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Prasad Konda,1 Mohammad Urooj Ahmed,2 Syed Mohammad Ali,3 Amaranth Konda4
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 be
erupted 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.
Introduction
Maxillary canine are important teeth in terms of
esthetics, functional occlusion & arch development.The
likelihood of their failing to erupt or becoming impacted
may range between 1 & 3 %,1which shows its 2nd most
commonly impacted tooth after the third molars. It is
twice as common in females as it is in males. Incidence
of 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%.
Keywords:
ETIOLOGY
There is some incidence that patients with Angles class
II 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 primary
Several methods have been used to radiographically
canine.
evaluate impacted maxillary canines. These methods
4) Ankylosis of the permanent canine.
include intraoral techniques (occlusal and periapical
5) Cyst or neoplasm.
projections) and extraoral techniques (panoramic,
6) Dilaceration of the root.
posteroanterior or lateral cephalometric radiographs).6
7) Absence of the maxillary lateral incisor.
8) Variation in root size of the lateral incisor.
IJCD DECEMBER,
2011 2(6)
65 9) Variation in timing of lateral incisor
root
2011 Int. Journal of Contemporary
Dentistry
Occlusal
radiographs:
formation.
REVIEW
Occlusal radiographs:
SEQUELE OF IMPACTIONS:
Periapical radiographs:
Traditional method of locating impacted teeth,
specifically maxillary canines, has been the use of a twodimensional technique with periapical radiographs,
known as the buccal object rule. This technique consists
of taking two periapical radiographs at different
mesiodistal angulations and using the same-lingualopposite buccal (SLOB) rule to determine the tooths
buccolingual position. The radiographic interpretation
of the SLOB rule is if, when obtaining the second
radiograph, the clinician moves the x-ray tube in a distal
direction, and on the radiograph the tooth in question
also moves distally, then the tooth is located on the
lingual or palatal side. Accordingly, if the impacted
canine 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 impacted
canine, particularly its relationship to other facial
structures (e.g., the maxillary sinus and the floor of the
nose).
(b) Panoramic films are also used to localize impacted
teeth in all three planes of space, much the same as
with two periapical films in the tube-shift method, with
the understanding that the source of radiation comes
from behind the patient; thus the movements are
reversed for position.5
Cone-beam computed tomography (CBCT):
Cone-beam computed tomography (CBCT) can identify
and locate the position of impacted canines accurately.
By using this imaging technique, dentists also can assess
any damage to the roots of adjacent teeth and the
amount of bone surrounding each tooth.
7
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REVIEW
Group
Position in maxilla
Close
Low
Close
3
4
Close
Distinct
Impaction
Labial
Palatal
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Table 2: Different Surgical Techniques For Labially And Palatally Impacted Canines
Exposure
Indications of
Indication of
Advantages
Disadvantages
technique
surgical
orthodontic
technique
treatment
Gingivectomy
Canine cusp is
Orthodontic traction
Easy to perform
Used only
coronal to the
is not required as the
occasionally
mucogingival
tooth tends to erupt
Less traumatic
Loss of attached
junction adequate
normally
gingiva
amount of
Possible damage to
keratinized
PDL
gingival is present.
Potential gingival
Canine is not
overgrowth at
covered by bone
surgical site.
Apically
Canine crown is
2-3 week after
Commonly used:
Increased risk of
repositioned flap
apical to MGJ, the
surgery
gingival recession,
amount of attached
Conservation of
Height differences
gingiva is
keratinized gingival
Relapse
minimized (used
More traumatic
when less than 3
mm of attached
gingival is present)
Closed eruption
Tooth is in the
1-2 weeks after
Greater esthetics
Pt discomfort
center of alveolus
surgery
Ease of tooth
Possible
Crown is apical to
movement
mucogingival
MGJ
problems
Closed flap
Canine is located
1-2 weeks after
Immediate
Bone recession,
near the lateral and
surgery
orthodontic traction
root resorption,
central incisors,
can be applied
longer operation
horizontally
time
positioned and
Repeat surgeries as
higher in roof of
a result of failure to
the mouth
erupt,
Bond failure due to
blood or saliva
contamination
Open eruption
Late mixed
When eruption is at Improved bone levels
Failure to erupt
dentition
level of occlusal
Little or no root
may extend total
Permanent
plane
resorption
treatment time that
dentition
Fewer exposure,
is unable to
shorter over all
influence the path
treatment, less time,
of eruption
good oral hygiene
during treatment
REVIEW
Open window
eruption
Tunnel traction
Canine is located
near the lateral and
central incisor,
horizontally
positioned and
higher in the roof
of mouth
Presence of
primary canine in
mouth
The suture is
removed 10 days
after surgery &
traction phase begin
Visualisation of
crown better control
of direction of tooth
movement
avoidance of
moving the
impacted tooth in to
the roots of adjacent
teeth
Reduced amount of
bone around
impacted tooth. The
permanent canine is
guided into
permanent canine
socket site
Gingival
overgrowth at
incisor site
Subjected to
infection.
Pt discomfort
Requires the
presence 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.
Temporary
anchorage devices.
(TADs)
Kim and
Colleagues12
Double-archwire
Mechanics.
Requires laboratory
procedure; patient
discomfort
Schubert13
Easy-Way-Coil
(EWC) system.
Tausche and
Harzer14
Minimizes root
resorption of the lateral
incisors; allows horizontal
tooth movement
Constant application of
force; a long activation
distance; simple
reactivation
Simple design; simple
Reactivation
Kornhauser and
Colleagues15
Auxiliary spring
Kalra16
Bishara17
Loosening of EWC
attachment; infectious
reactions in oral mucosa
Requires laboratory procedure;
tends to break easily
Requires extra chair time
to bend the spring
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REVIEW
1. Gingivectomy
2. Apically repositioned flap
3. Closed eruption technique. 9
SURGICAL TECHNIQUES:3
References
1. Eve T. and Winfried H. Treatment of a patient with
Class II malocclusion, impacted maxillary canine with a
dilacerated root, and peg-shaped lateral incisors. Am J
Orthod Dentofacial Orthop 2008;133:762-70
2. Patrick F,Mcsherry. Ectopic maxillary canine :a
review. BJO 1998; vol25;No3;209-216
ORTHODONTIC TECHNIQUES:
Conclusion
Management of the severely impacted canine is often a
complex undertaking and requires the joint expertise of
a number of clinicians. It is important that these
clinicians communicate with each other to provide the
patient 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. The
simplest interceptive procedure that can be used to
prevent impaction of permanent canines is the timely
extraction of the primary canines. This procedure
usually 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
69
REVIEW
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 a
dilacerated 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 palatalocclusal force from a buccal auxiliary. Am J Orthod
Dentofacial Orthop 1996;110(5):528-534.
16. Kalra V. The K-9 spring for alignment of impacted
canines. 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.
Reader,
Dept of Orthodontics and Dentofacial
Orthopedics,
Al Badar Dental College and Hospital,
Gulbarga, Karnataka.
PG student,
Dept of Orthodontics and Dentofacial
Orthopedics,
Al Badar Dental College and Hospital,
Gulbarga, Karnataka.
PG student,
Dept of Orthodontics and Dentofacial
Orthopedics,
Al Badar Dental College and Hospital,
Gulbarga, Karnataka.
70