Management of impacted all canines with surgical exposure and alignment by orthodontic treatment
A 16-year-old girl reported to Department of Orthodontics, Dental faculty of C.S.M. Medical University, Lucknow, with the chief complaint of severe intermittent pain in upper and lower anterior teeth. Patient had past dental history of root canal therapy in the lower right lateral incisor and amalgam restorations and her medical history was not significant.\nOn clinical examination, extra orally patient shows incompetent lips with convex profile [Figures and ] Intraoral examination showed there was 100% overbite, 5 mm overjet and molars were in Class I relation [Figures ] The most noticeable feature was absence of both maxillary and mandibular canines [Figures ] In the maxillary arch, space was present between the lateral incisors and the first premolars, but in mandibular arch, there was some arch length discrepancy.\nEvaluation of panoramic radiograph, shows impacted maxillary and mandibular canines. Both maxillary canines were palatally impacted and mandibular canines were lingually impacted. All four canines were exerting pressure on the roots of lateral incisors. Lateral cephalometric evaluation shows the prognathic maxillae, high mandibular plane angle with protrusion of both upper and lower lips [ and , ].\nThe main treatment objectives for the patient were to relieve pain that was due to pressure of impacted canines on lateral incisors and to correct the patient's esthetics, overjet, overbite and correction of functional occlusion by bringing all the four permanent canines into alignment and occlusion.\nSurgical exposure of the impacted maxillary and mandibular canines followed by directional forces to bring them into occlusion was planned. Extraction of the maxillary, first premolars was planned for correction of the overjet, overbite and space management for the impacted maxillary canines. In the mandibular arch, extractions of the lateral incisors were planned due to arch length discrepancy and poor prognosis of mandibular left lateral incisors.\nInitial maxillary and mandibular arch alignment was performed and 0.019” × 0.025” stainless steel arch wires were inserted. A transpalatal arch in the maxillary arch and a lingual holding arch in mandible arch was placed to stabilize the molars. Thus adequate anchorage was planned before the canines’ exposure.\nExposure of the palatally impacted maxillary canines was performed by an open window procedure and lingual buttons bonded on the exposed crown surface.[] [] because the crowns of mandibular canines were in close proximity to the roots of the lateral incisors, both canines were exposed with closed flap technique and then lingual buttons were attached on the accessible surface of the teeth. The flap was replaced over the crown and the hook were exposed for force application.[] Only when we were assured of tooth eruption, the maxillary first premolars and mandibular lateral incisors were extracted. Glass ionomer cement bite block was placed on mandibular posterior teeth to prevent obstruction and facilitate movement of maxillary canines. Light orthodontic forces were applied from K-9 extrusion spring for the traction of the impacted canines into the extraction space[] [].\nSince light exposure of impacted canines without exposing cementoenamel junction results in better bone support latter as compared with heavy exposure with complete removal of follicular sac, bone was removed conservatively.\nTo activate the spring after it is engaged in the auxiliary tube of molar buccal tube the vertical arm is swung upward and ligated to the bonded attachment on the impacted canine. This provides a gentle extrusive force on the canine; the spring also has a buccal component of force due to the arcial pattern of activation and deactivation. The force needed to distalize the canine is achieved by cinching the spring back about 2 mm after it has been ligated to the canine. When the vertical arm of the K-9 spring is rolled upward and inward to be engaged to an impacted canine, the result is an intrusive force and a clockwise moment on the molar and premolars. A transpalatal arch and lingual holding arch control this reactive force and moment.\nSimultaneously an intrusion arch was ligated in both arches for the intrusion of maxillary and mandibular incisors. After completion of the traction, a series of stainless steel wires (0.016,” 0.017” × 0.025,” 0.019” × 0.05” and 0.021” × 0.025”) were ligated and final alignment and leveling accomplished. The case was completed within 2 years and 4 months and the final results are shown in post treatment photographs.