Management of impacted teeth /certified fixed orthodontic courses by Indian dental academy


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Management of impacted teeth /certified fixed orthodontic courses by Indian dental academy

  1. 1.
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. Introducton contents Etiology Frequency of impactions Diagnosis Treatment strategies Impactions of incisors Impaction of canines Impactions of premolars Impactions of molars Conclusion
  4. 4. INTRODUCTION  The treatment of impacted teeth has caught the imagination of many in dental profession. However, the orthodontic / surgical modality has achieved the most satisfactory result in long-term.  According to Shafer, Hine and Levy,Impacted teeth are those which are prevented from erupting by some physical barrier in the eruption path.
  5. 5. A tooth which is completely or partially unerupted & is positioned against another tooth , bone or soft tissue, so that its further eruption is unlikely, described according to its anatomic position.
  6. 6. CAUSES OF IMPACTIONS -Local causes -Systemic causes
  7. 7. Local causes  Irregularity in the position and pressure of an adjacent tooth.  Density of overlying or surrounding bone.  Long continued chronic inflammation with resultant increase in the density of mucous membrane.  Lack of space due to underdeveloped jaws.
  8. 8.  Unduly long retention of primary teeth.  Premature loss of primary teeth.  Acquired diseases , such as necrosis due to infection or abscesses.  Inflammatory changes in the bone due to exanthematous diseases.
  9. 9. Systemic causes PRE – NATAL - Heredity.  POST – NATAL - Rickets. - Anemia. - Congenital Syphillis. - Tuberculosis. - Endocrine dysfunction. - Malnutrition. 
  10. 10.  RARE CONDITIONS - Cleidocranial Dysplasia. - oxycephaly. - Progeria. - Achondroplasia. - Cleft palate.
  11. 11. Normal eruption
  12. 12. 3rd molar impaction
  13. 13. Canine impaction
  14. 14. Premolar impaction
  15. 15. FREQUENCY OF IMPACTION         Mandibular 3 rd molar. Maxillary 3 rd molar. Maxillary canine. Mandibular bicuspid. Mandibular cuspid. Maxillary bicuspid. Maxillary central incisor. Maxillary lateral incisor.
  17. 17. CLINICAL METHOD FOR DIAGNOSIS o Examination to assess facial form, arch form and symmetry. o Relationship of maxillary dental midline to facial midline. o CR and CO position should be carefully recorded. o Overjet and Overbite should be carefully recorded. o Delayed eruption of permanent teeth. o Prolonged retention of deciduous teeth. o Absence of normal labial canine bulge. o Presence of palatal bulge (Abnormal). o Delayed eruption, distal tipping or migration of adjacent teeth
  18. 18. RADIOGRAPHIC METHOD FOR DIAGNOSIS In Orthodontic treatment planning, the exact localization of the position of an impacted teeth is necessary. I. Qualitative radiographs Extraoral Periapical Maxillary arch OPG Occlusal PA view Lateral ceph Mandibular arch Max. ant. occlusal True vertex/occlusal
  19. 19. II. 3-D diagnosis of the position Parallax method C T scanning Radiographic views at right angle
  20. 20. 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.
  22. 22. 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.
  24. 24. Occlusal Radiography: Mandibular arch: • In mandibular arch occlusal view is taken by tipping the patient’s head backwards & pointing the X-ray tube at right angle to the film in the occlusal plane. • In the canine or premolar region, this is a true occlusal view.
  25. 25. • To get a true occlusal view in the anterior region, the head is tipped back further & X-ray tube is angled at 110% to the horizontal plane at symphysis menti along the long axis of the incisor teeth.
  26. 26. Maxillary arch 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.
  27. 27. 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.
  28. 28. Extraoral Radiography: • OPG has the advantage of simplicity & quickly offering a good scan of the teeth & jaws from Temporomandibular joint to Temporomandibular joint.
  29. 29. 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 the canine.
  30. 30. 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.
  31. 31. 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.
  32. 32. 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
  33. 33. 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.
  34. 34. 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 .
  35. 35. 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.
  36. 36. • 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.
  37. 37. Rapid prototyping Limitations of CT Scan  However even the 3D reconstruction is obtained , the analysis by the orthodontist is still limited : 3D images are seen as 2 dimensional on film and computer screen.  This can be overcome with the use CT to make a model by means of rapid prototyping  This technique use data from computer aided design to produce physical models and devices by material addition .
  38. 38.
  39. 39. Labial tooth impaction - 1% to 2% of orthodontic patients and is often difficult to manage. The most common methods of uncovering labial impactions Excisional gingivectomy Apically positioned flap techniques . closed-eruption technique.
  40. 40. TYPES OF FLAPS FOR IMPACTED TEETH • Exposure only • Exposure with pack Buccally accessible impacted teeth • A circular incision
  41. 41. • Apically repositioned surgical flap .Full flap closure 1.) Labially impacted maxillary anterior teeth uncovered with an apically positioned flap technique have more unesthetic sequalae than those uncovered with a closed-eruption technique. 2 )Negative esthetic effects, such as increased clinical crown length, increased width of attached tissue, gingival scarring, and intrusive relapse were evident in the apically positioned flap. teeth treated with an
  42. 42.  Vanarsdall and Corn evaluated more than 75 labially impacted teeth which had been uncovered using a split-thickness apically positioned flap. The authors found no marginal bone loss or gingival recession after orthodontic treatment.  They stressed the need to provide attached gingiva in order to prevent the muscles of the face from detaching the marginal periodontal tissue from the tooth, causing marginal bone loss and gingival recession.  The closed-eruption technique is believed by some to be the best method of uncovering labially impacted
  43. 43. Palatal Impaction • Partial • Full flap closure
  44. 44. 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.
  45. 45. • 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.
  46. 46. Attachments: –  Lasso wires  Threaded pins  Orthodontic bands  Standard orthodontic bracket  A simple eyelet  Elastic ties and modules  Magnets
  47. 47. {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.
  48. 48. (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.
  49. 49. {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.
  50. 50. {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.
  51. 51. 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.
  52. 52. - Interferes with the investing tissues & leads to inflammation & periodontal damage. - As the impacted tooth advances into the arch the exuberant gingival tissues bunches in front of it & causes punching between the bracket & tissues.
  53. 53. {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.
  54. 54. (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
  55. 55. {f} Magnets: It is made up of rare earth lanthanide alloys . • It is rarely used. Disadvantage: - corrosion.
  56. 56. Maxillary incisors impaction The spectre of appearance of lateral incisors ,associated with non – appearance of one or both of central incisors ,should always deemed as abnormal ,whether or not a deciduous central incisor is still present .
  57. 57. Aetiology Obstructive causes supernumerary teeth Odontome Ectopoc position of tooth bud Traumatic causes Obstruction due to soft tissue repair Dilaceration Arrested root development Acute traumatic intrusion
  58. 58. Treatment timing Obstructions should be removed early before it causes delayed eruption. Clinically – when both laterel incisors are erupted Radio graphically – IOPA show atleast 2/3 rd of its root , the developmental landmark that tooth should be erupted . Orthodontic and surgical intervention is indicated at this time.
  59. 59. Attitudes of treatment Adequate space is created Obstructions are removed 1. Eruption - Battagel 1985, Houston 1986, mitchell and bennet 1992 2. Noneruption - Dibase 1971, Witsenburg 1981 3. Delayed eruption – 16 -20 months for eruption this is an unacceptable long period of time, 2 surgical episodes may be needed Mitchell and Bennet 1992, Bodenham 1967. 4.Alignment – Gardiner 1961 spontaneous alignment occurs only minority of patients
  60. 60. Treatment 1) An orthodontic appliance for the use in the early mixed dentition. 2) two by four appliance 3) Johnson’s twin wire arch
  61. 61. Prognosis 1.Root length 2. Type and height of periodontal ligament – window created over the impacted canine over attatched gingiva – poor prognosis full flap surgery – good prognosis 3. Relative height of the crestal alveolus – vertical movement of tooth is accompanied by vertical increase in the alveolar bone When the impaction is resolved by natural eruptive force bone support is good when the excess extrusive forces – tooth will erupt rapidlly without regeneration of alveolar bone
  62. 62. 4.preservation of vitality 5.oral hygiene
  63. 63. IMPACTION DUE TO TRAUMA SOFT TISSUE OBSTRUCTION Andreason and Andreason 1994 Removing of the fibrous mucosal covering or incising and resuturing it to leave the incisal edge exposed will generally lead to a fairly rapid eruption
  64. 64. The dilacerated central incisor and arrested root development long term prognosis of these teeth is poor and their extraction and replacement is a part of long term treatment strategy. But it is always advisable to disimpact these teeth into arch for timely purpose and replace it later with prothesis depending upon its prognosis for following reasons.
  65. 65. A permanent artificial solution can not considered in early childhood Following extraction of the dilacerated teeth ,alveolar ridge is deficient ridge vertically and labio-lingually making the case unsuitable for an implant Retention of the short rooted and endodontically treated teeth will preserve the normal shape and architecture of alveolar ridge
  66. 66. Apical root dilaceration The more apical the dilaceration of root the better is the prognosis.  Surgically expose  Attach an eyelet and a ligature is treaded to the eyelet and drawn towards the main arch wire As crown moves down the root rotates labially towards the labial plate.  If the root is prominent and still more labial root movement is desirable - amputation of the labially projected part of the root and endodontic treatment is carried on The prognosis is dependent on amount of root remaining after
  67. 67. Crown dilaceration If the dilaceration is in the crown of the tooth , prognosis improves the closer it is to the incisal edge When the crown is surgically exposed , an attatchment is placed on the labial surface . In this way a continued downwards directed orhtodontic traction will bring the root portion of the tooth from more palatal position to its normal position ,this is due to lingual tipping
  68. 68. The tooth will erupt with the incisal edge of the teeth more labially and post traumatic section in an acceptable position. Retoration of the teeth indicated after grinding off the portion of the crown developed before pre trauma.
  69. 69. Dilaceration of the crown near the CEJ junction , the progosis of aligned tooth is extremely poor Since most of the root portion developed after post trauma period , will need to be amputated , leaving the tooth with a non – vaible coronal remanent of the teeth
  70. 70. Treatment options 1) Open up the space Dilacerated tooth is exposed Condition is evaluated – hopeless – extraction not hopeless – ampute the root portion , crown pulp chamber is cleaned and filled with composite and used as space maintainer by bonding to the adj teeth 2) Crown is removed, immediate root filling is placed and treaded post is attatched and to this post a ligature wire is attatched and the prepared tooth is erupted in to the moth till the post becomes apparent at the gingival level and later a artificial crown is given.
  71. 71. Acute traumatic intrusive luxation  Shapira in 1986 - following traumatic intrusive luxation tooth may erupt spontaneously and eventually erupt into its original position  in some cases orthodontic intervention may be required
  72. 72. Individual tooth distraction  Miniature tooth-borne distractor
  73. 73.
  74. 74. ERUPTION OF CANINE • Dewel (1949) stated that “no tooth is more interesting from the development point of view than the maxillary canine” • Canine develops in deepest area of maxilla, has longest path of eruption, travels 22mm during its course or eruption and has longest period of development.
  75. 75. Reason for canine Impaction Becker Concepts : Becker (1984) hypothesized two processes in the palatal impaction of the maxillary canine: I) Absence of initial early guidance from an anomalous lateral incisor. II) Failure of buccal movement of the canine at an unspecified age . MC Bridge Concept Canine formed at high in the anterior wall at antrum, below the floor of orbit, long tortous path of eruption.
  76. 76. 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) Canine Erupt 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.
  77. 77. Berger Concept :{Systemic cause of impaction} 1) 2) 3) 4) 5) 6) 7) Malnutrition Tuberculosis Syphilis Rickets Anemia Progeria Syndromes: a) Cleidocranial dysplasia b) Achondraplasia c) Down syndrome
  78. 78. Vonder Heydt Concept Total arch length of permanent teeth is initially established very early in life at the time of eruption of first permanent molars. Canine is larger and later erupting and considering like a musical chair situation it may get impacted. 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.
  79. 79. First stage Impaction:If there is a loss of guidances due to missinig 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. 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 redeflect 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.
  80. 80. Peck and Peck Concept: 1) Occurrence of 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. 2) Bilaterally occurring Phenomenon (17%) 3) Females affected more than males (1:3.2) 4) Familial occurrence So they concluded palatally impacted canine as dental anomaly as GENETIC ORIGIN.
  81. 81. INCIDENCE OF CANINE IMPACTION • Dachi and Howell (1961) incidence of maxillary and mandibular canine impaction - 0.92% and 0.35% resp. • Ericson and Kurol (1986) - 1.7% • Johnston et al (1982) – greater incidence of palatal impaction than the labial • Gaulis and Joho (1982) -2:1 ratio of palatal to buccal impaction. • Of all patients with maxillary impacted canines, 8% have bilateral impactions.
  82. 82. SEQUELAE OF IMPACTION • Labial or lingual malposition of the impacted tooth. • Migration of the neighbouring teeth and loss of arch length. • Internal resorption. • Dentigerous cyst formation.
  83. 83. • External root resorption of the impacted tooth, as well as the neighbouring teeth. • Infection particularly with partial eruption. • Referred pain. • of the above sequelae.
  84. 84. CLASSIFICATION OF IMPACTED CANINE Impacted canine Maxillary canine Buccal Palatal Mandibular canine Buccal Lingual
  85. 85. 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
  86. 86. Group 1 - Proximity to the line of arch – close. - Position in the maxilla – low. Group 2 - Proximity to the line of arch – close. Position in the maxilla – forward , low & mesial to the lateral incisor root. Group 3 - Proximity to the line of arch – close. - Position in the maxilla – high.
  87. 87. 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.
  88. 88. Classification by ACKERMAN and FIELDS in 1935. IMPACTED CANINE Horizontally Palatal vertically Labial Mid- alveolar Above Below (With respect to the apex) ( With respect to the arch) (J CO 1979 DEC)
  89. 89. TREATMENT ALTERNATIVES 1. No treatment, if the patient does not desire it. Since the long term prognosis of deciduous canine is poor as its root may eventually resorb , it should be periodically evaluated. 2. Auto transplantation of the canine. 3. Extraction of impacted canine and moving premolar in its position. 4. Extraction of the canine & posterior segmental osteotomy to move the buccal segment mesially to close the residual space.
  90. 90. 5. Prosthetic replacement of the canine, not amendable for juvenile cases. 6. Transalveolar transplantation of maxillary canine By Soren Sagne et al in AJODO’ 86 for orthodontic treatment of impacted canine in adult patients. 7. Most desirable approach is surgical exposure of the canine followed by orthodontic treatment .
  91. 91. WHEN TO EXTRACT AN IMPACTED CANINE * If it is ankylosed & cannot be transplanted. * If it is undergoing external or internal root resorption. * If the root is severely dilacerated.
  92. 92.  If the impaction is severe on central & lateral incisors & orthodontic movement will jeopardize these teeth.  If the occlusion is acceptable, with first premolar in canine position.  If there are pathologic changes {cystic formation, infection}.
  93. 93. PALATAL VERSES LABIAL IMPACTIONS • Incidence - Palatal : Labial is 2:1 or 3:1. • Ectopic labially positioned canines may erupt on their own without surgical exposure. • Palatally impacted canine seldom erupt without surgical intervention due to thick palatal cortical bone & dense & resistant palatal mucosa. • Palatally impacted canines are more often inclined in a horizontal / oblique direction . • Labial impactions are more often vertically inclined.
  94. 94. FORCE GENERATING DEVICES Various methods have been used for moving the canine in to proper alignment with following considerations: • The use of light force (not more than 60 gms). • Creation of sufficient space. • Maintenance of the space. • Arch wire of sufficient stiffness.
  95. 95. Labially impacted teeth TMA BOX LOOP TMA .017 X .025 wire used. • Produce sagittal and horizontal corrections while continuing vertical eruption. Surendra Patel J C O 1999
  96. 96. 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
  97. 97. Procedure JCO Feb 1999
  98. 98. 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
  99. 99. 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
  100. 100. A combination of monkey hooks and bondable loopbuttons allows the production of a variety of different direction force such as: I. Vertical intermaxillay eruptive forces JCO July 2002
  101. 101. II. Vertical intra arch eruptive forces JCO July 2002
  102. 102. III. Lateral directional forces JCO July 2002
  103. 103. 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 JCO Sep 2000
  104. 104. Palatally impacted canine: When crown of canine is more palatally displaced,surgery on the buccal side needs to become more radical,rendering a palatal; approach preferable. Usually palatally impacted tooth is guided to occlusion in two stages. I) Guiding tooth to oral enviroment II) Guiding tooth to line of arch
  105. 105. 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
  106. 106. 2) Ballista Spring (Jacoby 1979) It is made of rectangular wires. It proceeds forward untill 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.
  107. 107. 3) Light Auxiliary Labial Arch (Kornhauser1996) It is made up of 0.014 inch round SS wire with vertical loops in the area of impacted canine on both sides.This loop has a small helix.This 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 .
  108. 108. THE K- 9 SPRING •Varun Kalra (2000) • Made in 0.017”X 0.025”TMA wire Adv: • Simple in design • Low cost • No patient compliance • Light continuous eruptive and distalizing forces JCO Oct 2000
  109. 109. Fabrication and Activation JCO Oct 2000
  110. 110. JCO Oct 2000
  111. 111. JCO Oct 2000
  112. 112. JCO Oct 2000
  113. 113. 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
  114. 114. Advantages • Simplicity in appliance design and application • Reduced overall treatment time AJO March 1999
  115. 115. MAGNETS • M.Ali Darendeliler (1994) • Samarium cobalt magnet coated with thermoplastic material (Eurcodur). • Initial force of attraction is 10gm JCO 1994
  116. 116. JCO 1994 Procedure
  117. 117. Guiding tooth to line of arch Once the tooth is moved to the oral enviroment,bonding attachment is placed on the midbuccal aspect to prevent iatrogenic rotation of canine and guided to the line of arch.
  118. 118. a) If the root apex of canine is close to the line of arch and crown related to the roots of incisors,pure buccal tipping will bring the crown to desirable position and inclination. b) If the root apex is distant to the line of arch and crown not related to the roots of the incisors,usually it will be impacted deep and may even crosses the mid palatal suture.These tooth can be directly guided to occlusion through labial arch wire since there is no inteference of roots of incisors. c) If there is an horizontal impaction,downward tipping should be cautiously applied.Force application should be like the fulcrum of the canine to be at the root end ,so that root apex don’t alter following the canine tipping movement.
  119. 119. Unfortunately ,fulcrum is usually located short away from the apical portion of the root, leads to concomitant palatal displacement of root apex of canine. This requires buccal root torquing after alignment of canine in the arch. d) If the root apex mesial to lateral incisor or distal to premolar , tooth is considered as TRANSPOSED. I) Incomplete transposition: Roots will be in line of arch in its position and crown tipped due to path of eruption.(uprighting of tooth will align the tooth in arch). II) Complete transposition: Both crown and root together will be completely interchanged.In these sutiation its better to align tooth to their respective position ,i.e canine between premolars or mesial to lateral incisors depends on type of transposition..
  120. 120. If we tried to align this tooth to their respective position,following will occur, I) If canine is palatal to line of arch,secondary effect of root contact will rotate the root apex both mesially and palatally across the palate in a wide sweeping motion.the tooth will be laid down beneath the periosteum with huge dehiscence. II) If canine is buccal to the line of arch ,secondary effect of root contact will cause further buccal displacement of root with gross dehiscence of buccal periodontium. e) If canine is erupting in line of arch and in place of lateral incisors and resorbing the roots,canine should be guided in distal direction without extrusion in horizontal plane in a direct line towards the maxillary molars.
  121. 121. Tunnel traction of infraosseous impacted canines A.crescini et al(1994) Adv: • No attachment loss • No recession AJO 1994
  122. 122.  The surgical orthodontic treatment of impacted canines is aimed at bringing the tooth into its correct position in the dental arch without causing periodontal damage.  submucosal impaction -mucogingival problems may arise. Performing a gingivectomy  "window approach indicates that statistically significant loss of attachment, recession and gingival inflammation occur on maxillary canines after surgical exposure  Therefore a part of the keratinized gingiva must be preserved or an apically positioned flap should be used..This approach aims at obtaining keratinized gingiva around the entire erupting maxillary canine. Regardless of the technique used, the tooth is left exposed after having positioned the attaching device to the crown.
  123. 123.  In the case of deep infraosseous impaction, these techniques cannot always be used safely and other steps are required to achieve a satisfactory periodontal outcome. Full thickness flaps must be reflected to adequately access the crown of the impacted tooth. Leaving the crown exposed entails bone resection and displacements of the soft tissues. In each cases, although the removal of a significant portion of cortical bone favors eruption of the tooth, removing tissue may result in the loss of bone support.  Satisfactory results could be expected if the physiologic eruption pattern is restored. "When a permanent tooth erupts ideally it will break through the gingiva near the crest of the ridge so that some gingiva will be present on the facial surface."
  124. 124.  Several studies have been published on the periodontal status of impacted canines after surgical orthodontic repositioning. Little data are available on the periodontal status from samples including only deep infraosseous impactions.  Tunnel approach is a surgical approach for the orthodontic treatment of deep infraosseous impacted canines. This technique allows for orthodontic traction of the impacted tooth to the center of the alveolar ridge. The periodontal outcome of these cases was evaluated after a 3-year follow-up period.
  125. 125. Tunnel approach
  126. 126. Full gingival flap is raised , with some cortical bone removal to expose the canine, deciduous teeth is extracted, a tunnel is made with a bur through socket of deciduous canine till the tip of the impacted canine
  127. 127. Attatchments used
  128. 128. Flap is sutured back and canine is disimpacted through the socket of deciduous teeth
  129. 129.  Impacted canine erupts at center of alveolar ridge.
  130. 130. EXTRUSION OF PALATALLY IMPACTED CUSPIDS  Materials needed are a Kobayashi hook, a split rectangular extraoral hook, and a specially bent .018" wire two helices, perpendicular to each other and about 1/8" apart; mesial and distal legs should extend about 1" past the helices .  Ligate the Kobayashi hook to the cuspid bracket before bonding the bracket to the exposed cuspid. Place a rectangular stabilizing wire in the arch. Crimp the extraoral hook, angulated labially and gingivally,
  131. 131.
  132. 132. Dentigerous Cyst: Dentigerous cyst is a well defined radiolucent lesion of alveolar bone and inhibit the eruption of the involved tooth. Treatment: Marsupialization is the procedure consists of fenestrating the outer wall of the cyst, and relieving the intracystic pressure. With this early decompression, the size of the cavity slowly decreases, enabling the surrounding bone to regenerate around the impacted tooth, which eventually will erupt into the dental arch. Thus Marsupialization has the advantage of reducing the cystic cavity and preserving the involved tooth.Average time to erupt after Marsupialization is 109 days,without any traction. Orthodontic traction is necessary if
  133. 133. Hyomoto 2003 showed Tooth will erupt after marsupilazation only it fulfill the following criteria 1) Less than 2/3 rd root formation. 2) Less than 80º to tooth axis angulation to occlusal plane 3) Less than 9mm deep in bone Impacted tooth and Periodontium In 1984 Becker showed Exposure of the crown should be sufficient to bond attachment rather than exposing upto CementoEnamelJunction.Previously for placing bands surgeons Deliberately and completely remove the follicle surrounding the tooth.When these tooth erupt in to occlusion,these tooth will have longer clinical crown and reduced alveolar height.
  134. 134. Kokich and Mathew showed that bone removal should not be more than 2/3rd of the impacted tooth crown. Light orthodontic movement like tipping , extrusion, and rotation have less periodontal breakdown than Heavy orthodontic movement like root uprighting and torquing. In 2002 Charles and Frank showed periodontal condition depends on the type of surgery.Closed approach seems to be preferable than open approach and apically repositioned flap.
  135. 135. COMPLICATION OF UNTREATED IMPACTED CANINE 1) Crown Resorption: With age reduced enamel epithelium surrounding the completed crown will degenerate and its integrity will lost.This leads to direct contact of bone and connective tissue with the crown and osteolytic activity will leads to resorption of enamel and its replaced by bone ,a process called Replacement Resorption. This is seen specially in adult patients who left untreated 2-3 decade of age.
  136. 136. 2) Labial or lingual malposition of impacted tooth 3 ) Migration of neighboring teeth and loss of arch length 4) Internal resorption of impacted tooth 5) Cyst formation {Dentigerous cyst} Trauma or carious lesion of deciduous canine will cause periapical pathology which may leads to direct nterconnection between apical pathology and Follicular sac surrounding the impacted canine. If the follicular sac enlarges more than 2-3mm,it represents cystic changes
  137. 137. Dentigerous cyst orginates after the crown of the tooth completely formed by acclumation of fluid between the reduced enamel epithelium and the tooth crown. Dentigerous cyst may enlarges at the expenses of maxillary bone and displace canine higher in the maxilla. Potential complication of dentigerous cyst a) ameloblastoma b) Epidermoid Carcinoma c) MucoEpidermoid carcinoma 6) Resorption ofLateral incisor root: This progress of undesirable phenomenon depends on eruptive movement of the impacted canine. If the impacted tooth is removed or redirected the resorption process usually ceases.
  138. 138. 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.
  139. 139. 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.
  140. 140. Orthodontic management of impacted canines can be very complex and requires a carefully planned interdisciplinary approach. As canine has unique functional and aesthetic importance,clinicians usually elect to bring an impacted canine into proper position to give a better smile.
  141. 141. Other single teeth Mandibular and maxillary second premolars Crowding and space loss Early extraction of second deciduous molar Distal tipping of 1 deciduous molar teeth is blocked from eruption Tipping of adj permanent teeth
  142. 142. Treatment alternatives Extraction of the first premolar – to resolve crowding and disimpaction Uprighting of adj teeth with coil compressed b/w 1 molar and I premolar Extraction of impacted teeth along with other tooth rxtraction in other
  143. 143. Improper orientation of premolar Distal tipped premolars causes only resorption of distal root of deciduous molar ,leaving mesial root unresorbed and overretention of deciduous molar. extract the deciduous molar Hold the space Surgically expose the mesial and occlusal aspects of impacted teeth and attatch an eyelet and tie a piggy tail and attach it to hook of the rigid bar used for maintaining
  144. 144.
  145. 145. Infraocclusion of deciduous second molar Due to infraocclusion - premolar is impacted more apically treatment extract the infraoccluded teeth Hold the space Wait and check for spontaneous eruption of teeth – vertical bone height is also developed.
  146. 146.
  147. 147. Maxillary first molars In early mixed dentition - common to see that erupting maxillaary molars caught by distal tuberosity of adj deciduous second molar. Clinically - marginal ridges of 2 teeth are not at same level or present beneath the distal CEJ of deciduous teeth Radiological - distal root of deciduous 2 molar is resorbed path of eruption of permanent molar is mesially tilted. Treatment - donot extract the deciduous molar - mesial tilt the permanent molar and occupy the space Mild cases - elastic separator can be used - relapse may occur after removal Fixed appliance - banding E of both sides and soldering a palatal arch with soldered spring on the deep occlusal pit of I st permanent molar.
  148. 148.
  149. 149. Third molar impactions  Archer defined an impacted third molar as ‘One which was completely or partly erupted and positioned against another tooth,bone or soft tissue, so that its further eruption was unlikely.  Dachi and Howell in their study found that the incidence of patients with atleast one impacted tooth was 16.7%.
  150. 150.  Bjork and colleagues identified 3 skeletal factors that are separately influencing third molar impaction – Reduced mandibular length,measured as the distance from the chin point to the condylar head. – Vertical direction of condylar growth as indicated by the mandibular base angle. – Backward directed eruption of mandibular dentition determined by the degree of alveolar prognathism of lower jaw.
  151. 151.  Capelli in a 1991 study evaluated 60 patients who underwent orthodontic treatment.  The findings from pretreatment and posttreatment cephalograms suggested that third molar impactions were more likely to occur in patients with pretreatment vertical mandibular growth. A long ascending ramus, short mandibular length, and greater mesial crown inclinations of third molars, seem to be indicative of third molar impaction.
  152. 152. TYPES OF IMPACTION Richardson  suggested five categories of impaction Type A : The tooth can follow the pattern of an ideally developing third molar, by decreasing its angle to the mandibular plane and becoming more upright, but the uprighting may not be enough to allow full eruption.
  153. 153.  Type B : The angular developmental position relative to the mandibular plane may remain unchanged  Type C : The tooth can increase its angulation to the mandibular plane ,and become more mesially inclined .There is at present no reliable way of predicting which teeth will follow this unfavourable pattern,which sometimes occurs unilaterally and leads to horizontal impaction
  154. 154.  Type D :The tooth can be seen to make favourable changes in angulation ,but fail to erupt owing to lack of space.These are so called vertical impactions.  Type E :The tooth can continue to change its angulation beyond the ideal occlusal position,and show disto angular impaction
  155. 155. MECHANISM FOR ERUPTION AND IMPACTION  Differential root elongation might explain differences in eruptive behaviour among lower third molars.  Richardson offered a theoretical explanation for favorable or unfavorable rotational movement.
  156. 156.  Favorable change in angulation ,to a more upright position ,seemed to occur in teeth where the mesial root developed ahead of the distal crown surface and root.  The typical root configuration showed a mesial root which was curved in a distal direction and was slightly longer than the distal root.
  157. 157.  Unfavorable mesial tipping, leading to horizontal impaction, seemed to occur when the distal root became the same length, and then longer than the mesial root.  The distal root on such teeth was seen to appear to have a mesial curvature.
  158. 158. FACTORS INFLUENCING AVAILABILITY OF SPACE  GROWTH Bjork et al measured the distance from the anterior border of the ramus to the second molar,and concluded that the bigger the space,the better the chance of eruption.Richardson measured an average of 11.4 mm of growth between the age of 10 and 15 years.
  159. 159.  BONE RESORPTION In 1987 Richardson examined the creation of space for third molars in 51 subjects. She found that increased space was obtained from both the mesial movement of the dentition and bone remodeling along the anterior border of the ramus. On average 2 mm of posterior space was created by bone remodeling
  160. 160. SPACE RELEASED BY ATTRITION In so-called primitive dentitions, where considerable attrition takes place, the third molars erupt to take up the space released. Begg felt that lack of this attrition,due to highly refined diets,was a major cause of third molar impaction. Other authors, such as Profitt,have questioned this hypothesis. Early and extensive interproximal caries could also reduce the size of erupted teeth, owing to disappearance of proximal contacts.
  161. 161. SECOND MOLAR EXTRACTION  Richardson and Richardson in AJO 93 investigated 63 patients after extraction of lower second molars and found that all the lower third molars erupted more or less successfully after an average observation period of 5.8 years.  There was considerable variation in the time taken for eruption, ranging from 3 to 10 years and Richardson noted that it is not possible to predict how long eruption will take.
  162. 162.  Bonham Magness in JCO 86 suggests that upper third molars has a much more predictable eruption pattern than lower third molars.  He suggested the extraction of upper second molars in some cases to assist first molar positioning and increase space for upper third molars.
  163. 163.  Tae-Woo Kim et al in AJO 2003 confirmed the findings of Faubion and Kaplan that impaction of mandibular third molars occurs about twice as often in non-extraction patients than in extraction patients.  The mechanism may be that premolar extraction therapy is associated with an increase in the amount of mesial movement of the maxillary and mandibular molars and an increase in the eruption space for the third molars.
  164. 164.  Cephalometric growth studies suggest 2 important mechanisms for development of the retromolar space in the mandible; Resorption at the anterior border of the ascending ramus and the anterior migration of the posterior teeth during the functional phase of tooth eruption.  More than 60% of the patients in the study, with a distance of 23 mm or less from the distal of the mandibular second molar to the Ricketts’ Xi point at the end of the active treatment experienced eruption of mandibular third molars.
  165. 165.  The retromolar space can increase about 2 mm from age 15 to adulthood.  They also showed that as many as 60% of the subjects with a distance from the anterior border of the ramus to the distal of second molar of 5 mm or less experienced eruption.  These suggest that the size of third molar eruption space associated with a high risk of impaction might be smaller than previously suggested
  166. 166. UPRIGHTING IMPACTED MOLARS  Third molar retention may be beneficial in many situations.  Some investigators maintain that third molars could be used at a later date as replacements or for prosthetic abutments in case of loss of first and second molars.  Third molars could also be used as transplants
  167. 167.   In shallow mesio-angular impactions Richardson used a one stage method. A second molar tube can normally be bonded onto the buccal aspect of a partly erupted lower third molar, if enough enamel is visible.  It is then possible to include the tooth in full treatment ,if other teeth are already bonded and bracketed.  If the case is not fully banded, then lower second or first molars alone can be used, with a lingual arch for support
  168. 168.    In deep mesio-angular impactions,a two-stage method is used. If it is not possible to bond onto the buccal surface,a different technique is used which can be delayed until 18 – 19 years of age, to allow time for the tooth to improve its position. The first stage involves bonding a second molar tube onto the occusal surface of the lower third molar.
  169. 169.     The hook is removed from the tube, before bonding. Lower first or second molars are banded with a lingual arch, using first molar bands and brackets. A small sectional archwire, with a compressed coil spring, is used to provide a distalizing and uprighting force to the crown of the impacted molars. After some uprighting using this method, it is normally possible to bond a tube buccally for the second stage.
  170. 170.  Ike Slodov et al in AJO 89 describes an orthodontic uprighting technique similar to ‘Sling shot’ appliance described by Moyers and by Profitt.  Modified impaction related surgical procedures provide easy application of techniques to facilitate exposure of unerupted and partially erupted third molars and allow orthodontic manipulation
  171. 171.     After surgical exposure a cleat is bonded in center of mesial marginal ridge. The wire portion of the appliance is fabricated from 0.032 inch stainless steel wire and adapted closely to the mucosa. The mesial hook is placed 3 mm distal to the distal portion of the third molar. Standard soldering techniques are used to attach the wire to the buccal (or lingual) surface of the band. Appliance is cemented in place and is activated with elastic modules
  172. 172.  By manipulation of the distal arm of the appliance either buccally or lingually ,depending on the desired movement,teeth can be directed or rotated with some effectiveness. Variation can also be accomplished by alteration of the bond position of the cleat.  Following activation,rapid uprighting and distalisation will occur in 3 to 6 months in most cases.Grinding of occlusal surface is not necessary. When the third molars are upright, the appliances are removed and the third molars are banded, leveled and aligned with the rest of the teeth.
  173. 173.  This procedure is contraindicated when the molar to be uprighted has no antagonist; is severely malformed or is abnormally large or small, and it should be done carefully when there is a tendency for open bite. Advantages are: 1. Ease of fabrication and manipulation 2. Rapid treatment 3. Little discomfort 4. No demands for patient cooperation
  174. 174.  Orton and Jones     in JCO 87 described a simple whip spring that is unobtrusive and fairly fast acting with a treatment time of 4 to 12 months. It is used for disimpacting , mild to severe mesially impacted lower terminal molars (LTM). LTM crown must be accessible for an edgewise tube, preferably on a band. Partial seating of the band on the mesial surface is acceptable at first, which can be fully seated as correction proceeds. If the impacted molar has not sufficiently erupted then surgically expose distobuccal surface and bond an attachment.
  175. 175.  The whip spring is fabricated with 0.018X 0.025 wire for 0.022 slot and 0.017X0.022 wire for 0.018 slot.  A circular loop is placed mesial to the tube to prevent posterior displacement of the wire and to provide attachment of an elastic module that anchors the wire in the tube.
  176. 176.    Wire extends mesially from the loop. A vertical bend is placed occlusally next to the midbuccal fissure of the anchor molar. The wire is curved lingually to pass through the midbuccal groove onto the occlusal surface. It is then contoured distally to run along the occlusal surface. Moving the whip to the occlusal surface of the anchor molar activates the appliance.
  177. 177.  The whip spring can be reactivated in the mouth by lifting the wire away from occlusal surface and gently squeezing the arm of the spring between loop and vertical bend with Tweeds loop forming plier.  After initial adjustment at 3 to 4 weeks, adjustments every 6 week seen to be adequate. Overcorrection is advised.
  178. 178.    The force of the whip tends to extrude the impacted molar and intrude the anchor molar. If there is too much intrusion of anchor molar, a new whip can be made that extends to another anchor tooth. The couple tends to disimpact the LTM by a combination of distal crown tipping and mesial root movement, resulting in root paralleling of the molars.
  179. 179.  If the vertical development of the LTM is impeded by an upper molar, then the overerupted upper molar must be intruded by a removable appliance with an intrusive arm
  180. 180. REPLACEMENT OF THIRD MOLARS FOR SECOND MOLARS  According to Malcolm.R.Chipman in AJO 1961 the third molars can be substituted for the second molars in certain situations and solve some of the problems of maxillary tuberosity area.
  181. 181.  The indications for eliminating maxillary second molar and replacing it with third molars are 1.Maxillary third molars of fair size and shape with the possibility of good root development 2.Small,restricted maxillary tuberosities and the possibility of interference with distal movement in maxillary posterior region. 3.Second molars erupted buccally.
  182. 182. 4.Second molars decayed ,badly decalcified or having large restorations. 5.Maxillary third molars in favourable position and angulation relative to second molars and maxillary tuberosity. 6.Maxillary third molars in favourable relation to mandibular second molars.
  183. 183. conclusion conclusion Thus management of the impacted teeth is one of the greatest challenge for orthodontist. Success of the treatment depends upon patient cooperation, Age of patient, Proper diagnosis, Level of impaction, Inclination and Depth of impaction, Amount of root formation, Type of exposure of tooth, Amount of bone removal, Type of attachment, Orthodontic traction. All these parameter plays important role when managing impacted teeth to achieve good alignment in the arch, Gingival level, and Integrity of periodontium. Orthodontic treatment can be very rewarding if we are ready to accept the challenge of anticipating the changes , on the basis of a sound problem list and treatment goals.
  184. 184. References 1) Orthodontic treatment of impacted teeth - Ardian Becker 2) AJO 1983 Aug 125 – 132 The etiology of maxillary canine impactions - Jacoby 3) AJO 1994 Jan 61 – 72 Tunnel traction of infraosseous impacted maxillary canines - Crescini, Clauser, Giorgetti, Cortellini, and Prato 4)AJO 1982 Mar 236 - 239 Txt Orthodontic considerations in the treatment of maxillary impacted canines - Fournier, Turcotte, and Bernard 5) AJO1991 Dec 494 - 512 Txt Rare earth magnets and impaction - Vardimon, Graber, Drescher, and Bourauel. 5) Seminar in orthodontics - management of impacted teeth.
  185. 185. Thank you Leader in continuing dental education