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1. Management of impacted teeth
Done by : Dr Luma Najada
Supervised by : Dr Ahmad Tarawneh
Dr Jumana Tbaishat
Dr Bashar Momani
Dr Anwar Rahamneh

2. Contents :
1. Impacted upper canines
2. Impacted upper central insicors
3. Impacted lower second premolars

3. Impacted upper canines
• Impacted tooth : is a tooth that is prevented
from erupting into its normal functional
position by bone,
tooth or fibrous tissue.
• Impacted 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.

4. Eruption
• Calcification start at 4-5 months after birth.
• Has long path of eruption from the infra-
orbital place along the roots of upper laterals
causing ugly duckling space which resolve
later, and then pass along the buccal surface
of the C.
• Upper canine erupts at 11-12yrs, lower at 9-10
yrs.
• 3's palpable in buccal sulcus by 8-10 yrs.

5. Prevalence
• Developmentally absent 3's: 0.08% (Brin et al, 1986)
• Impacted 3's: 2% (Ericsson, 1986)
• F:M = 70%:30%
• Unilateral: bilateral = 4:1
• Palatal: 61%; in line of arch: 34%; buccal: 4.5%
(Mandal, 2000, Brin et al, 1986)
• Associated with peg lateral incisors (Brin et al 1986)
• High incidence associated with CI II div 2 malocclusions
(Moosy, 1994)

6. Complications
• 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

7. Etiology
1. Long eruptive path
2. Trauma with displacement of tooth bud.
3. intra-alveolar obstruction :
- Retained deciduous teeth
- Supernumerary tooth or odontome
- Pathology (dentigerous cyst)
- Thickened mucosa following early extraction of deciduous teeth
- Dental crowding

8. Theories of impaction
• Two main theories have been proposed :
• A ) Guidance theory :
• underlines a role of the lateral incisor root in guiding
the erupting canine crown in the proper direction
towards the dental arch.
• Evidences:
• • With small or developmentally absent lateral incisors,
the incidence are three times (Becker)
• • Associated with peg lateral incisors (Brin et al 1986)
• • High incidence associated with CI II div 2
malocclusions (Moosy, 1994)

9. • B) Genetic theory: (Peck et al., 1994, 1995),
• The palatal displacement of the canine is genetically determined.
• This theory is supported by other dental anomalies frequently
occurring in patients with the ectopically erupting canines, so-called
microsymptoms (e.g. small teeth, enamel hypoplasia, aplasia of
second premolars, infraocclusion of primary molars, etc.)
• Occurrence with specific race
• Occurrence in family
• Occurrence in female more than male
• Occurrence with specific syndrome
• Occurrence unilateral: bilateral is 4:1

10. Diagnosis
• A) Inspection
Clinical signs of impacted 3s :
• Delayed eruption.
• Asymmetrical eruption.
• Prolonged retained of C.
• Absence of buccal bulge at age of 10 years.
• Presence of palatal buldges.
• Angulated or flared laterals.
• Change colour of centerls or laterals .

11. • B) Palpation and percussion :
• Palpation of the upper canines is a vital step in
assessing the developing dentition.
• Deciduous canines or adjacent permanent
teeth should be checked for mobility,
tenderness and vitality.

12. • C) Diagnostic imaging of 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

13. Radiographical techniques
1. Right angle technique
• The use of two radiographs taken at right angles to one another allows
three dimensional localisation of the canine :
• Lateral and posterio-anterior cephalometric films
• Occlusal vertex film with OPT
• Mand occ and opt or ceph for lower canines
- this technique need additional film for fine details.
Disadvantages associated with the vertex occlusal radiograph:
1. 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.
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.

14. 2. Magnification technique
• Chaushu and Becker (1999) have described a method of localising
maxillary canines using only a panoramic radiograph.
• Sensitivity of this technique is 80%
• This depends on the fact that objects nearer the x-ray source ( and further
from the film) project a larger image than objects closer to the film and
further from the x-ray source. So palataly positioned canine looks larger
than adjacent or normal contralateral if present.
• Not precise technique.

15. 3. Parallax technique (image/tube shift method, Clark’s rule, buccal object
rule).
- It is first described by Clark in 1909
• 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
• Then 2 occ radiographs
• 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
• Armstrong 2003 fond horizontal better than vertical parallex.

16. 4. CT spiral scanning
5. Cone beam volumetric tomography (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.

17. • 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 2=above CEJ but less than half of root,
• Grade 3= more than half but less than full root,
• Grade4=above apex

18. • 3. AP position of root apex
• Zone 1=at area of 3,
• zone 2=above 4,
• Zone3=above5
• 4. Coronal overlap
• 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

20. Treatment options According to
RCSEng 2016 Husain and McSherry
• 1 ) No active treatment/leave and observe
Indications :
1. Patient does not want treatment
2. Canine very displaced, ie high and above roots of incisors
3. No evidence of resorption of adjacent teeth or other pathology
4. Ideally good contact between lateral incisor and first premolar wih good
aesthetics
5. Good prognosis for the deciduous canine
• Radiographic monitoring should take place to rule out cystic formation
(frequency unknown), migration, resorption etc

21. • Disadvantages :
• 1. Not guarantee
• 2. Trauma to child
• 3. Loss of space

22. • 2) Interceptive treatment by extraction of the primary canine in selected
cases , where the ectopic permanent canine is not severely displaced ,
there is some evidence that interceptive extraction of the adjacent
primary canine can result in an improvement in position of an ectopic
permanent canine.
• the patient should be aged between 10-13 years

23. • Ericson and Kurol : suggested that removal of
the deciduous canine
• before the age of 11 years will normalize the position of the ectopically
erupting permanent canines in 91% of the cases if the canine crown is
distal to the midline of the lateral incisor. On the other hand, the success
rate is only 64% if the canine crown is mesial to the midline of the lateral
incisor

24. Evidences of interceptive extraction of
primary canine

26. • 3) Surgical exposure and orthodontic alignment
• interceptive treatment fails .
• The patient should be well motivated
• No pathology
• Favourable position of 3.
• Available space for 3
• Disadvantage :
• 1. Root resorption
• 2. Pulp obiltarion
• 3. Necrosis of teeth
• 4. Ankylosis
• 5. Fenestration and PD problems
• 6. Discontinuation of treatment

27. • 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 )

28. • 4) Surgical removal of the ectopic permanent canine:
• Indication
• 1. Pathology of 3
• 2. Good contact bet 2 and 4
• 3. Good c
• 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

29. • 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

30. • 5) Transplantation
• Where interception has failed and grossly
malpositioned canine.
• ideally with open apex at 13-14 yrs. to aid vitality.
• optimal development stage for auto transplantation is
when the root is 50-75% formed = half to three-
quarters complete .
• The prognosis should be good for the canine tooth to
be transplanted with no evidence of ankylosis .
•

31. II) Impacted maxillary central incisors
• Delayed eruption of the permanent maxillary incisor teeth can be
considered in the following circumstances:
• a. eruption of the contralateral incisor occurred more than 6 months
earlier.
• b. the maxillary incisors remain unerupted more than one year after the
eruption of the mandibular incisors.
• c. There is a significant deviation from the normal eruption sequence (for
example, lateral incisors erupting prior to the central incisor).
• Incidence : 0.13 %
• the maxillary central incisor is the third-most commonly impacted tooth
after third permanent molars and maxillary canines.

32. • Causes of delayed eruption:
• General causes :
• Hereditary gingival fibromatosis .
• down syndrome .
• Cleidocranial dystosis .
• CLP.
• Localized causes :
• Crowding .
• Delayed exfoliation of primary tooth.
• Supernumerary tooth .
• Dilacerations.
• Abnormal position of crypt .

33. Management of unerupted central
incisors

34. III) Impacted lower second premolar
• • The mandibular second premolar is one of the most frequently
impacted teeth.
• • The recommended treatment is to extract the second primary
molar with or without removing the bone along the eruption path,
to uncover the tooth surgically and move it into the arch by
orthodontic treatment.
• • The prevalence of impacted premolars has been found to vary
according to age . the overall prevalence in adults has been
reported to be 0.5%.
• • Premolar impactions may be due to local factors such as mesial
drift of teeth arising from premature loss of primary molars; ectopic
positioning of the developing premolar tooth buds; or pathology
such as inflammatory or dentigerous cyst.
• • They may also be associated with over retained or infraocclusal
ankylosed primary molars or with syndromes such as cleidocranial
dysostosis .

35. Management of infra-occluded
primary second molars.

36. • Referrences
• Clinical Management of Impacted Maxillary Canines Samir E. Bishara
• Maxillary incisor impaction and its relationship to canine displacement
Stella Chaushu, DMD, MSc,a Yerucham Zilberman, DMD,b and Adrian
Becker, BDS, LDS, DDOc Jerusalem
• Mohammed Almuzian, University of Glasgow, 2014
• Johnston WD. Treatment of palatally impacted canine teeth. AmJ Orthod
1969;56:589-596. 2. Dachi SF, Howell FV. A survey of 3,874 routine full
mouth radiographs. Oral Surg Oral Med Oral Pathol 1961;14:1165-1169. 3.
Thilander B, Myrberg N. The prevalence of malocclu- sion in Swedish
school children. Scand J Dent Res 1973;81:12-20. 4