presentation about impacted canine incidence, prevalence,classification,diagnosis, localization and treatment options including surgical and non surgical modalities

1. Impacted Canine
Prepared by :Marwan Ramadan
B.D.S

2. Impacted Canines
incidence :
 Impacted maxillary canines are quite common, and approximately 12%–15% of the population
present with impacted canines.
 They are localized palatally more often than labially.
 Twice common in female as it is in male
 Of all patient with impacted canine 8% have bilateral impaction
 the impacted canine presents five basic localizations (contralateral or ipsilateral and deep in the
bone) as follows:
1. Palatal localization
2. Palatal localization of crown and labial localization of root
3. Labial localization of crown and palatal localization of root
4. Labial localization
5. Ectopic positions

3. Etiology of impacted canine
 Several etiologic factors for canine impactions have been proposed: localized, systemic,
or genetic

4. Classification of maxillary Impacted Canines
According to axial inclination
Class I: Impacted canine located in the palate
 Horizontal
 Vertical
 Semi-Vertical
Class II: Impacted canine located in the buccal side
 Horizontal
 Vertical
 Semi-Vertical
Class III: Impacted canines located in both palatal as well as buccal alveolar bone.
Class IV: Impacted canines located vertically between incisors and premolars
Class V: Impacted canines located in edentulous maxilla
Class VI : when canine is placed in abnormal position, antral wall, infraorbital region

5. Classification of maxillary Impacted Canines
 According to According to Field and Ackerman(1935)
a. Labial position
(1) crown with intimate relationship with incisors
(2) crown well above apices of incisors
b. Palatal position
(1) Crown near surface in close relationship to root of incisors
(2) Crown deeply embedded in close relationship to apices of incisors
c. Intermediate position
(1) Crown between lateral incisor and first premolar root
(2) Crown above of these teeth with crown labially placed and root palatally placed,or vice versa
d. Unusual position
(1) In nasal or antral wall
(2) In infraorbital region

6. Classification of mandibular Impacted Canines
 CLASSIFICATION According to Field and Ackerman(1935)
a. Labial position
(1) Vertical
(2) Oblique
(3) horizontal
b. Unusual position
(1) At inferior border
(2) In mental protuberance
(3) Migrated to opposite side

7. Classification of mandibular Impacted Canines
Periapical radiograph
showing transmigrated and
erupted lower left canine in
the midline.

8. Classification of mandibular Impacted Canines
 CLASSIFICATION According to the depth
 Level A. The crown of the impacted canine tooth is at the cervical line of the adjacent teeth.
 Level B. The crown of the impacted canine tooth is between the cervical line and root apices of the
adjacent teeth.
 Level C. The crown of the impacted canines is beneath the root apices of the adjacent teeth

9. Sequelae of Canine Impaction
1. Labial or lingual malpositioning of the impacted tooth
2. Migration of the neighboring teeth and loss of arch length
3. Internal resorption
4. Dentigerous cyst formation
5. External root resorption of the impacted tooth, as well as the neighboring teeth,
6. Periodontal defects
7. Tooth transposition
8. Infection particularly with partial eruption
9. Referred pain and combinations of the above sequelae

10. Theories associated with palatally displaced
maxillary canines
 The guidance theory proposes that the canine erupts along the root
of the lateral incisor, which serves as a guide, and if the root of the
lateral incisor is absent or malformed, the canine will not erupt.
 The genetic theory includes other possibly associated dental
anomalies, such as missing, or small lateral incisors, also it may
associated with anomalies such as enamel hypoplasia,
infraocclusion of primary molars, and aplasia of second premolars.

11. Diagnosis and Localization:of Canine Impaction
 The diagnosis of canine impaction is based on both clinical and radiographic examinations
1. Delayed eruption of the permanent canine or prolonged retention of the deciduous
canine beyond 14–15 years of age
2. Absence of a normal labial canine bulge,
3. Presence of a palatal bulge in the canine region,
4. Delayed eruption, distal tipping, or migration (splaying) of the permanent lateral
incisor,
5. Loss of vitality and increased mobility of the permanent incisors
Clinical Evaluation

13. Diagnosis of Canine Impaction
Indicated in patients with unerupted and nonpalpable canine after the age of 11 years
Types
Intraoral
 Periapical and Occlusal
Extraoral
 OPG and lateral cephalogram
Digital imaging
 Ct scan and CBCT
 .
Radiographical Evaluation

14. Diagnosis of Canine Impaction
periapical film
 A single periapical film provides the clinician with a two-dimensional
representation of the dentition.
 It would relate the canine to the neighboring teeth both mesiodistally and
superoinferiorly

15. Diagnosis of Canine Impaction
 To evaluate the position of the
canine buccolingually
 Two periapical films are taken
of the same area, with the horizontal
angulation of the cone changed when
the second film is taken.
 If the object in question moves in the same direction as the cone, it is lingually positioned.
 If the object moves in the opposite direction, it is situated closer to the source of radiation and is
therefore buccally located
Tube-shift technique or Clark's rule or (SLOB) rule

16. Diagnosis of Canine Impaction
 The buccal object rule uses two radiographs taken with different vertical angulations of the
x-ray beam.
 An object located on the buccal side moves inferiorly with the beam
directed inferiorly,
 whereas an object located in a lingual or palatal position moves superiorly
Buccal object rule:

17. Diagnosis of Canine Impaction
Occlusal films
 help to determine the buccolingual position of the impacted canine in conjunction with
the periapical films, provided that the image of the impacted canine is not
superimposed on the other teeth
Radiographical Evaluation

18. Diagnosis of Canine Impaction
Extraoral films
1. lateral cephalograms
These can sometimes aid in the
determination of the position of
the impacted canine, particularly
its relationship to other facial
structures (e.g., the maxillary
sinus and the floor of the nose).
Radiographical Evaluation
A view of the anterior
section of the lateral skull
radiograph confirms the
palatal location of the fully
superimposed
impacted canines (arrow)

19. Diagnosis of Canine Impaction
Extraoral films
2. Panoramic films
 These are also used to localize impacted
teeth in all three planes of space
 as much the same as with two periapical films
in the tube-shift method, with the understanding
that the source of radiation comes from behind the
patient; thus, the movements are reversed for position.
 image size distortion; object further away from the
image receptor (film) will be depiceted more magnified
than objects closer to the film
Radiographical Evaluation
right maxillary canine impaction. The
image of the canine superimposes on
the middle of the root of the lateral
incisor

20. Diagnosis of Canine Impaction
Extraoral films
3. CT/CBCT
 Cone beam computed tomography (CBCT) can identify and locate the position of
impacted canines accurately.
 By using this imaging technique, dentists also can assess any damage to the roots
of adjacent teeth and the amount of bone surrounding each tooth.
 increased cost, time, radiation exposure, and medicolegal issues associated with
using CBCT limit its routine use
Radiographical Evaluation

21. Diagnosis of Canine Impaction
Extraoral films
Radiographical Evaluation
CT scan image showing impacted upper right canine
in the right maxillary sinus .
Ct scan Axial
view
Ct scan
coronal view

22. Diagnosis of Canine Impaction
Extraoral films
3. CBCT
Radiographical Evaluation
was designed to overcome some of the limitations of
conventional CT devices (eg high radiation dose to
produce the multiple images which are stacked to
produce a complete image
Three dimensional reconstructed image (CBCT) of
impacted maxillary canines

23. factors affecting treatment options
 Patient age
 General dental health and oral hygiene
 Whether space is available within the arch or if it can be established with
orthodontic manipulation
 Suitability of the first bicuspid to replace the canine
 Favorability of the position of the impacted canine and the likelihood of being able
to get it into position with orthodontic treatment
 Patient motivation for orthodontic treatment
 Medical contraindications for surgery

24. Treatment options
1. Interceptive
2. Surgical exposure with or without orthodontic traction
 Open surgical exposure with spontaneous eruption
 Open surgical exposure with packing only
 Open surgical exposure with packing and subsequent bonding of an auxillary.
 Closed surgical exposure and bonding of an attachment intraoperatively.(closed eruption
technique)
 Open surgical exposure and bonding of an attachment and repositioning of the covering
tissue (open eruption technique)
3. Surgical repositioning and alignment
4. Surgical Autotransplantation
5. Surgical removal
6.No treatment

25. 1. Interceptive Treatment
 In Class I non crowded situations where the permanent maxillary canine is
impacted or erupting buccally or palatally, it may be the preventive treatment of
choice in patient 10-13 years old.
 However, intercept early if
 There is any root resorption
 3 not palpable in its normal position and radiographic examination confirms palatal ectopia
 When canines are impacted buccally, retained primary canine should be
extracted.
 However, interception does not guarantee correction or elimination of the
problem.
 If NO radiographic evidence of improvement seen one year after treatment,
then surgical exposure and orthodontic eruption, is indicated

26. 2. Surgical Exposure with orthodontic traction
CONSIDERATION
 Patient must be willing to wear orthodontic appliance
 Patient must be motivated to maintain good OH
 Interceptive measures not suitable
 Position of malposition not too great to preclude treatment.
 The long axis of the 3 should not be too horizontal or oblique
 The optimal time for alignment is during adolescence
 3 must not be ankylosed
 The root of 3 should not be dilacerated

27. METHODS
A. surgical exposure with spontaneous eruption
B. surgical exposure with packing only
C. surgical exposure with packing and delayed bonding of an auxillary.
D. Open eruption technique .
E. Closed eruption technique
 For surgical exposure 3 surgical approach can be used
 1. Replacement flap technique
 2. Excisional exposure
 3. Apically position flap
 The goal is to choose a technique that exposes the canine within the a zone of keratinized
mucosa without involvement of the cementoenamel junction

28. A. surgical exposure with spontaneous eruption
 Usually has only soft tissue covering
 The technique involve excision of the gingivae over the canine with little exposure of the crown
and bone removal.
 This should be enough to allow eruption of the canine
unerupted maxillary left canine
The tooth was exposed and the
flap, which consisted of attached
gingiva, was apically
repositioned
At nine months post-surgery,
the tooth has erupted normally.

29. B. surgical exposure with packing
 The purpose of pack application is to prevent the gingival tissue from re-healing after exposure
 Indicated in deep impaction cases when spontaneous eruption is suspected

30. C. surgical exposure with packing and delayed bonding
of an auxillary
 Indicated in deep impaction cases when spontaneous eruption is failed
 of The packing is remove after a week postop and an attachment bonded with subsequent
traction using a fixed appliance.
 Adv
 Re-bonding can be done under direct vision
 Direct visualisation during movement

32. D. Open eruption technique
 In the “open eruption” technique, the crown of the impacted tooth is exposed with either an
opening cut into the overlying tissue without flap reflection, or a flap is reflected, a window
cut in it, and then the flap is repositioned
 simplest, most conservative and most direct manner to expose a tooth which is palpable
immediately under the oral mucosa
 attachment may then be bonded to the tooth and orthodontically encouraged eruption may
proceed without delay, to complete its alignment within a very short time.
A high buccal canine exposed
by circular incision of the
sulcus mucosa
Following alignment, the oral
mucosa is attached directly to
the gingiva

33. E. Closed eruption technique
 The alternative approach to surgical exposure, the closed eruption technique, has an attachment
placed at the time of the exposure and the tissues fully replaced and sutured to their former place,
to re-cover the impacted tooth
high labial canine has been exposed
with a full flap exposure, which
included the gingival margin of the
extracted deciduous canine
An attachment is bonded to the palatal aspect of the permanent
canine and its pigtail ligature is directed through the socket
vacated by the extracted deciduous tooth
The flap is sutured to its former place and vertical
traction will draw the tooth down, maintaining
alveolar bone on its labial side.

34. (a) The crown of an impacted canine is exposed using a wide flap, but with removal of minimal bone.
The unexposed crown lies between the roots of the central incisors, having traversed the midline
suture. (b) An attachment is bonded, while haemostasis is maintained by the surgeon. (c) The flap has
been divided to accommodate the ligature pigtail in its desired position, before being fully replaced and
sutured. (d) The labial spring auxiliary loop, seen in its passive position in (c), has been turned inwards
towards the palate and secured to the stainless steel ligature pigtail
Closed eruption
technique in palatally
impacted maxillary
canine

35. Surgical repositioning and alignment
 It suitable for tooth which are only mildly displaced.
 It involves de- rotation of the impacted canine within its socket
 It defer from transplantation because effort is made to avoid removal of the tooth from it socket
 The greater the displacement the poorer the prognosis as frequently the neurovascular bundle
are broken

36. Autotransplantation
 If patient is unwilling to wear orthodontic Appliance
 If the degree of malpositioning is too great for orthodontic alignment.
 Optimal time is when the root is about 50-75% formed
 Interceptive measure not appropriate or had failed
 Fixation at d recipient site is done using a preformed or vacuum splint which
covers the entire upper arch
 Splint is removed after 3-6wks and this is followed by bonded sectional fixed
appliance

37. Preoperative
Extraction of
the tooth from
impacted state
Intraoperative
after preparing
of the socket
Postoperative OBG showing alignment of
the tooth and splinting

38. Surgical removal
Indications
 Poor patient cooperation
 Patient decline treatment or is pleased with the appearance
 The tooth is lying in an unfavorable position (in horizontal position) and there is insufficient space
in the arch
 Presence of a pathology.
 Satisfactory occlusion and prognosis for treatment is poor.
 Evidence of early resorption of adjacent tooth.
 Good contact btw the 2 and 4,so as to substitute 4 for 3.

39. Methods of Surgical removal
Maxillary canine
 Extraction using labial approach
 Extraction using palatal approach
 Extraction of labially located canine with partial bone impaction
 Extraction of intra-alveolar impaction
 Ectopic Impacted Canine
Mandibular canine
 Extraction of mandibular canine with labial position

40. Flap design
 Buccal located canine: If the impacted canine is located buccally, we have three options depending on the
level of the tooth impaction.
1- Gingival crest incision can be made in the gingival sulcus.
2- If the impacted canine is high, the incision can be made horizontally above the papillae (flap with release
incision).
3- Vestibular incisions made at the level of the mucogingival junction should be made only when the impacted
canine is above the root apices.
 Palatal positioned canine: require long
incision to avoid damage to the
neurovascular bundles
(nasopalatine bundles &
the greater palatine bundle)
 Transversely located (in the middle of the ridge) we have to make 2 flaps one labially and the other one
palataly

41. Extraction of maxillary canine Using Labial Approach
OPG Impacted canine in right
and left side
Canine bulge on labial side trapezoidal flap
Reflection of the flap Bone removing Tooth sectioning

42. Extraction of maxillary canine Using Labial Approach
Removal of follicle
Bone smoothing
Removing of the crown Removing of the root
Surgical site after suturing

43. Extraction of maxillary canine Using palatal Approach
Bone removing Tooth sectioning
OPG Impacted canine in right
side
Palatal flap extend from
5 to 5
Reflection of the flap

44. Extraction of maxillary canine Using palatal Approach
Removing of crown Removing of root Re-approximation of
the flap
Surgical site after suturing

45. Extraction of Impacted Canine with Partial Bone Impaction
impacted maxillary canine
with a labial localization The ischemic protuberance
Trapezoidal incision

46. Extraction of Impacted Canine with Partial Bone Impaction
Creation of a groove between
the crown and bone, allowing
for positioning of the elevator
Removal of the tooth with elevator Bone smoothing
suturing

47. Extraction of Ectopic Impacted Canine
• The presence of ectopic impacted teeth is relatively
rare.
• Ectopic teeth are usually localized in the following
places:
1. underneath permanent teeth,
2. near the angle of the mandible,
3. inside the ramus,
4. near the mandibular notch,
5. the coronoid process,
6. the maxillary tuberosity,
7. the wall of the maxillary sinus,
8. the nasal cavity and,
9. rarely, near the orbit
Radiograph showing impacted canine with a labial
localization, which is in contact with the anterior wall
of the maxillary sinus

48. Extraction of Ectopic Impacted Canine
Incision in canine fossa region,
for sinus trephination using the
Caldwell–Luc approach
Reflection of the flap and
exposure of the anterior
wall of maxillary sinus Holes drilled through the bone
surface defining the border of bone
to be removed
Connecting holes to remove the
bone covering the impacted
tooth

49. Extraction of Ectopic Impacted Canine
Surgical field after suturing
a, Exposure and luxation of the impacted tooth using
straight elevator. b Removal of tooth using a hemostat

50. Extraction of mandibular canine: labially
positioned
Trapezoidal incision extending from the left lateral
incisor as far as the first premolar of the opposite side
of the mandible
Reflection of the flap

51. Extraction of mandibular canine: labially
positioned
Exposure of the crown of the impacted
tooth using a surgical bur
Luxation using the blade of the
elevator alternately on the
mesial and distal aspects of
crown of tooth
Surgical field after removal of
the impacted tooth and
odontomas

52. Extraction of mandibular canine: labially
positioned
Suturing

53. POSTOPERATIVE TREATMENT
 After Debridement and closure of incision the wound heals uneventfully
1. A post op radiograph is desirable
2. Cold application to face prevents disfiguring swelling and edema
3. Antibiotics are generally necessary especially if there is preexisting infection or the
antrum or nasal cavity has been opened.
4. Medication should be prescribed for pain