Management Of Impacted Teeth

Management Of Impacted TeethGuide Dr. Chandralekha BProf & HOD Dept Of Orthodontics And Dentofacial Orthopedics By : Dr. Nilofer Vevai Contents Introduction. Impaction.. Normal development of anteriorsTheories Regarding Impaction of teeth. Radiographic Diagnosis. Classification of Impacted Canines .Surgical Exposure Of Impacted TeethTreatment Options. Impacted Canines And Incisor root resorption Maxillary Central Incisors Traumatic Impaction & Impaction Of Single Teeth. ConclusionIntroduction A perfect set of 32 is something desired by all.

However it is not uncommon to find a case wherein individuals come forth with the sole complaint of not having the normal number of teeth in the oral cavity.

Mainly this situation arises when there is this lack in the anterior area & can be a great source of embarrassment to the patient who may feel socially inferior to his counterparts ...

2 situations when patients seek treatment :

Class 2 div 2. Impacted teeth in anterior region.

In general 3rd molars are the most commonly impacted teeth followed by maxillary canines and mandibular second premolars.

In cases of maxillary impacted canines palatal canine impaction is found to be more common than buccal canine impaction.

In cases of maxillary canine impaction Females affected more than males and buccal has higher incidence.A Brief recapNollas Stages Of Tooth Development

According to Macdonald a tooth erupts when the root is 2/3 formed.

According to Gron a tooth erupts when the root is developed.

Impaction Terms which are important : - Dental Age - Chronological Age - Morphological Age.

Eruption time is generally an indication for dental age is a wrong concept.

A tooth may have delayed eruption due to various local causes.

Dental age must be assessed depending on the root development of the teeth that should be in the oral cavity irrespective of its eruption status.

Retained Deciduous tooth : A term having positive connotation and which maybe defined as a tooth which remains in place due to the absence or retarded development of the permanent successor.

Over Retained Deciduous Tooth: A term used to describe an unshed deciduous tooth with an underlying tooth with root lengths in excess of three quarters of the full length.

A permanent tooth with delayed eruption : Is one whose root length is developed in excess of this length and whose spontaneous eruption is expected.

An Impacted tooth: A disorder in which a tooth is so crowded in its socket that it cannot erupt normally.

An impacted tooth is any tooth that is prevented from reaching its normal position in the mouth by tissue, bone, or another tooth.

An impacted tooth is a tooth that is all the way or partially below the gum line and is not able to erupt properly.

While assessing dental Age a base age of 9 yrs is taken and assessment made.- if mandibular central incisor roots are complete means pt is at least 9 yrs old).First molars 9-9.5 yrs Mandibular lateral incisors 9.5 yrs. Maxillary lateral incisors 11 yrs. Mandibular canines and first premolars 12- 13 yrs. maxillary first premolars 13-14 yrs. Normally developing maxillary canines and 2nd premolars 14-15 yrs. Factors which must also be considered while assessing dental age : Crown formation Root formation. Root resorption.

Supernumerary teeth coniform premolars and peg laterals excluded. A Late developing dentition : Typically dental age lags behind chronological age and radiographically less root formation

Extraction is contraindicated. Normal DevelopmentA periapical view of a 5 yr old child would give the impression of severe crowding .

Why so ? - Centrals and canines same Anteroposterior level. - Lateral incisor palatal irt both. - Canines sited higher up vertically. The Eruption Sequence and development of Ugly Duckling Stage and its resolution .Causes Of Impaction Inadequate resorption of deciduous root. An abnormal eruptive path. A supernumerary tooth. Dental Crowding. Disturbance in the eruption mechanism of teeth. Thickened ligament post trauma . Early loss of deciduous tooth. Impactions due to space loss.

Etiology Of Maxillary Canine Impaction (Multifactorial)

Bishara and associates summarized Moyers theory that impacted canine is caused byPrimary (Localized)1. Tooth size arch length discrepancies.Prolonged retention or early loss of deciduous canine.Abnormal position of the tooth bud (rotation of tooth buds).Trauma of the deciduous tooth bud.Disturbances in the tooth eruption sequence. Presence of an alveolar cleft. Ankylosis.Cystic or neoplastic formationDilaceration of the rootPremature root closure IatrogenicIdiopathic

Secondary (Generalised )Abnormal muscle pressureFebrile diseasesEndocrine disturbancesVitamin D deficiencyIrradiation

Dewel once said : No tooth is more interesting than the maxillary canine from the development point of view than the maxillary canine.

A canine in its buccally placed area can be palpated at 11-13 yrs of age.

Additional reasons for canine impactions:Long Path of eruption(Broadbent). High placement in the maxilla.

Crowding( Hitchins).

Non resorption of the roots of the deciduous canine(Lappin- palatal deflection).

Trauma : Brin I, Soloman Y & Zilberman Y Trauma as a possible factor in maxillary canine impaction AJO DO 1993 Vol 104: 132-137Case report Result : 1. Trauma causing abnormal path of eruption.Movement of unerupted canine y itself. Unharmed adjacent teeth should be also evaluated Short lateral incisor root due to development stunting by trauma leading to loss of guidance to canine.Soft tissue pathology. Heredity Contentious issue

Studies show high positive correlation and spotaneous reslution when local factor is removed.

Maxillary canine first premolar transposition,associated dental anomalies and genetic basis Peck L,Peck S, Attia Y Angle Orthod 1993;63;99-109

Primary tooth germ displacement

The Guidance theory: Miller (1963) & Bass (1967) Noticed that congenitally missing lateral incisors also had a high instance of palatally impacted canines.

Hypothesized this due to the lack of guidance generally being given by the lateral incisor during eruption.

Thus the canine follows a mesial and palatal path since the lateral incisor is now missing to guide it to its correct position.The Guidance Theory Comprises OF 5 elements: Normal Eruption: First Stage Impaction: Occurs when there is absence of lateral incisors or lateral incisors/peg shaped laterals due to this there is lack of guidance and the canines shift palatally or are horizontally impacted.First Stage impaction with Secondary correction: A corrective process of the vertical maxillary process redirecting the canine in a more favorable downward path. May or may not reach its desired position spontaneously. Second Stage Impaction: Self correction hampered by an anomalous late developing lateral, redeflecting the tooth palatally. An etiologic factor not seen if the lateral incisor is present. Aka Second Stage Displacement. Second Stage Impaction with secondary correction: Extraction of the over retained deciduous canine or the anomalous lateral incisor itself leading to the resolution of the problem. Miller :PEG SHAPED LATERALS AND ANOMALOUS LATERALS .However Becker and co workers in their studies claim the opposite.They agree with the Guidance theory but raise questions over the anomalous lateral incisors.

DiagnosisImportance..

An undiagnosed & severely resorbed tooth with a poor long term prognosis may be mistakenly included as an integral part of a final outcome dentition in a projected treatment plan but actually is a weak link can actually hamper your treatment plan. Clinical Examination : Inspection Palpation Radiodiagnosis : Radiographic methods of diagnosis recognition of pathologic entities as well as localization and recognition of impacted tooth.

Radio diagnosis: IOPAR Lateral Shift Technique Vertical Shift Technique Orthopantamographs Vertical Shift + Orthopantamographs Orthopantamographs + Lateral Cephalograms Occlusal Radiographs. Tangential View Postero-Antero Cephalogram CT & CBCT

Intraoral Periapical Radiographs:

The first simplest and most informative view.Shows the type of supernumerary tooth.Type of Obstruction a) Soft tissue. b) Hard Tissue.High clarity levels Disadvantage :Two dimensional. Only Mandibular posterior area is what we call True Lateral since all other areas the beam is angulated hence height assessment not very dependable. Occlusal Radiographs : Methodology. In the lower canine premolar area the occlusal view is a true occlusal view and should depict all the posterior standing teeth in cross section. Should depict the buccolingual placement of structures. True occlusal view of the anterior area of the mandibular arch 110 degTrue occlusal view of the molar area 90 deg to the horizontal + 15 deg medial tilt of the tooth .

In the maxilla we have :True Vertex Occlusal.Anterior maxillary occlusalPeriapical view.

True vertex occlusal is the best but clarity low. A high mesially placed canine seems similar to a high palatally placed canine this is avoided in true vertex view.In general mandibular occlusal film clarity is generally low due to dense cortical tissue.

3D diagnosis of tooth position.

Parallax method . Given by Clark CA in A method of ascertaining ethe relative position of unerupted teeth by mrans of film radiographs in 1910.

It is of 2 types :

The Lateral Tube Shift .

The Vertical Tube Shift.

The Lateral Tube Shift :Uses the parallax method. A popular technique. SLOB Rule

Can be used with

2 IOPARs

Lateral Cephalogram And OPG

Vertical parallax: When the canine is in an extremely high position this can be utilised as an alternative.

Reliability is low. Incisor area impaction with incisor mesiodens this is difficult to discern. SLOB rule.Can be used with two IOPARs.

Orthopantamograph+ IOPAR

Tangential View :Taken in the lateral ceph format with an occlusal radiograph.

Helpful for canine impaction Not useful for maxillary central incisor impaction.However during the course of resolution of central incisor impaction best view.Best for Dilacerated Central Incisor.

CT Scan Late 1980s used fro the first time for identifying exact position of palatally impacted canines.

Large dosesOnly exceptional cases Resorption of roots of incisor teeth also checked.

CBCT

Digital volume tomographic machines.Xray source and image intensifier.Reconstruction in every direction.360 deg rotation Panaromic and transaxial view.Slicing.Low radiation doses

Lindauer SJ, Rubenstein LK, Hang WM, Anderson WC, IsaacsonRJ. Canine impaction identified early with panoramic radiographs.J Am Dent Assoc 1992;123:91-7.

They modified Kurol & Ericson model for predicting eruption after deciduous canine extraction.

Lindauers method used the location of the cusp tip of the canine in question and its relationship to the adjacent lateral incisor.

He determined the probability for impaction based on the canine cusp tip location in 1 of 4 sectors. Lindauer et al reported that this method identifies up to 78% of the canines that are destined to become impacted.Sector I represents area distal to line tangent to distal heights of contour of lateral incisor crown and root. Sector II is mesial to sector I, but distal to bisector of lateral incisors long axis. Sector III is mesial to sector II, but distal to mesial heights of contour of lateral incisor crown and root.Sector IV includes all areas mesial to sector III.

Power SM, Short MB An investigation into the response of palatally displaced canines to the removal of deciduous canines and an assessment of factors contributing to a favourable eruption. Br J Orthod 1993;20:215-23.State that an Angulation of more than 310 would hamper a spontaneous eruption of the canine once the deciduous tooth is extracted.

Prediction Of Maxillary Canine Impaction Using Sectors & Angular MeasurementsArticle By J Warford, R Grandhi, Ajo Do 2003 vol 124

For every unit of change in sector, the odds of indication of impaction increase by a factor of 8.7.

Probability of canine impaction based onsector and angle measurementsSector I II III IVAngle (deg)4054 0.11 0.53 0.91 0.995569 0.08 0.43 0.87 0.987084 0.05 0.33 0.81 0.988599 0.04 0.25 0.75 0.96Angle not 0.06 0.38 0.87 0.99

consideredSurgical Exposure Of Impacted teeth Surgical intervention without Orthodontic treatment Exposure Only with spontaneous eruption. Exposure with pack. The Surgical Elimination Of PathologySoft Tissue Lesions Hard Tissue Obstruction - Primary - Secondary2 Basic approaches to surgically exposing impacted teeth:The Open Eruption TechniqueThe Window Technique The apically repositioned flap. First done for a labially impacted canine by Vanarsdall & Corn.

The Closed Eruption Technique :First described by Hunt & McBride. Modification by Crescini et al published in Tunnel traction of intraosseus impacted maxillary canines A a 3 yr follow up Ajo-do 1994; 105: 61-72

Orthodontic Management Creation Of An Anchor Unit: Modification must be made for anchor unit.A fully multi-bracketed appliance should normally be placed & the entire dentition treated through the stages of leveling & opening of adequate space in the arch for impacted tooth.

Devices to help: Lasso wires Threaded pins. Orthodontic bands. Standard Orthodontic Bracket. Simple Eyelet. Elastic ties And modules. Magnets. Lasso wires: It is twisted lightly around the neck of the canine. Disadvantages: This results in irritation of the gingivaPrevents reattachments of the healing tissues in area of CEJ (cemento-enamel junction).May produce areas of external resorption & ankylosis in areas of CEJ. It is rarely used now.

Threaded Pins: Provide the attachment for an impacted tooth.Disadvantages: - Dentally invasive. - Requires a subsequent restoration. - Difficult to place along the long axis of the tooth because of smaller surgical exposure. - The drilled hole may inadvertently enter the pulp(unerupted teeth may have large pulp chambers).Rarely used. Orthodontic bands: They largely replace the Lasso wires & threaded pins. Advantage: They are compatible with the health of periodontal tissues. Disadvantage: - Large surgical field required. - Inadequate moisture control may hamper with the cement-band bond.

Standard orthodontic brackets: Any edge-wise , Beggs , PAE brackets can be used. They are routinely used as direct attachments along with the composites.

Disadvantages:- As the bracket base is wide, it is difficult to adapt to any other tooth surface except for the buccal surface.- The brackets shear bulk creates irritation as the tooth is drawn the soft tissues. - Ligature wire or elastic thread tied to bring the impacted tooth into arch. Interferes with the investing tissues & leads to inflammation & periodontal damage. As the impacted tooth advances into the arch the exuberant gingival tissues bunches in front of it & causes punching between the bracket & tissues. A Simple Eyelet - An eyelet welded to band material with a mesh backing is soft & easy to contour making its adaptation to bonding surface more accurate which makes for superior retentive properties. - Because of small size they can be placed in more awkwardly placed teeth.- It is less irritating to the surrounding tissues.

Elastic ties and modulesAdvantages Application of light forces Good range of action Easier to tieDisadvantages Tends to loosen High degree of force decay

Magnets :Rare earth magnets .Made Of Lanthanum alloys. Forces generated along the line of magnetic plane.They can corrode hence covered with a coating of parylene.One Magnet placed on the appliance. One on the displaced tooth.Disadvantage: Distance.Classification Of Impacted CanineMaxillary or Mandibular Canine may be impacted

Bucally.

Palatally.Classification Of Palatally Impacted Canines : Transverse Relationship: Close to the midline Away from the midline.

Height Of the Crown of the tooth in relation to the tooth . High Low Based On The Above Group I : Transverse : Close Height : Low Group II : Transverse : Close Height : Forward Low and Mesial to lateral incisor root.

Group III : Transverse : Close Height : High Group IV: Transverse : Distant Height : High

Group V : Canine root apex mesial to that of lateral incisor or distal to that of first premolar.

Group VI : Erupting in the line of arch in place of and resorbing the roots of the incisors.1. Group I Transverse : Close to the arch. Position : Low

Prognosis : Good Most common form of palatal impaction. Root movement rarely necessary.

Surgery : minimally invasive. Removal of eggshell thin bone.Complications : Rotation: a) Auxiliary Niti Wire. b) Slingshot elastic. Mesial Crown displacement : Palatal root displacement :

Group II Transverse : Close Height : Forward low and mesial to the lateral incisor root.

Root apex correct position .Canine crown tilted mesially in close association with the palatal aspect of the root of the lateral incisor.

Surgery: Lateral Incisor roots may pose a risk. Careful Bone removal advised. Minimum required tooth exposure for bonding. Flap replaced entirely. Ligature pigtail made to pass through a electrocauterised slit. Hurdle : 180 degree rotation

Prevention : Vertical traction followed by alignment into desired positioned.

3 types of spring auxiliaries may be used : a) The Ballista. b) The active palatal Arch. c) The Light Auxiliary labial Arch. In all the 3 a heavy base archwire should be present to: a) Keep space regained open. b) Resist secondary distortion of the occlusal plane. c) Support for force.

Problems that may be encountered: Thick palatal tissues. Delay may cause adjacent teeth to intrude instead of canine erupting.

Group II Complications : Rotation. Palatally displaced root. Thick And Resistant Palatal Tissue. Risk Of Exposing and Damaging roots of adjacent teeth.

In All 5 types of tooth movements can be seen in Aligning a Group II impacted canine a) Vertical Extrusion. b) Buccal Tipping of the crown. c) Derotation. d) Mesio-distal uprighting. e) Buccal root torque Group III Transverse : Close Vertical : High Treatment Strategy :

Buccal Approach: The Apically repositioned flap. Full Flap reflection & Partial Replacement. The tunnel Approach.Palatal Approach Two Stage Traction Group IV Transverse : Distant Height : High The crowns of impacted canines in this case are placed medially and may even cross the mid-palatal suture.Normal Positioning of root apex.

Treatment : Two stage traction approach.

Difficult Mechanics.

High relapse rates with the canines being in an edge to edge/ Cross- bite relationship with the lower teeth. Group 5 Canine root apex mesial to that of lateral incisor or distal to that of first premolar. Transposed tooth. May be partially erupted. Four possible lines of treatment: To resolve the transposition to ideal relationship.

To move the premolar mesially or incisor laterally and align the canine into position.

To use the canine for autotransplantation into a prepared socket in its ideal site.

To extract the tooth ( Canine, incisor/premolar) with least prognosis and leave the deciduous canine intact.

Complications: Root dehiscence.

Group VI Erupting in the line of the arch In place of and resorbing the roots of the lateral incisors.

difficult to diagnose correct position.Devices Generating Extruding ForcesBallista Spring by Jacoby.Cantilever Spring & TMA Box Loop.Nickel Titanium Closed Coil Spring. Two Arch wire technique The monkey hook. K9 Spring Mandibular Anchorage. Australian Helical Archwire Tunnel Traction.

Ballista Spring : Ballista : An Ancient And Heavy Engine Of Warfare Used To Hurl Heavy Objects.

Harry Jacoby Ajo Do Feb 1979. It is an 0.014,0.016 or 0.018 inch round wire which accumulates its energy by being twisted around its long axis. Horizontal part of this wire accumulates the energy, is allowed to rotate in the premolar bracket acting like a hinge.

The last part of the spring is bent down vertically and ends in a loop shape to which a ligature elastomeric thread can be attached.

When the vertical portion of the spring is raised toward the impacted tooth, the horizontal part accumulates the energy into the twisted metal.

When the vertical section is released, it bumps down like a ballista.Creates a torsion on the molars hence a TPA must be given.Can be used for both Unilateral or bilaterally impacted canines.Aesthetic.

DiameterForce0.01660-100g of force 0.018120-150 gBest to start with 0.016 inch wire and proceed to 0.018 inch wire after 2 months and if required force increased by using double wires.

Advantages :

No impinging of roots. Ease of operating and changing the spring. Aesthetic. Minimal trauma during surgery. Can also be used for impacted upper incisors, vestibular upper and lower canines and premolars and molars. Cantilever Spring & TMA BOX Loop Given by Lindauer And Isaacson. Alignment of Impacted Canines with Cantilevers and Box LoopsVOLUME 33 : NUMBER 02 : PAGES (82-85) 1999SURENDRA PATEL,VITTORIO CACCIAFESTA,CARLES BOSCH 0.017 x 0.025 TMA wire. Auxillary tube one point contact. Statically determinate forces. Stiff posterior archwire segments And TPA required.

A. Cantilever for mesial and vertical eruption of impacted canine. Angulation of ligature between cantilever and attachment on canine corresponds to line of force. B. Full-size rectangular archwire and transpalatal arch used for anchorage and space maintenance. C. Within four months, canine has erupted with proper tip, allowing engagement in continuous rectangular archwire. Magnitude of force should not exceed 70gms. The line of action of the force exerted by the cantilever on the canine can be adjusted according to the situation.For a buccally impacted canine, the choice would be either to extrude and mesialize the canine or to extrude and distalize it.A palatal push-force component or a buccal pull-force component can be added if necessary. TMA Box loop :

Statically indeterminate system. Constructed from 0.017x 0.025 TMA

The desired activation depends on the postion

A Cantilever Spring For Extrusion Canine needs distal tipping Sagittal plane: box loop activated by inserting it into canine bracket; distal tipping and extrusion achieved in one month.

Horizontal plane: box loop activated for correcting canine rotation; mesial rotation achieved in one month.

101 Elastics pulling the canine generally have a decay of forces. Effectiveness high. TMA Advantageous. A NiTi Closed Coil Spring

NiTi Closed Coil Spring A Review Of the Diagnosis & Management of Impacted Maxillary canines By MariselaM, Bedoya, JH Park.

J Am Dent Assoc, Vol 140, No 12, 1485-1493.

Nickel Titanium Closed-Coil Spring for Extrusion of Impacted CaninesVOLUME 33 : NUMBER 02 : PAGES (99-100) 1999LORING L. ROSS0.009X 0.041 spring Provides 80 gm of force when stretched to twice its resting length

b. Slip the hook through the link of elastomeric chain (from the impacted canine) nearest the gingiva, and twist it a couple of times.c. 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.d. At the next visit, unwrap, reactivate, and rewrap the spring

Two Arch Wire Technique for Alignment Of Impacted Teeth:Samuels & Rudge Vol 31 No. 3 Pg 183-187 1997Gold Chain fixed to the active component .Tied to the 0.014 Niti Archwire Which is deflected towards the tooth by 3-4 mm.

Samuels.R.H.A (1997) 0.014 nickel titanium arch wire Gold chain is preferable because of flexibility and biocompatibility.Gold links removed for activation.The Monkey Hook: An Auxiliary for Impacted, Rotated, and Displaced TeethVOLUME 36 : NUMBER 07 : PAGES (375-378) 2002S. JAY BOWMAN, ALDO CARANO

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.

Inspired by the children's game, "Barrel of Monkeys", since more than one Monkey Hook can be linked together to form a chain. 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.

Vertical Eruptive Intermaxillary ForceA small area of the crown needs to be surgically exposed for direct bonding of a loop-button with attached Monkey Hook. 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.The Hooks give a more rigid support.Best use when used in conjunction with super-elastic archwire.

Lateral Directional ForcesMore than one Monkey Hook can be added to a loop-button attachment, much like keys on a key ring. Elastomeric chain or superelastic coil springs can be attached to these hooks to direct forces laterally, creating a slingshot effect.

Can also be used as a rotational couple and a retraction hook.

The K-9 Spring for Alignment of Impacted Canines Varun Kalra JCO Vol 34 (Oct) pg 606-611 2000.0.017x0.025 TMA wire.Advantages Simple in design Low cost No patient compliance Light continuous eruptive and distalizing forces

Horizontal arm inserted into first molar buccal tube and premolar brackets. Spring bent 90 downward about 7mm mesial to premolar bracket to form vertical arm, which is about 11mm long and ends in helix. Spring held just distal to vertical arm with plier, and vertical arm bent about 20 inward, toward palate.

Management Of Impacted Maxillary Canines using Mandibular Anchorage. Ajodo Vol 115, No. 3 , 255-259.

A mandibular impression is made to fabricate a mandibular lingual arch with o.036 mm SS wire to be soldered from the first molar band on one side to the first molar band on the other side. The mandibular lingual arch is cemented in place after fabrication.

After adequate space is opened, it is maintained with aclosed/open coil spring.

Elastic traction applied to bonded attachments.Traction with light forces is applied via directional elastics.The elastic size can vary to ensure the delivery of forces that range from 40 to 60 g based on the movements of the mandible. The elastic application is demonstrated to the patient, and a proficiency check is done a week after the surgical procedure.The canine is guided vertically toward the occlusal plane. An orthodontic bracket should be bonded on the labial surface of this tooth as soon as possible. Elastic force modules have the disadvantages of rapid force decay.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. 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.The stiff primary archwire prevents the flexible nickel titanium archwire from sliding freely through the brackets. Eruption of Impacted Canines with an Australian Helical Archwire Christine Hauser,Yon H. Lai, Elina Karamaliki. Volume 34 : Number 09 : Pages (538-541) 2000 O.o16 Australian Archwire special plus, Straight length. The force should not exceed 200g. Activation by twisting the steel ligature wire every two weeks

Tunnel Traction of Infra-osseus Canines. Aldo Crescini AjoDo 1994, 115,61-72. ERUPTION OF AN IMPACTED CANINE WITH A SEMI-FIXED APPLIANCE: A CASE REPORT by Dr. Neelima K,Dr. Nagaraj, Dr. Jatti, Dr. Priyanka Sethi. A semi fixed appliance used to create a favourable path of eruption. Flap raised o.o10 SS ligature wire placed thru flap. Tunnel created thru the bone. Pigtail lig. Tied to the clasps.

Because of the angulation a distally directed force was applied. Latero incisal + Distal force. Roth 0.022 Prescription placed .

Rapid Prototyping3D CT images are seen as 2D on film and computer screen. Rapid prototyping makes a 3D model with/ without the help of CT Images.It is capable of reproducing complex designs that are unthinkable by any other method.Eg. it can reproduce the maxilla with the maxillary sinus and, inside this cavity, a third molar that might have inadvertently been pushed into the cavity during the removal of a tooth.

Dental modeling by means of rapid prototyping was an efficient auxiliary method in diagnosis, orthodontic treatment planning, and communication with this patient and the orofacial surgeon. Rapid prototyping technology made possible the fabrication of an attachment for forced canine eruption. Rapid prototyping dental modeling might become the diagnostic procedureof choice in the evaluation of impacted maxillary canines.

American Journal of Orthodontics and Dentofacial OrthopedicsApril 2006 129 583-89 Faber, Berto, and QuaresmaMaxillary Central Incisors Congenitally missing Central Incisor extremely rare Patients appearance is abnormal and reminiscent of a Dental Cyclops.

Associated with : Absence of philtrum. Absence of dental midline. Square anatomy of incisor . Indeterminate Right/left designation. Etiology TraumaDisplacementOf tooth bud itself.Displacement may cause normally placed adjacent teeth to cause an obstruction to eruption.Traumatic Causes: Obstruction Due to Soft Tissue Repair. Dilacertation.

The Jerusalem Hypothesis.--

Arrested Root Development When a preschool child suffers a trauma the root might get arrested immediately, however the adjacent teeth continue to develop and eventually erupt leading to the development of the alveolar bone in the area, however at a later date when the concerned tooth refuses to erupt and investigations are made the tooth is found to be found in the normal position, vertical and with under-developed bone around it leading to narrow alveolar bone immediately around it.

Acute traumatic intrusion.(intrusive luxation) Actually an advantage since the tooth not allowed to dry.

Treatment Time : Reported at 7-8 yrs of age. Best treated at this age (4 yrs before canines erupt) Follow up to be done till the canines erupt. A standard protocol of treatment available followed in Europe a) Prepare space. b) Elimination of cause eg. Supernumerary tooth. Results : Quite disappointing 54-78% cases non eruption. Delay in Eruption. Alignment

Why they hesitate doing active mechanotherapy : Mills :Exposure of the crown of the permanent tooth during the procedure to remove the supernumerary tooth, since periodontal result of the final result is compromised. Also :Spontaneous eruption chances are high. Loss of labial bony plate. Poor gingival margin and less attached gingiva Gingival level discrepancy.

Treatment Protocol: An Orthodontic Appliance in the Early mixed Dentition Space :The Qualities Required : Leveling and derotation. Acheivement of good periodontal prognosis.Light and controlled extrusive forces.Final finishing without changing to another appliance.

Johnsons (Modified) Twin Wire Arch Given in Int J Of Ortho 1934 Vol 20 946-963. Appliance based on fixed molar bands connected by a soldered Palatal Arch. Long and narrow gauge ( 0.020 Int dm) tubes slide freely in the o.o36 dm buccal tube. This was extended upto the canine area. Initial alignment with 0.016 NiTi or 0.0175 Niti Post Alignment switch to plain round 0.018/0.020 SS. Place tubing for added retension thius rigidity

Now ready for Surgical Intervention. Best method With e-chain. When it reaches occlusal level reassessment .

Root Torquing of Impacted Canines According to Becker buccal root torque of the treated impacted canine required may be quite substantial. This may cause a reactive force on the adjacent teeth as well. Planning must be done in such a way so as to minimize the effects on the anchor units. Heavy base arch should be used and its form compensated to compensate for the expected movements. Intermaxillary S- elastics may be used.On the side of cross-bite tendency: Buccal of lower molar to lingual of upper molar.v/v on the opposite side.

A case of bilaterally impacted canine does not have loss of anchorage since the 2 sides are pitted against one another.

Retention Group 4 and 5 cases require maximum retention as the relapse tendencies are high. These 2 groups require permanent retainers.

Acc. To Wilbur Johnston Palatally Impacted Canines Dec 1969 Ajodo A Class I malocclusion case requires no retention.Evaluation of Post treatment Alignment by Becker et al: Incidence of rotations and spacings 1. Impacted side- 17.4% 2. Control side 8.7%Ideal alignment on control side is twice as often as the impacted side.

To minimize rotational relapse, options available are 1. Fiberotomy 2. Bonded fixed retainerThis can be done during or after the treatment.It has been suggested for palatally impacted canine: Lingual drifting can be prevented by removal of half-moon- shaped wedge of tissue from lingual aspect of canine.

Vermette ME, Kokich VG, Kennedy DB. Uncovering labially impacted teeth: apically positioned flap and closed eruption techniques. Angle Orthod 1995;65:23-32.

Compared the apically positioned flap with the closed eruption technique and found much superior results in terms of gingival( height, scarring levels), and pulp status with the closed-eruption technique.Periodontal status was similar in both.CE simulates natural eruption pattern.Mentions another method of Impaction assessment.Closed-eruption surgical techniquefor impacted maxillary incisors: Apostorthodontic periodontal evaluation

Adrian Becker, Ilana Brin, Yocheved Ben-Bassat, Yerucham Zilberman, and Stella Chaushu.

This study demonstrates that overall good long-termesthetic results can be achieved by treating impactedmaxillary incisors with a closed-eruption orthodonticsurgical technique.Soft-tissue management of labially positionedunerupted teeth Robert L. Vanarsdall, and Herman Corn. Am J Orthod Dentofacial Orthop 2004;125:284-93Advantages of Surgical exposure thru Apically repositioned flap:Tooth movement faster. Availability of Attached Gingiva. Attached gingiva restricts the regrowth of soft tissues. Delayed bonding/banding.Conclusion A versatile chapter in orthodontics showing the versatility of our branch in general.

A careful treatment approach to this is required as it is of great esthetic concern to us.

References Robert L. Vanarsdall, and Herman Corn. Am J Orthod Dentofacial Orthop 2004;125:284-93Advantages of Surgical exposure thru Apically repositioned flap:Tooth movement faster. Availability of Attached Gingiva. Attached gingiva restricts the regrowth of soft tissues. Delayed bonding/banding.Canine impaction identified early with panoramic radiographs. Lindauer SJ, Rubenstein LK, Hang WM, Anderson WC, Isaacson. J Am Dent Assoc 1992;123:91-7.

An investigation into the response of palatally displaced canines to the removal of deciduous canines and an assessment of factors contributing to a favourable eruption. Power And Short Br J Orthod 1993;20:215-23.

Prediction Of Maxillary Canine Impaction Using Sectors & Angular Measurements. Article By J Warford, R Grandhi, Ajo Do 2003 vol 124.

Tunnel traction of intraosseus impacted maxillary canines A a 3 yr follow up Ajo-do 1994; 105: 61-72.

Ballista Spring Harry Jacoby Ajo Do Feb 1979.

Alignment of Impacted Canines with Cantilevers and Box Loops. Surendra Patel,vittorio Cacciafesta, Carles Bosch. Volume 33 : Number 02 : Pages (82-85) 1999.

A Review Of the Diagnosis & Management of Impacted Maxillary canines By MariselaM, Bedoya, JH Park J Am Dent Assoc, Vol 140, No 12, 1485-1493.

Nickel Titanium Closed-coil Spring For Extrusion Of Impacted Canines. Loring L. Ross Volume 33 : Number 02 : Pages (99-100) 1999.

Two Arch Wire Technique for Alignment Of Impacted Teeth: Samuels & Rudge JcoVol 31 No. 3 Pg 183-187 1997

The Monkey Hook: An Auxiliary For Impacted, Rotated, And Displaced Teeth. S. Jay Bowman, Aldo Carano. Volume 36 : Number 07 : Pages (375-378) 2002.

The K-9 Spring for Alignment of Impacted Canines Varun Kalra JCO Vol 34 (Oct) pg 606-611 2000.

Management Of Impacted Maxillary Canines using Mandibular Anchorage. Ajodo Vol 115, No. 3 , 255-259.

Eruption of Impacted Canines with an Australian Helical Archwire Christine Hauser, Yon H. Lai, Elina Karamaliki. Volume 34 : Number 09 : Pages (538-541) 2000.

Eruption Of An Impacted Canine With A Semi-fixed Appliance: A Case Report by Dr. Neelima K,Dr. Nagaraj, Dr. Jatti, Dr. Priyanka Sethi. Cyberjournal American Journal of Orthodontics and Dentofacial Orthopedics. Faber, Berto, and Quaresma April 2006 129 583-89 Johnsons Modified Twin Wire Arch. Int J Of Ortho 1934 Vol 20 946-963.

Palatally Impacted Canines. Wilbur Johnston Dec 1969 Ajodo.Uncovering labially impacted teeth: apically positioned flap and closed eruption techniques. Vermette ME, Kokich VG, Kennedy DB. Angle Orthod 1995;65:23-32. Closed-eruption surgical technique for impacted maxillary incisors: A postorthodontic periodontal evaluation. Adrian Becker, Ilana Brin, Ben-Bassat, Yerucham Zilberman, and Stella Chaushu. Soft-tissue management of labially positionedunerupted teeth. Vanarsdall, Corn. Am J Orthod Dentofacial Orthop 2004;125:284-93.