Canine 2

Ectopic maxillary canine using a lower removable
appliance. Am J Orthod Dentofacial Orthop. 1995;.
• Orton et al reported a principle for
treating an unerupted canine by
assessing the vertical axial eruptive path
(VAEP). They suggested that an ideal
VAEP of an erupted upper canine is
about 10 of labial tipping relative to the
Frankfurt Horizontal plane. They further
suggested that forward tipping of 15
degrees to 25 degrees requires
treatment, tipping of 25 degrees to 45
degrees is progressively more difficult,
and labial tipping of over 45 degrees is
generally orthodontically untreatable.
www.indiandentalacademy.com

Prevention of Impacted
Teeth
• Early detection and intervention
• Removal of primary teeth and/or
supernumeraries to prevent deflection and
enhance the eruptive possibility of the
permanent tooth
• Space maintenance after early loss of
deciduous teeth

TREATMENT PLANNING
PRINCIPLES WITH IMPACTED
TEETH
• Prognosis is based on the extent of
displacement and the surgical trauma
required for exposure
• Tooth should be pulled into the arch
through keratinized tissue, not alveolar
mucosa
• Adequate space should be provided in the
arch prior to attempting to pull the
impacted tooth into positionwww.indiandentalacademy.com

Indications for Serial
Extraction
• a significant arch length discrepancy
exists
• facial profile can support extraction
treatment

Serial Extractionwww.indiandentalacademy.com

Serial Extraction and
Exposurewww.indiandentalacademy.com

Normalization of Mesially
Inclined Canines with
Extraction of Primary
Canines
• 91% normalize if the
canines overlap the
laterals <50% on the
Panorex
• 64% normalize if the
canines overlap the
laterals >50% on the
Panorex
Ericson & Kurol, Eur J Ortho, 1988

Indications for Primary
Canine Extraction
• 10-13 year age group
• normal space conditions are present
• no incisor root resorptions are found
• Follow-up radiographs should be taken at
6 month intervals to follow the intra-bony
eruptive movement of the permanent
canines.

IMPACTED TEETH
TREATMENT OPTIONS
• extraction of adjacent teeth to allow for
eruption of impacted tooth (serial
extraction)
• extraction of impacted tooth
• surgical exposure
• no treatment- allow tooth to remain
impacted
• transplantationwww.indiandentalacademy.com

Indications for
Transplantation
• otherwise well-aligned arch
• adequate space exists for the impacted
tooth
• favorable access to the impacted tooth
• Other issues contraindicate prolonged
orthodontic treatment

Transplantationwww.indiandentalacademy.com

Indications for Extraction of
Impacted Teeth
• Extreme malposition
• Otherwise well aligned arch
• Lengthy treatment contraindicated
– medically compromised
– poor cooperation
– root resorption potential
– periodontal problems
• Ankylosis

• CAUSES FOR POOR PROGNOSISCAUSES FOR POOR PROGNOSIS
• HorizontalHorizontal
• high palatalhigh palatal
• high labial (if above adjacent teeth)high labial (if above adjacent teeth)
• Transalveolar (apex on one side, crown on theTransalveolar (apex on one side, crown on the
other side of the alveolus)other side of the alveolus)
• sclerotic bonesclerotic bone
• closed apicesclosed apices
• abnormal root configurationabnormal root configuration
• older ageolder age
• NOT ALL CUSPIDS CAN BE SAVEDNOT ALL CUSPIDS CAN BE SAVED

EXTRACTION OF IMPACTED TEETHwww.indiandentalacademy.com

Surgical Exposure
Procedures
• Apically Positioned
Flap
• Closed Eruption
• Open Eruption

SURGICAL CONSIDERATIONS
• Maintain adequate amount of attached
gingiva
• avoid excessive bone removal
• do not expose CEJ
• avoid damage to adjacent teeth
• avoid movement, or excess movement

• Palatally inclined canines havePalatally inclined canines have
adequate space, seldom erupt withoutadequate space, seldom erupt without
surgical interventionsurgical intervention
• Labial impactions have arch lengthLabial impactions have arch length
discrepancy, erupt ectopicallydiscrepancy, erupt ectopically
IMPACTED MAXILLARY CANINEIMPACTED MAXILLARY CANINE

SURGICAL TECHNIQUES FOR EXPOSING CANINES
1. Window approach
2. Apically repositioned flap
3. Flap closed eruption procedure
4. Tunnel traction
? what is the criterion for choosing the correct technique.
THE LOCATION OF CANINE

LOCATION OF CANINE IMPACTION
**************
LABIOPALATALLY VERTICALLY
Labial Low
Palatal
Midalveolar High
***************

- LABIAL APPROACH- LABIAL APPROACH
1.Window approach
2. Gingiva Preservation (Vanarsdall & Corn 1977)2. Gingiva Preservation (Vanarsdall & Corn 1977)
* Laterally Positioned Flap For High ImpactionsLaterally Positioned Flap For High Impactions
* Apically Repositioned FlapApically Repositioned Flap
3. Flap closed eruption procedure
4. Tunnelling Method (Cresini 1994)Tunnelling Method (Cresini 1994)www.indiandentalacademy.com

- PALATAL APPROACH- PALATAL APPROACH
• Plenty Of Keratinized GingivaPlenty Of Keratinized Gingiva
• Full Thickness Palatal Flap, With Or
Without Placement Of Button HoleButton Hole
• Placement Of Button Hole Without Flap

IMPACTED MANDIBULARIMPACTED MANDIBULAR
CANINE - LABIAL APPROACHCANINE - LABIAL APPROACH
• Utilize Apically Repositioned Flap OrUtilize Apically Repositioned Flap Or
Vestibular IncisionVestibular Incision
• Watch For Mental NerveWatch For Mental Nerve
• Labial Impactions Often Associated WithLabial Impactions Often Associated With
Retained Primary DentitionRetained Primary Dentition

IMPACTED MANDIBULARIMPACTED MANDIBULAR
CANINE - LINGUAL APPROACHCANINE - LINGUAL APPROACH
• Full thickness flapFull thickness flap
• no releasing incisionsno releasing incisions
• very difficult accessvery difficult access
• fortunately, rarefortunately, rare
• watch for significant anatomywatch for significant anatomy
• does pt have toridoes pt have tori
• lingual impaction associated with shortage oflingual impaction associated with shortage of
arch lengtharch length www.indiandentalacademy.com

IMPORTANCE OF CHOOSING THE CORRECT
TECHNIQUE
- The esthetic appearance
- The periodontal health and
- The longevity of the tooth depend on the technique used
for exposing the tooth
SURGICAL EXPOSURE MAKES THE PERIODONTAL
APPARATUS VULNERABLE TO DESTRUCTION
Kohavi , Vanarasdal
Boyd, Vermette
Bishara, Kokich

- ITS WIDTH IS MAXIMUM IN THE INCISOR REGION AND
MINIMUM IN THE CANINE-PREMOLAR REGION
Alveolar mucosa
Attached gingiva
ATTACHED GINGIVA
For proper periodontal health, the tooth must have a
collar of attached gingiva measuring at least 2-3 mm
in width .

IN THE ABSENCE OF ATTACHED GINGIVA,
THE MUSCLES OF FACE CAN DETACH
THE MARGINAL PERIODONTAL
TISSUE FROM TOOTH CAUSING
MARGINAL BONE LOSS AND
GINGIVAL RECESSION

THE CREATION AND PRESERVATION OF A
FUNCTIONAL BAND OF ATTACHED GINGIVA
MUST BE AN IMPORTANT OBJECT IN THE
SURGICAL EXPOSURE OF LABIALLY
IMPACTED CANINE
*************
THE PALATE HAS A WIDE ZONE OF
ATTACHED GINGIVA

WINDOW APPROACH
Main considerations-
AFTER THE PROPOSED GINGIVECTOMY ,THE
TOOTH MUST HAVE A RESIDUAL COLLAR
OF ATTACHED GINGIVA MEASURING
AT LEAST 2-3 mmwww.indiandentalacademy.com

Palatally impacted canine

APICALLY POSITIONED
FLAP
• split thickness pedicle reflected from edentulous
area
• bone covering the enamel is removed
• flap sutured back to periosteum, leaving 1/2 - 2/3 of
the crown exposed
• surgical dressing placed for 1 week post-op to
prevent tissue overgrowth
• 2 weeks post-op: bond an attachment on the toothwww.indiandentalacademy.com

Apically Positioned Flap

SURGICAL PROCEDURE
Local infiltration anesthesia is given. An incision is
made along the ridge area in the edentulous space. The
incisogingival dimension to this keratinized band of
tissue will be determined by the amount of attached
gingiva that exists on the adjacent teeth or its antimere
in the arch. Vertical releasing incisions are made, and
the attached gingiva is freed. The connective tissue is
removed from the labial aspect of the tooth, and bone is
removed beyond the height of contour of the crown.
Bone removal is not performed beyond the cementoenamel
junction (CEJ) area. The CEJ area is not disturbed
because it is here that we would like to establish
the dentogingival attachment to the tooth
Robert L. Vanarsdall, and Herman Corn, 1977 ajodo

PLACEMENT OF ATTACHED
GINGIVA
• It is essential that the graft be placed to cover the
cementoenamel junction area and 2 to 3 mm of the crown
• The dressing is retained in position for 7 to 10 days to
afford the tissue time for reattachment to the tooth and for
epithelization to occur in the area. Upon removal of the
dressing, a direct bond bracket is attached to the tooth, and
tooth movement is begun immediately with light force.

APICALLY REPOSITIONED FLAP

INDICATIONS –
1 . CANINES WHICH ARE HIGH, SUPERFICIAL &
LABIALLY PLACED
LIMITATIONS –
1. CANNOT BE DONE IF CANINE IS VERY HIGH
2. CANNOT BE DONE IF CANINE IS MIDALVEOLAR

FULL THICKNESS SPLIT THICKNESS
Technique easier to do. Technique more difficult
Thick graft, Thin graft
More scarring Less scarring
Hence poor appearance Better appearance
Injury to flap can cause necrosis.

Complications of APF
• thick gingiva
• rolled margin
• long clinical
crown
• vertical relapse

CLOSED
ERUPTION
• Elevate A Flap At Midcrestal Region
• Remove Enough Bone To Bond An Attachment
• Ligature Wire Or Gold Chain Is Hung From The
Attachment
• Flap Returned To Original Position For Complete
Closure With The Chain Or Ligature Wire Passing
Under The Flap And Exiting At The Midcrestalwww.indiandentalacademy.com

INDICATIONS-
1. Very high canines
2. Midalveolar
canines
FLAP CLOSED ERUPTION PROCEDURE
STEPS-

Closed Eruption

APF vs CE
surgical technique for labially impacted
teeth
Vermette et al, Angle Ortho, 1995;65(1):23-34
• APF
– more post-op recession
– more unesthetic (gingival scarring) (90% vs 6%
with CE)
– significant vertical relapse (intrusion) (61% vs 0%
with CE)
• CE
– narrower post-op zone of attcached gingiva
• HYPOTHESIS
– CE duplicates more of a “natural” tooth eruptionwww.indiandentalacademy.com

Uncovering labially impacted teeth: apically
positioned flap and closed-eruption techniques
Michael E. Vermette, Vin.. Angle Orthodontist
1997 .
• The purpose of this study was to examine
the esthetic and periodontal differences
between two methods of uncovering labially
impacted maxillary anterior teeth: the
apically positioned flap and closed-eruption
techniques.
• The sample consisted of 30 patients who
were recalled a minimum of three months
after orthodontic treatment of a unilateral
labially impacted maxillary anterior tooth.

• . In the CE group, clinical examination showed less width
of attached gingiva on the distal surface and increased
probing bone level on the facial surface of the uncovered
teeth relative to their contralateral controls. Uncovered
teeth in the APF group showed more apical gingival
margins on the mesial and facial surfaces; greater crown
length on the midfacial surface; increased probing
attachment level on the facial surface; increased width of
attached gingiva on the facial surface; increased probing
bone level on mesial, facial, and distal surfaces; and
gingival scarring. Radiographic examination showed
shorter roots on the uncovered teeth in both groups.
Photographic examination revealed vertical relapse of
the uncovered teeth in the APF group.
• labially impacted maxillary anterior teeth uncovered with
an apically positioned flap technique have more
unesthetic sequalae than those uncovered with a closed-
eruption technique.

Indications for Apically
Positioned Flap
on labially positioned impactions
•Labially positioned impacted canine (not mid-alveolus)
•Tooth positioned slightly apical to the muco-gingival junction or
coronal to it
•There is insufficient gingiva in the area of the impacted canine
•The crown of the impacted canine is positioned mesially over the root
of the adjacent lateral incisor
Kokich , AJODO; 126:278-283

Indications for Closed Eruption
on labially positioned
impactions
• Any mid-alveolus impaction
• Labially positioned impacted canine IF:
» Tooth positioned well above the muco-gingival
junction
» There is sufficient gingiva in the area of the
impacted canine
» The crown of the impacted canine is not positioned
too far mesially or distally
Kokich , AJODO; 126:278-283

Open Eruption

OE vs CE
surgical technique for palatally impacted
teeth
Burden et al, AJODO, 1999;115:634-9
• Equal long-term periodontal health of ectopic
canines
• Repeat surgery was more often associated with
CE
• Treatment times were equal if ortho traction was
applied soon after surgery
• Treatment time was increased for OE if the
canine was allowed to erupt naturally before
orthodontic appliances were fitted.www.indiandentalacademy.com

Problems with traditional OE
or CE for palatally impacted
canines
Most orthodontists usually wait to uncover the palatally
impacted canines 6 – 9 months after starting mechanics to
open space for the tooth. By this time the crown of the
impacted tooth has often come in intimate contact with the
roots of the incisors – this makes it difficult for the surgeon
to remove adequate bone around the crown – this makes it
much more difficult to move the tooth through bone. And
then after it is exposed they begin traction within just a few
weeks.

Alternate OE Technique for
Palatally Impacted Cuspids
Kokich and Mathews offer an alternative technique:
Uncover the impacted tooth prior to ortho treatment,
even in the late, mixed dentition. The canine will
erupt without orthodontic forces and be at the level of
the occlusal plane before it is bonded.
Because they are getting to the impacted teeth earlier,
before they are in intimate contact with the roots of
the adjacent incisors, they can easily remove all
bone around the crown. This facilitates the eruptive
potential of the impacted tooth.
Kokich and Mathews, Orthodontic and dentofacial orthopedics, Ann Arbor: Needham Press; 2001

Full thickness muco-periosteal flap All palatal bone removed down to cej Flap replaced with a “window”
Canine erupted without orthodontic forces When the cusp tip is level with the occlsual plane,it is
bracketed
Kokich and Mathews, Orthodontic and dentofacial orthopedics, Ann Arbor: Needham Press; 2001

Open Eruption
Palatally Impacted Canines

TUNNEL
TRACTION
STEPS:-

Chain attached to the
impacted tooth & taken
to oral cavity through
tunnel & socket of ‘c’

Tooth exposed
through window &
a tunnel created
Probe
through
tunnel
During
treatment
Post treatment

Chain through tunnel Post treatment

THE DESIRABLE BIOMECHANICAL SEQUELAE
* Canine moves through cancellous
bone.
*Erupts through the socket of ‘C’.
*Erupts at the centre of the alveolar
crest.
*Better coverage by bone and
attached gingiva, labially and
palatally.
**************

TUNNEL TRACTION

* Located in the anterolateral curvature of maxillary alveolus.
* Overlying labial cortical bone is very thin.
∴ Avoid pulling the canine further labially or laterally
Canine position is
‘unique’

ARF FCET
UNDESIRABLE BIOMECHANICAL SEQUELAE IN
ARF & FCET

UNDESIRABLE BIOMECHANICAL SEQUELAE IN
ARF & FCET
* CANINE EXPERIENCES AN OUTWARD PULL *
* CANINE IS DRAGGED OVER THE LABIAL CORTEX*
* LABIAL CORTEX THINS OUT AND RESORBS *
* THE CANINE ERUPTS AT THE BUCCAL EXTREMITY OF THE
ALVEOLAR RIDGE AND NOT AT THE CENTRE*
* PHYSOLOGIC ERUPTION IS NOT SIMULATED *

CAN BALLISTA SPRING OVERCOME THIS PROBLEM ?
NOT COMPLETELY.

PALATALLY IMPACTED CANINE - FCET

SIMPLY REFLECTING A FLAP TO EXPOSE AN
IMPACTED TOOTH BY ITSELF CAN DAMAGE THE EPI.
ATTACHMENT AND THE PERIODONTAL LIGAMENT OF
AN ADJACENT TOOTH
Adams 1988
FLAP DESIGN IN ‘FLAP CLOSED’
- A Disadvantage -

MODIFIED FLAP DESIGN IN T .T
FCET
T.T

METHODS OF
ATTACHMENT
• Pin placed into hole created in crown of impacted
tooth
• Stainless steel crown
• Wire ligature around the crown
• Direct bonding of a bracket/button

ATTACHMENTS FOR
THE EXPOSED TOOTH
Extensive bone resorption
Circumferential wire ligation External root resorption
Ankylosis.
Bands
Extra coronal caps Necessitate extensive bone
Gold caps with cleats removal
Cast gold inlays

Indications for Stainless
Steel Crown
• Inability to attain an adequately dry field
for direct bonding
• Compromised enamel for bonding
(amelogenesis imperfecta)

STAINLESS STEEL CROWN

STAINLESS STEEL CROWNwww.indiandentalacademy.com

LIGATIONwww.indiandentalacademy.com

MAGNETS – POSITIONING IS VERY DIFFICULT
BONDING - REQUIRES ONLY MINIMAL BONE
REMOVAL (4-5mm)

Bur hole at cuspid tip

Ligation Vs. Bonding
• increased chance of ankylosis/external
resorption with ligation relative to bonding
• Increased loss of periodontal attachment with
ligation relative to bonding

DIRECT BONDINGwww.indiandentalacademy.com

DIRECT BONDING

Direct Bonding

PIN ATTACHMENT
Threaded pins
- Can
damage pulp

Attachment bonding to impacted
teeth at the time of surgical exposure
A. BeckerN. Shpack and A. Shteyer European Journal of
Orthodontics, October 1996.
• The results showed that bonding at the time of
exposure is superior to its performance at a
later date, that the use of an eyelet attachment
has a lower failure rate than the use of a
conventional bracket, that the palatal aspect
offers the poorest bonding surface and that
pumicing the exposed tooth offers no
advantage over immediate etching of the
exposed enamel.

MECHANICAL APPROACHES
FOR ALIGNING UNERUPTED
TEETH
• elastomeric material tied from a heavy
base arch to the exposed tooth
• alignment spring either soldered to heavy
base archwire or bent into a light archwire
(delivers more constant force over a
longer range)
• Direct light-wire (NiTi memory wire) to the
tooth
• magnetic forcewww.indiandentalacademy.com

Orthodontic Principles
• light forces for canine extrusion
• continuos tie or stop of the teeth mesial
and distal to the canine area
• rectangular archwire should be present
before extrusion mechanics are started
(resists the deformation caused by the
extruding forces)

ELASTOMERIC MATERIALwww.indiandentalacademy.com

ALIGNMENT SPRINGS

The Wave Spring
VOGT jco2004
• The Wave Spring* is a new
type of ortho-dontic
retraction spring that takes
the shape of a wave when
extended
• A superelastic nickel
titanium alloy delivers a
relatively large amount of
activation-about 90g of
force-from an extremely
compact spring-only 6mm
long in its resting statewww.indiandentalacademy.com

• When a closed-coil spring is activated. the ends of
the spring twist in opposite directions; as the spring
returns to its resting state, it unwinds, creating
torque on the attached teeth.
• The Wave Spring stretches in a linear direction and
thus produces no unwinding torque.
• Because the spring has no coils, it lies flat instead
of protruding into the buccal vestibule, making it
more comfortable and hygienic.
• Also, its attachment eyelets are integral to the
spring, which elimi-nates the problem of the eyelets
loosening and falling off.
• The Wave Spring's greatest attribute is its ability to
fit into a small space yet remain active over a long
distance

Kilroy Spring Bowman s
The Kilroy Spring is a pre-formed
module that is simply slid onto a
rectangular continuous arch wire at the
site of an impacted tooth. The vertical
loop of the Kilroy Spring extends
perpendicularly from the occlusal plane
in its passive state. A stainless steel
ligature is then placed through the helix
at the apex of the vertical loop of the
Kilroy and then this loop is directed
toward the impacted tooth. The ligature
is tied either directly to the helix of the
loop button or to the loop of the Monkey
hook that is in-turn linked to the loop
button attachment.

• The Kilroy Spring is supported by 1) the rectangular
base arch wire, 2) reciprocal force from the incisal
one-third of the adjacent teeth where contacted by
the lateral extensions of the Kilroy Spring
• The Kilroy I Spring was designed to produce both
vertical and lateral eruptive forces for palatally
impacted canines. The Kilroy II Spring produces
more vertical forces and was created for buccally-
impacted teeth. Due to the multiple helices and
cantilever design of the Kilroy II, there is a chance of
tissue impingement adjacent to the impacted tooth
therefore, more frequent visits to monitor progress
are recommended

"Ballista Spring" (1979 ajodo)
• The "Ballista Spring" system developed by Harry
Jacoby
• used for marsupialization of unerupted teeth
consists of a spring made from the Wilcock special
plus wire

• The Ballista spring system uses a spring which
creates a vertical traction on the impacted tooth
along its long axis thus separating the impacted
tooth from the roots of the adjacent tooth.
• The Ballista spring is easily inserted, ligated and is
independent of other parts of the appliance.
• In general most systems require full bonded arches
at the beginning of the treatment while the ballista
spring does not require any bonding of anterior teeth
till the crown of the impacted tooth erupts
completely.
• It can be used for buccally as well as palatally
impacted canines.

• A Double backed
portion entering the
double tube on the
molar around which
the wire is twisted.
• b. Coil to increase the
wire length, thus
increasing the
resiliency.
• c. Vertical arm with a
loop to be tied to the
canine

An Extrusion Spring for Palatally
Impacted Cuspids
OPPENHUIZEN jco aug 2003
Before placing the extrusion
spring, stabilize the arch with a
rectangular wire, and bring
the maxillary incisors into
reasonable alignment
The extrusion spring is made from
a prefabricated .018 s.s arch using
ant curvature to generate extrusive
component
For unilateral correction cut
opposite distal to lateral incisor
opposite to impactionwww.indiandentalacademy.com

• Bend the wire over space created for cuspid.
bend a tight helix at the point of eyelet attached
to impacted cuspid
• For bilateral impaction bend the wire on both
sides over the spaces created for the cuspids,
and form helices at both ends
• To activate the extrusion spring, bend the wire
inferiorly so It points straight down
perpendicular to the occlusal plane

Cantilever Mechanics for Treatment
of Impacted Canines
FISCHER, ZIEGLER, DMDCHRISTOPHER LUNDBERG, 2000 JCO,
A cantilever made from .0175" × .025"
TMA* can generate the 25-30g of force
needed to extrude a canine over a wide
range of activation.
The cantilever is tied into the auxiliary
molar tube or welded directly to the
continuous archwire
To prevent the generation of a second
couple, the cantilever should be
attached to the canine with a single-
point contact; an alternative is a
compensating bend that allows a
passive angle of entry into the canine
bracket

Management of Palatally
Impacted Canines
Cantilever between .032" bracket,
welded lingually to molar tube, and
single-point attachment to palatally
impacted canine.
Occasionally, a palatally impacted
canine will require buccal root
torque for proper axial inclination.
This problem can be solved by
bonding a mandibular second
bicuspid bracket with 22° of built-in
torque to the labial surface and using
a full-size rectangular wire.www.indiandentalacademy.com

In cases requiring more
anchorage, such as bilaterally
impacted canines, an .0175" × .
025" TMA composite cantilever
can be welded directly to an .
032" × .032" TMA transpalatal
arch between the .032" lingual
molar brackets .
As with the unilateral cantilever,
activations can be made to
generate extrusive forces
followed by buccal movement.
The combination of a stiff buccal
archwire and the transpalatal arch
provides superior control of the
reactive forces and excellent
anchorage. www.indiandentalacademy.com

The K-9 Spring for Alignment of
Impacted Canines
VARUN KALRA, JCO/OCTOBER 2000
– The K-9 spring is made of .
017" × .025" TMA* wire,
– The horizontal arm of the
spring is inserted into the first
molar buccal tube and the
premolar
– About 7mm mesial to the first
premolar bracket, the
horizontal arm is bent 90°
downward to form a vertical
arm, which is about 11mm
long and ends in a helix .www.indiandentalacademy.com

• While the spring is held with a
plier just distal to the vertical
arm, the vertical arm is bent
about 20° inward, toward the
palate.
• To activate the spring after it
is engaged in the buccal
segment , the vertical arm is
swung upward and ligated to
the bonded attachment on
the impacted canine

– . This provides a gentle
extrusive force on the canine;
the spring also has a buccal
component of force due to the
arcial pattern of activation and
deactivation.
– The force needed to distalize
the canine is achieved by
cinching the spring back about
2mm after it has been ligated to
the canine.
– Alternatively, the distalization
force can be provided by
bending the vertical arm distally
prior to its ligation to the canine

The Monkey Hook: An Auxiliary for
Impacted, Rotated,and Displaced Teeth
BOWMAN, ALDO CARANO, JCO/JULY 2002
• 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. 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.

• 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.

Monkey Hooks can be attached to intermaxillary
elastics, with anchorage derived from the opposing
dental arch . The hooks provide more rigid support
for intermaxillary elastics than is produced by
twisting a steel ligature into a hook. Although elastic
thread or chain can be tied from a ligature hook to a
base archwire, the forces produced by these
materials will decay dramatically over time. If
patients are asked to change the intermaxillary
elastics daily, thus avoiding the diminution of forces
to the impacted tooth, the variable of patient
compliance is introduced. An alternative is to place
a continuous superelastic archwire through the
Monkey Hook to direct tooth eruption. Later this
archwire can be passed directly through the lumen
of the loop button to continue the processwww.indiandentalacademy.com

If anchorage is unavailable
from the opposing arch,
vertical intra-arch eruptive
forces can
be produced using
superelastic coil springs

Eruption of Impacted Canines
with an Australian Helical
Archwire
• Elastic force modules have the disadvantages of rapid
force decay and 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.
J Clin Orthod. 2000 Sep;34(9):538-41.www.indiandentalacademy.com

• 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 sufficiently rigid main
archwire can be placed. Furthermore, the stiff
primary archwire prevents the flexible nickel
titanium archwire from sliding freely through the
brackets. The Australian wire is bent with helices
that serve as stops against the brackets of the
adjacent teeth to maintain space for the erupting
canine.

An additional incisal helix increases the resilience of the
system and anchors the stainless steel ligature running
to the canine attachment. The force vector for the
canine can be altered by changing the transverse
position of the incisal helix.
The appliance is activated by twisting the steel ligature.
This force also maintains space for the erupting tooth.
The amount of force can be varied by using different
archwire designs

In contrast with overlay or piggyback techniques, the
Australian helical archwire provides a virtually friction-
free system. It also avoids the side effects associated
with superelastic nickel titanium archwires. Unlike a
rectangular arch, a round arch has no torquing effect on
the adjacent teeth. The stiffness of the Australian wire
resists deformation by the forces applied to it and
reduces intrusive reciprocal forces on the adjacent teeth.
If intrusive forces are a concern, however, vertical
elastics can be used.

Nickel Titanium Closed-Coil Spring for
Extrusion of Impacted Canines
• Cut a 16mm Jones Jig spring in half. Pull out one
end slightly to form a small hook
• Slip the hook through the link of elastomeric chain
(from the impacted canine) nearest the gingiva, and
twist it a couple of times

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.
At the next visit, unwrap, reactivate, and rewrap the spring . This
will take only a few minutes

Alignment of Impacted Canines with
Cantilevers and Box LoopsJCO-2003
• The use of TMA box loops to produce 1st- and 2nd-
order corrections while continuing vertical eruption.
• 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.

A cantilever constructed from .017" × .025" TMA wire is
inserted into the auxiliary tube of the first molar and
connected by a one-point contact to the active unit The
magnitude of the force (F) used to extrude the canine
should not exceed 70g

• A box loop produces a statically indeterminate force
system.5 When used for canine alignment, it is
constructed of .017" × .025" TMA. The activation of
the box loop depends on the desired position of the
canine in both the sagittal and horizontal planes of
space

Magnetic Force
(Vardman, AJO, 1991)
• magnetic bracket bonded to an impacted
tooth and an intraoral magnet linked to a
Hawley-type retainer
• attraction was initiated 1-2 weeks after
healing
• stated advantages:
– less invasive
– effective forces at short distances
– controlled spatial guidancewww.indiandentalacademy.com

MAGNETIC FORCE

Direct NiTi wire to the tooth

Wire placed directly to the
tooth

Self-Ligation

Treatment Time
Stewart et al, AJODO 2001;119:216-25
• 3 groups :
– unilaterally impacted group
– bilaterally impacted group
– control group matched with similar
characteristics but without the impacted
canine
• Avg. duration of treatment:
– Control group: 22.4 months
– Unilateral group: 25.8 months
– Bilateral group: 32.3 monthswww.indiandentalacademy.com

Treatment Outcomes
D’Amico et al, Angle Orthod 2003;73:231-238
• Subjects followed 3.5 years post-ortho
• Canine rise occurred more often on
working sides with normally erupted
canines than with impacted canines

SUCCESS OF ADULT TREATMENT
with palatally impacted canines
• Sample of 19 adults (mean age 28.8 y, range 20 -47y) with 23
impacted teeth
• Control sample (mean age 13.7 y, range 12 – 16y) – matched
for positions of the impacted teeth in the 3 planes of space
• Success rate:
– Control:100%
– Adults: 69.5% - unsuccessful treatment defined as failure
to erupt (5 teeth) or partially extruded but not aligned with
the arch (2 teeth). All 7 failed canines occurred in patients
> 30 years old.
• Equal length of treatment – BUT adult patients had
significantly more visits and visits were significantly longer in
duration
Becker et al, AJODO 2003;124:509-14

Pulpal and periodontal reactions to orthodontic
alignment of palatally impacted canines
(Angle Orthodontist 1994 )
• The purpose of this study was to evaluate
differences in periodontal and pulpal status, root
length, and tooth alignment between contralateral
maxillary lateral incisors, canines, and premolars in
patients treated for unilateral impaction of maxillary
canines
• Clinical examinations were performed on 32
patients, average age 22 years 11 months and
average posttreatment observation period 3 years 7
months
• Probing attachment level was lower at the mesial
and distal aspect of the previously impacted canine
and at the distal aspect of the adjacent lateral
incisor. www.indiandentalacademy.com

• Crestal bone height was lower at the mesial aspect
of the previously impacted canine and at the distal
aspect of the adjacent lateral incisor. The roots of
the lateral incisors and premolars adjacent to the
previously impacted canines were shorter. Pulpal
obliteration was observed in six previously impacted
canines (21%), and pulp necrosis in one previously
impacted canine. The pulps of the remaining teeth
appeared normal radiographically. A negative
response to electric pulp testing was observed in
eight previously impacted canines. Approximately
40% of the previously impacted canines exhibited
noticeable relapse and were judged to be intruded,
lingually displaced, mesially rotated, as well as
discolored. Of the contralateral canines, 91% were
normal in appearance. The previously impacted
canine could be identified on posttreatment color
slides in approximately 75% of the cases.

Canine 2

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Andere mochten auch

Andere mochten auch (11)

Ähnlich wie Canine 2

Ähnlich wie Canine 2 (20)

Mehr von Indian dental academy

Mehr von Indian dental academy (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

Canine 2