- Impacted teeth present challenges for orthodontists in terms of tooth movement, esthetics, and functional outcomes. - Impacted canines in particular are the second most common impacted tooth after third molars, with palatal impaction being more common than buccal impaction. - Factors affecting treatment of impacted canines include patient motivation and cooperation, age, position and angulation of the canine, space availability, and dental health. Treatment may involve extraction of deciduous canines, surgical exposure and orthodontic alignment, or surgical removal of the impacted canine depending on the specific clinical situation.

1. Mohanad Elsherif
BDS (U of K), MFD RCSI, MFDS RCPS(Glasg), MSc (Orthodontics),
M.Orth. RCSEd
‫الرحيم‬‫الرحمن‬‫هللا‬ ‫بسم‬
Sudan International University
Faculty of Dentistry
Department of Orthodontics

2. • Impacted teeth present many problems for the
orthodontist. They can compromise tooth movement,
esthetics, and functional outcomes.

3. • Impacted:
– Condition where the canine is prevented from
eruption to the oral cavity by bone, tooth or fibrous
tissue.
• Ectopic eruption:
– Located away from the normal position.
3

4. 4-6 months
Development (calcification) begins
high in the maxilla
6 years Crown completed
10 years
Palpable high in the buccal vestibule
11-13years Eruption
14 - 15 years Root completed
4

5. ARCHER,S CLASSIFICATION
 Class I: Palatally Impacted canine
a) Horizontal b) Vertical c) Semivertical
 Class II: Buccally impacted canine
a) Horizontal b) Vertical c) Semivertical
 Class III
• Impacted canine located in both the palatal and labial surfaces.
 Class IV
• Impacted canine located in the alveolar process.
 Class V
• Impacted canine located in an edentulous maxilla.

6. • The maxillary canine is the second most commonly impacted
tooth after the third molars.
• incidence ranging from 2-3%
Eriscson and Kurol 1986
• More palatally impacted than buccally, with a ratio of about 2:1.
Johnston WD 1969
• Female > male 2:1.
Bishara SE. 1992
• Unilateral: bilateral 4:1.
Bishara SE 1992, Quirynen M al. 2000
• The incidence of mandibular canine impactions is much lower, at
only about 0.35%.
Dachi SF, Howell FV. 1961

7. • May be either general or local
• General causes:
• Endocrine deficiencies.
• Febrile diseases.
• Possibly irradiation.
Bishara SE al. 1976

8. Local causes:
1. Tooth size/arch length discrepancies (Crowding).
2. Prolonged retention or early loss of the primary canine.
3. Abnormal position of the tooth bud.
4. The presence of an alveolar cleft.
5. Ankylosis.
6. Cystic or neoplastic formation.
7. Dilacerations of the root.
8. Iatrogenic origin.
Bishara SE al. 1976

9. • Guidance Theory
Becker A. 1995.

10. • Some author believed that palatal canine may be genetic in
origin because:
• It’s prevalence varies between population with greater incidence
in European than other trait.
• Female> male.
• Familial occurrence.
• Occur bilaterally with greater than expected.
• Occur with other dental anomalies such as hypodontia in 2s,4s,
and 5s- peg shape 2 and class II div2.

11. It is either clinical or radiographic:
1. Clinical evaluation:
Possible clinical signs of canine impactions include:
• Failure to Palpating for the canine bulge above the primary
canine up to age of 10 years.
• Retention of the primary canine beyond 14 to 15 years of age.
• Asymmetry in the canine bulge.
• Presence of a palatal bulge.
• Delayed eruption, distal tipping, or migration of the lateral
incisor.
Bishara SE. 1994

13. 2. Radiographic evaluation:
• It has been reported that:
 29% of the time canines were not palpable at 10 years
of age.
 5% were not palpable at 11 years.
 3% were not palpable thereafter.
• For this reason, radiographic evaluation should be used
in combination with the clinical assessment.
Ericson S, Kurol J. 1986

14. • Several method are can be used to locate the
impacted canine e.g.:
• Parallax (Clark’s) method.
• Single upper occlusal (simpson projection).
• Computerized tomography (CT).
• Cone beam computerized tomography (CBCT).

15. SLOB Rule

16. The object (impacted tooth) moved in the same
direction as the movement of the x-ray beam, this will
mean that the tooth is located palatally (lingually).
Example: two periapical

17. The object (impacted tooth) moved in the opposite
direction of movement of the x-ray beam, this will
mean that the tooth is located buccally.

18. Example: Periapical and upper occlusal or DPT and
upper occlusal

19. Simpson projection:

20. • image enlargement and distortion.
• structure overlap.
• positioning problems.

23. Factors affecting treatment:
• Patient motivation and cooperation
• Age
• Position of the canine
• Space within arch
• Dental and periodontal health

24. 1. No treatment:
• Poorly motivated patient and
• The canine is not causing any problems.
• Inform of resorption risk and cystic
change within canine follicle.
• Monitor radiographically every 12
months.

25. 2. Extract Deciduous Canine:
• In an uncrowded arch in a child Age 10-13
years.
• good prognosis is seen when the 3 overlap
the distal rather than the mesial aspect of 2.
• Radiographic improvement in 6-18 months.

26. Success rates for eruption of impacted canines
18 months after extraction of the deciduous canine
(Ericson and Kurol, 1988)
64%91%

27. 3. Extraction and reimplation:
• Good prognosis if:
• Intact removal is guaranteed.
• Adequate buccal and palatal bone.
• The crown is 50-75% completed.
• Avoidance of handling the root during surgery.
• Rigid splinting is avoided.

28. 4. Surgical removal of impacted canine:
• Poorly motivated patients.
• Very unfavorable canine position.
• Evidence of resorption risk and cystic change.
• Orthodontic treatment is contraindicated.
• The lateral incisor and 1st premolar are in
good contact in case of Severe crowding
(substitute 1st premolar).

29. 5. Surgical exposure and orthodontic
alignment:
• Highly motivated patient.
• Spaced arch or possibly to create space.
• The position of canine is favorable (How):
 The height (vertical position)
 The anteroposterior position
 angulation of the canine
 Postion of apex

30. Decreasing prognosis (vertical)

31. Decreasing prognosis (horizontal)

32. Best prognosisvertical angulation
Worst prognosishorizontal angulation

33. Decreasing prognosis
Position of the apex

34. Poorest prognosis
Best
prognosis

35. 1. Open surgical exposure followed by spontaneous eruption. The
canine needs to be of correct angulations' for this to succeed.
2. Open surgical exposure of the canine with packing. About 1
week postoperatively the pack is removed and an attachment is
bonded to The canine to facilitate alignment with a fixed
appliance.
3. Closed surgical exposure of the canine with attachment bonded
during surgery. An eyelet or gold chain bonded to the mid-
buccal aspect of the crown has the best prospect of bond
survival.

41. located palataly

47. • Root resorption of adjacent teeth.
• Ankyloses
• Loss of vitality.
• Pulp obliteration.
• Attachment failure and re-surgery.
• Risk of treatment discontinue due
prolonged time.

48. Declaration
 The author wish to declare that; these presentations are his original
work, all materials and pictures collection, typing and slide design
has been done by the author.
 Most of these materials has been done for undergraduate students,
although postgraduate students may find some useful basic and
advanced information.
 The universities title at the front page indicate where the lecture was
first presented. The author was working as a lecturer of orthodontics
at Ibn Sina University, Sudan International University, and as a
Master student in Orthodontics at University of Khartoum.
 The author declare that all materials and photos in these
presentations has been collected from different textbooks, papers
and online websites. These pictures are presented here for education
and demonstration purposes only. The author are not attempting to
plagiarize or reproduced unauthorized material, and the intellectual
properties of these photos belong to their original authors.

49. Declaration
 As the authors reviews several textbooks, papers and other
references during preparation of these materials, it was
impossible to cite every textbook and journal article, the main
textbooks that has been reviewed during preparation of these
presentations were:
 Contemporary Orthodontics 5th edition; Proffit, William R, Henry
W. Fields, and David M. Sarver.
 Handbook of Orthodontics. 1st edition; Cobourne, Martyn T, and
Andrew T. DiBiase.
 Clinical cases in orthodontics. Martyn T. Cobourne, Padhraig S.
Fleming, Andrew T. DiBiase, Sofia Ahmad
 Essentials of orthodontics: Diagnosis and Treatment; Robert N.
Staley, Neil T. Reske
 Orthodontics: Current Principles & Techniques 5th edition;
Graber, Lee W, Robert L. Vanarsdall, and Katherine W. L. Vig
 Orthodontics: The Art and Science. 3rd Edition. Bhalajhi, S.I.

50. Declaration
 For the purposes of dissemination and sharing of
knowledge, these lectures were given to several
colleagues and students. It were also uploaded to
SlideShare website by the author. Colleagues and
students may download, use, and modify these
materials as they see fit for non-profit purposes. The
author retain the copyright of the original work.
 The author wish to thank his family, teachers,
colleagues and students for their love and support
throughout his career. I also wish to express my
sincere gratitude to all orthodontic pillars for their
tremendous contribution to our specialty.
 Finally, the author welcome any advices and enquires
through his email address: Mohanad-07@hotmail.com