IMPACTED CANAINE

INTRODUCTION

·       The most common impacted tooth after mandibular third molars is maxillary canine.

·        Since these impactions are asymptomatic, they are incidentally found on radiographic examinations. however, impaction of mandibular canines is less common.

·       Unerupted canines occur 20 times more frequently in the maxilla than in the mandible.

·        They are almost always rotated from 60 to 90 degree on their longitudinal axis.


ETIOLOGY

·       Hard palatal bone offers more resistance to eruption than alveolar bone on the ridge 

·       Thick mucoperiosteal soft tissue covering the anterior part of hard palate is dense and resistant than other soft tissues of the oral cavity.

·        Eruption of teeth depends to some extent on an associated increase in apical development. this aid to eruption is minimised in maxillary cuspid as root formation completes at the time of eruption.

·        The canines are the last of permanent tooth to erupt hence they are vulnerable for a long period of time to any unfavourable environmental influences

POSITIONS OF IMPACTED CANAINES

·       In maxilla, the malposedcuspids are found three times as frequently on the palatal side of the arch than on the labial side.

·       They are almost always rotated upon the longitudinal axis and are usually in an oblique position

 

 

CLASSIFICATION

 CLASSIFICATION BASED ON POSITION IN THE DENTAL ARCH

         Class i impacted cuspids in palate

                        1. Horizontal

                        2. Vertical

                        3. Semi vertical

         Class i impacted cuspids on buccal surface

                        1. Horizontal

                        2. Vertical

                        3. Semi vertical 

FIELD AND ACKERMAN CLASSIFICATION (1935) Maxillary canines

 A. Labial position

                         i. Crown in intimate relationship with incisors.

                         ii. Crown well above apices of incisors.

 b. Palatal position

                        i.  Crown near surface in close relationship to root of incisors.

                         ii. Crown deeply embedded in close relationship to apices of incisors.

C. Intermediate position

                         i. Crown between lateral incisors and first premolar roots.

                        ii. Crown above these teeth with crown labially placed and root palatally.

                        iii. Or vice versa.

d. Unusual position

                                    i.  In nasal or antral wall

                                    ii. In infraorbital region

 

RADIOGRAPHIC LOCALISATION

        Localising impacted maxillary cuspids

 Clinical clues

1. Presence of distinct bulge in the palate or on the buccal aspect of the maxilla.

2. If canine is labially impacted, there will be a heflection of the lateral incisor (apical portion of root lingually and the crown labially).

        The position of the upper canine is assessed from radiography which are taken in two planes to give three dimensional impressions of the tooth and associated structures. they are:

        1. Intraoral periapical films

        2. Vertex occlusal film

CLARK’S TUBE SHIFT METHOD

        By changing the angulation of the x-ray beam, an apparent displacement of the object to be localised was seen, when the reference object is considered as the tooth closest to the object to be localised,

        The image of the object that is farther (palatally or lingually placed object) from the x-ray tube moves in the same direction as the tube, whereas the image of the object closer to the x-ray tube (buccally placed object) moves in the opposite direction.

        This technique was introduced by clark 

MANAGEMENT

FACTORS DETERMINING TREATMENT 

        A.  Age of the patient

        B.  Stage of tooth development

         C. Position of impacted tooth d evidence of root resorption of adjacent permanent teeth.

Surgical removal

            Indications

1. Impacted canine is located very far from the oculus al plane

2. No other methods are possible to retain the tooth

            Contraindications

1. When the cuspid can be brought into normal position surgically or orthodontically.

2. Medically compromised patients, presenting with impacted cuspids.

Operative plan 

 a. Study radiographs

 b. Classify impaction 

 C. Plan the type of soft tissue flap

 d. Decide whether sectioning of tooth is needed.


PROCEDURE

        Soft tissue flap

        1. No. 12 bp blade is used to incise the tissues around the neck of the teeth beginning on the lingual side of the maxillary central incisor and extending to distal of 2nd bicuspid and the flap is raised as a mucoperiosteal flap from the hard palate by means of periosteal elevator until the bone is exposed.

        BONE REMOVAL

         After reflecting the flap, it can be retracted by help of a flat bladed instrument such as austin retractor or howarth periosteal elevator.

        Alternatively, the flap can be retracted by the help of tie sutures, tied around the necks of opposite side teeth.

        Bone is removed circumferentially 3 mm around the crown of the impacted tooth being careful not to damage the roots of adjacent teeth.

        Enlarge the size of the opening with burs so that the complete crown may be seen.

        Elevation of tooth

        An appropriate elevator is placed on one side of crown and with the palatal bone as the fulcrum impacted tooth is lifted from its crypt in the palate.

        Extreme care should be taken to prevent injury the adjacent teeth

        If this does not remove the impacted tooth, enlarge the opening and repeat the procedure, using two elevators in the same way.

        If the tooth is still not luxated, the tooth requires crown root sectioning and extraction.

        Wound irrigation and closure

        All the debris, spicules are removed and bony mar gins trimmed.

        Tooth follicle is removed if present and the flap is sutured back into position.

 


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