Impacted Max Canines

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Impacted Maxillary Canine - At a Glance

Prasad Konda,1 Mohammad Urooj Ahmed,2Syed Mohammad Ali,3Amaranth Konda4

Introduction

Maxillary canine are important teeth in terms ofesthetics, functional occlusion & arch development.The

likelihood of their failing to erupt or becoming impactedmay range between 1 & 3 %,

1which shows its 2nd most

commonly impacted tooth after the third molars. It istwice as common in females as it is in males. Incidenceof canine impaction in maxilla is more than twice that of

in mandible. Canine impaction is found palatally in 85%of cases and labially in 15%.

ETIOLOGY

There is some incidence that patients with Angles classII div 2 malocclusion and tooth aplasia may be at high

risk to the development of ectopic canine.2

LOCALIZED FACTORS

1)

Tooth sizearch length discrepancies.

2)

Failure of the primary canine root to resorb.3)

Prolonged retention or early loss of the primarycanine.

4)

Ankylosis of the permanent canine.5)

Cyst or neoplasm.

6)

Dilaceration of the root.7)

Absence of the maxillary lateral incisor.

ABSTRACT

Maxillary canines are important teeth in terms of esthetic and

function. Impaction of canines is a common occurrence and

clinicians must have a sound knowledge to manage such cases.

With early detection, timely interception and well managed

surgical and orthodontic treatment; impacted canines can beerupted and guided to an appropriate location in the dental arch.

This paper presents a literature review regarding etiology, clinical

and radiographic diagnosis, as well as surgical and orthodontic

management of impacted maxillary canine.

KEYWORDS: Impacted canines, surgical techniques, orthodontic

techniques.

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2(6) 2011 Int. Journal of Contemporary Dentistry

8)

Variation in root size of the lateral incisor.9)

Variation in timing of lateral incisor root

formation.10) Iatrogenic factors.

11) Idiopathic factors.SYSTEMIC FACTORS

1)

Endocrine deficiencies.2)

Febrile diseases.3)

Irradiation.

GENETIC FACTORS

1)

Heredity.

2)

Malposed tooth germ.3)

Presence of an alveolar cleft.3

CLASSIFICATION :4

Table 1 shows classification of impacted canine

DIAGNOSIS OF IMPACTION:

The diagnosis of canine impaction is based onboth clinical and radiographic examinations.

Clinical evaluation: It has been suggested that the following clinical

signs might be indicative of canine impaction:

(1) Delayed eruption of the permanent canine orprolonged retention of the deciduous canine beyond 14

to 15 years of age,(2) Absence of a normal labial canine bulge onpalpation.

(3) Presence of a palatal bulge, and(4) Delayed eruption, distal tipping, or migration

(splaying) of the lateral incisor.

According to Ericson and Kurol,5the absence of

the "canine bulge" at earlier ages should not beconsidered as indicative of canine impaction.

An accurate diagnosis of clinical examinationshould be supplemented with a radiographicevaluation.

Radiographic evaluation:

Several methods have been used to radiographicallyevaluate impacted maxillary canines. These methodsinclude intraoral techniques (occlusal and periapical

projections) and extraoral techniques (panoramic,posteroanterior or lateral cephalometric radiographs).

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Occlusal radiographs:

The most practical method of obtaining an occlusalradiograph is by positioning the x-ray tube directly over

the bridge of the nose, at a 60-degree angle to theocclusal plane. This method has been used to determine

the bucco-palatal position of impacted teeth.

Periapical radiographs:

Traditional method of locating impacted teeth,

specifically maxillary canines, has been the use of a two-dimensional technique with periapical radiographs,

known as the buccal object rule. This technique consistsof taking two periapical radiographs at different

mesiodistal angulations and using the same-lingual-opposite buccal (SLOB) rule to determine the toothsbuccolingual position. The radiographic interpretation

of the SLOB rule is if, when obtaining the second

radiograph, the clinician moves the x-ray tube in a distaldirection, and on the radiograph the tooth in questionalso moves distally, then the tooth is located on the

lingual or palatal side. Accordingly, if the impactedcanine is located buccally, the crown of the tooth moves

mesially3

Extra oral radiographs:

(a) Frontal and lateral cephalograms can sometimes aid

in the determination of the position of the impactedcanine, particularly its relationship to other facial

structures (e.g., the maxillary sinus and the floor of thenose).

(b) Panoramic films are also used to localize impactedteeth in all three planes of space, much the same as

with two periapical films in the tube-shift method, withthe understanding that the source of radiation comes

from behind the patient; thus the movements arereversed for position.

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Cone-beam computed tomography (CBCT):

Cone-beam computed tomography (CBCT) can identifyand locate the position of impacted canines accurately.

By using this imaging technique, dentists also can assessany damage to the roots of adjacent teeth and the

amount of bone surrounding each tooth.

In a study, Liu and colleagues7used CBCT to evaluatevariations in location of impacted maxillary canines.They found that the position of impacted maxillary

canines varies greatly. Reports of maxillary canineimpactions vary considerably in orientation, and CBCT

provides information to dentists so that they canproperly manage impacted canines surgically andorthodontically.

However, increased cost, time, radiation exposure and

medicolegal issues associated with using CBCT, limit itsroutine use

8.

SEQUELE OF IMPACTIONS:

Shafers et al suggested that the following sequel mighbe associated with canine impaction.

-Labial or lingual mal-positioning of impacted tooth,-Migration of neighboring teeth and resultant loss o

arch length,-internal resorption,

-Dentigerous cyst formation,

-External root resorption of the impacted as well asneighboring teeth,-Infections particularly associated with partiaeruptions,

-Referred pain,-Late resorption of the unerupted canine itself,

-Loss of vitality of the incisors can occur,-Poor esthetics associated with primary canines.

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DIFFERENT TREATMENT MODALITIES

Each patient with an impacted canine must undergo a

comprehensive evaluation of the malocclusion. Theclinician should then consider the various treatmen

options available for the patient, including thefollowing:

(a) No treatment if the patient does not desire it. Insuch a case, the clinician should periodically evaluate

the impacted tooth for any pathologic changes. Itshould be remembered that the long-term prognosis fo

retaining the deciduous canine is poor, regardless of itspresent root length and the esthetic acceptability of its

crown. This is because, in most cases, the root wileventually resorb and the deciduous canine will have to

be extracted .

(b) Auto transplantation of the canine.

(c) Extraction of the impacted canine and movement o

a first premolar in its position .

(d) Extraction of the canine and posterior segmenta

osteotomy to move the buccal segment mesially toclose the residual space.

(e) Prosthetic replacement of the canine.

(f) Surgical exposure of the canine and orthodontic

treatment to bring the tooth into the line of occlusionThis is obviously the most desirable approach.

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MANAGEMENT OF IMPACTED MAXILLARY CANINES:

The most desirable approach for managing the

impacted maxillary canine is early diagnosis andinterception of the potential impaction. In absence of

prevention, orthodontic treatment and surgicaexposure should be conducted.

Kokich reported three methods for uncovering animpacted maxillary canine

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Table 1:Classification Of Impacted Canine

Group Proximity of line of arch Position in maxilla

1 Close Low

2 Close Forward low & mesial to lateral incisor

root

3 Close High

4 Distinct High

5 Canine root apex is mesial to lateral incisor & distal to 1st

premolar

6 Erupting in the line of arch in place of it, & resorption root

of incisors.

Table 2:Different Surgical Techniques For Labially And Palatally Impacted Canines

Impaction Exposure

technique

Indications of

surgical

technique

Indication of

orthodontic

treatment

Advantages Disadvantages

Labial Gingivectomy Canine cusp is

coronal to the

mucogingival

junction adequateamount of

keratinized

gingival is present.

Canine is not

covered by bone

Orthodontic traction

is not required as the

tooth tends to erupt

normally

Easy to perform

Less traumatic

Used only

occasionally

Loss of attached

gingivaPossible damage to

PDL

Potential gingival

overgrowth at

surgical site.

Apically

repositioned flap

Canine crown is

apical to MGJ, the

amount of attached

gingiva is

minimized (used

when less than 3

mm of attached

gingival is present)

2-3 week after

surgery

Commonly used:

Conservation of

keratinized gingival

Increased risk of

gingival recession,

Height differences

Relapse

More traumatic

Closed eruption Tooth is in the

center of alveolus

Crown is apical to

MGJ

1-2 weeks after

surgery

Greater esthetics

Ease of tooth

movement

Pt discomfort

Possible

mucogingival

problems

Palatal Closed flap Canine is located

near the lateral and

central incisors,

horizontally

positioned and

higher in roof of

the mouth

1-2 weeks after

surgery

Immediate

orthodontic traction

can be applied

Bone recession,

root resorption,

longer operation

time

Repeat surgeries as

a result of failure to

erupt,

Bond failure due toblood or saliva

contamination

Open eruption Late mixed

dentition

Permanent

dentition

When eruption is at

level of occlusal

plane

Improved bone levels

Little or no root

resorption

Fewer exposure,

shorter over all

treatment, less time,

good oral hygiene

during treatment

Failure to erupt

may extend total

treatment time that

is unable to

influence the path

of eruption

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Open window

eruption

Canine is located

near the lateral and

central incisor,

horizontally

positioned and

higher in the roof

of mouth

1-2 weeks after

removal of pack

Visualisation of

crown better control

of direction of tooth

movement

avoidance of

moving the

impacted tooth in to

the roots of adjacent

teeth

Gingival

overgrowth at

incisor site

Subjected to

infection.

Pt discomfort

Tunnel traction Presence ofprimary canine in

mouth

The suture isremoved 10 days

after surgery &

traction phase begin

Reduced amount ofbone around

impacted tooth. The

permanent canine is

guided into

permanent canine

socket site

Requires thepresence of primary

canine

Table 3:Orthodontic Technique Used To Treat And Manage Impacted Maxillary Canines

STUDY TECHNIQUE USED ADVANTAGES DISADVANTAGES

Fischer and

Colleagues10

Cantilever system. Predictable tooth movement;

low load or

deflection; less frequent

reactivations

Potential side effects

should be identified on

the anchor tooth

Park and Collegues11

Temporary

anchorage devices.

(TADs)

Could provide absolute

anchorage for tooth

movement; bonding of

orthodontic brackets can

be delayed until the

canine is aligned

Does not produce root

movement; insertion and

removal of TADs

Kim and

Colleagues12

Double-archwire

Mechanics.

Minimizes root

resorption of the lateralincisors; allows horizontal

tooth movement

Requires laboratory

procedure; patientdiscomfort

Schubert13 Easy-Way-Coil

(EWC) system.

Constant application of

force; a long activation

distance; simple

reactivation

Loosening of EWC

attachment; infectious

reactions in oral mucosa

Tausche and

Harzer14

Auxiliary arm from

transpalatal arch.

Simple design; simple

Reactivation

Requires laboratory procedure;

tends to break easily

Kornhauser and

Colleagues15

Auxiliary spring No laboratory pro -cedure;

measured forces;

complete eruption control;

lack of damage toadjacent teeth

Requires extra chair time

to bend the spring

Kalra16 K-9 spring Simple design; Easy to

fabricate and activate;

continuous force

Side effects on the

posterior teeth

Bishara17 The ballista spring is a

0.014, 0.016, or 0.018 inch

round wire, which

accumulates its

energy by being twisted on

its long axis.

Control the direction of the

eruption of the impacted

tooth. Easily inserted and

ligated. Provides a

continuous force that is well

controlled.

Molars and premolars are

affected

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1.

Gingivectomy2.

Apically repositioned flap3.

Closed eruption technique.9

SURGICAL TECHNIQUES:3

Table 2: Shows different surgical techniques forlingually and palatally impacted canines.

ORTHODONTIC ATTACHMENT :

To be in the position of being able to influence thefuture development of an impacted tooth, its necessary

to place some form of attachment on the tooth.

Different methods of attachment to the impactedtooth have been suggested, including crowns, wireligatures, chain links, bands, and directly bonded

brackets.

It is strongly recommended that the surgical exposureof the impacted tooth be conservative to allow for the

placement of a bonded bracket or button.

ORTHODONTIC TECHNIQUES:

Table 3: Shows orthodontic technique used to treat and

manage impacted maxillary canines

RETENTION CONSIDERATIONS:To minimize or prevent rotational relapse, a fiberotomyor a bonded fixed retainer may need to be considered

by the clinician after completion of the desiredmovements and sometimes before the appliances are

removed. Clark suggested that, after the alignment ofpalatally impacted canines, lingual drift can be

prevented by removal of a "halfmoon-shaped wedge"of tissue from the lingual aspect of the canine.

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Conclusion

Management of the severely impacted canine is often acomplex undertaking and requires the joint expertise ofa number of clinicians. It is important that these

clinicians communicate with each other to provide thepatient with an optimal treatment plan based on

scientific rational.

When patients are evaluated and treated properly,clinicians can reduce the frequency of ectopic eruption

and subsequent impaction of the maxillary canine. Thesimplest interceptive procedure that can be used to

prevent impaction of permanent canines is the timelyextraction of the primary canines. This procedureusually allows the permanent canines to become

upright and erupt properly into the dental arch,provided sufficient space is available to accommodate

them.Various surgical and orthodontic techniques may be

used to recover impacted maxillary canines. Careful

selection of surgical and orthodontic techniques isessential for the successful alignment of impactedmaxillary canines.

References

1. Eve T. and Winfried H. Treatment of a patient withClass II malocclusion, impacted maxillary canine with a

dilacerated root, and peg-shaped lateral incisors. Am JOrthod Dentofacial Orthop 2008;133:762-70

2. Patrick F,Mcsherry. Ectopic maxillary canine :areview. BJO 1998; vol25;No3;209-216

3. Bedoya MM and Park JH.A review of the diagnosis

and management of impacted maxillary canines. J Am

Dent Assoc 2009;140;1485-1493

4. Becker A. The Orthodontic Treatment of Impacted

Teeth. 2nd ed. Abingdon, Oxon, England: InformaHealthcare; 2007:1-228.

5. Ericson S, Kurol J. Resorption of maxillary lateraincisors causedby ectopic eruption of the canines: a

clinical and radiographic analysisof predisposing factorsAm J Orthod Dentofacial Orthop 1988;94(6):503-513.

6. Bishara SE. Impacted maxillary canines: a review. AmJ Orthod Dentofacial Orthop 1992;101:159-71.

7. Liu DG, Zhang WL, Zhang ZY, Wu YT, Ma XC

Localization of impacted maxillary canines andobservation of adjacent incisor resorption with cone

beam computed tomography. Oral Surg Oral Med OraPathol Oral Radiol Endod 2008;105(1):91-98.

8. Elefteriadis JN, Athanasiou AE. Evaluation ofimpacted canines by means of computerized

tomography. Int J Adult Orthodon Orthognath Surg1996;11(3):257-264.

9. Kokich VG Surgical and orthodontic management o

impacted maxillary canines Am J Orthod DentofaciaOrthop 2004;126:278-83.

10. Fischer TJ, Ziegler F, Lundberg C. Cantileve

mechanics for treatment of impacted canines. J ClinOrthod 2000;34(11): 647-650.

11. Park HS, Kwon OW, Sung JH. Micro-implantanchorage for forced eruption of impacted canines.

Clin Orthod 2004;38(5):297-302.

12. Kim SH, Choo H, Hwang YS, Chung KR. Doublearchwire mechanics using temporary anchorage devicesto relocate ectopically impacted maxillary canines

World J Orthod 2008;9(3):255-266.

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bout the uthors

1. Dr.Prasad KondaReader,Dept of Orthodontics and DentofacialOrthopedics,Al Badar Dental College and Hospital,Gulbarga, Karnataka.

2 Dr. Mohammad Urooj AhmedPG student,Dept of Orthodontics and DentofacialOrthopedics,Al Badar Dental College and Hospital,Gulbarga, Karnataka.

3 Dr. Syed Mohammad AliPG student,Dept of Orthodontics and Dentofacial

Orthopedics,Al Badar Dental College and Hospital,Gulbarga, Karnataka.

4 Dr. Amaranth KondaMDS,Oral surgeon,Hyderabad.

Address for Correspondence

Dr.Prasad Konda

Reader,Dept of Orthodontics and Dentofacial Orthopedics,

Al Badar Dental College and Hospital, Gulbarga,

Karnataka.

[email protected]

ph: (+91) 9440662988

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DECEMBER, 2011


13. Schubert M. A new technique for forced eruption of

impacted teeth. J Clin Orthod 2008;42(3):175-179.

14. Tausche E, Harzer W. Treatment of a patient with

Class II malocclusion, impacted maxillary canine with adilacerated root, and peg-shaped lateral incisors. Am J

Orthod Dentofacial Orthop2008;133(5):762770.

15. Kornhauser S, Abed Y, Harari D, Becker A. The

resolution of palatally impacted canines using palatal-occlusal force from a buccal auxiliary. Am J OrthodDentofacial Orthop 1996;110(5):528-534.

16. Kalra V. The K-9 spring for alignment of impactedcanines. J Clin Orthod 2000;34(10):606-610

17.Jacoby H the ballista spring system for impacted

teeth.Am J Orthodofacial Orthop 1979;75(2):143-151.

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Impacted Max Canines