Treatment concept by Watted for a controlled alignment of palatally impacted maxillary canines

Pyrex Journals 2035-9876
Corresponding Author: abuhusseinmuhamad@gmail.com
Pyrex Journal of Dentistry and Oral Hygiene
Vol 0 (0) pp. 000-000 September, 2015
http://www.pyrexjournals.org/pjdoh
Copyright © 2015 Pyrex Journals
Original Research Article
Treatment concept by Watted for a controlled alignment
of palatally impacted maxillary canines
Nezar Watted1, Muhamad Abu-Hussein2*, Ala-Eldeen Sabbagh3, Peter Proff4 and Borbély
Péter5
1
University Hospital of Würzburg, Clinics and Policlinics for Dental, Oral and Maxillofacial Diseases of the Bavarian Julius-Maximilian-
University Wuerzburg, Germany.
2
Department of Pediatric Dentistry, University of Athens, Greece.
3
Private clinic, Erlangen, Germany.
4
University Hospital of Regensburg, Department of Orthodontics, University of Regensburg, Germany
5
University of Debrecen, Hungary
Accepted 8th October, 2015
It is known that maxillary canines remain impacted more often than the mandibular canines, and the inclusion can be
buccal or palatal. The treatment focuses mainly on the exposure and on the orthodontic realignment of the impacted
tooth. There are situations when canines erupt spontaneously after their surgical discovery. The present paper has the
purpose of approaching aspects related to impacted upper permanent canines by a literature review, including
localization and treatment conducts.
Key words: Impacted canine, periodontal, surgical-orthodontic treatment.
INTRODUCTION
Impacted teeth are those with a delayed eruption time or that
which are prevented from erupting into their normal functional
positions because of malposition, lack of space or some other
barriers and are not expected to erupt completely based on
clinical and radiographic assessment [1]
. The maxillary canine
is the second most frequent tooth to be impacted after the third
molars [2]
. The prevalence of impacted canines in the general
population is 1-2.2% and only one study reports it to be as high
as 3.85% [3]
. A total of 70-85% of these are located palatal in
the dental arch [4, 5]
. Females tend to be affected by this
condition twice as frequently as males [6, 7]
. The etiology is
multi-factorial and includes, extended development time, long
path of eruption, and the late sequence of eruption than any
other tooth in the anterior maxillary region [1-4]
. Furthermore
palatal and buccal impactions are considered to be two entirely
different entities with different etiologies, where lack of space
accounts for buccal impaction and excess space is held
responsible for palatal impactions, this is supported by the
finding that 85% of palatal impactions had sufficient space in
the arch to erupt [1]
. The authors explain this phenomenon by
assuming the canine has sufficient space to move from a more
buccal to palatal position rendering it impacted [1,2]
.
Palatal impacted canine requires a good surgical
exposure to guide it in occlusion. Once a palatal impaction is
confirmed and arch is prepared for the eruption of the impacted
canine, a full-thickness muco-periosteal flap is elevated in the
area of the impacted canine and the bone over the crown is
removed. The flap is repositioned, and a ligature wire is
passed through the gingival flap to apply light traction. Gingival
tissue on the erupted canine is generally adequate [1, 3]
.
Ectopic labially positioned canines may erupt on their own
without surgical exposure or orthodontic treatment, frequently
high in the sulcus or alveolar ridge. Conversely, palatally
impacted canines seldom erupt without intervention. It is
believed that this obstructed eruption is caused by the
thickness of the palatal cortical bone as well as the dense,
thick, and resistant palatal mucosa. Palatally impacted canines
are more often inclined in a horizontal/oblique direction,
whereas labial impactions usually offer a more favorable
vertical angulation. Yet the latter is still considered difficult
because of the needed delicacy in managing the associated
hard and soft tissues. Either an open or a closed surgical
approach can be used to uncover the crown of an impacted
tooth and to place an orthodontic attachment. The position of
the impacted tooth within the alveolus generally determines
which approach is used. In the open approach (OA), a gingival
flap is reflected or soft tissue is excised, and bone over the
crown is removed, creating a window to expose the crown of

M u h a m a d e t a l P Y R X . J . D e n . O r a . H y g | 002
www.pyrexjournals.org
the tooth. A periodontal pack is placed to prevent the window
from closing [12]
.
The advantages of the OA include the orthodontist’s
ability to observe the impacted tooth as it is moved and faster
eruption [13]
. In addition, bonding can be undertaken later under
more ideal conditions. The main problems associated with this
method are difficulty in cleaning the area, discomfort
associated with the wound and multiple periodontal concerns,
including gingival recession [14]
, bone loss, decreased width of
keratinized gingiva, and delayed periodontal healing and
gingival inflammation [12]
. Even when a decision has been
made to undertake an open approach, there are two further
options to be considered. The first of these is to permit natural
eruption of the canine and the second is to place an
attachment on the tooth at or very soon after surgery to
facilitate orthodontically-induced eruption [15]
. The spontaneous
eruption is most useful when the canine has a correct axial
inclination and does not need to be uprooted during its
eruption. The main disadvantages of this approach are the
spontaneous, but slow canine eruption, the increased
treatment time, and the inability to influence the path of
eruption of the impacted canine.
One of the important advantages of the placement of an
attachment is that when the force is applied to the impacted
tooth, the clinician is able to visualize and better control the
direction of tooth movement. This avoids moving the impacted
tooth into the roots of the neighboring teeth [12]
. In the closed
approach (CA), a gingival flap is reflected, exposing the crown
of the impacted tooth. The bone covering the crown is
removed, and an orthodontic attachment is placed. The flap is
replaced with a chain or wire extending from the attachment
into the oral cavity [12]
.
This procedure enables oral hygiene to be maintained
more readily and reduces post-operative discomfort. However,
direct inspection of the tooth is not possible post-operatively
and it may be difficult to keep the tooth sufficiently dry during
surgery to allow successful bonding [16]
. The purpose of this
paper was to describe a technique for the surgical exposure
and orthodontic positioning of an impacted maxillary canine.
CASE REPORT
A 45-year-old white male presented to Center for Dentistry
research and Aesthetics, Jatt/Israel for routine preventive and
restorative dental care. Clinical and radiographic examination
revealed palatal impaction of the maxillary right permanent
canine. The patient presented with a Class I molar relationship
with normal overbite and overjet. The only apparent space
discrepancy was in the immediate area of the impacted canine
(FIG 1a-d, FIG 2). A fixed appliance was placed in the upper
arch and lower arch. Adequate space for the canine was
gained during the leveling of the teeth and then by using a .018
round stainless steel wire with an open coil spring. The arch
was stabilized and quadrants secured with .018 x .025
stainless steel arch wire. The arch was now ready for surgery.
Arch preparations took approximately 5 months. After
adequate anesthesia was obtained using block and infiltration
injection of 2% lidocaine with 1:100,000 epinephrine, a full-
thickness mucoperiosteal flap was established. A palatal
sulcular incision was made which extended from the mesial
aspect of the left central incisor to the mesial aspect of the
second premolar (FIG 3 a). The flap was elevated and
retracted, and bone overlying the crown of the canine was
removed using a surgical bur and copious irrigation with
normal saline. Once adequate clinical crown was exposed,
hemostasis was achieved by applying direct pressure with
sterile gauze and cotton pellets (FIG 3 b).
Once a hemorrhage was controlled, the tooth surface was
isolated, etched with 35% phosphoric acid, rinsed with water,
and dried. The appliance used to apply traction to the canine
consisted of an orthodontic button, with a Titanium Button with
chain by Watted (Dentaurum, Ispringen /Germany), and
ligature wire, having been oriented such that traction would be
applied in a distal and facial direction. The appliance was tied
onto the arch wire via the ligature tie, and the flap repositioned
and closed primarily with interrupted sutures (FIG 3 c-f).
Postoperative instructions were given to the patient and parent
the sutures were removed 7 days post surgically, with excellent
wound healing. At 1-month intervals, the Titanium Button chain
by Watted (Dentaurum) was activated by tightening the ligature
tie. The first device to mobilize the impacted canine was
transpalatalbar with the extension that has been described by
watted. After the eruption of the impacted tooth, the second
phase of the concept has been used - segmental arch for
buccal movement of the tooth (FIG 3 g).
Movement of the canine was followed radiographically
and clinically by observing the amount of spring visible. Within
5 months, the canine was clinically visible and conventional
orthodontic mechanics were used to extrude, rotate, and align
the canine in the maxillary arch (FIG 4). The duration of
postsurgical active treatment was 14 months. After removal of
the fixed maxillary appliance, a Hawley retainer was placed.
The evaluation revealed bilateral Angle Class I molar and
canine relationships. The treated canine was in an excellent
position and alignment in the maxillary arch. Periodontal
assessment revealed healthy supporting tissues with normal
soft tissue color and texture; sulcus depths of the canine and
adjacent teeth ranged from 0 to 2 mm (FIG 5 a-d, FIG 6).

Fig. 1a-d: Clinical situation before the treatment, Lack of space for the tooth 13, excess space in the front
Fig.2: A patient before the treatment The Orthopantomogram shows the retention of tooth 13; the bone height is reduced because of
periodontal disease

Fig. 3a, b: Formation of a Mucoperiosteal flap and expose the crown of an impacted canine with substantial protection of the bone.
Fig. 3c-e: Titanium button with chain by Watted (DENTAURUM, Ispringen/Germany).
Fig. 3f: The full flap is now re-sutured into its former place and the titanium chain may be seen through the flap.

Fig 3g: Treatment concept by Watted for a controlled aligment of palatally impacted maxillary canines; Palatal bar with extension (0,9
mm springhard wire)
Fig. 4: clinical situation during active eruption of the impacted tooth
Fig 5a-d: Clinical situation after the treatment

Fig. 6: Orthopantomogram at the end of treatment
DISCUSSION
A combined surgical-orthodontic treatment is commonly used
to resolve tooth impaction. There are 2 basic surgical methods
for the exposure of a palatally impacted canine, i.e., the open
and the closed ones. There is considerable debate on the
issues of the choice of the surgical technique. The anatomical
structure of the soft tissue that covers the impacted tooth is
one of the major factors that determine the choice of a surgical
exposure method [1]
. The surgical-orthodontic treatment should
simulate the natural eruption pattern of the impacted tooth
through the attached gingival tissue. All palatal gingiva is
attached; therefore, both the closed and the open surgical
methods are appropriate. Other advantages of the surgical
techniques are discussed when comparing the operating time
and the extent of the surgical procedure [17]
, the patient’s
comfort after surgery, the need for repeated surgery, the time
of the eruption/extrusion of the impacted tooth, the overall
treatment time [18]
, the success of treatment, relapse, and post
treatment periodontal results. A lot of investigations concerning
the post treatment status have been limited to the evaluation of
only one of the surgical methods [19]
.
Orthodontist, Periodontist and the Pedodontist are the
stakeholders in the management of impacted teeth. The
various steps of the treatment involve firstly the pedodontist
giving an early diagnosis of impacted teeth. The orthodontist
intervenes presurgically for the creation of space and the
periodontist for the surgical exposure of the tooth [1]
. The
management of impacted canines, orthodontically is a daunting
task for most clinicians and knowledge of the extent of this
problem in our society is as important as finding a solution [2, 3,
4]
. Treatment should only be performed by a qualified specialist
orthodontist working in collaboration with a qualified specialist
oral and maxillofacial surgeon to maximize the effectiveness
and chance of successful orthodontic extrusion. Most teeth can
eventually be extruded through traction in those aged 12-22
years of age (95% success); although this may require 1 to 3
operations. One operation is by far the most common (95% of
successful extrusions). Repeat operations carry further
treatment costs. Gold chains are normally bonded to the
enamel of the buried crown, and this requires special glue. The
glue is designed to eventually detach from the tooth, but
spontaneous detachment occurs unpredictably in 10% of
impactions; this may (not always) lead to repeat operation. The
advantage of titanium button by Watted is the processing of the
surface with the laser. This increases the strength of the
attachment enormously, so that a detachment of the
attachment during the orthodontic extrusion is absolutely
minimized
With high nasal floor impactions, 2 chains may be glued
to the tooth due to high extrusion time; there is a higher risk of
spontaneous chain detachment during long treatment periods,
with all forms of impaction carrying a base level of such risk.
Teeth require 3-24 months of active orthodontic extrusion.
Orthodontists cannot rush extrusion; otherwise treatment can
devitalize the tooth (internal nerve death), or cause heavy root
resorption. Most teeth extrude at a rate of ~1/4-1cm/year.
Exposure and management of impacted teeth are both time
consuming and expensive and involves surgical exposure
(uncovering) followed by fixed orthodontic therapy for 2 to 3
years to bring the impacted tooth into alignment within the
dental arch. Two techniques for exposing impacted teeth,
which are routinely used are the closed technique and the
open technique. The closed technique involves orthodontically
moving the impacted tooth into its correct position beneath the
mucosa and the open technique involves orthodontically
moving the impacted tooth into its correct position after its
exposure [7, 8, 9]
. Wisth 1976, also compared the closed and

open techniques. The mean duration of treatment was 4
months or longer in the closed group which was attributed to
lack of direct vision of the impacted tooth from when it was
exposed and sequentially brought into the dental arch. The
teeth treated with the closed technique had less periodontal
damage, i.e. loss of attachment and bone levels [13]
.
Burden 1999, reviewed both the open and the closed
technique in terms of periodontal health and concluded that
there was no evidence to support either technique [20]
. Schmidt
2007, conducted a study comparing the periodontal health,
root length and aesthetics in cases with unilaterally and
bilaterally palatally displaced canines. Open technique was
used for the exposure and the canines were allowed to erupt
autonomously, later being brought into their position in the
dental arch with fixed orthodontic appliances. The outcomes
were compared to the contra-lateral untreated canine [21]
.
Another similar study was done by Woloshyn, where all
palatally displaced canines received a closed exposure. Both
studies found that the roots of the impacted canine and
adjacent lateral incisor were slightly shorter than those of the
contra-lateral canine and that the treated canine could be
visually identified from the untreated canine in 70% to 80% of
cases [22]
. Woloshyn, also found significant differences in
probing depths and crestal bone height when comparing,
treated with untreated canines; which was not in concordance
to the Schmidt's study. It was concluded that the overall
consequences to the impacted canine with this technique
seems better than with a closed technique, however
consequences to the lateral incisor were similar with both
techniques [23]
.
CONCLUSION
In conclusion, the management of impacted canines has a
multidisciplinary approach as it plays a vital role in esthetics
and function. Surgical exposure and orthodontic correction are
the most preferable treatment unless contraindicated.
Extraction of the impacted canine should be the last resort, as
every impacted canine should be treated in a hostile way to
prevent its complications. The development of treatment and
mechanical plans must be based on the careful analysis of the
clinical situation and identification of the correct force system is
necessary to obtain the desired tooth movement.
REFERENCES
[1] Becker A. Orthodontic Treatment of Impacted Teeth Wiley-Blackwell, 3rd ed.
2012;30-54
[2] Cooke J, Wang HL. Canine impactions: incidence and management. Int J
Periodontics Restorative Dent 2006;26:483-491.
[3] Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofacial
Orthop 1992; 101:159-71.
[4] Becktor KB, Steiniche K, Kjaer I. Association between ectopic maxillary
canines and first molars. Eur J Orthod 2006; 27: 186-9.
[4] Becker A, Sharibi s, Chaushu S. Maxillary tooth size variation in dentitions
with palatal canine impaction. Eur J Orthod 2002; 24: 313-8.
[5] Langberg B J, Peck S.Tooth-size reduction associated with occurrence of
palatal displacement of canines. Angle Orthod;2000; 70: 126–8
[6] McDonald F, Yap WL. The surgical exposure and application of direct traction
of unerupted teeth. Am J Orthod 1986;89(4):331–340.
[7] Conley RS, Boyd SB, Legan HL, Jernigan CC, Starling C, Potts C. Treatment
of a Patient with Multiple Impacted Teeth. Angle Orthodontist
2007;77(4):735-41.
[8] Stellzig A, Basdra EK, Komposch G. The etiology of canine impaction – a
space analysis. Fortschr Kieferorthop 1994;55:97-103.
[9] Gharaibeh TM, Al-Nimri KS. Postoperative pain after surgical exposure of
palatally impacted canines: closederuption versus open-eruption, a
prospective randomized study. Oral Surg Oral Med Oral Path Oral Radiol
Endod 2008;106:339-42.
[10] Alqerban A, Hedesiu M, Baciut M, Nackaerts O, Jacobs R, Fieuws S, at el.;
SedentexCT Consortium. Pre-surgical treatment planning of maxillary
canine impactions using panoramic vs cone beam CT imaging.
Dentomaxillofac Radiol 2013;42:20130157.
[11] Kokich VG, Mathews DP. Surgical-orthodontic management of impacted
teeth. Dent Clin North Am 1993;37:181-204
[12] Frank CA, Long M. Periodontal concerns associated with the orthodontic
treatment of impacted teeth. Am J Orthod Dentofacial Orthop. 2002
Jun;121(6):639-49.
[13] Wisth PJ, Norderval K, Boe OE. Comparison of two surgical methods in
combined surgical-orthodontic correction of impacted maxillary canines.
Acta Odontol Scand. 1976;34:53-7.
[14] Boyd RL. Clinical assessment of injuries in orthodontic movement of
impacted teeth. I. Methods of attachment. Am J Orthod. 1982
Dec;82(6):478-86.
[15] Ferguson JW, Parvizi F. Eruption of palatal canines following surgical
exposure: a review of outcomes in a series of consecutively treated cases.
British Journal of Orthodontics. 1997;24:203-7.
[16] Iramaneerat S, Cunningham SJ, Horrocks EN. The effect of two alternative
methods of canine exposure upon subsequent duration of orthodontic
treatment. International journal of paediatric dentistry / the British
Paedodontic Society [and] the International Association of Dentistry for
Children. 1998 Jun;8(2):123-9
[17] Pearson MH, Robinson SN, Reed R, Birnie DJ, Zaki GA. Management of
palatally impacted canines: the findings of a collaborative study. Eur J
Orthod 1997;19:511-5
[18] Gharaibeh TM, Al-Nimri KS. Postoperative pain after surgical exposure of
palatally impacted canines: closederuption versus open-eruption, a
prospective randomized study. Oral Surg Oral Med Oral Path Oral Radiol
Endod2008;106:339-42.
[19] Chaushu S, Becker A, Zeltser R, Branski S, Vasker N, Chaushu G. Patients
perception of recovery after exposure of impacted teeth: a comparison of
closed- versus openeruption techniques. J Oral Maxillofac Surg
2005;63:323-9.
[20] Burden DJ, Mullally BH, Robinson SN. Palatally ectopic canines: closed
eruption versus open eruption. Am J of Orthodontics and Dentofacia
Orthopedics 1999;115(6):640–4.
[21] Schmidt AD, Kokich VG. Periodontal response to early uncovering,
autonomous eruption, and orthodontic alignment of palatally impacted
maxillary canines. Am J Ortho & Dentofacial Orthopedics
2007;131(4):449–55.
[22] Woloshyn H,Artun J, Kennedy DB, Joondeph DR. Pulpal and periodontal
reactions to orthodontic alignment of palatally impacted canines.Angle
Orthodontist 1994;64(4):257–64.
[23] Parkin N, Benson PE, Thind B, Shah A. Open versus closed surgical
exposure of canine teeth that are displaced in the roof of the mouth
(Review). The Cochrane Library 2008; 4: 1-12.

Treatment concept by Watted for a controlled alignment of palatally impacted maxillary canines

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (7)

Similar to Treatment concept by Watted for a controlled alignment of palatally impacted maxillary canines

Similar to Treatment concept by Watted for a controlled alignment of palatally impacted maxillary canines (20)

More from Abu-Hussein Muhamad

More from Abu-Hussein Muhamad (20)

Recently uploaded

Recently uploaded (20)

Treatment concept by Watted for a controlled alignment of palatally impacted maxillary canines