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Case report
Published on 04/06/96
Orthodontic Case Report
Dr. Gabriele Floria DDS
The impaction of maxillary
permanent canines is a delicate problem for both its functional and aesthetic
implications. It requires the coollaboration of the oral surgeon, the ort hodontist and
the periodontist.
When there is a palatal bilateral impaction and the patient is an adult, various factors
which influence our clinical decisions must be considered.
A good clinical and radiographic examinations are essential to reach an accurate
diagnosis.
The absence of the canine bulge at earlier ages
should not be consider indicative of canine impaction (2).
Shafer et al.(3) also consider canine
impaction to be responsible for:
These sequelae may generate pain,
but usually impaction of maxillary canine is completely asymptomatic.
The purpouse of a radiographic examination is:
Various radiographic exposures, occlusal films,
panoramic views, lateral cephalograms, periapical films and tomography can be used. The
first examination should be the orthopantomograpy because it gives us the most
information.
Moreover putting the orthopantomogram on the
diaphanoscope, making a slide of the area involved, and transferring it on photo CD (Kodak
system) a digitized high resolution computer image can be obtained.
The computer also help us in comparing the
dimensions of the impacted tooth with the corresponding one should it be present, in order
to establish whether the impacted tooth is lingual or buccal. Since the X-ray moves in a
straight line, if the impacted tooth is buccal its image will be bigger than the
controlateral canine.
The enlargement of the radiological image is also
important to verify the absence of ankylosis, in which case the orthodontic treatment may
be very difficult or impossible.
Radiographically the ankylosis can be defined as
the absence of a periodontal ligament (radiolucent line) which is a sign of the fusion of
cement with alveolar bone (4).
If the panoramic view doesn't give us sufficient
information about the tooth location a periapical films following Clark's rule (tube
shift) can be used. In this technique the orizontal angulation of the cone is changed when
the second film is taken. If the tooth moves in the same direction as the cone, it is
lingually positioned, otherwise it is buccally located.
There are several treatment options:
This last option is
obviosly the most desirable situation.
Caso Clinico
 |
A 30 year-old male, heavy smoker,(fig.1) was
referred to the orthodontist by his family dentist. The clinical examination showed the presence of the left
deciduos canine, and distal migration of lateral and central incisors.
The absence of a canine bulge and the presence of a
bilateral palatal bulge were noted upon intraoral palpation.
There were no symptoms. |
 |
Panoramic radiographs showed the presence of two
impacted canines (fig.2). Considering the good morphology of the teeth, the position and
the absence of ankylosis, in agreement with the oral surgeon the surgical-orthodontic
disimpaction was decided. A fixed superior ceramic appliance was applied. |
 |
The oral surgeon performed the surgical exposure of
the impacted teeth and the orthodontist attached an auxilliary button directly to the
crown's enamel on the palatal side. This
one-step approach is preferable, and to assure good bonding to the enamel the exposure
should be the least traumatic possible. A fibrine sponge is useful to reduce the bleeding
around the crown, and a pariodontal curette can be used to remove the primary cuticle from
the enamel. An orthophosphoric acid (37 %) was used for 40 second and the button was
bonded. A ligature with several holes was prepared and attached to the button before
bonding (fig.3). |
 |
The surgical exposure was very
conservative. Only the bony tissue over the crown was excised and the flap completely
sutured.
We consider this light surgical
exposure to be beneficial to the future periodontal health. After a week the suture and
the surgical dressing were removed, and light orthodontic force (no more 60 grams/2
ounces) with elastic ligatures was started. |
 |
Concurrently sufficient space was created in the
arch thus reducing the diastema. A preformed round arch wire 0.020 was used to provide
sufficient stiffness. During the treatment two
endoral radiographs were made on each side to ensure that the movement of canine was not
damaging the roots of the neighbouring teeth. |
 |
When the crowns were erupted a metallic canine
bracket was bonded, and the remaining movements were made with sectional, later
repositioning the bracket twice. A Flexiloy tm (Unitek) * 0.021 X 0.025 was the finishing
arch and an Essix reteiner was used for retention. |
 |
 |
The active treatment lasted 2 years and 2 months
long. Both the canines at the end of treatment
had good periodontal conditions. |
Bibliografia:
1) Samir Bishara: Impacted maxillary
canines: A review. Am.J.Orthod. Dentofac. Orthop. 101;2:159-171,1992.
2) Ericson S,Kurol J. Longitudinal
study and analysis of clinical supervision of maxillary canine eruption. Comunity Dent.
Oral Epidemiol. 14:112-6, 1986.
3) Shafer W.G.; Hine M.K.; Levy B.M.;
A textbook of oral patology 2nd ed. W.B. Saunders Co.,Philadelphia, 2-75:1963.
4) Moyers R E. Handbook of
orthodontics, Second Ed., Chicago: Year Book Medical, 83-88,1963.
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