Treatment and management of impacted canine with speed appliance

Palatally displaced canine
Labially impacted canine
Mandibular impacted canine

slideshare.net/sylvainchamberland

Side effect of straight wire
mechanics in the 2 nd order

• Detrimental side effect
! Intrusion and tipping of the canine and premolar
toward the canine space
! Cant of the occlusal plane

• Tx objective of canine extrusion
! To avoid side effects

Sem. Ortho. 1: p24, 2001 & 3: p156, 2001

©Dr Sylvain Chamberland

Da.Le.0309 Da.Le.0710

•Mx: 3 segments
•016 Supercable in the auxilliary slot
•Patient was instructed to wear !
elastic 3/3-4
•He didn’t...
•Mx: 19x25 TMA, 17-22
•016 Supercable in the auxilliary slot
•Patient was instructed to wear ! elastic 3/3-4
Da.Le.0710

Da.Le.150710
Da.Le.181010

•After 6 weeks
•Occlusal plane is leveled
•Box loop will continue uprigthing of #13

Da.Le.300811

Patient went to Afghanistan 10 months

August, 10 October, 10 August, 11

Selective approach to canine
eruption
• Main rigid archwire

• Flexible overlay auxiliary wire

• SPEED bracket
! Auxiliary slot and arch wire

Sem. Ortho. 1: p24, 2001


OOPS!
• .016 supercable / .016 CNT •.016 CNT / .016 X .022 CNT

May 14

June 25


Segmented approach to canine
eruption

• Main rigid archwire
! To prevent mesial molar tipping

• Cantilever spring
! Anterior extrusion, posterior intrusion

! Counterclockwise moment at the molar


Segmented approach to canine
eruption

• RPE and coil to open the space for the canine
• Cantilever for canine extrusion

• No intrusive side effect in the anterior region

Segmented approach
• Cantilever on a
removable appliance
! Excellent anchorage
Fr.Tr.121107
15 w
Fr.Tr.121107
26 w
! Very few, if any, side effects

Fr.Tr.250208 Fr.Tr.120508


Flexible overlay wire

• Mx: .020 x .020 HA NiTi
! Auxiliary .016SC

Ma.La.19-03-09

F.O.W.:15 weeks

Ma.La.19-03-09 Ma.La. 30-06-09

+7w

Ma.La. 30-06-09 Ma.La. 17-08-09

Ma.La. 17-08-09 Ma.La. 29-09-09

Detrimental side effect in 2nd order
• High #23

• Cl II elastic to enhance
Al.Du. 15-05-09
extrusion + distallization Al.Du. 05-08-09

of 23 + protraction of 36

• But
! Forces & moments move
teeth


Canine impaction
• Sentalloy coil spring to open space.

• Main arch: .019 X .025 CNT.

• Auxiliary wire: .016 CNT.


Canine impaction
• TPA .032 X .032 TMA + mesial
out on #18 and #26.

• Elastomeric chain from molar
hook to 2nd premolar.

• Coil spring to open space.


Transpose #23
• Baliste cantilever
! .017 NiTi spring

Ce.Che. 07-04-09

Ce.Che. 12-01-09

Could be used with PDC

Cantilever Arm

Che.Ce 070409

Che.Ce 210509

Cé.Ch. 21-05-09 • Anchorage loss
! Should have been
anticipated
! Poor collaboration
with elastic wear did
not help
Cé. Ch.16-06-09


• Tooth #22 was not
engaged since last 6
weeks

• Transposition is
corrected
Cé. Ch.15-09-09
Cé. Ch.16-06-09


Cé. Ch.05-11-07
Cé. Ch.24-08-11, 9 months into retention Cé. Ch.20-01-11, 2 months into retention

• Lack of septal bone
between 22-23 need to
be monitored

• Root resorption is noted



Ch.St-P. 0408

• Full thickness palatal ﬂap

• Create opening through palatal
mucosa

• At 4 months
! Main arch: .020 x .020 HA niti Ch.St-P. 27-06-08

! auxiliary wire: .016 HA niti

• Ligatures are retighten

! Bonded button #23 buccal
Ch.St-P. 06-10-08

• Canine bonded at 35 weeks

! auxiliary .016SC engaged

• At 11 months

! Canines are rebonded

Ch.St-P. 08-04-09


Ph.St-Pi. 08-04-09

• Transmucosa exposition «à la Kokich» Ph.St-Pi. 22-09-09

• Removable appliance & ﬁnger spring
cantilever

Ph.St-Pi. 22-09-09


• Sequence

! September: Engagement

Ph.St-Pi. 22-09-09
! October:1st control
Ph.St-Pi. 20-10-09
! November: 2nd control

! December, at 13 weeks:
Bond 13 & 23

! February, at 19 weeks

Ph.St-Pi. 03-02-10 Ph.St-Pi. 23-12-09


Fixed appliances only

Ch.St-P. 150408 Ch.St-P. 030211

144 weeks

Removable cantilever spring & ﬁxed appliances

Ph.St-P. 080409 Ph.St-P. 310811

120 weeks

Surgical approach
Full thickness ﬂap
Ostectomy
Curettage of the dental
follicle

Opening window
through the mucosa
Flap closed + sutured
Ga.Vi. 120510


Ga.Vi. 120510
Sentalloy uprighting spring
02-000-01& 00
Sentalloy rotating spring
10-003-01;02; 03;04
Ga.Vi. 230610
Ga.Vi. 260510 At 6 weeks
At 2 weeks

Ga.Vi. 040810
Ga.Vi. 150910
At 12 weeks
At 18 weeks

Ga.Vi. 120510
02-000-01& 00
10-003-01;02; 03;04
Ga.Vi. 150910 Ga.Vi.261010
At 18 weeks At 24 weeks

•Bond #13
".016 SC™ aux. wire.

Ga.Vi.151210 Ga.Vi.020211 Ga.Vi.230211
At 31 weeks
©Dr Sylvain Chamberland At 38 weeks At 41 weeks

Ga.Vi. 120510
02-000-01& 00
Ga.Vi.230211 10-003-01;02; 03;04

At 41 weeks

• Rebond 13; .016 sent. aux. wire

Ga.Vi.060411
At 47 weeks post ligation

Ga.Vi.060411
At 47 weeks post ligation

• Rebond #13; .016 sent.; #13 is engaged

Ga.Vi.180511
At 53 weeks post ligation; 75 weeks into treatment

Remarks

• Pulling an impacted canine with ﬁxed appliance, ﬁnger
spring or auxilliray wire is a good and predictable
approach

• However, using a removable appliance with SS cantilever
spring may be faster to bring the canine at the level of the
mucosa


Remarks

• For more details about surgical exposure go to

• http://www.slideshare.net/sylvainchamberland/2-0-
ruptions-ectopiques-approche-chirurgicale

• 2 0 Éruptions ectopiques_Management chirurgical des
canines incluses


Ma-Ch.Po010910
Canine ligated at 41
weeks

Ma-Ch.Po061010 Ma-Ch.Po120111

• Can you explain why the canine is
rotated? Evolution of the
Evolution at 19
• In which direction? canine in 5 weeks
• Why the force couple is done this weeks post ligation
way at 19 weeks? post ligation

Ma-Ch.Po060411
Ma-Ch.Po240811

Ma-Ch.Po120111

31 weeks post 51 weeks post
Evolution at 19
ligation ligation
weeks post ligation
72 weeks into tx 92 weeks into tx

92 weeks
• Extraction: x, x, x, x X X
X X
• Surgical exposure of 13
X
was delayed X

• Ligation could have been
done from start and
traction initiated with a
removable appliance and
cantilever spring


Ma-Ch.Po291009

92 weeks into tx
• Finishing bends
Initial
June 2010

Ma-Ch.Po240811


Impacted Lower Canine
• What is your diagnosis?
! ...

• Full thickness ﬂap.
Ch.Tr0610
Should have been ligate
Ch.Tr260810
enough apically to
expose the crown
9 weeks
! #33 engaged

Ch.Tr071010
• Healing at 7 weeks Ch.Tr251010

! Finger spring initiated 13 weeks
I let the ginviva heal for 3 months.
The keratinized gingival bridge has gone
A bracket was bonded in late march
©Dr Sylvain Chamberland 2011
Ch.Tr231110

Impacted Lower Canine
• I apologies.

• The outcome, despite 9 weeks
nice eruption of the
canine, is the worse case Ch.Tr251010
Ch.Tr260810 scenario in term of
keratinized attached
gingiva 13 weeks

• A keratinized tissue Ch.Tr231110

graft is necessary

Ch.Tr040411

Impacted canine
• Vestibular position
• #12 & 22: displaced labially and distally
• High vestibular bulge #23
• Labial vestibular bulge #33

Fr. Tr 02-06

• #13 buccal to # 12

• #23 horizontal

• #33 mesially tipped Fr. Tr 02-06


• Extraction of 53, 63, 73, 83
Fr. Tr 02-06

Fr. Tr 09-06


Fr. Tr 02-06 Fr. Tr 09-06 Fr. Tr 03-07

• Extraction of 54, 64, 74, 84

• Favorable auto correction
of 13 & 33

•
Fr. Tr 10-07

23 still horizontal


• Tx:

! Ligature of 13, 23, 33

! Traction with removable appliance

Fr. Tr 10-07


• Closed eruption technique

• Traction with elastics & Hawley

Fr. Tr 11-07

Fr. Tr 10-07

• #13

Fr. Tr 01-08


Fr. Tr 02-08


Fr. Tr 04-08

Fr. Tr 05-08

• Ready for braces
3rd order discrepancy
! Tx initiated july-08

Fr. Tr 06-08


• Mx: .016 supercable

• Md: .019 x .025 HA niti

Fr. Tr 15-09-08


• Mx: .018 supercable

• Md: .020 x .020 HA niti

Fr. Tr 09-12-08


• Mx: .020 x.020 HA niti

! To initiate torque correction 12 & 22

• Md: .020 x.020 HA niti

Fr. Tr. 03-02-09


• Mx: .020 x .025 Niti Speed wire

• Note 3rd order problem to be
corrected

Fr.Tr. 19-03-09


• Rebond #12 with special torque

• .020 x .025 niti SW

Fr.Tr.11-05-09


• Reassessment of bracket
position Fr.Tr.17-08-09

• Pr: exo #75 & #85


• May 09 to Feb 10

• Torque of 12 and 22
has improved with
Fr.Tr.11-05-09
full dimensional 20 x Fr.Tr.09-02-10

25 SW

• Delayed eruption of
lower 2nd premolar
extrend the
treatment time


• Open eruption technique
! Full thickness palatal flap

" Bonded button on canines

A-A Gag 1104
" Closing + suturing the flap

" Create opening through the flap

A-A Gag 0505


A-A Gag 0505 A-A Gag 0605 A-A Gag 0805

A-A Gag 1105 A-A Gag 1106

A-A Gag 0805

A-A Gag 1105

A-A Gag 1105



Ca-A.Bo.04-05

• Age: 20 y

• Extraction 53, 63

• Closed eruption approach


Ca-A.Bo.08-07 Ca-A.Bo.10-07

• Bonded button + elastomeric chain

• Correction of rotations 13 & 23

Ca-A.Bo.04-08
©Dr Ca-A.Bo.11-07
Sylvain Chamberland Ca-A.Bo.01-08

Ca-A.Bo.08-07

Ca-A.Bo.10-07

Ca-A.Bo.11-07


Ca-A.Bo.11-07

Ca-A.Bo.01-08

Ca-A.Bo.04-08

Ca-A.Bo.04-05

• Tx duration: 32 months

Ca-A.Bo.11-08 Ca-A.Bo.08-10 21 months into retention

Transposed 23-22

Au.De. 17-11-08 Au.De. 12-01-09


Au.De. 12-01-09

• Severe ALD


Au.De. 30-06-09. •md: .016 sent med

• #23 was pulled distally from the removable appliance

• Removable appliance provide a good anchorage

• Root movement of the lateral incisor by ﬁxed appliances
is avoided

Au.De. 11-08-09. •md: .016 x.022 neost


Au.De. 30-06-09. •md: .016 sent med

Au.De. 11-08-09. •md: .016 x.022 neost

Au.De. 22-09-09.


Au.De. 17-11-08

• 8 months into treatment
Au.De. 05-10-09.

• From now: treatment is easy

Au.De. 05-10-09. Mx: .016 SC

Au.De. 19-12-06

Au.De. 23-02-09

• Easy, but it tooks times to get it done! 129 weeks

Au.De. 15-08-11


2006

Au.De. 17-11-08

2008

• She's happy!

Au.De. 15-08-11

2011


Pa.Be. 15-08-08

• Classe I

• Impacted #13

• Severe ALD


• Retained #53

• Very heigh #13

• Impacted 8's

Pa.Be. 15-08-08


• Bimaxillary protrusion

• Tx plan
!


At 54 weeks
• #13 is erupting

• Side effects are noted
! Cant of occlusal plane

! Intrusion of 12, 11

• Brackets and wires don't move teeth
! Forces and moments does


Pa.Be. 24-02-10

• Forced eruption was stopped from sept 09 to
feb. 10

• Mx occlusal plane had to be leveled: 22 weeks

! Mx: .020 x .025 niti & .016 sent cantilever to
distalize and extrude #13


Mx: .020 x .025 niti

Md: .020 x .025 SS
Pa.Be. 24-02-10

Pa.Be. 26-05-10 Pa.Be. 07-07-10 Pa.Be. 01-09-10

• Cantilever was effective to distallize and erupt #13

• Elastic ! was used to promote extrusion of the canine


Mx: .016 sent

Pa.Be. 01-09-10 Md: .020 x .025 SS

• Lower premolar are protracted with EC

Mx: .020 x.020 neost

Pa.Be. 06-10-10 Md: .021 x .021 x .020 x38 mm HDGW

• Mx: .020 x .020 neost, EC 23-o-25-26-27

• Md: HDGW to protract molars; square anterior section including
premolars is recommended

Pa.Be. 06-04-11

• Mx: .021 x .025 TMA (6 weeks)

! Does it slide? No!

• Md: .021 x .025 SS from january 2011 to august 2011


Pa.Be. 22-08-11

• 154 weeks!!

• Retrospectively, I would use a removable appliance and a
cantilever spring to erupt #13.

• It would have save me detrimental side effects and weeks of Tx


• Fairly good root parallelism

Pa.Be. 22-08-11


• She's happy


• Next


Treatment and management of impacted canine with speed appliance

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Treatment and management of impacted canine with speed appliance