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Orth,odontic considerations

in

the treatment

of maxillary impacted canines

Dr. Fournier

Andre Fournier, D.M.D.,* Jean-Yves Turcotte, D.D.S., C.D.,* and

Christian Bernard, D.D.S., MS.*

Quebec, Que., Canada

The purpose of this article is to describe and discuss a relatively unknown and underestimated technical

approach to the orthodontic extrusion of impacted canine teeth. It constitutes a preliminary report of a research

project conducted in our undergraduate clinics on patients treated for orthodontic extrusion of impacted teeth. Of

these patients, twenty-seven had maxillary canine impaction, sixteen unilateral and eleven bilateral, for a total of

thirty-eight teeth. Some surgical considerations and various fixation appliances for impactions are discussed, as

well as the advantages and disadvantages of exerting an extrusive force by means of a Hawley type of

removable appliance.

Key

words:

impacted canines, tooth extrusion, adult orthodontics, removable appliances

I

is well known that, after third molars,

maxi llary canines are among the most frequent teeth to

be impacted, and many possib le etiologic factors have

been mentioned. One of the most frequent causes

seems to be a lack of available space at the appropriate

time to ensure a normal eruption of the canine. It is also

known that the persistence of impacted teeth could pre-

sent some possible sequelae.

Many treatment possibilities have been considered

for this problem. One could decide to extract the im-

pacted tooth and replace it with a fixed bridge or move

a first premolar into its place when possible. Clark

treated many of these patients by surgical intervention

only, making a tunnel from the impacted tooth to

the oral cavity and thus removing some resistance to

eruption of the tooth. A one-step surgical intervention

is also possib le and well documented. The impacted

tooth can be removed and reimplanted in its proper

position., 4* .i Nevertheless, the prognosis for these

treatments may be very uncertain in many cases and

even poor in other instances. Another possib le treat-

ment approach, which also has its limitations, is to

expose the tooth surg ically , fix an attachment to it, and

exert an orthodontic extrusive force to bring the tooth

into occlusion.

This research p roject was partly suppon ed by a grant from the Fends Em ile-

Beaulieu.

*Associate Professors, EC& de MBdecine Dentaire, Universit& Lava].

Johnston and Gaulis and Joho stated that im-

pacted maxillary canines are more often situated in a

palatal than in a labial position, in a ratio of approxi-

mately 2 to 1. Of the thirty-eight teeth treated in our

clin ics, twenty-eight were palatally impacted and ten

were labial or in a good labiolingual position, for a ratio

of 3 to 1. Furthermore, the palatally impacted teeth

seem to have a more horizontal inclination, rendering

both the surgical and the orthodontic management ex-

236

0002.9416/82/030236+04 OO.40/0 0 1982 The C. V. Mosby Co.

The prognosis of orthodontic intervention depends

on many factors. The most important is the position and

angulation of the tooth in the maxilla and the possible

presence of anky losis. Many radiographic techniques

have been described to help localize an impacted

tooth. 2, 6--XVanarsdall and Corn mentioned some

clues

to

diagnose the anky losis of the impacted canines and

suggested that the orthodontic traction be applied im-

mediately after luxation of the tooth.

MATERIALS AND METHODS

Surgical procedures

As Gaulis and Joho mentioned, two basic types of

surgical debridement can be

used

for impacted teeth.

One involves a closed eruption in which the crown

of the tooth is exposed, an attachment is fixed to it, and

the flap is sutured back over the crown, leaving only a

twisted wire passing through the mucosa to apply the

orthodontic traction. In the second type, open erup-

tion, the crown is left uncovered by means of packed

cement or repositioning of a mucoperiosteal flap.

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Voh?w 81

Number 3

Trearmenr

of

maxillary impackd canines

237

Fig. 1. Note Hawley appliance with Adams clasps on first molars and spring engaged on canine tooth.

tremely difficult. These teeth are often in close proxim-

ity to the nasal fossae, and their crowns are in intimate

contact with the central or lateral incisors.

In all the cases of palata lly impacted teeth we used a

closed-eruption philosophy and chose an open

approach in the labia lly positioned teeth, using a re-

positioned mucoperiosteal flap to avoid the future

mucogingival problems reported by Vanarsdall and

Com.s

Some of the impacted canines presented a more

vertical position and were above their correct anatomic

space between the first premolar and the lateral incisor.

These cases dictated both palatal and labia l approaches

in order that one might be able to free the crown from

its bony crypt and fix to it an appliance that would

enable the orthodontist to bring it into the mouth.

As for the labially, vertically positioned canines for

which a labia l surgica l approach was indicated, these at

times were exposed by surgical means only, without a

traction device, depending on their position and the age

of the patient. In older patients in whom traction was

indicated for reasons of ankylosis , the crown of the

tooth was totally exposed and a traction appliance was

positioned, with surgical transfer of the attached gin-

giva to the cementoenamel junction of the impacted

canine in such a way as to prevent periodontal problems

when the tooth was fully aligned and in function.

Orthodontic procedures

Fixation of an attachment to the tooth. Many types

of attachments can be placed on the tooth. These in-

clude the cast-gold inlay, the ligature wire around the

cerv ical part of the tooth near the cementoenamel

junction), the direct-bonded attachment, a screw ce-

mented in the crown, the placement of a wire in a

filling, or a hole in the tip of the crown through which

to pass a ligature wire.

The position of the attachment on the crown is very

important because it determines, in part, the direction

and especially the type of movement the traction wil l

induce. The more horizontally the canine lies, the more

occlusal the attachment must be to assure a proper

tipping of the tooth to a vertical position. In another

spatial plane the proper placement of the attachment

more mesial or distal, buccal or lingual) can help ro-

tate a tooth.

We have stopped using the ligature wire around the

cerv ical part of the tooth, mainly because of the poor

control it offers with respect to the type of movement

and direction of extrusion. In three cases in which this

method of attachment was used, we have experienced

lateral incisor displacement labial and extrusive move-

ment). There is also a risk of root resorption near the

cementoenamel junction. We have often used a direct-

bonded attachment edgewise bracket or eyelet). How-

ever, th is attachment necessitates complete dryness of

the operative field , which is sometimes difficult to

maintain. If it is not perfectly done, there is a risk of

breakage during the treatment, thus necessitating a new

surgical intervention. When di rect bonding seems to be

difficult and not very reliable, we would rather perfo-

rate the tip of the crown in a labiolingual direction. The

hole is made near the tip of the cusp, far enough inci-

sal ly to prevent pulpal damage and far enough cerv i-

tally to avoid fracture of enamel. We star t the hole with

a No, 1 round burr on high speed and then finish with a

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23% Fournier, Turcotte, and Bernard

Am J. Urrhod.

March 1982

Fig. 2. Buccal view of spring used to deliver extrusive force.

Fig. 4. A case in which anchorage was extremely compro-

mised. In this case, the spring emerges directly from the acrylic

plate.

Fig. 3. Front view of appliance in mouth.

0.017 inch drill* on a low-speed handpiece. When the

tooth has made enough extrusion, the ligature is cut,

the hole is filled with acrylic, and a bracket is properly

positioned on the tooth to finish alignment.

In one case in which this type of attachment was

used, we encountered a carious lesion and pulpal dam-

age. This was the result of an improper angulation and

too large a diameter of the perforation because of

difficult access to the crown during the surgical proce-

dure. In the future we wil l pack a eugenol cement in the

hole after twisting the wire.

Orthodontic traction. Many authors have described

a principal technique used to extrude impacted canines.

The general principle is to tie an elastic force from the

emerging tooth to a heavy wire engaged in adjacent

teeth. Others eliminate the necessity of banding the

teeth but use the same princip le in placing a wire

*T.M.S. Min ik in, Whaledent Intemat lonal , New York, N.Y.

Fig. 5. In that case the ligature around the cervical part of the

tooth was changed for a direct-bonded attachment as soon as

the tooth emerged into the oral cavity.

bonded to adjacent teeth from which to

use

the elastic

traction. Jacoby described a fixed appliance, termed

ballista spring, which uses a spring engaged in the

buccal tubes of the molar bands and first premolar. To

prevent lingual tipping of the molar teeth and intrusion

of the first premolars, these teeth are all splinted to-

gether with a heavy palatal bar soldered to stainless

steel bands. Some clinicians also use intermaxillary

elastics to exert the extrusive force on the canine from

the lower teeth. The common point to all these

techniques is that the anchorage is entirely supported by

the teeth themselves.

In our undergraduate clin ics we have treated many

cases with a removable Hawley type of appliance with

springs soldered to Adams clasps or labial bows or

emerging direc tly from the acrylic to exert the extrusive

force Figs. 1 to 4). This type of appliance transfers a

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l o lume 81

Number 3

great part of the anchorage demands to the palatal vault

and alveolar ridge when many teeth are absent.

Discussion

This appliance is not a panacea, and it has some

disadvantages. It can also have great advantages, how-

ever, and in some cases it can be the only appliance

possible.

Principal disadvantages include the following:

It is limited in the poss ibility of treating related or

unrelated problems. For example, the impacted canine

may be associated with a malocclusion necessitating

full-banded orthodontic treatment.

The final alignment of the tooth, especially when

some root movement or important rotations are re-

quired, is sometimes very difficult.

It necessitates cooperation from the patient.

Principa l advantages are as follows:

It may be the only possible appliance when there is

a dramatic loss of anchorage, such as the absence of all

upper posterior teeth Fig. 4).

It offers some poss ibilities for treatment of minor

tooth malpositions, especially those for which we gen-

erally use this type of appliance for example, an an-

terior bite plate to level a curve of Spee or correct a

cross-b ite). It can also be used to maintain or reopen to

a certain amount the edentulous space with appropriate

springs.

It is placed in the mouth immediately after the sur-

gica l intervention and, simi lar to a surgical splint, it

helps to contain swelling and hematoma. If we suspect

anky losis of the tooth, immediate traction as suggested

by Vanarsdall can be instituted. This immediate trac-

tion also helps to hold the stainless steel wire shaped as

a hook into firm position, thus preventing injury to soft

tissues and avoiding the need to cover it with wax or

acrylic.

It reduces chair time and eliminates the need for

using bands and/or brackets. This advantage is

maximum when no other orthodontic correction is

needed.

It can often be used as a first phase in complete

orthodontic treatment, thus reducing the length of time

that fixed appliances must be worn, with all associated

benefits and t,he poss ibilit y of avoiding some gingival

and/or carious problems.

By leaving adjacent teeth free to move, it re-

Treatment of maxillary impacted caninrs

239

duces the possibili ties of damage to adjacent roots if

they are contacting the emerging canine.

It is more esthetic, which could be appreciated by

the adult patient.

In conclusion, we have observed that these proce-

dures could be a useful adjunct in an orthodontic office.

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