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ADVANCES IN ORTHODONTICS & DENTOFACIAL SURGERY

Surgical and orthodontic management of

impacted maxillary canines
Vincent G. Kokich, DDS, MSD
Tacoma, Wash

lip impaction
Chanical Man
Labial impaction of a maxillary canine is due either
Although the meof im
Aging to ectopic migration of the canine crown over the root
pacted teeth is a routine of the lateral incisor or shifting of the maxillary dental
task for most orthodon
midline, causing insufficient space for the canine to
tists, certain impactions erupt. Williams3 suggested that extraction of the
can be frustrating, and maxillary deciduous canine as early as 8 or 9 years of
the esthetic outcome
age will enhance the eruption and self-correction of a
can be unpredictable if
labial or intra-alveolar maxillary canine impaction. Olive4
the surgeon uncovers
suggested that opening space for the canine crown with
the im pacted tooth improperly.
routine orthodontic mechanics might allow for sponta
When referring a patient
neous eruption of an impacted canine. However, in
to have an impacted
some situations, even these techniques do not work,
tooth uncovered, theortho
and the orthodontist must refer the patient to have the
dontist might assume in
labial impaction uncovered surgically. There are 3
correctly that the surgeon knows which surgical
techniques for uncovering a labially impacted maxillary
procedure to use. However, if not instructed properly,
canine: excisional uncovering (Fig 1), apically positioned
the surgeon could select an inappropriate technique,
flap5 (Figs 2 and 3), and closed eruption techniques6 (Fig 4).
leaving the orth odontist with the difficult if not sometimes
Which technique should the orthodontist recommend?
lengthy and challenging task of erupting the impacted
When referring a patient for surgical exposure of
tooth into the dental arch. On the other hand, if the
a labial or intra-alveolar impaction of a maxillary
correct uncovering technique is chosen, the eruption canine, the orthodontist should evaluate 4 criteria to
process can be simplified, resulting in a predictably stable and esthetic result.
determine the correct method for uncovering the tooth.
This is especially true for impacted maxillary canines.
First, assess the labiolingual position of the impacted
After the third molars, the maxillary canines are the
canine crown. If the tooth is impacted labially, then
most commonly impacted permanent teeth.1 About one
any of the 3 techniques could be used, because
third of impacted maxillary canines are positioned
generally there is little if any bone covering the crown
labially or within the alveolus, and two thirds are located
of the impacted canine. However, if the tooth is
palatally.2 In most situations, the appropriate timing and
impacted in the center of the alveolus, an excisional
surgical procedure for uncovering an impacted canine
approach and an apically positioned flap are generally
are determined by specific criteria. This article will
more difficult to perform, because extensive bone
review the surgical and orthodontic management of might need to be removed from the labial surface of
impacted maxillary canines.
the crown. The second criterion to evaluate is the
Professor, Department of Orthodontics, School of Dentistry, University of vertical position of the tooth relative to the mucogingival
Washington, Seattle. junction. If most of the canine crown is positioned
Reprint requests to: Dr Vincent G. Kokich, University of Washington, Department
of Orthodontics, 1019 Corona Dr, Tacoma, Wash; e-mail,
coronal to the mucogingival junction (Fig 1), any of
[email protected]. the 3 techniques can be used to uncover the tooth.
Presented at the American Association of Orthodontists/American Association However, if the canine crown were positioned apical
of Oral and Maxillofacial Surgeons Symposium, February 6-8, 2004; Palm
Springs, Calif.
to the mucogingival junction (Figs 2 and 3), an
Submitted and accepted, June 2004. excisional technique would be inappropriate, because
Am J Orthod Dentofacial Orthop 2004;126:278-83 it would not result in any gingiva over the labial surface
0889-5406/$30.00 Copyright © 2004 by the
American Association of Orthodontists. doi:10.1016/
of the tooth after it had erupted. In addition, if the
j.ajodo.2004.06.009 crown were positioned significantly apical to the mu cogingival junctio

278
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Fig 1. Patient had impacted maxillary right canine. A, Space was created orthodontically, but tooth did
not erupt. B, Tooth was labially positioned, coronal to mucogingival junction, and there was sufficient
gingiva in area. C, simple excisional procedure was used to uncover it. D, After orthodontic eruption,
relationship of gingival margins relative to adjacent teeth was normal with adequate zone of gingiva.

would also be inappropriate, because it would result alveolar ridge. This method would produce normal
in instability of the crown and possible reintrusion of labial gingival relationships over the erupted tooth.
the tooth after orthodontic treatment.7 In the latter The orthodontist should avoid mechanics that draw
situation, a closed eruption technique will provide the tooth labially, which could produce a bony
adequate gingiva over the crown and does not result dehiscence and accelerated migration of the labial
in reintrusion of the tooth in the long term.8 gingival margin, resulting in labial recession. A ballista
The third criterion to evaluate is the amount of loop (Fig 4) is a simple, convenient, unobtrusive
gingiva in the area of the impacted canine. If there method of applying a vertical vector of force to a
were insufficient gingiva in the area of the canine (Fig labially impacted tooth to erupt the crown into the
3), the only technique that predictably would produce center of the alveolus. When the canine crown is
more gingiva is an apically positioned flap. However, displaced mesially and lies over the root of the
if there were sufficient gingiva to provide at least 2 to permanent lateral incisor (Fig 2), an apically positioned
3 mm of attached gingiva over the canine crown after flap is the appropriate surgical uncovering technique.
it had been erupted, any of the 3 techniques could be Exposure of the crown facilitates attach ment of an
used. The fourth and final criterion to evaluate is the elastomeric chain (Fig 2) directed toward the center
mesiodistal position of the canine crown. If the crown of the edentulous alveolar ridge to gradually guide the
were positioned mesially and over the root of the canine crown into the dental arch.
lateral incisor (Fig 2), it could be difficult to move the Vermette et al7 compared the periodontal and
tooth through the alveolus unless it was completely esthetic result after closed eruption and apically
exposed with an apically positioned flap. In this latter positioned flap techniques. They found no significant
situation, closed eruption or excisional uncovering differences in gingival index, plaque index, pocket
generally would not be recommended. depth, and bone level between these 2 techniques,
but they identified significant esthetic differences.
Orthodontic mechanics and long-term stability With an api cally positioned flap, the crown length of
The mechanics to erupt a labially impacted tooth the impacted tooth is longer than normal, due to apical
should mimic the normal eruptive process. If the migration of the gingival margin. The crown lengths of
canine crown were uncovered with a closed-eruption uncov ered teeth with closed eruption were similar to
technique (Fig 4), the orthodontist should select contralateral non-impacted teeth in the same mouth.
mechanics that erupt the tooth into the center of the Second, and perhaps more disturbing, high labial impactions uncov
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Fig 2. A, Patient had impacted maxillary left canine. B, Buccal object rule indicated tooth was
positioned labially. C, Teeth were initially aligned, and, because canine crown was positioned labially,
any of 3 uncovering techniques could be used. However, cusp tip was positioned above mucogingival
junction and was displaced mesially. D, Apically positioned flap technique was chosen. E, After
gingival tissues had healed, tooth was gradually moved distally. F, Placed in its correct position.

Fig 3. A, Patient had impacted maxillary right canine. Crown was positioned labially between lateral
and first premolar and was partially below mucogingival junction. Simple excisional uncovering could
not be used, because there was insufficient gingiva in region. B, Mucosa stained with Schiller's iodine
solution. Apically positioned flap was used to expose tooth and increase width of gingiva. C, After
healing, bracket was attached. D, Tooth erupted into position with adequate zone of gingiva.

ered with an apically positioned flap tend to reintrude the impacted tooth at the time of uncovering. As the
after orthodontic treatment. This is due to the healing tooth is erupted into the dental arch, the mucosa is
of the apically positioned flap to the mucosa adjacent to drawn coronally. After orthodontic treatment, this mu
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Fig 4. A, Patient had intra-alveolar impaction of maxillary right canine. B, Space was opened
orthodontically for impacted tooth. Crown was positioned above mucogingival junction and in alveolus,
so neither excisional uncovering nor apically positioned flap was appropriate. C, Closed eruption
technique was used. D, Labial flap was elevated, and sufficient bone around crown was removed to
allow eruption without impinging on bone. E, F, and G, Ballista loop was used to erupt tooth into center
of alveolar ridge. Canine was then placed in its proper position in arch. H, After orthodontic treatment,
right canine has sufficient gingiva and resembles contralateral nonimpacted canine.

cosal attachment tends to pull the crown of the tooth beam. If the impacted canine were located palatally,
apically. This disadvantage was not observed in teeth the crown of the tooth would move in the same
uncovered with closed eruption. Becker et al8 found direction as the x-ray beam. A mnemonic method for
similar favorable esthetic results in their study of the remembering this principle is the SLOB rule (same
closed eruption technique for uncovering impacted lingual oppo site buccal).
maxillary central incisors.
palatal impaction
Radiographic verification of crown position The most common impaction encountered by
While evaluating the position of the impacted ortho dontists is the palatal impaction of maxillary
canine, the orthodontist must assess radiographs to canines.2 However, Ericson and Kurol10 showed that
determine the accurate position of the crown. The early extraction of deciduous maxillary canines will
orthodontist must rely on the buccal object rule9 to result in normal eruption of ectopically displaced
identify the exact labiolingual position of the crown. permanent maxillary canines. In their extensive study,
The buccal object rule states that when viewing 2 they found that, if periapical radiographs showed that
adjacent periapical radiographs of the impacted tooth the crown of the permanent canine were positioned
taken at slightly different horizontal angles, the buccal over the root of the maxillary lateral incisor, but not
object will move in the opposite direction of the x-ray past the mesial surface of the root, self-correction of the ectopic canin
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Fig 5. A, Patient had palatally impacted maxillary right canine. To allow impacted canine to erupt
autonomously and reduce time in orthodontic appliances, impacted tooth was uncovered before
orthodontic treatment. B, Mucoperiosteal flap was elevated, and it was determined that the crown was
still covered with bone. C, All palatal bone down to cementoenamel junction was removed so that
tooth could erupt unimpeded. D, Hole was placed in flap, and it was repositioned and sutured over
crown of impacted canine. E and F, Canine erupted without orthodontic forces. G, When cusp tip was
at level of occlusal plane, bracket was placed on crown and root was moved labially. H, After
orthodontic treatment, it is difficult to identify differences between previously impacted right canine and
contralateral nonimpacted canine.

occurred with high predictability if the deciduous edentulous site. However, the crown of a palatally
canine were removed. However, if the permanent impacted canine is often in intimate contact with the
canine were positioned well beyond the mesial surface lingual surfaces of the roots of the ipsilateral central
of the lateral incisor root, self-correction does not and lateral incisors. If the tooth was not uncovered
occur with extraction of the deciduous canine. The properly, it could appear to the orthodontist that the
palatally impacted canine must be uncovered by a tooth is not moving and perhaps could be ankylosed.
surgeon and positioned in the dental arch by the orthodontist.
The incidence of ankylosed maxillary canines is low.11
If not uncovered properly, palatally impacted ca The problem in these situations is insufficient bone
nines can be the most frustrating impactions for the removal over the crown of the impacted canine. If this
orthodontist to resolve. For most orthodontists, uncov occurs, after the dental follicle is deflated and removed,
ering a palatally impacted canine occurs after the first the tooth cannot resorb the bone over the crown
6 to 9 months of orthodontic alignment of the maxillary efficiently. When a force is placed on the tooth and
dentition. Space is created for the crown of the im the enamel of the impacted crown comes into contact
pacted tooth, and the patient is referred to a surgeon with the bone, there are no cells in the enamel to
to uncover the crown. Usually, soon after the surgery, resorb the bone. Resorption will eventually occur
the orthodontist begins dragging the crown toward the through pressure sure necrosis, but it will occur slowly.
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Woloshyn et al12 evaluated 32 patients who had impacted canine. It seems appropriate to uncover pal
palatally impacted canines that were uncovered in this atally impacted canines early, during the mixed
manner and then dragged into the dental arch across dentition, so that they can erupt autonomously, without
the lingual surface of the lateral incisor roots. These orthodontic intervention, until the crown has erupted
au thors found that the bone levels on the distal surface to the level of the occlusal plane. At that time, it can
of the lateral incisor and mesial surface of the canine be moved more efficiently into the dental arch. By
were positioned more apically compared with the treating palatally impacted canines in this manner, the
contralateral nonimpacted control teeth. In addition, overall treatment time for the patient is reduced, and
root resorp tion of the lateral incisor and the canine the periodontal and esthetic results are superior
were typical when the canine was erupted in this compared with previous methods for exposing palatally
manner. Finally, after orthodontic treatment, judges impacted canines.
could identify which canine had been palatally impacted
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