After the third molar most common impaction is maxillary canines. This article help to how to treat impacted maxillary canines by surgical and orthodontic.

1. Journal Club
Dr. Mahipal Singh
Junior resident
Govt. Dental College,Kottayam.

2. Introduction of Author
 He was editor-in-chief of the AJO-DO.
 Dr Kokich wrote 21 book chapters,84 scientific articles,
48 review articles, and 32 editorials
for the AJO-DO.

3. Introduction
• Impaction is a condition in which a tooth is embedded in the alveolus so that its eruption is impeded and is
locked in position by bone or adjacent teeth.(KUFTINEC & SHAPIRA)
• The mechanical management of impacted teeth is a routine task for most orthodontists.
• After the third molars, the maxillary canines are the most commonly impacted permanent teeth.
• One third of impacted maxillary canines are positioned labially or within the alveolus, and two thirds are
located palatally.
• This is literature review type of article.
• The appropriate timing and surgical procedure for uncovering an impacted canine are determined by specific
criteria.

4. Labial impaction
• According to Jacoby (AJ0;1983) 83% of buccal
impaction have insufficent space for eruption.
• Williams (Angle Orthod 1981) suggested that
extraction of the maxillary deciduous canine as
early as 8 or 9 years of age will enhance the
eruption and self-correction of a labial or intra-
alveolar maxillary canine impaction.

5. • Labial impaction of a maxillary canine is due to
ectopic migration.
• Olive (Aust Orthod J 2002) suggested that opening
space for the canine crown with routine
orthodontic mechanics might allow for
spontaneous eruption of an impacted canine. but
in some situations, even these techniques do not
work, and the orthodontist must refer the patient
to have the labial impaction uncovered surgically.
• Three techniques for uncovering a labially
impacted maxillary canine.
 Excisional uncovering.
 Apically positioned flap.
 Closed eruption techniques.
In impacted labially any of the3 techniques could
be used, because generally there is little if any
bone covering the crown of the impacted canine.

6. Orthodontist should evaluate 4 criteria to determine the correct method for uncovering the tooth.
 Assess the labiolingual position of the impacted canine crown.
 The second criterion to evaluate is the vertical position of the tooth relative to the mucogingival junction.
 The third criterion to evaluate is the amount of gingiva in the area of the impacted canine.
 The fourth and final criterion to evaluate is the mesiodistal position of the canine crown

7. • There are four techniques under two groups;
Closed
technique
Tunnel
traction
Flap closed
eruption
technique(
M c bride
1979)
Open
technique
Window
exposure
Apically
repositioned
flap

8. Excisional uncovering
Space creation
Tooth was labially.
positioned coronal to mucogingival
junction.
 sufficient gingiva in area
Simple excisional use for
uncovering.
• In this procedure 15 no. surgical blade
used.
• Ideal exposure technique should expose
½ to 2/3 part of crown.
• Ensure proper health for the erupting
tooth.(tooth must have a coller of
attached gingiva at least 2-3 mm in
width.

9. Apically positioned flap
• the canine crown were positioned apical to the
mucogingival junction(2nd criteria) , an excisional
technique would be inappropriate, because it
would not result in any gingiva over the labial
surface of the tooth after it had erupted.
• Vanarsdall& corn (1977) For superficial , high ,
labially placed canine .
• Surgical transfer of attached gingiva to a higher
apical level is done, creating a wide attached
gingiva zone.

10. Apically positioned
flap technique
Buccal object rule
indicated tooth was
positioned labially.
cusp tip was positioned above
mucogingival junction and was
displaced mesially
Tooth was
gradually
moved distally

11. • For both labial and palatal canine impactions located high in the alveolus both superfical and deep.
• a closed eruption technique will provide adequate gingiva over the crown and does not result in reintrusion
of the tooth in the long term.
• Procedure
 Flap is raised but should not expose cemetoenamel junction.
 Window of bone removed
 Multipurpose attachment with is bonded to the canine.
 Reposition flap and suture .
Closed eruption techniques

12. Closed
eruption
technique
Labial flap was elevated, and
sufficient bone around crown
was
removed to allow eruption
without impingingon bone.
Ballista loop was used to erupt
tooth
Canine was then
placed in its proper
position in arch.
After
orthodontic
treatment

13. Orthodontic mechanics and long-term stability
• The mechanics to erupt a labially impacted tooth should mimic the normal eruptive process.
• If the canine crown were uncovered with a closed-eruption technique then the orthodontist should select mechanics
that erupt the tooth into the center of the alveolar ridge.
• This method would produce normal labial gingival relationships over the erupted tooth.
• To avoid mechanics that draw the tooth labially, which could produce a bony dehiscence and accelerated migration of the
labial gingival margin, resulting in labial recession.
BALLISTA SPRING(jacoby 1979)
It is a simple, convenient, unob-
trusive method of applying a vertical vector of
force
to a labially impacted tooth to erupt the crown
into
the center of the alveolus.
0.018 INCH Continuous SS wire used.

14. • Early treatment auxillaryes before FAT (Fleming et al
2010)
 Magnets in conjuction with removable appliance.
 TAD’S
 Removable appliance to apply traction to palatally
impacted canine using elastics and monkey hook.
 TMA- “fishing rod”(17x25)
• Auxillary in conjunction of PEA
 Stainless steel auxillary made with 014 SS with
vertical loop and helix.(kornhauser1996)
 Active palatal arch(becker1978)
 The K-9 spring for alignment of impacted canine
(Varun kalra2000)

15. • Vermette et al compared the periodontal and esthetic result after
closed eruption and apically positioned flap techniques.
• They found no significant differences in gingival index, plaque
index, pocket depthand bone level between these 2 techniques,
but they identified significant esthetic differences.
• With an apically positioned flap, the crown length of the
impacted tooth is longer than normal.
• The crown lengths of teeth uncovered with closed eruption were
similar to contralateral nonimpacted teeth in the same mouth.
• Second, and perhaps more disturbing, high labial impactions
uncovered with an apically positioned flap tend to reintrude after
orthodontic treatment.
• As the tooth is erupted into the dental arch, the mucosa is drawn
coronally. this mucosal attachment tends to pull the crown of the
tooth apically. This disadvantage was not observed in teeth
uncovered with closed eruption.

16. • Becker et al (Am J OrthodmDentofacial Orthop
2002) found similar favorable esthetic results in
their study of the closed eruption technique for
uncovering impacted maxillary central incisors.

17. Radiographic verification of crown position
• Radiographic examination
To assess
 Relation to midline
 Relation to adjacent teeth
 Resorption status of the canine
• In three dimension vertical,mesiodistal& bacco-palatal.

18. • PERAPICAL FILM
Tube shift technique or clarke rule- SLOB;This is based on binocular principle where two periapical views of same
object are taken in different angle.
. OCCLUSAL FILM – it gives buccolingual position in conjuction with periapical film.
. Extraoral-
 frontal & lateral cephalogram
 CT SCAN-
 PANORAMIC FILM-
• The orthodontist must rely on the buccal object rule to identify the exact labiolingual position of the crown.
• The buccal object rule states that when viewing 2adjacent periapical radiographs of the impacted tooth taken at
slightly different horizontal angles, the buccal object will move in the opposite direction.
• If the impacted canine were located palatally, the crown of the tooth would move in the same direction as the
x-ray beam.
• A mnemonic method for remembering this principle is the S.L.O.B. rule (same lingual oppo-site buccal). of the x-
ray beam.

19. • Palatal impaction accounts for almost 85% of all canine impaction.(Jacob;AJO 1983)
• Palatally impacted canine are related to excessive space in the dental arch.
• The mesiodistal dimension of maxillary teeth including were reduced significantaly in palatal impaction
canine.(BECKER;EJO 2002)
• The shape of the maxillary arch was narrower and longer in palatally impacted canine group.(KIM et al; AJODO20120
• According to Power & Shot(1993)- Extraction of primary canines result ed in 62% of the canine erupted normally and 19%
showed improvement in the positioning.
• Baccetti (EJO2008)- Removal of deciduous canine alone showed correction in 65.2% cases.
• Baccetti (AJO2009)- Use of a RME as a early interceptive approach is effective for increasing rate of impacted canine.
Palatal impaction

20. • Ericson and Kurol(Eur J Orthod1988;10:283-95.) showed
that early extraction of deciduous maxillary canines will
result in normal eruption of ectopically displaced
permanent maxillary canines.
• In their extension study They found that, if periapical
radiographs showed that the crown of the permanent
canine were positioned over the root of the maxillary
lateral incisor, but not past the mesial surface of the root,
self-correction of the ectopic canine occurred with high
predictability if the deciduous canine were removed.
• But if it is not occured then The palatally impacted canine
must be uncovered by a surgeon and positioned in the
dental arch by the orthodontist.

21. • Most orthodontists, uncovering a palatally impacted canine occurs after the first 6to 9 months of orthodontic alignment of
the maxillary dentition.
• Space is created for the crown of the impacted tooth, and the patient is referred to a surgeon to uncover the crown.
• Usually, soon after the surgery, the orthodontist begins dragging the crown toward the edentulous site.
• The crown of a palatally impacted canine is often in intimate contact with the lingual surfaces of the roots of the ipsilateral
centraland lateral incisors.

22. • The tooth was not uncovered properly, it could appear to the orthodontist that the tooth is not moving and perhaps could be
ankylosed.
• The problem in these situations is insufficient bone removal over the crown of the impacted canine.
• The dental follicle is deflated and removed,the tooth cannot resorb the bone over the crown efficiently.
• When a force is placed on the tooth and the enamel of the impacted crown comes into contact with the bone, there are no cells in
the enamel to resorb the bone.
• Resorption will eventually occur through pres-sure necrosis, but it will occur slowly.
• Woloshyn et al (Angle Orthod 1994) evaluated 32 patients who had palatally impacted canines that were uncovered in this
manner and then dragged into the dental arch across the lingual surface of the lateral incisor roots. These authors found that the
bone levels on the distal surface of the lateral incisor and mesial surface of the canine were positioned more apically compared
with the contralateral nonimpacted control teeth.

23. • Kokich and Mathews (Impacted teeth: surgical and orthodontic considerations.2001) recommend an
alternative technique with earlier timing for uncovering palatally impacted canines.
 They time the uncovering of palatal canines before the start of orthodontic treatment.
 In some cases teeth are uncovered during the late mixed dentition.
 A full-thickness mucoperiosteal flap is elevated in the area of the impacted canine .
 All bone over the crown is removed down to the cementoenamel junction. The flap is repositioned, and a
hole is made through the gingival flap .
 If the tooth is positioned high in the palate, a dressing is placed over the exposed area in the flap.
 Once the bone and tissue have been removed, these palatally displaced canines will erupt on their own .
 In about 6 to 8 months, the canines generally have erupted to the level of the occlusal plane.
 At that point, a bracket can be placed on the tooth, and the root can be moved through the bone as the
crown is gradually translated into the dental arch.

24. Palatally impacted
maxillary right canine.
Mucoperiosteal flap was
elevated, and it was
determinedthat crown was
still covered with bone.
All palatal bone down to
cementoenamel junction
was removed so that
tooth could erupt
unimpeded.
Hole was placed in flap, and it was
repositioned and sutured over
crown of impacted canine.
Canine erupted
without orthodontic
forces.
Bracket was placed on
crown and root was
moved labially.

25. • Uncover palatally impacted canines early, during the mixed dentition, so that they can erupt autonomously, without
orthodontic intervention, until the crown has erupted to the level of the occlusal plane.
 At that time, it can be moved more efficiently into the dental arch.
 The overall treatment time for the patient is reduced.
 The periodontal and esthetic results are superior compared with previous methods for exposing palatally impacted
canines.

26. CONCLUSION
• It is important for an orthodontics to be aware of normal canine development and associated dental
anomalies.
• Evidance based , scientific assessment of the severity of impaction will help the discering clinician in planning
treatment for more successful outcome.

29. THANK YOU