Maxillary impacted canine management

Surgical and orthodontic management of
impacted maxillary canines-Anila Charles, Sangeetha
Duraiswamy1, Krishnaraj R1, Sanjay Jacob.(SRM Journal of Research in Dental Sciences | Vol.
3 | Issue 3 | July-September 2012)
Department of Orthodontia, Madha Dental College, M.G.R University, 1Department of Orthodontia, SRM Dental College, SRM
University, Chennai, Tamil Nadu, India
Presented by- Dr. parag s. deshmukh

Contents:
 Introduction
 Eruption
 Incidence
 Classification
 Etiology
 Diagnosis
 Management
 Case reports

Introduction
 IMPACTUS (latin origin) = pushed against
 Archer (1975) defines impacted tooth as one
which is completely or partially unerupted and is
positioned against another tooth or bone or soft
tissue so that its further eruption is unlikely.
Archer William H. Oral and Maxillofacial Surgery, Vol. I,ed. 5, Philadelphia, WB Saunders Co. 1975

Impacted canine
◦ Impaction of maxillary and
mandibular canines is a
frequently encountered clinical
problem.
◦ Third molars are the most
commonly impacted teeth and
canines stood second.

Eruption of canine :
 According to Broadbent, 1941-
 Development of canine :
• It develops at 4 – 5 months of age between the roots of
deciduous Ist molar.
 Calcification of canine :
• It begins to calcify around 12 months of age.

• calcification is taking place far above the roots of deciduous molar ,
allowing development of the first premolar between the deciduous
molar roots.
• At this stage the permanent canine is
located immediately above both the
erupting first premolar and the erupted first
deciduous molar.
• As the deciduous teeth erupts towards the
occlusal plane, the permanent incisor and
canine crypts migrate forward in the jaws
• The positional changes between 8 and 10
years of age need careful observation for
detection of potential impaction (Williams,
1981).

• During this stage of development the canine normally migrates buccally
from a position lingual to the root apex of the deciduous precursor;
however, some canines do not make the transition from the palatal to
the buccal side of the dental arch and remain palatally unerupted.
• With sufficient increase in the size of the subnasal area, the maxillary
canine normally moves downward, forward and laterally away from the
root of the lateral incisor.
• Between 8 and 12 years of age, the 'ugly duckling' stage, there is
insufficient space at the apical base to permit the axis of the lateral
incisor to shift into the more erect alignment of young adulthood until the
canine approaches its place in the dental arch.
• In the final phase of eruption, canines drive their way between the
lateral incisors and first premolars, forcing these teeth to become more
upright.

Incidence
Dachi and Howell
reported that the
incidence of
maxillary canine
impaction is
0.92%(Dachi SF, Howell FV. A
survey of 3,874 routine full mouth
radiographs. Oral Surg Oral Med
Oral Path 1961;14:1165-9.)
Thilander and Myrberg
estimated the
cumulative
prevalence of canine
impaction in 7 to 13-
year-old children to be
2.2%(Thilander B, Myrberg N.
The prevalence of malocclusion
in Swedish school children.
Scand J Dent Res 1973;81:12-
20.)
Ericson and Kurol
estimated the
incidence at 1.7%
Impactions are twice
as common in females
(1.17%) as in males
(0.51%).(Ericson S, Kurol J.
Radiographic assessment of
maxillary canine eruption in
children with clinical signs of
eruption disturbances. Eur J Orthod
1986;8:133-40.)
Of all patients
with maxillary
impacted
canines, it is
estimated that
8% have bilateral
impactions

The incidence of
permanent canine
impactions was 20
times higher in the
maxilla than in the
mandible. (Johnston WD.
Treatment of palatally impacted
canine teeth. Am J Orthod
1969;56:589-96.)
Becker et al. reported
that the palatally
displaced canines
occurred three times
more frequently than
those found buccally.
(Becker A, Smith P, Behar R.
Theincidence of anomalous
maxillary lateral incisors in relation to
palatally-displaced cuspids.
AngleOrthod 1981;51:24-9.)
Johnston reported
that the palatal
impactions were twice
as common as the
labial impactions.

CLASSIFICATION OF IMPACTED CANINE
Impacted canine
Maxillary canine Mandibular canine
Buccal Palatal Buccal Lingual

Classification of palatally impacted canine
The classification is based on two variables:
(1) Transverse relationship of the crown of the tooth to
the line of dental arch which may be
(a) Close
(b) Distant ( nearer the midline)
(2) Height of the crown of the teeth in relation to the
occlusal plane which may be
(a) High
(b) Low

Group 1 - Proximity to the line of arch – close.
- Position in the maxilla – low.
Position in the maxilla – forward , low &
mesial to the lateral incisor root.
- Position in the maxilla – high.

Group 4 - Proximity to the line of arch – distant.
- Position in the maxilla – high.
Group 5 - canine root apex mesial to that of lateral incisor or
distal to that of first premolar.
Group 6 - Erupting in the line of arch in place and resorbing the
roots of incisors.

Classification by ACKERMAN and FIELDS in 1935.
IMPACTED CANINE
Horizontally vertically
Palatal
Above
Labial
Mid- alveolar
Below
( With respect to the arch)
(With respect to the apex)
(J CO 1979 DEC)

Etiology:
Becker Concepts :
◦ Becker (1984) hypothesized two processes in the palatal impaction
of the maxillary canine:
1. Absence of initial early guidance from an anomalous lateral incisor
2. Failure of buccal movement of the canine at an unspecified age .
MC Bridge Concept
Canine formed at high level in the anterior wall of antrum, below the
floor of orbit, having long tortous path of eruption.

 Moyers Concept: Summarized by Bishara:
A)Primary cause:
1) Trauma to decidious tooth bud
2) Rate of Resorption of decidious tooth
3) Availability of space in the arch
4) Disturbance in tooth Eruption Sequence
5) Rotation of tooth buds
6) In Cleft area in Person with Cleft
7) Premature root Closure
B)Secondary cause:
1) Abnormal muscle pressure
2) Febrile diseases
3) Endocrine disturbances
4) Vitamin D deficency.
AJO. 1992.Feb.Bishara

 Berger Concept :{Systemic cause of
impaction}
1)Malnutrition
2) Tuberculosis
3) Syphilis
4) Rickets
5) Anemia
6) Progeria
7) Syndromes:
a) Cleidocranial dysplasia
b) Achondraplasia
c) Down syndrome

Vonder Heydt Concept:
“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 tooth is all gone,
and it must assume an awkward and embarrassingly
inappropriate position on the arch alignment.”

Guidance Theory - Miller
-Normal Eruption: Canine usually have a more mesial development
path, which is guided downwards apparently along the distal aspect of
the lateral incisor roots.
1) First stage Impaction : If there is a loss of guidance's due to missing
lateral incisors or late developing laterals, canine will have mesial
and palatal path of eruption. In this event there is no vertical
movement of canine into the alveolar process, results in more
horizontal impaction.
2) First stage impaction and secondary correction : Once it reached the
palatal alveolar process, canine is redirected to more favorable path
of eruption.

Second stage Impaction :
Self correction is prevented by, late developing
lateral incisors (peg laterals) which deflect the tooth
further palatally
Second stage Impaction and secondary correction:
Extraction of deciduous canine or even extraction of
lateral incisors leads to spontaneous eruption of the
impacted tooth.

Genetic Theory
◦ This theory indicates multiple evidential categories for the genetic
origin of palatally impacted canines, such as: Familial and
bilateral occurrence, Sex differences, as well as an increased
occurrence of other significant reciprocal dental associations
such as ectopic eruption of first molars, infraocclusion of primary
molars, aplasia of premolars and one third molar.
◦ Pirinen et al., showed that 106 patients with palatally displaced
canines had first and second degree relatives with some dental
anomalies.

 Peck and peck:
 Occurrence with other dental anomalies:
Palatally impacted canine is an inherited trait occurs in
combination with tooth agenesis, tooth size reduction,
Supernumery tooth and other ectopically positioned tooth.
 Peck et al., examined the specificity of tooth-agenesis sites
associated with the occurrence of 58 palatally displaced canines.
Palatally displaced canines associated significantly with
third molar agenesis. (Peck S, Peck L, Kataja M. Concomitant occurrence of canine malposition and
tooth agenesis: evidence of orofacial genetic fields. Am J Ortho Dentofacial orthop. 2002;122:657–60.)

SEQUELAE OF IMPACTED
CANINE
Labial or
lingual
malpositioning
of impacted
tooth
Migration of
neighbouring
teeth and loss of
arch length
Internal resorption or
external root
resorption of
impacted or
neighbouring tooth
Dentigerous
cyst formation
Infection
particularly with
partial eruption
Referred pain
Shafer et al.

DIAGNOSIS
CLINICAL EVALUATION
•Amount of space available in dental arch for impacted
canine is assessed in model. Study model analysis
•Gives clue of position of impacted tooth.
Morphology of adjacent
tooth
•Canine bulge present buccally or palatally.
Contours of adjacent
alveolar bone
Mobility of adjacent
tooth •Root resorption.
Delayed eruption of
deciduous canine

RADIOGRAPHIC METHOD FOR DIAGNOSIS
In Orthodontic treatment planning, the exact localization of
the position of an impacted canine is necessary.
I. Qualitative radiographs
Periapical
Extraoral
Mandibular arch
Max. ant. occlusal True vertex/occlusal
OPG Lateral ceph
Maxillary arch Occlusal
PA view

II. 3-D diagnosis of the position
Parallax method
C T scanning
Radiographic views at right angle

Periapical Radiography-
•Are the simplest and the most informative X-ray films.
• As this view passes through minimum of surrounding
tissues, it gives accuracy & quality of resolution.
• It is aimed to be perpendicular to an imaginary plane
bisecting the angle between the long axis of an erupted
tooth and the film plane to produce minimum
distortion.

The periapical film gives the following information:
[1] Presence or absence of impacted tooth.
[2] Stage of development.
[3] Presence & size of follicle.
[4] Indicates crown or root resorption, resorption pattern
& integrity.
[5] Indicates presence or absence of supernumerary tooth.
[6] Indicates soft tissue lesions like cysts.

1.Maxillary anterior occlusal
• In the maxillary arch, the nose and forehead interfere with
the positioning of x-ray tube close to the area to be viewed.
• The best that can be achieved by positioning the tube
close to the face, so that it becomes high and steeply angled
view.

2. Ture vertex / occlusal
• A true vertex view is one which passes parallel to the long
axis of central incisors.This is possible if the cone is placed
over the vertex of the skull to produce vertex occlusal film.
• Since the beam has to travel a great distance there is loss of
clarity.

Extraoral Radiography:
• OPG has the advantage of simplicity & quickly
offering a good scan of the teeth & jaws from
Temporomandibular joint to Temporomandibular joint.

• True & oblique lateral extraoral views are also used for
localization of impacted teeth, however the results are
misleading.
• True P-A view defines the buccolingual relationship of
an object.

 Parallax method:
- By Clark & Richards
• Principle:
• 2 periapical views of the same object are taken from
slightly different angles which can provide depth to
the flat 2-D picture depicted by each of the films
individually.
• Useful in distinguishing the buccal or lingual
displacement of the canine.

 Procedure:
1. In the periapical film, the
X-ray is taken in the area of
interest with the X-ray beam
passing perpendicular to a
tangent to the line of arch at
this point & at an appropriate
angle to horizontal plane.

2. In the second film, the X-ray tube is shifted mesially or
distally round the arch but held at the same angle to the
horizontal plane. The X-ray tube should describe between
30-450 of an arc of circle whose centre is somewhere in
the middle of the palate.

 Result:
• It is based on the SLOB principle.
• If the object has moved on the same side as that
of the X-ray tube it is lingually placed & if it has
moved on the opposite side it is on the buccal
side

Radiographic views at right angles:
1. A true lateral view {e.g. Lateral
cephalograph} gives information
regarding the antero-posterior &
ventral location of an object . However,
it gives no information regarding
bucco-lingual {transverse} plane of an
object.

2. A true occlusal view will provide information in the
transverse & antero-posterior direction of an object .

3. True postero-anterior view defines the
ventral plane & buccolingual
relationship of an object.
• These views provide complete information regarding
3 planes of space of any impacted teeth .

CT Scanning:
By Ericson & Kurol
• Used to diagnose the exact
position of an impacted
tooth.
• Clear serial radiographs
may be taken at graduated
depth in any part of
human body in this
method.

• This technique allows the
elimination of
superimposition of other
structures.
• It is however rarely used in
the diagnosis of impacted teeth
because of
(1) Large radiation
dosage.
(2) High cost.

DETERMINING THE PROGNOSIS
◦ FACTORS INFLUENCING THE TREATMENT DECISION
OF AN IMPACTED CANINE
Position of canine –
Favorable or Unfavorable
Age of patient
Availability of space
Presence of adequate
width of attached gingiva
VERTICAL
RULE OF
THIRDS
HORIZONTA
L RULE OF
THIRDS

LABIAL IMPACTION
Either due to ectopic migration of the canine crown over the root
of the lateral incisor or insufficient space in the arch caused by a
midline shift of dental origin.
Arch length tooth material discrepancy is the most common
cause
Williams suggested that extraction of the maxillary deciduous
canine at an early age of eight or nine years will enhance the
eruption and self-correction.
Olive suggested that opening space for the canine crown with
routine orthodontic mechanics might allow for spontaneous
eruption of an impacted canine.

Techniques for uncovering a labially impacted
maxillary canine:
• Excisional uncovering
• Apically positioned flap &
• Closed eruption technique.

 When referring a patient for surgical exposure of a labial or intra-alveolar
impaction of a maxillary canine, the orthodontist should evaluate 4
criteria to determine the correct method for uncovering the tooth.
1. Assessement of labiolingual position of the canine crown.
• If labially impacted- any of the technique can be used.
• If the tooth is impacted in the center of the alveolus, an excisional
approach and an apically positioned flap are generally more difficult to
perform, because extensive bone might need to be removed from the
labial surface of the crown.
2. To evaluate is the vertical position of the tooth relative to the
mucogingival junction.
• If most of the canine crown is positioned coronal to the mucogingival
junction , any of the 3 techniques can be used to uncover the tooth.
• If placed apical to mucogingival junction-excisional technique & apically
positioned flap will not be used; closed eruption technique should be
used.

3. Criterion to evaluate is the amount of gingiva in the area of the
impacted canine.
• If there were insufficient gingiva in the area of the canine , the only
technique that predictably would produce more gingiva is an
apically positioned flap.
• However, if there were sufficient gingiva to provide at least 2 to 3
mm of attached gingiva over the canine crown after it had been
erupted, any of the 3 techniques could be used.
4. To evaluate is the mesiodistal position of the canine crown.
• If the crown were positioned mesially and over the root of the lateral
incisor, it could be difficult to move the tooth through the alveolus
unless it was completely exposed with an apically positioned flap.

Palatal impaction
The most common
impaction
encountered by
orthodontists is the
palatal impaction of
maxillary canines.
Ericson & Kurol stated
that if periapical
radiographs showed
that the crown of the
permanent canine
were positioned over
the root of the
maxillary lateral
incisor, but not past
the mesial surface of
the root, self-correction
of the
ectopic canine
occurred with high
predictability if the
deciduous canine
were removed.
However, if the
permanent canine
were positioned well
beyond the mesial
surface of the lateral
incisor root, self-correction
does not
occur with extraction
of the deciduous
canine.

For most orthodontists, uncovering a palatally impacted canine
occurs after the first 6 to 9 months of orthodontic alignment of the
maxillary dentition.
Space is created for the crown of the impacted tooth, and the
patient is referred to a surgeon to uncover the crown.
Usually, soon after the surgery, the orthodontist begins dragging the
crown toward the edentulous site.
However, the crown of a palatally impacted canine is often in
intimate contact with the lingual surfaces of the roots of the
ipsilateral central and lateral incisors.
The problem in these situations is insufficient bone removal over the
crown of the impacted canine.

When a force is placed on the tooth and the enamel of the
impacted crown comes into contact with the bone, there are
no cells in the enamel to resorb the bone.
Resorption will eventually occur through pressure necrosis, but
it will occur slowly.
Wololshyn et al studied bone levels adjacent to impacted
canine after bringing it to the level.
He found that bone level distal to lateral & mesial to canine
were more apical suggesting bone loss post orthodontics

Kokich and Mathews recommend an alternative technique with
earlier timing for uncovering palatally impacted canines.
They time the uncovering of palatal canines before the start of
orthodontic treatment.
In these situations, a full-thickness mucoperiosteal flap is elevated in
the area of the impacted canine .
All bone over the crown is removed down to the cementoenamel
junction.
The flap is repositioned, and a hole is made through the gingival flap
.
Once the bone and tissue have been removed, these palatally
displaced canines will erupt on their own .
In about 6 to 8 months, the canines generally have erupted to the
level of the occlusal plane.

It seems appropriate to uncover palatally impacted canines
early, during the mixed dentition, so that they can erupt
autonomously, without orthodontic intervention, until the crown
has erupted to the level of the occlusal plane.
At that time, it can be moved more efficiently into the dental
arch.
By treating palatally impacted canines in this manner, the overall
treatment time for the patient is reduced, and the periodontal
and esthetic results are superior compared with previous
methods for exposing palatally impacted

Surgical Exposure of impacted
tooth:
 Circular incision or open approach :
This is done by removing mucosa over the crown to expose
the
impacted tooth.
 Advantages:
a) Easy to perform
b) Suitable access can be provided for bonding of the
attachment
c) Reduction of impaction is rapid.

 Disadvantages:
a) Tooth will be invested on labial side with thin oral mucosa
rather than attached gingiva.
b)Typical soft tissue contour aggravates Plaque acclumation
which leads to gingivitis. Inflammation will prevent
regeneration of the Periodontal ligament which leads to
apical movement of the epithelial attachment

 Apically Repositioned Flap:
◦ This method was proposed by Vanarsdall and corn in 1977.
 procedure:
◦ In cases without deciduous canine, Mucoperiosteal flap is elevated
from the crest of the ridge that includes attached gingiva.
◦ In cases with deciduous canine, tooth was extracted and the flap
was designed to include the entire area of buccal gingival that invest
it.
◦ In either cases, Split thickness Flap is elevated by incision made
vertically into the vestibule someway up into the sulcus,to expose the
canine.
◦ 2/3rd of bone covering the crown was removed.
◦ Connective tissue follicle was curreted from periphery of the exposed
portion of the crown.

◦ Flap is then sutured to the labial side of the crown of the permanent
canine, to cover the denuded periosteum and overlying cervical portion
of the crown; while remainder portion of the crown is exposed.
◦ Surgical dressing was placed on enamel to prevent overgrowth of
adjacent tissue. Dressing was removed 1 week post operatively. After 2
weeks, orthodontic traction was started.

 Advantages:
a) Maintain the width of attached gingiva
b) Easy access for bonding of the attachment
c) Tooth can be visualized from the time of exposure
still it come to occlusion
 Disadvantages: Vermette , 1995
a) Uneven and unesthetic gingival margin
b) Increased Clinical crown length
c) Some degree of attachment and bone loss on the labial
surface,which was considered as possibly related to an
increased potential for plaque accumulation.
d) Vertical orthodontic relapse : After apical repositioning the
gingival tissue heals to the adjacent mucosa, producing soft
tissue band of gingival scarring. As the tooth is pulled incisally
this mucosa get stretched down with it,toward the alveolar
crest.Thus it tend to relapse once the force is released .

Full Flap Exposure:
◦ This method was proposed by MCBride in 1979.This method is more
effective for buccal and palatally impacted tooth.
 Procedure:
◦ A full buccal surgical flap is raised to expose the canine.An
attachment is bonded to the tooth and the flap is sutured back to its
former place itself.
◦ Then a Twisted thread is tied to the bonded tooth and then drawn
inferiorly and through the sutured ends of the replaced flap, or
through the crest of the ridge or through the socket vacated by the
extracted deciduous canine.
Advantages:
a) Tooth can be erupted towards and through the attached
gingiva which maintains the width of the attached gingiva
b) No gingival scarring and good periodontal attachment is
established
c) No vertical relapse
d) Conservative bone removal
e) Immediate traction possible
f) Less discomfort and good post operative Haemostasis

 Disadvantage:
a) Placement of the bonding attachment is necessary at the time
of exposure
b) If there is a bond failure it needs re-exposure
c) Difficulty in gaining dry field
d) Buttonholing: This occurs because of the buccal
prominence of the tooth, lack of buccal
bone and relative tightness of the
replaced flap. The damage to the
mucogingival tissue is due to the bulk
of wide and high profile conventional
bracket, which may leads to a breakdown of
the overlying tissue to cause a dehiscence.

Apically positioned flap:
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 126, Number 3

 Anchor unit:
• When dealing with a malocclusion that incorporates an
impacted tooth, 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.

• A heavy & more rigid arch wire is then placed into
the brackets on all the teeth of aligned & complete
dental arch, the aim is to provide solid anchor base that
will not allow distortion of arch wire to occur as a
result of force that will be applied to the impacted
tooth after exposure.

Attachments: –
 Lasso wires
 Threaded pins
 Orthodontic bands
 Standard orthodontic bracket
 A simple eyelet
 Elastic ties and modules
 Magnets

{a} Lasso wires:
It is twisted lightly around the neck of the canine.
Disadvantages:
 This results in irritation of the gingiva
 Prevents reattachments of the healing tissues in area of
CEJ (cemento-enamel junction).
 May produce areas of external resorption & ankylosis in
areas of CEJ.
So, it is rarely used now.

(b) 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).
So it is rarely used.

{c} 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.

{d}Standard orthodontic brackets:
• Any edge-wise , Begg’s , 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 bracket’s 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.

{e} A simple eyelet:
Advantages:
- 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.

(f) Elastic ties and modules
Advantages
- Application of light forces
- Good range of action
- Easier to tie
Disadvantages
- Tends to loosen
- High degree of force decay

{f} Magnets:
It is made up of rare earth lanthanide alloys .
• It is rarely used.
Disadvantage:
- corrosion.

 Ballista Spring (Jacoby 1979)
◦ A ballista loop is a simple, convenient, unobtrusive method of
applying a vertical vector of force to a palatally impacted tooth
to erupt the crown into the center of the alveolus.
◦ When the canine crown is displaced mesially and lies over the
root of the permanent lateral incisor, an apically positioned flap is
the appropriate surgical uncovering technique.
◦ Exposure of the crown facilitates attachment of an elastomeric
chain directed toward the center of the edentulous alveolar
ridge to gradually guide the canine crown into the dental arch.

• It is made of rectangular wires.
• It proceeds forward until it is opposite to canine space and bent
vertically downwards and terminate into a small loop.
• With slight finger pressure ,spring is tied to pigtail ligature, by this it
provide an extrusive force for the canine to erupt.
• If the impacted tooth is resistant to movement or if the distance for the
tooth to move is more it will leads to lingual molar root torque leads to
loss of anchorage. To overcome this feature TPA is used.

 CRESCINI approached a method called as TUNNEL TRACTION.
Procedure:
a) Extract deciduous canine
b) Full thickness mucoperiosteal flap is elevated to expose the
cortical plate.
c) Drill with bur until exposing crown of canine
d) Tooth was bonded and ligature wire tied
e) Traction force given after 1week of surgery
Advantage:
a) No buccal or palatal access
b) No loss of supporting tissue
Disadvantage:
a) Post operative discomfort will be more.

Guiding tooth to oral enviroment :
I) Active palatal arch (Becker1978)
• It consist of fine 0.020 inch removable palatal arch wire carrying an
omega loop on each side.
• End of the wire is doubled for Frictionless fit in lingual sheath.
• It is activated by elevating downward activated palatal arch wire and
hooking the pigtail ligature around it

3) Light Auxiliary Labial Arch (Kornhauser1996)
It is made up of 0.014 inch round SS wire with vertical loops in the
• This loop has a small helix.
• Wire is tied with the basal arch wire in piggyback fashion.
• If basal arch wire is not used it will leads to extrusion of adjacent tooth
and cause alteration of occlusal plane .

Kilroy spring:
• The Kilroy Spring is a constant force
module that is slid onto a rectangular
archwire over the site of an impacted
tooth.
• In the passive state, the vertical loop of
the Kilroy Spring extends perpendicularly
from the occlusal plane (Fig. 2).
• To activate the spring, a stainless steel
ligature is guided through the helix at the
apex of the vertical loop, and the loop is
directed toward the impacted tooth. The
ligature is then tied to an attachment
that has been direct-bonded to the
surgically exposed tooth. (Fig. 3)

Kilroy II Spring
• The Kilroy II Spring was designed to
produce more vertical than lateral
eruptive forces for eruption of buccally
impacted teeth.
• Its multiple helices increase its flexibility,
but also increase the likelihood of
impingement on the adjacent soft
tissue.
• Consequently, more frequent progress
checks are recommended with the
Kilroy II.

THE K- 9 SPRING
•Varun Kalra (2000)
• Made in 0.017”X 0.025”TMA wire
 Advantages:
• Simple in design
• Low cost
• No patient compliance
• Light continuous eruptive and distalizing
forces
JCO Oct 2000

CANTILEVER SPRING
 Lindauer and Isaacson
(1995)
• TMA .017 X .025 wire used
• Force generated was measured
by dontrix guage.
• It should not exceed 70gms.
JCO Feb 1999

TMA BOX LOOP
• TMA .017 X .025 wire
used.
• Produce sagittal and
horizontal corrections while
continuing vertical eruption.
Surendra Patel J C O 1999

NICKEL TITANIUM CLOSED-COIL SPRING
Loring L.Ross (1999)
• 0.009”X 0.041” spring
• Provides 80 gm of force when stretched to twice
its resting length
JCO Feb 1999

THE MONKEY HOOK
S.Jay Bowman (2002)
• It is a simple auxiliary with an open loop on each
end for the attachment of intra oral elastic or
elastomeric chain or for connecting to a bondable
loop button. JCO July 2002

A combination of monkey hooks and bondable loop-buttons
allows the production of a variety of different
direction force such as:
I. Vertical intermaxillay eruptive forces
JCO July 2002

MANDIBULAR ACHORAGE
• Pramod K.Sinha (1999)
• Lingual arch is fabricated with 0.036 inch SS wire
• Vertical hooks (5-6mm in length)
• Elastic force should not exceed 40-60 gm
AJO March 1999

Advantages
• Simplicity in appliance
design and application
• Reduced overall treatment
time

AUSTRALIAN HELICAL ARCHWIRE
• Christine Hauser (2000)
• Made in special plus .016”
arch wire
• Force should not exceed
200 gm
• Activation by twisting the
steel ligature wire every two
weeks

The amount of force can varied by using different
arch wire designs

RETENTION CONSIDERATIONS
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 retainer
This can be done during or after the treatment.
Clark’s suggestion for palatally impacted canine: Lingual
drifting can be prevented by removal of halfmoon- shaped
wedge of tissue from lingual aspect of canine.

Case report
◦ ERUPTION OF AN IMPACTED CANINE WITH A SEMI-FIXED
APPLIANCE: - Dr. K. Neelima, Dr. K. Nagaraj , Dr. Roopa Jatti (The Orthodontic CYBER journal,
February 2010)

• A 19 1/2 year old female patient presented with an impacted upper left
canine and an over-retained primary upper left canine.. She had a
permanent dentition, with a Class I molar relationship and a proclined
maxillary left lateral incisor. The overjet was 3mm and the overbite was
close to normal. A palpable bulge was present on the buccal side of
the impacted canine region on intraoral examination.
• Intraoral periapical radiographs taken with the slob technique and
occlusal films confirmed that the impacted canine was on the labial
side, with its crown mesially angulated and the tooth almost horizontally
impacted. The crown of the impacted tooth was in close proximity to
the root of the permanent lateral incisor

APPLIANCE DESIGN:
A semi-fixed appliance was used in the initial phases to achieve
a favorable path of eruption. The appliance, comprised of wires
extending from the maxillary first molar bands palatally into the
Nance button to reinforce the proposed anchorage.
Circumferential Clasps extending from the distal of the lateral
incisor and the mesial of the first premolar were inserted into
the Nance button to maintain space for alignment of the
impacted canine.

SURGICAL TECHNIQUE:
◦ A labial flap was raised in the maxillary left canine region under local anesthesia.
The crown of the impacted canine was exposed and a bracket was bonded to an
accessible site on the tooth, using a light-cured adhesive for
◦ maximum strength. A 0.010” stainless steel ligature wire was passed through the
bracket and brought out of the flap.
◦ A tunnel was created through the bone following extraction of the deciduous
canine and the flap was then closed with silk sutures, which were to be removed
one week later. The semi-fixed appliance was cemented an hour after the surgical
procedure. The ligature wire was loosely ligated to the clasps of the semi-fixed
appliance.

CASE PROGRESS:
◦ A distally directed force was initially applied to the tooth because of its
angulation. Once a favorable angulation was achieved, in approximately
90 days, an incisal eruptive force was applied, in addition to the distalizing
force. Periodic intraoral periapical and occlusal radiographs were taken
to assess the angulation and case progress. Once the tooth was almost
upright, a full 0.022” x 0.028” Roth fixed appliance was bonded.

• Once the proper accomplished, the semi-fixed appliance was removed by cutting
the wires extending from the molar bands into the Nance palatal button.
• Molar bands with buccal tubes were retained for further fixed appliance therapy.
• A 0.016” Nickel Titanium archwire was then placed for initial leveling and
alignment followed by 0.017” x 0.025” and 0.019 x 0.025” Nickel Titanium
aligning wires.
• A passive open coil spring was threaded over 0.019” x 0.025” stainless steel
base arch wire for space maintenance in the canine region after which a 0.022” x
0.028” bracket was bonded to the now erupting upper left canine for its
alignment into the arch.
• A 0.016” NiTi auxiliary overlay wire was placed
on stainless steel base arch wire for further
alignment of canine

RESULT:
◦ Total treatment time was about 14 months, which included an
initial 7-8 months of treatment with a semi-fixed appliance,
followed by full bonded fixed mechanotherapy.
◦ A minor amount of gingival recession was observed on the
canine along with a slight amount of apical root resorption with
regard to the adjacent lateral incisor.
◦ Both of these findings were, however, insignificant considering the
amount of tooth movement required in this case and, most
importantly, preserving the vitality of the associated teeth.

Case report:
◦ Labially Impacted Maxillary Canines Causing Severe Root
Resorption of Maxillary Central Incisors. - Diane J. Milberga (Angle
Orthod 2006;76:173–176.)

This 10-year-old African-American girl presented with a: Class II skeletal pattern due
to mandibular retrusion; end to end molar relationships, retroclined maxillary
incisors; labially impacted maxillary canines; and mandibular canines in labial
Crossbite with the maxillary lateral incisors.

• The maxillary canines could not be palpated clinically. A panoramic
radiograph revealed that the maxillary canines were erupting into the middle
third of the apices of the maxillary central incisors.

Treatment plan:
◦ To reduce orthodontic treatment time and prevent further damage
to the maxillary central incisor roots, the impacted maxillary canines
and mandibular first premolars were extracted. Because of the
proximity of maxillary canines and central incisor roots, alternative
extraction sequences were not considered.
◦ The patient was referred to an endodontist to check the health of the
asymptomatic maxillary central incisors and to monitor potential
changes in the root length during orthodontic treatment.
◦ Orthodontic treatment plan included full upper and lower edgewise
appliances, headgear wear at home, and full-time bite plate wear
for crossbite. Maxillary first premolars would be substituted for the
impacted maxillary canines.
◦ Maxillary first premolar and mandibular canine guidance would be
the final occlusal treatment goal.

• Alignment of the dental arches was achieved with a 0.022 X 0.025
edgewise appliance.
• The wire sequence was:
1. 0.01750 wildcat twist, three strand;
2. 0.0160 round stainless steel;
3. 0.0180 round stainless steel;
4. 0.019 3 0.0250 rectangular stainless steel.
• The maxillary incisors were moved slowly, and achievement of
ideal root torque was not attempted because of the apical end
root resorption.
• Active treatment time was 22 months. During orthodontic
treatment, the patient did not have any clinical symptoms of
pulpal sensitivity of the maxillary central incisors.

• The final frontal facial photographs show a pleasing smile. Substitution of
the shorter maxillary first premolar for the impacted and extracted canines
was not an esthetic problem because of the patient’s long upper lip, which
covered the gingival contours of her maxillary anterior teeth.
• Profile photographs show an improvement in maxillomandibular relationship
because of favorable mandibular growth.

• At the present time, six years after treatment, the occlusion remains stable.
The maxillary central incisors, which suffered external root resorption due to the
impacted maxillary canines, remain symptom free and have normal mobility.
With removal of the maxillary canines and the source of pressure resorption,
long-term prognosis for the maxillary central incisors is excellent.
• Six years later, the compromised orthodontic treatment result has proven
to be stable and satisfactory, and the maxillary central incisors remain
asymptomatic, have normal mobility, and continue to function well.

CONCLUSION:
◦ Various surgical and orthodontics techniques may be used to
recover impacted maxillary canines.
◦ Proper management of these teeth requires appropriate surgical
techniques to apply forces in a favourable direction and to have
complete control for efficient correction, thereby avoiding
damage to the adjacent teeth.
◦ The management of impacted canine is a complex procedure
requiring a multidisciplinary approach.
◦ The clinician should communicate with each other to provide the
patient with an optimal treatment plan based on scientific
rationale.

Maxillary impacted canine management

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