CATEGORY 64 AUSTRALASIAN DENTIST LINICAL u There should be no evidence of any pathological change or root resorption affecting the adjacent teeth. u Regular radiographic review is recommended in the growing patient because incisor roots can be vulnerable to resorption. u Retaining the deciduous canine is poor, regardless of its present root length and the esthetic acceptability of its crown. This is because, in most cases, the root will eventually resorb and the deciduous canine will have to be extracted. u If the canine is asymptomatic without evidence of any infection or pathology, the tooth is left as such in a well-aligned arch. Periodic annual review is necessary. Extract: u Teeth that are unfavorably positioned. u Teeth showing signs of pathology. u Tooth that causes resorption and displacement of adjacent tooth should be extracted and prosthetic replacement of the canine should be considered. Only surgical exposure: u Surgical exposure alone is indicated in the following conditions: u Favorably positioned canine with the apex close to normal position. u Unobstructed path of eruption. u Availability of adequate room or space to accommodate the canine. u Tooth is not deeply placed. u Tooth is well within the eruptive period. Surgical exposure and Orthodontic alignment: u Insufficient space available. u Tooth requires proper positioning. u Associated with other orthodontic problems. u Autotransplantation of the canine. u Extraction of the impacted canine and movement of a first premolar in its position. u Extraction of the canine and posterior segmental osteotomy to move the buccal segment mesially to close the residual space. u Surgical exposure of the canine and orthodontic treatment to bring the tooth into the line of occlusion. This is obviously the most desirable approach. 6. MANAGEMENT OF IMPACTED CANINES Early management 1. Interceptive Treatment When the clinician detects early signs of ectopic eruption of the canines, an attempt should be made to prevent their impaction and its potential sequelae. The most desirable approach for managing impacted maxillary canines is early diagnosis and interception of potential impaction. Clinical assessment at the age of 9 to11years, is an opportunity to prevent later problems, and this can be called ‘early management’. The first step is palpation apical to the primary canine. The following clinical signs may be indications of an ectopically positioned canine or impaction: u absence of a normal labial canine bulge or a marked difference in the canine bulge between the right and the left sides at the palpation; u presence of a palatal bulge; u delayed eruption of a permanent canine or prolonged retention of a primary canine; u distal tipping or migration of the lateral incisor; u a widened canine dental follicle, as seen on periapical intra oral radiographs Also the clinical investigation will need to be supplemented with intra oral or panoramic radiographs. Intervention will often require the extraction of primary canines, sometimes followed by limited appliance therapy. Selective extraction of the deciduous canines as early as 8 or 9 years of age as an interceptive approach to canine impaction in Class I uncrowded cases. Ericson and Kurol (1986) suggested that removal of the deciduous canine before the age of 11 years will normalize the position of the ectopically erupting permanent canines in 91% of the cases if the canine crown is distal to the midline of the lateral incisor. On the other hand, the success rate is only 64% if the canine crown is mesial to the midline of the lateral incisor. An interceptive treatment by extraction of deciduous canines, in patients aged 10–13 years with palatally ectopic canine has found to normalize the path of eruption in 1 year in 78% of cases. Impacted canines tend to move mesially with time. Hence, early detection of the condition and timely intervention is the key to success. The best results seem to be obtained under the following conditions: u Patient aged between 10 and 13 years and in themixed dentition; u Canine positioned distal to the midline of the lateral incisor root and less than 55° to the mid-sagittal plane; u An absence of crowding in the maxillary arch. u If radiographic evidence of an improvement in canine position is not evident within 12 months of extraction, further treatment should be considered. Extraction of primary canines indicated Path of eruption 2. Surgical exposure of impacted teeth In the labial regions of the maxilla, and both labially and lingually in the mandible, the alveolar crest is covered by a keratinized, firmly attached gingiva, which is replaced by a more mobile, nonkeratinized alveolar mucosa at the mucogingival junction. On the palatal side of themaxilla there is no alveolar mucosa, the attached gingiva and palatal mucosa are both keratinized and firmly attached to the underlying bone, with no recognizable boundary between them. It is important for an impacted tooth to erupt through attached gingiva because this tissue provides a firm attachment at the dentogingival junction, to maintain integrity of the periodontium during masticatory function and provides the best potential for long-term periodontal health. Impacted teeth are surgically exposed using one of two basic techniques: The prognosis for successful orthodontic alignment of a palatally impacted maxillary canine is influenced by the position of lateral incisor tooth. As the height increases, distance towards the dental midline reduces or angle to the mid-sagittal plane increases beyond 55°, the prognosis worsens.
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