According to Dewel 7 , canine teeth determine the shape of the dental arch, defining the contour of the mouth, maintain the harmony and symmetry of the occlusal relationship, and support lateral movements and masticatory load. There are reports that maxillary canines have a longer eruption path, in terms of time and distance, in addition to a more tortuous path of eruption than any other tooth 5. Thus, several treatment suggestions can be found in the literature, including methods to guide or move the impacted teeth into proper position for occlusion.
Removal of mechanical interference, such as supernumerary teeth or any pathology, and even the creation of space in the arch to allow spontaneous eruption have been described in the literature 8. However, in most cases, surgical exposure and orthodontic traction of the unerupted tooth are required to move the teeth to their correct arch position. Several factors should be taken into account when surgical—orthodontic traction of an unerupted tooth is chosen, including meticulous surgical technique with complete flap closure, minimal removal of bone and dental follicle, avoiding manipulation of the root until the application of orthodontic mechanics, and application of light forces, with a reliable anchorage unit that is resistant to the applied load.
Adverse effects on periodontal tissues and unfavorable aesthetic and functional results have been associated with inadequate diagnosis and treatment planning. This study presents an objective review of the literature on the main factors that lead to successful treatment of impacted canines. Diagnosis, surgical—orthodontic treatment planning, therapeutic approaches and their advantages and disadvantages are emphasized in order to optimize the overall treatment time. The etiology of canine impaction may be related to general factors, such as inheritance, endocrine deficiencies, febrile diseases, and irradiation.
Regarding local factors, the causes include tooth size-arch length discrepancy, prolonged retention, premature loss of primary canines, abnormal position of the tooth germ, presence of alveolar cleft, agenesis, ankylosis, supernumerary teeth, deleterious oral habits, trauma, disruption of the root structure, iatrogenic and idiopathic causes 1,3,10 , and ectopic path of eruption The incidence of canine impaction ranges from 0.
The condition affects females more than males , exhibiting leftsided predominance of unilateral occurrence The main signs observed on clinical examination to diagnose the presence of impacted canines are: delayed eruption after 14 years of age, prolonged retention of a primary canine, elevation of the palatal or labial mucosa, and distal migration of the crown of the maxillary lateral incisors with or without a midline shift 3.
The calcification process of maxillary permanent canines begins between 4 and 12 months of age, and the canines are complete at years of age. The canine develops in the frontal process of the maxilla, near the infraorbital rim This long path of eruption, starting at a high position beneath the orbital floor, contributes to the high frequency of eruption problems. After years of age, the presence of canines may be diagnosed by palpation, which helps identify their general position and crown angulation.
Dental crowding is regarded as a factor causing an ectopic path of eruption in permanent canines. Radiographic examination is essential for the diagnosis, confirming the presence of an impacted canine in the upper jaw at buccolingual, cervico-occlusal and mesiodistal directions, as well as its relationship with adjacent structures. On radiographs, other aspects related to the canine should also be observed, such as root formation and morphology, presence of crown or root resorption, and cysts, among others.
The first film orthoradial projection enables mesiodistal and cervicoocclusal assessment. The second film with a mesial or distal shift adds the possibility of diagnosis at the buccolingual position. In the presence of an unerupted canine in the permanent dentition, the orthodontist, supported by orthodontic records and reliable clinical evaluation, should determine the actual need for orthodontic treatment.
At first, extraction is not recommended, given the great importance of the maxillary canine in the dental arch, both aesthetically and functionally.
The prognosis of surgical-orthodontic traction depends on many factors, including the position of the canine in relation to the adjacent teeth and height of the alveolar process 3. As a rule, after dental age assessment from the beginning of the calcification process of the canine until complete formation of the root apex , correlating it with chronological age at each stage, the appropriate moment for surgical-orthodontic treatment is defined. Before the introduction of bonding materials composite resin and ionomer , orthodontic appliances and the development of more conservative surgical techniques, the failure rate was particularly high in the treatment of impacted teeth.
Alternative approaches, such as circumferential steel wires around the crown, perforation in the crown, and cementation of threaded pins, provided poor and ineffective results regarding orthodontic movement and especially regarding the health of teeth and supporting tissues. The excessive and traumatic removal of bone tissue may result in ankylosis and external resorption.
Perforation in the crown is not recommended due to risk of pulp damage and crown destruction Currently, the most widely used technique involves surgical exposure of the crown, with a full—thickness flap involving the keratinized gingiva and alveolar mucosa, with one or two relaxing incisions, and minimal removal of bone and dental follicle sufficient to attach an orthodontic appliance.
It all depends on the extent of the problem. Extracting a baby tooth may be all that is needed to make room for the permanent tooth to erupt into the proper position. But if an upper jaw is too narrow, it may be necessary to expand the jaw, which creates more room for permanent teeth to come in. Other problems might require a combination of oral surgery and orthodontic treatment to place an attachment on the impacted tooth and the orthodontist then guides the tooth into the proper position. Timely treatment by an AAO orthodontic specialist ensures teeth come in properly, reducing the damage done to other teeth.
Many AAO orthodontists offer initial consultations at no cost and with no obligation.
No referral is needed from the dentist, but dental check-ups are necessary during any orthodontic treatment. A check-up with an orthodontist gives your child the best opportunity to enjoy a healthy, beautiful smile. It is well known that for every 1. Dental intercuspation was improved, especially on the left side, that started out with a Class II malocclusion. The sliding jigs mechanics and Class II elastics proved to be efficient in correcting the dental asymmetry. Overbite and overjet were corrected together with the midline deviation.
Dental element 13 was successfully tractioned, causing no harm to the neighbouring teeth Figs 6 and 7. Last but not least, regarding the functional aspect, some improvement in the masticatory function was observed, alongside with good gingival and periodontal health, that presented adequate gingival contours. All things considered, the stomatognathic system health in general was preserved.
Getting Braces for Impacted Teeth: What to Expect
Simultaneous bilateral equipotent alternating contacts in centric relation and in maximum intercuspation were accomplished, together with normal disocclusion parameters during mandible excursion movements. No occlusal adjustments or selective wear were needed to refine the occlusal contact distribution. Panoramic, periapical and interproximal radiographs revealed no cavities or endodontic problems, roots with preserved contours and good parallelism, with alveolar bone crest heights preserved were observed Figs 6 and 7. The final result was quite satisfactory, and the treatment was rigorously delivered within the planned time: 4 months for rapid maxillary expansion and 24 months for fixed corrective orthodontics.
Orthodontic management of impacted canine may offer considerable challenges. Therefore, good tomographic images are fundamental to a successful traction, for they allow professionals to accurately identify and locate the position of the impacted tooth, evaluate possible injuries to adjacent roots and to quantify the bone around each tooth.
It also helps in detecting the existence of possible ankylosis in the roots of such teeth, 24 which could be interpreted as the most probable cause for them failing to reach the expected position during the eruptive movement. The visualization of these ankylosed zones may help professionals to choose a different treatment protocol, if compared to the conventional surgical exposure followed by orthodontic traction. This will assist in the right choice for either the impacted tooth extraction, autotransplantation or the execution of a deep alveolar corticotomy followed by immobilization, especially if the canine is more labially positioned.
In the clinical case presented, the post treatment image evaluation did not show signs of external root resorption of neither the tractioned tooth nor adjacent teeth, despite some studies showing this to be the main side effect related to orthodontic traction of impacted teeth.
The orthodontic treatment of impacted teeth, 2nd edition
Once again, no doubt remains about the benefits of using CT scans, which improved predictability and accuracy 32 for diagnostic purposes. Regarding the choice for the surgical exposure method, the correct diagnosis led to the conclusion that the closed approach was the most appropriate one. Some authors recommend this approach because it may possibly spare patients from a new periodontal surgical procedure, with less tissue manipulation of the dental follicle, an important structure for eruption process. It also allows traction forces to be applied on the long axis of the tooth.
An adequate management of impacted canines, from both functional and aesthetic perspectives, is of utmost importance for the overall success of the orthodontic therapy. The most suitable method to be chosen by the orthodontist should be one that allows the application of ideal traction forces in the most favorable direction, avoiding further injuries to adjacent teeth. A review of early displaced maxillary canines: Etiology, diagnosis and interceptive treatment. Open Dent J. Early treatment of palatally erupting maxillary canines by extraction of the primary canines. Eur J Orthod.
Am J Orthod Dentofacial Orthop. Impacted canines: Etiology, diagnosis and orthodontic management. J Pharm Biollied Sci. A review of impacted permanent maxillary cuspids: diagnosis and prevention. J Can Dent Assoc.
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What Does Impaction Mean?
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Orthodontic treatment of impacted teeth, 3rd edition | British Dental Journal
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