Ballista Spring - Palatally Impac Canine

IJCPD
Treatment of Maxillary Impacted Canine using Ballista10.5005/jp-journals-10005-1457

Spring and Orthodontic Wire Traction
CASE REPORT
Treatment of Maxillary Impacted Canine using Ballista

Spring and Orthodontic Wire Traction
1
Pradeep Raghav, 2Kanika Singh, 3C Munish Reddy, 4Divya Joshi, 5Shalu Jain
ABSTRACT with placement of an auxiliary attachment.2 Orthodon-

tic forces are subsequently applied to the attachment
In orthodontic practice, impaction of maxillary permanent
to move the impacted tooth. This is a case report that
canines is a frequently encountered clinical problem. After the
third molar, the canine is the most frequently impacted tooth. illustrates the effects of Ballista spring for the eruption
For functional occlusion, bringing the impacted canine into of palatally impacted canine.
occlusion is important to achieve final esthetic in orthodontic
practice. This article illustrates a distinct case in which the three CASE REPORT
permanent canines maintained their unerupted status till the
age of 18 years. The three impacted canines were surgically A 18-year-old female reported with a chief complaint of
exposed, attachment bonded, traction given with ballista spring retained milk teeth in upper and lower front region. On
for vertical and labial movement, and ideally positioned with extraoral examination, the profile of patient was convex
fixed orthodontic mechanotherapy.
with normal interlabial gap (Fig. 1). On intraoral exami-
Keywords: Ballista spring, Canine impaction, Surgical nation, she presented with end-on molar relationship
exposure. on right and left side, with unerupted maxillary canines
How to cite this article: Raghav P, Singh K, Reddy CM, Joshi D, and mandibular right canine, retained deciduous canine
Jain S. Treatment of Maxillary Impacted Canine using Ballista except for left mandibular canine. Palatal bulge was iden-
Spring and Orthodontic Wire Traction. Int J Clin Pediatr Dent tified in the maxillary left and right palatal region sug-
2017;10(3):313-317.
gestive of the position of the impacted canines. Spacing
Source of support: Nil was present between lateral incisor and canine on left
Conflict of interest: None side. Anterior cross-bite and rotation was present with
respect to the right lateral incisor with normal overjet
and overbite (Fig. 1). Orthodontic records were taken,
BACKGROUND
which included maxillary and mandibular impressions,
The reported incidence of impacted teeth is 0.921 and extraoral and intraoral photographs, lateral cephalogram,
1.7%.2 According to Bishara,2 the most common causes orthopantomogram, and cone beam computed tomogra-
for canine impactions are usually localized and are phy (CBCT; Fig. 2). The panoramic radiograph showed all
the result of any one, or a combination of the follow- permanent teeth including developing third molar buds
ing factors: (a) Tooth size–arch length discrepancies, and impacted maxillary right and left canine. The left
(b) prolonged retention or early loss of the deciduous and right maxillary canine were mesially inclined toward
canine, (c) abnormal position of the tooth bud, (d) the the midline with angulation to the midline of 31° and 30°
presence of an alveolar cleft, (e) ankylosis, (f) cystic respectively. They were overlapping, the mesial third of
or neoplastic formation, (g) dilaceration of the root, the maxillary lateral incisor and as par the sector classifi-
(h) iatrogenic origin, and (i) idiopathic condition with cation3 were in sector IV (Fig 2). The CBCT evaluation of
no apparent cause. Two most commonly used methods impacted canines was done in relation to adjacent teeth.
for exposing impacted canine are (1) surgical exposure, A fixed mechanotherapy with nonextraction treatment
allowing natural eruption, and (2) surgical exposure was planned for the case. For anchorage preparation,
transpalatal arch was soldered to first maxillary molars.
The vertical arm of ballista spring with 0.014″ Australian
1
Professor and Head, 2,4
Postgraduate Student (Final Year) wire was attached to the impacted canine to direct a palatal-
3
Professor, 5Reader occlusal force from the buccal side and horizontal arm was
1-5
Department of Orthodontics, Subharti Dental College, Meerut ligated into the slot of premolar brackets. In a period of
Uttar Pradesh, India 3 months vertical and labial traction of maxillary canine
Corresponding Author: Kanika Singh, Postgraduate Student was achieved using ballista spring (Figs 3 and 4). After 12
(Final Year) Student, Department of Orthodontics, Subharti Dental months by the dual traction (vertical and labial) of ballista
College, Meerut, Uttar Pradesh, India, Phone: +911212621715 spring, both the canines were fully erupted and almost
e-mail: [email protected]
close to the arch.
International Journal of Clinical Pediatric Dentistry, July-September 2017;10(3):313-317 313
Pradeep Raghav et al
A B C
D E
F G H
Figs 1A to H: Extra- and intraoral views of 18-year-old female patient with palatally impacted maxillary canines
and retained deciduous canines
A B C
Figs 2A to C: Lateral cephalogram, orthopantomogram, and CBCT view with impacted maxillary canines bilaterally
DISCUSSION
016 NITI wire overlay for bringing the canines into main
Maxillary canines are the cornerstone of the dental arch arch (Figs 5 and 6). A cuspid circle was constructed midway
and play a very important role in smile esthetics and are between the lateral incisor and first premolar. Retained
essential for maintaining a functional occlusion. Extraction deciduous canines were not extracted for maintenance of
of impacted canine should be avoided. In the present case, space between lateral incisor and first premolar. Followed
metal brackets (American orthodontics) of 0.022″ slot were by exposure of the impacted maxillary canine, anesthesia
used. After leveling and alignment phase was done by was obtained using block and infiltration injection of 2%
following wire sequence (0.014″, 0.016″, 0.018″ nickel–tita- lidocaine with 1:100,000 epinephrine. Deciduous canines
nium) .This was followed by Stabilizing the maxillary arch were extracted in the same appointment with the same
with 0.018″ Australian wire. Once canines were closer to the protocol before the exposure of canine (Figs 3A to C). As
main arch, Twin arch wires was used , a 019*025 stainless Graber and Vanarsdall4 state, as the palate is all mastica-
steel base arch was placed for stabilization along with the tory mucosa, graft is not placed on the tooth. So, in this
314
IJCPD
Treatment of Maxillary Impacted Canine using Ballista Spring and Orthodontic Wire Traction
A B
C
Figs 3A to C: (A) Surgical exposure of maxillary canine using open window technique; (B) lingual button bonded onto the
exposed canines; and (C) after 1 week of healing
A B
C D
Figs 4A to D: (A) Ballista spring attached after 10 days of healing; (B) after 1 month; (C) after 2 months; and (D) after 3 months

Pradeep Raghav et al
A B
Figs 5A and B: Midstage lateral cephalogram and orthopantomogram showing maxillary
impacted canine into the arch
A B
C
Figs 6A to C: Midstage intraoral photographs showing alignment of canines into the arch
report, the successful exposure of a palatally impacted for bringing the impacted canine in occlusion.7 But, after 1
maxillary canine was performed using the open window week of healing, ballista spring was placed. Ballista spring
technique with electrocautery. This method controls local- was given by Jacoby6 because it has an added advantage
ized bleeding by cauterizing vessels and coagulating blood over other methods that it could be used before and during
and provides good visualization of the surgical field.5 The leveling and alignment phase. As the patient wanted the
advantage of this technique includes vertical traction on treatment to get finished early we used ballista spring. For
the impacted tooth toward the middle of the palate, easy construction of ballista spring 0.014″ round Australian wire
fabrication, less traumatic in comparison to other tech- was used. Horizontal arm was placed in the slot of premo-
niques, and easy to insert and remove.6 Then a bonded lar and molar headgear tube. It stores its energy by being
attachment was placed and tooth movement was initiated.4 twisted on its long axis. Transpalatal arch was soldered to
Ligature wire was attached from the lingual button to the maxillary first molars to maintain anchorage. To avoid any
cuspid circle of the main archwire (Figs 3A to C), although rotation of the wire in the headgear tube, bends were given
in recent years various techniques have been developed just flushing with the headgear tube on the distal and the
316
IJCPD
Treatment of Maxillary Impacted Canine using Ballista Spring and Orthodontic Wire Traction
mesial side. The horizontal arm accumulates the energy REFERENCES

when ballista spring is activated and ligated on first and 1. Dachi SF, Howell FV. A survey of 3,874 routine full mouth
second premolar bracket. It allows to rotate the wire in slot radiographs. Oral Surg Oral Med Oral Pathol 1961 Aug;14:
as hinge axis. For vertical arm a 90° bend from middle of 916-924.
the extraction space of deciduous canine was given. The 2. Bishara SE. Impacted maxillary canines. Am J Orthod Dentofac
Orthop 1992 Feb;101(2):159-171.
length of the vertical arm is kept 2 mm short from maxillary
3. Ericson S, Kurol J. Radiographic assessment of maxillary
permanent canine to direct an occlusal force palatally and canine eruption in children with clinical signs of eruption
horizontally.5 Hence, we were able to bring the impacted disturbances. Eur J Orthod 1986 Aug;8(3):133-140.
canine into occlusion successfully using ballista spring. 4. Graber TM, Vanarsdall RL Jr. Orthodontics current principles
and techniques. 3rd ed. St. Louis: Mosby; 2000. p. 822-838.
5. Cheng J, Chang CH. Simplified open-window technique for
CONCLUSION
palatally impacted cuspids. Int J Orthod Implantol 2012;25:
This approach has been successfully used in the current 48-52.
case in terms of adequate attached gingival tissue preser- 6. Jacoby H. The “ballista spring” system for impacted teeth.
Am J Orthod 1979 Feb;75(2):143-151.
vation around the disimpacted canine. Hence, it could be 7. Richardson G, Russell KA. A review of impacted permanent
stated that within 3 to 4 months, ballista spring can show maxillary cuspids: diagnosis and prevention. J Can Dent Assoc
a great success for treating impacted maxillary canine. 2000 Oct;66(9):497-501.

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IJCPD

Treatment of Maxillary Impacted Canine using Ballista10.5005/jp-journals-10005-1457

Treatment of Maxillary Impacted Canine using Ballista

ABSTRACT with placement of an auxiliary attachment.2 Orthodon-

International Journal of Clinical Pediatric Dentistry, July-September 2017;10(3):313-317 315

mesial side. The horizontal arm accumulates the energy REFERENCES

International Journal of Clinical Pediatric Dentistry, July-September 2017;10(3):313-317 317

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