Pathology of impacted canines

1. Disorders associated with impacted MAXILLAR canine

- Mild suppurative complications od pericoronitis may progress to:
 Suppurative rhinitis
 Odontogenic suppurative sinusitis
 Osteitis of the jaw
 Abscesses of the primary or secondary fascial spaces, fistulas
- Nervous accidents : cause ocular sensory disorders and polyneural neuralgia accompanied by facial
spasms, a particular aspect is the pfysiognomic disorders induced by the inclusion of the upper canine as
well as the tilting of mobile prostheses in an edentulous patient.
- Mechanical, trophic and tumor disorders

2. Therapeutic attitude- can be radical or conservative in relation to:

- Position and depth of inclusion
- Abnormalities in shape and volume of the included canine
- The existing space on the arch
- The complications caused by the inclusion
- Age of the patient
► The establishment of therapeutic behavior must be decided by the OMF surgen in collaboration with the
orthodontist through its major aesthetic and functional implications. The canine is an indispensable
tooth to ensure a balanced state of the dento-maxillary apparatus. That , the extraction of the canine is
practiced only in extreme situation, when it is not possible to recover it on the arch, due to the
morphology, position or complications that it has determined.
► Radiological examination is essential to establish the appropriate treatment and surgical technique.
► The orthopantomogram has the advantage that is offers a complete image of the relationships with the
neighboring anatomical structures.

Treatment options:

a. Surgical-orthodontic treatment: conservative method that consists in uncovering the included canine
crown and anchoring it in order to strengthen and pull slowly, progressively until the tooth resume
its normal position on the arch.
Indications :
 In young patients
 When there is enough space on the arch, or it can be created by orthodontic methods
 Inclusion is not deep
 The tooth is in a vertical or slightly oblique position
 The tooth does not show anomalies in shape or volume
 The tooth is located near its normal eruption space

Main stages:
1. Maintaining or obtaining the necessary space on the arch.
2. Surgical discovery of the crown and anchoring of the tooth.
3. Slow and progressive traction until the canine aligns on the arch.

b. Transplantation: rarely used, consists in the extraction of the included canine and its immediate
introduction in a newly created alveolus in the alveolar ridge or in the alveolus left after the
extraction of the temporary tooth, which will have to be widened and deepened depending on the
root volume.
c. Ododntectomy
3. Exposure of impacted teeth for orthodontic treatment-
Impacted teeth remain inside the bone resulting in a delay of their eruption, causing orthodontic problems.
This delay may be the result of endocrine problems, supernumerary teeth, odontomas, crowding of teeth,
sclerosis of soft tissue covering tooth, etc.  to facilitate eruption combination of surgical and orthodontic
techniques is necessary.
The procedure involves exposing the tooth by creating a flap and removing the bone over the tooth. If there
are still deciduous teeth, supernumerary teeth or odontomas removed and after exposing a large paert of
the crown, orthodontic brackets are bonded to the crown , and the tooth is gradually aligned in its correct
position.
If the crown covered only by soft tissue removes the tissue by scalpel or electrosurgical blade, thus
creating a 'window' at the crown which will help it to erupt- on its own or with orthodontic treatment.
- Impacted canine with palatal position : (14-21)
1. removal of the deciduous teeth  palatal flap which exposed underneath part of the bone covering
the teeth .
2. round bur is used to remove the bone covering the crown orthodontic brackets are placed for
traction of the tooth into the normal position in the dental arch.
3. the area is irrigated with saline and the flap is closed with interrupted sutures.

4. Extraction techniques
Impacted maxillary canine present in 12%-15% of the population.
In young people (under 30) impacted maxillary canines may be correctly aligned in the dental arch after
surgical exposure and orthodontic treatment. After the age of 30 surgical removal is preferred.
The technique depends on the:
- Position of impaction (palatal or labial)
- Relationship of the impacted tooth to adjacent teeth
- Inclination of its crown.

These factors should be assessed before planning the surgical procedure.

The localization is achieved by radiographs & clinical examination. Most used intraoral projections are:
occlusal projection, periapical & panoramic radiographs. The technique for exact localization of the labial or
palatal position is based on the tube shift principle. (27)
Present 5 basic localizations (contralateral or ipsilateral and deep in the bone):
1. palatal localization
2. palatal localization of crown and labial localization of root
3. labial localization of crown and palatal localization of root
4. labial localization
5. ectopic positions
Based on the data the extraction may be performed in 3 ways:
i. Extraction using labial approach: (30-37)
a. Trapezoidal incision & reflection of the mucoperiosteum
b. Removing of the bone using round bur with steady stream of saline, until the
entire crown and part of the root are exposed.
c. Creation of a groove at the cervical line using a fissure bur, in order to
separate the crown from the root.
d. Separation is achieved by using a straight elevator which is placed in the
groove with rotational movement and separate the tooth into 2 segments
e. The crown is removed first and the root is then luxated, after creating a
purchase point on the surface of the root for placement of the tip of the
elevator blade.
f. Smoothing the bone and irrigation with saline, sutured the wound.
When the impacted canine is not entirely covered by bone, removal of the tooth is easier since it
does not have to be sectioned into 2 pieces. (39-43)
 ii. Extraction using palatal approach (46-55)
a. Bilateral palatal flap – begins at the 1 st or 2nd ipsilateral premolar and after
continuing along the cervical lines of the teeth, ends at the 1 st premolar on
the contralateral side.
b. Reflection of the mucoperiosteum and expose of the entire crown- the
crown may be cover by bone or exposed resulting is protuberance at that
site
c. Groove creation at the cervical line of the tooth using a fissure bur and after
placing the elevator blade in the groove created, the instrument is rotated
until the crown is separated from the root. If the tip of the crown is
positioned between the roots of the lateral and central incisors there is a
risk of injuring theie roots during the exposure attempt. This is way the
extraction must be achieved using the technique of separating the crown
from the root .
d. The crown is moved and then using round bur to create a purchase point on
the root for placement of the angled elevator's tipthe root is elevated
from its bed.
e. Smoothed the bone edges and irrigate with saline, reposition of the flap and
sutured with interrupted sutures.

iii. Combination of the two

iv. Ectopic impacted canine -rare (58-63)
Usually localized in : underneath permanent teeth, near the angle of the mandible, inside the ramus,
near the mandibular notch, the coronoid process, maxillary tuberosity, the wall of the maxillary
sinus, nasal cavity, near the orbit.
a. Horizonal incision in the region of the canine fossa, from the lateral incisor
to the 1st molar.
b. Mucoperiosteum is reflected and the bone of the anterior wall of the sinus is
exposed.
c. Holes are drilled through the bone using a small round bur where the
impacted tooth is estimated to be, and these holes are then joined together.
d. After removal of bone surface the impacted tooth is exposed and luxated
outwards.
e. Smoothing bone edges, irrigation with saline, suctioning of any foreign
matter that entered the sinus and suturing the flap.
f. Nasal decongestant are prescribed

5. Disorders associated with impacted MANDIBULAR canine-rare

- Can cause neuralgic phenomena through the close relationship with the inferior alveolar nerve canal and
the chin hole.
- The inclusion is deep and favors the fracture of the mandible at this level.

6. Exposure of impacted teeth for orthodontic treatment (68-71)

- In labial position :
1. if the area locating the impacted canine presents as light protuberance and the crown of the tooth is
covered by soft tissue only.
To expose the tooth – incision using an electrosurgical blade is made over the crown and then the soft
tissue is excised using scissors and a periosteal elevator. After a surgical dressing is applied to the wound
until the orthodontist bonds the brackets for traction of the tooth to its normal position on the arch.
2.exposure of the crown by creating L-shaped flap and then reflection of the flap that expose the crown.
The tooth is then dried and after the orthodontist has placed the brackets on the crown , the flap is
repositioned and the wound is sutured.
7. Extraction techniques (74-80)
Impacted mandibular canine usually localized buccaly and next to or underneath the roots of the incisord , in
a vertical \ horizontal \ oblique position
a. trapezoidal flap & reflection
b. exposing of the crown with round bur while using a fissure bur to remove bone
around the crown to permit positioning of the elevator.
c. The tooth is luxated mesially and distally and the odontomas are then removed using an arrow angled
elevator, after being exposed using a narrow round bur.
d. care of the wound , repositioned of the flap and interrupted sutures.

8. Use of piezosurgery in tooth impaction (88-96)

- Piezo = pressure
- Involves the appearance of an electric charge across certain crystals when they are under mechanical
pressure.
- The unite is made of : power supply, handpiece & its holder, irrigant solution holder, foot control switch.
- Working tips used for surgical purposes are interchangeable inserts, which can be of different shapes,
sizes and cutting edges based on the intended clinical application.
- To create a cutting effect rather than a debriding effect, the vibrations of the insert enter into a
resonance with the ceramic chips, which increases the energy output.  this combined with the form of
the insert, acts like a micrometric oscillating saw.
- The main energy unit has an interactive touchpad, which allows the operator to control the frequency of
vibration, power and the amount of irrigating or coolant fluid.
- The pressure applied on the insert can also be manually controlled by the operator and can affect the
frequency delivered to the target tissue, which in turn affect the cutting efficiency.
- When higher pressure is applied at the tip, it impedes the cutting efficiency of the insert and release the
energy as heat, which detrimental to the bone as well as adjacent soft tissue.
- Advantages :
 Decreased risk of damage to adjacent soft tissues
 Improved visibility
 Increased patient comfort
 Improved survival of osteocytes.
- Piezosurgery can be applied toward multiple dentoalveolar procedures where there is a requirement for
meticulous bone preparation, atraumatic tooth extraction\exposure, and when the location of the
surgical site is in proximity to vital anatomical structure. For example : ankylotic tooth root extrzction,
impacted 3rd molar extraction, surgical exposure of impacted teeth, extractions in patients with a thin
periodontal biotype
- Piezo has the potential to limit bone loss and maximize maintenance of alveolar bone integrity,
especially when the alveolar bone is thin and the procedure requires a high degree of precision.
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