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8/6/2019 Combined Surgical and Orthodontic Treatment of Impacted Maxillary Canines
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COMBINED SURGICAL AND ORTHODONTICTREATMENTOF IMPACTED MAXILLARYCANINES
Wissam Marzouk, BDS, MSc, PhD*; K.M. Ragai ElMostehy, BDS, FDSRCS**;
Abdullah Al-Qurashi, BDS, MS***
Positional variations of the maxillary cuspid are frequently encountered in dental practice. In such cases, because
of its devious path to reach its position in the arch, it often gets impacted and becomes difficult to bring into
occlusion. Both the orthodontist and surgeon should aim at early diagnose, schedule a plan, surgically expose the
cuspid and use all acceptable orthodontic mechanics to bring it into occlusion. Sixty-six cases of unerupted
maxillary canines were treated by two different surgical exposures and methods (window and open-closed flap
techniques) and were orthodontically moved into occlusion. The etiology, diagnosis and evaluation of the
impaction, as well as the possible orthomechanics used to arrange the canine's position, need a clear
understanding to plan a final treatment. The findings of this study showed that buccally-impacted canines are
more common and to reach occlusion more quickly than palatally-impacted canines. The axial inclination of the
palatally impacted canines with the Frankfort horizontal plane has a direct effect upon the rapidity of treatment.
The window surgical technique was found to be more convenient to the surgeon, orthodontist and patient.
Introduction
The positional variations that the maxillary cuspid adopts
are frequently encountered in orthodontic practice. While
bringing the unerupted maxillary canine into the dental arch
could be difficult, the therapist's diagnostic and treatment plan
should be in the best interest of the patient.
Incidence of impaction of the maxillary canine rank second
to that of third molar impaction.1'2
In any orthodontic practice
the anticipation of problems related to maxillary canine
impaction should be kept in consideration by early diagnosis.
Early referral to the proper specialist is mandatory where
Received 16/01/96; revised 06/08/96 and 29/11/96, accepted 18/12/96* Consultant Orthodontist, Dental Department, King Fahd
National Guard Hospital
** Professor of Periodontics & Consultant, Dental Department,King Fahd National Guard Hospital
*** Oral & Maxillofacial Surgeon and Consultant, King FahdNational Guard Hospital, Jeddah, Saudi ArabiaAddress reprint requests to : Dr. A. Al-Qurashi
The Saudi Dental Journal, Volume 9 Number 2, May - August 1997.
certain interceptive measures could be instituted so as to
diminish further complications such as incisal root
resorption4'5or cystic degeneration
6.
In reviewing the etiological factors that lead to maxillary
canine impaction, it is generally accepted that the devious path
it follows during its eruption and the long period of its
development play a great role in its impaction.2'7
Although
crowding has been implicated,3
this factor has been neglectedby several authors. Among other causes of canine impaction is
heredity where several members of the same family are
affected. Cystic degeneration around unerupted canines might
cause their impaction.10
Bishara5
and Isiekwe et al14
listed the most common cause
that participate in maxillary canine impaction such as
tooth-size, arch length discrepancy, prolonged retention or
early loss of deciduous canines, ankylosis of the developping
canine, presence of alveolar clefts, root dilaceration of the
develoipng canine, cystic degeneration of the enamel organ of
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SURGICALAND ORTHODONTIC TREATMENT 91
the canine during its eruption, iatrogenic etiology and
idiopathic maxillary canine impaction.
This study was to review the causes of maxillary canine
impaction and to present 66 cases treated surgically by two
different surgical approaches and orthodontically moved intotheir respective positions in the arch.
Materials and Methods
This study comprises 66 patients who sought dental
treatment in King Fahd General Hospital Dental Department,
Jeddah, Kingdom of Saudi Arabia. Not all the patients came
for orthodontic treatment but have been referred for other
dental problems. Their ages ranged from 13 to 19 years. All
impacted maxillary canines were accidentally discovered
through the routine clinical and radiographic investigations.
Hence, such cases were referred to the Orthodontic Unit for
further investigations and treatment.Patients were clinically, radiographically and
cephalometrically evaluated and findings were documented.
Clinical photographs were taken and study models were made
on each patient.
The position of the impacted canine was determined by
either palpation or location on lateral cephalometric as well as
intraoral occlusal radiogprahs [Figs. 1,2]. Another method used, which some authors consider superior to cephalostats in
locating the impacted canine, is the parallax technique. Two or
more periapical radiographs were taken in the same area,
shifting the tube horizontally between exposures. In this
investigation, the cross-sectional occlusal radiographs as well
as cephalostat technique yielded the best localization of
impacted canine.
The lateral cephalometric radiographs were traced and the
skeletal and dental cephalometric angles were measured to
decide whether a case would require extraction mechanics or
not. Moreover, the palatally impacted canines were traced and
the angle formed by its long axis and Frankfort horizontal plane
was measured in an attempt to find a relation between the axial
inclination of the impacted canine and the period it would take
to descend to occlusion [Figs. 3].
To complete orthodontic records, upper and lower alginate
impressions were taken and poured in stone to serve as primary
and study models for each use. Once the line of etreatment was
reached, the patients were divided orthodontically into two
groups. The first group was the extraction cases for which the
maxillary first premolars were to be extracted and the second
group were the non-extraction cases for which repositioning of
the impacted canines was the only procedure performed after
its surgical exposure.
Patients space establishment were referred to have
restorations, scaling and oral hygiene instructions and
extractions of premolars for the first group.
The patients were scheduled for bracketing and bonding to
start the active orthodontic tooth movement. The brackets were
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92 MARZOUKET AL
standard stainless steel Edgewise brackets with 0.022" slot.
The bands used were double tubed bands, the cervical round
tube for extra-oral force application if required and the other
rectangular tube for the arch wire.
Treatment for both groups was started by aligning andlevelling the teeth by nickle titanium arch wires starting by
round 0.014" followed by 0.016" then by 0.18". At times the
teeth were so irregular that to commence treatment, 0.012"
round nickle titanium wire was used. A round 0.018" stainless
steel wire was then placed with first order bend to complete
alignment.
In the first group (extraction cases), the patients were
scheduled for surgical exposure of the canines by either
procedure mentioned below. In the second group
(non-extraction), spaces were created for the impacted
canines. In those instances where there was retained
deciduous canines and some spaces between teeth, an elastic
chain over a rectangular 0.018"x0.022" stainless steel wire
and/or push coil between lateral incisor and first premolar was
used until a suitable space was created.
In cases of Class I subdivision malocclusion where there
was a unilateral mesial shift of posterior teeth, Class II elastics
(1/4" medium pull) were used on that side over the maxillary
first premolar and mandibular first molar with a lower lingual
arch for maximum anchorage. In the case with bilateral canine
impaction, there was absolutely no space for ethem and the
molars were in Class II malocclusion. A cervical face bow
was used over the first molar until enough space was created
bilaterally [Fig. 4a,b,c,]. Finally, the patients were ready for
surgical interference.
Surgical Procedure
Surgical exposure of the impacted canine was done in
either of two ways without any criteria of selection. The first
method was the open-closed flap technique and the second
was the Window technique.
First Group: In 33 cases, a flap was raised and the crown
of the unerupted canine was exposed and surgical osteotomy
was performed around the greatest circumference of the tooth
taking in consideration not to expose the amelo-cemental
junction. Bonding the orthodontic brackets was done during
surgery after drying the exposed tooth surface from blood asbest as possible.
The bracket was then bonded according to the accessibility
obtained. Before bonding the bracket, a ligature wire was tied
to it and twisted to form a long pig tail tie with an eyelet at its
free end [Fig. 5]. This extension was to dangle down into the
oral cavity through the flap that is replaced to cover the tooth
with its bracket bonded to its crown [Fig. 6]. By emeans of this
wire, the tooth was pulled to its destined position in the arch.
Second Group : This group comprised 33 patients. A
graduated periodontal probe was used to perforate the
anaesthetized oral mucosa to give a general idea as to the
position of the unerupted canine for determing the line of
incision. A semilunar incision was performed along the tip of
the located cusp and extended for 0.5 cm on both sides of the
tooth [Figs. 7a,b,c]. This was to allow viewing the position of
the embedded crown. The created flap was raised by blunt
dissection to expose the tooth around its great circumference
and to expose as much of the clinical crown as possible just
short of the amelo-cemental junction. Osseous surgery was
done with Ochschenbein chisels so as to avoid any heat
production from rotating instruments.
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Osseous surgery was done in a way that did not leave any
bulbous or bony projections that could hinder the path of
canine eruption. It should be noted that, approximately, 2 mm
of bone was left coronal to the amelo-cemental junction. This
would allow a proper co-aptation of the dentogingival
interface and secure a knife-like pattern of marginal gingiva.
The edges of the flap have been bluntly undermined and then
The Saudi Dental Journal, Volume 9 Number 2, May - August 1997.
sutured all around the window with any soft tissue
immediately surrounding the crown. Periodontal pack wasapplied to burrow itself under and around the window and left
for one week [Figs. 7e,f,g]. At the time of bonding brackets
after one week, it was ascertained that the crown surface was
totally dry of any fluid.
To commence active orthodontic movement, a 0.018"x
0.022" rectangular stainless steel arch wire with a hellicle
between the lateral incisor and the tooth distal to the created
space, was ligated to the brackets. Teeth on either side of the
canine space were ligated together by stainless steel ligature
wire to secure anchorage and to prevent any loss of the
created space. By means of the elastic threads that were tied
to the hellicle in the arch wire and to the stainless steel
extension in the first method or the brackets in the second
method, gradual pulling forces were achieved until the canine
reached a convenient position. Once the crown was fully
exposed into the oral cavity, adjusting the position of the
brackets was done by rebonding. The time required to have
the impacted canine come actually into the oral cavity was
recorded for each case taking the time of commencement of
force applicatioon as a zero hour. Finally, the canine was
positioned in the dental arch by using 0.014", 0.016", 0.018"
and 0.018"x0.022" nickle titanium wires as deemed
necessary.
ResultsOf the 66 cases treated in this study, none came seeking
treatment for the impacted canine as all patients were not aware
of the presence of any abnormality. Accidental discovery of the
impaction was through routine screening in the Dental
Department.
Thirty-six (54.5%) cases had the canines bucally situated
while thirty (45.5%) were palatally impacted. Intraoral
examination revealed that 65 cases were unilaterally impacted
while bilateral impaction was present in only one case. Forty
cases (60.6%) showed retained deciduous canines. As a
prominent clinical finding, there was a bulge of the mucosa
either labial or palatal that determined the position of the
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SURGICAL AND ORTHODONTIC TREATMENT 95
impaction. Although this was not a common finding, it was,
more often than not, accurately determined radiographically. In
those cases which could not be detected by palpation or by the
presence of a bulge, lateral cephalometrics helped in locatingthe impacted canine [Fig. 1]. Intraoral occlusal films were
merely confirmatory to the cephalometrics.
Out of the 33 cases treated by the open-closed flap, 10 cases
showed loosening of the bonded brackets under the flap once,
while one case showed loosening of the bracket twice.
Re-entry surgeries were performed in those 11 cases to rebond
the brackets. A significant difference in the treatment time was
noticed in the bucally impacted canines compared to those
presenting palatally in both surgical procedures. The bucally
impacted canines reached occlusion at a faster rate than the
palatally presenting as indicated in Tables 1, 2, 3 and 4 treated
by either the Window or the Open-closed method.
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Table 1.Time required for maxillary impacted canines to reach occlusion (both bucally and palatally impacted) in the open-clos flap technique.
Buccally Impacted Palatally Impacted
No. of Cases Time to Reach Occlusion No. of Cases Time to Reach Occlusion
4
5
6
3
3 months4 months
5 months
6 months
5
4
5
1
8 months9 months
10 months
11 months
Table 2. Distribution of mean time to reach occlusion in months for
bucally and labially impacted canines in open-close flap technique.
Buccally Impacted Palatally Impacted
Time (N = 8) (N = 15)
Range 3-6 months 8-11 months
Mean 4.4 9.1
S.D.
1.1
0.99
T = T= 12.78
SD = Standard DeviationP < 0.05 There is a significant difference
Tables 1- and 2 show that 18 cases of bucally impacted
maxillary canines reached occlusion during a period ranging
from 3-6 months with a mean time distribution of 4.4 months
+1.1. Fifteen palatally impacted cuspids reached occlusion
during a period of 8-11 months with a mean time distribution
of mean time of 9.1 months = 0.99. Both types of impactions
were surgically exposed by the open-closed flap techniques.
Tables 3 and 4 indicate that 18 cases of bucally impactedcuspids erupted and reached occlusion during a period of 3-5
months with a distribution mean time of 3.9 months with a SD
= +0.8 while 15 palatally impacted canines reached occlusion
within a period of 8-10 months with a SD = +0.63. Both types
Table 3.Time required for maxillary impacted canines to reach occlusion (both bucally and palatally impacted) in the window technique.
Buccally Impacted Palatally Impacted
No. of Cases Time to Reach Occlusion No. of Cases Time to Reach Occlusion
7 3 months 7 8 months
6 4 months 7 9 months
5 5 months 1 10 months
Table 4. Distribution of mean time to reach occlusion in months for
bucally and labially impacted canines in the window technique.Table 5.Angles formed by the long axis of impacted canines and the
Frankfort horizontal plane.
Buccally Impacted Palatally Impacted
Time (N = 8) (N = 15)
Range 3 - 5 months 8- 10 months
Mean 3.9 8.6
S.D. 0.8 0.63
T = T= 18.46
P < 0.05 There is a significant difference
of impactions were surgically exposed by the Window
technique.
Table 5 illustrates the effect of angulation of the long axis of
palatally impacted canines with Frankfort horizontal plane on
the time taken by the impacted canine to arrive to occlusion. It
was shown that the more acute the angle was, the faster the
impacted canine reached occlusion and the more obtuse the
angle was, the longer the period taken by the impacted canine
to reach occlusion. Thus, as depicted from this table, for 12
cases with an angle ranging from 95 to 110, the time of
No. of Cases Range of Angle Treatment Time
12 95- 110 8 months
11 110- 120 9 months
7 120- 135 10 months
treatment was 8 months. In 11 cases with angles ranging
between 110 and 120, the teeth reached occlusion in nine
months of treatment.
Seven cases with angles ranging from 120 to 135 reached
occlusion after 10 months irrespective of the surgical technique
used to expose them. It was also found that four of the cases
treated by the Window technique showed active tooth eruption
without any ortho-mechanics applied.
Discussion
Impaction of the maxillary canine is a problem frequently
encountered in orthodontic practice. The complexity of
diagnosis and treatment plan using taxes the orthodntist's and
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SURGICALAND ORTHODONTICTREATMENT 97
surgeon's intelligence. Indeed, there are several modalities in
treating impacted maxillary canines dictated by several
parameters.
The results obtained from this study showed that labial
maxillary canine impaction is more common than palatalimpaction. This does not coincides with the findings of
Fergusson3
who concluded that displacement from normal path
of eruption most commonly occurs in a palatal direction. Also,
Orton et al8
asserted that most ectopic canines are palatally
impacted. On the other hand, Richardson and McKay4
questioned the validity of this concept as applied to many
maxillary displaced canines. Although heredity has been
implicated as a cause in maxillary canine impaction4
yet, in the
present study, no familial background has been detected.
Fearne et al9
correlated impaction of maxillary canine and
cystic formation around the unerupted canine.
In the cases presented in this report, only one patient
exhibited a cystic formation around an impacted canine.
Anterior segment crowding has been considered as a cause in
maxillary canine impaction3
yet some cases presented in this
report showed the presence of enough spaces to accommodate
normal eruption of the impacted tooth to its destined position.
The available spaces resulted from the presence of peg-shaped
laterals, congenitally missing laterals and retained deciduous
canines. In this respect, crowding could not be a major factor in
maxillary canine impaction. This is in agreement with the
findings of Moss2, Brin et al
10and Jacoby"
Surgical management of impacted canine for orthodontic
mechanics has been a subject of controversy. The Window
technique, performed by several authors,3'6 did not gain
acceptance. Opponents to this technique advocated that
removal of a tissue from an impacted canine might result in a
"pathological" dento-gingival junction of the finally erupted
tooth.2'12
Proponents of the open-closed technique concluded
that the risk of attachment loss is reduced if a flap is raised
and then replaced over the exposed crown of the impacted
canine after attaching a suitable means with which traction of
the impacted canine is applied.1213
In this study, the Window
technique gave better clinical results when compared to the
open-closed technique for several reasons. It was found
indeed that such a procedure is more convenient to the
surgeon, the orthodontist as well as to the patient himself.Bonding of the impacted exposed canine could be easily
performed in "open air" after controlling the fluid
contamination of the tooth surface if it is bonded during
surgery. Another advantage of the Window technique is that it
enables the orthodontist to observe all professional tooth
movements during the treatment period, rather than moving
the hidden canine under a flap which is indeed unpredictable.
A second and, at times, a third surgical re-entry procedure
should be performed to re-bond a loose bracket, which in
itself is traumatic both to the patient and the gingival tissues.
It should be added in this respect that the Window technique
allowed the impacted canine to reach its destined position at a
faster rate than impacted canines exposed by the open-closed
technique. The suturing procedure adopted in the Window
technique allowed the soft tissues to heal in a knife-like edge
with the tooth surface resulting in proper co-aptation of the
marginal gingiva of the finally erupted tooth. The extrusion ofa peg-tail extention from under the raised flap in the
open-closed technique method was reported by several
patients in this study to be very irritating.
Finally, the angle existing between the long axis of the
impacted canine and Frankfort horizontal plane could affect the
period taken by the impacted maxillary canine to reach
occlusion irrespective of the technique performed to expose it.
In this report, it was found that the most favorable angle is
from 95 to 100 degrees.
Conclusion
Based on the results of this study, the following conclusions
are drawn :
1. The devious path and the late development of themaxillary canine seemed to be the most acceptable cause
of its impaction.
2. Impaction of the maxillary canine was found to be morecommon buccally than palatally.
3. A significant difference was found between bucally andpalatally impacted maxillary canines in terms of
treatment time. Bucally impacted canines reached
occlusion faster than palatally impacted canines.
4. The impactions reported in this study were discoveredaccidentally in patients who came for other dental
consultations.
5. The angulation of the palatally impacted canine inrelation to Frankfort horizontal plane had a direct effect
on the period of treatment taken by the orthodontically
moving canine to reach occlusion.
6. Comparing the two surgical techniques of exposing theimpacted maxillary canine, the Window technique was
more advantageous than the Open-closed flap technique
in our hands and more promising in bringing the tooth
into occlusion.
7. Greater number of cases should be treated by the Window technique in future studies to validate our
conclusion that the Window technique was superior tothe Open-closed flap technique.
References
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2. Moss JP. The unerupted canine. Dent Pract Dent Rec1972;22:241-48.
3. Fergusson JW. Management of unerupted maxillary canine.Br Dent J 1990;169:11-17.
4. Richardson A., McKay C. Delayed eruption of maxillarycanine teeth. Part II. Treatment. Proc Br Pedodont Soc
1983;13:13-23.
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5. Bishara SE. Impacted maxillary canine: A review. Am JOrthod Dentofac Orthop 1992;84:159-71.
6. Hunter SB. Treatment of the unerupted maxillary canine.Preliminary consideration and surgical methods. Br Dent J
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7. Dewel BF. The upper cuspid. Its development and impaction.Angle Orthodont 1949;19:79-90.
8. Orton HS, Gravey MT, Pearson MH. Extrusion of the ectopicmaxillary canine using a lower removable appliance. Am J
Orthod Dentofac Orthop 1995;107:349-59.
9. Fearne J, Lee RT. Favorable spontaneous eruption ofseverely displaced maxillary canines with associated
follicular disturbance. Br J Orthodont 1988; 15: 93.98.
10. Brim I, Becker A, Shalhay M. Position of the maxillar
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incisor. A population study. Eur J Orthod 1986;8:245-55.
11. Jacoby H. The etiology of maxillary canine impaction. Am JOrthod Dentofac Orthop 1938;84:125-32.
12. Wisth PJ, Nodeval K, Boe OE. Comparison of two surgicalmethods in combined surgical orthodontic correction of
impacted maxillary canines. Acta Odontol Scan
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13. Wong-Lee TK, Wong FCK. Maintaining an ideal toothgingiva relationship when eexposing and aligning an
impacted tooth. Br J Orthod 1985;12:189-92.
14. Isiekwe MC, Nwoku AL. Surgery as an adjunct in theorthodontic management of impacted maxillary canine.
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The Saudi Dental Journal, Volume 9 Number 2, May - August 1997.