CATEGORY AUSTRALASIAN DENTIST 65 LINICAL a. Open eruption The crown is surgically uncovered and the tooth left exposed within the oral cavity; it is then allowed to erupt naturally, or the orthodontist places an attachment directly to guide eruption. Factors concerning Treatment plan u Root Resorption: One of the main issues to consider when drawing up a treatment plan for patients with impacted maxillary canines is whether root resorption is present on the adjacent lateral or central incisors. Using this information, a decision can be made about the best time to start treatment; patients in this group normally need surgical exposure of the impacted canines and a long and complex orthodontic treatment. In case of already resorbed incisor roots, treatment includes creating space between the canine and the incisor root to prevent further resorption. In these cases, the longterm prognosis for the resorbed incisors is good. Also the canine must be moved away from the incisor first, before starting the traction out towards the alveolar crest. u Close proximity to root: If the canine is in close proximity to the incisor roots and a buccally directed force is applied, it will contact the roots and may cause damage. Ideally moving the impacted tooth in an occlusal and posterior direction first and then moving it buccally into the desired position is acceptable. When using a bonded attachment and orthodontic forces to bring the impacted canines into occlusion, it is important to remember that first premolars should not be extracted until a successful attempt is made to move the canines. If the attempt is unsuccessful, the permanent canines should be extracted. In such cases, the orthodontist has to decide if the premolar should be moved into the canine position. 1. Surgical exposure and orthodontic alignment Orthodontists suggest to first create adequate space in the dental arch to accommodate the impacted canine and then surgically expose the tooth to give them access so that they can apply mechanical force for the tooth to erupt through the attached gingiva and not through alveolar mucosa. Labial impaction For labially placed tooth, flap is raised from the crest of the alveolus and sutured. Tooth then erupts through the attached gingiva and normal contour is maintained. A buccally impacted tooth usually shows a bulge in the buccal sulcus on palpation. Surgical access can be achieved by an apically repositioned flap. Where the crown is left exposed, the eruption of the tooth is speeded up by this surgery and a bonded attachment may apply light force on the tooth. But periodontal problems, with unesthetic gingival margin and a clinically long crown length may result. There is also some attachment loss and bone loss. Another technique is a closed flap eruption method, where a buccal flap was raised and attachment was bonded to the impacted tooth. A twisted stainless steel ligature wire is passed through the bracket through the flap and the flap is closed and sutured back to Procedure: Open eruption either involves removal of the overlying mucosa accompanied by any necessary bone (window technique), or an apically repositioned flap (a modification for labially impacted teeth that relocates the flap apically, covers the cervical margin of the exposed tooth with attached gingiva and ensures that this tissue accompanies the tooth into its final eruptive position). Advantages: Orthodontist can directly visualize the tooth following exposure. Disadvantages: Presence of an open wound can also result in more postoperative discomfort for the patient. b. Closed eruption The crown is surgically exposed, an orthodontic attachment is placed and the overlying mucosa is replaced. A chain or wire extends from the attachment through the mucosa, which allows to place traction to the teeth. This method attempts to simulate normal tooth eruption and foster good long-term periodontal health. Disadvantages: Lengthy overall procedure, moisture control is often difficult at surgery and the attachment can become detached during traction, which may necessitate further surgery to replace. The open window or closed techniques are suitable for teeth impacted beneath attached gingiva. Those situated below nonkeratinized alveolar mucosae require either an apically repositioned flap or closed eruption. Indications for Surgical Exposure An unerupted canine may be a candidate for surgical exposure if: u No sign of the tooth even after 12years of age u Adequate room in the arch is present or can be created orthodontically or by extraction of some other tooth. u Potential path of eruption is unobstructed by other teeth. u The apex of canine situated as normal as possible u Radiographically the root is not dilacerated. Late management When the canine is irreversibly impacted, there is normally a need to start treatment immediately. This normally includes patients of 11 years or older in late mixed dentition or early permanent dentition, where intervention was not attempted or where extraction of the primary canines did not lead to an improvement in the eruption direction in the following 6 to 12 months. Also included will be cases with atypical early root resorption on one or both adjacent incisors. The later management cases require computed tomography to improve the accuracy of location of impacted maxillary canines and resorption status of adjacent roots, thus allowing better treatment planning for both surgical and orthodontic treatments. Chain extending through mucosa
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