Management Of

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

wherein individuals come forth with the sole

complaint of not having the normal number of
teeth in the oral cavity.

 Mainly this situation arises when there is

this lack in the anterior area & can be a great

source of embarrassment to the patient
who may feel socially inferior to his
counterparts ...
2 situations when patients seek treatment :

Class 2 div 2.
Impacted teeth in anterior region.

 In general 3rd molars are the most commonly

impacted teeth followed by maxillary canines

and mandibular second premolars.
In cases of maxillary impacted canines

palatal canine impaction is found to be more

common than buccal canine impaction.
In cases of maxillary canine impaction

Females affected more than males and buccal

has higher incidence.

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.

 Eruption time is generally an indication for

dental age
is a wrong concept.
A tooth may have delayed eruption due to

various local causes.

Dental age must be assessed depending on

the root development of the teeth that should

be in the oral cavity irrespective of its
eruption status.

Retained Deciduous tooth :

A term having positive connotation and which

maybe defined as a tooth which remains in
place due to the absence or retarded
development of the permanent successor.
Over Retained Deciduous Tooth:

A term used to describe an unshed deciduous

tooth with an underlying tooth with root
lengths in excess of three quarters of the full
length.

A permanent tooth with delayed eruption :

Is one whose root length is developed in excess

of this length and whose spontaneous
eruption is expected.

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

prevented from reaching its normal position in

the mouth by tissue, bone, or another tooth.
An impacted tooth is a tooth that is all the

way or partially below the gum line and is not

able to erupt properly.

 While assessing dental Age a base age of

9 yrs is taken and assessment made.

if mandibular central incisor roots are
complete means pt is at least 9 yrs old).
First molars
9-9.5 yrs
Mandibular lateral incisors 9.5 yrs.
Maxillary lateral incisors 11 yrs.
Mandibular canines and first premolars
1213 yrs.
maxillary first premolars 13-14 yrs.
Normally developing maxillary canines and
2nd premolars
14-15 yrs.

 Factors which must also be considered while

assessing dental age :

Crown formation
Root formation.
Root resorption.
Supernumerary teeth coniform premolars and

peg laterals excluded.

 A Late developing dentition :

Typically dental age lags behind

chronological age and radiographically less
root formation
Extraction is contraindicated.

Normal Development
A periapical view of a 5 yr old child would give

the impression of severe crowding .

Why so ?

- Centrals and canines same Anteroposterior

level.
- Lateral incisor palatal irt both.
- Canines sited higher up vertically.

 The Eruption Sequence and development of

Ugly Duckling Stage and its resolution .

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.

ETIOLOGY OF MAXILLARY CANINE

IMPACTION (MULTIFACTORIAL)
Bishara and associates summarized Moyers theory that

impacted canine is caused by

Primary (Localized)
1. Tooth size arch length discrepancies.
2. Prolonged retention or early loss of deciduous canine.
3. Abnormal position of the tooth bud (rotation of tooth buds).
4. Trauma of the deciduous tooth bud.
5. Disturbances in the tooth eruption sequence.
6. Presence of an alveolar cleft.
7. Ankylosis.
8. Cystic or neoplastic formation
9. Dilaceration of the root
10. Premature root closure
11. Iatrogenic
12. Idiopathic

Secondary (Generalised )

Abnormal muscle pressure

Febrile diseases
Endocrine disturbances
Vitamin D deficiency
Irradiation

 Dewel once said :

No tooth is more interesting than the

maxillary canine from the development point
of view than the maxillary canine.
A canine in its buccally placed area can be
palpated at 11-13 yrs of age.

Additional reasons for canine impactions:

Long Path of eruption(Broadbent).
High placement in the maxilla.
Crowding( Hitchins).
Non resorption of the roots of the deciduous

canine(Lappin- palatal deflection).

Trauma :

Brin I, Soloman Y & Zilberman Y

Trauma as a possible factor in maxillary canine
impaction AJO DO 1993 Vol 104: 132-137
Case report
Result :
1. Trauma causing abnormal path of eruption.
2. Movement of unerupted canine y itself.
3. Unharmed adjacent teeth should be also
evaluated
4. Short lateral incisor root due to development
stunting by trauma leading to loss of guidance
to canine.

Soft tissue pathology.

Heredity

Contentious issue

Studies show high positive correlation and spotaneous

reslution when local factor is removed.

Maxillary canine first premolar transposition,associated dental

anomalies and genetic basis Peck L,Peck S, Attia Y Angle

Orthod 1993;63;99-109
Primary tooth germ displacement

The Guidance theory:

Miller (1963) & Bass (1967)

Noticed that congenitally missing lateral incisors
also had a high instance of palatally impacted
canines.
Hypothesized this due to the lack of guidance

generally being given by the lateral incisor during

eruption.
Thus the canine follows a mesial and palatal path

since the lateral incisor is now missing to guide it to

its correct position.

The Guidance Theory Comprises OF 5

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.

Second Stage Impaction: Self correction

hampered by an anomalous late developing
lateral, redeflecting the tooth palatally. An
etiologic factor not seen if the lateral incisor
is present. Aka Second Stage
Displacement.
5. Second Stage Impaction with secondary
correction:
Extraction of the over retained deciduous
canine or the anomalous lateral incisor itself
leading to the resolution of the problem.
4.

 Miller :

PEG SHAPED LATERALS AND ANOMALOUS

LATERALS .
However Becker and co workers in their studies
claim the opposite.
They agree with the Guidance theory but raise
questions over the anomalous lateral incisors.

Diagnosis

Importance..
An undiagnosed & severely resorbed tooth

with a poor long term prognosis may be

mistakenly included as an integral part of a
final outcome dentition in a projected
treatment plan but actually is a weak link can
actually hamper your treatment plan.

 Clinical Examination :

Inspection
Palpation
Radiodiagnosis :

Radiographic methods of diagnosis recognition

of pathologic entities as well as localization
and recognition of impacted tooth.

 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

Intraoral Periapical Radiographs:

The first simplest and most informative view.

Shows the type of supernumerary tooth.
Type of Obstruction a) Soft tissue.
b) Hard Tissue.
High clarity levels
Disadvantage :
Two dimensional.
Only Mandibular posterior area is what we call True
Lateral since all other areas the beam is angulated
hence height assessment not very dependable.

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

In general mandibular occlusal film clarity is

generally low due to dense cortical tissue.

3D diagnosis of tooth position.

1. Parallax method .

Given by Clark CA in A method of

ascertaining ethe relative position of
unerupted teeth by mrans of film
radiographs in 1910.

It is of 2 types :

The Lateral Tube Shift .

The Vertical Tube Shift.

 The Lateral Tube Shift :

Uses the parallax method.

A popular technique.
SLOB Rule

 Can be used with

2 IOPARs
Lateral Cephalogram And OPG

Vertical parallax:

When the canine is in an extremely high

position this can be utilised as an alternative.
Reliability is low.
Incisor area impaction with incisor mesiodens
this is difficult to discern.
SLOB rule.

Can be used with two IOPARs.

Orthopantamograph+ IOPAR

Tangential View :

Taken in the lateral ceph format with an occlusal

radiograph.
Helpful for canine impaction
Not useful for maxillary central incisor
impaction.
However during the course of resolution of
central incisor impaction best view.
Best for Dilacerated Central Incisor.

CT Scan

Late 1980s used fro the first time for

identifying exact position of palatally
impacted canines.
Large doses
Only exceptional cases
Resorption of roots of incisor teeth also
checked.

CBCT

Digital volume tomographic machines.

Xray source and image intensifier.
Reconstruction in every direction.
360 deg rotation
Panaromic and transaxial view.
Slicing.
Low radiation doses

 They modified Kurol & Ericson model for predicting

eruption after deciduous canine extraction.

Lindauer SJ, Rubenstein LK, Hang WM, Anderson WC, Isaacson

RJ. Canine impaction identified early with panoramic radiographs.
J Am Dent Assoc 1992;123:91-7.

Lindauers method used the location of the cusp tip of

the canine in question and its relationship to the

adjacent lateral incisor.
He determined the probability for impaction based on

the canine cusp tip location in 1 of 4 sectors.

Lindauer et al reported that this method identifies up
to 78% of the canines that are destined to become
impacted.

Sector I represents area distal to line tangent to distal heights of

contour of lateral incisor crown and root.

Sector II is mesial to sector I, but distal to bisector of lateral
incisors long axis.
Sector III is mesial to sector II, but distal to mesial heights of
contour of lateral incisor crown and root.
Sector IV includes all areas mesial to sector III.

Power SM, Short MB An investigation into the

response of palatally displaced canines to the
removal of deciduous canines and an
assessment of factors contributing to a
favourable eruption.
Br J Orthod 1993;20:215-23.
State that an Angulation of more than 31 0 would
hamper a spontaneous eruption of the canine
once the deciduous tooth is extracted.

Prediction Of Maxillary Canine

Impaction Using Sectors & Angular
Measurements
Article By J Warford, R Grandhi, Ajo Do 2003

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

Surgical Exposure Of Impacted

teeth
Surgical intervention without Orthodontic

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.

The Closed Eruption Technique :

First described by Hunt & McBride.
Modification by Crescini et al published in Tunnel traction of intraosseus

impacted maxillary canines A a 3 yr follow up Ajo-do 1994; 105: 61-72

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.

It is rarely used now.

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:
-

Large surgical field required.

- Inadequate moisture control may hamper

with the cement-band bond.

Standard orthodontic
brackets:
Any edge-wise ,

Beggs , PAE brackets

can be used.
They are
routinely used as direct
attachments along with
the composites.

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.

Interferes with the investing tissues & leads to

inflammation & periodontal damage.

As the impacted tooth advances into the arch

the exuberant gingival tissues bunches in front of
it & causes punching between the bracket &
tissues.

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.

Elastic ties and modules

Advantages
- Application of light forces
- Good range of action
- Easier to tie

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.

Classification Of Impacted Canine

Maxillary or Mandibular Canine may be

impacted
a) Bucally.
b) Palatally.

Classification Of Palatally
Impacted Canines :
Transverse Relationship:

Close to the midline

Away from the midline.
Height Of the Crown of the tooth in relation

to the tooth .
High
Low

 Based On The Above

Group I : Transverse : Close

Height
: Low
Group II : Transverse : Close
Height
: Forward Low
and Mesial to lateral incisor root.
Group III : Transverse : Close
Height
: High
Group IV: Transverse : Distant
Height
: High

 Group V :

Canine root apex mesial to that

of lateral incisor or distal to that of first
premolar.

Group VI : Erupting in the line of arch in place

of and resorbing the roots of the incisors.

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:

Lateral Incisor roots may pose a risk.

Careful Bone removal advised.
Minimum required tooth exposure for
bonding.
Flap replaced entirely.
Ligature pigtail made to pass through a
electrocauterised slit.
Hurdle : 180 degree rotation

Prevention :

Vertical traction followed by alignment into

desired positioned.
3 types of spring auxiliaries may be used :
a) The Ballista.
b) The active palatal Arch.
c) The Light Auxiliary labial Arch.

 In all the 3 a heavy base archwire should be present to:

a)
b)
c)

Keep space regained open.

Resist secondary distortion of the occlusal plane.
Support for force.

Problems that may be encountered:

Thick palatal tissues.

Delay may cause adjacent teeth to intrude instead of
canine erupting.

Group II Complications :

Rotation.
Palatally displaced root.
Thick And Resistant Palatal Tissue.
Risk Of Exposing and Damaging roots of
adjacent teeth.

 In All 5 types of tooth movements can be

seen in Aligning a Group II impacted canine

a) Vertical Extrusion.
b) Buccal Tipping of the crown.
c) Derotation.
d) Mesio-distal uprighting.
e) Buccal root torque

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 :

Two stage traction approach.

 Difficult Mechanics.
High relapse rates with the canines being in

an edge to edge/ Cross- bite relationship with

the lower teeth.

 Group 5

Canine root apex mesial to that

of lateral incisor or distal to that of first
premolar.
Transposed tooth.
May be partially erupted.

 Four possible lines of treatment:

To resolve the transposition to ideal

relationship.

To move the premolar mesially or incisor

laterally and align the canine into position.

To use the canine for autotransplantation

into a prepared socket in its ideal site.

To extract the tooth ( Canine,

incisor/premolar) with least prognosis and

leave the deciduous canine intact.

Complications:

Root dehiscence.

Group VI
Erupting in the line of the arch In place of
and resorbing the roots of the lateral incisors.

 difficult to diagnose correct position.

Devices Generating Extruding

Forces
Ballista Spring by Jacoby.
Cantilever Spring & TMA Box Loop.
Nickel Titanium Closed Coil Spring.
Two Arch wire technique
The monkey hook.
K9 Spring
Mandibular Anchorage.
Australian Helical Archwire
Tunnel Traction.

 Ballista Spring :
Ballista : An Ancient And Heavy Engine Of

Warfare Used To Hurl Heavy Objects.

Harry Jacoby Ajo Do Feb 1979.
It is an 0.014,0.016 or 0.018 inch round wire

which accumulates its energy by being

twisted around its long axis.
Horizontal part of this wire accumulates the
energy, is allowed to rotate in the premolar
bracket acting like a hinge.

The last part of the spring is bent down

vertically and ends in a loop shape to which a

ligature elastomeric thread can be attached.
When the vertical portion of the spring is

raised toward the impacted tooth, the

horizontal part accumulates the energy into
the twisted metal.
When the vertical section is released, it

bumps down like a ballista.

Creates a torsion on the molars hence a TPA must be given.

Can be used for both Unilateral or bilaterally impacted

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.

 Cantilever Spring & TMA BOX Loop

Given by Lindauer And Isaacson.

Alignment of Impacted Canines with

Cantilevers and Box Loops
VOLUME 33 : NUMBER 02 : PAGES (82-85) 1999
SURENDRA PATEL,VITTORIO
CACCIAFESTA,CARLES BOSCH
0.017 x 0.025 TMA wire.
Auxillary tube one point contact.
Statically determinate forces.
Stiff posterior archwire segments And TPA required.

A. Cantilever for mesial and vertical

eruption of impacted canine.
Angulation of ligature between
cantilever and attachment on canine
corresponds to line of force. B. Fullsize rectangular archwire and
transpalatal arch used for anchorage
and space maintenance. C. Within
four months, canine has erupted with
proper tip, allowing engagement in
continuous rectangular archwire.

Magnitude of force should not exceed 70gms.

The line of action of the force exerted by the

cantilever on the canine can be adjusted

according to the situation.
For a buccally impacted canine, the choice
would be either to extrude and mesialize the
canine or to extrude and distalize it.
A palatal push-force component or a buccal
pull-force component can be added if
necessary.

A Cantilever Spring For Extrusion

Canine needs distal tipping

TMA Box loop :

Statically indeterminate system.

Constructed from 0.017x 0.025 TMA
The desired activation depends on the postion

Sagittal plane: box loop activated by inserting it into canine

bracket; distal tipping and extrusion achieved in one month.

Horizontal plane: box loop activated for correcting

canine rotation; mesial rotation achieved in one month.

 Elastics pulling the canine generally have a

decay of forces.
Effectiveness high.
TMA Advantageous.

A NiTi Closed Coil Spring

 NiTi Closed Coil Spring

A Review Of the Diagnosis

& Management of
Impacted Maxillary
canines By MariselaM,
Bedoya, JH Park.

J Am Dent Assoc, Vol 140, No 12,

1485-1493.

Nickel Titanium Closed-Coil Spring for

Extrusion of Impacted Canines
VOLUME 33 : NUMBER 02 : PAGES (99-100)
1999
LORING L. ROSS
0.009X 0.041 spring
Provides 80 gm of force when stretched to twice its
resting length

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

Two Arch Wire Technique for Alignment Of Impacted Teeth:

Samuels & Rudge Vol 31 No. 3 Pg 183-187 1997

Gold Chain fixed to the active

component .
Tied to the 0.014 Niti Archwire
Which is deflected towards
the tooth by 3-4 mm.
Samuels.R.H.A (1997)
0.014 nickel titanium arch wire
Gold chain is preferable because of
flexibility and biocompatibility.
Gold links removed for activation.

The Monkey Hook: An Auxiliary for

Impacted, Rotated, and Displaced Teeth
VOLUME 36 : NUMBER 07 : PAGES (375378) 2002
S. JAY BOWMAN, ALDO CARANO
The Monkey Hook is a simple auxiliary with

an open loop on each end for the

attachment of intraoral elastics or
elastomeric chain, or for connecting to a
bondable loop-button.
Inspired by the children's game, "Barrel of

Monkeys", since more than one Monkey

Hook can be linked together to form a chain.
The hook can be closed with a plier to
prevent disengagement.
A combination of Monkey Hooks and

bondable loop-buttons allows the production

of a variety of different directional forces to
assist in the correction of impacted, rotated,
or displaced teeth.

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.

The Monkey Hook can extend through the

gingival tissue after surgical exposure.
If the tooth is deeply impacted, a second
Monkey Hook can be linked to the first.
The Hooks give a more rigid support.
Best use when used in conjunction with superelastic archwire.

Lateral Directional Forces

More than one Monkey Hook can be added to a

loop-button attachment, much like keys on a
key ring.
Elastomeric chain or superelastic coil springs
can be attached to these hooks to direct
forces laterally, creating a slingshot effect.
Can also be used as a rotational couple and a
retraction hook.

 The K-9 Spring for Alignment of Impacted

Canines Varun Kalra

JCO Vol 34 (Oct) pg 606-611 2000.
0.017x0.025 TMA wire.
Advantages
Simple in design
Low cost
No patient compliance
Light continuous eruptive and distalizing forces

Horizontal arm inserted into first

molar buccal tube and premolar
brackets. Spring bent 90
downward about 7mm mesial to
premolar bracket to form vertical
arm, which is about 11mm long
and ends in helix.
Spring held just distal to vertical
arm with plier, and vertical arm
bent about 20 inward, toward
palate.

Management Of Impacted Maxillary Canines using

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.

Elastic traction applied to

bonded attachments.
Traction with light forces is applied via directional elastics.
The elastic size can vary to ensure the delivery of forces that range
from 40 to 60 g based on the movements of the mandible.
The elastic application is demonstrated to the patient, and a
proficiency check is done a week after the surgical procedure.
The canine is guided vertically toward the occlusal plane. An
orthodontic bracket should be bonded on the labial surface of this
tooth as soon as possible.

Elastic force modules have the disadvantages of rapid force

decay.
The need for stiff main archwires to avoid side effects on the
adjacent teeth.
If a superelastic nickel titanium wire is inserted directly into
the canine bracket, the wire must be deflected, and
archform can become distorted. This can result in tipping
or intrusion of adjacent teeth, canting of the occlusal
plane, and a consequent lateral or anterior open bite.
An overlay or piggyback wire avoids these side effects, but
delays the forced eruption of the impacted canine, since
the rest of the dentition must be fully aligned before a suffi
ciently rigid main archwire can be placed.
The stiff primary archwire prevents the flexible nickel
titanium archwire from sliding freely through the brackets.

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

 Tunnel Traction of Infra-osseus Canines.

Aldo Crescini AjoDo 1994, 115,61-72.

 ERUPTION OF AN

IMPACTED CANINE WITH A

SEMI-FIXED APPLIANCE:
A CASE REPORT by Dr.
Neelima K,Dr. Nagaraj, Dr.
Jatti, Dr. Priyanka Sethi.
A semi fixed appliance used
to create a favourable path of
eruption.
Flap raised o.o10 SS ligature
wire placed thru flap.
Tunnel created thru the bone.
Pigtail lig. Tied to the clasps.

 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.

Dental modeling by means of rapid prototyping was an

efficient auxiliary method in diagnosis, orthodontic

treatment planning, and communication with this
patient and the orofacial surgeon.
Rapid prototyping technology made possible the
fabrication of an attachment for forced canine eruption.
Rapid prototyping dental modeling might become the
diagnostic procedure
of choice in the evaluation of impacted maxillary canines.
American Journal of Orthodontics and Dentofacial

OrthopedicsApril 2006 129 583-89 Faber, Berto, and

Quaresma

Maxillary Central
Incisors

 Congenitally missing Central Incisor

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:

Obstruction Due to Soft Tissue

Repair.
Dilacertation.

The Jerusalem Hypothesis.--

Arrested Root Development
When a preschool child suffers a trauma the root

might get arrested immediately, however the

adjacent teeth continue to develop and eventually
erupt leading to the development of the alveolar
bone in the area, however at a later date when
the concerned tooth refuses to erupt and
investigations are made the tooth is found to be
found in the normal position, vertical and with
under-developed bone around it leading to narrow
alveolar bone immediately around it.
Acute traumatic intrusion.
(intrusive luxation)

Actually an advantage since the tooth not

allowed to dry.

 Treatment Time :

Reported at 7-8 yrs of age.

Best treated at this age (4 yrs before
canines erupt)
Follow up to be done till the canines erupt.

A standard protocol of treatment available

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

Why they hesitate doing active

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:

An Orthodontic Appliance in the Early mixed

Dentition Space :
The Qualities Required :
Leveling and derotation.
Acheivement of good periodontal prognosis.
Light and controlled extrusive forces.
Final finishing without changing to another
appliance.

Johnsons (Modified) Twin Wire Arch

Given in Int J Of Ortho 1934 Vol 20 946-963.
Appliance based on fixed molar bands

connected by a soldered Palatal Arch.

Long and narrow gauge ( 0.020 Int dm)
tubes slide freely in the o.o36 dm buccal
tube.
This was extended upto the canine area.
Initial alignment with 0.016 NiTi or 0.0175
Niti
Post Alignment switch to plain round
0.018/0.020 SS.

Now ready for Surgical Intervention.

Best method With e-chain.
When it reaches occlusal level reassessment .

Root Torquing of Impacted Canines

According to Becker buccal root torque of the

treated impacted canine required may be

quite substantial. This may cause a reactive
force on the adjacent teeth as well.
Planning must be done in such a way so as to
minimize the effects on the anchor units.
Heavy base arch should be used and its form
compensated to compensate for the expected
movements.

 Intermaxillary S- elastics may be used.

On the side of cross-bite tendency: Buccal of

lower molar to lingual of upper molar.
v/v on the opposite side.
A case of bilaterally impacted canine does

not have loss of anchorage since the 2 sides

are pitted against one another.

Retention
Group 4 and 5 cases require maximum

retention as the relapse tendencies are high.

These 2 groups require permanent retainers.
Acc. To Wilbur Johnston Palatally Impacted

Canines Dec 1969 Ajodo

A Class I malocclusion case requires no
retention.

Evaluation of Post treatment Alignment by

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.

To minimize rotational relapse, options available are

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.

Vermette ME, Kokich VG, Kennedy DB.

Uncovering labially impacted teeth: apically
positioned flap and closed eruption techniques.

Angle Orthod 1995;65:23-32.

Compared the apically positioned flap with the

closed eruption technique and found much
superior results in terms of gingival( height,
scarring levels), and pulp status with the
closed-eruption technique.
Periodontal status was similar in both.
CE simulates natural eruption pattern.
Mentions another method of Impaction
assessment.

Closed-eruption surgical technique

for impacted maxillary incisors: A
postorthodontic periodontal evaluation

Adrian Becker, Ilana Brin, Yocheved Ben-Bassat,

Yerucham Zilberman, and Stella Chaushu.

This study demonstrates that overall good

long-term
esthetic results can be achieved by treating
impacted
maxillary incisors with a closed-eruption
orthodontic
surgical technique.

Soft-tissue management of labially

positioned
unerupted teeth
Robert L. Vanarsdall, and Herman Corn.

Am J Orthod Dentofacial Orthop 2004;125:28493

Advantages of Surgical exposure thru Apically
repositioned flap:
1. Tooth movement faster.
2. Availability of Attached Gingiva.
3. Attached gingiva restricts the regrowth of
soft tissues.
4. Delayed bonding/banding.

Conclusion
A versatile chapter in orthodontics showing

the versatility of our branch in general.

A careful treatment approach to this is

required as it is of great esthetic concern to

us.

References
Robert L. Vanarsdall, and Herman Corn.

Am J Orthod Dentofacial Orthop 2004;125:28493

Advantages of Surgical exposure thru Apically
repositioned flap:
1. Tooth movement faster.
2. Availability of Attached Gingiva.
3. Attached gingiva restricts the regrowth of
soft tissues.
4. Delayed bonding/banding.

5.Canine impaction identified early with panoramic radiographs.

Lindauer SJ, Rubenstein LK, Hang WM, Anderson WC, Isaacson.

J Am Dent Assoc 1992;123:91-7.
6.An investigation into the response of palatally displaced canines to

the removal of deciduous canines and an assessment of factors

contributing to a favourable eruption. Power And Short Br J Orthod
1993;20:215-23.
7. Prediction Of Maxillary Canine Impaction Using Sectors & Angular

Measurements. Article By J Warford, R Grandhi, Ajo Do 2003 vol

124.
8. Tunnel traction of intraosseus impacted maxillary canines A a 3 yr

follow up Ajo-do 1994; 105: 61-72.

9. Ballista Spring Harry Jacoby Ajo Do Feb 1979.

10. Alignment of Impacted Canines with Cantilevers and Box Loops.

Surendra Patel,vittorio Cacciafesta, Carles Bosch. Volume 33 : Number

02 : Pages (82-85) 1999.
11. A Review Of the Diagnosis & Management of Impacted Maxillary

canines By MariselaM, Bedoya, JH Park J Am Dent Assoc, Vol 140, No

12, 1485-1493.
12. Nickel Titanium Closed-coil Spring For Extrusion Of Impacted Canines.

Loring L. Ross Volume 33 : Number 02 : Pages (99-100) 1999.

13. Two Arch Wire Technique for Alignment Of Impacted Teeth: Samuels
& Rudge JcoVol 31 No. 3 Pg 183-187 1997

14.The Monkey Hook: An Auxiliary For Impacted, Rotated, And

Displaced Teeth. S. Jay Bowman, Aldo Carano. Volume 36 : Number

07 : Pages (375-378) 2002.
15.The K-9 Spring for Alignment of Impacted Canines Varun Kalra

JCO Vol 34 (Oct) pg 606-611 2000.

16.Management Of Impacted Maxillary Canines using Mandibular

Anchorage. Ajodo Vol 115, No. 3 , 255-259.

17.Eruption

of Impacted Canines with an Australian Helical

Archwire Christine Hauser, Yon H. Lai, Elina Karamaliki.
Volume 34 : Number 09 : Pages (538-541) 2000.

18. Eruption Of An Impacted Canine With A

Semi-fixed Appliance: A Case Report by

Dr. Neelima K,Dr. Nagaraj, Dr. Jatti, Dr.
Priyanka Sethi. Cyberjournal
19. American Journal of Orthodontics and
Dentofacial Orthopedics. Faber, Berto, and
Quaresma April 2006 129 583-89
20. Johnsons Modified Twin Wire Arch. Int J Of
Ortho 1934 Vol 20 946-963.

21. Palatally Impacted Canines. Wilbur Johnston

Dec 1969 Ajodo.

22.Uncovering labially impacted teeth: apically

positioned flap and closed eruption

techniques. Vermette ME, Kokich VG, Kennedy DB.
Angle Orthod 1995;65:23-32.

23. Closed-eruption surgical technique for impacted

maxillary incisors: A postorthodontic periodontal
evaluation. Adrian Becker, Ilana Brin, Ben-Bassat,
Yerucham Zilberman, and Stella Chaushu.
24. Soft-tissue management of labially positioned
unerupted teeth. Vanarsdall, Corn. Am J Orthod
Dentofacial Orthop 2004;125:284-93.