Pacific Coast Society of Orthodontists Bulletin Summer 2017 - 21

Program Talk

Impacted Maxillary Canines
With early detection, timely interception, and
well-managed surgical and orthodontic treatment, impacted maxillary canines can be allowed
to erupt and be guided to an appropriate location
in the dental arch.1 The identification and management of impacted canines requires collaboration between general dentists and specialists,
including orthodontists, periodontists, pediatric
dentists, and oral surgeons.
Dr. Dawn Pruzansky
Administrative Director
Postgraduate Orthodontic Program,
Arizona School of
Dentistry & Oral Health

Maxillary canines are the most commonly
impacted teeth after third molars.2 Management
of these impactions is crucial to decreasing the
risks of root resorption and gingival and periodontal defects, as well as to maximizing the
esthetic outcome. Identification of ankyloses and
selection of retention protocol are additional factors that influence the success and stability of
the case.
Exploring Various Treatment Modalities
The two main categories of surgical exposures,
open and closed techniques, also have subsets
based on the position of the tooth and evaluation of the periodontal status.2 Diagnostic and
surgical techniques are subjective and vary
according the treating orthodontist and surgeon.
The Program Directors of all PCSO postgraduate
orthodontic programs were e-mailed a survey
regarding the methods of management, diagnosis, and treatment planning of impacted maxillary canines. What follows is an exploration of
the various modalities of treatment that our
residents encounter.
Of the PCSO residency programs that responded
to our questionnaire (N=8), all required at least
two cases of impacted canines per resident.
When potential impaction of a maxillary canine
is recognized in the mixed dentition, the recommended course of action is extraction of primary
canines (N=8), extraction of primary canines and
first molars (N=4), expansion (N=7), distalization
(N=5), extraction of permanent canines (N=2),
surgical exposure (N=1) and observation (N=4).
Each course of action is accompanied its own
rationale. Extraction of primary canines is recom-

Summer 2017  PCSO Bulletin

mended when eruption of permanent canines is
delayed or ectopic, especially if the position of
the canine overlaps the lateral incisor root. The
decision to also extract the primary first molar is
made when the arch length discrepancy is significant in addition to the ectopic position. Expansion is considered in the presence of maxillary
constriction or posterior crossbites. Distalization
is considered if the patient is Class II with anterior
crowding, or when there is inadequate space for
the canine. Observation is selected when eruption is delayed but there is a relatively normal
path for eruption, overlap with lateral incisor root
is minimal, and space is adequate. Dr. Flores-Mir
of the University of Alberta notes that most
cases will require monitoring before decisions
are made. Extraction of permanent canines is
recommended if the prognosis is poor or for
severe ectopic eruption in crowded cases. Surgical exposure is recommended when the canine
cannot erupt naturally.
Exposure Techniques
There are many types of exposure techniques,
and the most appropriate specialist depends on
the technique that is recommended. If a gingivectomy is indicated, a resident (N=3) or periodontist
(N=5) will most likely perform the procedure. For
an apically repositioned flap, a periodontist (N=6)
is the specialist of choice. Open and closed exposures may be performed by an oral surgeon
(N=5), periodontist (N=5), or resident (N=1).
Tunnel technique is referred to an oral surgeon
(N=4) or periodontist (N=4). Apicotomy may
be performed by an endodontist (N=1) or oral
surgeon (N=4). Transalveolar transplantation is
exclusively referred to an oral surgeon (N=7).
Residents may be exposed to anywhere from 1 to
10 gingivectomies during their program, followed
by 1 to 3 from all other techniques. Transalveloar
transplantation is the least performed procedure
seen by residents when treating impacted
canines. Only two of the programs reported that
their residents are required to be present at exposure appointments, although two additional programs encourage but do not require participation.

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Summer 2017