Canine impaction maxillary teeth part 2

By
Dr.VILVA KARTHICK
JUNIOR RESIDENT -1st YEAR
DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY
GOVERNMENT DENTAL COLLEGE, KOTTAYAM
1

INCIDENCE
• 3rd most commonly impacted tooth.
• Approximately 12%–15% of the population.
• Palatally(85%) more often than labially(15%).
• According to Ericson & Kurol :
Prevalence - 0.92% to 4.3%, whereas 8.0% cases are bilateral
Twice common in Females(1.17%) than Males(0.51%).
• Rohrer – Maxilla 20 times more frequently than in mandible.
• Palatal side : Labial - 3:1 (Jacoby).
• Oliver 1989 shows Asians have more buccal impactions than palatal.
3

• Almost always rotated upon their longitudinal axis and are usually in an oblique
position.
• Frequently impacted maxillary cuspids often found in a horizontal position.
• The impacted canine presents five basic localizations as follows:
1. Palatal localization.
2. Palatal localization of crown and labial localization of root.
3. Labial localization of crown and palatal localization of root.
4. Labial localization.
5. Ectopic positions.
4

ETIOLOGY of palatally impacted canine
Beckers Concept
McBridge Concept
Moyers Concept
Van Der Heyedt
Concept
5The etiology of maxillary canine impactions, Dr. Jacoby Harry Jacoby, D.M.D.

ETIOLOGY
• BECKERS CONCEPTS :
Becker (1984) hypothesized two processes
 Absence of initial early guidance from an anomalous lateral incisor.
 Failure of the buccal movement of the canine at an specified age.
• MC BRIDGE CONCEPT:
Canine formed at high in the anterior wall at antrum, below the floor of orbit,
long tortuous path of eruption.
• MOYERS CONCEPT :
Moyers states, “The maxillary cuspid follows a more difficult and tortuous path of
eruption than any other tooth.
At the age of 3 it is high in the maxilla, with its crown directed mesially and
somewhat lingually.

Moves towards the occlusal plane, gradually up-righting itself.
Deflected to a more vertical position;
Erupts with a marked mesial inclination.”
Although there are hereditary patterns leading to impaction, the etiologic factors
of most concern are :
prolonged retention of primary teeth,
localized pathologic lesions and shortening of the length of the arch.

8
• MOYERS CONCEPT SUMMARIZED BY BISHARA:
PRIMARY CAUSES SECONDARY CAUSES
1. Rate of root resorption of deciduous
teeth.
2. Trauma of the deciduous tooth bud.
3. Disturbances in tooth eruption
sequence.
4. Availability of space in the arch.
5. Rotation of tooth buds.
6. Premature root closure.
7. Canine eruption into the cleft area in
persons with cleft palate.
1. Abnormal muscle pressure.
2. Febrile diseases.
3. Endocrine disturbances.
4. Vitamin D deficiency.
The etiology of maxillary canine impactions, Dr. Jacoby Harry Jacoby, D.M.D.

• VON DER HEYEDT CONCEPT:
 Because the total arch length for the permanent teeth is primarily established
very early in life, at the time of eruption of the first permanent molars, and
because the canine is large and late in erupting, it is often not found in the
alignment of the arch.
 As in musical chairs, the room for this late and prodigious tooth is all gone, and
it must assume an awkward and embarrassingly inappropriate position on the
arch alignment.

THEORIES OF CANINE IMPACTION
GENETIC
THEORY
GUIDANCE
THEORY
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• GUIDANCE THEORY (Miller, 1963):
• Proposes that canine erupts through a long, tortuous path.
• Lateral incisors serve as a guide to canine during the course of the eruption.
• Lateral incisor guide the mesially erupting canine in a more favourable distal and
incisal direction.
• GENETIC THEORY (Peck & Peck, 1994):
• Polygenetic multifactorial inheritance.
• Genetic factor as primary aetiology and may be associated with missing or small
lateral incisor.
• MSX1 and PAX9 might be involved.
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ETIOLOGY of labially impacted canine
• 85% of palatally displaced canines had sufficient space to erupt (Jacob).
• 17% of buccally impacted canines had sufficient space to erupt (Jacob).
• Arch length discrepancy - primary etiologic factor for labially impacted canines.
12
Impacted canines: Etiology, diagnosis, and orthodontic management Ranjit Manne, ChandraSekhar Gandikota,
Shubhaker Rao Juvvadi, Haranath Reddy Medapati Rama, Sampath Anche

INDICATIONS FOR REMOVAL
1. Change in position of adjacent teeth in unfavorable position.
2. Resorption of adjacent teeth roots.
3. Pathology, like formation of a dentigerous cyst.
4. Teeth in the alveolar cleft in cleft palate patients, if the tooth cannot be aligned
orthodontically after bone grafting.
5. Impacted tooth in edentulous patient.
6. Neurological symptoms like pain.
7. Prior to orthodontic treatment.
8. Lack of motivation of the patient or lack of facilities for orthodontic alignment
13

CONTRAINDICATIONS FOR REMOVAL
1. Extreme of age.
2. Compromised medical status.
3. Probable excessive damage to adjacent structure
14

FIELDS AND ACKERMAN CLASSIFICATION(1935)
A. LABIAL POSITION :
1.Crown in intimate relationship with incisors.
2.Crown above apices of incisors.
B.PALATAL POSITION :
1.Crown near surface in close relationship to roots of incisors.
2.Crown deeply embedded in close relationship to apices of incisors.
C.INTERMEDIATE POSITION :
1.Crown between lateral incisor and first premolar roots.
2.Crown above these teeth with crown labially placed and root palatally placed or vice versa.
D.UNUSUAL POSITION :
1.In nasal or antral wall.
2.In infraorbital region.
15

ARCHER CLASSIFICATION
• According to ARCHER(1975),
Class I – Impacted Cuspids located in the palate.
a)Horizontal.
b)Vertical.
c)Semi vertical.
Class II – Impacted Cuspids located in the labial or buccal side of maxilla.
a)Horizontal.
b)Vertical.
c)Semi vertical.
Class III – Impacted Cuspid located both in the palatal process & buccal maxillary
bone.
16

 Class IV – Impacted Cuspids located in the alveolar process, usually vertically
between the incisor & first bicuspid.
Class V – Impacted Cuspids located in an edentulous maxilla.
17

CLASSIFICATION BY YAMAMOTO
• The angle between the tooth axis and the occlusal plane was estimated using
orthopantomograms, and impacted canines were classified according to this
estimated angle.
18

CLASSIFICATION
• Type I — vertically impacted canines, with the tooth axis being almost
perpendicular to the occlusal plane, and located between the lateral incisor and
first premolar. A tooth situated in close relation to the lateral incisor is also
included in this classification. (40.4%)
• Type II — impacted canines inclined mesially against the occlusal plane. (34.3%)
• Type III — impacted canines inclined distally against the occlusal plane. (1.4%)
• Type IV — horizontally impacted canines with the crown directed mesially.
(11.5%)
• Type V — horizontally impacted canines with the crown directed distally. (1.4%)
• Type VI — inversely impacted canines. (7.1%)
• Type VII — labio-lingual (palatal) impaction and ectopic impaction. Impacted
canines transposed in the arch resulting in a different order of teeth. (4.3%)
19

COMPLICATING FACTORS
• Greater danger of injury to adjacent teeth & vital structures.
• Possibility of forcing the cuspid into maxillary sinus is always present.
• Right asepsis should be followed; otherwise, an acute infection of the sinus may
ensue.
21

LOCALIZATION OF IMPACTED CANINE
INSPECTION :
• Over retained primary canine,
• Lack of Canine prominence in buccal sulcus, but, according to Ericson and Kurol,
the absence of the "canine bulge" at earlier ages should not be considered as
indicative of canine impaction,
• Inclined lateral incisor,
• Swelling in either buccal or palatal area,
• Non – vital or mobile lateral incisor.
Palpation : Palpable protuberance of the area designates the position of the tooth
quite accurately.
X-Rays: OPG, PA, Lateral Cephalogram.
22

Ericson and Kurol SECTOR LOCALIZATION
• Sector 1: if the cusp tip of the canine is between the inter incisor median line and
the long axis of the central incisor;
• Sector 2: if the peak of the cuspid of the canine is between the major axes of the
lateral and central;
• Sector 3: if the peak of the cuspid of the canine is between the major axis of the
lateral and the first premolar.
• α - angle formed between the inter incisor midline and long axis of canine.
• d - perpendicular distance of the peak of the cuspid of the impacted canine with
respect to the occlusal plane.
23

24
 The risk of resorption of the root of
the lateral incisor increases by 50% if
the cusp of the canine belongs to
sector 1 or 2 and if α angle is greater
than 25°.
 The duration of treatment is longer if
the canine is found in sector 1,
shorter if it belongs to sector 3, with
respect to sector 2.
Localization of Impacted Canines - Surubhi Kumar , Praveen Mehrotra , Jitendra Bhagchandani , Ashish Singh, Aarti Garg, Snehi Kumar, Ashish Sharma,
Harsh Yadav

• PA View:
• To evaluate the medio-lateral position of the canines with respect to a line
connecting the inferior borders of the orbits.
• Prognostic evaluation.
• Evaluation of the angle formed by the long axis of the canine and the transorbital
line.
• The prognosis and the degree of treatment difficulty increase as the angle
between the long axis of the canine and the transorbital line decreases.
25
Harsh Yadav

• Lateral Cephalogram : To establish the height of the impacted tooth and the
anteroposterior position of the impacted canine with respect to the apices of the incisors.
• Evaluation by tracing its axis and intersecting it with the perpendicular to Frankfurt’s
plane.
• Readings under 10° are considered to be within the norm;
1. between 15 and 25°, Necessity of treatment are increased;
2. between 25 and 45°, difficulties involved in treatment
increase;
3. Over 45°, reservations as to the possibilities of
treatment success arise.
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Harsh Yadav

DIAGNOSTIC TECHNIQUES
1. Occlusal radiographs:
The cusp of the canine is positioned in front of the ideal line
connecting the apices of the lateral incisors, the position will be labial.
2. Clark’s Rule or Parallax Method or Tube Shift Method: (SLOB- same lingual
opposite buccal)
Horizontal tube shift.
Vertical tube shift.
3. Right Angle Technique.
4. 3-D Techniques – CT, CBCT,
5. Rapid Prototyping.
27

MANAGEMENT
28
• The most important factors for the successful management of impacted maxillary
canines are angulation of canine to the midline, age of the patient, vertical height,
and bucco-palatal position.
• These factors can also affect the duration of the treatment.
No treatment with periodic evaluation
Interceptive removal of deciduous canine (Ericson
& Kurol, 1988)
Surgical Exposure & Orthodontic alignment
(Bishara 1992)
Auto transplantation (Shaw et al 1981 & Sagne et
al 1986)
Prosthetic replacement

Interceptive removal of deciduous canine
• Preventive treatment of choice.
• No crowding is present.
• Resolved permanent canine impaction in 62% cases.(Power and short).
• According to ERICSON AND KUROL :
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1. Eruption normalized within 12 months after extraction – 78%.
2. Improved positions after only 6 months - 64%.
3. Position improved after 12 months - 36%.
Guidelines for the Assessment of the Impacted Maxillary Canine - Kate Counihan, EA Al-Awadhi and Jonathan Butle

Assessment for interceptive management
• The prognostic factors have been investigated by McSherry and Pitt et al,
30
Guidelines for the Assessment of the Impacted
Maxillary Canine -
Kate Counihan, EA Al-Awadhi and Jonathan Butle

• Distal to lateral incisor root, self-correction occurred if the deciduous canine were
removed (91%).
• Mesial surface of the lateral incisor root, self-correction does not occur (64%).
(Ericson & Kurol).
31
Early treatment of palatally erupting maxillary canines by extraction of
the primary canines - Sune Ericson and Juri Kurol.
European Journal of Orthodontics IO(1988) 283-295

GUIDED ERUPTION
• Undergo an initial phase of orthodontic treatment.
• To create adequate arch space.
• Intended to permit natural eruption of impacted teeth.
• Exposed in the direction most appropriate for crown movement.
• The wound is then packed until it is totally epithelialized.
32

Surgical exposure of impacted maxillary canine
• Techniques for Surgical Exposure of Impacted Maxillary Canine :
33
Window approach
or Gingivectomy
Apically positioned
flap
Full flap closure or
Closed
Tunnel traction
Mc Bridge
(1979)
Crescini et al (1994)
Tunnel traction of infraosseous impacted maxillary canines. A three-year periodontal follow-up A Crescini, C Clauser, R Giorgetti, P Cortellini, G P Pini
Prato

Surgical exposure of impacted maxillary canine
 Evaluate 4 criteria to determine the correct method for uncovering the
tooth(Kokich et al).
1. Labiolingual position of the canine crown.
Labially impacted- Open Technique.
Impacted in the centre of the alveolus - Open or Closed.
Palatal – Closed.
2. The vertical position of the tooth relative to the mucogingival junction.
Coronal to the mucogingival junction – Open technique.
At the level of MGJ – Apically repositioned flap.
Apical to mucogingival -; closed eruption technique.
34
Surgical Management of Impacted Canines: A Literature Review and Case Presentations - Bassam M Kinaia, Kiran Agarwal, Brandon Bushong, Natasha
Kapoor, Kristyn Hope, Filip Ambrosio and Maanas Shah.

3. The amount of gingiva in the area of the impacted canine.
Insufficient gingiva - apically positioned flap.
Sufficient gingiva to provide at least 2 to 3 mm of attached gingiva - any of the 3
techniques.
4. The mesiodistal position of the canine crown.
Mesial to lateral incisor – Closed.
Distal to Lateral – Open.
35

36

SURGICAL EXPOSURE & BONDING FOR PALATALLY
IMPACTED CANINE
• An apically-positioned flap - full-thickness mucoperiosteal flap.
• A zone of keratinized gingiva must be included in the flap.
• Vertical releasing incisions on each.
• Bonding of bracket = 1–2 weeks after surgery.
• For bonding during surgery, bone overlying the unerupted tooth is removed .
• Do not remove bone that compromise the tissues of the impacted or adjacent
teeth.
37

• The ideal location of the bonded bracket is the most incisal portion of the crown.
• Bleeding can hinder visualization of the tooth and bonding of the bracket.
• Control bleeding before bonding.
• Upon completion of the bonding the flap may be repositioned in its original
place.
• Traction carried out closed, with the traction chain or wire submerged.
38

The Palatal Canine and the Closed Exposure Technique
39
Surgical Management of Impacted Canines: Adrian Becker, BDS, LDS, DDO, Stella Chaushu, DMD, MSc, PhD

SURGICAL EXPOSURE & BONDING FOR LABIALLY
IMPACTED CANINE
• Follows similar principles to the palatal impaction, with the added concern of
maintaining keratinized, attached mucosa adjacent to the cervical line of the
tooth when eruption is complete.
• Adequate space in the arch.
• A full-thickness mucoperiosteal flap is elevated with mesial and distal releasing
incisions extending along the sides of the canine crown.
• Make these incisions more closely parallel.
• The crown of the tooth is uncovered.
• A bonded bracket is attached and the flap is repositioned.
40

• When the tooth is too far superior to allow an apically repositioned flap, the wire
or chain secured to the bracket is brought out from under the flap at the crest of
the ridge and the flap is returned to its original position.
• As the tooth is orthodontically moved into position, an adequate band of
keratinized gingiva either migrates with the tooth or remains in place at the
alveolar crest and the tooth is guided to erupt through it.
• Avoid removal of the attached gingiva, leaving alveolar mucosa surrounding the
cervical area of the tooth.
41

The Labial Canine and open (Window) Technique
42

The Labial Canine and the Apically Repositioned Flap Technique
43
Peterson’s Principles of Oral & Maxillofacial Surgery (3rd edition)

The Midalveolar Canine and the Tunnel (Closed Exposure)
Technique
• fg
44

SURGICAL REMOVAL OF IMPACTED MAXILLARY
CANINE
45

REMOVAL OF CLASS I IMPACTED CANINE
• Incision begins on the lingual side of maxillary central incisor and extending to
the distal side of second premolar using BP blade No: 12.
• With the No: 15 blade, beginning at the crest of the interdental papilla on the
lingual side, between the maxillary central incisors, carry the incision straight back
along the centre of the palate for 1 ½ inches.
• Reflect the mucoperiosteum.
• Drill holes in the palatal bone 3mm apart around the crown.
• Connect the holes & remove overlying bone.
• Lift the tooth by placing No.73 & No. 74 Miller Apexo elevator.
46

• Not removed - enlarge the opening, repeat the procedure
• If still not removed, grasp the crown with a No: 286 forceps & remove by rotatory
motion.
• Clean out all debris & trim smooth the edges.
• Suture the flap back to its position.
• Pack gauze over mucoperiosteal flap to the level of occlusal surface.
• Keep it for 4 hrs.
47

48
Incision made & flap raised Holes drilled & enlarged
Tooth is elevated & Sutured
Oral & Maxillofacial Surgery Volume One by W. Harry Archer (5th edt)

ALTERNATE TECHNIQUE FOR CLASS I
• Indicated when the tip of cuspid crown is close to the root of the central & lateral
incisors.
• Make bilateral palatal flap.
• Flap begins at the first or second ipsilateral premolar and, after continuing along
the cervical lines of the teeth, ends at the first premolar on the contralateral side.
• Cut off the crown with a large crosscut fissure bur.
• Drill a slot in the root of the impacted tooth.
• Move the root forward.
• Complete the remaining steps as described earlier.
49

50
Incision made & flap raised
Fragiskos D. Fragiskos (Ed.) Oral Surgery

51
Removal of bone & exposing
the crown
Sectioning of the crown

52
Removal of root
Surgical field after removal

53
Surgical field after suturing
Removed Impacted Cuspid

REMOVAL OF CLASS II IMPACTED CANINE
• Trapezoidal Incision made & mucoperiosteum flap is raised.
• Bone is removed.
• A groove is created at the cervical line.
• Place straight elevator in the groove.
• Separate the tooth into two segments by rotating elevator.
• The crown is removed first and the root is then luxated.
• Create a purchase point on the surface of the root.
• Move the root into the space created by the removal of the crown by placing the
tip of No:11R elevator into the groove.
54

55Oral & Maxillofacial Surgery Volume One by W. Harry Archer (5th edt)

56

57

REMOVAL OF CLASS III IMPACTED CANINE
Technique for when root is in labial side & crown is in palatal side:
• A semi-circular labial flap is made over the root & flap is raised.
• The root is exposed by removal of bone.
• The root is severed with a sharp chisel or cut off with crosscut fissure bur & root is
elevated from the bed.
• A palatal flap is outlined & reflected & bone overlying the crown is removed.
• Root end of crown tapped with mallet through the buccal crypt.
• The flaps are repositioned & sutured.
58

59
Oral & Maxillofacial Surgery Volume One by W. Harry Archer (5th edt)

REMOVAL OF CLASS III IMPACTED CANINE
• Technique for when crown is in labial side & root is in palatal side:
• The incision is around the necks of the teeth, then to the mucobuccal fold at 45°
angle. The flap is raised.
• Remove the labial & buccal plate . Holes are drilled as described before.
• Engage the crown with No.286 forceps.
• The tooth is rotated mesially & distally, toward the labial side & removed from its
bed.
• If the attempt is unsuccessful, cut off the crown, raise palatal flap & remove the
bone over root & push the root passed through labial opening.
• Clean out all debris & the flaps are repositioned & sutured.
60

REMOVAL OF CLASS V IMPACTED CANINE
• The incision for palatally impacted canine is along the crest of the ridge and back
along the centre of the palate for 1 ½ inches.
• The technique for exposure & removal is the same as described earlier.
• However there is no danger of exposure of the roots or trauma to the adjacent
teeth.
61

REMOVAL OF ECTOPIC IMPACTED CANINE
• Technique for impacted canine, localized in the anterior wall of the maxillary
sinus:
• Horizontal incision is made in the region of the canine fossa, from the lateral
incisor as far as the first molar.
• The mucoperiosteum is then reflected and the bone of the anterior wall of the
maxillary sinus is exposed.
• Holes are drilled & joined together.
• The impacted tooth is exposed and luxated.
• Saline irrigation done.
• Suturing and nasal decongestants are prescribed.
62

63
Flap is raised Holes are drilled
Preop X-ray & Incision made

64
Holes are connected
Removal of Impacted Canine
Flap repositioned & sutured

REFERENCES (BOOKS)
• ESSENTIALS OF ORAL & MAXILLOFACIAL SURGERY – By M. ANTHONY (TONY)
POGREL , KARL-ERIK KAHNBERG , LARS ANDERSSON.
• ORAL & MAXILLOFACIAL SURGERY VOLUME ONE – By W.HARRY ARCHER.(5TH
Edition).
• ORAL SURGERY - By FRAGISKOS D. FRAGISKOS (Ed.).
• PETERSON’S PRINCIPLES OF ORAL & MAXILLOFACIAL SURGERY(5th Edition)– By
MICHAEL MILORO, G.E. GHALI, PETER LARON, PETER WAITE.
• TEXTBOOK OF ORAL & MAXILLOFACIAL SURGERY (4th Edition) – By NEELIMA
ANIL MALIK.
• TEXTBOOK OF ORAL & MAXILLOFACIAL SURGERY – By SM BALAJI.
65

• Etiology of maxillary canine impaction: A review - Adrian Beckera and Stella
Chaushu. ( 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.06.013).
• The etiology of maxillary canine impactions - Dr. Harry Jacoby (August 1983).
• A New Classification of Impacted Canines and Second Premolars Using
Orthopantomography - Gaku Yamamoto, Yoshiyuki Ohta, Yoshizou Tsuda, Akio
Tanaka, Masanori Nishikawa, Hirofumi Inoda. (Asian J Oral Maxillofac Surg
2003;15:31 – 37 , https://doi.org/10.1016/S0915-6992(03)80029-8 ).
66
REFERENCES (ARTICLES)

REFERENCES (ARTICLES)
• Localization of Impacted Canines - Surubhi Kumar, Praveen Mehrotra, Jitendra
Bhagchandani, Ashish Singh, Aarti Garg, Snehi Kumar, Ashish Sharma, Harsh
Yadav. (Journal of Clinical and Diagnostic Research. 2015 Jan, Vol-9(1): ZE11-ZE14,
https://dx.doi.org/10.7860%2FJCDR%2F2015%2F10529.5480 ).
• Surgical Treatment of Impacted Canines - Adrian Becker, Stella Chaushu.(Oral
Maxillofacial Surg Clin N Am 27 (2015) 449–458.
http://dx.doi.org/10.1016/j.coms.2015.04.007. )
67

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