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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 78-82

An orthodontic guided, closed eruption of impacted maxillary canine


1 Department of Orthodontics, Dr. HSJ Institute of Dental Sciences and Hospital, Panjab University, Chandigarh, India
2 Department of Pedodontics, Dr. HSJ Institute of Dental Sciences and Hospital, Panjab University, Chandigarh, India
3 Department of Oral and Maxillofacial Surgery, Dr. HSJ Institute of Dental Sciences and Hospital, Panjab University, Chandigarh, India
4 Department of Oral Pathology, Dr. HSJ Institute of Dental Sciences and Hospital, Panjab University, Chandigarh, India

Date of Web Publication13-Feb-2017

Correspondence Address:
Urvashi Sharma
Department of Pedodontics, Dr. HSJ Institute of Dental Sciences and Hospital, Panjab University, Sector 25, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-6027.199982

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  Abstract 

The current case report demonstrates orthodontic management of an impacted permanent maxillary right canine using 0.016” nickel–titanium auxiliary archwire on a 19” × 25” stainless steel base archwire. In the present case, the reason for impaction of the canine was an overlying retained primary canine and a calcifying epithelial odontogenic tumor (CEOT) in that area. The over-retained primary canine was extracted and CEOT was enucleated. Closed eruption technique, with a Begg's bracket bonded on the labial surface of the impacted canine, was followed as it facilitates the preservation of attached gingiva around the newly erupted tooth. This case report demonstrates an orthodontic-guided eruption and repositioning of an impacted permanent maxillary canine using a ligature tie and a Begg's bracket. Closed eruption of the impacted maxillary right canine was followed by a comprehensive fixed mechanotherapy.

Keywords: cuspid, orthodontic extrusion, tooth eruption, tooth impacted


How to cite this article:
Singh DP, Sharma U, Batra H, Gulati A. An orthodontic guided, closed eruption of impacted maxillary canine. Int J Oral Health Sci 2016;6:78-82

How to cite this URL:
Singh DP, Sharma U, Batra H, Gulati A. An orthodontic guided, closed eruption of impacted maxillary canine. Int J Oral Health Sci [serial online] 2016 [cited 2017 Jun 26];6:78-82. Available from: http://www.ijohsjournal.org/text.asp?2016/6/2/78/199982


  Introduction Top


Impaction results when a tooth fails to erupt due to a mechanical barrier, an arch length–tooth material discrepancy, or an abnormal inclination of the tooth germ. The overall prevalence of tooth impaction is approximately 20%.[1] The prevalence of impacted maxillary canine is 1%–2%,[2] and it is more commonly reported in females than males (2:1).[3] In our case, the cause of impaction of permanent canine was an over-retained primary canine and an associated calcifying epithelial odontogenic tumor (CEOT). The origin of CEOT is controversial. The proposed etiological sites of origin include the remnants of dental lamina; reduced enamel epithelium; basal cells of the epithelium of gingiva; and even, stratum intermedium due to its structural similarity.

Various techniques have been used to treat impacted permanent maxillary canines. The use of a Bionator or any other functional appliance as a mode of attachment for elastics to reposition the impacted tooth is limited to patients with skeletal malocclusions.[4] Hauser et al.[5] used a wire ligature pigtail with an elastic chain. Sectional arches lead to taxing of the anchorage as the forces of the erupting canine are dissipated upon a limited number of teeth compared to the entire upper arch. Nance-type appliance with a circumferential clasp and a ligature wire has also been used.[6] In the present case, a piggyback 0.016” nickel–titanium (NiTi) archwire was engaged to the ligature wire to reposition the impacted maxillary canine.


  Case Report Top


A 9-year-old boy reported with a convex profile, competent lips, acute nasolabial angle, and a recessive chin with a pleasant smile [Figure 1]. The patient had angle's Class II molar relationship with Class II incisors. The overbite and overjet were 7 mm and 7.5 mm, respectively [Figure 2]. Cephalometric analysis indicated a skeletal Class II jaw relationship; a retrognathic mandible with a horizontal growth pattern [Figure 3]a and [Table 1]. Cast analysis revealed arch–length discrepancies of +2.5 mm and +2 mm in the upper and lower arches, respectively.
Figure 1: Extraoral pretreatment photographs (from left to right): (a) Frontal view, (b) smiling view, (c) profile view

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Figure 2: Intraoral pretreatment photographs: (a) Frontal view, (b) right lateral view, (c) left lateral view, (d) maxillary occlusal view, (e) mandibular occlusal view

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Figure 3: Pretreatment radiographs (from left to right): (a) Lateral cephalogram, (b) orthopantomogram

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Table 1: Cephalometric data

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The patient subsequently reported after 4 years, and an orthopantomogram revealed an impacted permanent maxillary right canine and a firmly retained deciduous counterpart [Figure 3]b. The deciduous canine was extracted, and the lesion was surgically enucleated [Figure 4]a. Biopsy confirmed CEOT.
Figure 4: Intraoral photographs: (a) Enucleated tumor space, (b) exposed canine, (c) frontal view, (d) right lateral view

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The impacted canine was exposed, and a Begg's bracket with a ligature wire was bonded on the labial surface [Figure 4]b. The upper arch was stabilized using 19” × 25” stainless steel archwire (Captain Orthodontics, Liberal Traders, New Delhi, India), and a piggyback 0.016” NiTi archwire (Captain Orthodontics, Liberal Traders, New Delhi, India) was inserted. After about a week, the piggyback NiTi archwire was engaged to the ligature wire. After every 4 weeks, the piggyback NiTi archwire was activated by about 1–1.5 mm [Figure 4]c and [Figure 4]d, and the canine repositioned in about 7 months.

The established malocclusion was corrected using comprehensive fixed mechanotherapy with a preadjusted edgewise appliance (Roth prescription, 0.022 slot). Proper intercuspation of both anterior and posterior teeth with the Class II molar and canine relationships was achieved. The rotations of teeth were corrected, anterior teeth were aligned, and proper overjet and overbite were attained. The treatment was completed in about 24 months with the canine fully repositioned [Figure 5],[Figure 6],[Figure 7].
Figure 5: Extraoral posttreatment photographs (from left to right): (a) Frontal view, (b) smiling view, (c) profile view

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Figure 6: Intraoral photographs: (a) Frontal view, (b) right lateral view, (c) left lateral view, (d) maxillary occlusal view, (e) mandibular occlusal view

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Figure 7: Posttreatment radiographs (from left to right): (a) Lateral cephalogram, (b) orthopantomogram

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The posttreatment evaluation of the periodontal status of the orthodontically erupted right maxillary canine depicted an adequate width of attached gingiva in relation to it. The probing sulcus depth was also within the normal clinical range with no evidence of clinical attachment loss [Table 2].
Table 2: Clinical periodontal measurements of orthodontically guided tooth as well as that of adjoining teeth (six sites per tooth)

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  Discussion Top


Various methods have been proposed to reposition the impacted canines after surgical exposures. A Bionator with a hook soldered to the bottom of the lower left canine loop was constructed. The impacted canine was surgically exposed, and a cleated bracket was bonded to its labial surface. Traction was initiated with 3/16, 41/2 oz elastics.[4]

A wire ligature pigtail is tied to the bonded attachment at the time of surgery and is rolled downward to form a loop to which is attached the elastic chain. The elastic chain is placed across the span between the first premolar and lateral incisor with midline portion stretched toward the pigtail to provide light vertically directed force with a wide range of action.[5] Elastic force modulus has the disadvantage of rapid force decay [7] and requires stiff main archwires to avoid side effects on the adjacent teeth.

If a superelastic NiTi archwire is inserted directly into the canine bracket, the wire must be deflected and the arch form can be distorted. This can result in tipping or intrusion of the adjacent teeth, canting of the occlusal plane, and a consequent lateral or anterior open bite.

A case was reported by Neelima et al.,[6] wherein a displaced, impacted maxillary canine was repositioned using a closed eruption technique with a semifixed appliance, and subsequently, a fixed appliance therapy. The appliance comprised of wires extending transpalatally into the Nance button to reinforce anchorage. Circumferential clasps were extended from the Nance button to maintain space for the impacted canine. A bracket was bonded to the impacted tooth and a 0.010” stainless steel ligature wire gradually repositioned the tooth.

A closed eruption technique in the present case preserved attached gingiva around the newly erupted tooth.[8] Orthodontic treatment of impacted teeth requires meticulous personal and professional plaque control measures to preserve periodontal health.[9] The present technique necessitates the alignment of the rest of the dentition before a sufficient rigid main archwire can be placed. Furthermore, the stiff primary archwire prevents the flexible NiTi archwire from sliding freely through the brackets. If the movement of an impacted canine is delayed, subsequent bleeding and scarring of the surrounding tissues may prevent further eruption and may also require additional surgery.[5] In addition, loss of attachment and subsequent gingival recession has been observed in orthodontic patients.[10] Care was taken to minimize the side effects as much as possible during the course of treatment.


  Conclusion Top


This article demonstrates the use of an overlay or piggyback 0.016” NiTi archwire over a 19” × 25” stainless steel base archwire to reposition the impacted permanent maxillary canine. Closed eruption technique with a Begg's bracket bonded on the labial surface of the impacted canine facilitated preservation of the attached gingiva around the newly erupted tooth. Light forces prevented damage to the teeth and the supporting structures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Andreasen JO, Petersen JK, Laskin DM. Textbook and Color Atlas of Tooth Impactions. Copenhagen, Denmark: Munksgaard; 1997. p. 199-208.  Back to cited text no. 1
    
2.
Richardson G, Russell KA. A review of impacted permanent maxillary cuspids – Diagnosis and prevention. J Can Dent Assoc 2000;66:497-501.  Back to cited text no. 2
    
3.
Bishara SE. Clinical management of impacted maxillary canines. Semin Orthod 1998;4:87-98.  Back to cited text no. 3
    
4.
Spencer GW. Orthodontic extrusion of a horizontally impacted mandibular canine. J Clin Orthod 2006;40:613-9.  Back to cited text no. 4
    
5.
Hauser C, Lai YH, Karamaliki E. Eruption of impacted canines with an Australian helical archwire. J Clin Orthod 2000;34:538-41.  Back to cited text no. 5
    
6.
Neelima K, Nagaraj K, Jatti R, Sethi P. Eruption of an impacted canine with a semi-fixed appliance. Orthod CYBER J 2010, February. Available from: http://www.orthocj.com/2010/02/eruption-of-an-impacted-canine-with-a-semi-fixed-appliance. [Last cited on 2013 Oct 16].  Back to cited text no. 6
    
7.
Taloumis LJ, Smith TM, Hondrum SO, Lorton L. Force delay and deformation of elastomeric ligatures. Am J Orthod Dentofacial Orthop 1997;111:1-11.  Back to cited text no. 7
    
8.
Becker A. The Orthodontic Treatment of Impacted Teeth. London: Martin Dunitz Publishers; 1998. p. 49.  Back to cited text no. 8
    
9.
Frank CA, Long M. Periodontal concerns associated with the orthodontic treatment of impacted teeth. Am J Orthod Dentofacial Orthop 2002;121:639-49.  Back to cited text no. 9
    
10.
Chugh VK, Sharma VP, Tandon P, Singh GP. Treatment of an unusual crossbite with an impacted mandibular second premolar. J Clin Orthod 2008;42:341-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2]



 

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  Introduction
  Case Report
  Discussion
  Conclusion
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