Case Report Correction of Multiple Canine Impactions by

Case ReportCorrection of Multiple Canine Impactions by Mixed Straightwireand Cantilever Mechanics A Case Report

Sergio Paduano1 Iacopo Cioffi2 Giorgio Iodice2 Vincenzo drsquoAntograve2 Francesco Riccitiello2

Gioacchino Pellegrino2 and Rosa Valletta2

1 Department of Health University ldquoMagna Graeciardquo of Catanzaro Viale Europa Loc Germaneto 88100 Catanzaro Italy2 Department of Neurosciences and Oral Sciences University of Naples Federico II Via Pansini 5 80131 Naples Italy

Correspondence should be addressed to Sergio Paduano paduanouniczit

Received 10 March 2014 Accepted 10 June 2014 Published 22 July 2014

Academic Editor Maria Beatriz Duarte Gaviao

Copyright copy 2014 Sergio Paduano et alThis is an open access article distributed under the Creative CommonsAttribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Background This case report describes the orthodontic treatment of a woman aged 17 years with a permanent dentitionbrachyfacial typology Angle Class I with full impaction of two canines (1333) and a severe ectopy of the maxillary left canine Hermain compliant was the position of the ectopic teeth Methods Straightwire fixed appliances together with cantilever mechanicswere used to correct the impaired occlusion and to obtain an ideal torque control Results and ConclusionThe treatment objectiveswere achieved in 26 months of treatment The impactions were fully corrected with an optimal torque The cantilever mechanicssucceeded in obtaining tooth repositioning in a short lapse of time After treatment the dental alignment was stable

1 Introduction

The impaction of canines is a frequent report in clinicalpractice Previous studies report frequencies ranging between1 and 3 for the maxillary canines [1] and about 2 for themandibular cuspids [2] The palatal impaction of maxillarycuspids is about four times greater than labial impactions[3] Furthermore canine impaction occurs more frequentlyunilaterally than bilaterally [4 5]

The aetiology of canine impaction is generally related tothe upper dental arch length deficiency or to the develop-mental position of the tooth that could be more cranial thanthe norm Mechanical factors have also been proposed to berelated to the impaction of a canine For instance the prema-ture loss of deciduous canines or their prolonged retentioncould be associated with mechanical impingement of perma-nent canine This can also be the consequence of displace-ment of lateral incisors or of the presence of impacted teethor odontomas [4 5]

Untreated impacted canines may determine arch lengthdiscrepancies loss of vitality of adjacent teeth follicular cystscanine ankylosis infections and pain [6] As a consequenceof this orthodontic treatment is strongly recommended

Cantilever mechanics have been proposed for orthodon-tic recovery of impacted teeth A two-tooth system stressedby a couple of forces can be used to obtain an extrusiveforce to the canine and an intrusive force to the molar One-couple orthodontic appliances can increase the predictabilityof toothmovement and reduce the need of appliance reactiva-tion and the occurrence of possible intra-arch unwanted sideeffects [7 8]

We present the case of a 17-year-old girl with a permanentdentition (Figure 1) brachyfacial typology AngleClass I withfull impaction of two canines (1333) severe ectopic eruptionof themaxillary left canine and posterior crossbite Hermaincompliant was the position of the ectopic teeth Straightwirefixed appliances together with cantilever mechanics wereused to correct the impaired occlusion and to obtain an idealtorque control

2 Case Report

The patient presented this objective problem list

(i) Class 1 skeletal and dentalmalocclusion in the perma-nent dentition

Hindawi Publishing CorporationCase Reports in DentistryVolume 2014 Article ID 925019 9 pageshttpdxdoiorg1011552014925019

2 Case Reports in Dentistry

Figure 1 Extraoral and intraoral photographs before treatment

(ii) full crossbite extended from the maxillary left decid-uous canine to the first permanent molar

(iii) ectopic eruption of the maxillary left canine(iv) palatal impaction of the maxillary right canine(v) impaction of the mandibular left canine due to the

presence of an odontomas(vi) discrepancy of themidlines of upper and lower dental

arches

The cephalometric evaluation highlighted a brachyfacialtypology with a sagittal skeletal relationship of Class I(Figure 2) The panoramic radiograph showed the germs ofwisdom teeth of both dental arches (Figure 2) A palatalimpaction of the maxillary right canine the ectopic eruptionof the maxillary left canine and the impaction of themandibular left canine due to a small odontoma were visiblein the CT scan (Figure 3) The patient did not present signs

or symptoms of temporomandibular disorders according toResearch Diagnostic Criteria for Temporomandibular Disor-ders (RDCTMD) [9]

The treatment plan included the correction of crossbitealigning and levelling by straightwire fixed appliance man-agement of the space for impacted and ectopic teeth by coilsprings surgical exposure recovery of impacted and ectopicteeth by cantilevers torque control of recovered teeth andfinishing

Initially a TPA proclination spring was scheduled [10]for obtaining a buccal movement of the maxillary incisorsHowever the patient reported a slight discomfort As a con-sequence of this it was removed and a conventional multi-bracket treatment was planned

A 03610158401015840 stainless steel transpalatal arch was mod-elled to obtain unilateral expansion of the maxillary leftside Alignment of both dental arches was achieved byusing multibracket appliance (Roth prescription slot size

Case Reports in Dentistry 3

50

55

36

3387

4616

21 04

2

92 95

17

137

minus5

Figure 2 Cephalometric values and panoramic radiograph at the start of treatment

(a) (b) (c)

(d)

(e)

(f)

Figure 3 CT scan showing the axial (a) and the sagittal ((b) (c)) view of the maxillary impacted canine and the axial and frontal view of themandibular canine ((d) (e) (f))


Figure 4 A cantilevermodelled using 01910158401015840times02510158401015840 TMA Initially a first ordermdashoffset (a) and a second order (b) bends aremodelled close tothe maxillary molar to avoid interferences with premolar brackets and to activate the cantileverThen a first order bend (c) directed palatallyis used to anchor the canine

(a)

(b)

(c)

Figure 5 Cantilever activated for obtaining extrusion by a third order bend (a) and a second order bend (b) Cantilevers in position (c)

022

10158401015840times 028

10158401015840) with heat activated Ni-Ti archwires (round01410158401015840 and round 01610158401015840) The space for impacted and ectopicteeth was obtained by using superelastic coil springs onround 01810158401015840 AJ Wilcock Australian wire (regular+ GampHOrthodontics Franklin IN USA)

A flap for the surgical exposure of the impactedmaxillaryleft caninewas obtained by an intrasulcular incision extendedfrom the first right maxillary incisor to the second upperpremolar of the same side Once exposed the palatal surface

of the tooth was etched for 30 seconds and rinsed with waterTransbond XT (3M Unitek Monrovia USA) adhesive primerwas used for its strength [11 12] following the instructionof the manufacturer The lingual sheath was anchored to a01210158401015840 stainless steel ligature and bonded onto the distal palatalsurface of the tooth in order to prevent unwanted rotationsduring buccal movement Eyelets were created within theligature for a proper cantilever insertion A flapwas then usedto remove the odontoma and to expose the mandibular


Figure 6 From left to right progressive recovery of the maxillary canines

Figure 7 From left to right progressive recovery of the mandibular canine

left canine A lingual sheath was bonded using the sameprocedure described above

The cantilever was modelled using 01910158401015840 times 02510158401015840 TMAwire (Ormco Orange CA USA Figure 4) TMA is an elastictitanium molybdenum alloy showing Youngrsquos modulus ofabout 100GPa [13] Initially a first order bendmdashoffset (a) wasmodelled close to the molar to avoid interferences with pre-molar brackets A second order bend (b) was then modelledto activate extrusion Finally a first order bend (c) directedpalatally was used to anchor the canine A hook was bendedat the end of the cantilever to allow a proper tooth engage-ment

The extrusion of the maxillary right canine was obtainedby inserting a third order bend (read as a buccal root torqueof the molar) at the insertion of the maxillary molar (Figures5(a) and 5(c)) This activation leads to a caudal displacementof the hook at the boundary of the cantilever The forcedelivered was about 150 grams as measured by means of adynamometer This cantilever was also activated to obtain abuccal movement of the tooth by activating the first orderbend close to the molar

For the maxillary left canine the cantilever was activatedin extrusion by a second order bend (Figures 5(b) and 5(c))which determined a caudal displacement of the hook Also


Figure 8 Extraoral and intraoral photographs after treatment

for this case the force deliveredwas about 150 grams To avoidbuccal root torque of the maxillary right molar and distaltipping of the left maxillary molar the transpalatal arch waskept in place Also this reduced unwanted side effects such asmesiopalatal rotation of the right firstmaxillarymolar relatedto the buccal activation of the cantilever in the right side Toobtain additional anchorage a second transpalatal arch wasplaced on the maxillary second molars

A straight cantilever wasmodelled for themandibular leftcanine because of the good position of the tooth A secondorder bend was modelled close to the molar for obtainingextrusion (Figure 5) To further obtain an adequate torque ofthe canines during treatment a bracket with minus17∘ torque (leftsecond mandibular premolar) was used to obtain a palatalroot torque of the maxillary left canine For the maxillaryright canine a similar bracket was bonded but turned 180∘to obtain a buccal root torque

The progressive orthodontic recovery of both maxillaryand mandibular canines is documented in Figures 6 and 7

The archwire treatment considered superelastic nickel-titanium (Ni-Ti) archwires These materials undergo phasetransition driven by temperature and stressThemain featureof this alloy is its capability to release an almost constant levelof stress during the orthodontic treatment [14] The archwiretreatment sequence included the following

(i) 01410158401015840 HA Ni-Ti (heat-activated) upper and loweralignment archwires (3M Unitek Monrovia CAUSA)

(ii) 01610158401015840 HANi-Ti upper and lower alignment archwires(3M Unitek Monrovia CA USA)

(iii) 01810158401015840 AJ Wilcock Australian archwire regular+ withcoil springs for space opening


52

57

87

33 48 15

25

3

9230

91

29

19

124

minus4

Figure 9 Panoramic and lateral radiographs with cephalometric tracing before debonding at the end of treatment

Figure 10 Superimpositions of the upper and lower dental arches before (black) and after (red) treatment

(iv) 01810158401015840 times 02510158401015840 HA Ni-TI upper and lower archwires(3M Unitek Monrovia CAUSA)

(v) 01910158401015840 times 02510158401015840 SS upper and lower archwires (3MUnitek Monrovia CAUSA)

(vi) 01810158401015840 times 02510158401015840 multibraded wires with vertical elastics(1810158401015840 4 Oz) for improving intercuspation

A translation utility arch (TRUA) was also used for upperincisors retraction preserving an ideal torque [15] Duringrepositioning of the canines the patient experienced slightdiscomfort

3 Results and Discussion

A patient with multiple impaction of canines and unilateralposterior crossbite extended from the left maxillary firstmolar to the deciduous canine was successfully treated bya combination of cantilever mechanics and straightwireappliance The patient affected with crossbite did not presenttemporomandibular disorders [16]The extraoral and intrao-ral photographs of the patient at the end of treatment arereported in Figure 8 The total treatment duration was 26months Patient compliance was high throughout the treat-ment and good oral hygiene was maintained The cantilevermechanics allowed a correct repositioning of the ectopic andimpacted canines However since the force was applied ona single point of the canines it did not allow for a proper


Figure 11 Extraoral and intraoral photographs at two-year follow-up

correction of their torque [7] Hence it was decided to useextratorque brackets for a proper torque control Molar andcanine Class I relationships were obtained as well as a properoverjet and overbite The facial profile was improved due tothe correction of the incisor torque which resulted in thedecreased nasolabial angleThe repositioning of themaxillarycanines provided better lip support as shown in Figures 8and 9 Panoramic and lateral radiographs with cephalometrictracing before debonding at the end of treatment and tracingsuperimpositions are reported in Figures 9 and 10

For this orthodontic treatment we decided to use con-ventional brackets because it has been suggested that passiveself-ligating brackets may be less effective for obtaining anadequate torque control [17ndash19] Also we used heat activatedNi-Ti archwires to reduce patient discomfort [20] Ferric-sulphate gel for bleeding control in surgical exposure ofimpacted canines was also used in order to reduce postop-erative pain [21]

A lower fixed retainer was bonded from the mandibularright canine to left canine to maintain lower incisor align-ment Post-treatment photographs at two-year follow-up arepresented in Figure 11 The results achieved were maintainedduring the retention period by means of the fixed lingualretainer that has not been removed yet

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

References

[1] S F Dachi and F V Howell ldquoA survey of 3874 routine full-mouth radiographs II A study of impacted teethrdquoOral SurgeryOralMedicine Oral Pathology vol 14 no 10 pp 1165ndash1169 1961


[2] S Peck L Peck and M Kataja ldquoThe palatally displaced canineas a dental anomaly of genetic originrdquo Angle Orthodontist vol64 no 4 pp 249ndash256 1994

[3] A Alqerban R Jacobs P Lambrechts G Loozen and GWillems ldquoRoot resorption of the maxillary lateral incisorcaused by impacted canine a literature reviewrdquo Clinical OralInvestigations vol 13 no 3 pp 247ndash255 2009

[4] B Yan Z Sun H Fields LWang and L Luo ldquoEtiologic factorsfor buccal and palatal maxillary canine impaction a perspectivebased on cone-beam computed tomography analysesrdquo Amer-ican Journal of Orthodontics and Dentofacial Orthopedics vol143 no 4 pp 527ndash534 2013

[5] M M Bedoya and J H Park ldquoA review of the diagnosis andmanagement of impacted maxillary caninesrdquoThe Journal of theAmerican Dental Association vol 140 no 12 pp 1485ndash14932009

[6] W G Shafer M K Hine and B M Levy A Textbook of OralPathology WB Saunders Philadelphia Pa USA 4th edition1984

[7] S J Lindauer andR J Isaacson ldquoOne-couple orthodontic appli-ance systemsrdquo Seminars in Orthodontics vol 1 no 1 pp 12ndash24 1995

[8] S Paduano G Spagnuolo G Franzese G Pellegrino RValletta and I Cioffi ldquoUse of cantilevermechanics for impactedteeth case seriesrdquoThe Open Dentistry Journal vol 30 no 7 pp186ndash197 2013

[9] S F Dworkin and L LeResche ldquoResearch diagnostic criteria fortemporomandibular disorders review criteria examinationsand specifications critiquerdquo Journal of Craniomandibular Dis-orders Facial amp Oral Pain vol 6 no 4 pp 301ndash355 1992

[10] S Paduano G Spagnuolo G di Biase and I Cioffi ldquoTreatmentof a class II division 2 patient with severe skeletal discrepancyby using a custom made TPA proclination springrdquo The OpenDentistry Journal vol 7 pp 109ndash117 2013

[11] R Valletta D Prisco R de Santis L Ambrosio and RMartinaldquoEvaluation of the debonding strength of orthodontic bracketsusing three different bonding systemsrdquo European Journal ofOrthodontics vol 29 no 6 pp 571ndash577 2007

[12] G Merone R Valletta R de Santis L Ambrosio and RMartina ldquoA novel bracket base design biomechanical stabilityrdquoEuropean Journal of Orthodontics vol 32 no 2 pp 219ndash2232010

[13] G Laino R De Santis A Gloria et al ldquoCalorimetric and ther-momechanical properties of titanium-based orthodontic wiresDSC-DMA relationship to predict the elastic modulusrdquo Jour-nal of Biomaterials Applications vol 26 no 7 pp 829ndash844 2012

[14] R de Santis F Dolci A Laino R Martina L Ambrosio andL Nicolais ldquoThe Eulerian buckling test for orthodontic wiresrdquoEuropean Journal of Orthodontics vol 30 no 2 pp 190ndash1982008

[15] R Martina and S Paduano ldquoThe translation archrdquo Journal ofClinical Orthodontics vol 31 no 11 pp 750ndash753 1997

[16] G Iodice G Danzi R Cimino S Paduano and A MichelottildquoAssociation between posterior crossbite masticatory musclepain and disc displacement a systematic reviewrdquo EuropeanJournal of Orthodontics vol 35 pp 737ndash744 2013

[17] S Paduano I Cioffi G Iodice A Rapuano and R SilvaldquoTime efficiency of self-ligating vs conventional brackets inorthodontics effect of appliances and ligating systemsrdquo Progressin Orthodontics vol 9 no 2 pp 74ndash80 2008

[18] A Archambault R Lacoursiere H Badawi P W Major JCarey and C Flores-Mir ldquoTorque expression in stainless steelorthodontic brackets a systematic reviewrdquo Angle Orthodontistvol 80 no 1 pp 201ndash210 2010

[19] H M Badawi R W Toogood J P R Carey G Heo and P WMajor ldquoTorque expression of self-ligating bracketsrdquo AmericanJournal of Orthodontics and Dentofacial Orthopedics vol 133no 5 pp 721ndash728 2008

[20] I Cioffi A Piccolo R Tagliaferri S Paduano A Galeotti andR Martina ldquoPain perception following first orthodontic arch-wire placementmdashthermoelastic vs superelastic alloys a ran-domized controlled trialrdquo Quintessence international vol 43no 1 pp 61ndash69 2012

[21] A Lucchese F Carinci and G Brunelli ldquoUse of ferric-sulphategel for bleeding control in surgical exposure of impactedcaninesrdquo European Journal of Inflammation vol 10 no 1 pp79ndash82 2012

Submit your manuscripts athttpwwwhindawicom

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

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Oral ImplantsJournal of


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Radiology Research and Practice

Environmental and Public Health

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The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014


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Preventive MedicineAdvances in


EndocrinologyInternational Journal of



OrthopedicsAdvances in


Figure 1 Extraoral and intraoral photographs before treatment

(ii) full crossbite extended from the maxillary left decid-uous canine to the first permanent molar

(iii) ectopic eruption of the maxillary left canine(iv) palatal impaction of the maxillary right canine(v) impaction of the mandibular left canine due to the

presence of an odontomas(vi) discrepancy of themidlines of upper and lower dental

arches

The cephalometric evaluation highlighted a brachyfacialtypology with a sagittal skeletal relationship of Class I(Figure 2) The panoramic radiograph showed the germs ofwisdom teeth of both dental arches (Figure 2) A palatalimpaction of the maxillary right canine the ectopic eruptionof the maxillary left canine and the impaction of themandibular left canine due to a small odontoma were visiblein the CT scan (Figure 3) The patient did not present signs

or symptoms of temporomandibular disorders according toResearch Diagnostic Criteria for Temporomandibular Disor-ders (RDCTMD) [9]

The treatment plan included the correction of crossbitealigning and levelling by straightwire fixed appliance man-agement of the space for impacted and ectopic teeth by coilsprings surgical exposure recovery of impacted and ectopicteeth by cantilevers torque control of recovered teeth andfinishing

Initially a TPA proclination spring was scheduled [10]for obtaining a buccal movement of the maxillary incisorsHowever the patient reported a slight discomfort As a con-sequence of this it was removed and a conventional multi-bracket treatment was planned

A 03610158401015840 stainless steel transpalatal arch was mod-elled to obtain unilateral expansion of the maxillary leftside Alignment of both dental arches was achieved byusing multibracket appliance (Roth prescription slot size


50

55

36

3387

4616

21 04

2

92 95

17

137

minus5


(a) (b) (c)

(d)

(e)

(f)




(a)

(b)

(c)


022

10158401015840times 028





















52

57

87

33 48 15

25

3

9230

91

29

19

124

minus4
















References






























Biomaterials












Journal of




















50

55

36

3387

4616

21 04

2

92 95

17

137

minus5


(a) (b) (c)

(d)

(e)

(f)




(a)

(b)

(c)


022

10158401015840times 028





















52

57

87

33 48 15

25

3

9230

91

29

19

124

minus4
















References






























Biomaterials












Journal of





















(a)

(b)

(c)


022

10158401015840times 028





















52

57

87

33 48 15

25

3

9230

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29

19

124

minus4
















References






























Biomaterials












Journal of




































52

57

87

33 48 15

25

3

9230

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19

124

minus4
















References






























Biomaterials












Journal of





























52

57

87

33 48 15

25

3

9230

91

29

19

124

minus4
















References






























Biomaterials












Journal of




















52

57

87

33 48 15

25

3

9230

91

29

19

124

minus4
















References






























Biomaterials












Journal of


























References






























Biomaterials












Journal of















































Biomaterials












Journal of


























Biomaterials












Journal of



















Documents

Case Report Correction of Multiple Canine Impactions by