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 t is well known that, after third molars,
maxillary canines are among the most frequent teeth to
be impacted, and many possible 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 possible 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 possible treat-
ment approach, which also has its limitations, is to
expose the tooth surgically, fix an attachment to it, and
exert an orthodontic extrusive force to bring the tooth
into occlusion.
This research project was partly supponed by a grant from the Fends Emile-
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
clinics, 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 ankylosis. Many radiographic techniques
have been described to help localize an impacted
tooth. 2, 6--X Vanarsdall and Corn mentioned some clues
to diagnose the ankylosis 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.
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 palatally impacted teeth we used a
closed-eruption philosophy and chose an open
approach in the labially 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 labial 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 labial surgical 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
cervical 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 will
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
cervical 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, this 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 direct 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-
sally to prevent pulpal damage and far enough cervi-
tally to avoid fracture of enamel. We start the hole with
a No, 1 round burr on high speed and then finish with a
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 will 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 principle in placing a wire
*T.M.S. Minikin, Whaledent Intematlonal, 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 clinics we have treated many
cases with a removable Hawley type of appliance with
springs soldered to Adams clasps or labial bows or
emerging directly from the acrylic to exert the extrusive
force (Figs. 1 to 4). This type of appliance transfers a
lolume 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 possibility 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.
Principal 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 possibilities 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-bite). 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-
gical intervention and, similar to a surgical splint, it
helps to contain swelling and hematoma. If we suspect
ankylosis 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 possibility 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 possibilities 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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