Uploaded byMarwan Ramadan,Dentist
Impacted canine
L'impactation des canines maxillaires est fréquente, affectant environ 12 % à 15 % de la population, avec une prévalence doublée chez les femmes par rapport aux hommes. Plusieurs classifications des canines impactées existent en fonction de leur localisation et de leur inclinaison, et divers traitements peuvent être envisagés selon l'âge du patient et d'autres facteurs cliniques. Les options de traitement incluent des approches interceptives, chirurgicales avec ou sans traction orthodontique, et des interventions telles que la transplantation autologue ou l'extraction.
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Impacted canine
- 1. Impacted Canine Prepared by:Marwan Ramadan B.D.S
- 2. Impacted Canines incidence : Impacted maxillary canines are quite common, and approximately 12%–15% of the population present with impacted canines. They are localized palatally more often than labially. Twice common in female as it is in male Of all patient with impacted canine 8% have bilateral impaction the impacted canine presents five basic localizations (contralateral or ipsilateral and deep in the bone) as follows: 1. Palatal localization 2. Palatal localization of crown and labial localization of root 3. Labial localization of crown and palatal localization of root 4. Labial localization 5. Ectopic positions
- 3. Etiology of impactedcanine Several etiologic factors for canine impactions have been proposed: localized, systemic, or genetic
- 4. Classification of maxillaryImpacted Canines According to axial inclination Class I: Impacted canine located in the palate Horizontal Vertical Semi-Vertical Class II: Impacted canine located in the buccal side Horizontal Vertical Semi-Vertical Class III: Impacted canines located in both palatal as well as buccal alveolar bone. Class IV: Impacted canines located vertically between incisors and premolars Class V: Impacted canines located in edentulous maxilla Class VI : when canine is placed in abnormal position, antral wall, infraorbital region
- 5. Classification of maxillaryImpacted Canines According to According to Field and Ackerman(1935) a. Labial position (1) crown with intimate relationship with incisors (2) crown well above apices of incisors b. Palatal position (1) Crown near surface in close relationship to root of incisors (2) Crown deeply embedded in close relationship to apices of incisors c. Intermediate position (1) Crown between lateral incisor and first premolar root (2) Crown above of these teeth with crown labially placed and root palatally placed,or vice versa d. Unusual position (1) In nasal or antral wall (2) In infraorbital region
- 6. Classification of mandibularImpacted Canines CLASSIFICATION According to Field and Ackerman(1935) a. Labial position (1) Vertical (2) Oblique (3) horizontal b. Unusual position (1) At inferior border (2) In mental protuberance (3) Migrated to opposite side
- 7. Classification of mandibularImpacted Canines Periapical radiograph showing transmigrated and erupted lower left canine in the midline.
- 8. Classification of mandibularImpacted Canines CLASSIFICATION According to the depth Level A. The crown of the impacted canine tooth is at the cervical line of the adjacent teeth. Level B. The crown of the impacted canine tooth is between the cervical line and root apices of the adjacent teeth. Level C. The crown of the impacted canines is beneath the root apices of the adjacent teeth
- 9. Sequelae of CanineImpaction 1. Labial or lingual malpositioning of the impacted tooth 2. Migration of the neighboring teeth and loss of arch length 3. Internal resorption 4. Dentigerous cyst formation 5. External root resorption of the impacted tooth, as well as the neighboring teeth, 6. Periodontal defects 7. Tooth transposition 8. Infection particularly with partial eruption 9. Referred pain and combinations of the above sequelae
- 10. Theories associated withpalatally displaced maxillary canines The guidance theory proposes that the canine erupts along the root of the lateral incisor, which serves as a guide, and if the root of the lateral incisor is absent or malformed, the canine will not erupt. The genetic theory includes other possibly associated dental anomalies, such as missing, or small lateral incisors, also it may associated with anomalies such as enamel hypoplasia, infraocclusion of primary molars, and aplasia of second premolars.
- 11. Diagnosis and Localization:ofCanine Impaction The diagnosis of canine impaction is based on both clinical and radiographic examinations 1. Delayed eruption of the permanent canine or prolonged retention of the deciduous canine beyond 14–15 years of age 2. Absence of a normal labial canine bulge, 3. Presence of a palatal bulge in the canine region, 4. Delayed eruption, distal tipping, or migration (splaying) of the permanent lateral incisor, 5. Loss of vitality and increased mobility of the permanent incisors Clinical Evaluation
- 13. Diagnosis of CanineImpaction Indicated in patients with unerupted and nonpalpable canine after the age of 11 years Types Intraoral Periapical and Occlusal Extraoral OPG and lateral cephalogram Digital imaging Ct scan and CBCT . Radiographical Evaluation
- 14. Diagnosis of CanineImpaction periapical film A single periapical film provides the clinician with a two-dimensional representation of the dentition. It would relate the canine to the neighboring teeth both mesiodistally and superoinferiorly
- 15. Diagnosis of CanineImpaction To evaluate the position of the canine buccolingually Two periapical films are taken of the same area, with the horizontal angulation of the cone changed when the second film is taken. If the object in question moves in the same direction as the cone, it is lingually positioned. If the object moves in the opposite direction, it is situated closer to the source of radiation and is therefore buccally located Tube-shift technique or Clark's rule or (SLOB) rule
- 16. Diagnosis of CanineImpaction The buccal object rule uses two radiographs taken with different vertical angulations of the x-ray beam. An object located on the buccal side moves inferiorly with the beam directed inferiorly, whereas an object located in a lingual or palatal position moves superiorly Buccal object rule:
- 17. Diagnosis of CanineImpaction Occlusal films help to determine the buccolingual position of the impacted canine in conjunction with the periapical films, provided that the image of the impacted canine is not superimposed on the other teeth Radiographical Evaluation
- 18. Diagnosis of CanineImpaction Extraoral films 1. lateral cephalograms These 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). Radiographical Evaluation A view of the anterior section of the lateral skull radiograph confirms the palatal location of the fully superimposed impacted canines (arrow)
- 19. Diagnosis of CanineImpaction Extraoral films 2. Panoramic films These are also used to localize impacted teeth in all three planes of space as 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. image size distortion; object further away from the image receptor (film) will be depiceted more magnified than objects closer to the film Radiographical Evaluation right maxillary canine impaction. The image of the canine superimposes on the middle of the root of the lateral incisor
- 20. Diagnosis of CanineImpaction Extraoral films 3. CT/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. increased cost, time, radiation exposure, and medicolegal issues associated with using CBCT limit its routine use Radiographical Evaluation
- 21. Diagnosis of CanineImpaction Extraoral films Radiographical Evaluation CT scan image showing impacted upper right canine in the right maxillary sinus . Ct scan Axial view Ct scan coronal view
- 22. Diagnosis of CanineImpaction Extraoral films 3. CBCT Radiographical Evaluation was designed to overcome some of the limitations of conventional CT devices (eg high radiation dose to produce the multiple images which are stacked to produce a complete image Three dimensional reconstructed image (CBCT) of impacted maxillary canines
- 23. factors affecting treatmentoptions Patient age General dental health and oral hygiene Whether space is available within the arch or if it can be established with orthodontic manipulation Suitability of the first bicuspid to replace the canine Favorability of the position of the impacted canine and the likelihood of being able to get it into position with orthodontic treatment Patient motivation for orthodontic treatment Medical contraindications for surgery
- 24. Treatment options 1. Interceptive 2.Surgical exposure with or without orthodontic traction Open surgical exposure with spontaneous eruption Open surgical exposure with packing only Open surgical exposure with packing and subsequent bonding of an auxillary. Closed surgical exposure and bonding of an attachment intraoperatively.(closed eruption technique) Open surgical exposure and bonding of an attachment and repositioning of the covering tissue (open eruption technique) 3. Surgical repositioning and alignment 4. Surgical Autotransplantation 5. Surgical removal 6.No treatment
- 25. 1. Interceptive Treatment In Class I non crowded situations where the permanent maxillary canine is impacted or erupting buccally or palatally, it may be the preventive treatment of choice in patient 10-13 years old. However, intercept early if There is any root resorption 3 not palpable in its normal position and radiographic examination confirms palatal ectopia When canines are impacted buccally, retained primary canine should be extracted. However, interception does not guarantee correction or elimination of the problem. If NO radiographic evidence of improvement seen one year after treatment, then surgical exposure and orthodontic eruption, is indicated
- 26. 2. Surgical Exposurewith orthodontic traction CONSIDERATION Patient must be willing to wear orthodontic appliance Patient must be motivated to maintain good OH Interceptive measures not suitable Position of malposition not too great to preclude treatment. The long axis of the 3 should not be too horizontal or oblique The optimal time for alignment is during adolescence 3 must not be ankylosed The root of 3 should not be dilacerated
- 27. METHODS A. surgical exposurewith spontaneous eruption B. surgical exposure with packing only C. surgical exposure with packing and delayed bonding of an auxillary. D. Open eruption technique . E. Closed eruption technique For surgical exposure 3 surgical approach can be used 1. Replacement flap technique 2. Excisional exposure 3. Apically position flap The goal is to choose a technique that exposes the canine within the a zone of keratinized mucosa without involvement of the cementoenamel junction
- 28. A. surgical exposurewith spontaneous eruption Usually has only soft tissue covering The technique involve excision of the gingivae over the canine with little exposure of the crown and bone removal. This should be enough to allow eruption of the canine unerupted maxillary left canine The tooth was exposed and the flap, which consisted of attached gingiva, was apically repositioned At nine months post-surgery, the tooth has erupted normally.
- 29. B. surgical exposurewith packing The purpose of pack application is to prevent the gingival tissue from re-healing after exposure Indicated in deep impaction cases when spontaneous eruption is suspected
- 30. C. surgical exposurewith packing and delayed bonding of an auxillary Indicated in deep impaction cases when spontaneous eruption is failed of The packing is remove after a week postop and an attachment bonded with subsequent traction using a fixed appliance. Adv Re-bonding can be done under direct vision Direct visualisation during movement
- 32. D. Open eruptiontechnique In the “open eruption” technique, the crown of the impacted tooth is exposed with either an opening cut into the overlying tissue without flap reflection, or a flap is reflected, a window cut in it, and then the flap is repositioned simplest, most conservative and most direct manner to expose a tooth which is palpable immediately under the oral mucosa attachment may then be bonded to the tooth and orthodontically encouraged eruption may proceed without delay, to complete its alignment within a very short time. A high buccal canine exposed by circular incision of the sulcus mucosa Following alignment, the oral mucosa is attached directly to the gingiva
- 33. E. Closed eruptiontechnique The alternative approach to surgical exposure, the closed eruption technique, has an attachment placed at the time of the exposure and the tissues fully replaced and sutured to their former place, to re-cover the impacted tooth high labial canine has been exposed with a full flap exposure, which included the gingival margin of the extracted deciduous canine An attachment is bonded to the palatal aspect of the permanent canine and its pigtail ligature is directed through the socket vacated by the extracted deciduous tooth The flap is sutured to its former place and vertical traction will draw the tooth down, maintaining alveolar bone on its labial side.
- 34. (a) The crownof an impacted canine is exposed using a wide flap, but with removal of minimal bone. The unexposed crown lies between the roots of the central incisors, having traversed the midline suture. (b) An attachment is bonded, while haemostasis is maintained by the surgeon. (c) The flap has been divided to accommodate the ligature pigtail in its desired position, before being fully replaced and sutured. (d) The labial spring auxiliary loop, seen in its passive position in (c), has been turned inwards towards the palate and secured to the stainless steel ligature pigtail Closed eruption technique in palatally impacted maxillary canine
- 35. Surgical repositioning andalignment It suitable for tooth which are only mildly displaced. It involves de- rotation of the impacted canine within its socket It defer from transplantation because effort is made to avoid removal of the tooth from it socket The greater the displacement the poorer the prognosis as frequently the neurovascular bundle are broken
- 36. Autotransplantation If patientis unwilling to wear orthodontic Appliance If the degree of malpositioning is too great for orthodontic alignment. Optimal time is when the root is about 50-75% formed Interceptive measure not appropriate or had failed Fixation at d recipient site is done using a preformed or vacuum splint which covers the entire upper arch Splint is removed after 3-6wks and this is followed by bonded sectional fixed appliance
- 37. Preoperative Extraction of the toothfrom impacted state Intraoperative after preparing of the socket Postoperative OBG showing alignment of the tooth and splinting
- 38. Surgical removal Indications Poorpatient cooperation Patient decline treatment or is pleased with the appearance The tooth is lying in an unfavorable position (in horizontal position) and there is insufficient space in the arch Presence of a pathology. Satisfactory occlusion and prognosis for treatment is poor. Evidence of early resorption of adjacent tooth. Good contact btw the 2 and 4,so as to substitute 4 for 3.
- 39. Methods of Surgicalremoval Maxillary canine Extraction using labial approach Extraction using palatal approach Extraction of labially located canine with partial bone impaction Extraction of intra-alveolar impaction Ectopic Impacted Canine Mandibular canine Extraction of mandibular canine with labial position
- 40. Flap design Buccallocated canine: If the impacted canine is located buccally, we have three options depending on the level of the tooth impaction. 1- Gingival crest incision can be made in the gingival sulcus. 2- If the impacted canine is high, the incision can be made horizontally above the papillae (flap with release incision). 3- Vestibular incisions made at the level of the mucogingival junction should be made only when the impacted canine is above the root apices. Palatal positioned canine: require long incision to avoid damage to the neurovascular bundles (nasopalatine bundles & the greater palatine bundle) Transversely located (in the middle of the ridge) we have to make 2 flaps one labially and the other one palataly
- 41. Extraction of maxillarycanine Using Labial Approach OPG Impacted canine in right and left side Canine bulge on labial side trapezoidal flap Reflection of the flap Bone removing Tooth sectioning
- 42. Extraction of maxillarycanine Using Labial Approach Removal of follicle Bone smoothing Removing of the crown Removing of the root Surgical site after suturing
- 43. Extraction of maxillarycanine Using palatal Approach Bone removing Tooth sectioning OPG Impacted canine in right side Palatal flap extend from 5 to 5 Reflection of the flap
- 44. Extraction of maxillarycanine Using palatal Approach Removing of crown Removing of root Re-approximation of the flap Surgical site after suturing
- 45. Extraction of ImpactedCanine with Partial Bone Impaction impacted maxillary canine with a labial localization The ischemic protuberance Trapezoidal incision
- 46. Extraction of ImpactedCanine with Partial Bone Impaction Creation of a groove between the crown and bone, allowing for positioning of the elevator Removal of the tooth with elevator Bone smoothing suturing
- 47. Extraction of EctopicImpacted Canine • The presence of ectopic impacted teeth is relatively rare. • Ectopic teeth are usually localized in the following places: 1. underneath permanent teeth, 2. near the angle of the mandible, 3. inside the ramus, 4. near the mandibular notch, 5. the coronoid process, 6. the maxillary tuberosity, 7. the wall of the maxillary sinus, 8. the nasal cavity and, 9. rarely, near the orbit Radiograph showing impacted canine with a labial localization, which is in contact with the anterior wall of the maxillary sinus
- 48. Extraction of EctopicImpacted Canine Incision in canine fossa region, for sinus trephination using the Caldwell–Luc approach Reflection of the flap and exposure of the anterior wall of maxillary sinus Holes drilled through the bone surface defining the border of bone to be removed Connecting holes to remove the bone covering the impacted tooth
- 49. Extraction of EctopicImpacted Canine Surgical field after suturing a, Exposure and luxation of the impacted tooth using straight elevator. b Removal of tooth using a hemostat
- 50. Extraction of mandibularcanine: labially positioned Trapezoidal incision extending from the left lateral incisor as far as the first premolar of the opposite side of the mandible Reflection of the flap
- 51. Extraction of mandibularcanine: labially positioned Exposure of the crown of the impacted tooth using a surgical bur Luxation using the blade of the elevator alternately on the mesial and distal aspects of crown of tooth Surgical field after removal of the impacted tooth and odontomas
- 52. Extraction of mandibularcanine: labially positioned Suturing
- 53. POSTOPERATIVE TREATMENT AfterDebridement and closure of incision the wound heals uneventfully 1. A post op radiograph is desirable 2. Cold application to face prevents disfiguring swelling and edema 3. Antibiotics are generally necessary especially if there is preexisting infection or the antrum or nasal cavity has been opened. 4. Medication should be prescribed for pain