of surgery  Unfortunately, fulcrum is usually located short away from the
• f)Guiding tooth to the line of arch . apical portion of the root, leads to concomitant palatal
displacement of root apex of canine. This requires buccal root
torquing after alignment of canine in the arch.
• Advantage  If the root apex mesial to lateral incisor or distal to premolar,
• a) No buccal or palatal access tooth is considered as transposed.
• b) No loss of supporting tissue
Tunnel traction of infraosseous impacted maxillary canines –Tunnel traction of infraosseous impacted maxillary canines. A three-year periodontal follow-up.Crescini et al. AJO-DO, Volume 1994 Jan (61 - 72)
 28

• abs
enc
e of
any • Torq
den • straig ue
corre
tal ht ction
or profli and
e contr
peri • facial ol.
• abse
odo sym nce
metr of
ntal y rotati
bno • main on.
taina • inter
rma nce cusp
alliti of ation
smile • occlu
es. arc sal
conta
• root cts.
par
allel
ism
ORAL HELTH
AESTHETICS
OCCLUSION
ORAL HELTH
AESTHETICS
OCCLUSION
FINISHING
 RETENTION
• Evaluation of post treatment alignment
• Incidence of rotations and spacing
1. Impacted side - 17.4%
2. Control side - 8.7%
• Ideal alignment on control side is twice as often as the impacted side.
• To minimize rotational relapse, by:
1. Fiberotomy
2. Bonded fixed retainer
Clark’s suggestion for palatally impacted canine: Lingual drifting can be
prevented by removal of half moon- shaped wedge of tissue from lingual
Impacted maxillary canines:
Impacted maxillary canines: A review; Samir E. Bishara; AJODO 1992;101:159
CONCLUSION

Impacted tooth is the common challenge faced by dentists in routine practice. Successful and untroubled
management of impaction depends on comprehension of mechanism of impaction, which depends on
detailed knowledge of the development and eruption paths and patterns of the teeth. Usually
management of impacted tooth requires the collaborative efforts of the orthodontist, periodontist and
oral surgeon. But early recognition and keen understanding of impaction sometimes is sufficient to correct
or check the development of malocclusion by interceptive treatment alone.
REFERANCES
• Orthodontic Treatment of Impacted Teeth – Adrian Becker (Third edition).
• Impacted Maxillary Canines: A Review; Samir E. Bishara; AJODO 1992;101:159-71
• Adrian Becker. Success rate and duration of orthodontic treatment for adult patients with palatally impacted maxillary
canines. AJODO 2003;124:509-14.
• Early treatment of palatally erupting maxillary canines by extraction of the primary canines. Ericson S. & Kurol J.;
European Journal of Orthodontics 1988;10: 283-295
• Micro-Implant Anchorage for Forced Eruption of Impacted Canines PARK et al, JCO 2004; 38; 297-302.
• Treatment of an impacted canine with magnets.Darendelier et al; JCO 1994;28:639-43.Alignment of Impacted
Canines with Cantilevers and Box Loops; Surendra Patel; JCO 1999.
• Management of impacted maxillary canines using mandibular anchorage. Pramod K. Sinha, and Ram S. Nanda; AJODO March
1999
• Eruption of impacted canines with an Australian Helical Archwire. Hauser et al; JCO Sep 2000
• Shapira Y, Kuftinec MM. Treatment of impacted cuspids: the hazard lasso. Angle Orthod 1981; 51: 203–207
• The K-9 Spring for Alignment of Impacted Canines. Varun Kalra; JCO Oct 2000
• The Monkey Hook: An Auxiliary for Impacted, Rotated, and Displaced Teeth. S. JAY BOWMAN et al; JCO 2002
July. Bowman S. & Carano A. JCO Dec., 2003
• Tunnel traction of infraosseous impacted maxillary canines. A three-year periodontal follow- up. Crescini et al. AJO-DO,
Volume 1994 Jan (61- 72)
THANK YOU....