Management of ectopic canine

Interception of displaced canine

• Management of ectopic canine is difficult• Early detection of an abnormal eruption path gives the opportunity

for interceptive measures.• Essential to routinely palpate for unerupted canine when examining child

aged 10 years old and older• also important to locate position of canines before undertaking the

extractions of other permanent teeth

Buccally ectopic canine

• Buccal displacement usually associated with crowding – relief of crowding prior to eruption of canine will usually effect in some spontaneous improvement• In erupted bucally displaced canine – managed by relief of crowding, if indicated,

and alignment usually with fixed appliance. • Extraction of the first premolars

• distalizing the maxillary molars and premolars to create space for accommodation of the canine

• In severely crowded cases ( no additional space exists to accommodate canine) extraction of canine itself may be indicated

• In impacted canine

surgical exposure of impacted tooth may be indicated

Then in order to apply traction to align the canine, an attachment can be

bonded to the tooth at the time of surgery.

A gold chain or stainless steel ligature can be attached to the tooth and used to

apply traction

Replaced flap. A mucoperiosteal flap was retracted so that an attachment could be bonded to the crown of the maxillary right canine. A twisted steel ligature was tied to the attachment and left lying against the bone. The flap was returned to its original position and sutured around the exposed loop of the ligature.

Displaced flap. This partial-thickness flap was raised from the gingival crest. It was then displaced apically and mesially so that a portion of the blocked-out tooth’s crown, with its bonded steel button and attached ligature, remained exposed to the oral cavity.

Palatally impacted canine

• There are various treatment modalities for palatally impacted canine. Patient and parent counseling on the various treatment options are essential.

• Factors affecting treatment decisions: patients opinion of appearance and motivation towards orthodontic treatment malocclusion position of displaced canine : is it within range of orthodontic alignment? presence of space/ crowding Condition of teeth

1. Interceptive Treatment by Extraction of Deciduous Canine

• Timely extraction of deciduous canine in patients aged 10-13 years with palatally ectopic canines has been found to normalize the eruptive path of canines within 12 months in 78% of cases (Ericson & Kurol, 1988).• will reduce the treatment complexity involved with impacted canine, the

treatment time and cost.

Indications (Ericson & Kurol, 1988.) Patients aged between 10-13 years Arches are spaced Ectopic canine root still developing Horizontal overlap of ectopic canine with lateral incisor not mesial to midline of

incisor (Ericson & Kurol, 1988.; Powers & Short, 1993.)

2. Surgical Exposure and Orthodontic Treatment • The purpose of surgical exposure is for alignment of the ectopic canine with

fixed orthodontic appliances.

• indications for the procedure:

Patient must be willing to wear fixed appliances Since the treatment time is normally prolonged, the general dental health of the

patient should be good When interceptive extraction is not feasible Favorable canine positionSpace available ( or can be created)

Whether orthodontic alignment is feasible or not depends on the three-dimensional positioned of unerupted canine

• Height :• The higher a canine is positioned relative to occlusal plane the poorer the prognosis.• access for surgical exposure will be more restricted• If crown tip is at or above the apical third of the incisor roots, rthodontic alignment will be very

difficult

• Anteroposterior position :• The nearer the canine crown to the midline, more difficult alignment will be.

• Positon of apex :• The further away the canine apex is from normal, the poorer the prognosis for successful

alignment

• Inclination :• The smaller the angle with the occlusal plane the greater need for traction

If these factors are favorable, the usual sequence of treatment is as follow:

Make space available

Arrange exposure

Allow the tooth to erupt for2-3 months

Commence tractionWith deeply buried canine, there is danger that gingiva will cover the tooth again. An attachment plus means of traction ( wire ligature or gold chain) can be bonded to the tooth at the time of exposure.

3. Surgical removal of canine• This option can be considered when :

• The patient refuses orthodontic treatment • The contact between the lateral incisor and first premolar is acceptable • Pathological changes associated with the ectopic canine or radiographic evidence of early

root resorption of the adjacent teeth • The ectopic canine is ankylosed and cannot be tract into the arch or transplanted. • Prognosis for the alignment of the ectopic canine depends on its 3 dimensional position. It is

poor when (Southall & Gravely, 1989):

The canine crown is tilted towards the midline of the arch The position of the crown tip is less than one third of the incisor roots The inclination of the canine is more horizontal Canine root apex is away from its normal position.

4. Transplantation Orthodontic alignment is preferable whenever possible. Autotransplantation can be an alternative to orthodontic treatment and surgical removal of ectopic canines if:

a. The patient rejects orthodontic treatment because of social and aesthetics reasons.

b. The canine is severely malpositioned and cannot be aligned orthodontically.

c. Sufficient space and bucco-palatal bone must be provided for the transplant.

Management of ectopic permanent first molars

Ectopic eruption of permanent molars is classified into two types: self-correctSixty-six percent of ectopic eruption permanent molars self-correct by age seven.others that remain impacted. permanent molar that presents with part of its occlusal surface clinically visible and part under the distal of the primary second molar usually does not self-correct and is the impacted type.

Guideline on Management of the Developing Dentition and Occlusion in Pediatric Dentistry, American Academy Of Pediatric Dentistry, revised 2014

• Treatment depends on how severe the impaction appears clinically and radiographically. • For mildly impacted first permanent molars, where little of the tooth

is impacted under the primary second molar, elastic or metal orthodontic separators can be placed to wedge the permanent first molar distally. (Warren JJ et al 2001)

• For more severe impactions, distal tipping of the permanent molar is required. (Yaseen SM et al, 2011)

• Tipping action can be accomplished with brass wires, removable appliances using springs, fixed appliances such as sectional wires with open coil springs, sling shot-type appliances, a Halter-man appliance, or surgical uprighting.

Guideline on Management of the Developing Dentition and Occlusion in Pediatric Dentistry, American Academy Of Pediatric Dentistry, revised 2014

Halter-man appliance

orthodontic separators

Unerupted central incisor

• Neil, a 9-year-old boy, presents with 11 unerupted

Sequence in management of unerupted 1.Obtain oral surgical/orthodontic opinion (and possibly paediatric dental

opinion); if prognosis for 1 alignment judged satisfactory then,Open space for unerupted 1 (may involve primary tooth extractions).Remove supernumerary.Bond attachment to 1.

an attachment with a length of gold chain should be bonded to 1 followed by flap replacement (closed technique).

Do not surgically expose 1.Align 1 with appropriate appliance. ( removable appliance)Maintain 1 correction with bonded retainer.Reassess malocclusion regarding further treatment needs.

It is likely that further treatment, probably loss of a premolar unit from each quadrant and fixed appliance therapy, will be required at a later date and detailing of 1 position can be undertaken at that stage

Upper removable appliance to open space for 1.

Following extraction of four first premolars, fixedappliance therapy

Refferences

• Millett D, Welbury R, Clinical Problem Solving in Dentistry Orthodontics and Peadiatrics Dentistry © 2010 Elsevier Ltd. All rights reserved.• Laura Mitchell, An Introduction to Orthodontics, Fourth Edition• Clinical Practice Guidelines, Management Of The Palatally Ectopic Maxillary

Canine , Ministry Of Health Malaysia September 2004• Guideline on Management of the Developing Dentition and Occlusion in Pediatric

Dentistry, American Academy Of Pediatric Dentistry, revised 2014.• Hessa M Alkhal, Bakr Rabie,Ricky W K Wong, Orthodontic tooth movement of

total buccally blocked-out canine: a case report, Cases Journal 2009, 2:7245