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Surgical Treatment of Impacted Canines: What the Orthodontist

Would Like the Surgeon to Know

Article  in  Oral and maxillofacial surgery clinics of North America · August 2015

DOI: 10.1016/j.coms.2015.04.007 · Source: PubMed

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S u r g i c a l Tre a t m e n t o f
Impacted Canines
What the Orthodontist Would Like the
Surgeon to Know
Adrian Becker, BDS, LDS, DDO*, Stella Chaushu, DMD, MSc, PhD

KEYWORDS
 Impacted canine  Surgical exposure  Open or closed exposure  Attachment bonding
 Immediate traction  Steel ligature connector

KEY POINTS
 If there is an existing malocclusion that requires orthodontic treatment, a full orthodontic appraisal
is needed for planning the overall mechanotherapy.
 It is incumbent on the oral and maxillofacial surgeon and the orthodontist to evaluate the 3-dimen-
sional location of the tooth and assess whether the tooth or teeth are salvageable.
 Excepting the very simplest and mildest forms of impaction, orthodontics will be necessary to
properly resolve the impaction and align the tooth.

Videos of two very high impacted canines using cone beam computed tomography
accompany this article at http://www.oralmaxsurgery.theclinics.com/. One is located high
on the palatal side of the incisor root apices and the second in the line of the arch, high
above the premolar with interference from abnormal premolar roots

INTRODUCTION encourage autonomous eruption of the

canine.1,2
When an impacted permanent maxillary canine 3. A supernumerary tooth or odontome that has
has been diagnosed, the general practitioner or impeded the normal eruption of the tooth could
pediatric dentist typically thinks in terms of surgery be removed.
and orthodontics and, usually, in that order. Thus, 4. Access to the tooth may be provided for the
the patient is frequently referred to the oral sur- later placement of an attachment and for the
geon in the first instance. application of traction if rehealing of the tissues
In this scenario, a “surgery first” approach can over the crown is prevented using a surgical/
achieve several important goals. periodontal pack over the open wound or by
1. By exposing the tooth to the oral environment, apically repositioning a surgical flap higher up
surgery can provide a way for autonomous nat- on the crown of the exposed tooth.
ural eruption. However, surgery alone is limited when:
oralmaxsurgery.theclinics.com

2. Surgery could simplify orthodontic treatment

that would then be delayed for several months 1. Space is inadequate in the dental arch to
if, as advocated by the late Vince Kokich, expo- accommodate the impacted tooth, thereby
sure and packing of the exposure wound would impeding its natural eruption.

Department of Orthodontics, Hebrew University-Hadassah School of Dental Medicine, 6 Shalom Aleichem

Street, Apartment #3, Jerusalem 92148, Israel
* Corresponding author.
E-mail address: adrian.becker@mail.huji.ac.il

Oral Maxillofacial Surg Clin N Am 27 (2015) 449–458

http://dx.doi.org/10.1016/j.coms.2015.04.007
1042-3699/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
450 Becker & Chaushu

2. To maintain a patent exposure, an excessive which he or she may not be prepared. Perhaps
amount of gingival tissue and bone must be oral hygiene is poor or there is frank caries in
removed, to the detriment of the periodontal other teeth, or simply that the patient is unwilling
outcome.3–5 or financially unprepared to wear braces.
3. Autonomous eruption is unlikely to occur and
the surgeon feels the necessity for a much THE ORTHODONTIST MUST BE THE “MASTER
more radical open exposure and/or the tooth OF CEREMONIES”
is “gently” elevated to “free” it from the sur-
rounding tissues, or if bone channeling is per- If there is an existing malocclusion that requires or-
formed. These procedures are highly suspect thodontic treatment, a full orthodontic appraisal is
for inflicting irreversible damage to the perio- needed for planning the overall mechanotherapy.
dontium4 or the cementum layer of the root.6 The orthodontist will undertake a clinical examina-
4. Immediate application of traction cannot be em- tion, including plaster casts and the routine radio-
ployed because there is no orthodontic appli- graphs needed for any orthodontic case. For a
ance or temporary orthodontic bone anchor patient with an impacted maxillary canine, there
present, from which to apply the traction force. will be the additional requirement of accurately
5. The tooth needs to be moved away from the locating the impacted tooth in 3 planes of space
root of an adjacent tooth, particularly when and in relation to the adjacent teeth. Further radi-
there are signs of resorption of that root.7 ography, together with cone beam CT, will often
6. The tooth is located in a grossly ectopic site.8 be required to diagnose resorption of the roots of
the incisors and to confirm the integrity of the
Surgery without orthodontic coordination may outline and texture of the impacted tooth itself.9,10
occasionally result in: When all the information is collated, a treatment
plan will be formulated to resolve the overall
1. The surgeon exposing an impacted tooth before malocclusion and to decide the future of the
an orthodontic appraisal has been made. This impacted tooth, which may lead to a decision to
may be one of the teeth that the orthodontist extract permanent teeth. In general, the choice of
would wish to sacrifice in the course of subse- tooth for extraction devolves on a premolar in
quent orthodontic treatment, because overall each quadrant. However, no tooth is sacrosanct
and comprehensive considerations may demand and, if the choice is between an erupted healthy
the remedial extraction of 4 permanent teeth. premolar and a deeply buried canine in an ectopic
2. Rehealing of the surrounding tissues over the location, whose periodontal outcome may be
exposed tooth, making it once again compromised in the final analysis, the canine
inaccessible. should be extracted.4
3. The surgeon bonding an attachment to an Excepting the very simplest and mildest forms
aspect of the crown of the tooth in a strategi- of impaction, orthodontics will be necessary to
cally incorrect position during the operation, resolve properly the impaction and align the tooth.
which may make subsequent orthodontic trac- This being so, the dental arches need to be aligned
tion difficult to direct or control. and leveled and adequate space provided in the
4. Poor timing, because active traction may be canine location, to place a heavy archwire in the
impossible to apply for several months or years, bracket slots and, thus, to establish a sound
during which reburial of the tooth may still occur. anchorage base from which to apply traction to
5. A successful treatment from the surgical and or- the tooth. This preparatory step takes time—occa-
thodontic standpoints, but that may become a sionally, as much as a year or more—but ortho-
periodontal disaster if the root apex of an dontists are well-practiced at achieving these
impacted tooth is in a severely displaced initial goals.
location. The orthodontist may consider that, Clearly then, the orthodontist is the person who
although it may be possible to achieve a good or- is ultimately responsible to the patient for the suc-
thodontic resolution of the impaction and align- cess of the treatment plan as a whole. The oral and
ment of the tooth into its place in the dental maxillofacial surgeon is responsible only for the
arch, the periodontal prognosis may be compro- success of the immediate operative procedure,
mised, after the difficult orthodontic root move- in which he or she provides access to the tooth,
ments of the tooth, with the outcome showing previously denied. It is incumbent on both the
insufficient bony support, poor soft tissue cover, oral and maxillofacial surgeon and the orthodontist
and an unsightly and elongated clinical crown. to evaluate the 3-dimensional location of the tooth
6. Committing the patient to orthodontic treatment, and, together, assess whether the tooth or teeth
because this is the “best” line of treatment, but for are salvageable. If the canine position is beyond
 Surgical Treatment of Impacted Canines 451

reasonable bounds, extraction will be advised. For the direction he or she will have planned, to reduce
the oral and maxillofacial surgeon, an assessment the impaction and align the tooth.
of the location of the crown of the canine in the 3
planes of space and in relation to the roots of the THE SURGICAL PROCEDURE
adjacent teeth is essential, because the surgeon
is only interested in exposing the crown and pre- There are several appropriate surgical procedures
venting damage to the adjacent teeth. Orientation that need to be contemplated and these are
of the root of the tooth is not relevant to his or her classified into open procedures and closed proce-
ability to achieve success in the exposure dures. Each method must additionally take into ac-
procedure. count the elimination of a supernumerary tooth or
For the orthodontist, the assessment also in- odontome, if appropriate.
volves the 3-dimensional orientation of the long
The Palatal Canine and the Open Exposure
axis of the tooth and an exact positional diagnosis
Technique
of its root apex. If the apex is in the line of the arch in
the buccolingual plane and in the mesiodistal The palatal area is composed of tightly bound
plane, then the crown of the tooth will only need attached mucosa, which means that a palatally
to be tipped into its place in the arch, a relatively impacted canine that is erupted through it, after
simple biomechanical exercise. For as long as the an open exposure procedure, will be invested
tooth is not fully engaged in the main archwire, no with attached epithelium in the final instance. After
root movements are possible and, thus, any devia- this procedure, the canine must be left exposed to
tion of the location of the apex, particularly in the the oral environment and care taken to ensure that
buccolingual plane, will demand complicated up- healing of the adjacent soft tissues will not recover
righting and torqueing mechanotherapy, which is the tooth and again make it inaccessible. This may
technically difficult to perform and reduces the be done by clearing a broad area of soft tissue,
periodontal prognosis of the tooth in the long term.4 including the entire dental follicle, oral mucosa
Accordingly, the orthodontist’s evaluation as to and bone, down to the cementoenamel junction
whether surgical exposure should be undertaken (CEJ) and placing a surgical pack to cover the
at all must be considered of primary importance. area (Fig. 1). This pack would normally be left for
It follows that the surgeon’s essential role is to pro- 2 to 3 weeks in the hope that the tooth remains
vide optimal conditions for the orthodontist to be visible when the pack is removed, and to provide
able to proceed to apply forces to the tooth in access for later bonding of an attachment in the

Fig. 1. (A) Panoramic view showing palatally impacted maxillary canine and other dental anomalies. (B) Occlusal
view to show the palpable bulges indicative of relatively superficial, palatally displaced, canines (arrows). (C)
Open exposure of the 2 canines. (D) A suture-stabilized periodontal pack covers the exposed area, with the
aim of preventing healing over of the palatal soft tissue and maintaining access to the tooth. (Treatment by grad-
uate student Dr O. Yitschaky.)
452 Becker & Chaushu

relative comfort of the orthodontist’s office. A word will still be invested with the same healthy attached
of caution arising from overzealous surgical expo- gingiva, but the clinical crown length, the gingival
sure is at this juncture. To ensure that the tooth level, the alveolar crest height and the periodontal
does not become recovered by the tissues during parameters will be much more favorable.13 This
the healing period, bone and mucosal tissue are method is particularly useful when the impacted
often pared back liberally around the tooth. tooth is situated deeply. An open procedure would
Together with a complete elimination of the dental leave a very wide mucosal deficiency in the palate.
follicle, the entire crown down to the CEJ is Conversely, a superficially palpable canine should
revealed and a surgical pack placed to maintain be left open after the exposure, with or without a
the patency of the open exposure site. Exposure surgical pack as a dressing.
of the tooth down to the CEJ and excessive
removal of bone and soft tissue will have a detri- The Labial Canine and the Window Technique
mental effect on the periodontal outcome of an A labially impacted canine, on the other hand, is
otherwise successfully treated case, because the usually palpable above the level of the attached
junctional epithelium that encircles the cervical gingiva and covered only by a thin and mobile
few millimeters of crown enamel will be severed oral mucosa. To expose the tooth by opening a
irreparably and be pushed apically. The outcome semilunar window in the oral mucosa directly
will be seen many months later when the ortho- over it is very simple, very popular, and often per-
dontic treatment has been completed, in the formed by the orthodontist. However, this will
form of a long clinical crown, with loss of bone result in the tooth being drawn down with no
height, gingival recession, and poor periodontal attached gingiva on its labial side and with only
appearance. On occasion, particularly with the this thin, mobile, and easily traumatized covering
more deeply located teeth, the surgeon will for its long-term protection (Fig. 3). The only time
moderately luxate the tooth, with the intention of that this is acceptable is when there is a broad
“loosening it up” or “to check if it is ankylosed” band of attached gingiva within which the incision
by pushing an elevator beyond the CEJ and into is made, leaving a portion of the thicker tissue
the sensitive cementum covering the root surface. above the cut. This will then become the labial
This has been claimed by many to facilitate spon- gingiva when the tooth is brought into alignment.
taneous eruption and even to positively redirect its There are 2 alternatives to the window tech-
eruption path. However, this common practice, nique, each of which will produce superior results
whose intention is to facilitate the orthodontist’s in terms of the periodontal health and appearance.
later resolution of the impaction, may actually
initiate a cervical root resorption process or an The Labial Canine and the Apically
ankylotic union at that site. The development of Repositioned Flap Technique
these pathologic entities will then prevent eruption
of the tooth, causing the failure of all attempts at The first is the apically repositioned flap, which is only
orthodontic traction.6,11 suitable for the canine which is not displaced mesi-
ally or distally from its normal location in the arch. It
involves raising a flap from the keratinized gingiva
The Palatal Canine and the Closed Exposure at the crest of the ridge or from the gingival margin
Technique of the retained deciduous canine. It is elevated above
Alternatively, the orthodontic attachment may be the height of the labial canine and to reveal the follicle
bonded as an integral part of the surgical proce- of the canine. The follicle is opened over its labial sur-
dure in the office of the oral and maxillofacial sur- face only and the flap sutured tightly to the cervical
geon. This method demands a less radical surgical half of the crown of the tooth, leaving the coronal
procedure, eliminating the need for exposure half exposed (Fig. 4). Either at the same time or at
down to the CEJ and leaving the deeper part of a subsequent visit to the orthodontist, an attachment
the dental follicle intact.12 This is because contact may be placed on the tooth, although the vertical
with and control of the tooth may be maintained force of the upward-displaced and tightly sutured
through the ligature wire that is tied to the attach- flap creates a mild extrusive force on the canine
ment. This is the thinking involved in the closed that will often improve its position quite markedly in
exposure procedure (Fig. 2, Video 1, available a short time.14,15
online at http://www.oralmaxsurgery.theclinics.
The Labial Canine and the Closed Exposure
com/). In essence, hard and soft tissue preserva-
Technique
tion, particularly in the CEJ area, and full replace-
ment of the surgical flap create an environment The second alternative is appropriate even in
at the completion of treatment, in which the tooth cases where the labial canine is displaced in the
 Surgical Treatment of Impacted Canines 453

Fig. 2. (A) Panoramic view of impacted maxillary canine high at the level of the incisor root apices. (B) Anterior
section of the lateral cephalogram shows the impacted canine in the same long axis as the incisors. (C) A 3-dimen-
sional screen shot extracted from the cone beam CT. (D) Transaxial slices from the cone beam CT to show the rela-
tionship of the canine with the central and lateral incisors. (E) The orthodontic setup with the preoperative
auxiliary labial archwire in its passive (vertical) state. (F) Minimal exposure of the canine from the palatal aspect.
Note that the labial-facing surface of the crown has not been exposed, to avoid exposing the incisor roots. Metic-
ulous hemostasis and moisture control are necessary at this point and are best achieved by the surgeon to enable
the orthodontist to perform reliable attachment bonding. (G) With the attachment in place, the ligature exit site
must be decided before resuturing. It will be appreciated that the tip of the canine is mesial to the roots of the
central incisor and there is no direct route to the canine’s location in the arch. (H) The deciduous canine has been
extracted and the full flap resutured to its former place. The twisted steel ligature from the bonded attachment
pierces the flap overlying the impacted tooth. (I) The active loop of the auxiliary labial archwire is ensnared hor-
izontally in the steel ligature to produce vertical traction. (J) After many months of vertical traction and addi-
tional posterior movement of the tooth using a miniscrew in the palate, the tooth has erupted and a new
eyelet bonded to its labial surface for its renewed traction in the direction of the main archwire.
454 Becker & Chaushu

Fig. 3. (A) Open surgical exposure through the oral mucosa. (B) Successful alignment of the tooth; however, that
labial aspect of the tooth is invested with thin and easily ulcerated oral epithelium. (Courtesy of Dr G. Engel, Je-
rusalem, Israel.)

mesiodistal plane, making the technique more uni- limiting these complications insofar as it erupts
versally applicable. The same partial thickness flap the canine down through the evacuated socket of
is raised from within the keratinized gingiva of the the extracted deciduous canine, leaving the labial
crest of the ridge, as with the apically repositioned part of the socket wall intact (Fig. 5).17
flap technique. The follicle of the canine is opened
to a very minimal extent over the middle of the
crown, with an aperture only large enough to BONDING THE ATTACHMENT
accommodate a small, preferably, eyelet attach- Some surgeons will not undertake the task of
ment, yet large enough for hemostasis to be bonding the attachment at the time of surgery,
secured, because bonding must be performed preferring to opt for an open procedure to expose
immediately. The remainder of the follicle is left the tooth and then placing a pack to maintain
intact. The attachment is bonded and the gold patency and access to the tooth. The pack will
chain or twisted steel pigtail ligature is drawn be removed 2 to 3 weeks later and the patient re-
downwards and held in place by the sutured turned to the orthodontist to continue orthodontic
edge of the flap.15,16 treatment, including the placement of an attach-
ment on the canine. Inevitably, time elapses and
the wound will partially close over in many cases.
The Midalveolar Canine and the Tunnel
Even when performed promptly, the healing tissue
(Closed Exposure) Technique
surrounding the exposed tooth is hemorrhagic and
Generally considered together with the labial ca- may ooze exudate, particular for those canines
nines because surgical access to it is performed that are located more deeply in the palate. Acid
on the labial side of the alveolar process, the mid- etch bonding under these circumstances will
alveolar impaction is often the result of a mesioan- almost certainly fail and a second surgical expo-
gular canine impacting against the distal aspect of sure to reestablish access may be necessary.
the lateral incisor. In these cases, exposing the Thus, bonding the attachment at the time of sur-
crown of the tooth in the usual manner will require gery is preferable, both to permit a choice of surgi-
the removal of a relatively large area of overlying cal procedures and to ensure a more reliably
labial plate of bone, which will result in the erupted bonded attachment.18
tooth exhibiting a long, unaesthetic, clinical crown, It goes without saying that a surgeon is perfectly
and reduced bone support on the labial side. Cres- capable to bond an attachment to an exposed
cini’s tunnel technique is an excellent method of tooth! But does the oral and maxillofacial surgeon

Fig. 4. (A) The unerupted canine of this 16-year-old girl has been in this situation for 2 years and has not pro-
gressed. (B) A flap has been raised from the crest of the ridge incorporating a thick band of attached gingiva
and sutured apically on the teeth, exposing half of the crown. (Surgery by Prof L. Shapira.) (C) At 9 months post-
operatively, the canine has erupted spontaneously, invested with an optimal periodontal environment.
 Surgical Treatment of Impacted Canines 455

Fig. 5. (A) A cone beam CT 3-dimensional screen shot of a very high midalveolar canine, whose location is the
result of the mesial curvature on the roots of the first premolar. The deciduous canine has a completely unre-
sorbed root. (B, C) Transaxial cone beam CT cuts in the deciduous canine and first premolar areas, respectively,
show the relationship between the canine and the premolar roots. (D) Orthodontic preparation before surgery
was performed to create space in the arch for the canine and the roots of the premolar were moved distally, to
distance the apices from the canine eruption path. The illustration shows a full flap raised from the cervical mar-
gins of lateral incisor, deciduous canine, and premolar teeth, after extraction of the deciduous canine. The crown
of the canine was exposed minimally in the incisal area. (E) An eyelet attachment has been bonded to the canine
and the twisted stainless steel ligature has been drawn down and through the socket of the extracted deciduous
canine, leaving the entire labial wall intact. (F) The flap has been sutured back to its former place and traction is
applied to the hooked end of the twisted steel ligature by the “swinging gate” offset in the labial archwire. (G)
The case at completion. (H) A panoramic view on the day the orthodontic appliances were removed.

know about the preferred bonding site for the spe- pigtail ligature that is connected to the attachment
cific case in treatment? Is it important for the be made to exit the surgical field? Should this
attachment to be placed in the midlabial aspect connector be drawn directly toward the space
of the canine, just like the brackets on the other that will have been prepared in the arch or in a
teeth, or is it acceptable or even preferable in spe- different direction? (Video 2, available online at
cific cases to locate it on the palatal, mesial, or http://www.oralmaxsurgery.theclinics.com/)
distal aspects? Does it matter if it is sited close Bonding site preference depends entirely on the
to the cusp tip or near the cervical area of the intended direction of the initial traction force that
crown? How should the gold chain or twisted steel will be applied to the tooth.19 For the simpler
456 Becker & Chaushu

impactions, where a palatally impacted canine is orthosurgical modality for the treatment of
adjacent to the line of the arch, the tooth needs impacted teeth.
to be drawn direct to the labial archwire into the
space provided. If the attachment in this case is 1. Choice of surgical technique: This choice re-
bonded mistakenly to the palatal aspect of the lates to the periodontal outcome and depends
tooth, direct ligation to the archwire will cause on the location of the tooth and on the planned
the tooth to rotate adversely and end up 180 direction of traction, where one technique may
rotated when it reaches the wire. On the other be more suited than another.
hand, an attachment sited in the midbuccal posi- 2. Extent of surgical exposure: Exposure of the
tion will generate a favorable rotation as the tooth area around the CEJ, the unnecessary elimina-
moves toward the archwire. tion of the entire dental follicle, when partial
In direct contrast, should the canine lie mesial to removal will suffice, and the aggressive removal
the root of the lateral incisor, which is a frequent of alveolar bone and of the soft tissue is
occurrence, then this tooth will obstruct the direct damaging. The more radical the surgery, the
path of the canine to the labial archwire. In this sit- greater and the more permanent will be the
uation, the canine must first be distanced from the periodontal consequences.
root of the lateral incisor. To achieve this, a pala- 3. Bonding the attachment: The acid-etch
tally placed attachment will be useful to avoid bonding procedure is highly technique sensi-
any rotation, as the tooth is moved in a vertically tive. It is a procedure that an oral surgeon
downward and/or posterior direction.7 Much later, uses quite rarely. To expect the oral and maxil-
when the tooth has cleared the obstruction and lofacial surgeon to bond a small attachment un-
lies erupted in midpalate with an unobscured der the conditions of an open, bleeding surgical
path to the archwire, the orthodontist will substi- field and to know exactly where to position it, is
tute the attachment for another. This will be placed unfair and, for the orthodontist, self-defeating.
in a more strategic location on the crown, for the Accidental detachment of a bonded device at
tooth to be drawn to the archwire. the time of surgery will involve repeat surgery.
An experienced and skilled orthodontist will have It has been shown that when this is performed
planned the location on the orthodontic appliance by the orthodontist and surgeon working as a
from which the traction force will be applied to the team, the procedure is highly reliable.
attachment on the impacted tooth, which therefore 4. Bonding site selection: Bonding on the wrong
presumes that placement of an attachment on one site on the crown of the tooth will introduce a
aspect of the tooth rather than another, will make a rotational component when traction is applied.
considerable difference to the outcome. Both the The degree of rotation will increase markedly
exact bonding site of the attachment and the direc- before the tooth reaches the labial archwire.
tion that the gold chain or twisted steel ligature exits Correcting the rotation toward the end of treat-
the surgical wound should, as far as possible, be ment will unnecessarily extend treatment time
decided in advance to enable the orthodontist to considerably.
exercise full control over the movement of the 5. Directing the connector: Drawing the gold chain
tooth. Directional planning of forces is fully in the or steel pigtail ligature connector in the wrong
realm of the orthodontist, who is answerable for direction means either applying traction in the
both the initial response of the tooth and for its later wrong direction or that a second round of sur-
artistic alignment. gery will be needed to reorient it.
For the orthodontist, the outcome of the surgical 6. Surgical flap closure: In a closed exposure
episode is of crucial importance and is often the procedure, the soft tissue flap needs to be sutured
“make or break” factor of the entire treatment back to its former place. In some cases, the
plan. Because surgical exposure is a critical pro- connector should be drawn down and held in its
cedure where the possibilities for failure are place by the sutures at the cut edge of the flap.
many, it surely behooves the orthodontist to be In others, particularly for a palatal canine that
present even if only in a supervisory capacity. has to avoid the adjacent lateral incisor root, the
connector needs to be drawn through the middle
IT IS ALL A QUESTION OF MAKING THE RIGHT of the flap to permit traction in a path that avoids
CHOICES clashing with this potential obstruction.
7. The application of immediate traction: The
In the light of the many points raised in the forego- value of applying traction immediately after
ing description, we present a list that summarizes the flap is closed, as the last task to be per-
the many aspects where choices need to be made formed in the operating room, should not be
to suit the special circumstances surrounding the underestimated. Immediate force application
 Surgical Treatment of Impacted Canines 457

using a mechanism that imparts a light force invested in preparing the other teeth to act in con-
over a wide range can be placed with ease cert as a multiple orthodontic anchor base is time
while the patient is anesthetized. In many well spent. However, the presence of a palatally
cases, there is rapid eruption seen at the next impacted maxillary canine associated with marked
visit to the orthodontist. However, the oral and resorption of the root of the adjacent incisor is one
maxillofacial surgeon cannot be expected to of the rare instances that must be considered an
place this mechanism and must opt instead orthodontic emergency. In an earlier study, we
for making sure the connector is exposed and showed that distancing the canine from the imme-
not irritant or sharp, leaving activation to the diate vicinity will effectively arrest the resorption
orthodontist at the next visit. This and subse- process and will later permit the orthodontic
quent adjustments will be much more difficult movement of the affected incisor without its un-
for the orthodontist to achieve and uncomfort- dergoing further resorption. Accordingly, in these
able for the patient to tolerate, and there are cases surgery should be arranged as soon as
many cases for which considerable delay is possible, even before the placement of an ortho-
incurred because of the inability to properly dontic appliance. At the same time the tooth is
activate a traction mechanism. exposed in the palate and an attachment bonded
to the tooth, a miniscrew bone anchor should be
This is a very long list of possible bad choices and placed at a convenient site in the posterior palate.
operational errors of judgment that emanate from Elastic thread or an elastic chain should then be
ignorance on the part of the surgeon for the require- applied under tension between the steel ligature
ments of the orthodontist and vice versa, or simply from the bonded attachment to the head of the
a lack of coordination between the two. Making the miniscrew (Fig. 6). This will need to be reapplied
wrong choices will lead to longer overall treatment 3 or 4 times more until, in favorable circumstances,
and/or poorer periodontal outcome and even to the the palatal tissue bulges as the canine is drawn
difference between success and failure. What can away from the anterior teeth, to erupt in the midpa-
go wrong will go wrong! Thus, any factor that can latal area.20 Once the tooth shows positive signs of
streamline the treatment must be adopted. None eruption, a full maxillary fixed orthodontic appli-
of these prophesies of doom need occur if the ance may be placed. This will need to be reapplied
orthodontist is present at the surgical procedure 3 or 4 times more until, in favorable circumstances,
as an essential and active member of the team. the palatal tissue bulges as the canine is drawn
away from the anterior teeth, to erupt in the midpa-
IS THIS TREATMENT URGENT? latal area. Once the tooth shows positive signs of
movement away from the anterior teeth, a full
For the overriding majority of cases, there is no ur- maxillary fixed orthodontic appliance may be
gency to expose the impacted tooth and time placed, with confidence that further root

Fig. 6. (A) A palatal canine was exposed minimally in an adult patient in whom there was some concern as to
whether the tooth would respond to traction. An attachment was bonded to its palatal aspect. (B) After fully
suturing the flap back to its former place, a miniscrew was inserted in the posterior palate and an elastic chain
stretched between the hooked end of the pigtail ligature and the miniscrew, to apply extrusive traction. The
elastic chain was changed several times until evidence of canine movement could be seen as a bulge in the palate.
Only at that point were orthodontic appliances placed to achieve a successful orthodontic outcome. (From Becker
A. Orthodontic treatment of impacted teeth. 3rd edition. Oxford (United Kingdom): Wiley Blackwell Publishers;
2012; with permission).
458 Becker & Chaushu

resorption will not occur.20 This approach may 9. Chaushu S, Chaushu G, Becker A. The role of digital
also be used when treating an adult in whom there volume tomography in the imaging of impacted
may be concern that the impacted canine is anky- teeth. World J Orthod 2004;5(2):120–32.
losed and may not therefore respond to orthodon- 10. Becker A, Chaushu S, Casap-Caspi N. Cone-beam
tic traction. With the increased risk of noneruption computed tomography and the orthosurgical man-
that exists with advancing age,21 checking if there agement of impacted teeth. J Am Dent Assoc
will be positive movement of the canine before em- 2010;141(Suppl 3):14S–8S.
barking on expensive orthodontics, may save the 11. Becker A, Chaushu G, Chaushu S. Analysis of failure
patient much time, discomfort, and money. in the treatment of impacted maxillary canines. Am J
Orthod Dentofacial Orthop 2010;137(6):743–54.
SUPPLEMENTARY DATA 12. Becker A, Chaushu S. Palatally impacted canines:
the case for closed surgical exposure and immedi-
Supplementary data related to this article can be ate orthodontic traction. Am J Orthod Dentofacial
found online at http://dx.doi.org/10.1016/j.coms. Orthop 2013;143(4):451–9.
2015.04.007. 13. Chaushu S, Dykstein N, Ben-Bassat Y, et al. Peri-
odontal status of impacted maxillary incisors uncov-
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