The Diagnosis and Management of Impacted Maxillary Canines

Eyas Abuhijleh BDS, PhD

Abstract

Specialist Orthodontist and

Assistant Professor, Tawam Hospital, Dental Center Al Ain - UAE

eabuhijleh@tawamhospital.ae

General dental practitioners and orthodontists will commonly encounter this problem (impacted maxillary canines) and need to be fully aware of managing this situation. Failure to diagnose and manage the ectopic upper canine efficiently can result in more complex remedial treatment becoming necessary, which would be costly in terms of clinical time for both the practitioner and patient. There is also the risk of damage to the adjacent teeth which may lead to their loss and eventually to costly litigation claims. The aims of this article are to: 1. Present evidence based recommendations to assist Dental Clinicians (Dental Surgeon, Orthodontist, Pediatric Dental Specialist, Oral Surgeon) in the timely detection and management of the ectopic maxillary canine. 2. Detect and manage impacted maxillary canines early. 3. Learn the complications associated with an impacted maxillary canine.

Dalal Masri BDS

General Dental Practitioner

Tawam Hospital, Dental Center, Al Ain - UAE dmasri@tawamhospital.ae

Keywords: Impacted canines, Surgical exposure, Orthodontic treatment.

Nadia Farawana MDSc

German Board of

Introduction

Orthodontics, Tawam Hospital Dental Center, Al Ain - UAE

nfarawana@tawamhospital.ae

Mariam Nmari DDS

Canines play a vital role in facial appearance, dental esthetics, arch development and functional occlusion. Canine impaction is a common occurrence, because it develops deep within the maxilla and has the longest path to travel compared with any other tooth in the oral cavity. It is only with interdisciplinary care of general dentists and specialists by early detection, timely interception, and well-managed surgical and orthodontic treatment that impacted maxillary canines can be erupted and guided to an appropriate location in the dental arch.2

General Dental Practitioner

Yas Medical Center Al Buraimi - Oman mariam.nmari@yahoo.com

Diagnosis
Clinical signs Over-retention of the primary canine.2 Delayed eruption of the permanent canine.2 Absence of a labial bulge in a 10- or 11- year-old patient.2,3 Presence of a palatal bulge.2 Distal crown tipping of the lateral incisor.2,3 Radiographic investigation The examination usually involves taking two radiographs and using the principle of horizontal or vertical parallax, the horizontal parallax technique being the more reliable in localizing impacted canines:1 1. Horizontal parallax involves taking either: Two periapicals with different angulations and follow the (SLOB = same lingual opposite buccal) rule1-4 or An upper occlusal and a periapical.

| 40 | Smile Dental Journal | Volume 6, Issue 4 - 2011

Flow chart of the sequence of management of impacted maxillary canines Clinical Examination at Age 10 Absence of Buccal Bulge and Presence of Palatal Bulge Radiographic Localization Line of Arch Monitor Eruption of Canine / Space Creation
YES

Buccally Ectopic

Palatally Ectopic

Extract Deciduous Canines / Space Creation Canine not Erupting in 1 year Radiographic Localization: Beneficial Change in Position
NO

Monitor Eruption of Canine

Canine Buccally or Palatally Impacted Surgical Exposure & Orthodontic Alignment

NO

Surgical Removal or Auto-Transplantation

NO

No Treatment and continuous Monitoring

2. Vertical parallax involves taking either: An upper occlusal (7075) and an orthopantomogram (OPG) or A periapical and an orthopantomogram (OPG).1,4 3. Advanced three-dimensional (3D) imaging techniques: Cone-beam computed tomography (CBCT)1-4

Either non-vertical or no resorption of the deciduous

canine root.3 Canine crown overlapping adjacent incisor roots.3 Resorption of adjacent incisor roots.2,3 Magnification of the permanent maxillary canine crown on a panoramic radiograph.3

Radiographic features

Management

Interceptive treatment by extraction of the deciduous canine The patient should be aged between 10-13 years.1,4 Better results are achieved in the absence of crowding.1,4 Position of the canine in the dental arch and in its relationship to the adjacent lateral decides the outcome of the interceptive treatment.1,4 The need to maintain space (or even create additional space) requires consideration.1,4 If radiographic examination reveals no improvement in the impacted canines position 12 months after extraction of the deciduous canine, alternative treatment should be considered.1,4

Surgical exposure and orthodontic alignment The patient should be well motivated and willing to wear fixed orthodontic appliances.1,4 The patient should have good medical and oral health, and maintain proper oral hygiene.1,4 The patient is considered to be unsuitable for interceptive treatment.1,4 The degree of malposition of the impacted canine should not be too great to preclude orthodontic alignment.1,4 Exposure and alignment of the impacted canine is indicated in cases when severe root resorption of an incisor tooth has occurred necessitating its extraction.4 The optimal time for surgical exposure and orthodontic alignment is during adolescence.4 Open communication between the orthodontist and oral surgeon is essential for the choice of appropriate surgical techniques. Careful selection of surgical and orthodontic techniques is essential for the successful alignment of impacted maxillary canines. Measured orthodontic forces in a favorable direction leads to successful alignment. Surgical removal of the palatally impacted permanent canine This treatment option should be considered if the patient declines active treatment and/or is happy with their dental appearance.1,4 Surgical removal of the impacted canine should be considered if there is radiographic evidence of early root resorption of the adjacent incisor.1,4

Smile Dental Journal | Volume 6, Issue 4 - 2011| 41 |

 The best results are achieved if there is good contact

between the lateral incisor and first premolar.1,4 It is indicated in patients willing to undergo orthodontic treatment to substitute the first premolar for the canine.1,4 The possible risk of damaging the roots of adjacent teeth during the surgical removal of the impacted canine should be assessed and discussed with the patient.1

Auto-transplantation This treatment option should be considered if the patient is unwilling to wear orthodontic appliances.1,4 Transplantation is indicated where interceptive extraction of the deciduous canine has failed or is unsuitable, and exposure and alignment of the impacted canine is not possible.1,4 There should be adequate space available for the canine and sufficient alveolar bone to accept the transplanted tooth.1,4 The prognosis should be good if the canine to be transplanted shows no evidence of ankylosis.1 The best results are achieved if the impacted canine can be removed atraumatically.1,4 Depending on the stage of root formation (more than 3/4 of the root formed) the transplanted canine may require root canal therapy to be commenced within ten days following transplantation.1 No treatment and continuous monitoring The patient does not want treatment or is happy with their dental appearance.1,4 There should be no evidence of root resorption of adjacent teeth or other pathology.1 There should be good contact between the lateral incisor and first premolar or the deciduous canine should have a good prognosis.1,4 Severely displaced palatally impacted canines with no evidence of pathology may be left in-situ, particularly if the canine is remote from the dentition.1 Impacted canines left in-situ necessitate radiographic monitoring to check for cystic changes or root resorption.1,4 Regular review to ensure that the impacted canine does not pose any risk to the adjacent structures.1,4

References

1. Management of the palatally ectopic maxillary canine, Husain J. et al., Publication of the Royal College of Surgeons, Faculty of Dental Surgery, online publication, updated March 2010. 2. A review of the diagnosis and management of impacted maxillary canines, Bedoya M. and Park J., The Journal of the American Dental association (JADA). 2009;140:12:1485-93. 3. Managing the maxillary canine: 1. Diagnosis, localization and interceptive treatment, McIntyre G., Orthodontic Update, January 2008;1:7-15. 4. Clinical Practice Guidelines, The management of the palatally ectopic canine, Ministry of Health Malaysia, September 2004.