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REVIEW

Impacted Maxillary Canine - At a Glance

Prasad Konda,1 Mohammad Urooj Ahmed,2 Syed Mohammad Ali,3 Amaranth Konda4

ABSTRACT
Maxillary canines are important teeth in terms of esthetic and
function. Impaction of canines is a common occurrence and
clinicians must have a sound knowledge to manage such cases.
With early detection, timely interception and well managed
surgical and orthodontic treatment; impacted canines can be
erupted and guided to an appropriate location in the dental arch.
This paper presents a literature review regarding etiology, clinical
and radiographic diagnosis, as well as surgical and orthodontic
management of impacted maxillary canine.
KEYWORDS: Impacted canines, surgical techniques, orthodontic
techniques.

Introduction
Maxillary canine are important teeth in terms of
esthetics, functional occlusion & arch development.The
likelihood of their failing to erupt or becoming impacted
may range between 1 & 3 %,1which shows its 2nd most
commonly impacted tooth after the third molars. It is
twice as common in females as it is in males. Incidence
of canine impaction in maxilla is more than twice that of
in mandible. Canine impaction is found palatally in 85%
of cases and labially in 15%.
Keywords:

ETIOLOGY
There is some incidence that patients with Angles class
II div 2 malocclusion and tooth aplasia may be at high
risk to the development of ectopic canine.2

8) Variation in root size of the lateral incisor.


9) Variation in timing of lateral incisor root
formation.
10) Iatrogenic factors.
11) Idiopathic factors.
SYSTEMIC FACTORS
1) Endocrine deficiencies.
2) Febrile diseases.
3) Irradiation.
GENETIC FACTORS
1) Heredity.
2) Malposed tooth germ.
3) Presence of an alveolar cleft.3
CLASSIFICATION :4
Table 1 shows classification of impacted canine
DIAGNOSIS OF IMPACTION:
The diagnosis of canine impaction is based on
both clinical and radiographic examinations.
Clinical evaluation:
It has been suggested that the following clinical
signs might be indicative of canine impaction:
(1) Delayed eruption of the permanent canine or
prolonged retention of the deciduous canine beyond 14
to 15 years of age,
(2) Absence of a normal labial canine bulge on
palpation.
(3) Presence of a palatal bulge, and
(4) Delayed eruption, distal tipping, or migration
(splaying) of the lateral incisor.
According to Ericson and Kurol,5 the absence of
the "canine bulge" at earlier ages should not be
considered as indicative of canine impaction.
An accurate diagnosis of clinical examination
should be supplemented with a radiographic
evaluation.
Radiographic evaluation:

LOCALIZED FACTORS
1) Tooth sizearch length discrepancies.
2) Failure of the primary canine root to resorb.
3) Prolonged retention or early loss of the primary
Several methods have been used to radiographically
canine.
evaluate impacted maxillary canines. These methods
4) Ankylosis of the permanent canine.
include intraoral techniques (occlusal and periapical
5) Cyst or neoplasm.
projections) and extraoral techniques (panoramic,
6) Dilaceration of the root.
posteroanterior or lateral cephalometric radiographs).6
7) Absence of the maxillary lateral incisor.
8) Variation in root size of the lateral incisor.
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2011 Int. Journal of Contemporary
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Occlusal
radiographs:
formation.

REVIEW
Occlusal radiographs:

SEQUELE OF IMPACTIONS:

The most practical method of obtaining an occlusal


radiograph is by positioning the x-ray tube directly over
the bridge of the nose, at a 60-degree angle to the
occlusal plane. This method has been used to determine
the bucco-palatal position of impacted teeth.

Shafers et al suggested that the following sequel might


be associated with canine impaction.
-Labial or lingual mal-positioning of impacted tooth,
-Migration of neighboring teeth and resultant loss of
arch length,
-internal resorption,
-Dentigerous cyst formation,
-External root resorption of the impacted as well as
neighboring teeth,
-Infections particularly associated with partial
eruptions,
-Referred pain,
-Late resorption of the unerupted canine itself,
-Loss of vitality of the incisors can occur,
-Poor esthetics associated with primary canines.5

Periapical radiographs:
Traditional method of locating impacted teeth,
specifically maxillary canines, has been the use of a twodimensional technique with periapical radiographs,
known as the buccal object rule. This technique consists
of taking two periapical radiographs at different
mesiodistal angulations and using the same-lingualopposite buccal (SLOB) rule to determine the tooths
buccolingual position. The radiographic interpretation
of the SLOB rule is if, when obtaining the second
radiograph, the clinician moves the x-ray tube in a distal
direction, and on the radiograph the tooth in question
also moves distally, then the tooth is located on the
lingual or palatal side. Accordingly, if the impacted
canine is located buccally, the crown of the tooth moves
mesially3
Extra oral radiographs:
(a) Frontal and lateral cephalograms 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).
(b) Panoramic films are also used to localize impacted
teeth in all three planes of space, 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.5
Cone-beam computed tomography (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.
7

In a study, Liu and colleagues used CBCT to evaluate


variations in location of impacted maxillary canines.
They found that the position of impacted maxillary
canines varies greatly. Reports of maxillary canine
impactions vary considerably in orientation, and CBCT
provides information to dentists so that they can
properly manage impacted canines surgically and
orthodontically.
However, increased cost, time, radiation exposure and
medicolegal issues associated with using CBCT, limit its
routine use8.

DIFFERENT TREATMENT MODALITIES


Each patient with an impacted canine must undergo a
comprehensive evaluation of the malocclusion. The
clinician should then consider the various treatment
options available for the patient, including the
following:
(a) No treatment if the patient does not desire it. In
such a case, the clinician should periodically evaluate
the impacted tooth for any pathologic changes. It
should be remembered that the long-term prognosis for
retaining the deciduous canine is poor, regardless of its
present root length and the esthetic acceptability of its
crown. This is because, in most cases, the root will
eventually resorb and the deciduous canine will have to
be extracted .
(b) Auto transplantation of the canine.
(c) Extraction of the impacted canine and movement of
a first premolar in its position .
(d) Extraction of the canine and posterior segmental
osteotomy to move the buccal segment mesially to
close the residual space.
(e) Prosthetic replacement of the canine.
(f) Surgical exposure of the canine and orthodontic
treatment to bring the tooth into the line of occlusion.
This is obviously the most desirable approach.5
MANAGEMENT OF IMPACTED MAXILLARY CANINES:
The most desirable approach for managing the
impacted maxillary canine is early diagnosis and
interception of the potential impaction. In absence of
prevention, orthodontic treatment and surgical
exposure should be conducted.
Kokich reported three methods for uncovering an
impacted maxillary canine

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REVIEW
Group

Position in maxilla

Close

Low

Close

3
4

Close
Distinct

Forward low & mesial to lateral incisor


root
High
High

Canine root apex is mesial to lateral incisor & distal to 1st


premolar
Erupting in the line of arch in place of it, & resorption root
of incisors.

Impaction

Labial

Palatal

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Table 1: Classification Of Impacted Canine


Proximity of line of arch

Table 2: Different Surgical Techniques For Labially And Palatally Impacted Canines
Exposure
Indications of
Indication of
Advantages
Disadvantages
technique
surgical
orthodontic
technique
treatment
Gingivectomy
Canine cusp is
Orthodontic traction
Easy to perform
Used only
coronal to the
is not required as the
occasionally
mucogingival
tooth tends to erupt
Less traumatic
Loss of attached
junction adequate
normally
gingiva
amount of
Possible damage to
keratinized
PDL
gingival is present.
Potential gingival
Canine is not
overgrowth at
covered by bone
surgical site.
Apically
Canine crown is
2-3 week after
Commonly used:
Increased risk of
repositioned flap
apical to MGJ, the
surgery
gingival recession,
amount of attached
Conservation of
Height differences
gingiva is
keratinized gingival
Relapse
minimized (used
More traumatic
when less than 3
mm of attached
gingival is present)
Closed eruption
Tooth is in the
1-2 weeks after
Greater esthetics
Pt discomfort
center of alveolus
surgery
Ease of tooth
Possible
Crown is apical to
movement
mucogingival
MGJ
problems
Closed flap
Canine is located
1-2 weeks after
Immediate
Bone recession,
near the lateral and
surgery
orthodontic traction
root resorption,
central incisors,
can be applied
longer operation
horizontally
time
positioned and
Repeat surgeries as
higher in roof of
a result of failure to
the mouth
erupt,
Bond failure due to
blood or saliva
contamination
Open eruption
Late mixed
When eruption is at Improved bone levels
Failure to erupt
dentition
level of occlusal
Little or no root
may extend total
Permanent
plane
resorption
treatment time that
dentition
Fewer exposure,
is unable to
shorter over all
influence the path
treatment, less time,
of eruption
good oral hygiene
during treatment

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REVIEW
Open window
eruption

Tunnel traction

Canine is located
near the lateral and
central incisor,
horizontally
positioned and
higher in the roof
of mouth

1-2 weeks after


removal of pack

Presence of
primary canine in
mouth

The suture is
removed 10 days
after surgery &
traction phase begin

Visualisation of
crown better control
of direction of tooth
movement
avoidance of
moving the
impacted tooth in to
the roots of adjacent
teeth
Reduced amount of
bone around
impacted tooth. The
permanent canine is
guided into
permanent canine
socket site

Gingival
overgrowth at
incisor site
Subjected to
infection.
Pt discomfort

Requires the
presence of primary
canine

Table 3 : Orthodontic Technique Used To Treat And Manage Impacted Maxillary Canines

STUDY

TECHNIQUE USED

ADVANTAGES

DISADVANTAGES

Fischer and
Colleagues10

Cantilever system.

Predictable tooth movement;


low load or
deflection; less frequent
reactivations

Potential side effects


should be identified on
the anchor tooth

Park and Collegues11

Temporary
anchorage devices.
(TADs)

Could provide absolute


anchorage for tooth
movement; bonding of
orthodontic brackets can
be delayed until the
canine is aligned

Does not produce root


movement; insertion and
removal of TADs

Kim and
Colleagues12

Double-archwire
Mechanics.

Requires laboratory
procedure; patient
discomfort

Schubert13

Easy-Way-Coil
(EWC) system.

Tausche and
Harzer14

Auxiliary arm from


transpalatal arch.

Minimizes root
resorption of the lateral
incisors; allows horizontal
tooth movement
Constant application of
force; a long activation
distance; simple
reactivation
Simple design; simple
Reactivation

Kornhauser and
Colleagues15

Auxiliary spring

Kalra16

K-9 spring Simple design;

Bishara17

The ballista spring is a


0.014, 0.016, or 0.018 inch
round wire, which
accumulates its
energy by being twisted on
its long axis.

No laboratory pro -cedure;


measured forces;
complete eruption control;
lack of damage to
adjacent teeth
Easy to
fabricate and activate;
continuous force
Control the direction of the
eruption of the impacted
tooth. Easily inserted and
ligated. Provides a
continuous force that is well
controlled.

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2011 Int. Journal of Contemporary Dentistry

Loosening of EWC
attachment; infectious
reactions in oral mucosa
Requires laboratory procedure;
tends to break easily
Requires extra chair time
to bend the spring

Side effects on the


posterior teeth
Molars and premolars are
affected

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REVIEW
1. Gingivectomy
2. Apically repositioned flap
3. Closed eruption technique. 9
SURGICAL TECHNIQUES:3

selection of surgical and orthodontic techniques is


essential for the successful alignment of impacted
maxillary canines.

Table 2: Shows different surgical techniques for


lingually and palatally impacted canines.
ORTHODONTIC ATTACHMENT :
To be in the position of being able to influence the
future development of an impacted tooth, its necessary
to place some form of attachment on the tooth.

References
1. Eve T. and Winfried H. Treatment of a patient with
Class II malocclusion, impacted maxillary canine with a
dilacerated root, and peg-shaped lateral incisors. Am J
Orthod Dentofacial Orthop 2008;133:762-70
2. Patrick F,Mcsherry. Ectopic maxillary canine :a
review. BJO 1998; vol25;No3;209-216

Different methods of attachment to the impacted


tooth have been suggested, including crowns, wire
ligatures, chain links, bands, and directly bonded
brackets.

3. Bedoya MM and Park JH. A review of the diagnosis


and management of impacted maxillary canines. J Am
Dent Assoc 2009;140;1485-1493

It is strongly recommended that the surgical exposure


of the impacted tooth be conservative to allow for the
placement of a bonded bracket or button.

4. Becker A. The Orthodontic Treatment of Impacted


Teeth. 2nd ed. Abingdon, Oxon, England: Informa
Healthcare; 2007:1-228.

ORTHODONTIC TECHNIQUES:

5. Ericson S, Kurol J. Resorption of maxillary lateral


incisors causedby ectopic eruption of the canines: a
clinical and radiographic analysisof predisposing factors.
Am J Orthod Dentofacial Orthop 1988;94(6):503-513.

Table 3: Shows orthodontic technique used to treat and


manage impacted maxillary canines
RETENTION CONSIDERATIONS:
To minimize or prevent rotational relapse, a fiberotomy
or a bonded fixed retainer may need to be considered
by the clinician after completion of the desired
movements and sometimes before the appliances are
removed. Clark suggested that, after the alignment of
palatally impacted canines, lingual drift can be
prevented by removal of a "halfmoon-shaped wedge"
of tissue from the lingual aspect of the canine.5

Conclusion
Management of the severely impacted canine is often a
complex undertaking and requires the joint expertise of
a number of clinicians. It is important that these
clinicians communicate with each other to provide the
patient with an optimal treatment plan based on
scientific rational.
When patients are evaluated and treated properly,
clinicians can reduce the frequency of ectopic eruption
and subsequent impaction of the maxillary canine. The
simplest interceptive procedure that can be used to
prevent impaction of permanent canines is the timely
extraction of the primary canines. This procedure
usually allows the permanent canines to become
upright and erupt properly into the dental arch,
provided sufficient space is available to accommodate
them.
Various surgical and orthodontic techniques may be
used to recover impacted maxillary canines. Careful

69

6. Bishara SE. Impacted maxillary canines: a review. Am


J Orthod Dentofacial Orthop 1992;101:159-71.
7. Liu DG, Zhang WL, Zhang ZY, Wu YT, Ma XC.
Localization of impacted maxillary canines and
observation of adjacent incisor resorption with conebeam computed tomography. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2008;105(1):91-98.
8. Elefteriadis JN, Athanasiou AE. Evaluation of
impacted canines by means of computerized
tomography. Int J Adult Orthodon Orthognath Surg
1996;11(3):257-264.
9. Kokich VG Surgical and orthodontic management of
impacted maxillary canines Am J Orthod Dentofacial
Orthop 2004;126:278-83.
10. Fischer TJ, Ziegler F, Lundberg C. Cantilever
mechanics for treatment of impacted canines. J Clin
Orthod 2000;34(11): 647-650.
11. Park HS, Kwon OW, Sung JH. Micro-implant
anchorage for forced eruption of impacted canines. J
Clin Orthod 2004;38(5):297-302.
12. Kim SH, Choo H, Hwang YS, Chung KR. Doublearchwire mechanics using temporary anchorage devices
to relocate ectopically impacted maxillary canines.
World J Orthod 2008;9(3):255-266.

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REVIEW
13. Schubert M. A new technique for forced eruption of
impacted teeth. J Clin Orthod 2008;42(3):175-179.
14. Tausche E, Harzer W. Treatment of a patient with
Class II malocclusion, impacted maxillary canine with a
dilacerated root, and peg-shaped lateral incisors. Am J
Orthod Dentofacial Orthop2008;133(5):762770.
15. Kornhauser S, Abed Y, Harari D, Becker A. The
resolution of palatally impacted canines using palatalocclusal force from a buccal auxiliary. Am J Orthod
Dentofacial Orthop 1996;110(5):528-534.
16. Kalra V. The K-9 spring for alignment of impacted
canines. J Clin Orthod 2000;34(10):606-610
17.Jacoby H the ballista spring system for impacted
teeth.Am J Orthodofacial Orthop 1979;75(2):143-151.

About the Authors

1. Dr. Prasad Konda

Reader,
Dept of Orthodontics and Dentofacial
Orthopedics,
Al Badar Dental College and Hospital,
Gulbarga, Karnataka.

2 Dr. Mohammad Urooj Ahmed

PG student,
Dept of Orthodontics and Dentofacial
Orthopedics,
Al Badar Dental College and Hospital,
Gulbarga, Karnataka.

3 Dr. Syed Mohammad Ali

PG student,
Dept of Orthodontics and Dentofacial
Orthopedics,
Al Badar Dental College and Hospital,
Gulbarga, Karnataka.

4 Dr. Amaranth Konda MDS,


Oral surgeon,
Hyderabad.

Address for Correspondence

Dr. Prasad Konda


Reader,
Dept of Orthodontics and Dentofacial Orthopedics,
Al Badar Dental College and Hospital, Gulbarga,
Karnataka.
docprasad18@yahoo.co.in
ph: (+91) 9440662988

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