The document discusses impacted maxillary canines, including:
- Unerupted canines is a common clinical problem, with prevalence ranging from 0.8-2.8%.
- Normal development involves calcification starting at age 1 and eruption around 11-12 years old.
- Factors that can cause impaction include crowding, prolonged retention of primary canines, abnormal position of tooth buds, and genetic factors.
- Diagnosis involves inspection for delayed/asymmetric eruption, palpation of buds, and diagnostic imaging to determine location, development stage, and other anatomical details of unerupted canines.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Root resorption /certified fixed orthodontic courses by Indian dental academy Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Orthodontic management of cleft lip and palate /certified fixed orthodontic ...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Surgical orthodontics /certified fixed orthodontic courses by Indian dental a...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Description :
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Frankles appliance Is a myofunctional appliance
Functional appliance are removable or fixed appliances that aim to utilize eliminate or guide the forces arising from muscle function,tooth eruption and growth inorder to alter skeletal and dental relationship
Root resorption /certified fixed orthodontic courses by Indian dental academy Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Orthodontic management of cleft lip and palate /certified fixed orthodontic ...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Surgical orthodontics /certified fixed orthodontic courses by Indian dental a...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Description :
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Frankles appliance Is a myofunctional appliance
Functional appliance are removable or fixed appliances that aim to utilize eliminate or guide the forces arising from muscle function,tooth eruption and growth inorder to alter skeletal and dental relationship
Arch Form in orthodontics /certified fixed orthodontic courses by Indian dent...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Canine Impaction and Its Importance in OrthodonticsAnalhaq Shaikh
Canine Impaction, Its Importance in Orthodontics, Etiology, Diagnosis and Management.
by Dr Analhaq Shaikh, 2nd year Postgraduate student, Sharavathi Dental College and Hospital, Shimoga, Karnataka
Canine Impaction can also be termed as Shy Canine.
Maxillary canine impaction / oral surgery courses /certified fixed orthodon...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
00919248678078
Maxillary canine impaction 02 /certified fixed orthodontic courses by Indian ...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Ma...Abu-Hussein Muhamad
Abstract: Advances in bonding techniques and materials allow for reliable bracket placement on ectopically positioned teeth. This prospective study evaluates the outcome of forced orthodontic eruption of impacted canine teeth in both palatal and labial positions. Eighty-two impacted maxillary canines in 2200patients were included in the study and were observed for 2006 to 2013 ,in Center for Dentistry research and Aesthetics, Jatt/Israel after exposure. Following exposure by means of a palatal flap or an apically repositioned buccal flap, an orthodontic traction hook, with a Titanium Button with chain by Watted (Dentaurum) attached, was bonded to each impacted tooth using a light cured orthodontic resin cement. A periodontal dressing was placed over the surgical site for a period of time. All teeth were successfully erupted. Complications consisted of: failure of initial bond, at the time of surgery, which required rebonding; premature debonding at the time of pack removal and; debonding of brackets during orthodontic eruption. There was no infection, eruption failure, ankylosis, resorption or periodontal defect (pocket greater than 3 mm) associated with any of the exposed teeth. Forced orthodontic eruption of impacted maxillary canines with a well bonded orthodontic traction hook and ligation chain, used in conjunction with a palatal flap or an apically repositioned labial flap, results in predictable orthodontic eruption with few complications. Key Words: cuspid/surgery; orthodontics, corrective; tooth, impacted/therapy
Detailed description on management of impacted maxillary and mandibular third molars. Surgical approaches and complications are also discussed in details.
Prevalence of Impacted Mandibular Third Molars in Population of Arab Israel...Abu-Hussein Muhamad
Abstract:
Introduction: Impaction may be defined as the failure of complete eruption into a normal functional position of one tooth within normal time due to lack of space in the dental arch, caused by obstruction by another tooth or development in an abnormal position. The mandibular third molar is the most frequently impacted tooth. The incidence varies from 9.5% to 68% in different populations.
Methods: The study was conducted in Center for Dentistry Research and Aesthetics, Jatt, Israel .Study represents retrospective analysis of panoramic radiographs (orthopantomograms) of patients referred to Center for Dentistry Research and Aesthetics, Jatt, Israel from January 2006 to December 2015 .
Results: A total of 1076 patients,649(60,3%) males ,and 427 (39,7%) females visited Center for Dentistry Research and Aesthetics, Jatt, Israel between January2006 and December2015. . A total of 206 patients met the inclusion criteria. The age ranged from 17 to 55years, with a mean age of 28.1 years and the standard deviation was 5.8 years.The prevalence of impacted mandibular third molars for this study was 19,2%.
Conclusion: This study demonstrated that males (62,2%) were more likely to present with impacted mandibular third molars than females (37,8%). The prevalence of third molar impactions was almost the same on both the left (47.8%) and right (52,2%) sides. This study also noted that mesio-angular impactions (50%) were the most common type of impaction. The least common form of impactions was the inverted types (0.3%). The prevalence of impacted mandibular third molars for this study was 19,2%.
Keywords: impacted mandibular third molars, incidence,Arab Israeli(Arab48)
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Impacted upper canines / for orthodontists by Almuzian
1. Mohammed Almuzian, University of Glasgow, 2014 Page 1
UNIVERSITY OF GLASGOW
Impacted maxillary Canines
Personal note
Mohammed Almuzian
1/1/2014
.
2. Mohammed Almuzian, University of Glasgow, 2014 Page 2
Impacted maxillary Canines
Introduction
1. Unerupted and Impacted of canines is a frequently encountered clinical problem. If orthodontic
treatment is not started, there is always a risk of retention and also of resorption of the roots of
the permanent incisors.
2. Impaction is from a Latin word impacto which means pressing together (Thomas 1984).In dental
term, impaction means failure of tooth eruption to occlusion due to physical obstruction e.g.
supernumerary prevents maxillary incisors from eruption. However, in most cases of canines
impaction, no obvious physical barrier to eruption is found.
3. Some authors prefer the term unerupted or nonerupted canines to describe the condition (Rayne
1969, Von der Heydt 1975, Krejci and Bissada 1988, Mermingos and Full 1989). In the
assignment, the term unerupted canine or unerupted maxillary canines (UMC) , palatal
displacement canine (PDC) and impacted maxillary canine (IMC) will be used.
4. Uneruption of canines is a common clinical problem. The maxillary canine tooth is second only
to the mandibular third molar in its frequency of impaction . The report ed prevalence varies
from less than 0.8-2.8 per cent ( Shah et al., 1978 ; Grover and Lorton , 1985 ). and the incidence
of mandibular canine uneruption is only 0.35% (Dachi and Howell 1961). Since failure of
maxillary canines eruption occurs more frequently, the emphasis of this assignment will be on its
incidence, normal develop and eruption, aetiology, complication, assessment, prevention and
treatment.
5. Normal development and eruption pattern: Broadbent (1941) stated that calcification of the
permanent maxillary canine crown starts at 1 year old, between the roots of the first primary
molar , and is complete at 5-6 years. By the age of 12 months the crown of the tooth is found
between the roots of the first primary molar. At 3-4 years of age the canine passes over the line
of the primary incisors to lie on the labial side of the root of the lateral incisor( Miller,1963). At
age 4 years the primary first molar, the first premolar germ and the canine lie in vertical row .
Subsequent growth on the facial surface of the maxilla provides space for the forward movement
of the canine so that its cusp comes to lie medial to the root of the deciduous canine. Moss
(1972) states that the canine remains high in the maxilla just above the root of the lateral incisor
until the crown is calcified.It then erupts along the distal aspect of the lateral incisor resulting in
3. Mohammed Almuzian, University of Glasgow, 2014 Page 3
closure of the physiological diastema if present and the correction of the so called ‘Ugly
Duckling ‘dentition ( Kurol et al.,1997 )
6. Has long path of eruption from the infra-orbital place along the roots of 2 causing ugly duckling
space which resolve later, and then pass along the buccal surface of the c.
7. Upper erupts 11-12yrs
8. 3's palpable in buccal sulcus by 8-10 yrs old (Ferguson, 1990)
Prevalence
1. Developmentally absent 3's: 0.08% (Brin et al, 1986)
2. Impacted 3's: 2% (Ericsson, 1986)
Review of the dental literature reveals that the incidence of unerupted or impacted canines to
range from1.5 to 3.0 % of the general population.
Frequency: The maxillay canine is second only to the mandibular third molar in its frequency of
impaction.The frequency varies from less than 0.8-2.8 % ( Shah et al.,1978; Grover and Lorton .
1985 )and the incidence of mandibular canine uneruption is only 0.35% (Dachi and Howell
1961).
Sex: The condition is more than twice as common in girls(1.2 %) than in boys ( 0.5 % ) ; Dachi
and Howell, 1961 ; Ericson and Kurol 1986; Rayne 1969 and Peck et al 1994)
Family history
Site: Canine impaction is found palatal to a the arch in 85 % of cases and labial/buccal in
15%(Rayne,1969;Ericson and Kurol, 1987 ). Johnston and Gaulis and Joho also stated that
impacted maxillary canines are more often situated in a palatal than in a labial position, in a ratio
of approximately 2 to 1 . Ericson and Kurol (1986) reported that 8% of PDC were bilateral.
However, a much higher incidence has been reported by Bass (1967) Rayne (1969) which was
17% and 25% respectively.Becker et al.5 found 70% incidence in females with 45% of the
sample showing bilateral impactions. Kuftinic found that laterality existed in the incidence of
canine impactions. Left side impactions occurred more frequently than right sided ones in the
ratio of 5:2. The palatal displaced canine usually is detected late i.e. after the age of 13 and 14
and it requires surgical treatment. Palatally displaced canines very rarely erupt spontaneously.
However, the buccally unerupted canines, in most cases, are detected and operated much. It is
impossible to verify that those labially unerupted teeth could not erupt spontaneously in a labial
4. Mohammed Almuzian, University of Glasgow, 2014 Page 4
ectopic position. There is some evidence that patients with class II division 2 malocclusions and
tooth aplasia may be at higher risk to the development of an ectopic canine. ( Kettle,1957; Harzer
et al .,1994; Mossey et al.,1994;Brenchley and oliver,1997).
Complication
1. Nothing
2. May erupt in a Labial / lingual malposition
3. If the C lost, then Migration of neighbouring teeth and loss of arch length
4. Internal or external root resorption of teeth adjacent to impacted canine.
5. Resorption of canine itself can also occur.
6. Dentigerous cyst formation and infection with referred pain
7. Damage to adjacent teeth during surgery
8. Ankylosis
Aetiology
The aetiology of the ectopic canine is obscure, but probably multifactorial .The maxillary
canine has the longest path of eruption in the permanent dentition and this may be a factor in the
aetiology ( Coulter and Richardson , 1997 ). Moyers (1963) summarised the aetiology of UMC
into primary causes and secondary causes :
1. Primary causes :
a) rate of root resorption of deciduous teeth
b) trauma to the primary tooth bud.
c) disturbances in tooth eruption sequence.
d) availability of space in the arch.
e) rotation of tooth buds.
f) premature root closure.
g) canine eruption into the cleft area in the persons with cleft palate.
5. Mohammed Almuzian, University of Glasgow, 2014 Page 5
2. Secondary causes :
a) abnormal muscle pressure.
b) febrile diseases.
c) endocrine disturbances.
d) vitamin D deficiency.
The most common causes for canine uneruption are usually localised and are the results of any
one, or combination of the following factors (Bishara 1992):
A: Tooth size-arch length discrepancies: Crowding is the most common cause of tooth
impaction. However, lack of space is usually associated with labially unerupted maxillary
canines but not PDC. (Jocoby 1983).
B : Prolong retention or early loss of the primary canine: The prolong retention of deciduous
canine may be related to abnormal slow root resorption rate of primary canines or the result of
ectopic eruption of permanent canine. However, removal of primary canines in PDC cases
improves the severity of impaction (Ericson and Kurol 1988a). The early loss of the primary
canine may be an indication of arch length discrepancies.
C : Abnormal position of tooth bud: Many authors support that a more difficult and tortuous path
of eruption and true ectopic development is one of the main causes of unerupted canines (Rayne
1969, Von der Heydt 1975, Chase 1989, Peck et al 1994). Becker (1995) argued that if there was
a clear and unequivocal ectopic development of the entire tooth bud from the earliest stages, a
positional anomaly of major proportions should be indicated. However, PDC usually referred to
a crown displacement only, with the root more or less ideally placed.
D : Presence of an alveolar cleft: Local disturbance may deflect eruption of canine or just lack of
alveolar bone may delay or prevent eruption (Rayne 1969). Other dental anomalies e.g..
supernumerary, presence of scarred tissue, may affect the eruption of maxillary canines.
E : Ankylosis: Ankylosis of maxillary canine is uncommon but still is a possible cause of
uneruption. Anecdotal clinical experience of canine traction after surgical exposure indicates a
6. Mohammed Almuzian, University of Glasgow, 2014 Page 6
low incidence of ankylosis (Counsel 1997, personal communication). New surgical technique
which minimises the damage the root surfaces prevents iatrogenic ankylosis.
F : Cystic or neoplastic formation: Physical obstruction by cyst or neoplasm in the path of
eruption may cause deflection of the crown of the canine (Ferguson 1990). However, the
incidence of cyst and neoplasm is much lower than incidence of UMC. Moreover, the cystic
appearance related to PDC in the radiograph might be enlarged follicle due to delayed eruption
instead of the cause of impaction.
G : Dilaceration of root: Rayne (1969) concluded that the mechanism of impaction was one of
maldirection of eruption; the inclination of the impacting canine was mesial, and it became
deflected by the root of the lateral incisor. Dilaceration of the apex might result from proximity
to the wall of the nose or the floor of the antrum.
H : Iatrogenic origin: Broadbent (1941) suggested the early correction of the flared and distally
tipped lateral incisors might either impact the canines or cause resorption of roots of the lateral
incisors. This view has been shared by many other clinicians. (Duncan 1997, Darendeliler 1997,
Vickers 1997, personal communication).
I : Idiopathic condition with no apparent cause: This covers everything under the sun!!
Jocoby (1983) found that 85% of the PDC had sufficient space for eruption. He concluded that a
canine could be palatally impacted if an extra space was available in the maxillary bone. This
space should be provided by:
a) excessive growth in the base of maxillary bone;
b) space created by agenesis;
c) stimulated erupted of lateral incisor or the first premolar.
Other factors are also suggested as aetiology of UMC (Ferguson 1990):
a) Narrowness of the upper arch
b) Class II division 2 incisor relationship
c) Familial tendency
7. Mohammed Almuzian, University of Glasgow, 2014 Page 7
Theories
The recent debate of the aetiology of PDC between Lateral Incisors Guidance Theory
(Becker et al 1981) and Genetics Factors as Primary Origin (Peck et al 1994) generate a lot of
interest in this area (Becker 1995, Peck et al 1995). Jacobs (1996) reviewed both theories in his
review article.
Guidance theory, evidences: Small, peg-shaped or missing maxillary lateral incisors have been
implicated in contributing to the palatal impaction of maxillary canines. Jacoby (1983) found that
the presence of excessive arch space due to agenesis or peg-shape lateral incisor was one of the
aetiology of PDC. Brin et al (1986) found that if a patient had a small or peg lateral incisor, there
was approximately a 1:10 probability that the canine would be palatally placed; and if the patient
had a missing lateral incisor, a 1:20 probability. Becker et al (1984)found absence of maxillary
lateral incisors in 5.5 % of a large group of patients with palatal canines, which is 2.4 times the
rate in the general population and concluded that anomalous or missing lateral incisors
contributed towards palatal displacement of canines initially by absence of guidance for erupting
canine, and later by obstructing the misplaced canine’s attempt to rectify its position (Jacobs
1996)
Genetic theory, polygenic inheritance, evidences: Peck. A genetic or familial trend has been
pointed out by some workers (Peck et al., 1994). Pirinen et al. (1996) examined first and second
degree relatives of 106 consecutive patients with displaced canines, and concluded that palatal
displacement of the canine is both genetic and related to hereditary incisor or premolar
abnormalities such as peg-shaped lateral incisors. Mossey et al. (1994) found a weak statistical
relationship between the occurrence of a palatally displaced canine and the absence or reduced
crown width of the adjacent lateral incisor , but Brenchyley and Oliver (1997) were unable to
comfirm this finding in respect of crown size. Peck et al (1994) reviewed the literature and stated
that the evidence pointed to genetic factors as the primary origin of most PDC. They grouped
their material into five categories.
1) Occurrence of other dental anomalies: Other dental anomalies besides size reduction or absence
of maxillary lateral incisors e.g. canine transposition with first premolar are associated with
8. Mohammed Almuzian, University of Glasgow, 2014 Page 8
PDC. A genetic interrelationship exists among tooth agenesis, systematic tooth size reduction
and generalised retardation of tooth development.
2) Bilateral occurrence: High percentage of bilateral occurrence of PDC indicated an intrinsic
aetiology such as a genetic mechanism.
3) Sex difference: Sex ratio reporting patterns of male-female differences suggested genetic links
involving the sex chromosomes. Male to female prevalence rate ratios range from 1:1.3 to 1:3.2
which compare favourably with sex ratios recorded for other dental anomalies of genetic origin.
4) Familial occurrence: There was an elevated occurrence rates of PDC and various related
anomalies among other family member.
5) Population differences: The difference frequency of PDC in different populations, coincident
with racial grouping, is supportive evidence of genetic involvement in the aetiology of PDC.
Peck et al (1994) concluded that mechanical causes such as blockage form retained
primary canines or from dental arch space inadequacies were not valid. They also suggested that
PDC was not a dependent variable of anatomical variations of the maxillary lateral incisor but
that the associated canine and lateral incisor phenomena are covariables: coincident traits
appearing within the context of genetic control. The clinical significance of genetic theory is that
siblings are at a higher risk of having PDC than other members of the population
Diagnosis unerupted teeth
1. Inspection
Clinical signs of impacted 3s
Delayed eruption
Asymmetrical eruption
Prolonged retained c
Absence of buccal budges at age of 10 years
Presence of palatal budges
Angulated laterals
Change colour of 1 or 2
9. Mohammed Almuzian, University of Glasgow, 2014 Page 9
2. Palpation and percussion
a) Palpation of the upper canines is a vital step in assessing the developing dentition.
b) Deciduous canines or adjacent permanent teeth should be checked for mobility, tenderness and
vitality
3. Diagnostic imaging and unerupted teeth
Features of ectopic maxillary canines that should be determined by radiographs
1. Presence or absence of the canine
2. Overall stage of dental development
3. Local anatomic considerations
4. Size of the follicle
5. Inclination of the long axis of the tooth
6. Relative buccal and palatal positions
7. Relative superior-inferior positions
8. Amount of the bone covering the tooth
9. 3D proximity and resorption of roots of adjacent teeth
10. Condition of adjacent teeth
Radiographical techniques
I. Right angle technique
a. The use of two radiographs taken at right angles to one another allows three dimensional
localisation of the canine; e.g.
• Lateral and posterio-anterior cephalometric films
• Occlusal vertex film with OPT
• Mand occ and opt or ceph for lower canines
b. But this technique need additional film for fine details.
Disadvantages associated with the vertex occlusal radiograph:
1. A large radiation exposure since the brain, the pituitary, salivary glands, thyroid, and the lenses
of both eyes receive unnecessary exposure.
2. The film is usually difficult to interpret.
10. Mohammed Almuzian, University of Glasgow, 2014 Page 10
Because of these disadvantages the British Orthodontic Society guidelines for radiography state
that there are very few indications for a vertex occlusal view in any patient even when taken with
rare earth intensifying screens/cassette.
II. Magnification technique
V.Gavel and L. Dermaut (1999) evaluated localization of impacted canine by using panoramic
tomograms to define the exact location and concluded that :
Although buccal impaction shortens the tooth length on the films ,this is mostly caused by its
inclination in a sagittal direction. The more thetooth is uprighted in the frontal plane, the more
pronounced the influence of the sagittal inclination on tooth length.
Displacing the impacted tooth in a posterior direction (i.e. palatal impaction) widens the crown
width. Inclination in a sagittal direction and uprighting towards the mid-sagittal plane enchances
this phenomenon.
The impacted position(Buccal/Palatal) of the impacted canine does not influence angulation
tooth-axis/ occlusal plane.This value changes negatively when the tooth is inclined in a sagittal
direction and positively when the tooth is uprighted in the frontal plane.
Buccal and median impaction ( in the frontal plane ) shorten the imaged distance to the mid-
sagittal plane compared with imaging of the well-aligned canine.Displacement in a sagittal
direction (palatal impaction) widens this distance.
The migration of the impacted canine in a sagittal or median direction projects the crown point
higher on the panoramic film than a canine bucally impacted at the same vertical level.
An increased curvature of the root of an impacted canine demonstrates an inclination of the tooth
in a sagittal direction.
Chaushu and Becker (1999) have described a method of localising maxillary canines using only
a panoramic radiograph. Sensitivity of this technique is 80%
III. Parallax technique (image/tube shift method, Clark’s rule, buccal object rule).
1. It is first described by Clark in 1909
11. Mohammed Almuzian, University of Glasgow, 2014 Page 11
2. Principle of parallax. In radiologic terms, parallax is the apparent displacement of an image
relative to the reference object caused by an actual change in the angulation of the x-ray beam.
First they used 2 PA radiographs (Clark)
Then 2 occ radiographs
Then OPT+occ at 60 degree
Then OPT+occ at 70degree (Jacobes 1999 in order to increase the effect of parallax)
The horizontal shift in the horizontal parallex is 10-20 degree
3. DPT overestimates the angulation and underestimates proximity to midline (Ferguson, 1990)
4. Armstrong 2003 fond horizontal better than vertical parallex.
IV. CT spiral scanning
V. Cone beam volumetric tomography (CBCT), CBCT indicate if there is a possible resorption
which cannot be seen by conventional radiograph, Birnie recommend that CBCT would be
indicated in 30% of cases.
Classification of radiographical feature of impacted canine, Power & Short 1993
1. Angulation
Grade 1=0-15 degree,
Grade2=16-30,
Grade 3= more than 30
2. Vertical height
Grade 1=below CEJ,
Grade=above CEJ but less than half of root,
Grade 3= more than half but less than full root,
Grade4=above apex
3. AP position of root apex
Zone 1=at area of 3,
zone 2=above 4,
Zone3=above5
4. Coronal overlap
12. Mohammed Almuzian, University of Glasgow, 2014 Page 12
Sector 1=before lateral,
Sector 2= before long axis of 2,
Sector 3 after long axis but before central,
Sector 4=over the central). The same had been used by Kurol and Ericsson 1987.
5. Labio-palatal position of crown and root
6. Resorption
Radiographic Factors Affecting the Management of Impacted Upper Permanent Canines,l
Stivaros & Mandall, 2000
The aim of the investigation was to evaluate which radiographic factors influenced the
orthodontists' decision whether to expose or remove an impacted upper permanent canine and
was a retrospective, cross-sectional design. The sample consisted of all radiographic records of
patients referred to the Orthodontic Department at Manchester University Dental Hospital with
impacted upper permanent canines between 1994–1998 (n = 44). The following canine position
measurements were made from the OPG: angulation to the midline, vertical height, antero-
posterior position of the root, overlap of the adjacent incisor, and presence of root resorption of
adjacent incisor(s). The labio-palatal position of the impacted canine was assessed from the
lateral skull radiograph. Whether the impacted canine had been exposed and orthodontically
aligned or removed was also recorded.
Stepwise logistic regression analysis showed that the labio-palatal position of the crown
influenced the treatment decision, with palatally positioned impacted canines more likely to be
surgically exposed and those in the line of the arch, or labially situated, removed (P < 0•05).
Additionally, as the canine angulation to the midline increased, the canine was more likely to be
removed (P < 0•05).
The orthodontists' decision to expose or remove an impacted upper permanent canine, based on
radiographic information, seems to be primarily guided by two factors: labio-palatal crown
position and angulation to the midline.
Root resorption from ectopic canines
1. Resorption occurred as early as 9 years of age and reached a peak frequency around 10-11 years
(at the normal age of tooth eruption).
13. Mohammed Almuzian, University of Glasgow, 2014 Page 13
2. Incidence: 12% of cases with impacted 3's, amount underestimated with plane R/G, CT studies
show 48% of 2's demonstrate a degree of root resorption (Ericson and Kurol, 2000). Walker
2004 used CBCT and showed 67%
3. Aetiology of resorption:
• Active pressure during eruption.
• cellular activities in the tissues at the contact points.
4. Risk factors for resorption: Ericson & Kurol,1988
• Female
• Age <14yrs
• Horizontal palatal canines
• Advanced canine root development
• Canine crown medial to midline of lateral incisor
• Root of laterals in contact with crown of the canines
5. The following are not significant risk factors:
• Size of follicle,
• Quantity of deciduous canine root resorption
6. Classification of resorption asscoated with U3s (Ericson & Kurol,2000)
Grade 1: no resorption
Grade 2 cementum resorption only
Grade 3 cementum+dentine without pulp
Grade4 puplal involvement
Factors to be considered in the treatment planning (RCSEng 2010 Husain and McSherry)
1. Age
2. General oral health
3. Patient cooperation
4. Intra-arch relationship
5. Inter-arch relationship (Crowding / spacing)
6. Position of canine (A-P, vert, horiz.)
7. Resoption of the adjacent
14. Mohammed Almuzian, University of Glasgow, 2014 Page 14
8. Clinical condition of the 3 itself
9. Clinical condition of the Cs
Treatment options
1. No treatment, observe and monitor
Indications
1. Patient does not want treatment
2. Medical contraindication
3. Canine very displaced, ie high and above roots of incisors
4. No evidence of resorption of adjacent teeth or other pathology
5. Ideally good contact between lateral incisor and first premolar wih good aesthetics
6. Good prognosis for the deciduous canine
Radiographic monitoring should take place to rule out cystic formation (frequency unknown),
migration, resorption etc
2. Interceptive treatment
The principles of interceptive treatment for palatal canines are:
1. Remove any obstruction – this usually means removal of the deciduous canine
2. Ensure adequate space for eruption
Advantages
1. Good chance of improvement of 3
2. Reduce need for surgery
3. Reduce time for FA
4. Reduce risk of resorption
5. It’s only indicated if there is no root resorption.
Disadvantages
1. Not guarantee
2. Trauma to child
3. Loss of space
15. Mohammed Almuzian, University of Glasgow, 2014 Page 15
Evidences for interception of ectopic U3s
1. Extraction of c, Ericson and Kurol, 1988
• 46 consecutive ectopic palatally placed maxillary canines were studied.
• The children, 14 boys and 21 girls, were between 10 and 13 year.
• In (78%) the palatal eruption changed to normal after 12 months.
• It suggest that extraction of the primary canine is the treatment of choice in young individuals
(10-13 years) to correct palatally ectopically erupting maxillary canines provided that normal
space conditions are present and no incisor root resorptions are found.
2. Extraction of c in crowded and non-crowded cases, Power and Short, 1993
The only study for crowded cases
39 consecutive patients of mean age 11.2 years.
In general 62 % showed improvement in eruptive position.
In crowded cases the success rate was 14% as opposed to 86% in un-crowded cases.
Horizontal overlap of the nearest incisor was found to be the most significant factor. If this
exceeded half the tooth width, success was unlikely.
The presence of crowding was found to affect adversely the favourable eruption of the canine.
16. Mohammed Almuzian, University of Glasgow, 2014 Page 16
3. Extraction of c compared to control in a spilt mouth study, Bazagani 2014
Objective: To evaluate the effect of the extraction of deciduous canines on palatally displaced
canines (PDCs), to analyze the impact of the age of the patient on this interceptive treatment, and
to assess the outcome of one-sided extraction of a maxillary primary canine on the midline of the
maxilla.
Materials and Methods: This study included 48 PDCs in 24 consecutive patients with bilateral
PDCs. The mean age of the patients at diagnosis was 11.6 years (standard deviation 1.2 years).
After randomization, one deciduous canine of each patient was assigned to extraction, and the
contralateral side served as control. The patients were then followed at 6-month intervals for 18
months with panoramic and intraoral occlusal radiographs.
Results: The rates of successful eruption of the PDCs at extraction and control sites were 67%
and 42%, respectively, at 18 months. The difference between the sites was statistically
significant, and the effect was significantly more pronounced in the younger participants. A
significant decrease in arch perimeter occurred at extraction sites compared to control sites
during the observation period. No midline shift toward the extraction side was observed in any
patient.
Conclusions: The extraction of the deciduous canine is an effective measure in PDC cases, but it
must be done in younger patients in combination with early diagnosis, at the age of 10–11 years.
Maintenance of the perimeter of the upper arch is an important step during the observation
period, and a palatal arch as a space-holding device is recommended.
4. Extraction and space opening, Olive, 2002
Reported the treatment of impacted maxillary canines by the extraction of the deciduous canine
and creation of excess space for the impacted tooth.
The space which was created was 1 cm with the incisors being proclined and displaced up to 3
mm across the midline.
The results were impressive. 94% success rate.
5. HG and extraction Leonardi et al., 2004
3 groups:
17. Mohammed Almuzian, University of Glasgow, 2014 Page 17
Extraction of C + HG (to increase arch length); 80% success
Extraction of C only, (50% successful eruption of 3)
Control group, 34% success
6. HG and extraction, Baccetti et al., 2008
• 3 groups
1) Xtn C + HG, group 2) 88% successful eruption of 3,
2) with Xtn of C only, 65% successful eruption of 3,
3) control, group 3) 36% successful eruption of 3
7. RME and extraction, Baccetti et al., 2009
RME only 65.7%
No treatment: 13.6% .
8. HG+RME+extraction, Armi & Baccetti, 2011
The randomized prospective design comprised 64 subjects
three groups:
1. rapid maxillary expansion and cervical pull headgear (RME/HG); successful eruption was 86 %
2. cervical pull headgear (HG); successful eruption was 83%
3. untreated control group (CG), successful eruption was (36%).
9. RME + transpalatal arch+extraction, Baccetti 2011
Results and Discussion:
80 per cent for the RME/TPA/EC group,
79 per cent for the TPA/EC group,
62.5 per cent for the EC group,
28 per cent in the CG
18. Mohammed Almuzian, University of Glasgow, 2014 Page 18
Conclusions: The use of a TPA in absence of RME can be equally effective than the RME/TPA
combination in PDC cases not requiring maxillary expansion, thus reducing the burden of
treatment for the patient.
10. Extraction of C and D, Bonetti 2011
50% of canines in the ECMG improved position by one sector and 13% by two sectors, while on
32% of the canines in ECG improved by one sector and none by two sectors.
The extraction of maxillary first deciduous molars, in addition to the deciduous canines, appears
to create more space and allow canines, at risk from impaction, to improve their position
spontaneously.
11. A systematic review, Kurol 2011
No evidence-based conclusions could be drawn due to the few studies identified, the
heterogeneity in study design, and the unequivocal results
12. Cochrane review, Parkin N, 2009 and 2012
There is currently no evidence to support the extraction of the deciduous maxillary canine to
facilitate the eruption of the palatally ectopic maxillary permanent canine. Two randomised
controlled trials (Baccetti 2008; Leonardi 2004) were identified but unfortunately, due to
deficiencies in reporting, they cannot be included in the review at the present time
Why 3 erupt after c exo?
1) Removal of obstruction
2) Presence of c might cause inflammation of 3 follicle causing its delaying in eruption and its
removal will resolve this problem
3. Surgical removal
Indication
1. Pathology of 3
2. Good contact bet 2 and 4
3. Good c
19. Mohammed Almuzian, University of Glasgow, 2014 Page 19
4. Sever impaction
5. Poor compliance
Disadvantages
1. Surgery can further compromise prognosis of C
2. Poor esthetic
3. Loss of canine eminence
4. Alveolar bone loss
Mechanics of subsequent orthodontic treatment in canine substitution
4 as a replacement for 3, apply;
1. mesiopalatal rotation
2. buccal root torque
3. grinding the 4 palatal cusp
4. Surgical exposure and orthodontic alignment
Indication
• When IO fails
• Available space for 3
• Favourable position of 3
• Pt motivation
• No pathology with 3 or 1 or 2
Disadvantages
1. Root resorption
2. Pulp obiltarion
3. Necrosis of teeth
4. Ankylosis
5. Fenestration and PD problems
6. Discontinuation of treatment
20. Mohammed Almuzian, University of Glasgow, 2014 Page 20
7. Relapse
Types of attachment
Many types of attachments can be placed on the tooth . These include the cast-gold inlay, the
ligature wire around the cervical part of the tooth, the direct bonded attachment , a screw
cemented in the crown , the placement of a wire in a filling , or a hole in the tip of the crown
through which to pass a ligature wire.( Andre Fournier 1982 )
Position of attachment
The position of attachment on the crown is very important because it determines, in part, the
direction and especially the type of movement the traction will induce . The more horizontally
the canine lies, the more occlusal the attachment must be to assure a proper tipping of the tooth
to a vertical position. In another spatial plane the proper placement of the attachment ( more
mesial or distal , buccal or lingual ) can help rotate a tooth. ( Andre Fournier 1982 )
Mechanically erupt a palatal canine
Fleming et al 2010 (JO)
A. Early treatment to facilitate canine eruption (auxiliary appliances)
Sectional TMA spring with a palatal arch
TAD Chaushu et al (2008)
Archwires with loops
Magnet: Magnets have also been used for traction of exposed PDC (Darendeliler 1997b). A
small magnet is bonded on the exposed and then covered canine. An attraction magnet embedded
in a upper removable appliance is used to generate force for canine traction.
URA
Opposing arch with intermaxillary elastic
Elastomeric chain or string to main aw
21. Mohammed Almuzian, University of Glasgow, 2014 Page 21
modified TPA with ballista spring: Jacoby (1979) described a ballista spring, which was inserted
in the buccal tubes of molar and premolar bands and attached to the impacted canine, to extruded
exposed canine. The advantages of ballista spring include the following:
I. vertical force on the exposed tooth
II. without compressing the impacted tooth toward the adjacent roots
III. controlled force (60-100gm with 0.016” spring, 120-150gm with 0.018” spring)
IV. easily modified
V. better aesthetics
Catapult elastic
B. Treatment to mid-treatment mechanics to facilitate canine final alignment
A thin continuous ligature wire
Elastomeric traction to fixed appliance
Piggyback NiTi archwires
Nickel–titanium coil ligated to the canine in a similar fashion to elastomerics;
Stainless steel archwire auxiliary
Easy canine’ auxiliary for eruption of ectopic canine
Maxillary lingual arch with a fairlead strut
the cuspid through the fairlead’s lumen. Maxillary
lingual arch with a fairlead strut (Fair-lead means a
pulley, thimble, etc., used to guide a rope forming
part of the rigging of a ship, crane, etc., in such a
way as to prevent chafing.) Johnson 2012. The
22. Mohammed Almuzian, University of Glasgow, 2014 Page 22
anteroposterior and occluso-gingival positions of the fairlead can be adjusted by bending the
strut at its base. Its bucco-lingual position can be adjusted by coiling or uncoiling the terminal
fairlead’s eyelet.
C. After exposing the canine, usually the movement to align 3 include:
1. Eruption either passive (3-6months) or active to move it away from roots of other teeth to reduce
the risk of resorptions and to prevent overgrowth of soft tissue
2. Then buccal movement
3. Then root torque
Open or closed surgical exposure? McSherry, 1996
A. Open exposure
Advantages
Less bond failure
No need for re-surgery
Easy monitoring
Better rotational control
Disadvantages
More tissue removed and discomfort
Infection
Bone loss
Poor esthetic
Pd lig problem and gum recession
Closed exposure
Advantages
Less infection,
Less bone exposure
Rapid healing
Better aesthetic
23. Mohammed Almuzian, University of Glasgow, 2014 Page 23
Disadvantages
Re-surgery
Uncontrolled movement
Evidences for open and closed exposure?
There is no evidence to support one surgical technique over the other in terms of dental health,
aesthetics, and economics and patient factors. Parkin, 2008 (Cochrane)
Criteria to determine method of exposure, Kokich 2004
1. Labial or palatal or along the arch
2. Vertical position
3. Mesidistal position of canine over the 2 (if 3 overlaping 2 then apical repositiong is the best)
4. Amount of attached gingiva
The “tunnel technique”
Crescini A,ClauserC,Giorgetti R,Cortellini P,Pini PratoGP.Tunnel tractionof infraosseous
impactedmaxillarycanines.A three-yearperiodontalfollow-up.AmJOrthodDentofacial Orthop 1994;
105:61–72.32.
Crescini A,Nieri M,RotundoR, Baccetti T, CortelliniP,PratoGP. Combinedsurgical and
orthodonticapproachtoreproduce the physiologiceruptionpatterninimpactedcanines:Reportof 25
patients.IntJPeriodonticsRestorativeDent 2007;27:529–537.
In 1994, Crescini etal.(1994), proposedinthe internationalliterature the very favourableorthodontic
and periodontal resultsof the “tunnel technique”inrepositioning impactedcanines.A surgical-
orthodonticprocedure wasusedtotreatdeep infraosseousimpactedcanines(testteeth) associated
withthe persistence of the primarytoothin15 patientswhohad the contralateral canine normally
erupted(control teeth).The periodontal outcomewasevaluatedatthe endof the orthodontic
treatmentand3 yearslater.In the “tunnel technique”,afterextractionof the primarycanine,a
mucoperiostealflapwasraisedonthe buccal (sevencases) or palatal (eightcases) aspecttoexposethe
cusp of the impactedtooth.The empty socketof the primarytoothwasextendedtoreachthe impacted
cusp andto form an osseoustunnel.A chainwaspassedthroughthe tunnel andfixedtoabonded
24. Mohammed Almuzian, University of Glasgow, 2014 Page 24
device onthe impactedcusp.The flapwassuturedback intoitsoriginal position.The chain wasusedfor
tractionto the impactedcanine towardthe centerof the alveolarridge. Noattachmentlossandno
recessionwere observedatthe endof the active therapy or 3 years later.Nosignificantdifferencesin
keratinizedtissue widthwere observed betweentestandcontrol teethatthe follow-upexamination.
The purpose of a furtherstudybyCrescini etal (2007) was to evaluate the periodontal variablesof
impactedmaxillarycaninesthatwere treatedwithacombinedsurgical andorthodonticapproachaimed
at reproducingthe physiologiceruptionpatternof a largernumberof canineswithrespecttothe
original report.Twenty-five patientswhopresentedwithunilateral impactedmaxillarycanineswere
consecutively enrolled(age range,13.2to 23.2 years).They were treatedwithasurgical flapand
orthodontictractiondirectedtothe centerof the crest and were evaluated periodontallyatthe endof
treatmentandagainat a follow-upvisit(2to 5 years posttreatment).Pocketdepth,keratinizedtissue
width,and gingival recessionwere recorded.Atthe endof orthodontictreatment,all 25 treatedcanines
presentedwith normal pocketdepth(2.0± 0.3 mm) anda normal amountof keratinizedtissue (5.0±1.2
mm).Nositesshowedgingivalrecession.Atthe follow-upvisit,bothpocket depthsandkeratinized
tissueswere slightlyreduced.The combinedtechnique permitstractionof the impactedcaninestothe
centerof the crest,simulatingthe physiologiceruptionpatternandresultingincorrectalignmentand
goodperiodontal status.
25. Mohammed Almuzian, University of Glasgow, 2014 Page 25
Retention considerations after aligning maxillary impacted canines
The following measures are suggested to prevent relapse:
Full correction of torque
Early correction of rotations
Pericision
Bonded retainers
5. Transplantation, Moss, 1974
Indication
1. Failed IO
2. Pt willingness
3. Teeth for transplantation should have root development that is half to three-quarters complete.
4. Available space
5. No pathology
Disadvantages
1. Trauma
2. Rsorption
3. Ankylosis
4. Infection
NB:
• SURGICAL TECHNIQUE for transplant AS USUAL
• The use of template generated by CAD CAM system is valuable to prepare the receipt site before
transplantation (Cross 2013)
• If the position of the canine prevents orthodontic space regaring for future transplant, it is
recommended to extract the canine and park it under the mucosa until the space regain then
another surgery to transplant it again.
Success rates can be over 90% if transplanted into extraction socket
26. Mohammed Almuzian, University of Glasgow, 2014 Page 26
As low as 60% in artificially-formed sockets ( when tooth fully- developed)
6. Recommended approaches for the management of impacted and ankylosed maxillary canines
(Urebi 2013)
Extraction of the ankylosed tooth followed by prosthetic replacement.
Surgical luxation of the tooth followed by orthodontic traction.
Osteotomy of the dentoalveolar segment with immediate repositioning of the dentoalveolar
structures.
Osteotomy followed by intraoral distraction.
Osteotomy followed by heavy orthodontic forces
Osteotomy with partial repositioning followed by heavy orthodontic forces.
27. Mohammed Almuzian, University of Glasgow, 2014 Page 27
Lingual corticotomy of the dentoalveolar segment, followed by a labial corticotomy three weeks
later and a conventional orthodontic force.
Treatment of buccaly ectopic canine
• IO+relief crowding and provide space, it will commonly erupt spontaneously
• FA to complete alignment
• Might need exposure either closed or apical repositioning
(Mitchell, 2007)
A treatment difficulty index for unerupted maxillary canines, Pitt, Hamdan and Rock, 2006
The prognosis for alignment of an impacted maxillary canine is affected by several factors
(McSherry, 1996 RCS England):
1. Horizontal position
2. Angulation to midline.
3. Vertical height.
4. Bucco-palatal position.
5. Age of patient.
6. Rotation.
7. Coincidence of arch midlines.
8. Alignment and spacing of the upper labial segment.
Result of this study, Difficulty score in order: (Almuzian ACRONYM HAV BARMA)
28. Mohammed Almuzian, University of Glasgow, 2014 Page 28
Conclusion:
Unerupted canine is a common orthodontic problem. Palatally displaced canines (PDC)
contribute the majority of the total number of unerupted canines and impacted mandibular
canines are far less common. PDC is usually associated with anomalous or missing maxillary
lateral incisors while labial unerupted canines (maxillary and mandibular) are related to lack of
arch space. Many causative factors have been suggested in PDC. However, Lateral Incisors
Guidance Theory and Genetics Factors as Primary Origin attract the most of the attention.
Assessment with palpation supplemented with radiographs are recommended above the age of 10
years old. Parallax technique is used to localize the unerupted canine.
Complications of unerupted canines can be severe e.g. loss of maxillary lateral incisor due to
root resorption.
Treatment options for unerupted canine include :
a) extraction of primary canine
b) no treatment
c) surgical removal of canine
d) surgical exposure with or without traction
e) autotransplantation.
The decision should be based on :
a) age of the patient and development stage of the dentition
b) the position of the unerupted canine
c) other features of the malocclusion that may also require treatment
d) evidence of root resorption affecting the permanent incisors
e) the patient’s own perception of the problem and the amount of treatment that they are prepared
to undergo.
Different surgical exposure techniques have been reported. Minimising periodontal
complication after surgery is a major consideration especially in cases with buccally impacted
canines. Different orthodontic methods of traction have also been reported. The use of light
forces to move the impacted tooth, creation and maintenance of sufficient space in the arch for
29. Mohammed Almuzian, University of Glasgow, 2014 Page 29
the impacted tooth and provision of anchorage during canine extrusion are the main principles in
applying traction to surgical exposed canine.