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

Management of impacted teeth

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 An impacted tooth is a condition in which a

tooth is embedded in the alveolus so that
its eruption is prevented or the tooth is
locked in position by bone or by adjacent
teeth.


 Studies have reported that the incidence of

tooth impaction varies from 5.6 to 18.8 % of
the population.( Kramer RM, Williams AC
and Dachi SF, Howell FV. Oral Surg Oral
Med Oral Pathol 1970, 1961)
 Any tooth in the dental arch can be
impacted, but the teeth most frequently
involved in a descending order are the
mandibular and maxillary third molars, the
maxillary canines, the mandibular and
maxillary second premolars, and the
maxillary central incisors.

 But, the maxillary canine, has been the

most frequently impacted teeth.

 In our esthetic-conscious society, it is

increasingly important to preserve the
natural dentition. This certainly includes
keeping or “saving” the impacted teeth.

 Replacing or “substituting” the teeth that

may be lost because of impaction just is
not an appealing treatment option.

Diagnosis:
 The diagnosis and localization of the

impacted teeth are usually made on the
basis of clinical and radiographic
examination.
 The routine panoramic radiograph of the
mixed dentition patient can also be used
to identify the potential impaction of the
teeth.
 Computed tomography (CT) has recently
been introduced as a standard method
used in medical radiology to detect bone
pathology.

 V. Ravinder, Nikhar Anand verma, and

Valiathan: 3 - Dimensional Computed
Tomography. A new method for
localization for impaction of canine:
 The proper localization of the impacted
tooth plays a crucial role in determining
the feasibility as well as the proper access
for the surgical approach, the proper
direction for the application of orthodontic
forces, and the extent of root resorption,
and damage to the adjacent teeth.
( Bishara SE, Semin Orthod 1998)

 To increase the diagnostic accuracy,

conventional polytomography has been used.
Computed tomography eliminates blurring
problems of conventional tomography and
increases the perceptibility of root resorption
substantially.
 CT has been proven to be most effective in
detecting root resorption.
 CT is also used for assessing the positions of
the teeth and their mutual relationship
compared to other diagnostic methods.
(Elfteriadis JN, Athanasiou AE,Int J Adult
Orthod Orthognathic Surg. 1996)

 Disadvantage of CT is the relatively high

radiation dose to the patient and also cost.
Preda et al (1997) reported on the technique of
spiral CT with a 1:1 or 2:1 pitch using
multiplanar reconstruction. Spiral CT reduces
examination time and the risk of accidental
movement, without loss of image quality.
The probability of stochastic effects , expressed
as an equivalent whole body radiation dose , in
this CT approach increases about 2-8 times,
compared to conventional full mouth or
panoramic radiograph.

 A 21 year old female patient reported to

the orthodontic department with a
complaint of retained deciduous left upper
canine. She presented with a class I molar
relationship, a non-mobile retained
deciduous canine and lower incisor
crowding.
 In order to carefully localize the impacted
canine and predict the prognosis
accurately, it was decided to carry out a
spiral CT scan.

 The use of lateral cephalometric radiographs

forms an important diagnostic tool in
orthodontic treatment as well as orthognathic
surgery.
 Three-dimensional imaging of the human body
via computed tomography has been available
to the field of medicine for the last 30 years
 With the development of Cone Beam
Computed Tomography, there has been a
drastic reduction in radiation exposure to the
patient, which allows its use for safely obtaining
3 dimensional images of the craniofacial
structures. (Ashima Valiathan, Siddhartha
Dhar, Nikhar Verma TIBAO (in Press) 2006 )

 Treatment options:
 There are four treatment options for

impacted teeth Observation
 Intervention,
 Relocation,
 Extraction.

Preimpaction periods
Postimpaction periods
Surgical relocation
Orthodontic relocation


 OBSERVATION –

Observation of the
dentition normally begins with the
completion of the deciduous dentition
eruption and ends with the removal or
eruption of the impacted tooth.
The preimpaction observation begins with
the eruption of first permanent molars at
approximately 6 years of age.

 INTERVENTION:

If a decision to treat is made, treatment
should be as minimal as needed to facilitate
natural eruption.
“The majority of impacted teeth erupt if hard – or soft

– tissue obstructions are removed from their eruption
paths.”
Di Biase conducted a survey, which found that
after the removal of supernumerary teeth, 75%
of the impacted maxillary incisors
spontaneously erupted. (Di Biase DD. Dent
pract Dent rec1971)

 RELOCATION:

When interceptive treatment fails to
improve the position of the developing tooth or
when teeth is impacted, efforts to reposition
them should be considered
Surgical relocation:
Indication’s for surgical
repositioning include: patient’s age, the need to
eliminate or minimize orthodontic treatment and
patient compliance.
Other factors to consider are presence or
absence of adequate space, shape and status
of the impacted tooth, and shape and status of
the adjacent teeth.

 Orthodontic relocation:

Kokich and Mathews
recommended surgical exposure and
orthodontic eruption of an impacted tooth
when its apex is completely formed.
Frequently. Space must be orthodontically
created before the clinician can surgically
expose and orthodontically erupt an
impacted tooth. ( Kokich VG, Mathews
DP. Dent Clin North Am 1993)

 Complications associated with orthodontic

repositioning of impacted teeth include –
absence of or inadequate keratinized
gingivae, reduced sulcular depth, gingival
recession, increased gingivitis, ankylosis,
multiple exposures, devitalization, pulpal
obliteration, external root resoption, injury
to adjacent periodontium, marginal bone
loss and extraction of impacted teeth.
 “Clinician should consider only those treatment

goals for impacted teeth that minimize injury to
the dentition and periodontium.”

 EXTRACTION:

Since it is not possible to reposition
all impacted teeth within the alveolus, their
removal may be indicated.
Complications that are associated with the
surgical removal of the impacted teeth
include periodontally compromised
adjacent teeth, damage to adjacent teeth,
root fracture, neuropathy, sinus
involvement and osseous defect.

Impaction of canine


 An impacted maxillary canine is usually

stationary and asymptomatic.
In rare cases, emergence may start late in life,
sometimes activated by the insertion of the
denture, leading to pressure atrophy of the
bone and mucosal covering of the impacted
tooth.
Other complications consists of follicular cysts
and late resorption of the impacted canine.

 Incidence of canine impaction :

( Bishara AJODO: 1992)
Dachi and Howel (1961) reported that the
incidence of maxillary canine is 0.92% whereas
Thilander and Myrberg (Scand J Res 1973)
estimated the cumulative prevalence of canine
impaction in 7-13 year old children to be 2.2%,
and Ericson and Kurol (EJO 1986) estimated
the incidence at 1.7%.
Impactions are twice as common in females
(1.17%) than in males (0.15%).
The incidence of mandibular canine impaction is
0.35%. (Dachi and Howell 1961)

 Prediction of impaction:

Palpation of the buccal alveolar bone is
the most useful clinical method to predict the
eruption of the canine. A negative finding on
palpation is more difficult to assess because
this may include both normal and abnormal
situations.



1.
2.
3.
4.
5.
6.

Treatment planning:
When an ectopic path of canine eruption
or a definite impaction is diagnosed, several
factors should be considered in the treatment
planning.
Age of the individual and dental maturation.
Space conditions.
Resorption of the permanent incisor roots.
Position of the canine.
Form of the crown.
Patient demand for treatment.

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1.
2.
3.
4.
5.
6.

Treatment option:
No treatment of the unerupted canine
Prophylactic space augmentation.
Extraction of the primary canine.
Surgical exposure and orthodontic
repositioning.
Surgical repositioning.
Extraction of the impacted canine and
movement of the first premolar in its position.

 Prevention of maxillary canine impaction :

Selective extractions of the deciduous canines
as early as 8-9 years of age has been
suggested by Williams (AO 1981) as an
interceptive approach to canine impaction in
class I uncrowded cases.
Ericson and Kurol (EJO 1988) suggested the
removal of the deciduous canine before the age
of 11 years will normalize the position of the
ectopically erupting permanent canines in 91%
of the cases if the canine crown is distal to the
midline of the lateral incisor. On the other hand
the success rate, if the canine is mesial to the
midline of the lateral incisor is only 64%.

 No treatment:

In few cases, ectopically
positioned canine may spontaneously upright
and show a normal eruption.
The most frequent complication appears to be
the development of the follicular cyst. The
treatment of choice for this condition is
usually fenestration of the cyst.
When the impacted canine and adjacent teeth
are in close proximity, loss of attachment
ensues around these teeth. The final result
can be extensive marginal breakdown, which
may not only require removal of the impacted
canine but also effected neighboring teeth.

 A variant of this condition is the loss of

bone from denture pressure, which may
expose an otherwise fully impacted
canine. This condition also necessitates
removal of the canine.


 Prophylactic space augmentation :

Elimination of severe crowding
in the dental arch can make room for an
impacted canine and possibly simulate
eruption into the correct position.


 Extraction of the primary canine :

In young individuals 10-13 years old,
extraction of the primary canine can correct a
palatally erupting ectopic maxillary canine.
When the cusp of the canine had passed
medial to the midline of the root of the lateral
incisor, 645 of the ectopically positioned
teeth could be corrected and 91% could be
corrected when the canine was located more
distally.

 In view of the generally favorable results,

extraction of the primary canine is the treatment
of choice in young individuals to correct
palatally erupting maxillary canines provided
that normal space is present and no incisor
resorption is found.
 Extraction of the primary canines may show
less favorable results with ectopic permanent
canines located in a more horizontal position
high in the alveolar position.

 Exposure and orthodontic repositioning :

This is usually the treatment of choice in
cases of ectopic positioning, and normally
leads to a predictable and successful result.
However minor complications can be
encountered, such as loss of pulpal sensitivity,
root surface resorption, loss of marginal bone
support, and gingival recession.







The prognosis for orthodontic correction depends on,
the patients age, space conditions, and the sagittal
and transverse position of the canine crown root.
In general, exposure alone can be expected to lead to
eruption in 65-95% of the cases.
The optimal time for treatment is during adolescence.
The more vertical the orientation of the impacted
canine, the better. An axial inclination which is greater
than 45° distally may worsen the prognosis. The
closer the crown is to the midline and the root to the
midpalatal suture, the poorer the prognosis. Finally the
PDL space should be visible along the entire root
surface and the root apex should not be dilacerated.

 Management of labially positioned canine :

Labial position of the maxillary canine is less
frequent than palatal impaction and is often
caused by insufficient arch length.
Fournier et al (AJO 1982) suggested that labially
impacted teeth with a favorable vertical position
may be treated initially by surgical exposure but
without the application of the traction force.
The absence of an adequate band of attached
gingiva around the erupting canine may cause
inflammation. Vanarsdall and Corn (AJO 1977)
emphasized that it is hazardous to move teeth
in the presence of inflammation.

 Before the labially impacted canine is exposed

careful consideration should be given for
creation of sufficient space to allow for the
canine to be positioned in the arch.
 During the surgical procedure, Vanarsdall and
Corn recommended placement of surgical
dressings to protect the tissue for 7 to 10 days.
After removal of the dressing, a direct bond
attachment can be placed in the dry field and
tooth movement can then be initiated.

 Treatment of impacted canines has been

advocated for occlusal, functional, and esthetic
reasons. Root resorption of the adjacent teeth,
cyst formation, infections, periodontal defects,
and referred pain have been reported.
 Traditionally, most surgical techniques involved
exposure of the entire crown.
 An extensive surgical procedure was used for
the placement of the lasso loop wire ligature
around the neck of the tooth, which often
required removal of bone beyond the CEJ.
Which was reported to cause most serious
damage.

 Management of palatally impacted canine :

Palatally impacted canines erupt without
intervention, and this impeded eruption is due
to the thickness of the palatal cortical bone, as
well as the dense, thick and resistant palatal
mucosa.
Palatally impacted canines are often inclined in
a horizontal / oblique direction.
The general premise is that there should be
adequate access to the crown of the canine,
allow efficient control of bleeding during
attachment of brackets. The design of the flap
should ensure adequate blood supply.

 Surgical repositioning:

Maxillary canine impaction is often not detected
before root development is complete. However
if transplantation is carried out early, the
prognosis is very favorable.
- Ectopic location where the canine’s path of
eruption has resulted in marked resorption of
the lateral and central incisor root.
- -Ectopic placement of the canine, where
surgical exposure and subsequent orthodontic
realignment are difficult, impossible or can
seriously damage the supporting structures of
adjacent teeth. www.indiandentalacademy.com

 When surgical exposure and orthodontic

repositioning have failed or were refused.
 Canine transplantation should be planned as
early as possible, preferably at 11 or 12 years
of age when the root development is not yet
complete.
 Before transplantation is decided upon, it is
essential that a detailed analysis of the space
conditions of the recipient site be made.

 A common method for exposing impacted

canines was to cement a orthodontic band
at the time of exposure.
 A “closed eruption” in which the crown is
surgically exposed, an attachment is
bonded during the exposure, and the flap
sutured back over the crown, leaving a
twisted soft ligature wire passing through
the mucosa to apply the orthodontic
traction.
 In “open window” eruption technique, a
flap is raised and a minimum amount of
bone is removed, enough to expose the
tip of the impacted crown to be bonded.

 When the tip of the canine is located outside

the palatal bone presurgically, only 3-4mm of
palatal mucosa is sectioned, and no bone has
to be removed to gain access for bonding.
 In the flap design frequently, a sulcular incision
along the neck of the teeth is performed, and
the mucoperiosteal flap raised included the
gingival margins and the lingual aspects of the
interdental papillae.
 Other techniques involved autotransplantation
of canine, and posterior segmental osteotomy,
after the removal of the canine and
advancement of the posterior segment to close
the extraction space.

 Adrain Becker, and Stella Chaushu : Success

rate and duration of orthodontic treatment for
adult patients with palatally impacted maxillary
canines: (AJODO 2003)
A sample of 19 adults (mean age, 28.8 + 8.6
years; range, 20-47 years), who had been
treated for a total of 23 impacted maxillary
canines, was compared with a young control
group (mean age, 13.7+ 1.3years; range, 12-16
years).

 The success rate among the adults was 69%

compared with 100% among the young
controls. The lower success rate was due to 5
canines that had failed to erupt and 2 canines
that had been partially extruded but could not
be aligned in the arch. The duration of treating
the overall malocclusion of the adults and
young subjects did not materially differ.
However, the adults showed significant
increases in the duration and number of
treatment visits required for resolving the
canine impaction, in both the simpler and the
more difficult cases.

 Conclusion: The prognosis for successful

orthodontic resolution of an impacted
canine in an adult is lower than in the
young patient and that the prognosis
worsen with age. Furthermore, when such
treatment is undertaken, its successful
completion should be expected to take
considerably longer.

 M.M. Kuftinec. D Stom, and Y. Shapira :

The impacted maxillary canine: Clinical
approaches and solutions:
Orthodontic and surgical intervention should
not be delayed, to avoid unnecessary
difficulties in aligning the tooth in the arch.
In the most difficult cases of horizontally
located canines with the cusp edge in
close contact with the roots of the incisors,
managing the impacted canine may
endanger the incisor roots and failure may
be expected.

 It can be generally stated that the

impacted canine should be erupted to a
site in the mouth that is closest to its
impacted position, but consistent with the
rule of safe play. That means that the
labially impacted teeth should be
enchoraged to erupt labially, and those
palatally impacted to move through the
palatal tissues.

 Palatal arch is a most desirable approach

to the correction of many impacted
maxillary canines. The palatal arch
provides a spring with a relatively low
degree of force rate a useful moment to
force ratio. This system is usually suitable
for treatment of bilateral impactions.


 Surgical approach:

Traditionally, most surgical techniques to
make access to impacted teeth involved
exposure of the entire crown. Extensive
surgical procedure was advocated by
some, with removal of bone and the dental
follicle.


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1.

2.
3.
4.

Complications after impaction:
Resorption of incisor roots: occurs in
12% of the ectopic eruptions, can be
diagnosed at 10 years of age.
Follicular cysts
Tumorous changes in the follicle
Marginal breakdown of supporting bone
around adjacent teeth.

Traction hooks used for correcting canine
impactions:
The “Ballista spring” system for impacted teeth :
This system was developed by Harry Jacoby
(1979).


The ballista spring is a 0.014”, 0.016”, or 0.018”
round wire, which accumulates its energy on
its long axis. Its anchorage extremity
penetrates in both headgear and edgewise
vestibular tubes of the first or second
maxillary molars and it is ligated to this tube.
Thus the wire cannot rotate in the tubes.

 The horizontal part of the wire accumulates the

energy. This part of the wire is attached by a
ligature on the first premolar, which allows it to
rotate in the slot of the bracket as a hinge axis.
The last part of the spring is bent down
vertically and ends in an loop shape to which a
ligature elastomeric thread can be attached.
When the vertical portion of the spring is raised
towards the impacted tooth, the horizontal part
accumulates the energy into the twisted metal.
When the vertical section is released, it bumps
down like a “ballista”.

Advantages of the “ballista spring”:
1.

The Ballista spring system uses a spring
which creates a vertical traction on the
impacted tooth along its long axis thus
separating the impacted tooth from the roots
of the adjacent tooth.

2.

The Ballista spring is easily inserted, ligated
and is independent of the other parts of the
appliance.


3. It can be used for buccally as well as
palatally impacted canines.
4. In general most systems require full
bonded arches at the beginning of the
treatment while the Ballista spring does
not require any bonding of the anterior
teeth till the crown of the impacted tooth
erupts completely.

The Monkey hook used for canine
impaction:
 This was developed by

Bowman and Carano
(JCO 2002), is a simple auxiliary consisting of
a short section of wire with open loops on
opposite ends. Intraoral elastics, elastic chain,
or NITI coils can be attached to these open
loops to produce forces to direct the eruption or
rotate the teeth. The loops can be closed with
pliers. When linking one hook to another to
form a chain or when connecting the Monkey
hook to a bondable “loop-button”.

 The loop button: (bondable eyelet)

This consists of a 1mm helix of round wire
that has been welded or braised to a small
diameter, bondable base.
Only a small surgical exposure of any
surface on the crown of an impacted tooth
is required to bond its attachment.
If the tooth is deeply impacted, then a
second monkey hook needs to be linked
to the first.

 Mode of action:

Vertical eruptive force: Typical intraarch
mechanics to direct the eruption of the
impacted teeth utilize reciprocal forces that may
tend to tip or intrude the adjacent teeth. In
contrast vertical eruptive forces can be created
using an intermaxillary elastic stretched from
the monkey hook on the arch wire or bracket on
a tooth in the opposing dental arch.
This arrangement does unfortunately introduce
the unpredictable factor of patient compliance
with elastic wear.

 Lateral eruptive force: (Slingshot effect)

If anchorage is not available from an opposing
arch, the intraarch mechanics can be produced
using multiple Monkey hooks added to the
same loop button attachment; much like keys
on a key ring.
Elastic chain is attached to one end of the
monkey hook and directed to adjacent teeth;
thereby, creating a slingshot affect.
A closed coil spring is placed on the base arch
wire top prevent tipping of the adjacent teeth
towards the impacted tooth.
A combination of intermaxillary elastic and
slingshot effect can be used to provide both
vertical and lateral eruptive forces .

Kilroy spring
 This spring is pre-formed module that is

simply sliding onto the rectangular arch
wire at the site of an impacted tooth. The
vertical loop of the Kilroy spring extends
perpendicularly from the occlusal plane, in
its passive state. A stainless steel ligature
is then placed through the helix at the
apex of the vertical loop of the Kilroy and
then this loop is directed toward the
impacted tooth.

 The ligature is tied either directly to the

helix of the loop button or to the loop of
the Monkey hook that is in turn linked to
the loop button attachment.
 Mode of action: The Kilroy spring is
supported by, 1) the rectangular base arch
wire, 2) reciprocal space from the incisal
one third of the adjacent teeth where
contacted by the lateral extensions of the
Kilroy spring. The Kilroy spring need to be
periodically retied to maintain a constant
force as the tooth is erupting.

 The Kilroy I spring was designed to

produce both vertical and lateral eruptive
forces for palatally impacted canines.
The Kilroy II spring produces more vertical
forces and was created for buccally
impacted teeth.
The amount of force produced by the Kilroy
spring can be increased or decreased by
bending the vertical loop towards or away
from the impacted tooth prior to activation.

Impacted mandibular
canine


 Impacted mandibular canine :

Treatment planning: Indications for tooth
removal can be interference with planned
orthodontic treatment, impingement on
adjacent teeth or development of a follicular
cyst. In other cases, it may be indicated to have
the impacted canine repositioned by surgical or
orthodontic means.
When none of these treatment modalities are
carried out, observation of the impacted tooth is
a third possibility.

 Observation of the impacted tooth :

In many cases it is acceptable to leave the
impacted canine in situ if indications for
removal do not exist.
The primary canine can continue to function
an extended period in some cases. When
the impacted teeth is not removed, it
should be radiographed periodically to
check that pathologic changes have not
occurred.

 Exposure and orthodontic repositioning :

This treatment should only be carried out if
space analysis reveals that the tooth can
be brought into occlusion and that
deviation of the tooth axis is not too
excessive. A measurement of the
contralateral erupted canine will indicate
whether there is sufficient space; if it is
insufficient, additional space may be
created orthodontically.

 Surgical removal of tooth:

Surgical removal of a mandibular impacted
canine is indicated if there is evidence of
pathology around the tooth.
Another indication is close proximity of the
follicle to the marginal periodontium of
adjacent teeth.
Finally, removal is indicated if there is an
orthodontic need to move adjacent teeth
into the area. www.indiandentalacademy.com

 V. Surendra Shetty, gurkeerat Singh :

Modified Ribbon arch mechanics in the
treatment of ectopically eruptiong canines.
(JIOS 2001)
 A patient reported to the department with
the complaint of irregularly placed lower
front teeth.
 The mandibular canines were ectopically
erupting between the central and lateral
incisors. The right canine had already
erupted and the left canine bulge could be
felt in addition to a slight exposure of its
crown.

 It was decided to treat the case without

extracting any teeth using the Begg light
wire technique.
 A segmental co-axial wire was engaged to
bring about the derotation of the lateral
incisors.
 Elastic threads tied to canine loops placed
mesial to the premolar brackets, were
used to distalise and aid the extrusion of
the canines.

Impacted incisor


 Retention and impaction:

The overall frequency of permanent incisor
retention or impaction in adults has been
reported to range from 0.1% to 0.5%.
The frequency of maxillary incisor impaction
has been found to range from 0.06% to
0.2% and for mandibular impaction a
frequency of 0.01% has been reported.
The type of incisor most frequently impacted
appears to bewww.indiandentalacademy.com central incisor.
the maxillary

 Timing of removal of supernumerary teeth

involves a balance between the risk of injury to
the developing permanent incisor and early
clearance of the eruption path to prevent space
loss.
 TREATMENT:
Ectopic eruption of incisors: There are various options
for extracting the corresponding primary incisor
to correct lingual ectopic eruption of mandibular
permanent incisors.
Mandibular incisors generally erupt in a lingual
direction. Furthermore, when the mandibular
lateral incisors fully erupts, the intercanine
width increases, thus relieving any tendency to
crowding.

 Guidelines for managing permanent

successors that erupt lingually:
If labial migration has not occurred by 8.2
years for the central and 8.4 years for
lateral incisor, over retention of the
primary incisor exists and its removal
should be considered.
Only if the primary incisor is firm and the
roots have failed to resorb, is extraction
indicated.

 Supernumerary teeth:

It has been shown that the removal of the
supernumerary teeth leads to spontaneous
eruption of the involved permanent teeth in 3949% of the cases and emergence takes place
after approximately 1½ years.
If the permanent incisor is located superficially,
exposure of the incisal edge may facilitate
eruption. If the permanent incisor is located
deeper in the alveolus, clearance of the
eruption pathway should be performed.

 Thus, bone positioned coronal to the

incisor should be removed; however, the
follicle should be left intact unless damage
has occurred to this structure, during
removal of supernumerary tooth. In such
case, bonding of a bracket to the labial
surface is indicated, followed by
orthodontic traction.

 Impacted normal – shaped incisor :

Here, there is a premature loss of primary
teeth and the obstacle to eruption is either
space loss, the presence of
supernumerary teeth or ectopic position of
the tooth germ when the tooth has
developed into an apical and labial
position.
If space loss due to crowding or migration of
adjacent teeth is the origin of impaction,
orthodontic expansion is the treatment
choice, and this will lead to spontaneous
eruption. If this does not occur, a surgical
exposure should be reformed.

 Impacted malformed incisor:

Radiographic examination is important to
disclose the extent of malformation so that
a decision can be made about whether the
tooth should be removed or an attempt
should be made to bring it into occlusion.
If the tooth is removed, it is important not to
injure adjacent permanent tooth germs or
interfere with their eruption pathway.

 With crown dilacerated teeth it is important

to consider that the crown malformation
often prevents normal eruption. Therefore
surgical exposure of the malformed tooth
is often necessary.
 Root angulated teeth should be treated
with surgical exposure, orthodontic
realignment or autotransplantation so that
crown is left in a vertical position.
In many instances the presence of
supernumerary teeth may lead to curve
apices or blunted roots, but does not
interfere with the eruption and thus
requires no treatment.

 Manuel De Echave – Krutwig, and Leyre

Sanchez-Fernandez: Impacted incisors
with dilacerated roots: (JCO 2002)
 An 18 year old patient presented with two
impacted upper central incisor, with
dilacerated roots. The intraoral
examination reveled class I molar and
canine relationship on right side and class
II on left side.
 The impacted upper central incisors were
observed on the panoramic radiograph,
both with roots dilacerated toward the
distal.

 Treatment planning:

Surgical exposure and extrusion of the
dilacerated central incisors was planned
after explaining the patient that it was
impossible to position these teeth correctly
without the roots coming into contact with
those of the upper lateral incisors, with the
consequent resorption of all four roots

 Autotransplantation of permanent

maxillary incisors: Danny Gleiser and
Clara Jaramillo: (JCO 2002).
A female patient presented with a severe
class II malocclusion with open bite,
excessive overjet, and upper crowding
that left no space for the eruption of the
left cuspid.
A radiograph showed the left permanent
incisor inverted 180° on its long axis. A
supernumerary was also observed
adjacent to the inverted incisor.

 Surgical procedure:

The inverted incisor was extracted. A full
thickness flap was laid with vertical incisions at
the level of the distally adjacent teeth. The
gingival periodontal fibers were incised with a
scalpel. The alveolar vestibular bone was lifted
and left unattached to the base of the flap.
The tooth was extracted in the labial direction
because its long axis was facing the apex of
the adjacent teeth, and extracting it through the
alveolus might have damaged the periodontal
fibers.

 The incisor socket did not need to be

modified because of the recent extraction
of the supernumerary tooth. Although the
root apex was complete, which was a
clear disadvantage.
 Stabilization was achieved using .018”
standard edgewise brackets and bands
and a passive .014” stainless steel arch
wire.

 Osmar Aparecido Cuoghi et al: Extrusion

and alignment of an impacted tooth using
removable appliances:
 Forced orthodontic eruption of an
impacted tooth can be performed with
either fixed or removable appliances. In
fixed appliances the wire attached to the
impacted tooth may be more easily
deflected than with the removable
appliances, causing undesirable
movements of adjacent teeth.

 Removable appliances require less chair

time, promote better oral hygiene, and are
more esthetic, and the forced eruption can
start as soon as the appliance is installed.
 A female patient presented with the chief
compliant of a missing left central incisor.
A fixed prosthesis was contraindicated
because the patient was likely to have
remaining growth potential.

 Periodontal status following surgical –

orthodontic alignment of impacted central
incisors with open-eruption technique:
S. Chaushu, I. Brin, Y. Ben-Bassat, Y.
Zilberman and A. Becker: (EJO 2003).
Several factors may effect the outcome of the
orthodontic/surgical modality for the resolution
of impacted central incisors, but particularly
the manner in which the impacted teeth is
exposed.
12 subjects (4 males and 8 females), aged 22
years, previously treated for impacted central
incisor, were examined 10 years post
retention. A split mouth method was used for
the comparison with the unaffected side.

 Results showed statistically significant

difference between the affected and control
incisors in most of the periodontal parameters
measured, although some were small and of
minimal clinical importance.
 The increase in the mesio-labial pocket depth

was associated with a highly significant 10%
reduction in bone level at this site. A highly
statistical increase in crown length and a
reduction in the width of attached gingiva were
seen in the previously impacted teeth.

 It was concluded that the convenience of the

open-eruption technique must be weighted
against the long term negative aesthetic and
periodontal effects on the treated tooth.
Patients should be informed of the possible
need for additional periodontal procedures at
the end of orthodontic treatment, to improve the
aesthetic and periodontal health of the treated
teeth.


Management of third molar
impaction


 The impaction rate is higher for the third molars

than for any other teeth in modern populations.
 When the remodeling resorption at the anterior

aspect of the mandibular ramus is limited, the
eruption of the mandibular third molars might
be blocked. (i.e., retromolar space is
inadequate.)
 The eruption space for the mandibular third

molars is also affected by the direction the
teeth erupt during the functional phase of
eruption.

 Mesial drift of the posterior teeth, because of

excessive interproximal attrition, thereby
increasing the retromolar space. It is also found
that extraction therapy is associated with
mesial movement of the mandibular molars.
 The average age for third molar emergence
ranges from 17 to 21 years, so accordingly,
third molar impaction could be diagnosed at
around 20 years old.
 Some practitioners believe that the mesial
pressure of erupting third molars is a significant
factor for relapse of incisor alignment are likely
to recommend early removal.

 A study was conducted by

Tae-Woo Kim et al
(AJODO 2003) to confirm that premolar
extraction treatment is associated with mesial
movement of the molars concomitant with an
increase in the eruption space for the third
molars and to test the hypothesis that such
treatment reduces the frequency of third molar
impaction.
 Results showed that the impaction for the
maxilla and the mandibular third molars were
higher for the nonextraction than the extraction
patients.

 Dierkes and Faubion

(AO 1975, JADA
1968) concluded that only 15% of
mandibular third molars erupted in good
position after nonextraction therapy.

 Richardson

(BJO 1975) found that, in
nonextraction cases atleast 56% of the
mandibular third molars were impacted.

 Results also showed that the size of the

third molar eruption space associated with
a high risk of impaction might be smaller.

 Another study was done by

Sinan Ay et al
(AJODO 2006) to compare the spontaneous
angular and positional changes between the
mandibular third molars in patients with
asymmetric mandibular first-molar extraction.
 The results showed that the prevalence of third
molars at the anterior border of the mandibular
ramus was significantly greater on the
extraction side than on the nonextraction side.
 Third molars were positioned more occlusally in
the mandible on the nonextraction side than on
the extraction side.

 The prevalence of vertically angulated

third molars was greater on the extraction
side than on the nonextraction side.
Conclusion: Mandibular first molar extraction
increases the space for mandibular third
molar eruption and helps the third molars
to move in better position.
But early extraction can lead to uncontrolled
tipping of the adjacent teeth in to the
extraction space.

 Extraoral removal of a lower third molar

tooth: ( N. Milner and A. Baker BDJ 2005)
In this case a 39 year old was referred to
the maxillofacial surgery department with
pericoronitis of the lower left third molar.
There was a deep pocket distal to the
lower left second molar. All other teeth in
the lower quadrant were clinically and
radiologically assessed as disease free.

 As the patient was experiencing continuing

symptoms, the decision was taken to remove
the tooth via standard transoral approach,
extraction was attempted.
 One year following the surgery the patient
attended complaining of intermittent pain and
swelling. Further imaging using a dentogram
revealed the interdental nerve had been
displaced buccally and was situated
immediately adjacent to the crown of the
tooth.
 A standard submandibular approach was
used and the marginal mandibular nerve
identified andwww.indiandentalacademy.com
protected.

 A drill was used to remove the overlying

bone on the lingual side of the lower border
of the mandible. Through the lingual
approach it was possible to visualise the
crown of the tooth.
 Care was taken to ensure the tooth was
disimpacted from the surrounding bone. The
crown was elevated followed by the roots.
 An extraoral drain was placed to prevent a
hamatoma developing and to allow the blood
lose from the surgical site to be monitored.

Impacted first and second
molar


 TREATMENT:

Delayed eruption: This condition does not
involve any treatment apart from
continuous observation, because normal,
although delayed, eruption is expected to
take place. However if signs of eruption
obstacles occur the diagnosis should be
revised and treatment instituted.

 Ectopic eruption path of the second molar :

Treatment of ectopically erupted second molars
is important in order to prevent marginal
periodontal problems or caries in the contact
area with the adjacent molar.
When ectopic eruption of a second molar is
diagnosed, treatment varies according to the
eruption status.
Before emergence – a surgical exposure should
be attempted if the tooth germ is only
moderately displaced.

 When second molars have erupted in an

ectopic position, the treatment of choice is
orthodontic uprighting, and several orthodontic
devices have been described.
 In cases with moderate mesial tipping and
locking, separating springs or elastics may be
used.
 With ectopically erupted second molars, distal
orthodontic tipping appears to have a
significantly better chance of success than
mesial tipping. Also horizontal mesially tilted
mandibular second molars can be uprighted by
orthodontic appliances.

 Yao – Qiang Miao, and Hui Zhong : An

uprighting appliance for impacted
mandibular second and third molars:
In case of missing first molar, the second
and third molar are to be moved mesially
into the first molar space. But mandibular
third molars are the most likely to be
impacted, and requires to upright the
severely impacted molars.
Many appliances have been introduced, but
most of them are removable appliances
requiring patient cooperation.

 Since 1999, an uprighting appliance have

been used for uprighting mandibular
second and third molars and also distal
tipping without the need for surgery, bone
exposure, or splinting.
 Appliance construction and activation:
A mini-hook is fabricated from .014”
stainless steel wire. ( Bend the wire into a
circle with a 1.5mm diameter, extending in
a perpendicular arm 1.5mm in length. At
the top of the arm, bend a hook parallel to
the circle.

 Bond the mini-hook conventionally to the

distal surface of a horizontally impacted
molar or occlusal surface of a mesially
impacted molar, so that the hook opens
mesially. Make sure the hook does not
contact the opposing maxillary molar
during closure. Surgical exposure is
needed only if a horizontal impaction is so
severe that the molar has not erupted at
all.

 Solder an .018” stainless steel wire, about

60mm in length, to the middle of the lingual
surface of the mesially adjacent molar band. Be
sure not to compromise the flexibility of the wire
in soldering. Bend the wire at the distolingual
corner of the band, extending it 2-3mm
buccally, and then turn it distally, making a
double or triple-bend push-spring.
 Cement the band with the push-spring to the
mesially adjacent molar. Stretch the spring 45mm distally, and attach it to the open mesial
end of the mini-hook. The push-spring will then
exert a distalizing and uprighting force. It
should be reactivated until the impacted molar
is upright.

 Margherita Santoro, Eun – Sock Kim, and

Monica Teredesai, and Nikos
Karaggannopoulos: Modified removable
transpalatal bar for rapid uprighting of impacted
second molars:
A preformed transpalatal bar shown here offers a
mechanically advantageous and efficient
solution for uprighting an impacted second
molar, especially when bonding a standard
tube to the molar would be impossible and
other methods would require surgical exposure
of the impacted tooth.

 A preformed transpalatal bar is connected to a

lingual attachment on the adjacent first molar,
then cut and modify according to the clinical
situation and the patients anatomy. The bar will
not interfere with the occlusion, being
positioned on the mandibular retromolar pad
and above the occlusal plane of the maxillary
second molars.
A metal button is bonded as mesially as possible
to the available crown surface of the impacted
molar. Unless the tooth is completely covered
by gingival tissue, surgical exposure of the
impacted crown is not required.

 Power chain is connected from

the
bonded button to the distal extension of
the bar, along the distal marginal ridge of
the mandibular second molar. Power
chain is preferred over bulkier coil springs
to ensure patient comfort during
mastication, and also because its light
intrusive force on the distal marginal ridge
prevents overextrusion during the
uprighting. www.indiandentalacademy.com

 The power chain greatly accelerates the

eruption of the second molar due to the
favorable direction of the force vector.
 A rigid base arch, .018”x .025” , should be
used to stabilize the first molar. As soon
as the crown is completely exposed and
partly uprighted, a tube is bonded to the
buccal surface of the second molar, and a
flexible continous arch wire can be applied
to facilitate mesial movement of the roots.

Management of Impacted
premolar


 Treatment planning:

The treatment plan should include a cost-benefit
analysis of a no treatment approach versus
alternatives such as realignment by various
surgical or orthodontic means, as well as
removal of the unerupted premolar.
In many cases, retention of premolars will not be
diagnosed initially, first becoming apparent as
an accidental finding.
The usual treatment is acceptance of the
impacted tooth unless a radiographic
examination indicates that there is an obvious
risk of damage to adjacent structures or definite
signs of pathology.

 Observation:

Follicular cyst formation may occur,
although it is rare. Marginal infection may
develop, especially when the crown of the
impacted tooth is positioned close to the
cervical region of adjacent teeth.
Finally, alveolar bone atrophy later in life
may expose an otherwise completely
impacted premolar and lead to
inflammation.www.indiandentalacademy.com

 Realignment of the impacted premolars :

In most cases, realignment of impacted
premolars is indicated for functional or
esthetic reasons.
- Extraction of the primary molar
- Extraction of the primary molar and
exposure of the premolar with or without
follicle removal.
- Autotransplantation of the premolar.

 Extraction of the primary molar :

when the primary molar and the permanent
premolar are in close proximity, i.e., with
no or minimal occlusal bone separating
the premolar from the primary molar,
extraction of the primary molar is indicated
to activate and guide the eruption process.


 Extraction of the primary tooth and surgical

exposure of the premolar:
This approach is usually successful in cases
where the axial tilt of the premolar is limited to
45°, whereas exposure in cases where the
axial tilt comes close to 90° gives
unpredictable results.
The principle in surgical exposure is to create a
pathway for eruption by removing the bone
covering the crown of the tooth germ.

 The coronal part of the follicle represents the

definitive eruption mechanism through hard
tissue and alveolar mucosa, it should be
replaced by an active force (i.e., orthodontic
traction). Otherwise the premolar will remain
impacted. This dictates two surgical
approaches:
- Surgical exposure until the follicle is
encountered (partial uncovering)
- Surgical exposure until the crown is uncovered
enamel. (total uncovering)

 Surgical repositioning:

If the tipping of the premolar tooth germ is not
too extreme and root formation not too
advanced, surgical repositioning by a tipping
procedure is a possibility.
After removing the primary predecessor and
sufficient bone in the intended displacement
direction, the tooth is tilted into its new position
using an elevator.
If the tilt of the premolar is approximately 90 °,
this treatment alternative will not yield
satisfactory results and surgical repositioning of
the tooth germ, indicated.

 This treatment consists of atraumatic tooth

removal and repositioning so that eruption
into the normal position is possible.
 Due to the usual lingual tilt of both
mandibular and maxillary premolar
impactions, a lingual approach is generally
necessary.


 Yuko Taniomoto et al: Orthodontic treatment of

a patient with an impacted maxillary second
premolar and odontogenic keratocyst in the
maxillary sinus: (AO 2005)
 An eight year old girl was brought to the
orthodontic clinic of Okayama university.
 The patient had an impacted upper left second
premolar because of an odontogenic keratocyst
and showed a skeletal class II jaw relationship.
 At age of 6 years marsupialization of a cyst was
performed, because the patient had shown a
swelling in the left cheek.

 At the age of 9 years, after regaining the

space for the eruption of the premolar, the
impacted premolar erupted without
traction.
 At 12 years, edgewise treatment was

initiated, which continued for three years.

 Complications:

- Pulp necrosis: subsequent to repositioning is
the consequence of unsuccessful
revascularization of the transplant, and
this event is primarily related to the size of
the apical foramen.
In case of pulp necrosis, a lack of periapical
healing is usually diagnosed one or two
months postoperatively.

 Root resorption:

This is result of trauma to the
root surface during root removal, and this
complication is primarily related to the stage of
tooth development at transplant removal.
Surgical repositioning in stages when root
development is complete and the expected
eruption time has been exceeded often leads to
progressive root resorption.
Surgical repositioning generally leads to limitation
of root growth, usually about 2mm reduction in
potential root length, which is usually of minor
practical importance.

 In conclusion, surgical repositioning of

ectopic premolars appear to be
reasonably successful procedure that
should be considered when the ectopic
position deviates 90° or more from normal.


conclusion
 The management of tooth impaction, generally

speaking ascends from acceptance of the
situation to the removal of the impacted tooth
concerned.
 When the situation is considered acceptable,
periodic X-ray examination will be conducted to
check the tooth position, primary tooth root
resorption, occlusal position, and for evidence
of pathological changes. With this non-invasive
“wait and see” approach, future treatment
options are still open.

References:
 William

R. Proffit, Henry W. Fields, and
James L. Ackerman: Contemporary
Orthodontics: Third edition. 2000.
 Thomas M. Graber, Robert L. Vanarsdall,
and Katherine W.L. Vig: Orthodontics:
Current principles technique. Fourth
edition. Elsevier Mosby: 2005.
 Jens O. Andreasen, Jens Kolsen Petersen, and
Daniel M. Laskin: Textbook and color atlas of
tooth impactions. Diagnisis, Treatment, and
prevention: First edition. 1997.

 Samir E. Bishara: Impacted maxillary

canines: A review. AJODO 1992; vol 101:
Page 159-71.
 Charles A. Frank: treatment options for
impacted teeth: JADA May 2000; vol 131:
Page 623-632.
 Sanjay Suri, Ashok Utreja, and Vidya
Rattan: Orthodontic treatment of bilaterally
impacted maxillary canines in an adult:
AJODO 2002; vol 429: Page 429-37.

 Kazem Al – Nimri and Tareq Gharaibeh: Space

conditions and dental and occlusal features in
patients with palatally impacted maxillaary
canines: and aetilogical study. EJO 2005; vol
27: Page 461-465.
 P.J. Wisth, K. Norderval, and O. e. Boe:
Periodontal status of orthodontically treated
impacted maxillary canines: AJO January 1976;
vol 46:Page 69-76.
 Rozmary Mark D’Amico, Krister Bjerkin, Juri
Kurol, and Babak Falahat: Long term results of
orthodontic treatment of impacted maxillary
canines: AO 2003; vol 73: Page 231-238.

 M.M Kultinec, D Strm, amd Y. Shapira: The

impacted maxillary canines: I. Review of
concepts. Journal of dentistry for children
September-october 1995: Page 317-324.
 M.M Kultinec, D Strm, amd Y. Shapira: The
impacted maxillary canines: II. Review of
concepts. Journal of dentistry for children
September-october 1995: Page 325-334.
 V. Surendra Shetty, Gurkeerat Singh: Modified
ribbon arch mechanics in the treatment of
ectopically erupting mandibular canines: A case
report. JIOS 2001; vol 34: Page 20-23.

 S. Jay Bowman, and Aldo Carano: The

Monkey hook: An auxiliary for impacted,
rotated, and displaced teeth: JCO 2002;
vol 35: Page 375-378.
 Jay Bowman, Aldo Carano: Canine
obedience training: Monkey hook and
Kilroy spring. JIOS 2003; vol 36: 179-184.
 Harry Jacoby: The “ballista spring” system
for impacted teeth: AJO february 1979; vol
75: Page 143-151.

 R. Kontham, T.M. Bhagtani. P.V. Wadkar: The

“Ballista Spring” for impacted canine: JIOS
2000; vol 33: Page 21-23.
 Margherita Santoro, Eun-Sock Kim, Monica
Teredesai, and Nikos Karaggiannopoulos:
Modified removable transpalatal bar for rapid
uprighting of impacted second molars: JCO
september 2002; vol 36: Page 496-499.
 Danny Gleiser, Clara Jaramillo:
Autotransplantation of a permanent maxillary
incisor: JCO 2002; vol 36: Page 671-675.

 V. Ravinder, Nikar Anand Verma, Ashima

Valiathan: 3 – Dimensional computed
tomography: A new method for location of
impacted canines: JIOS 2002: vol 35: Page 7375.
 Ashima Valiathan, Siddhartha Dhar, Nikhar
Verma: 3D imaging in orthodontics: Adding a
new dimension to diagnosis and treatment
planning: Trends In Biomaterial and Artificial
Organ 2006, (in press)
 Jon Artun, Faraj Behbehani, Lukman Thalib:
Prediction of maxillary third molar impaction in
adolescent orthodontic patients: AO 2005; vol
75: Page 904-911.

 PatricK P.C Lee: Impacted premolars: Dent

Update 2005; vol 32: Page 152-157.
 Yuko Tanimoto, Shouichi Miyawaki, Mikako
Imai, Ryoko Takeda, Teruko TakanoYamamoto: Orthodontic treatment of a patient
with an impacted maxillary second premolar
and odontogenic keratocyst in the maxillary
sinus: AO 2005; vol 76: Page 1077-1083.
 N. Milner and A. Baker: Extraoral removal of a
lower third molar tooth: BDJ september 2005;
vol 24: Page 345-346.

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