Management of impacted teeth /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
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www.indiandentalacademy.com


Introducton

contents

Etiology
Frequency of impactions
Diagnosis
Treatment strategies
Impactions of incisors
Impaction of canines
Impactions of premolars
Impactions of molars
Conclusion

INTRODUCTION
 The treatment of impacted teeth has caught the
imagination of many in dental profession. However, the
orthodontic / surgical modality has achieved the most
satisfactory result in long-term.
 According to Shafer, Hine and Levy,Impacted teeth are
those which are prevented from erupting by some
physical barrier in the eruption path.

A tooth which is completely or
partially unerupted & is positioned
against another tooth , bone or soft
tissue, so that its further eruption is
unlikely, described according to its
anatomic position.


CAUSES OF IMPACTIONS

-Local causes
-Systemic causes


Local causes
 Irregularity

in the position and pressure of an
adjacent tooth.
 Density of overlying or surrounding bone.
 Long continued chronic inflammation with
resultant increase in the density of mucous
membrane.
 Lack of space due to underdeveloped jaws.


 Unduly

long retention of primary teeth.
 Premature loss of primary teeth.
 Acquired diseases , such as necrosis due to
infection or abscesses.
 Inflammatory changes in the bone due to
exanthematous diseases.


Systemic causes
PRE – NATAL
- Heredity.
 POST – NATAL
- Rickets.
- Anemia.
- Congenital Syphillis.
- Tuberculosis.
- Endocrine dysfunction.
- Malnutrition.



 RARE

CONDITIONS
- Cleidocranial Dysplasia.
- oxycephaly.
- Progeria.
- Achondroplasia.
- Cleft palate.


Normal eruption


3rd molar impaction


Canine impaction

Premolar impaction

FREQUENCY OF IMPACTION



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

Mandibular 3 rd molar.
Maxillary 3 rd molar.
Maxillary canine.
Mandibular bicuspid.
Mandibular cuspid.
Maxillary bicuspid.
Maxillary central incisor.
Maxillary lateral incisor.

CLINICAL

RADIOGRAPHIC


CLINICAL METHOD FOR
DIAGNOSIS
o Examination to assess facial form, arch form and symmetry.
o Relationship of maxillary dental midline to facial midline.
o CR and CO position should be carefully recorded.
o Overjet and Overbite should be carefully recorded.
o Delayed eruption of permanent teeth.
o Prolonged retention of deciduous teeth.
o Absence of normal labial canine bulge.
o Presence of palatal bulge (Abnormal).
o Delayed eruption, distal tipping or migration of adjacent teeth

RADIOGRAPHIC METHOD FOR DIAGNOSIS
In Orthodontic treatment planning, the exact localization of
the position of an impacted teeth is necessary.
I. Qualitative radiographs

Extraoral

Periapical
Maxillary arch

OPG

Occlusal

PA view
Lateral ceph

Mandibular arch
Max. ant. occlusal

True vertex/occlusal

II. 3-D diagnosis of the position

Parallax method

C T scanning

Radiographic views at right angle


Periapical Radiography• Are the simplest and the most informative X-ray films.
• As this view passes through minimum of surrounding
tissues, it gives accuracy & quality of resolution.
• It is aimed to be perpendicular to an imaginary plane
bisecting the angle between the long axis of an erupted
tooth and the film plane to produce minimum distortion.

PERIAPICAL RADIOGRAPH


The periapical film gives the following information:
[1] Presence or absence of impacted tooth.
[2] Stage of development.
[3] Presence & size of follicle.
[4] Indicates crown or root resorption, resorption pattern
& integrity.
[5] Indicates presence or absence of supernumerary tooth.
[6] Indicates soft tissue lesions like cysts.

OCCLUSAL
RADIOGRAPH


Occlusal Radiography:
Mandibular arch:
• In mandibular arch occlusal view is taken by tipping the
patient’s head backwards & pointing the X-ray tube at
right angle to the film in the occlusal plane.
• In the canine or premolar region, this is a true occlusal
view.

• To get a true occlusal view in the anterior region, the
head is tipped back further & X-ray tube is angled at
110% to the horizontal plane at symphysis menti along
the long axis of the incisor teeth.

Maxillary arch
1.Maxillary anterior occlusal

• In the maxillary arch, the nose and forehead interfere with

the positioning of x-ray tube close to the area to be viewed.
• The best that can be achieved by positioning the tube
close to the face,so that it becomes high and steeply angled
view.


2. Ture vertex / occlusal

• A true vertex view is one which passes parallel to the long

axis of central incisors.This is possible if the cone is placed
over the vertex of the skull to produce vertex occlusal film.
• Since the beam has to travel a great distance there is loss of
clarity.


Extraoral Radiography:

• OPG has the advantage of simplicity & quickly
offering a good scan of the teeth & jaws from
Temporomandibular joint to Temporomandibular joint.

Parallax method:
By Clark & Richards

Principle:
• 2 periapical views of the same object are taken from
slightly different angles which can provide depth to
the flat 2-D picture depicted by each of the films
individually.
• Useful in distinguishing the buccal or lingual
displacement ofwww.indiandentalacademy.com
the canine.

Procedure:
1. In the periapical film, the X-ray is taken in the area
of interest with the X-ray beam passing perpendicular
to a tangent to the line of arch at this point & at an
appropriate angle to horizontal plane.

2. In the second film, the X-ray tube is shifted mesially or
distally round the arch but held at the same angle to the
horizontal plane. The X-ray tube should describe between
30-450 of an arc of circle whose centre is somewhere in
the middle of the palate.


Result:
• It is based on the SLOB principle.
• If the object has moved on the same side as that
of the X-ray tube it is lingually placed & if it has
moved on the opposite side it is on the buccal side


Radiographic views at right angles:
1. A true lateral view {e.g. Lateral
cephalograph} gives information
regarding the antero-posterior &
ventral location of an object . However,
it gives no information regarding
bucco-lingual {transverse} plane of an
object.

True postero-anterior view defines
the ventral plane & buccolingual
relationship of an object.

These views provide complete information regarding
3 planes of space of any impacted teeth .

CT Scanning:
By Ericson & Kurol
• Used to diagnose the exact
position of an impacted
tooth.
• Clear serial radiographs
may be taken at graduated
depth in any part of human
body in this method.

• This technique allows the
elimination of superimposition of
other structures.
• It is however rarely used in the
diagnosis of impacted teeth because
of
( 1) Large radiation dosage.
(2) High cost.

Rapid prototyping
Limitations of CT Scan
 However even the 3D reconstruction is obtained , the
analysis by the orthodontist is still limited : 3D
images are seen as 2 dimensional on film and computer
screen.
 This can be overcome with the use CT to make a model
by means of rapid prototyping
 This technique use data from computer aided design
to produce physical models and devices by material
addition .

Labial tooth impaction

-

1% to 2% of orthodontic patients and is often difficult to
manage.
The most common methods of uncovering labial impactions

Excisional gingivectomy
Apically positioned flap techniques .
closed-eruption technique.


TYPES OF FLAPS FOR IMPACTED TEETH
• Exposure only
• Exposure with pack

Buccally accessible impacted teeth
• A circular incision


• Apically repositioned surgical flap

.Full flap closure

1.) Labially impacted maxillary anterior teeth uncovered with an apically
positioned flap technique have more unesthetic sequalae than those
uncovered with a closed-eruption technique.
2 )Negative esthetic effects, such as increased clinical crown length,
increased width of attached tissue, gingival scarring, and intrusive
relapse were evident in the www.indiandentalacademy.com apically positioned flap.
teeth treated with an

 Vanarsdall

and Corn evaluated more than 75
labially impacted teeth which had been uncovered
using a split-thickness apically positioned flap. The
authors found no marginal bone loss or gingival
recession after orthodontic treatment.

 They

stressed the need to provide attached gingiva
in order to prevent the muscles of the face from
detaching the marginal periodontal tissue from the
tooth, causing marginal bone loss and gingival
recession.

 The

closed-eruption technique is believed by some to
be the best method of uncovering labially impacted

Palatal Impaction

• Partial

• Full flap closure


Anchor unit
•

When dealing with a malocclusion that incorporates

an impacted tooth, modification must be made for anchor
unit.
• A fully multi-bracketed appliance should normally be
placed & the entire dentition treated through the stages of
leveling & opening of adequate space in the arch for impacted
tooth.

• A heavy & more rigid arch wire is then placed into
the brackets on all the teeth of aligned & complete
dental arch, the aim is to provide solid anchor base that
will not allow distortion of arch wire to occur as a
result of force that will be applied to the impacted
tooth after exposure.


Attachments: –
 Lasso wires
 Threaded pins
 Orthodontic bands
 Standard orthodontic bracket
 A simple eyelet
 Elastic ties and modules
 Magnets

{a} Lasso wires:
It is twisted lightly around the neck of the canine.
Disadvantages:
 This results in irritation of the gingiva

 Prevents reattachments of the healing tissues in area of
CEJ (cemento-enamel junction).
 May produce areas of external resorption & ankylosis in
areas of CEJ.
So, it is rarely used now.

(b) Threaded Pins:
Provide the attachment for
an impacted tooth.
Disadvantages:
- Dentally invasive.
- Requires a subsequent restoration.
- Difficult to place along the long axis of the tooth because of
smaller surgical exposure.
- The drilled hole may inadvertently enter the pulp(unerupted
teeth may have large pulp chambers).
So it is rarely used.


{c} Orthodontic bands:
They largely replace the
Lasso wires & threaded pins.
Advantage:
They are compatible with the health of periodontal
tissues.
Disadvantage:
-

Large surgical field required.

- Inadequate moisture control may hamper with the
cement-band bond.

{d}Standard orthodontic brackets:

Any edge-wise , Begg’s , PAE brackets can be
used.
They are routinely used as direct attachments along
with the composites.

Disadvantages:
- As the bracket base is wide, it is difficult to adapt to

any other tooth surface except for the buccal surface.
- The bracket’s shear bulk creates irritation as the tooth
is drawn the soft tissues.
- Ligature wire or elastic thread tied to bring the
impacted tooth into arch.

- Interferes with the investing tissues & leads to
inflammation & periodontal damage.
- As the impacted tooth advances into the arch
the exuberant gingival tissues bunches in front of it &
causes punching between the bracket & tissues.


{e} A simple eyelet:

Advantages:
- An eyelet welded to band material with a mesh backing is
soft & easy to contour making its adaptation to bonding surface
more accurate which makes for superior retentive properties.
- Because of small size they can be placed in more
awkwardly placed teeth.
- It is less irritating to the surrounding tissues.

(f) Elastic ties and modules

Advantages
- Application of light forces
- Good range of action
- Easier to tie

Disadvantages
- Tends to loosen
- High degree of force decay


{f} Magnets:

It is made up of rare earth lanthanide alloys .

• It is rarely used.
Disadvantage:
- corrosion.

Maxillary incisors impaction
The spectre of appearance of lateral
incisors ,associated with non – appearance
of one or both of central incisors ,should
always deemed as abnormal ,whether or not
a deciduous central incisor is still present .


Aetiology
Obstructive causes
supernumerary teeth
Odontome
Ectopoc position of tooth bud
Traumatic causes
Obstruction due to soft tissue repair
Dilaceration
Arrested root development
Acute traumatic intrusion

Treatment timing
Obstructions should be removed early
before it causes delayed eruption.
Clinically – when both laterel incisors are
erupted
Radio graphically – IOPA show atleast
2/3 rd of its root , the developmental
landmark that tooth should be erupted .
Orthodontic and surgical intervention is
indicated at this time.

Attitudes of treatment
Adequate space is created
Obstructions are removed
1. Eruption - Battagel 1985, Houston 1986,
mitchell and bennet 1992
2. Noneruption - Dibase 1971, Witsenburg 1981
3. Delayed eruption – 16 -20 months for eruption
this is an unacceptable long period of time, 2
surgical episodes may be needed
Mitchell and Bennet 1992, Bodenham 1967.
4.Alignment – Gardiner 1961 spontaneous
alignment occurs only minority of patients

Treatment
1) An orthodontic
appliance for the use
in the early mixed
dentition.
2) two by four
appliance
3) Johnson’s twin wire arch


Prognosis
1.Root length
2. Type and height of periodontal ligament –
window created over the impacted canine over attatched
gingiva – poor prognosis
full flap surgery – good prognosis
3. Relative height of the crestal alveolus –
vertical movement of tooth is accompanied by vertical
increase in the alveolar bone
When the impaction is resolved by natural eruptive force bone support is good
when the excess extrusive forces – tooth will erupt rapidlly
without regeneration of alveolar bone

4.preservation of vitality
5.oral hygiene


IMPACTION DUE TO TRAUMA
SOFT TISSUE OBSTRUCTION
Andreason and Andreason 1994
Removing of the fibrous mucosal
covering or incising and resuturing it to
leave the incisal edge exposed will
generally lead to a fairly rapid eruption

The dilacerated central incisor and
arrested root development
long term prognosis of these teeth is poor and
their extraction and replacement is a part of
long term treatment strategy.
But it is always advisable to disimpact these
teeth into arch for timely purpose and replace
it later with prothesis depending upon its
prognosis for following reasons.


A permanent artificial solution can not considered in early
childhood
Following extraction of the dilacerated teeth ,alveolar ridge is
deficient ridge vertically and labio-lingually making the case
unsuitable for an implant
Retention of the short rooted and endodontically treated teeth
will preserve the normal shape and architecture of alveolar ridge


Apical root dilaceration
The more apical the dilaceration of root the better is the
prognosis.


Surgically expose



Attach an eyelet and a ligature is treaded to the eyelet and
drawn towards the main arch wire

As crown moves down the root rotates labially towards the
labial plate.


If the root is prominent and still more labial root movement
is desirable - amputation of the labially projected part of the
root and endodontic treatment is carried on

The prognosis is dependent on amount of root remaining after

Crown dilaceration
If the dilaceration is in the crown of the
tooth , prognosis improves the closer it is
to the incisal edge
When the crown is surgically exposed , an
attatchment is placed on the labial
surface . In this way a continued
downwards directed orhtodontic traction
will bring the root portion of the tooth
from more palatal position to its normal
position ,this is due to lingual tipping

The tooth will erupt with the incisal edge of
the teeth more labially and post traumatic
section in an acceptable position.
Retoration of the teeth indicated after
grinding off the portion of the crown
developed before pre trauma.


Dilaceration of the crown near the
CEJ junction , the progosis of aligned
tooth is extremely poor
Since most of the root portion developed after
post trauma period , will need to be
amputated , leaving the tooth with a non –
vaible coronal remanent of the teeth


Treatment options
1)

Open up the space
Dilacerated tooth is exposed
Condition is evaluated –
hopeless – extraction
not hopeless – ampute the root portion , crown pulp
chamber is cleaned and filled with composite and used
as space maintainer by bonding to the adj teeth
2) Crown is removed, immediate root filling is placed and
treaded post is attatched and to this post a ligature
wire is attatched and the prepared tooth is erupted in
to the moth till the post becomes apparent at the
gingival level and later a artificial crown is given.

Acute traumatic intrusive
luxation
 Shapira

in 1986 - following traumatic
intrusive luxation tooth may erupt
spontaneously and eventually erupt into
its original position
 in some cases orthodontic intervention
may be required


Individual tooth distraction
 Miniature

tooth-borne distractor


ERUPTION OF CANINE
• Dewel (1949) stated that “no tooth is more interesting
from the development point of view than the maxillary
canine”
• Canine develops in deepest area of maxilla, has
longest path of eruption, travels 22mm during its
course or eruption and has longest period of
development.


Reason for canine Impaction
Becker Concepts

:

Becker (1984) hypothesized two processes
in the palatal impaction of the maxillary canine:
I) Absence of initial early guidance from an
anomalous lateral incisor.
II) Failure of buccal movement of the canine at
an unspecified age .
MC

Bridge Concept
Canine formed at high in the anterior wall
at antrum, below the floor of orbit, long tortous path
of eruption.

Moyers Concept: Summarized by Bishara
A)Primary cause:
1) Trauma to decidious tooth bud
2) Rate of Resorption of decidious tooth
3) Availability of space in the arch
4) Disturbance in tooth Eruption Sequence
5) Rotation of tooth buds
6) Canine Erupt in Cleft area in Person with Cleft
7) Premature root Closure
B)Secondary cause:
1) Abnormal muscle pressure
2) Febrile diseases
3) Endocrine disturbances
4) Vitamin D deficency.

Berger Concept :{Systemic cause of impaction}
1)
2)
3)
4)
5)
6)
7)

Malnutrition
Tuberculosis
Syphilis
Rickets
Anemia
Progeria
Syndromes:
a) Cleidocranial dysplasia
b) Achondraplasia
c) Down syndrome

Vonder Heydt Concept
Total arch length of permanent teeth is initially
established very early in life at the time of eruption of first permanent
molars. Canine is larger and later erupting and considering like a
musical chair situation it may get impacted.

Guidance Theory - Miller
Normal Eruption: Canine usually have a more mesial development
path,which is guided downwards apparently along the distal aspect of
the lateral incisor roots.

First stage Impaction:If there is a loss of guidances due to missinig
lateral incisors or late developing laterals, canine will have mesial and
palatal path of eruption.In this event there is no vertical movement of
canine into the alveolar process,results in more horizontal impaction.
First stage impaction and secondary correction:Once it reached the
palatal alveolar process,canine is redirected to more favorable path of
eruption.
Second stage Impaction:Self correction is prevented by, late
developing lateral incisors (peg laterals) which redeflect the tooth
further palatally
Second stage Impaction and secondary correction:Extraction of
deciduous canine or even extraction of lateral incisors leads to
spontaneous eruption of the impacted tooth.

Peck and Peck Concept:
1) Occurrence of other dental anomalies:
Palatally impacted canine is an inherited trait occurs in
combination with tooth agenesis,tooth size reduction, supernumery
tooth and other ectopically positioned tooth.
2) Bilaterally occurring Phenomenon (17%)
3) Females affected more than males (1:3.2)
4) Familial occurrence
So they concluded palatally impacted canine as dental
anomaly as GENETIC ORIGIN.

INCIDENCE OF CANINE IMPACTION
• Dachi and Howell (1961) incidence of maxillary and
mandibular canine impaction - 0.92% and 0.35% resp.
• Ericson and Kurol (1986) - 1.7%
• Johnston et al (1982) – greater incidence of palatal
impaction than the labial
• Gaulis and Joho (1982) -2:1 ratio of palatal to buccal
impaction.
• Of all patients with maxillary impacted canines, 8% have
bilateral impactions.


SEQUELAE OF IMPACTION
•

Labial or lingual malposition of

the impacted tooth.
• Migration of the neighbouring teeth
and loss of arch

length.

• Internal resorption.
• Dentigerous www.indiandentalacademy.com
cyst formation.

• External root resorption of the
impacted tooth, as well as the
neighbouring teeth.
• Infection particularly with partial
eruption.
• Referred pain.
• Combinationwww.indiandentalacademy.com
of the above sequelae.

CLASSIFICATION OF IMPACTED CANINE
Impacted canine

Maxillary canine

Buccal

Palatal

Mandibular canine

Buccal


Lingual

Classification of palatally impacted canine
The classification is based on two variables:
(1) Transverse relationship of the crown of the tooth to

the line of dental arch which may be
(a) Close
(b) Distant ( nearer the midline)
(2) Height of the crown of the teeth in relation to the
occlusal plane which may be
(a) High
(b) Low


Group 1

- Proximity to the line of arch – close.
- Position in the maxilla – low.

Group 2

Position in the maxilla – forward , low &

mesial to the lateral incisor root.
Group 3

- Position in the maxilla – high.

Group 4

- Proximity to the line of arch – distant.
- Position in the maxilla – high.

Group 5

- canine root apex mesial to that of lateral incisor or

distal to that of first premolar.
Group 6 - Erupting in the line of arch in place and resorbing the
roots of incisors.


Classification by ACKERMAN and FIELDS in 1935.
IMPACTED CANINE

Horizontally

Palatal

vertically

Labial
Mid- alveolar

Above

Below

(With respect to the apex)

( With respect to the arch)
(J CO 1979 DEC)


TREATMENT ALTERNATIVES
1. No treatment, if the patient does not desire it. Since the
long term prognosis of deciduous canine is poor as its root
may eventually resorb , it should be periodically evaluated.
2. Auto transplantation of the canine.
3. Extraction of impacted canine and moving premolar in
its position.
4. Extraction of the canine & posterior segmental
osteotomy to move the buccal segment mesially to close the
residual space.


5. Prosthetic replacement of the canine, not amendable

for juvenile cases.
6. Transalveolar transplantation of maxillary canine By
Soren Sagne et al in AJODO’ 86 for orthodontic
treatment of impacted canine in adult patients.
7. Most desirable approach is surgical exposure of the
canine followed by orthodontic treatment .

WHEN TO EXTRACT AN
IMPACTED CANINE
* If it is ankylosed & cannot be transplanted.

* If it is undergoing external or internal root
resorption.
* If the root is severely dilacerated.

 If the impaction is severe on central & lateral

incisors & orthodontic movement will jeopardize these
teeth.
 If the occlusion is acceptable, with first premolar in
canine position.
 If there are pathologic changes {cystic formation,
infection}.

PALATAL VERSES LABIAL IMPACTIONS
• Incidence -

Palatal : Labial is 2:1 or 3:1.

• Ectopic labially positioned canines may erupt on their own
without surgical exposure.
• Palatally impacted canine seldom erupt without surgical
intervention due to thick palatal cortical bone & dense &
resistant palatal mucosa.
• Palatally impacted canines are more often inclined in a
horizontal / oblique direction .
• Labial impactions are more often vertically inclined.

FORCE GENERATING DEVICES
Various methods have been used for moving the canine in to
proper alignment with following considerations:
• The use of light force (not more than 60 gms).
• Creation of sufficient space.
• Maintenance of the space.
• Arch wire of sufficient stiffness.

Labially impacted teeth
TMA BOX LOOP

TMA .017 X .025 wire
used.
• Produce sagittal and
horizontal corrections while
continuing vertical eruption.
Surendra Patel J C O 1999


NICKEL TITANIUM CLOSED-COIL SPRING
Loring L.Ross (1999)

• 0.009”X 0.041” spring

• Provides 80 gm of force when stretched to twice
its resting length
JCO Feb 1999


Procedure

JCO Feb 1999


CANTILEVER SPRING
• Lindauer and Isaacson (1995)
• TMA .017 X .025 wire used
• Force generated was measured
by dontrix guage.
• It should not exceed 70gms.
JCO Feb 1999


THE MONKEY HOOK
S.Jay Bowman (2002)

• It is a simple auxiliary with an open loop on each
end for the attachment of intra oral elastic or
elastomeric chain or for connecting to a bondable
loop button.

JCO July 2002


A combination of monkey hooks and bondable loopbuttons allows the production of a variety of different
direction force such as:
I. Vertical intermaxillay eruptive forces

JCO July 2002


II. Vertical intra arch eruptive forces

JCO July 2002


III. Lateral directional forces

JCO July 2002


AUSTRALIAN HELICAL ARCHWIRE
• Christine Hauser (2000)
• Made in special plus .016”
arch wire
• Force should not exceed
200 gm
• Activation by twisting the
steel ligature wire every
two weeks

JCO Sep 2000


Palatally impacted canine:
When crown of canine is more palatally displaced,surgery on
the buccal side needs to become more radical,rendering a palatal;
approach preferable.
Usually palatally impacted tooth is guided to occlusion in two
stages.
I) Guiding tooth to oral enviroment
II) Guiding tooth to line of arch


Guiding tooth to oral enviroment
I) Active palatal arch (Becker1978)

It consist of fine 0.020 inch removable palatal arch wire
carrying an omega loop on each side. End of the wire is doubled
for Frictionless fit in lingual sheath.It is activated by elevating
downward activated palatal arch wire and hooking the pigtail
ligature around it

2) Ballista Spring (Jacoby 1979)

It is made of rectangular wires. It proceeds forward untill
it is opposite to canine space and bent vertically downwards and
terminate into a small loop.With slight finger pressure ,spring is tied
to pigtail ligature. By this it provide an extrusive force for the canine
to erupt.If the impacted tooth is resistant to movement or if the
distance for the tooth to move is more it will leads to lingual molar
root torque leads to loss of anchorage.To overcome this feature TPA
is used.

3) Light Auxiliary Labial Arch (Kornhauser1996)

It is made up of 0.014 inch round SS wire with vertical
loops in the area of impacted canine on both sides.This loop has a
small helix.This wire is tied with the basal arch wire in piggyback
fashion.If basal arch wire is not used it will leads to extrusion of
adjacent tooth and cause alteration of occlusal plane .

THE K- 9 SPRING
•Varun Kalra (2000)
• Made in 0.017”X 0.025”TMA wire
Adv:
• Simple in design
• Low cost
• No patient compliance
• Light continuous eruptive and distalizing
forces
JCO Oct 2000


Fabrication and Activation

JCO Oct 2000


JCO Oct 2000


MANDIBULAR ACHORAGE
• Pramod K.Sinha (1999)

• Lingual arch is fabricated with 0.036 inch SS wire
• Vertical hooks (5-6mm in length)
• Elastic force should not exceed 40-60 gm

AJO March 1999

Advantages
• Simplicity in appliance
design and application
• Reduced overall treatment
time

AJO March 1999


MAGNETS

• M.Ali Darendeliler (1994)

• Samarium cobalt magnet coated
with thermoplastic material
(Eurcodur).
• Initial force of attraction is 10gm

JCO 1994

JCO 1994

Procedure


Guiding tooth to line of arch
Once the tooth is moved to the oral enviroment,bonding
attachment is placed on the midbuccal aspect to prevent iatrogenic
rotation of canine and guided to the line of arch.


a) If the root apex of canine is close to the line of arch and
crown related to the roots of incisors,pure buccal tipping will bring
the crown to desirable position and inclination.
b) If the root apex is distant to the line of arch and crown
not related to the roots of the incisors,usually it will be impacted deep
and may even crosses the mid palatal suture.These tooth can be
directly guided to occlusion through labial arch wire since there is no
inteference of roots of incisors.
c) If there is an horizontal impaction,downward tipping
should be cautiously applied.Force application should be like the
fulcrum of the canine to be at the root end ,so that root apex don’t
alter following the canine tipping movement.

Unfortunately ,fulcrum is usually located short away
from the apical portion of the root, leads to concomitant palatal
displacement of root apex of canine. This requires buccal root
torquing after alignment of canine in the arch.
d) If the root apex mesial to lateral incisor or distal to
premolar , tooth is considered as TRANSPOSED.
I) Incomplete transposition: Roots will be in line of arch in its
position and crown tipped due to path of eruption.(uprighting of
tooth will align the tooth in arch).
II) Complete transposition: Both crown and root together will
be completely interchanged.In these sutiation its better to align tooth
to their respective position ,i.e canine between premolars or mesial
to lateral incisors depends on type of transposition..

If we tried to align this tooth to their respective position,following
will occur,
I) If canine is palatal to line of arch,secondary effect of root
contact will rotate the root apex both mesially and palatally across
the palate in a wide sweeping motion.the tooth will be laid down
beneath the periosteum with huge dehiscence.
II) If canine is buccal to the line of arch ,secondary effect of
root contact will cause further buccal displacement of root with gross
dehiscence of buccal periodontium.
e) If canine is erupting in line of arch and in place of lateral
incisors and resorbing the roots,canine should be guided in distal
direction without extrusion in horizontal plane in a direct line
towards the maxillary molars.

Tunnel traction of infraosseous
impacted canines
A.crescini et al(1994)

Adv:
• No attachment loss
• No recession

AJO 1994



The surgical orthodontic treatment of impacted
canines is aimed at bringing the tooth into its
correct position in the dental arch without
causing periodontal damage.



submucosal impaction -mucogingival problems may
arise. Performing a gingivectomy



"window approach indicates that statistically
significant loss of attachment, recession and
gingival inflammation occur on maxillary
canines after surgical exposure



Therefore a part of the keratinized gingiva
must be preserved or an apically positioned
flap should be used..This approach aims at
obtaining keratinized gingiva around the entire
erupting maxillary canine. Regardless of the
technique used, the tooth is left exposed after
having positioned the attaching device to the
crown.



In the case of deep infraosseous impaction, these
techniques cannot always be used safely and other steps
are required to achieve a satisfactory periodontal
outcome. Full thickness flaps must be reflected to
adequately access the crown of the impacted tooth.
Leaving the crown exposed entails bone resection and
displacements of the soft tissues. In each cases,
although the removal of a significant portion of cortical
bone favors eruption of the tooth, removing tissue may
result in the loss of bone support.



Satisfactory results could be expected if the physiologic
eruption pattern is restored. "When a permanent tooth
erupts ideally it will break through the gingiva near the
crest of the ridge so that some gingiva will be present
on the facial surface."

 Several

studies have been published on the
periodontal status of impacted canines after
surgical orthodontic repositioning. Little
data are available on the periodontal status
from samples including only deep infraosseous
impactions.
 Tunnel approach is a surgical approach for
the orthodontic treatment of deep
infraosseous impacted canines. This technique
allows for orthodontic traction of the
impacted tooth to the center of the alveolar
ridge. The periodontal outcome of these cases
was evaluated after a 3-year follow-up
period.

Tunnel approach


Full gingival flap is raised , with some cortical bone removal to
expose the canine, deciduous teeth is extracted, a tunnel is made
with a bur through socket of deciduous canine till the tip of the
impacted canine

Attatchments used


Flap is sutured back and canine is
disimpacted through the socket of
deciduous teeth

 Impacted

canine erupts at center of
alveolar ridge.

EXTRUSION OF PALATALLY IMPACTED
CUSPIDS


Materials needed are a
Kobayashi hook, a split
rectangular extraoral hook,
and a specially bent .018"
wire two helices,
perpendicular to each other
and about 1/8" apart;
mesial and distal legs
should extend about 1" past
the helices .



Ligate the Kobayashi hook
to the cuspid bracket before
bonding the bracket to the
exposed cuspid. Place a
rectangular stabilizing
wire in the arch. Crimp the
extraoral hook, angulated
labially and gingivally, www.indiandentalacademy.com

Dentigerous Cyst:
Dentigerous cyst is a well defined
radiolucent lesion of alveolar bone and inhibit the eruption of
the involved tooth.
Treatment:
Marsupialization is the procedure consists of
fenestrating the outer wall of the cyst, and relieving the
intracystic pressure. With this early decompression, the size of
the cavity slowly decreases, enabling the surrounding bone to
regenerate around the impacted tooth, which eventually will
erupt into the dental arch.
Thus Marsupialization has the advantage of
reducing the cystic cavity and preserving the involved
tooth.Average time to erupt after Marsupialization is 109
days,without any traction. Orthodontic traction is necessary if

Hyomoto 2003 showed Tooth will erupt after marsupilazation
only it fulfill the following criteria
1) Less than 2/3 rd root formation.
2) Less than 80º to tooth axis angulation to occlusal
plane
3) Less than 9mm deep in bone

Impacted tooth and Periodontium
In 1984 Becker showed Exposure of the crown
should be sufficient to bond attachment rather than exposing
upto CementoEnamelJunction.Previously for placing bands
surgeons Deliberately and completely remove the follicle
surrounding the tooth.When these tooth erupt in to
occlusion,these tooth will have longer clinical crown and
reduced alveolar height.

Kokich and Mathew showed that bone removal should not be
more than 2/3rd of the impacted tooth crown.
Light orthodontic movement like tipping , extrusion, and rotation
have less periodontal breakdown than Heavy orthodontic movement like
root uprighting and torquing.
In 2002 Charles and Frank showed periodontal condition depends
on the type of surgery.Closed approach seems to be preferable than open
approach and apically repositioned flap.


COMPLICATION OF UNTREATED
IMPACTED CANINE
1) Crown Resorption:
With age reduced enamel epithelium surrounding
the completed crown will degenerate and its integrity will
lost.This leads to direct contact of bone and connective tissue
with the crown and osteolytic activity will leads to resorption of enamel
and its replaced by bone ,a process called Replacement Resorption. This is seen
specially in adult patients who left untreated 2-3 decade of age.


2) Labial or lingual malposition of impacted tooth
3 ) Migration of neighboring teeth and loss of arch length
4) Internal resorption of impacted tooth
5) Cyst formation {Dentigerous cyst}
Trauma or carious lesion of deciduous canine will cause
periapical pathology which may leads to direct nterconnection
between apical pathology and Follicular sac surrounding the
impacted canine.
If the follicular sac enlarges more than 2-3mm,it represents
cystic changes

Dentigerous cyst orginates after the crown of the tooth
completely formed by acclumation of fluid between the reduced enamel
epithelium and the tooth crown.
Dentigerous cyst may enlarges at the expenses of maxillary
bone and displace canine higher in the maxilla.
Potential complication of dentigerous cyst
a) ameloblastoma
b) Epidermoid Carcinoma
c) MucoEpidermoid carcinoma
6) Resorption ofLateral incisor root:
This progress of undesirable phenomenon depends on eruptive
movement of the impacted canine. If the impacted tooth is removed or
redirected the resorption process usually ceases.

RETENTION CONSIDERATIONS
Evaluation of post treatment alignment by Becker et al

• Incidence of rotations and spacings
1. Impacted side- 17.4%
2. Control side 8.7%
• Ideal alignment on control side is twice as often as the
impacted side.

To minimize rotational relapse, options available are
1. Fiberotomy
2. Bonded fixed retainer
This can be done during or after the treatment.
Clark’s suggestion for palatally impacted canine: Lingual
drifting can be prevented by removal of halfmoon- shaped
wedge of tissue from lingual aspect of canine.

Orthodontic management of impacted canines can be
very complex and requires a carefully planned interdisciplinary approach.
As canine has unique functional and aesthetic
importance,clinicians usually elect to bring an
impacted canine into proper position to give a better
smile.


Other single teeth
Mandibular and maxillary second
premolars
Crowding and space loss
Early extraction of second deciduous
molar
Distal tipping of 1 deciduous molar
teeth is blocked from eruption
Tipping of adj permanent teeth

Treatment alternatives
Extraction

of the first premolar –
to resolve crowding and
disimpaction
Uprighting of adj teeth with coil
compressed b/w 1 molar and I
premolar
Extraction of impacted teeth along
with other tooth rxtraction in other

Improper orientation of
premolar
Distal tipped premolars causes only
resorption of distal root of deciduous
molar ,leaving mesial root unresorbed
and overretention of deciduous molar.
extract the deciduous molar
Hold the space
Surgically expose the mesial and occlusal
aspects of impacted teeth and attatch
an eyelet and tie a piggy tail and attach
it to hook of the rigid bar used for
maintaining space.www.indiandentalacademy.com

Infraocclusion of deciduous
second molar
Due to infraocclusion - premolar is
impacted more apically
treatment
extract the infraoccluded teeth
Hold the space
Wait and check for spontaneous eruption
of teeth – vertical bone height is also
developed.

Maxillary first molars
In early mixed dentition - common to see that erupting
maxillaary molars caught by distal tuberosity of adj
deciduous second molar.
Clinically - marginal ridges of 2 teeth are not at same level or
present beneath the distal CEJ of deciduous teeth
Radiological - distal root of deciduous 2 molar is resorbed
path of eruption of permanent molar is mesially tilted.
Treatment - donot extract the deciduous molar - mesial tilt
the permanent molar and occupy the space
Mild cases - elastic separator can be used - relapse may
occur after removal
Fixed appliance - banding E of both sides and soldering a
palatal arch with soldered spring on the deep occlusal pit
of I st permanent molar. www.indiandentalacademy.com

Third molar impactions
 Archer

defined an impacted third molar as ‘One
which was completely or partly erupted and
positioned against another tooth,bone or soft tissue,
so that its further eruption was unlikely.
 Dachi and Howell in their study found that the
incidence of patients with atleast one impacted tooth
was 16.7%.


 Bjork

and colleagues identified 3 skeletal factors
that are separately influencing third molar
impaction
– Reduced mandibular length,measured as the distance from
the chin point to the condylar head.
– Vertical direction of condylar growth as indicated by the
mandibular base angle.
– Backward directed eruption of mandibular dentition
determined by the degree of alveolar prognathism of lower
jaw.


 Capelli

in a 1991 study evaluated 60 patients who
underwent orthodontic treatment.

 The

findings from pretreatment and posttreatment
cephalograms suggested that third molar impactions
were more likely to occur in patients with
pretreatment vertical mandibular growth.

A

long ascending ramus, short mandibular length,
and greater mesial crown inclinations of third
molars, seem to be indicative of third molar
impaction.


TYPES OF IMPACTION
Richardson


suggested five categories of impaction

Type A : The tooth can follow the pattern of an ideally
developing third molar, by decreasing its angle to the
mandibular plane and becoming more upright, but the
uprighting may not be enough to allow full eruption.




Type B : The angular
developmental position
relative to the mandibular
plane may remain unchanged



Type C : The tooth can
increase its angulation to
the mandibular plane ,and
become more mesially
inclined .There is at
present no reliable way
of predicting which teeth
will follow this unfavourable
pattern,which sometimes occurs unilaterally and leads
to horizontal impaction



Type D :The tooth can
be seen to make favourable
changes in angulation ,but
fail to erupt owing to lack
of space.These are so called
vertical impactions.



Type E :The tooth can
continue to change its
angulation beyond the ideal
occlusal position,and show
disto angular impaction


MECHANISM FOR ERUPTION AND IMPACTION
 Differential

root elongation might explain
differences in eruptive behaviour among lower
third molars.

 Richardson

offered a theoretical explanation for
favorable or unfavorable rotational movement.


 Favorable

change in angulation ,to a more upright
position ,seemed to occur in teeth where the mesial
root developed ahead of the distal crown surface and
root.
 The typical root configuration showed a mesial root
which was curved in a distal direction and was
slightly longer than the distal root.




Unfavorable mesial tipping, leading to horizontal
impaction, seemed to occur when the distal root became the
same length, and then longer than the mesial root.
 The distal root on such teeth was seen to appear to have a
mesial
curvature.


FACTORS INFLUENCING AVAILABILITY OF SPACE


GROWTH

Bjork et al measured the distance from the anterior
border of the ramus to the second molar,and concluded
that the bigger the space,the better the chance of
eruption.Richardson measured an average of 11.4 mm of
growth between the age of 10 and 15 years.


 BONE RESORPTION

In 1987 Richardson examined the creation of
space for third molars in 51 subjects.
She found that increased space was obtained from
both the mesial movement of the dentition and
bone remodeling along the anterior border of the
ramus.
On average 2 mm of posterior space was created by
bone remodeling


SPACE RELEASED BY ATTRITION
In so-called primitive dentitions, where considerable attrition takes place,
the third molars erupt to take up the space released.
Begg felt that lack of this attrition,due to highly refined diets,was a
major cause of third molar impaction. Other authors, such as Profitt,have
questioned this hypothesis.
Early and extensive interproximal caries could also reduce the size of
erupted teeth, owing to disappearance of proximal contacts.


SECOND MOLAR EXTRACTION
 Richardson and Richardson

in AJO 93 investigated 63
patients after extraction of lower second molars
and found that all the lower third molars erupted
more or less successfully after an average
observation period of 5.8 years.
 There was considerable variation in the time taken
for eruption, ranging from 3 to 10 years and
Richardson noted that it is not possible to predict
how long eruption will take.


 Bonham Magness

in JCO 86 suggests that upper third
molars has a much more predictable eruption pattern
than lower third molars.
 He suggested the extraction of upper second molars
in some cases to assist first molar positioning and
increase space for upper third molars.


 Tae-Woo Kim et al in AJO 2003 confirmed the findings of

Faubion and Kaplan that impaction of mandibular third molars
occurs about twice as often in non-extraction patients than in
extraction patients.
 The mechanism may be that premolar extraction therapy is
associated with an increase in the amount of mesial movement of
the maxillary and mandibular molars and an increase in the
eruption space for the third molars.


 Cephalometric

growth studies suggest 2 important
mechanisms for development of the retromolar space
in the mandible; Resorption at the anterior border of
the ascending ramus and the anterior migration of
the posterior teeth during the functional phase of
tooth eruption.
 More than 60% of the patients in the study, with a
distance of 23 mm or less from the distal of the
mandibular second molar to the Ricketts’ Xi point at
the end of the active treatment experienced eruption
of mandibular third molars.


 The

retromolar space can increase about 2 mm from
age 15 to adulthood.
 They also showed that as many as 60% of the
subjects with a distance from the anterior border
of the ramus to the distal of second molar of 5 mm
or less experienced eruption.
 These suggest that the size of third molar eruption
space associated with a high risk of impaction
might be smaller than previously suggested


UPRIGHTING IMPACTED MOLARS

 Third

molar retention may be beneficial in many
situations.
 Some investigators maintain that third molars
could be used at a later date as replacements or
for prosthetic abutments in case of loss of first
and second molars.
 Third molars could also be used as transplants





In shallow mesio-angular impactions Richardson used a one
stage method.
A second molar tube can normally be bonded onto the buccal
aspect of a partly erupted lower third molar, if enough
enamel is visible.



It is then possible to include the tooth in full treatment ,if
other teeth are already bonded and bracketed.
 If the case is not fully banded,
then lower second or first
molars alone can be used,
with a lingual arch for support







In deep mesio-angular impactions,a two-stage method is
used.
If it is not possible to bond onto the buccal surface,a
different technique is used which can be delayed until 18 –
19 years of age, to allow time for the tooth to improve its
position.
The first stage involves bonding a second molar tube onto
the occusal surface of the lower third molar.








The hook is removed from the tube, before bonding.
Lower first or second molars are banded with a lingual arch,
using first molar bands and brackets.
A small sectional archwire, with a compressed coil spring, is
used to provide a distalizing and uprighting force to the crown
of the impacted molars.
After some uprighting using this method, it is normally
possible to bond a tube buccally for the second stage.


 Ike Slodov et al in AJO 89 describes an orthodontic

uprighting technique similar to ‘Sling shot’
appliance described by Moyers and by Profitt.
 Modified impaction related surgical procedures
provide easy application of techniques to facilitate
exposure of unerupted and partially erupted third
molars and allow orthodontic manipulation







After surgical exposure a cleat is bonded in center of mesial
marginal ridge.
The wire portion of the appliance is fabricated from 0.032
inch stainless steel wire and adapted closely to the mucosa.
The mesial hook is placed 3 mm distal to the distal portion of
the third molar.
Standard soldering techniques are used to attach the wire to
the buccal (or lingual) surface of the band. Appliance is
cemented in place and is activated with elastic modules




By manipulation of the distal arm of the appliance either
buccally or lingually ,depending on the desired movement,teeth
can be directed or rotated
with some effectiveness.
Variation can also be accomplished
by alteration of the bond position
of the cleat.



Following activation,rapid uprighting and distalisation will
occur in 3 to 6 months in most cases.Grinding of occlusal
surface is not necessary.
When the third molars are upright,
the appliances are removed and
the third molars are banded, leveled
and aligned with the rest of the teeth.


 This

procedure is contraindicated when the molar to
be uprighted has no antagonist; is severely
malformed or is abnormally large or small, and it
should be done carefully when there is a tendency
for open bite.
Advantages are:
1. Ease of fabrication and manipulation
2. Rapid treatment
3. Little discomfort
4. No demands for patient cooperation


 Orton and Jones







in JCO 87

described a simple whip spring that is unobtrusive and
fairly fast acting with a treatment time of 4 to 12 months.
It is used for disimpacting , mild to severe mesially impacted
lower terminal molars (LTM).
LTM crown must be accessible for an edgewise tube,
preferably on a band.
Partial seating of the band on the mesial surface is
acceptable at first, which can be fully seated as correction
proceeds.
If the impacted molar has not sufficiently erupted then
surgically expose distobuccal surface and bond an
attachment.


 The

whip spring is fabricated with 0.018X 0.025
wire for 0.022 slot and 0.017X0.022 wire for 0.018
slot.
 A circular loop is placed mesial to the tube to
prevent posterior displacement of the wire and to
provide attachment of an elastic module that anchors
the wire in the tube.







Wire extends mesially from the loop. A vertical bend is placed
occlusally next to the midbuccal fissure of the anchor molar.
The wire is curved lingually to pass through the midbuccal
groove onto the occlusal surface. It is then contoured distally
to run along the occlusal surface.
Moving the whip to the occlusal surface of the anchor molar
activates the appliance.


 The

whip spring can be reactivated in the mouth by
lifting the wire away from occlusal surface and gently
squeezing the arm of the spring between loop and
vertical bend with Tweeds loop forming plier.
 After initial adjustment at 3 to 4 weeks, adjustments
every 6 week seen to be adequate. Overcorrection is
advised.






The force of the whip tends to extrude the impacted molar
and intrude the anchor molar.
If there is too much intrusion of anchor molar, a new whip
can be made that extends to another anchor tooth.
The couple tends to disimpact the LTM by a combination of
distal crown tipping and mesial root movement, resulting in
root paralleling of the molars.


 If

the vertical development of the LTM is impeded
by an upper molar, then the overerupted upper molar
must be intruded by a removable appliance with an
intrusive arm


REPLACEMENT OF THIRD MOLARS
FOR SECOND MOLARS
 According

to Malcolm.R.Chipman in AJO
1961 the third molars can be substituted
for the second molars in certain
situations and solve some of the
problems of maxillary tuberosity area.


 The

indications for eliminating maxillary second
molar and replacing it with third molars are
1.Maxillary third molars of fair size and shape
with the possibility of good root development
2.Small,restricted maxillary tuberosities and the
possibility of interference with distal movement in
maxillary posterior region.
3.Second molars erupted buccally.

4.Second molars decayed ,badly decalcified or having
large restorations.
5.Maxillary third molars in favourable position and
angulation relative to second molars and maxillary
tuberosity.
6.Maxillary third molars in favourable relation to
mandibular second molars.


conclusion

conclusion

Thus management of the impacted teeth is one of the greatest
challenge for orthodontist. Success of the treatment depends
upon patient cooperation, Age of patient, Proper diagnosis, Level
of impaction, Inclination and Depth of impaction, Amount of root
formation, Type of exposure of tooth, Amount of bone removal,
Type of attachment, Orthodontic traction. All these parameter
plays important role when managing impacted teeth to achieve
good alignment in the arch, Gingival level, and Integrity of
periodontium.
Orthodontic treatment can be very rewarding if we are
ready to accept the challenge of anticipating the changes ,
on the basis of a sound problem list and treatment goals.

References
1) Orthodontic treatment of impacted teeth - Ardian
Becker
2) AJO 1983 Aug 125 – 132 The etiology of maxillary
canine impactions - Jacoby
3) AJO 1994 Jan
61 – 72 Tunnel traction of
infraosseous impacted maxillary canines - Crescini,
Clauser, Giorgetti, Cortellini, and Prato
4)AJO 1982 Mar 236 - 239
Txt
Orthodontic
considerations in the treatment of maxillary impacted
canines - Fournier, Turcotte, and Bernard
5) AJO1991 Dec 494 - 512
Txt
Rare earth
magnets and impaction - Vardimon, Graber, Drescher, and
Bourauel.
5) Seminar in orthodontics - management of impacted
teeth.

Thank you
Leader in continuing dental education


Management of impacted teeth /certified fixed orthodontic courses by Indian dental academy

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