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Impacted Teeth
Guide
Dr. Chandralekha B
Prof & HOD
Dept Of Orthodontics
And Dentofacial Orthopedics
By :
Dr. Nilofer Vevai
Contents
Introduction.
Impaction..
Normal development of anteriors
Theories Regarding Impaction of teeth.
Radiographic Diagnosis.
Classification of Impacted Canines .
Surgical Exposure Of Impacted Teeth
Treatment Options.
Impacted Canines And Incisor root resorption
Maxillary Central Incisors
Traumatic Impaction & Impaction Of Single Teeth.
Conclusion
Introduction
A perfect set of 32 is something desired by
all.
However it is not uncommon to find a case
Class 2 div 2.
Impacted teeth in anterior region.
A Brief recap
Nollas Stages Of
Tooth Development
According to
Macdonald a tooth
erupts when the
root is 2/3 formed.
According to Gron a
tooth erupts when
the root is
developed.
Impaction
Terms which are important :
- Dental Age
- Chronological Age
- Morphological Age.
dental age
is a wrong concept.
A tooth may have delayed eruption due to
An Impacted tooth:
A disorder in which a tooth is so crowded in
its socket that it cannot erupt normally.
An impacted tooth is any tooth that is
Normal Development
A periapical view of a 5 yr old child would give
Causes Of Impaction
Inadequate resorption of deciduous root.
An abnormal eruptive path.
A supernumerary tooth.
Dental Crowding.
Disturbance in the eruption mechanism of
teeth.
Thickened ligament post trauma .
Early loss of deciduous tooth.
Impactions due to space loss.
Secondary (Generalised )
Trauma :
Contentious issue
Orthod 1993;63;99-109
Primary tooth germ displacement
elements:
1. Normal Eruption:
2. First Stage Impaction: Occurs when there
is absence of lateral incisors or lateral
incisors/peg shaped laterals due to this
there is lack of guidance and the canines
shift palatally or are horizontally impacted.
3. First Stage impaction with Secondary
correction: A corrective process of the
vertical maxillary process redirecting the
canine in a more favorable downward path.
May or may not reach its desired position
spontaneously.
Miller :
Diagnosis
Importance..
An undiagnosed & severely resorbed tooth
Clinical Examination :
Inspection
Palpation
Radiodiagnosis :
Radio diagnosis:
1. IOPAR
2. Lateral Shift Technique
3. Vertical Shift Technique
4. Orthopantamographs
5. Vertical Shift + Orthopantamographs
6. Orthopantamographs + Lateral Cephalograms
7. Occlusal Radiographs.
8. Tangential View
9. Postero-Antero Cephalogram
10. CT & CBCT
Occlusal Radiographs :
Methodology.
In the lower canine premolar area the
occlusal view is a true occlusal view and
should depict all the posterior standing teeth
in cross section.
Should depict the buccolingual placement of
structures.
True occlusal view of the anterior area of the
mandibular arch 110 deg
True occlusal view of the molar area 90 deg to
the horizontal + 15 deg medial tilt of the tooth
.
In the maxilla we
have :
True Vertex Occlusal.
Anterior maxillary
occlusal
Periapical view.
True vertex occlusal is
the best but clarity
low.
A high mesially placed
canine seems similar
to a high palatally
It is of 2 types :
2 IOPARs
Lateral Cephalogram And OPG
Vertical parallax:
Tangential View :
CT Scan
CBCT
vol 124
For every unit of change in sector, the odds
of indication
of impaction increase by a factor
Probability of canine impaction based
of 8.7.
on
sector and angle measurements
Sector
I
II
III
IV
Angle (deg)
4054
0.11
0.53
0.91
0.99
5569
0.08
0.43
0.87
considered
0.98
treatment
Exposure Only with spontaneous eruption.
Exposure with pack.
The Surgical Elimination Of Pathology
Soft Tissue Lesions
Hard Tissue Obstruction
- Primary
- Secondary
2 Basic approaches to
surgically exposing
impacted teeth:
The Open Eruption
Technique
a) The Window Technique
b) The apically
repositioned flap.
First done for a
labially impacted
canine by Vanarsdall &
Corn.
Orthodontic Management
Creation Of An Anchor Unit:
Modification must be made for anchor unit.
A fully multi-bracketed appliance should
normally be placed & the entire dentition
treated through the stages of leveling &
opening of adequate space in the arch for
impacted tooth.
Devices to help:
Lasso wires
Threaded pins.
Orthodontic bands.
Standard Orthodontic Bracket.
Simple Eyelet.
Elastic ties And modules.
Magnets.
Lasso wires:
It is twisted lightly around the
neck of the canine.
Disadvantages:
This results in irritation of the
gingiva
Prevents reattachments of
the healing tissues in area of
CEJ (cemento-enamel junction).
May produce areas of
external resorption & ankylosis
in areas of CEJ.
Threaded Pins:
Provide the attachment for an impacted tooth.
Disadvantages:
- Dentally invasive.
- Requires a subsequent restoration.
- Difficult to place along the long axis of the
tooth because of smaller surgical exposure.
- The drilled hole may inadvertently enter the
pulp(unerupted teeth may have large pulp
chambers).
Rarely used.
Orthodontic bands:
They largely replace the
Lasso wires & threaded pins.
Advantage:
They are compatible with the health of
periodontal tissues.
Disadvantage:
-
Standard orthodontic
brackets:
Any edge-wise ,
Disadvantages:
- As the bracket base is wide, it is difficult to
adapt to any other tooth surface except for the buccal
surface.
- The brackets shear bulk creates irritation as
the tooth is drawn the soft tissues.
- Ligature wire or elastic thread tied to bring the
impacted tooth into arch.
A Simple Eyelet
- An eyelet welded to band material with a mesh
backing is soft & easy to contour making its adaptation to
bonding surface more accurate which makes for superior
retentive properties.
- Because of small size they
can be placed in more awkwardly placed teeth.
- It is less irritating to the surrounding tissues.
Disadvantages
- Tends to loosen
- High degree of force decay
Magnets :
Rare earth magnets .
Made Of Lanthanum alloys.
Forces generated along the line of magnetic plane.
They can corrode hence covered with a coating of
parylene.
One Magnet placed on the appliance. One on the
displaced tooth.
Disadvantage: Distance.
impacted
a) Bucally.
b) Palatally.
Classification Of Palatally
Impacted Canines :
Transverse Relationship:
to the tooth .
High
Low
Group V :
1.
Group I
Transverse : Close to the arch.
Position
: Low
Prognosis : Good
Most common form of palatal impaction.
Root movement rarely necessary.
Surgery :
minimally invasive.
Removal of eggshell thin bone.
Complications :
Rotation:
a) Auxiliary Niti Wire.
b) Slingshot elastic.
Mesial Crown
displacement :
Palatal root
displacement :
Group II
Transverse : Close
Height
: Forward low
and mesial to the lateral
incisor root.
Root apex correct position .
Canine crown tilted mesially
in close association with
the palatal aspect of the
root of the lateral incisor.
Surgery:
Prevention :
a)
b)
c)
Group II Complications :
Rotation.
Palatally displaced root.
Thick And Resistant Palatal Tissue.
Risk Of Exposing and Damaging roots of
adjacent teeth.
Group III
Transverse : Close
Vertical :
High
Treatment Strategy :
Buccal Approach:
The Apically repositioned
flap.
Full Flap reflection &
Partial Replacement.
The tunnel Approach.
Palatal Approach
Two Stage Traction
Group IV
Transverse : Distant
Height
: High
The crowns of impacted canines in this case are placed
medially and may even cross the mid-palatal suture.
Normal Positioning of root apex.
Treatment :
Difficult Mechanics.
High relapse rates with the canines being in
Group 5
relationship.
Complications:
Root dehiscence.
Group VI
Erupting in the line of the arch In place of
and resorbing the roots of the lateral incisors.
Ballista Spring :
Ballista : An Ancient And Heavy Engine Of
canines.
Aesthetic.
Diameter
Force
0.016
60-100g of force
0.018
120-150 g
Best to start with 0.016 inch wire and proceed to 0.018 inch wire after 2 months
and if required force increased by using double wires.
Advantages :
No impinging of roots.
Ease of operating and changing the spring.
Aesthetic.
Minimal trauma during surgery.
Can also be used for impacted upper incisors,
vestibular upper and lower canines and
premolars and molars.
decay of forces.
Effectiveness high.
TMA Advantageous.
b. Slip the hook through the link of elastomeric chain (from the impacted canine)
nearest the gingiva,
and twist it a couple of times.
c. Activate the spring, and wrap several links around a stable rectangular
archwire with an occlusal step.
Be sure to leave a "tail" of chain for reactivation.
d. At the next visit, unwrap, reactivate, and rewrap the spring
Vertical Eruptive
Intermaxillary Force
A small area of the crown
needs to be surgically
exposed for direct bonding
of a loop-button with
attached Monkey Hook.
The loop should be
positioned parallel to the
roots of the adjacent teeth
to allow subsequent
attachment of more hooks
for production of a variety
of forces.
Mandibular Anchorage.
Ajodo Vol 115, No. 3 , 255-259.
A mandibular impression is made to fabricate a
mandibular lingual arch with o.036 mm SS wire to be
soldered from the first molar band on one side to the
first molar band on the other side.
The mandibular lingual arch is cemented in place after
fabrication.
After adequate space is opened, it is maintained with a
closed/open coil spring.
Eruption of Impacted
Canines with an
Australian Helical
Archwire Christine
Hauser,Yon H. Lai, Elina
Karamaliki. Volume 34 :
Number 09 : Pages (538541) 2000
O.o16 Australian Archwire
special plus, Straight length.
The force should not
exceed 200g.
Activation by twisting the
steel ligature wire every two
weeks
ERUPTION OF AN
Because of the
angulation a distally
directed force was
applied.
Latero incisal + Distal
force.
Roth 0.022 Prescription
placed .
Rapid Prototyping
3D CT images are seen as 2D on film and
computer screen.
Rapid prototyping makes a 3D model with/
without the help of CT Images.
It is capable of reproducing complex designs that
are unthinkable by any other method.
Eg. it can reproduce the maxilla with the maxillary
sinus and, inside this cavity, a third molar that
might have inadvertently been pushed into the
cavity during the removal of a tooth.
Maxillary Central
Incisors
extremely rare
Patients appearance is abnormal and
reminiscent of a Dental Cyclops.
Associated with :
Absence of philtrum.
Absence of dental midline.
Square anatomy of incisor .
Indeterminate Right/left
designation.
Etiology
Trauma
Displacement
Displacement may cause normally placed adjacent
Of tooth bud itself. teeth to cause an obstruction to eruption.
Traumatic Causes:
Treatment Time :
followed in Europe
a) Prepare space.
b) Elimination of cause eg. Supernumerary
tooth.
Results : Quite disappointing
a) 54-78% cases non eruption.
b) Delay in Eruption.
c) Alignment
mechanotherapy :
Mills :
Exposure of the crown of the permanent tooth
during the procedure to remove the
supernumerary tooth, since periodontal result
of the final result is compromised.
Also :
a) Spontaneous eruption chances are high.
b) Loss of labial bony plate.
c) Poor gingival margin and less attached
gingiva
d) Gingival level discrepancy.
Treatment Protocol:
Retention
Group 4 and 5 cases require maximum
Becker et al:
Incidence of rotations and spacings
1. Impacted side- 17.4%
2. Control side 8.7%
Ideal alignment on control side is twice as often
as the impacted side.
1. Fiberotomy
2. Bonded fixed retainer
This can be done during or after the treatment.
It has been suggested for palatally impacted canine: Lingual
drifting can be prevented by removal of half-moonshaped wedge of tissue from lingual aspect of canine.
long-term
esthetic results can be achieved by treating
impacted
maxillary incisors with a closed-eruption
orthodontic
surgical technique.
Conclusion
A versatile chapter in orthodontics showing
References
Robert L. Vanarsdall, and Herman Corn.
13. Two Arch Wire Technique for Alignment Of Impacted Teeth: Samuels
& Rudge JcoVol 31 No. 3 Pg 183-187 1997