notes on orthodontic management of palataly and labialy positioned canines *cases by many authors all photo rights are reserved to them

1. Dr Abdelrahman Mosaad , BDS

2. Canine impactions :

3.  Canine impactions involve 0.92% of the white
American population. Epidemiological data shows
different incidences among other populations.
• Finnish = 1.8 % • Italian = 2.4 %
• Japanese = 0.27 % • White American = 0.92 %

5.  Canine impactions are more frequent among females
than males (F : M = 2.3 : 1) or 1.17% of females and
0.51% of males
 85% of impactions are palatal impactions compared to
15% that are vestibular impactions.
 Early diagnosis : Palatal bulge , retained c , x-ray

8.  keeping a primary canine in the mouth beyond the
timeframe where it should normally shed
guarantees that the permanent canine is either ectopic
or impacted

9. Complications :
- Granulomas
- Cysts
- tumors
- Ectopic eruptions
- Root resorptions

10. Preventive diagnosis
The permanent canine normally erupts around 11-12 years of age. It
is thus wise to verify its position and its evolution as early as 9-10
years of age. We must suspect that an anomaly can occur if we
observe:
• A microtooth or a congenital absence of a lateral incisor
• An overall delay of eruption
• The retention of the primary canine beyond 12-13 years of age
without any signs of moving
• A palpable palatal vault
• A congenital absence of premolar(s). One or more absent
premolar.
• An ankylosis of a second primary molar
• A lateral incisor in labioversion, palatoversion, distoversion

11.  When the patient is between 10 and 13 years old
interceptive diagnosis takes place .
 The relative position of the permanent canine with
regard to the adjacent teeth is an important factor in
the success of the interception. By success, I mean that
the canine will go back to a normal path of eruption

12. Erikson and Kurol developed a little evaluation
diagram. If the tip of the unerupted canine does not go
past more than half of the root of the lateral
incisor (zone 2 and 3) and the inclination angle related
to the medial plane is not greater than 55o
>>> the average success rate (normal eruption) is
about 80%. This means that 80% of the cases showed a
normalization of the canine eruption in the 6 to 12
months following the extraction of the primary canine

16. Good prognosis

17.  If the permanent canine is in zone 1-2, the success rate
is about 90%. If the canine goes past the lateral incisor
and the tip is in zone 4, the success rate decreases
to 64%.
 If no improvement Is observed, then the
autocorrection prognosis is weak and a procedure
must be considered
 N.B. auto-correction with normal canine eruption after
extraction of primary canines may take up to 2 years
according to the case

18.  Ericson S, Kurol J. Early treatment of palatally erupting
maxillary canines by extraction of the primary canines.
Eur J Orthod 1988;10:283-295.

19.  important factors regarding treatment of
impacted canines are:
 The horizontal position of the impacted tooth (degree
of overlap with the lateral and central incisors).
 The patient’s age.
 The height or vertical position of the impacted tooth.
 The oro-palatal position of the impacted tooth

20. CBCT diagnosis

24. ttt

25. 17*25 at 60 gm

26. Lower 3s technique

28. case

33. Mechanics of lower

34. Case
Months

36. Case 3

38. Case

40. Case

45.  N.B. Becker et al. reported that repeat surgery was
required for 62.9% of the impacted canines in which
corrective treatment was started, mostly to redirect the
ligature wires with the guidance of the 3-dimensional
imaging

46.  If, the tooth does not show clear evidence of
movement after six months of orthodontic force
application, a re-evaluation is necessary. Ankylosis,
one of the major complications associated with
impacted canines, can rarely be detected based on
clinical and conventional radiographic examinations
however CBCT provides a better diagnosis of the area
of ankylosis

47.  The percentage of ankylosis was 3.5% in the open
technique and 14.5% in the closed technique. They
have defined anyklosis as impacted canines being
immobilized a priori or during traction, due to all the
possible causes that could contribute to
immobilization, such as all types of external tooth
resorption and other known or unknown factors

48.  D'Amico et al. reported the adverse effects of the
orthodontic-surgical treatment for impacted maxillary
canines in the long term conducted in a sample of 61
cases. 6.5% of the patients were dissatisfied with the
esthetic results, whereas the orthodontist estimated
the results as good in only 57% of the cases

49.  Woloshyn et al evaluated the posttreatment changes
nearly 4 years after treatment and compared the
differences in the periodontal and pulpal status, root
length, and tooth alignment between the side of the
forced-erupted ectopically canine and the contralateral
side.
 The probing attachment level was found lower on the
mesial and distal aspect of the previously impacted
canines, also the roots of the adjacent teeth were
found shorter.

50.  The incidance of pulpal obliteration was 21% in the
previously impacted canines. Significant
posttreatment changes such as intrusion, lingual
displacement, rotation, and discoloration was
determined in 40% of the previously impacted teeth
where as 91% had a normal appearance on the
contralateral side

53. 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 i.e. 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 i.e. with the first premolar in
the position of the canine and with an otherwise functional
occlusion with well-aligned teeth
6. If there are pathologic changes (e.g., cystic formation,
infection
7. If the patient does not desire orthodontic treatment
When to extract ?

54.  N.B. labially impacted canines are more challenging to
manage without the occurrence of adverse periodontal
problems
 So , special attention has to be given to surgical
technique, marginal gingival placement, control of
inflammation, magnitude of force, atraumatic surgery,
and proper gingival attachment

55.  3 techniques are used for uncovering a labially
impacted maxillary canine :
excisional uncovering (gingivectomy)
apically positioned flap
closed eruption techniques
The orthodontist should be the guide to the surgeon to
efficiently manage the case surgically

58. Excisional uncovering
Apically positioned flap

59. Closed flap eruption

60. Closed flap is
the choice
All techniques
could be done
Apically positioned
flap could give good
results

61.  Evaluate the canine position Mesiodistally , mesially
positioned canine toward the roots of lateral central
could require apically positioned flap
 Evaluate the amount of gingiva could be present after
the canine euprtion , at least 2 to 3 mm of attached
gingiva over the canine crown after it had been
erupted is needed for good esthetic results

62.  the labiolingual position of the impacted canine crown
should be determined. If the tooth is impacted
labially, then any of the 3 techniques could be
performed, since there is usually little or any bone
covering the crown of the impacted canine.
 However, if the tooth is impacted in the center of the
alveolus, an excisional approach and an apically
positioned flap are usually more difficult to perform,
for large amount of bone removal might be required
from the labial surface of the crown

68. Piggyback

69. Tunnel

70.  Palatally positioned canine :
 With palatal impactions it is critical to recognize
that the entire palate is covered with specialized
mucosa
 The surgical methods for exposing the impacted
canine are:
open surgical exposure and allowing for natural
eruption
open surgical exposure and packing with subsequent
bonding of an auxillary
closed surgical exposure with the placement of an
auxiliary attachment intraoperatively.

73.  The orthodontic force to be applied to the bonded
attachment requires careful planning
 the tooth should be erupted vertically and once a
facial attachment can be bonded, forces should direct
the tooth facially

74.  During closed-eruption technique, the orthodontist
should select mechanics that erupt the tooth through
the center of the alveolar ridge. The eruption of the
tooth between the alveolar cortical plates prevents
bone dehiscence and unfavorable orthodontic and
esthetic consequences

75. impaction canine brought vertically then labially

76. Kilroy 18 st.st

77. Ballista 18 stst

79.  in recent studies evaluating the differences in the
periodontal outcomes of palatally displaced canines
(PDC) exposed with either an open or a closed surgical
technique, no significant differences in post-treatment
periodontal status of the canines and adjacent teeth
were determined between the techniques.
 Both treatment methods were found acceptable for
treatment of the palatally impacted canine