ANAHTAR KELİMELER

Gömülü maksiller kanin, Tünel traksiyon

ÖZET

KEYWORDS

Impacted maxillary canine, Tunnel traction

ABSTRACT

15 yaşındaki erkek hastada Angle Sınıf I malokluz-

yona eşlik eden palatal olarak gömülü sağ maksiller

kanin varlığı teşhis edildi. Sağ süt kaninin de ağızda

olduğu tespit edildi. Tedavisinde gömülü kanin dişi-

nin süt dişi soketi içerisinden sürdürülmesini sağla-

yan tünel traksiyon yönteminin uygulanması plan-

landı. Traksiyon 11 ay, toplam tedavi 31 ay sürdü.

Tedavi sonunda, sürdürülen sağ maksiller kanin

dişin labial dişeti bölgesine apikale repozisyone flep

cerrahisi uygulanarak gingival konturu düzeltildi ve

daha estetik bir görüntü sağlandı. Tünel traksiyon

metodu, süt dişlerinin varlığında, doğal intraosseoz

tünel oluşturması bakımından gömülü maksiller

kaninlerin tedavisinde avantajlı bir yaklaşımdır.

The patient was a 15-year-old boy who had an Angle

Class I malocclusion with a right palatally impacted

maxillary canine. The right deciduous canine was

also persisted in the mouth. The treatment involved

the tunnel traction method, by which the impacted

canine was pulled toward the center of the alveolar

ridge via the deciduous canine socket. The duration

of the traction was 11 months and the total treatment

time was 31 months. At the end of treatment, an

apically repositioned flap operation was performed to

correct the low gingival contour on the buccal side of

the maxillary right canine to improve esthetics.

The tunnel traction method is an advantageous treat-

ment technique in maxillary canine impaction cases

with retained deciduous canine by providing a natural

intraosseous tunnel toward the dental arch.

Hacettepe Dişhekimliği Fakültesi DergisiCilt: 30, Sayı: 2, Sayfa: 48-58, 2006

The Treatment of a Palatally Impacted Maxillary Canine by Tunnel Traction

Method

Palatinalde Gömülü Maksiller Kanin Dişin Tünel Traksiyon Yöntemiyle Tedavisi

*Müge AKSU DDS, PhD, *Tülin (Uğur) TANER DDS, PhD

* Hacettepe University, Faculty of Dentistry, Department of Orthodontics

OLGU RAPORU (Case Report)

49

INTRODUCTION

The palatal impaction of maxillary permanent

canines is a frequently encountered clinical prob-

lem. Genetic factors are largely responsible for

this anomaly1,2. Other causes suggested for cani-

ne impactions are usually the results of any one

or combination of the following factors: Tooth

size-arch length discrepancies, prolonged reten-

tion or early loss of the deciduous canine, abnor-

mal position of the bud, dilacerations of the root,

ankylosis, cystic or neoplastic formation and the

absence of the maxillary lateral incisor3-5.

The presence of the impacted canine may

cause some effects such as migration of the ne-

ighboring teeth and loss of arch length, internal

resorbtion, dentigerous cyst formation, external

root resorbtion of itself as well as the neighbo-

ring teeth and combinations of the above sque-

lae. Potential complications emphasize the need

for close observation of the development and

eruption of these teeth during the examination

of the growing child6.

The orthodontic treatment of a palatally im-

pacted canine is aimed at bringing the tooth into

its correct position in the dental arch without ca-

using any periodontal damage. To achieve this

goal, a variety of surgical7-11 and orthodontic 3,12-

15 techniques have been proposed in relation to

the position of the impacted tooth and to the

treatment method used for traction16,17. Tunnel

traction is one of the approaches for orthodontic

treatment of the deep infraosseous impacted ca-

nines by providing an osseous tunnel toward the

centre of the alveolar ridge18. This method can

be valid when the deciduous canine is persisted

in the mouth, so that the socket of the decidu-

ous canine can be used to form a tunnel for

movement of the impacted canine. In this case

report, we describe the surgical and orthodontic treatment of a palatally impacted canine by using the tunnel traction method.

CASE REPORT

Diagnosis:

A 15 year-old boy was referred to the ortho-

dontic clinic for the unaesthetic appearance of

his crowded maxillary anterior teeth. The clini-

cal examination revealed an Angle Class I molar

relationship, a highly positioned maxillary left

canine on the vestibule and a persistent right de-

ciduous canine. The permanent right canine was

not seen in the arch. There was also a total of 2

mm diastema between the central incisors and

the right lateral incisor. Mandibular teeth were

aligned reasonably well with a 2 mm diastema

between left canine and first premolar (Fig 1A-

L). The radiological examination showed that the

right permanent canine was impacted palatally

(Fig 2A-C).

A

50

FIGURE 1

(A) Pretreatment extraoral facial photograph (B) Pretreatment extraoral lateral photograph (C) Pretreatment smiling photograph (D-G) Pretreatment intraoral photographs

B

C

E

D

F

G

51

FIGURE 1

(H-L) Pretreatment study models

FIGURE 2

(A) Pretreatment panoramic radiograph (B) Pretreatment occlusal radiograph

H

I

J

K

L

A

B

52

Treatment:

The objective of treatment was to prepare

adequate space for the upper canines and pro-

perly positioning the impacted right canine into

the arch to obtain a good alignment of the teeth.

Because the lower teeth were in good alignment,

no treatment was planned in the lower jaw.

A transpalatal arch was used for providing

anchorage during the traction of the impacted

canine. .018 x .025 inch Roth brackets were

bonded to the maxillary teeth. Initial leveling was

accomplished with a .016 x .016-inch nickel ti-

tanium wire, followed by a .016 x .022-inch sta-

inless steel wire. Open-coil springs were used to

gain spaces for the maxillary canines. Then, .016

x .022-inch stainless steel wire with a helix on

the right canine side was inserted. The helix was

bent to be used for tying the gold chain during

traction of the impacted canine. The deciduous

right canine was not removed and kept in place

during the preoperative orthodontic treatment.

Following 10 months of orthodontic therapy, the

patient was referred to the surgeon for exposure

of the impacted canine.

Surgical procedure:

A full thickness mucoperiosteal flap was ra-ised to expose the cortical plate and the deci-duous canine was extracted. Cortical bone was removed to provide access to the crown. With a low speed bur, a perforation on to the bone from the socket of the deciduous canine was perfor-med to reach the crown of the impacted canine. The socket of the deciduous canine was then for-med like an osseous tunnel that would be used for traction. A gold-chain bonded on the impa-cted tooth was passed through the tunnel. The flap was sutured back into its original position.

Treatment progress:

One week after surgery, the sutures were re-moved and the traction phase began. Elastic th-read was placed through the first link of the gold chain and tied to the helix on the arch, applying a traction force to the impaction canine. The di-rection of the traction was directed toward the center of the alveolar ridge (Fig 3A-D). During the traction phase, the movement of the impac-ted tooth was guided through the tunnel. As the canine moved closer to the designated position more gold chain became exposed through the mucosa. Excess chain was then cut. This was repeated every 2 weeks until the impacted ca-nine and the attached part of the chain became exposed in the oral cavity and the cusp of the impacted canine emerged at the center of the alveolar process. The postsurgical panoramic ra-diograph shows the canine in its proper position (Figure 3E). The gold chain was eventually remo-ved and the canine bracket was bonded to the upper right canine..016-inch and .016 x .016-inch nickel titanium arch wires were used to level the right canine sequentially. When the canine was completely aligned within the dental arch, a finishing arch wire of .016 x .022-inch stain-less steel was placed and the patient was seen at monthly intervals. The brackets were debonded after good alignment and interdigitation of teeth were achieved (Fig. 4A-C). As the gingival con-tour of the right canine was lower then the left

FIGURE 2

(C) Pretreatment lateral cephalometric tracing

C

53

FIGURE 3

At the start of traction phase: (A) Intraoral lateral photograph (B) Occlusal photograph (C) Occlusal radiograph (D)

Panoramic radiograph (E) During traction: Canine directed into its proper position

FIGURE 4

(A-C) Posttreatment intraoral photographs

A

B

C

D

C

A

B

E

54

one, an apically repositioned flap was performed to correct the gingival contour.

Results:

At the end of treatment, the palatally impa-cted maxillary right canine was positioned into proper alignment, resulting in a pleasing smile. (Fig. 5A-L) Radiographically, the right canine displayed proper root inclination and the in-cisors remained stable at the end of treatment (Fig. 6A-C). The duration of the traction was 11 months which elapsed between the application of the traction and the eruption of the cusp of the impacted canine. Total treatment time was 31 months. For retention, a Hawley retainer was placed and the patient was instructed to wear it 24 hours a day.

The impacted canine was brought into the arch and properly without complaints of signi-ficant discomfort. There was no attachment loss at the site of the impacted canine during the tre-atment, and the maximum probing depth was 3 mm. The pseudo- pocket on the buccal side of the right canine tooth was corrected by a flap

FIGURE 5

(A) Posttreatment extraoral facial photograph (B) Posttreatment extraoral lateral photograph (C) Posttreatment

smiling photograph A

B

C

55

FIGURE 5

(D-G) Posttreatment intraoral photographs

FIGURE 5

(H-K) Posttreatment study models

D

E

F

G

H

I

J

K

56

operation. No root resorption of the adjacent

teeth was seen on the periapical radiographs du-

ring the traction of the impacted canine.

DISCUSSION

Maxillary permanent canines are important

for an attractive smile and are also essential for a

functional occlusion. Therefore, extraction of the

canines should be avoided, if at all possible. In the

case of maxillary impaction, surgical exposure of

the related tooth and the use of fixed orthodontic

appliances is the most frequently used treatment

alternative as long as the tooth position is favorab-

le. Various methods have been used for moving

the canine into proper alignment3,7-18. Fournier et

al15 have proposed the use of a removable plate.

Becker and Zilberman12 have recommended the

use of a flexible palatal arch slotted into horizon-

tal, soldered, palatal tubes on the molar bands

of any type of fixed multibonded appliance. Ja-

coby14 has suggested his ballista spring to direct a

palatal-occlusal force from the buccal side.

FİGURE 6

(C) Posttreatment lateral cephalometric tracing

FIGURE 5

(L) Posttreatment study models

FİGURE 6

(A) Posttreatment panoramic radiograph (B) Posttreatment periapical radiographs

L

A

B

C

57

In this report, the successful treatment of a palatally impacted maxillary canine using the tunnel traction method was presented. The only study presenting the long-term effect of the tun-nel traction method was reported by Crescini et

al18. The advantage of this technique was that the impacted canine was moved through an os-seous tunnel to its proper place on the dental arch. However, this method could be used in the presence of a retained deciduous canine tooth on the affected side.

The duration of the traction needed to resol-ve the impaction was 11 months and the total treatment time was 31 months in this case. Cres-cini et al18 also reported 11 months of tunnel tra-ction time. However, their total treatment time was 22 months. Becker and Chaushu19 revealed that in young patients, the duration of canine traction took about one third of the overall tre-atment time. The duration of the treatment for the impacted canines was reported to change due to age, gender, molar relation, severity of impaction, amount of crowding, unilateral and bilateral impactions. Thus, individual treatment times for the impacted canine teeth showed a

large range20.

This case report showed that with the use of the tunnel traction method, the right palatal-ly impacted maxillary canine was erupted in its proper place on the dental arch without giving any damage to the neighboring teeth. It has been reported that the orthodontic treatment of pala-tally impacted canines may cause root resorption

of the adjacent lateral incisors21 or premolars22.

After the completion of the orthodontic treat-ment, the buccal gingival height of the impacted teeth often needs correction8 though some aut-hors18 suggested no gingival augmentation pro-cedure after treatment of impacted canines with the tunnel traction method. In presented case, an apically repositioned flap was performed to increase the clinical crown height of the right ca-nine. The patient’s smile esthetics was improved following the procedure.

CONCLUSION

The impacted canine associated with the per-sistent deciduous canine was treated successfully by tunnel traction method. The extraction of the deciduous tooth provided a natural osseous tun-nel for movement of the impacted tooth. Traction through the osseous tunnel ensured an eruption path that closely follows the physiologic pattern

REFERENCES

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CORRESPONDING ADDRESS

Müge AKSU DDS, PhDHacettepe University, Faculty of Dentistry, Department of Orthodontics 06100 Sıhhiye-Ankara/TURKEY

Business: +90 312 311 64 61, Fax: +90 312 309 11 38, E-mail: mugepeh@hacettepe.edu.tr

14. Jacoby H. The ‘ballista spring” system for impacted teeth. Am J Orthod. 1979;75:143-151.

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16. McDonald F, Yap WL. The surgical exposure and application of direct traction of unerupted teeth. Am J Orthod. 1986;89:331-340.

17. Boyd RL. Clinical assessment of injuries in orthodontic movement of impacted teeth. I. Methods of attachment. Am J Orthod. 1982;82:478-486.

18. Crescini A, Clauser C, Giorgetti R, Cortellini P, Pini Prato GP. Tunnel traction of infraosseous impacted maxillary canines. A three-year periodontal follow-up. Am J Orthod Dentofacial Orthop. 1994;105:61-72.

19. Becker A, Chaushu S. Success rate and duration of orthodontic treatment for adult patients with palatally impacted maxillary canines. Am J Orthod Dentofacial Orthop. 2003;124:509-514.

20. Stewart JA, Heo G, Glover KE, Williamson PC, Lam EWN, Major PW. Factors that relate to treatment duration for patients with palatally impacted maxillary canines. Am J Orthod Dentofacial Orthop. 2001;119:216-225.

21. Linge L, Linge BO. Patient characteristics and treatment variables associated with apical root resorption during orthodontic treatment. Am J Orthod Dentofacial Orthop. 1991;99:35-43.

22. Woloshyn H, Artun J, Kennedy DB, Joondeph DR. Pulpal and periodontal reactions to orthodontic alignment of palatally impacted canines. Angle Orthod. 1994;64:257-264.