Canine Impaction, Its Importance in Orthodontics, Etiology, Diagnosis and Management. by Dr Analhaq Shaikh, 2nd year Postgraduate student, Sharavathi Dental College and Hospital, Shimoga, Karnataka Canine Impaction can also be termed as Shy Canine.

1. Dr Shaikh Analhaq A.
2nd year PG
Dept. of Orthodontics and Dentofacial
Orthopedics
SDCH, Shimoga
CANINE IMPACTION

2. Content
2
 Introduction
 Eruption
 Incidence
 Classification
 Etiology
 Diagnosis
 Prognosis

3. Content
3
 Management
 Success & Duration
 Root resorption & canine impaction
 Impacted canine & periodontium
 Retention
 Complications of untreated impacted canine
 Conclusion
 Bibliography

4. INTRODUCTION

5. Introduction
 Canine play an important role in esthetics, being
corner tooth of mouth and function deserves
special attention for its impaction to be properly
diagnosed and managed.
 The treatment of impacted teeth has caught the
imagination of many in dental profession.
However, the orthodontic / surgical modality has
achieved the most satisfactory result in long-
term.5

6. Assesment of
tooth eruption
Tooth
development
3/4th root
completion teeth
appears in arch
Dental age
Nolla and
Moores have
given charts
Normal tooth eruption
6

7. Impaction
 IMPACTUS (latin origin) = pushed against
 Archer (1975) defines impacted tooth as one
which is completely or partially unerupted and is
positioned against another tooth or bone or soft
tissue so that its further eruption is unlikely.
Archer William H. Oral and Maxillofacial Surgery, Vol. I,ed. 5,
Philadelphia, WB Saunders Co. 1975
7

8. Impaction
According to Shafer, Hine and Levy,
 Impacted teeth are those which are
prevented from erupting by some
physical barrier in the eruption
path.
Or
 When the crown remains at some
distance from the alveolar crest
after its scheduled eruption time
because of insufficient room or an
ectopic eruption pattern.
8

9. Impacted canine
 Impaction of maxillary and
mandibular canines is a
frequently encountered
clinical problem.
 Third molars are the most
commonly impacted teeth
and canines stood
second.
9

10. ERUPTION OF CANINE

11. Eruption of canine :
According to Broadbent, AO 1941-
 Development of canine :
• It develops at 4 – 5 months of age between the
roots of deciduous 1st molar.
 Calcification of canine :
• It begins to calcify around 12 months of age.
• Calcification is taking place far above the roots of
deciduous molar, allowing development of the
first premolar between the deciduous molar roots.
11

12.  At this stage the permanent
canine is located
immediately above both the
erupting first premolar and
the erupted first deciduous
molar.
 As the deciduous teeth
erupts towards the occlusal
plane, the permanent
incisor and canine crypts
migrate forward in the jaws.
 The positional changes
between 8 and 10 years of
age need careful
observation for detection of12

13.  During this stage of development the
canine normally migrates buccally from a
position lingual to the root apex of the
deciduous precursor; however, some
canines do not make the transition from
the palatal to the buccal side of the dental
arch and remain palatally unerupted.
 With sufficient increase in the size of the
subnasal area, the maxillary canine
normally moves downward, forward and
laterally away from the root of the lateral
incisor.
 Between 8 and 12 years of age, the 'ugly
duckling' stage, there is insufficient space
at the apical base to permit the axis of the13

14.  In the final phase of eruption, canines drive
their way between the lateral incisors and
first premolars, forcing these teeth to
become more upright.
14

15. Factors governing eruption of
canine
Four factors govern the
eruption of permanent canines
into normal position
1. Position of tooth bud in bony
crypt
2. Path of eruption
3. Shape and position of lateral
incisors
4. Amount of space available
for canines in the arch
15

16. INCIDENCE

17. Incidence
 Dachi and Howell (1961) reported that the
incidence of maxillary canine impaction is
0.92%, and mandibular canine impaction is
0.35%
 Asians present more of buccal canine
impactions.
 Impactions are twice as common in
females (1.17%) as in males (0.51%).
 Of all patients with maxillary impacted
canines, it is estimated that 8% have
bilateral impactions.
SAMIR BISHARA. AJO-DO Feb. 1992 & Semin Orthod June 199817

18. CLASSIFICATION

19. Impacted canine
Maxillary canine Mandibular canine
Buccal Palatal LingualBuccal
Classification of impacted canine
19

20. Classification of palatally impacted
canine
 Based on two variables:
(1). Transverse relationship of the crown of the
tooth to the line of dental arch which may be
(a) Close
(b) Distant (nearer the midline)
(2). Height of the crown of the teeth in relation
to the occlusal plane which may be
(a) High
(b) Low
20

21. Group 1
Proximity to the line of arch – close.
Position in the maxilla – low.
Group 2
Proximity to the line of arch – close.
Position in the maxilla – forward , low
& mesial to the lateral
incisor root.
21

22. 22
Group 3
Proximity to the line of arch –
close.
Position in the maxilla – high.
Group 4
Proximity to the line of arch –
distant.
Position in the maxilla – high.22

23. Group 5
Canine root apex mesial to that of lateral
incisor or distal to that of first premolar.
Group 6
Erupting in the line of arch in place and
resorbing the roots of incisors.
23

24. Classification by ACKERMAN and FIELDS in 1935.
IMPACTED CANINE
Horizontally Vertically
Palatal
Above
Labial
Mid- alveolar
Below
(With respect to the arch)
(With respect to the apex)
(JCO 1979 DEC)24

25. ETIOLOGY

26. Etiology
 Maxillary canines erupt bilaterally where
anterior and posterior regions of maxillary
arch intersect, these osseous structures
have different embryologic origins
 Ant. Maxilla is derived from Ant. Nasal bud
and Post. Maxilla is formed by fusion of
Maxillary buds
 The follicles of maxillary canine are located
at the mesial of the pre maxillary suture
during periods of active growth.
 Any deviation in or disturbance of that
osseous growth can provoke a change in
orientation of canine tooth buds.26

27. Etiology of impacted canine
• LOCALIZED
• SYSTEMIC
• GENETIC
27

28. LOCALIZED
Tooth size- arch length
discrepancies
Failure of the primary canine
root to resorb
Prolonged retention or early
loss of primary canine
Ankylosis of permanent canine
Cyst or neoplasm
28

29. LOCALIZED
Dilaceration of the root
Absence of maxillary lateral
incisor
Variation in timing of lateral
incisor root formation
Iatrogenic factors
Idiopathic factors
29

30. SYSTEMIC
Endocrine deficiencies
Febrile diseases
Irradiation
30

31. GENETIC
Heredity
Malposed tooth germ
Presence of alveolar cleft
31

32. 32
( Moyers concept summarized by Bishara)
• Moyers say that maxillary cuspid follows a
more difficult and tortous path of eruption
than any other tooth.
• At age of 3 it is high in maxilla and its crown
directed mesially and lingually.
• It moves toward occlusal plane gradually
uprighting itself until it seems to strike the
distal aspect of the root of the lateral incisor.
SAMIR BISHARA. AJO-DO Feb. 1992 & Semin Orthod June 1998

33.  Other authors like Bayer et al AO 1981 and
Frank CA AJO 2000 reported some common local
causes that include one or more combination of
the following• Generalized
causes
(a) Endocrine
deficiencies,
(b) Febrile diseases,
and
(c) Irradiation.
•Localized factors
(a) Tooth size-arch length
discrepancies,
(b) Prolonged retention or early
loss of the deciduous canine,
(c) Abnormal position of the tooth
bud,
(d) The presence of an alveolar
cleft,
(e) Ankylosis,
(f) Cystic or neoplastic formation,
(g) Dilaceration of the root,
(h) Iatrogenic origin
33

34. Theories put forth for impacted
canine
 Mc Bridge concept
 Canine is formed high in the anterior wall at antrum,
below the floor of orbit, long tortous path of eruption.
 Tooth have much to travel from floor of orbit to oral
cavity hence had greater chances of “losing its way”
34

35.  Becker 1984
 He noted that there appear to be two processes for
palatal displacement of maxillary cuspid
1. Developmental: due to absence of guidance of
lateral incisor
2. It relates to more advanced period when tooth
moving down into a narrower part of alveolar
process
35

36. Vonder Heydt concept
 Total arch length of permanent teeth is initially
established very early in life at the time of eruption of
first permanent molars.
 Canine is larger and later erupting and considering
like a musical chair situation it may get impacted.
36

37.  Peck and peck concept:
1) Palatally impacted canine is an inherited trait occurs in
combination with tooth agenesis,tooth size reduction,
supernumery tooth and other ectopically positioned
tooth.
2) Bilaterally occuring phenomenon (17%)
3) Females affected more than males (1:3.2)
4) Familial occurrence
So they concluded palatally impacted canine as dental
anomaly having GENETIC ORIGIN.
37

38.  Guidance theory of Miller:
 Normal eruption: canine usually have a more mesial
development path, which is guided downwards
apparently along the distal aspect of the lateral incisor
roots.
 Miller (1963) and Bass (1967) reported that there
appeared to be an unusually high prevalence of
congenitally missing lateral incisors associated with
palatally impacted canine teeth.
38

39. First stage impaction: if there is a loss of guidance due
to missing lateral incisors or late developing laterals,
canine will have mesial and palatal path of eruption. In
this event there is no vertical movement of canine into the
alveolar process, results in more horizontal impaction.
First stage impaction and secondary correction: once
it reached the palatal alveolar process,the canine is
redirected to more favorable path of eruption.
39

40.  Second stage impaction: self
correction is prevented by, late
developing lateral incisors (peg
laterals) which redeflect the tooth
further palatally.
 Second stage impaction and
secondary correction: extraction
of deciduous canine or even
extraction of lateral incisors leads
to spontaneous eruption of the
impacted tooth.
40

41.  Vincent Kokich 2004
 He said that labial impact of the maxillary canine is
due to either ectopic migration of the canine crown
over the root of lateral incisor or shifting of maxillary
dental midline causing insufficient space for the
canine to erupt.
41

42. Labial or lingual
malpositioning
of impacted
tooth
Migration of
neighbouring teeth
and loss of arch
length
Internal resorption or
external root
resorption of impacted
or neighbouring tooth
Dentigerous
cyst formation
Infection
particularly with
partial eruption
Referred pain
Shafer et al.
SEQUELAE OF IMPACTED
CANINE
42

43. DIAGNOSIS

44. Diagnosis
Inspection Palpation
Radiograp
hs
44

45. Inspection
 Non-appearance of
permanent canine clinically
by its eruption age.
 Presence of antimere.
 Presence of anterior spacing
for a long period.
 Persistent median diastema.
 Abnormal morphology of
lateral incisor or presence of
peg laterals.
 Improper angulations of45

46. Palpation
 Bulge of permanent Canine could be palpated
buccally above the deciduous canine 2-3 yrs
before its eruption.
 It should be palpated deep above attached
gingiva in the sulcus where mucosa reflects.
 Deciduous canine should be checked for
mobility.
 Palpation should be done in abnormal
locations after getting clue from inspection.
46

47. Clinical Assessment of impacted
canine
 Determine patients dental age.
 Assess the primary tooth its absence, colour,
mobility, extent of root resorption.
 Examine the morphology and thickness of
bony contour showing presence of labial or
palatal bulge.
 Examine the cast to determine the arch shape
transverse and sagittal symmetry, intercanine
distance and lack of harmony between tooth
size and arch size.
47

48. RADIOGRAPHS
48
Periapical
Mandibular arch
Max. ant. occlusal True vertex/occlusal
OPG Lateral ceph
Extraoral
I. Qualitative radiographs
Maxillary arch
Occlusal
PA view
Parallax method Radiographic views at right angle C T scanning
II. 3-D localisation

49. Occlusal radiograph
 Provides a third i.e. horizontal
dimension.
 57x76 mm films are used.
 Distoocclusal upper median film.
 Central ray of x-ray is placed on
the median sagittal plane and
adjusted at an angle of 60-70 to
long axis of perm. max. canine.
 It provides a topographic depiction
of palatal vault aiding in
localization of palatally impacted
tooth.
 Does not show exact cross49

50. Occlusal radiograph
Maxillary true (vertex)
occlusal
• X-ray beam runs parallel to
long axis of incisors.
• Possible to get cross section
of anteriors.
• Allows for bucco-lingual
position of impacted
canines or supernumerary
teeth irt to roots of incisors
50

51. Occlusal radiograph
Maxillary true (vertex)
occlusal Ong’s projection
• Extra-oral technique for
vertex occlusal view
• To increase clarity and
reduce exposure due to use
of intensifying screen
Alternative technique to vertex/true occlusal view
Ong: AJO-DO, Volume 1994 Dec (621 - 626)51

52. Occlusal radiograph
Mandibular occlusal
900 to OP – cross-section of
PM, molar region
1100 to OP – cross-section of
incisor region
52

53. OPG
 Panoramic radiographs are basic radiograph
for assessment of impacted teeth
• Tooth position whether deep or shallow
• General orientation horizontal or inclined
mesially/distally
• Relationship with neighbouring teeth
• Risk of their transposition
• Presence or absence of apical resorption of
roots of adjacent teeth
53

54. OPG
 Basic radiographic principle that an object
placed closer to the film throws a smaller
shadow than an object localized at a greater
distance
 Study done by Becker found that more
superior the tooth greater its magnification. An
impacted canine found in the coronal zone is
most likely (2.4:1) to be labially located
whereas in the middle zone has a strong
tendency (8.9:1) of being palatally located.
54

55.  When mesio distal width of canine crown was
1.5 times larger (i.e. 15% larger) than the
adjacent central incisor, then the canine is
palatally placed
 This is only true in cases where canine should
not be at a higher level
Reliability of a method for localisation of displaced maxillary canines using a single
panoramic radiograph. Chaushu et al; clin orthod res 1999; 2: 194-9
55

56. 56
 Ericson and Kurol in EJO 1988 defined number of
sectors to denote different types of impaction.
i. Sector 1: if the cusp tip of the canine is
between the interincisor median line and the
long axis of the central incisor;
ii. Sector 2: if the peak of the cuspid of the canine
is between the major axes of the lateral and
central;
iii. Sector 3: if the peak of the cuspid of the canine
is between the major axis of the lateral and the
first premolar.

57. 57
 Modification of Ericson & Kurol’s definition of sectors
used in the study:
• Sector I: Located distal to a tangent to the distal crown &
root of the lateral incisor.
• Sector II: The area from the tangent on the distal surface
to a midline bisector of the lateral incisor tooth.
• Sector III: The area from the midline bisector to a
tangent to the mesial surface of the lateral incisor
crown & root.
• Sector IV: All areas mesial to
sector III.
Steven Lindauer et al. JADA March
1992. Canine Impaction identified
early with Panoramic Radiographs

58. 58
 In the year 2003, Warford et al., did a study for
predicting the maxillary canine impaction using
sectors and angular measurement. He localised
the canine according to 4 sectors and measured
the angle between the bicondylar line and long
axis of canine. He concluded that the probability
of canine impaction increases as the angle
reduces and the sector increases. 82% of the
impacted canines had cusp tips located in sectors
II, III, and IV.(AJODO Dec., 2003)

59. Study done by Stivaros and Mandall to investigate the
radiographic factors that influence the orthodontists
decision to expose align or remove an impacted tooth
panoramic radiographs. (JO 2000)
59

60.  The factors were:
1. Canine angulation to the midline;
2. Vertical height of the canine crown;
3. Antero-posterior position of the canine root
apex;
4. Canine crown overlap of the adjacent incisor;
5. Root resorption of adjacent incisor;
6. Labio-palatal position of the canine crown;
7. Labio-palatal position of the canine apex.
60

61. 1.Canine angulation to the midline
Grade 1: 0–15°
Grade 2: 16–30°
Grade 3 31°
61

62. 2. Vertical Canine Crown Height
Grade 1: Below the level of the cemento-enamel
junction (CEJ).
Grade 2: Above the CEJ, but less than half way up
the root.
Grade 3: More than half way up the root, but less
than the full root length.
Grade 4: Above the full length
of the root.
62

63. 3. Position of Canine Root Apex Antero-posteriorly
Grade 1: Above the region of the canine
position.
Grade 2: Above the upper first premolar
region.
Grade 3: Above the upper second premolar
region.
63

64. 4. Canine Overlap of the Adjacent Incisor Root
Grade 1: No horizontal overlap.
Grade 2: Less than half the root width.
Grade 3: More than half, but less
than the whole root width.
Grade 4: Complete overlap of root
width or more.
64

65. 5. Presence of Root Resorption of the Adjacent
Incisor
The presence or absence of root resorption of the
adjacent upper incisor was recorded as judged
from examination of the OPG, although, a further
50 per cent of patients may have bucco-lingual root
resorption that is not diagnosed by routine
radiography (Ericson and Kurol, 1987).
65

66.  Conclusion:
The orthodontists’ decision to expose or remove an
impacted upper permanent canine, based on
radiographic information, seems to be primarily
guided by its labiopalatal position and it angulation
to the midline.
66

67. 67
Dentmaxillofacial Radiology 2012
British Institute of Radiology
 Study done by YH Jung, H
Liang, BW Benson, DJ Flint and
BH Cho: to correlate the position
of impacted maxillary canines on
panoramic radiography with
cone beam CT (CBCT) and
analyse the labiopalatal position
of canines and root resorption of
permanent incisors in CBCT
according to the mesiodistal
position of canines on
panoramic radiographs.
 This study suggests that the
labiopalatal position of impacted
canines and resorption of
permanent incisors might be

68. Lateral Cephalogram
 This represent a true
lateral view of the skull
which defines the
anteroposterior i.e
mesiodistal position and
vertical position of the
tooth. Periapical views can
be misleading to determine
vertical position of canine.
 A lateral cephalogram
gives a accurate location of
canine in vertical and68

69. Perapical view
 First and the most simplest view
Advantages
1) Root development, pattern and
integrity
2) Crown resorption
3) Root resorption of adjacent tooth
4) Minimum of surrounding tissue is
exposed which increase
accuracy and resolution.
5) Minimal radiation exposure
Disadvantage
1) 2D picture of 3D object
2) cannot determine bucco-lingual
position of tooth & vertical
position of impacted tooth.69

70. 70
Principle:
• 2 periapical views of the same object are taken from slightly
different angles which can provide depth to the flat 2-D
picture depicted by each of the films individually.
• Useful in distinguishing the buccal or lingual displacement of
the canine.
Tube shift technique or Clarke
technique (parallax method)
Mesial
angulation
Normal
angulation
Distal
angulation
Given by CLARK in 1909
Based on binocular principle
Later refined by Richard in 1948

71. 71
Procedure:
1.In the periapical film, the X-ray
is taken in the area of interest
with the X-ray beam passing
perpendicular to a tangent to
the line of arch at this point & at
an appropriate angle to
horizontal plane.
2.In the second film, the X-ray
tube is shifted mesially or
distally round the arch but held
at the same angle to the
horizontal plane. The X-ray
tube should describe between
30-450 of an arc of circle whose

72. 72
Result:
• It is based on the SLOB principle.
• If the object has moved on the same side as that
of the X-ray tube it is lingually placed & if it has
moved on the opposite side it is on the buccal
side.
Disadvantage:
In cases when canine is highly placed, and
Periapical film shows no superimposition of canine
with the roots of erupted tooth or when

73. Vertical tube shift method
 Left canine is highly placed in OPG.
 In IOPA left canine moves towards apical 1/3 of lateral
incisor.
73

74. CT Scan
 By Ericson & Kurol
 Used to diagnose the exact
position of an impacted tooth.
 Clear serial radiographs may be
taken at graduated depth in any
part of human body in this
method.
 This technique allows the
elimination of superimposition
of other structures.
 It is however rarely used in the
diagnosis of impacted teeth
because of
(1) Large radiation dosage.
74

75. CBCT
75
 Cone beam
computed
tomography
(or CBCT, also
referred to as C-arm
CT, cone beam
volume CT, or flat
panel CT) is a
medical imaging
technique consisting
of X-ray computed
tomography where
the X-rays are

76. CBCT
76
 CBCT is more accurate than
conventional techniques in
localising impacted maxillary
canines.
 CBCT is more reliable than
conventional techniques
 There is no robust evidence
that supports using CBCT as
the first line imaging technique.
We should only use it when
conventional radiography does
not provide sufficient
information.
Cone-beam computed tomography vs conventional radiography in visualization
of maxillary impacted-canine localization: A systematic review of comparative
studies. Ehsan Eslami et al. Am J Orthod Dentofacial Orthop 2017;151:248-58

77. 77
Journal of
Orthodontic
Sciences 2014

78. 78
 A study was done by Ali Alqerban et al AJODO March
2015, to compare 3D CBCT images of unilaterally
impacted canines with the normal contralateral sides,
and to detect possible radiographic factors involved in
maxillary canine impaction.
 Prediction of the probability of canine impaction based
on CBCT was excellent. The canine angulation to the
lateral incisor on the coronal view, the canine cusp tip to
the occlusal plane on the sagittal view, and the canine
crown position were the strongest predictors based on
the CBCT radiographs and may help orthodontists to
identify the probability of impaction for optimally timing
the intervention.

79. Cone-beam computed tomographyand the orthosurgical management of impacted
teeth79
CBCT imaging can be used to interpret buccolingual
information in detail, to distinguish and define the extent and
depth of root resorption, and to delineate long-axis orientation
of unerupted teeth, including root apex location. It is able to
synthesize traditional panoramic and cephalometric
radiographs. permits oral surgeons to visualize the position
and surgical anatomy of the tooth as it will be seen in the
operating theater and allows orthodontists to plan directional
traction.

80. Rapid Prototyping
 A new method for diagnosis and treatment
planning of maxillary canine impaction.
 Rapid prototyping' is a group of techniques
used to quickly fabricate a scale model of a
physical part or assembly using three-
dimensional computer aided design (CAD)
data.
Rapid prototyping as a tool for diagnosis and treatment planning for maxillary canine
Jorge Faber, Patrícia Medeiros Berto, and Marcelo Quaresma, AJODO 2006;129:583
80

81. 81

82. PROGNOSIS

83. Determining the Prognosis
 Factors influencing the treatment
decision of an impacted canine
Position of canine –
Favorable or Unfavorable
Age of patient
Availability of space
Presence of adequate
width of attached gingiva
VERTICA
L RULE
OF
THIRDS
HORIZONTAL
RULE OF
THIRDS83

84. Treatment alternatives
1. No treatment, if the patient does not desire it.
Since the long term prognosis of deciduous canine
is poor as its root may eventually resorb , it should
be periodically evaluated.
2. Auto transplantation of the canine.
3. Extraction of impacted canine and moving
premolar in its position.
4. Extraction of the canine & posterior segmental
osteotomy to move the buccal segment mesially to
close the residual space.84

85. Treatment alternatives
5. Prosthetic replacement of the canine, not
amendable for juvenile cases.
6. Most desirable approach is surgical exposure of
the canine followed by orthodontic treatment.
85

86. TO BE CONTINUED…
86

87. RECAPE
87

88. MANAGEMENT

89. General Steps in
Mechanotherapy
 Leveling and Alignment of the erupted teeth.
 Creating enough space for the impacted
canine and maintaining it.
 Conversion of the arch into a rigid anchorage
unit.
 Surgical exposure of the crown of the
impacted canine and attachment bonding.
 Application of low force (60gm) traction from
rigid anchorage unit.
89

90. Method of creating space
 One of the primary objective of orthodontic
treatment of impacted canine is the creation of
space in the dental arch for the impacted tooth
alignment.
A) Existing incisor space
Becker showed incisor spacing was due to failure
of completion of ugly duckling stage of
development. During final stage these existing
space will be closed by mesial movement of
lateral incisor.
90

91. 91
B) Improving arch form
 The achievement of good
arch form is an important
initial goal in the maxillary
arch in non extraction
cases.
 Maxillary canine erupt more
buccally to deciduous
canine and slightly buccally
to premolar and lateral
incisors.
 So improving arch form
after extraction of
deciduous canine will add
2-3 mm of space.
Method of creating space

92. 92
C) Increasing arch
length
In mild crowding cases
distalization of molar
is recommended which
increases the arch
length.
Method of creating space

93. 93
D) Extraction as means of prevention
(Mixed dentition period)
A) deciduous canine
Erickson and Kurol concluded that patient with age
of 10-13 years preferably with delayed dental
age, palatal displacement of canine with apex
confirmed in line of arch requires extraction of
deciduous canine for good prognosis for eruption
of permanent canine.
Method of creating space

94. 94
B) First Premolar
I) Crowding Of Maxillary Arch
II) Bimaxillary Protrusion
III) Class II Relation
C) Lateral Incisor
Peg Shaped Or Severely Malformed Lateral
Incisor (Dens Invaginatus) Can Be Extracted Instead
Of Healthy Premolars.
D) Central Incisor
When There Is Advanced Resorption Of Central
Incisor Roots More Than 23rd And Canine Erupting
In A Line Close To The Long Axis Of The Incisor,
Extraction Of Incisor Is Indicated.

95. Anchorage consideration and space
maintenance
95
 Use of full dimension
stainless steel rectangular
wire in edgewise brackets
 Use of 0.022 / 0.020 wires
with uprighting springs or
torquing springs to act as
brakes if necessary in
beggs and tip-edge
appliance.

96. Micro implant anchorage
96
• The microscrew should be placed in the labial
cortical alveolar bone, at an angle of 10-20° to
the bone surface and as parallel to the tooth's
long axis as possible.
• This keeps the apex of the microscrew on the
buccal side and reduces the likelihood of its
contacting the root.
• The head of the microscrew should be located
as incisally as possible to maximize the
vertical component of force.
Micro-Implant Anchorage for Forced Eruption of Impacted
Canines
PARK et al, JCO 2004; 38; 297-302.

97. 97
Micro-Implant Anchorage for Forced Eruption of Impacted
Canines
PARK et al, JCO 2004; 38; 297-302.
Micro implant anchorage

98. Micro implant anchorage
98
 In lingual treatment, the smaller
arches that are required for the
shorter interbracket distances
and smaller bracket slots may
not be able to resist distortion.
 The impacted canine needs to
pass over the archwire during
buccal movement.
 These considerations make
skeletal anchorage for eruption
of impacted canines even more
appealing in lingual
orthodontics than in labial
appliance treatment.
Micro-Implant Anchorage for Forced Eruption of Impacted
Canines
PARK et al, JCO 2004; 38; 297-302.

99. 99
Mandibular Anchorage
• Lingual arch is fabricated with
0.036 inch SS wire
• Vertical hooks (5-6mm in length)
• Elastic force should not exceed
40-60 gm
Advantages
• Simplicity in appliance design
and application
• Reduced overall treatment time
Management of impacted maxillary canines using mandibular anchorage.
Pramod K. Sinha, and Ram S. Nanda; AJODO March 1999

100. Surgical exposure to allow natural
eruption to occur
100
• Most useful when the canine has a correct axial
inclination and does not need to be uprighted
during its eruption.
• Clark recommended that a polycarbonate crown
be placed over the impacted tooth after its
surgical exposure.
• The crown should be made long enough to
extend through a window cut in the palatal tissue.
• Often, 6 months to 1 year may elapse before the
impacted tooth has erupted sufficiently to permit
removal of the polycarbonate crown and its
replacement with an orthodontic attachment.
• If the tooth fails to erupt, clark recommends the
removal of any cicatricial tissue surrounding the
crown.
Clark D. The management of impacted canines: free physiologic eruption. J Am
Dent Assoc 1971;82:836-40.

101. Types of Flaps for Impacted
Canine
101

102. 102

103. Type of Flaps for Impacted
Canine
103
Buccally accessible impacted tooth
 A circular incision

104. 104
Type of Flaps for Impacted
Canine
Apically repositioned surgical flap Full flap
closure
Uncovering labially impacted teeth: apically positioned flap and closed
eruption technique. Vermette et al; AO 1995; 65: 23-32.

105. 105
Type of Flaps for Impacted
Canine
Palatal Impaction
• Partial
• Full flap closure

106. Two approaches are generally
recommended in regard to the timing
of placing the attachment
106
 Two-step approach.
• First, the canine is surgically uncovered and the
area is packed with a surgical dressing to avoid
the filling in of tissues around the tooth.
• After wound healing, within 3 to 8 weeks, the
pack is removed, and an attachment is placed on
the impacted tooth.
AJO-DO1998 Volume 1992 Feb SPECIAL ARTICLE - Bishara

107. Two approaches are generally
recommended in regard to the timing
of placing the attachment
107
 One-step approach.
• The attachment is placed on the tooth at the time of
surgical exposure. The tissues over the attachment
should be excised, and a periodontal pack should be
placed. This approach is particularly recommended for
palatally impacted teeth.
• One of the important advantages of such an approach
is that when the force is applied to the impacted tooth,
the clinician is able to visualize the crown of the tooth
and to have better control over the direction of tooth
movement.

108. Attachments for canine
108
A. Lasso wire – Shapira and
Kuftinec
1) poor control over direction of
extrusion
2) risk of external root
resorption near CEJ
3) risk of alveolar crestal bone
loss and loss of attachment
epithelium
B. Orthodontic bands
1) Requires extensive bone
rempval
Shapira Y, Kuftinec MM. Treatment of impacted cuspids: the
hazard lasso. Angle Orthod 1981; 51: 203–207.

109. Attachments for canine
109
C. Threaded Pins – Becker and
Zilberman
1) Chances for non vitality of
the tooth
2) Needs restoration of the
tooth at the end of treatment
D. Standard Orthodontic
Brackets – Jacobi, Nielson
1) easy to perform
2) more reliable method

110. Attachments for canine
110
E. 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

111. Attachments for canine
111
F. Magnets
During developmental stage.
- Greatest disadvantage is
corrosion.
- Method is clumsy and
inconvenient.
G. Cast Canine Cap – Lewis,
Dewel
- Requires extensive crown
preparation
Treatment of an impacted canine with magnets. Darendelier et al; JCO 1994;28:63

112. Force Generating Devices
112
 Active palatal arch
(Becker1978)
• It consist of fine 0.020 inch
removable palatal arch wire
carrying an omega loop on each
side.
• End of the wire is doubled for
Frictionless fit in lingual sheath.
• It is activated by elevating
downward activated palatal arch
wire and hooking the pigtail

113. Force Generating Devices
113
Ballista Spring (Jacoby 1979)
• A ballista loop is a simple, convenient,
unobtrusive method of applying a vertical vector
of force to a palatally impacted tooth to erupt the
crown into the center of the alveolus.
• When the canine crown is displaced mesially and
lies over the root of the permanent lateral incisor,
an apically positioned flap is the appropriate
surgical uncovering technique.
• Exposure of the crown facilitates attachment of
an elastomeric chain directed toward the center
of the edentulous alveolar ridge to gradually
guide the canine crown into the dental arch.

114. 114
• It is made of rectangular wires.
• It proceeds forward until it is opposite to canine
space and bent vertically downwards and
terminate into a small loop.
• With slight finger pressure ,spring is tied to pigtail
ligature, by this it provide an extrusive force for
the canine to erupt.
• If the impacted tooth is resistant to movement or
if the distance for the tooth to move is more it will
leads to lingual molar root torque leads to loss of

115. 115
Kokich V. AJODO Sept., 2004

116. Force Generating Devices
116
 Light Auxiliary Labial Arch
(Kornhauser1996)
• This loop has a small helix.
• Wire is tied with the basal
arch wire in piggyback
fashion.
• If basal arch wire is not used
it will leads to extrusion of
adjacent tooth and cause
alteration of occlusal plane.

117. Force Generating Devices
117
 TMA Box Loop
• TMA .017 X .025 wire used.
• Produce sagittal and horizontal
corrections while continuing
vertical eruption.
Alignment of Impacted Canines with Cantilevers
and Box Loops; Surendra Patel; JCO 1999

118. Force Generating Devices
118
 Cantilever Spring
• Initial extrusion mechanics with
a cantilever.
• Use of a box loop to continue
canine extrusion and to make
1st- and 2nd-order corrections.
• Incorporation of the canine into
a continuous archwire for
finishing.
• TMA .017 X .025 wire used
JCO Feb 1999

119. 119
 Australian Helical Archwire
• Made in special plus .016”
arch wire
• Force should not exceed
200 gm
• Activation by twisting the
steel ligature wire every two
weeks
Eruption of impacted canines with an Australian Helical Archwire. Hauser et al;
JCO Sep 2000
Force Generating Devices

120. 120
The amount of force can varied by using different arch
wire designs

121. 121
 The K-9 Spring
• Made in 0.017”X 0.025”TMA
wire
• Simple in design
• Low cost
• No patient compliance
• Light continuous eruptive and
distalizing forces
The K-9 Spring for Alignment of Impacted Canines. Varun Kalra;
Force Generating Devices

122. Force Generating Devices
122
 The Monkey Hook S.Jay Bowman (2002)
• It is a simple auxiliary with an open loop on
each end for the attachment of intra oral elastic
or elastomeric chain or for connecting to a
bondable loop button.
• A combination of monkey hooks and bondable
loop-buttons allows the production of a variety of
different direction force such as:
The Monkey Hook: An Auxiliary for Impacted, Rotated, and Displaced
Teeth.

123. 123
Alternative is forming a coil on the place where canine should
lie at the end of treatment and Applying traction using monkey
loop
Application of force in different
planes possible with monkey loop
Application of traction from lower

124. Force Generating Devices
124
 Kilroy Spring
• The Kilroy Spring is a constant
force module that is slid onto a
rectangular archwire over the site of
an impacted tooth.
• In the passive state, the vertical
loop of the Kilroy Spring extends
perpendicularly from the occlusal
plane (Fig. 2).
• To activate the spring, a stainless
steel ligature is guided through the
helix at the apex of the vertical
loop, and the loop is directed
toward the impacted tooth. The
ligature is then tied to anBowman S. & Carano A. JCO

125. Force Generating Devices
125
 Kilroy II Spring
• The Kilroy II Spring was
designed to produce more
vertical than lateral eruptive
forces for eruption of buccally
impacted teeth.
• Its multiple helices increase
its flexibility, but also increase
the likelihood of impingement
on the adjacent soft tissue.
• Consequently, more frequent
progress checks are
recommended with the Kilroy

126. 126
 Tunnel Traction
Crescini approached a method called as TUNNEL
TRACTION.
Procedure:
a) Extract deciduous canine
b) Full thickness mucoperiosteal flap is elevated to expose
the cortical plate.
c) Drill with bur until exposing crown of canine
d) Tooth was bonded and ligature wire tied
e) Traction force given after 1week of surgery
Advantage
a) No buccal or palatal access
b) No loss of supporting tissue
Disadvantage:
AJODO 1994

127. 127
Tunnel traction of infraosseous impacted maxillary canines –Tunnel traction of
infraosseous impacted maxillary canines. A three-year periodontal follow-up.
Crescini et al. AJO-DO, Volume 1994 Jan (61 - 72)

128. Guiding tooth to the line of arch
 Once the tooth is moved to the oral environment,
bonding attachment is placed on the midbuccal
aspect to prevent iatrogenic rotation of canine
and guided to the line of arch.
 If the root apex of canine is close to the line of
arch and crown related to the roots of incisors,
pure buccal tipping will bring the crown to
desirable position and inclination.
 If the root apex is distant to the line of arch and
crown not related to the roots of the incisors,
usually it will be impacted deep and may even
cross the mid palatal suture. These tooth can be

129. Guiding tooth to the line of arch
 If there is an horizontal impaction, downward
tipping should be cautiously applied. Force
application should be like the fulcrum of the
canine to be at the root end, so that root apex
don’t alter following the canine tipping movement.
 Unfortunately, fulcrum is usually located short
away from the apical portion of the root, leads to
concomitant palatal displacement of root apex of
canine. This requires buccal root torquing after
alignment of canine in the arch.
 If the root apex mesial to lateral incisor or distal to
premolar, tooth is considered as transposed.

130. Dentigerous Cyst
Dentigerous cyst may inhibit the
eruption of the involved canine.
Dentigenous cyst can be
defined as an odontogenic cyst that
surrounds the crown of an impacted
tooth; caused by fluid accumulation
between the reduced enamel
epithelium and the enamel surface,
resulting in a cyst in which the crown
is located within the lumen.

131. 131
Treatment:
• Marsupialization is the procedure consists of
fenestrating the outer wall of the cyst, and
relieving the intracystic pressure.
• With this early decompression, the size of the
cavity slowly decreases, enabling the surrounding
bone to regenerate around the impacted tooth,
which eventually erupt the tooth into the dental
arch.
• No traction should be applied until bone
regenerates to an acceptable level, as the
periodontal apparatus of such a tooth is weak and
Dentigerous Cyst

132. SUCCESS RATE & DURATION OF
TREATMENT

133. Success rate and duration of
treatment
133
 Younger patients required
a longer treatment.
 The younger the patient,
the more severely
impacted the canine.
 If the canine was impacted
less than 14 mm from the
occlusal plane, treatment
duration averaged 23.8
months;
 If the canine was impacted
more than 14 mm from the
occlusal plane, treatment
duration averaged 31.1
months.Factors that relate to treatment duration for patients with palatally impacted
maxillary canines.
Jeffrey A. Stewart (AJODO 2001;119:216-25)

134. Success rate and duration of
treatment
134
 The success rate among the adults was 69.5%
compared with 100% among the younger controls
 The adults showed significant increase in the
duration and number of treatment visits required
for resolving the canine impaction, in both the
simpler and the more difficult cases.
 It was concluded that the prognosis for successful
orthodontic resolution of an impacted canine
worsens with age.
Success rate and duration of orthodontic treatment for adult patients with
palatally impacted maxillary canines. Adrian Becker, AJODO 2003;124:509-14

135. Success rate and duration of
treatment
135
A rough prediction can be made for number of visits
required:
 Patients aged more than 25 years require remarkably
longer treatments than younger patients (30
additional visits on average).
 The canines with cusp tips farther from the occlusal
plane require longer treatments: 1 additional visit was
required if the distance increased by 0.63 mm in the
panoramic radiograph.
Factors associated with the duration of forced eruption of impacted maxillary ca
A retrospective study. Zuccati et al, AJODO 2006;130:349-56

136. 136
 The canines with cusp tips located mesially to
the axes of the lateral incisors required 10
more visits than the distally located canines
on average.

137. ROOT RESORPTION AND
CANINE IMPACTION

138. Root resorption and canine impaction

139. Impacted maxillary canines and root resorptions of neighbouring teeth: a
radiographic analysis using cone-beam computed tomography Caroline S. Lai, et
• Precise localization of
an impacted canine in
the sagittal plane, as
well as assessment of
the presence and
degree of root
resorption of
neighbouring teeth, is
mandatory in order for
surgeons and
orthodontists to be
able to make an
accurate diagnosis
and interdisciplinary

140. 140
 When used to supplement clinical examination
and conventional radiographic imaging, CBCT
provides additional accurate information about
location of the impacted canine and prevalence
and degree of root resorption of neighbouring
teeth, with high interrater correlation.
 This study found a statistically significant
correlation between root resorption on adjacent
teeth and localization of the impacted canine in
relation to bone or soft tissue coverage as well as
vertical localization of the impacted canine in
relation to the long axis of the neighbouring
incisor.

141. Root resorption and canine impaction
141
• Resorption of roots stops when
canine impaction has been solved.
• Subsequent orthodontic movement
of resorption affected teeth does
not generate further resorption.
• Incisors with severely resorbed
roots have high survival rate.
• Teeth remain vital, and retain their
color, and appearance.
• Teeth show very low degree of
mobility and an improvement in
periodontal bone support following
post treatment retention.
• Splinting is not usually necessary.
Long-term follow-up of severely resorbed maxillary incisors after resolution of an
etiologically associated impacted canine. Adrian Becker; AJODO 2005;127:650-4

142.  The long-term prognosis for
maxillary incisors with root
resorption associated with
ectopically positioned canines is
good.
 In most cases the resorption heals
after management of the ectopic
canine by surgical exposure and
orthodontic repositioning, or by
surgical removal.
 Even in cases with severe
resorption, the incisor roots show
good long-term healing.Incisor Root Resorption Due to Ectopic Maxillary Canines A Long-Term
Radiographic Follow-Up Babak Falahat; Sune Ericson; Rozmary Mak D’Amico;
Krister Bjerklin Angle Orthodontist, Vol 78, No 5, 2008

143. 143
 Resorption sites, which are recorded at initial
registration and subsequently undergo repair,
might be difficult to identify at follow-up if
evidence is limited to intraoral radiographs.
 Incisors with root resorption can be used in an
orthodontic appliance system.
 No indications are present for endodontic
treatment to arrest further root resorption.

144. IMPACTED CANINE &
PERIODONTIUM

145. 1. Labially impacted maxillary anterior teeth
uncovered with an apically positioned flap
technique have more unaesthetic sequalae than
those uncovered with a closed-eruption
technique.
2. Negative esthetic effects, such as increased
clinical crown length, increased width of attached
tissue, gingival scarring, and intrusive relapse
were evident in the teeth treated with an apically
positioned flap.Uncovering labially impacted teeth: apically positioned flap and closed-eruption tech
Vermette et al; Angle Orthodontist 1995 No. 1, 23 - 33:
Apically positioned flap vs closed eruption
Impacted Canine and
Periodontium

146. Impacted Canine and
Periodontium
 A study was done to evaluate the periodontal health
and tooth vitality of palatally impacted and buccal
ectopic maxillary canines after completion of
orthodontic treatment.
 Conclusion: All ectopic canines had increased plaque
and gingival bleeding index, greater pocket depths,
reduced attached gingival width, higher gingival
levels, increased crown lengths, higher electric pulp
testing scores, and reduced bone levels compared to
their contralaterals.
Periodontal status of ectopic canines after orthodontic treatment. AO
2014

147. RETENTION

148. Retention considerations
148
Evaluation of post treatment alignment by Becker et
al
• Incidence of rotations and spacing
1. Impacted side - 17.4%
2. Control side - 8.7%
• Ideal alignment on control side is twice as often
as the impacted side.
Impacted maxillary canines: A review; Samir E. Bishara; AJODO 1992;101:159

149. Retention considerations
149
 To minimize rotational relapse, options available
are
1. Fiberotomy
2. Bonded fixed retainer
 Clark’s suggestion for palatally impacted canine:
Lingual drifting can be prevented by removal of
half moon- shaped wedge of tissue from lingual
Impacted maxillary canines: A review; Samir E. Bishara; AJODO 1992;101:159

150. When to extract impacted
canines???
150
(1) If it is ankylosed and cannot be transplanted,
(2) If it is undergoing external or internal root
resorption,
(3) If its root is severely dilacerated,
(4) If the impaction is severe (e.G., The canine is
lodged between the roots of the central and
lateral incisors and orthodontic movement will
jeopardize these teeth)
(5) If the occlusion is acceptable, with the first
premolar in the position of the canine and with
an otherwise functional occlusion with well-
aligned teeth
(6) there are pathologic changes (e.G., Cystic

151. Mandibular Canine Impaction
151
 Not much is present in literature about
mandibular canines as its occurrence is a rare
condition.
 For lingually placed canine, attachment has to be
bonded on buccal surface only, buccal surgical
exposure preferred.
 Treatment principles are same as followed during
maxillary canines, keeping the final prognosis in
mind.

152. 152
 The incidence of impacted and transmigrant
mandibular canines in the mandible is not as high as
that in the maxilla; consequently, it is more difficult to
find clinical guidelines derived from sound studies
based on large patient samples.
 Conclusions
1.The incidence of mandibular canines impaction
ranges between 0.92 and 5.1 per cent, while that of
transmigration ranges from 0.1 to 0.31 per cent.
2.Although the precise aetiology remains unknown,
odontomes, cysts, and lateral incisor anomalies are
more likely to play a role.
3.The most common treatment strategies are surgical
extraction and orthodontic traction for impacted
mandibular canines, surgical extraction, and
radiographic monitoring for transmigrant mandibular
canines: based on the finding of the present review, a
decision tree was proposed in order to guide
practitioners through the treatment plan elaboration.
Impacted and transmigrant mandibular canines incidence, aetiology, and
treatment: a systematic review. Dalessandri D. et al. Eur J Orthod 2017;

153. 153

154. 154
 An article was publised in Journal of Orthodontic
Sciences by Sneh Lata Verma (2012) to report
the management of a transmigrated mandibular
canine with emphasis on saving the tooth as
natural part rather than surgical removal of the
transmigrated tooth.
 The technique, surgical repositioning of a tooth
involves the surgical extraction of impacted tooth
and fixation in the correct position in the dental
arch after surgical preparation (correction) of the
alveolar socket. It is especially valuable in cases
of difficult-to-treat impaction.

155. 155
 A repositioned
tooth is better
substitute than
fixed or removable
prostheses, and
the technique is
more cost effective
than other
methods. Patients
with excellent oral
hygiene should be
considered as
preferred
candidates for

156. 156

157. 157
 Disadvantages include the invasiveness of
surgery, the difficulty of projecting long term
stability due to chances of root resorption and
loss of gingival attachment.

158. CONCLUSION

159. Conclusion
 Various surgical and orthodontics techniques may
be used to recover impacted maxillary canines.
 Proper management of these teeth requires
appropriate surgical techniques to apply forces in
a favourable direction and to have complete
control for efficient correction, thereby avoiding
damage to the adjacent teeth.
 The management of impacted canine is a
complex procedure requiring a multidisciplinary
approach.
 The clinician should communicate with each other
to provide the patient with an optimal treatment
plan based on scientific rationale.
159

160. BIBLIOGRAPHY

161. Bibliography
 Orthodontic Treatment of Impacted Teeth –
Adrian Becker (Third edition).
 Impacted Maxillary Canines: A Review; Samir E.
Bishara; AJODO 1992;101:159-71
 Reliability of a method for localisation of
displaced maxillary canines using a single
panoramic radiograph. Chaushu et al; clin orthod
res 1999; 2: 194-9
 Early treatment of palatally erupting maxillary
canines by extraction of the primary canines.
Ericson S. & Kurol J.; European Journal of
Orthodontics 1988;10: 283-295161

162.  Prediction of maxillary canine impaction using
sectors and angular measurement. Warford J. Jr
et al AJO-DO 2003; 124(6): 651-655
 Radiographic Factors Affecting the Management
of Impacted Upper Permanent Canines. Stivaros
N. & Mandall N.A. Journal of Orthodontics 2000;
27: 169-173
 Localization of Impacted Canines: A Review.
Kumar S. Journal of Clinical and Diagnostic
Research 2015; 9(1): 11-14
 Micro-Implant Anchorage for Forced Eruption of
Impacted Canines PARK et al, JCO 2004; 38;
297-302.
162

163. 163
 Clark D. The management of impacted canines:
free physiologic eruption. J Am Dent Assoc
1971;82:836-40.
 Uncovering labially impacted teeth: apically
positioned flap and closed eruption technique.
Vermette et al; AO 1995; 65: 23-32.
 Shapira Y, Kuftinec MM. Treatment of impacted
cuspids: the hazard lasso. Angle Orthod 1981;
51: 203–207.
 Treatment of an impacted canine with magnets.
Darendelier et al; JCO 1994;28:639-43
 Alignment of Impacted Canines with Cantilevers

164. 164
 Management of impacted maxillary canines using
mandibular anchorage. Pramod K. Sinha, and
Ram S. Nanda; AJODO March 1999
 Eruption of impacted canines with an Australian
Helical Archwire. Hauser et al; JCO Sep 2000
 The K-9 Spring for Alignment of Impacted
Canines. Varun Kalra; JCO Oct 2000
 The Monkey Hook: An Auxiliary for Impacted,
Rotated, and Displaced Teeth. S. JAY BOWMAN
et al; JCO 2002 July. Bowman S. & Carano A.
JCO Dec., 2003

165. 165
 Tunnel traction of infraosseous impacted
maxillary canines. A three-year periodontal follow-
up. Crescini et al. AJO-DO, Volume 1994 Jan (61
- 72)
 Factors that relate to treatment duration for
patients with palatally impacted maxillary canines.
Jeffrey A. Stewart (AJODO 2001;119:216-25)
 Success rate and duration of orthodontic
treatment for adult patients with palatally
impacted maxillary canines. Adrian Becker,
AJODO 2003;124:509-14
 Factors associated with the duration of forced
eruption of impacted maxillary canines: A

166. 166
 Incisor Root Resorption Due to Ectopic Maxillary
Canines A Long-Term Radiographic Follow-Up
Babak Falahat; Sune Ericson; Rozmary Mak
D’Amico; Krister Bjerklin Angle Orthodontist, Vol
78, No 5, 2008
 Uncovering labially impacted teeth: apically
positioned flap and closed-eruption techniques.
Vermette et al; Angle Orthodontist 1995 No. 1, 23
- 33
 Periodontal status of ectopic canines after
orthodontic treatment. AO 2014. Ays¸egu¨ l
Dalkılıc¸ Evrena; S¸ irin Nevzatog˘ lub; Tu¨ lin
Arunc; Ahu Acard
 Impacted and transmigrant mandibular canines

167. THANK YOU