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Impacted canine
Dr.Bara Sultan
B.D.S, M.Sc, F.I.C.M.S
2008\ 11\ 4
Mosul university- College of dentistry-oral & maxillofacial surgery department
Upper canine are more frequently fail to
erupt than lower canine . In both cases
malposition of the unerupted tooth is
common and in some circumstances the
tooth lies a substantial distance from its
normal path of eruption .Failure of bilateral
upper canines to erupt properly is also a
frequent occurrence.
Mosul university- College of dentistry-oral & maxillofacial surgery department
• Normally, the maxillary canine teeth are the last
of the “anterior” teeth to erupt into place. They
usually come into place around age 13 and cause
any space left between the upper front teeth to
close tight together. If a cuspid tooth gets
impacted, every effort is made to get it to erupt
into its proper position in the dental arch.
• Canine =cuspid
• Premolar = bicusped
1- disturbance of the long axis of the tooth
germ .
2-scar tissue in the path of eruption .
3-Failure of the root of the deciduous
predecessor to resorbed.
4- ankylosis of the deciduous predecessor
5- congenital absence of the lateral incisors ,
the root of which may act as a guiding
influence for the canines.
Mosul university- College of dentistry-oral & maxillofacial surgery department
-maxillary canines start their development at
a higher level than and erupt after the
adjacent teeth .
with a greater distance to travel through the
bone to its normal position there is an
increased chance of deflection from its path .
In a crowded arch , the additional space
required for the canine may be taken up by
the first premolar which erupted before the
canine .
Mosul university- College of dentistry-oral & maxillofacial surgery department
If by the age of 13 the upper canine have
failed to erupt their position should be
investigated . By inspection the canine may
be partially erupted or there may be an
obvious bulge on either the buccal aspect of
the alveolar process or in the palate ,which
denote its position . A palatal impaction is
more common than the buccal.
Mosul university- College of dentistry-oral & maxillofacial surgery department
The exact position of the tooth and the
precise relationship to other unerupted teeth
must be determined .it is of particular
importance to determine whether impacted
tooth lying labially or palataly to the standing
teeth , so that the surgeon knows whether to
use a labial or palatal approach. If the
impacted tooth lies within the arch of the
standing teeth the use of both labial and
palatal approach may be indicated .
Mosul university- College of dentistry-oral & maxillofacial surgery department
Palpation of the maxilla through the labiobuccal
sulcus may also reveal the crown of the tooth to
be high in the maxilla and adjacent to the floor
of the nose .
Occasionally the lateral incisor may be proclined
due to the presence of the canine crown lying
labial to the root . Palatal inclination of the
lateral incisor can be caused by a palataly placed
canine which is impacted against the apical part
of its root .
Mosul university- College of dentistry-oral & maxillofacial surgery department
The periapical radiograph provide a fine
detailed picture of the tooth and its
surroundings
and
is
helpful
for
demonstrating the degree of root formation
of the canine , apical curvature , the
existence of any root resorption affecting
the adjacent lateral incisor and the presence
of an associated cyst .
Mosul university- College of dentistry-oral & maxillofacial surgery department
The relative radiopacity of the crown
of the impacted canine may assist in
the determination of the tooth
position (the more radiopaque lie
palataly )
Mosul university- College of dentistry-oral & maxillofacial surgery department
The occlusal views are 3 types ,anterior ,
vertex , and true . the vertex occlusal
technique is the only technique used for
determination of the true position of the
impacted tooth.
Mosul university- College of dentistry-oral & maxillofacial surgery department
the anterior occlusal radiograph is taken
the x ray tube is sited at the nasion
the vertex occlusal view the x ray tube is
arranged so that the central ray passes
along the long axis of the central incisors
the true occlusal view is taken with x
ray tube positioned so that the central
ray is at right angle to the film
Parallax method in this technique a
periapical radiograph of the area is taken and
the x ray tube is then moved in either mesial
or distal direction before a second periapical
film is taken .the two radiograph is then
compared and if the impacted tooth seen to
move in the same direction as the x ray tube
it is lying palataly , whilst if it moves in the
opposite direction it is lying labially.
Mosul university- College of dentistry-oral & maxillofacial surgery department
1- before the insertion of complete or partial denture or
a bridge .
2- to permit orthodontic alignment of other anterior
teeth.
3- where there is resorption of the root of an adjacent
lateral or central incisor .if resorption is noticed at time ,
it may be arrested by removal of the impacted canine ,
but , if resorption is marked ,exposure of the canine and
removal f the lateral incisor should be considered .
4 – where a follicular cyst has developed
Mosul university- College of dentistry-oral & maxillofacial surgery department
If the canine located buccally a buccal
incision should be made and if it is
impacted in the palate a palatal approach
is required .. If the long axis of the
impacted canine lies across the arch with
the root lies on one side and the crown
on the other both labial and palatal flaps
should be reflected from the beginning.
Mosul university- College of dentistry-oral & maxillofacial surgery department
In the edentulous patient one incision made
along the crest of the ridge will permit access
from both aspects .
Incision in the palate should never be made
directly over the impacted tooth . If the suture
edges of the flap rest over a socket this will
lead to the formation of an oroantral or
oronasal communication .
Mosul university- College of dentistry-oral & maxillofacial surgery department
Three sided flap is designed so that
complete interdental papilla is left at each
corner .after the flap has been raised a bony
bulge may be visible or palpable indicating
the site of the impacted tooth .occasionally
there is no clinical indication of the exact
position of the tooth .
Mosul university- College of dentistry-oral & maxillofacial surgery department
Sufficient overlying bone is removed to
expose the crown of the impacted tooth .if
root configuration prevent simple elevation
the root should be exposed over a good part
of its length before further force is applied .if
delivery of the canine still can not be effected
, the tooth must be sectioned at its neck and
the 2 segments removed separately .
Mosul university- College of dentistry-oral & maxillofacial surgery department
The length of the palatal incision will depend
upon whether one or two impacted canines are
to be removed .if two canines required
extraction the incision line runs in the gingival
crevice from the first molar region in one side
to the first molar in the opposite side . But if
only a single canines to be removed the incision
extend from the first molar in the side of
operation to the canine of the other side .
Mosul university- College of dentistry-oral & maxillofacial surgery department
The mucoperiosteal flap is raised with a
Howarth periosteal elevator ,working from
each side toward the midline .the
neurovascular bundle passing through the
incisive foramen should be divided with a
sharp scalpel close to the bone .
Mosul university- College of dentistry-oral & maxillofacial surgery department
Once the palatal mucoperiosteal flap has been
raised , the crown of the tooth may be
immediately visible , or a bulge may present in
the palate and there is a thin layer of bone
overlying the crown . The bone should be
removed to expose the neck of the impacted
tooth .
Mosul university- College of dentistry-oral & maxillofacial surgery department
If the impacted canine is lying in close
proximity to adjacent teeth , bone removal
must be restricted to the palatal and distal
aspect of the tooth .this approach will reduce
the risk of damage to the root of adjacent
incisor or premolars . After exposing the
crown of the tooth , it can be extracted with
Copland chisel elevator , otherwise tooth
sectioning is required .
Mosul university- College of dentistry-oral & maxillofacial surgery department
When the root of the canine lies across the
alveolar process between the root of the
standing teeth , in this case both palatal and
buccal flaps are raised .
A thin acrylic palatal splint held in place by a
clasp on the first molars , will prevent the
formation of a hematoma beneath the palatal
flap .
Mosul university- College of dentistry-oral & maxillofacial surgery department
Alternative methods of treatment of
the unerupted canine
1 – leave it in situ
2 - Surgical exposure
3- transplantation and surgical
repositioning .
Mosul university- College of dentistry-oral & maxillofacial surgery department
Leave it in situ
It is indicated when the impacted canine is
asymptomatic and its extraction might cause
damage to the adjacent teeth .
When there is intimate contact between the
lateral incisor and the first premolar where it
is acceptable from the esthetic point of view.
The patient should be kept under annual
review to see if any complication occur .such
as resorption of adjacent tooth or
progressive widening of the follicular space .
Mosul university- College of dentistry-oral & maxillofacial surgery department
Surgical exposure
An attempt is made to assist the eruption of a
malposed and unerupted canine into a
functional position . It is considered when :
1- there is adequate room in the arch to
accommodate the tooth .
2- the potential path of eruption is unobstructed
3- exposure of the crown can be carried out as
close as possible to the time at which normal
eruption would occur .
Mosul university- College of dentistry-oral & maxillofacial surgery department
Surgical exposure :the path of eruption is not
obstructed
Surgical exposure with orthodontic
traction: the path of eruption is obstructed
Surgical exposure with orthodontic
treatment (palatal approach )
The initial stage of the operation is to reflect
the mucoperiosteum and to remove the bone
overlying the tooth to expose the greatest
coronal diameter, the incisal edge and the
cingulum . before repositioning the palatal flap
a window is excised in it corresponding to the
bony cavity containing the crown .the flap is
then sutured as usual and a pack of iodoform
gauze should be pressed firmly in to the bony
defect so as to cover the exposed crown .
Mosul university- College of dentistry-oral & maxillofacial surgery department
This pack should be held in position with suture
and left insitu for 2-3 weeks to prevent
granulation tissue and mucosa from overgrowing
the denuded crown .after removal of the pack
the progress of eruption should be observed at
frequent intervals .
Following eruption of the tooth , orthodontic
treatment may be required to guide it into a
good position in the arch . Some times
orthodontic traction is arranged at the time of
surgery .
Mosul university- College of dentistry-oral & maxillofacial surgery department
Transplantation and surgical
repositioning
The success rate with transplantation is highest
for unerupted teeth which have open apices
because of the possibility of revascularization .
It is essential to establish that there is sufficient
space to accommodate the canine crown.
minimal space deficiency may be overcome by
grinding of the crown
, but otherwise
orthodontic therapy may be required to move
the premolar distally .
Mosul university- College of dentistry-oral & maxillofacial surgery department
The canine should be extracted carefully and
transferred to the surgically prepared socket
in the dental arch with the minimum of delay.
It is preferable that the root surface should
not be touched either with instruments or
fingers as the viability of the cementum and
periodontal membrane remnants will
determine the success of the transplant. The
tooth is stored under the flap until the new
socket is prepared .
Mosul university- College of dentistry-oral & maxillofacial surgery department
Root filling is not attempted so as to reduce
handling of the tooth . The transplanted tooth
should be splinted in its new position for a
month after the operation .
Mosul university- College of dentistry-oral & maxillofacial surgery department
1- hematoma can some times developed.
Patients will return with the hard palate
bulging down from the roof of the mouth
as a result of a large hematoma collection
.this complication can be prevented by
acrylic splint fabricated before surgery .
Mosul university- College of dentistry-oral & maxillofacial surgery department
2-perforation into the floor of the nose may
occur with some post operative nasal
bleeding . If a small opening is seen during
surgery it should be covered with a small
layer of gel-foam or surgicel or collagen
membrane before the mucosal closure .
Mosul university- College of dentistry-oral & maxillofacial surgery department
Thank you
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Mosul university- College of dentistry-oral & maxillofacial surgery department