orthodontic perception of impacted canine

1. SHY CANINE
“Unveiling The Hidden”
Author: Theertha Sudhakaran (CRRI)
Guide: Dr. Ashwin Mathew George
Department of Orthodontics
Sathyabama University Dental College &
Hospital

2. IMPACTION
• Impacted tooth is one that fails to erupt and will not
attain its anatomical position beyond the chronological
eruption date even after its root completion.

3. • Canines play a role in functional occlusion and form the
foundation of an esthetic smile.
• As such, any factors that interfere with the normal
development of canines and their eruption can have
serious consequences

4. IMPACTED CANINE
• Impaction of maxillary and mandibular canines is a
frequently encountered clinical problem.
• Maxillary canines are the most commonly impacted
teeth, second only to third molars.

5. INCIDENCE
•
Maxillary canine impaction occurs in approximately 2%
of the population.
• Twice as common in females as it is in males.
• The incidence of canine impaction in the maxilla is
more than twice that in the mandible.
• Of all patients who have impacted maxillary
canines, 8% have bilateral impactions.

6. • . The prevalence of impacted maxillary canines varies and is
reported as follows: 2%, 0.9% to 2%, 1% to 2%, 1.5% to
2%, 1% to 3%, with a palatal location 85% of the time and a
labial location 15% of the time.
• Unlike buccal displacement of maxillary canines, palatal
displacement of maxillary canines, and the frequent ensuing
impaction, most often occurs in cases in which adequate
perimeter arch space exists.

7. ETIOLOGY OF IMPACTED CANINE
•LOCALIZED
•SYSTEMIC
•GENETIC

8. 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

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

10. SYSTEMIC
Endocrine deficiencies
Febrile diseases
Irradiation

11. GENETIC
Heredity
Malposed tooth germ
Presence of alveolar cleft

12. THEORIES OF CANINE
IMPACTION
GUIDANCE THEORY
GENETIC THEORY

13. GUIDANCE
THEORY
• Canine erupts along the root of
lateral incisors, which serve as a
guide, and if the lateral incisor is
absent or malformed, the canine
will not erupt.

14. GENETIC
THEORY
• Genetic factors are primary origin
of palatally displaced maxillary
canine and include other possibly
associated dental anomalies, such
as missing or small lateral incisor.

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

16. CLINICAL EVALUATION
Study model
analysis
Morphology of
adjacent tooth
• Amount of space available in dental arch
for impacted canine is assessed in model.
• Gives clue of position of impacted tooth.
Contours of adjacent • Canine bulge present buccally or palatally.
alveolar bone
Mobility of adjacent
tooth
• Root resorption.

17. RADIOGRAPHIC EXAMINATION
• Indicated in individual with unerupted and non-palpable
canines after the age of 11 years.
• INTRA ORAL RADIOGRAPHS
• IOPA
• Occlusal
• EXTRAORAL RADIOGRAPHS
• OPG
• Lateral cephalometric
• DIGITAL IMAGING
• CT
• CBCT

18. INTRAORAL VIEWS
IOPA
• Clark’s rule tube shift technique.
• Locates canine positioned buccally or palatally to
other teeth in the arch.
OCCLUSAL RADIOGRAPHS
• Determining position of canines relative to the
midline.
A periapical, panoramic, or occlusal view will not reveal the
presence of a canine that is outside their fields of view.

19. EXTRAORAL VIEWS
OPG
• Used to localize impacted teeth in all
three planes.
LATERAL CEPHALOMETRICS
• Realtionship of impacted canine with
other facial structures can be studied.
superimposition in the anterior and palatal regions of the maxilla may mask
the presence of a canine. In addition, the canine may not be adequately
visualized with conventional imaging to correctly identify its position.

20. 3 DIMENTIONAL IMAGING
• 3-dimensional imaging modalities provide a volume of
information that can be used to assess and localize teeth within
the entire maxilla and adjacent regions without the limitation of
visualization with superimposed structures.

21. CT
• Superior diagnostic tool.
• Early detection of root resorption.
• Accurate localization of impacted canine and
visualization of associated structures.

22. CBCT
• Identify and locate the position of impacted canine
accurately.
• Dentists can assess any damage to adjacent tooth
roots and amount of bone surrounding each tooth .

23. DETERMINING THE PROGNOSIS
• FACTORS INFLUENCING THE TREATMENT DECISION OF AN
IMPACTED CANINE
Age of patient
Availability of space
Favourable position of canine
Presence of adequate width of attached gingiva

24. POSITION OF CANINE
•
CANINE ANGULATION TO MIDLINE.
•
VERTICAL HEIGHT OF IMPCATED CANINE.

25. •
POSITION OF THE CANINE APEX RELATIVE TO THE ADJACENT TEETH.
•
MESIODISTAL POSITION OF CANINE TIP TO ADJACENT TOOTH.

26. MANAGEMENT OF
IMPACTED CANINE
Interceptive treatment.
Treatment of labial impaction.
Treatment of palatal impaction
Methods of applying traction.
Retention consideration.

27. INTERCEPTIVE TREATMENT
• When the clinician detects early signs of ectopic
eruption of canines, an attempt should be made to
prevent their impaction and its potential sequelae.
• Selective extraction of the deciduous canines as early
as 8 0r 9 years of age.
• Normalize the eruption of ectopicaly erupting
permanent canine.

28. LABIAL IMPACTION OF UPPER
CANINE
• Due to ectopic migration of canine crown over the root
of lateral incisor or insufficient space in the arch caused
by midline shift of dental origin.
• Arch length- tooth material discrepancy is the most
common cause.
• Extraction of deciduous canine at early age of 8 or 9
years will enhance eruption and self correction of labial
impaction.

29. Labial
impaction
Initial orthodontic treatment was aimed
at creating space in the maxillary arch
with fixed appliance therapy.
Surgical exposure and orthodontic
traction.

30. SURGICAL EXPOSURE
• Indicated when tooth does not erupt spontaneously
after creating space in the arch.
• Attempted 6 months after the root formation
• Flap designs should preserve the band of attached
gingiva and should guide tooth to erupt through its
natural path of eruption.

31. OPEN TECHNIQUE
Canine crown
coronal to
mucogingival
junction
• Excisional approach
Canine crown
apical to
mucogingival
junction
• Apically positioned flap

32. CLOSED ERUPTION TECHNIQUE
• Indicated if tooth is impacted in the centre of the
alveolus.
Flap is elevated
Attachment placed on impacted tooth
Ligature or chain placed over the
attachment to activate after a week
Raised flap is repositioned in its original
location
Permit eruption of impacted canine in
normal direction

33. PATIENT 1

34. PRE OP
POST OP
PRE OP
POST OP

35. PERIODONTAL CONSIDERATION
• Excisional technique must be parformed only when
sufficient gingiva is present, to provide atleast 2-3mm
of attached gingiva over the canine crown after it has
erupted.
• If crown is positioned mesially and over the root of the
lateral incisor, the crown should be exposed completely
with an apically positioned flap.

36. PALATAL IMPACTION OF UPPER
CANINE
CLOSED
ERUPTION
• Crown is surgically exposed, an attachment is bonded
during the exposure, flap is sutured back, leaving a
twisted ligature wire passing through the mucosa to
apply orthodontic traction.
OPEN
WINDOW
ERUPTION
TECHNIQUE
• A flap is raised, bone covering crown is
removed, small window or fenestration
is made, orthodontic attachment is
bonded and flap is sutured in to place.

37. PATIENT 2

38. PRE OP
POST OP
PRE OP
POST OP

39. METHODS OF APPLYING
TRACTION
•
Force elements
Ligature wire
Rubber bands
Elastomeric chains
Elastic threads

40. • Ballista springs (mouse trap loops)
• Magnetic forces

41. • Eyelet attachment
• TMA sectional arch wire

42. • Miniimplants
• Elastic traction using lower fixed or removable
appliance as anchorage.

43. TUNNEL TRACTION TECHNIQUE
• For aligning deep infraosseous impacted
canines.
• Osseous tunnel provided towards the centre of
the alveolar ridge.
• Socket of deciduous canine can be used as
tunnel, for movement of impacted canine.

44. RETENTION CONSIDERATION
Relapse of rotations and spacing may occur after completion of the
orthodontic treatment of an impacted canine.
 SUPRACRESTALFIBROTOMY
 FIXED RETAINERS
 REMOVAL OF HALF MOON SHAPED WEDGE OF TISSUE ( To
prevent lingual drift of palatally impacted canine)

45. 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.

46. ACKNOWLEDGEMENT
• GUIDE Dr Ashwin Mathew George, Professor & Head
:
•
Dr. V. Sudhakar, Reader
•
Dr Shrinivaasan N. R, Senior lecturer
• Dr Xavier, Senior lecturer
• Dr Navaneetha, Senior lecturer
DEPT OF ORTHODONTICS.