5. Write short notes on the management alternatives for
an unerupted maxillary canine?
7. Write short notes on localization and management of
impacted canine?
31. A 15 yr old pt presents at your surgery complaining
of malocclusion problems. On oral examination u notice
that both permanent upper canines are missing. What
additional examination techniques would u undertake
and what treatment options would u suggest?
45. Localization of impacted max. Canine?
62.A 15 year boy has deciduous canine. a. how you
investigate the permanent canine is present or not? b. If
it is present how would you manage the case?
DIAGNOSIS AND MANAGEMENT
1. History and Examination
3) Orthopantomagraphy is a fundamental examination
which gives an overview but does not permit precise
localization of an impacted canine in three-dimensional
space
4) Image enlargement
In orthopantomography, the image of a tooth situated
palatally with respect to the dental arch, i.e. nearer to the
radiogenic source and farther from the film, undergoes
magnification with respect to the nearby teeth or the
controlateral analogues
5) Image overlapping
In panoramic radiography impacted upper canines project
their image on the root or neck of the central incisors if
they are positioned palatally
Practitioners should become suspicious of the possibility of
canine ectopia if the canine is not palpable in the buccal
sulcus by the age of 10-11 years of age or if palpation
indicates an asymmetrical eruption pattern.
6) Computerised axial tomography
In recent years, CAT scans have becomethe technique of
choice as they supply more realistic information than
traditional radiographic methods. CT provides excellent
tissue contrast and eliminates blurring and overlapping
of adjacent teeth
Palpation should be done clinically to feel if a bulge or
convexity can be felt in the palate or labially.
7) Posteroanterior teleradiography
Posteroanterior teleradiography is fundamental for
evaluating the mediolateral position of the canines
with respect to a line connecting the inferior borders of the
orbits.
Radiographic examination
Radiographs need to be taken in two planes-horizontal
and vertical. Lateral cephalograms and OPGs are also
taken.
1)parallax method:
Lateral shift:vertical angulation is same, horizontal
angulation is changed.
Based on Clark’s rule-Same Lingual
Opposite Buccal, SLOB).If the canines move in the
opposite directions to the tube underlining that the canines
are positioned bucally to the adjacent teeth.
The various combinations that can be done:
i)IOPAs taken at different horizontal angles
ii)Maxillary anterior occlusal and one lateral occlusal
iii)one IOPA and one maxillary anterior occlusal
iv)one panoramic, one maxillary anterior occlusal
2)Occlusal radiography/Vertex occlusal:
This may be carried out according to various projections:
the most frequently used is that of Simpson (perpendicular
beam to the film through the glabella).
If, in the image produced by this technique, the cusp of the
canine is positioned in front of the ideal line connecting the
apices of the lateral incisors, the position will be labial
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8)Laterolateral teleradiography
dental age of the patient is between 8 and 9 years
This technique is useful in establishing the height of the
impacted tooth and the anteroposterior position of the
cuspid of the impacted canine with respect to the apices
of the incisors In teleradiography, evaluation of
the impacted canine is carried out by tracing its axis and
intersecting it with the perpendicular to Frankfurt’s
plane.
9) 3D rendering and stereoscopy
3D reconstruction is carried out via a particular technique
of retroprojection onto a matrix which assembles
the data, determining the reconstruction of a volume which
can be subject to detailed analysis in layers
10) Stereolithografic models
CAT derived data can be elaborated to obtain a
stereolithographic model of the anatomical parts under
investigation. The software used consents visualization
of the three-dimensional model which will be subsequently
created in resin or another material
11)multiple exposure method
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2. Treatment
1) Radiographic examination should be carried out initially
to confirm the position of the unerupted canine.It could be
impacted or developmentally missing
Patient and parent counselling on the various treatment
options is essential.
2.1 Interceptive treatment by extraction of the
deciduous canine20,21
· The patient should be aged between 10-13 years.
· The need to space maintain requires consideration.
· Better results are achieved in the absence of crowding.
· If radiographic examination reveals no improvement in
the ectopic canine’s position 12 months after extraction of
the deciduous canine, alternative treatment should be
considered.
2.2 Surgical exposure 22 and orthodontic alignment
· The patient should be willing to wear fixed orthodontic
appliances.
· The patient should be well motivated and have good
dental health.
· The patient is considered to be unsuitable for interceptive
extraction of the deciduous canine.
· The degree of malposition of the ectopic canine should
not be too great to preclude orthodontic alignment.
The treatment of buccally or palatally impacted canines
involves exposure and then a form of traction to pull the
tooth into the correct position in the arch
Palatally impacted teeth can be exposed and allowed to
erupt. This tends to form a better gingival attachment since
the tooth is erupting into attached mucosa.
If the tooth lies horizontally it is extremely difficult to
correct this and generally the closer the tooth to the midline
the more difficult the correction will be.
2.3 Transplantation
· This treatment option should be considered if the patient
is unwilling to wear orthodontic appliances or the degree of
malposition is too great for orthodontic alignment to be
practical.
· Transplantation would not normally be considered unless
interceptive extraction of the deciduous canine has failed or
is considered to be inappropriate.
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· There should be adequate space available for the canine
and sufficient alveolar bone to accept the transplanted
tooth.
· The prognosis should be good for the canine tooth to be
transplanted with no evidence of ankylosis. The best results
are achieved if the ectopic canine can be removed
atraumatically.
2.4 No active treatment/leave and observe
· The patient does not want treatment or is happy with their
dental appearance.
· There should be no evidence of root resorption of adjacent
teeth or other pathology.
· Ideally there should be good contact between the lateral
incisor and first premolar or the deciduous canine should
have a good prognosis. Leaving the deciduous canine in
place and either observing the impacted canine or removing
it. Long term, the deciduous canine will need prosthetic
replacement.
· Severely displaced palatally ectopic canines with no
evidence of pathology may be left in-situ,particularly if the
canine is remote from the dentition. If the ectopic canine is
left in-situ radiographic monitoring is recommended to
check for cystic change or root resorption
2.5 Extraction of impacted canine
Indications:
Impacted canine causing resorption of adjacent teeth ,cystic
changes, unfavourable position not feasible to correct the
malposition by ortho , Already crowded dentition
Aesthetically there are problems since the palatal cusp
hangs down. This can be disguised by grinding or rotating
the tooth orthodontically so that the palatal cusp is
positioned more distally. The placement of a veneer on the
premolar is another way of improving the appearance.
2.6 Canine extracted due to cystic changes or
Developmentally missing canine spaced dentition
Implants: Implants are also an option and as single tooth
implants improve, this may become more favoured in
future. It is important to remember that implants in a
growing child will ankylose and appear to submerge as the
alveolus continues to develop. These are not therefore an
option until the patient is at least 20 years of age.
PROBLEMS
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There are a number of problems with moving permanent
canines from either a buccal or a palatal position. By and
large, the older the patient the less chance there is of
succeeding, and certainly moving canines in adults requires
caution. If the canines have to be moved a considerable
distance then ankylosis is a distinct possibility as well as
loss of vascular supply and therefore pulp death.
Treatment often takes in excess of 2 years and it is
important to maintain a motivated and co-operative
patient. It is necessary to create sufficient space for the
canine to be aligned and this is usually around 9 mm.
The periodontal condition of canines that have been moved
into the correct position in the arch can deteriorate, this is
particularly true if care has not been taken to ensure that
the canine either erupts or is positioned into keratinized
mucosa.
There may also be damage to adjacent teeth during surgery,
Root resorption of adjacent teeth (either the lateral incisor
or the first premolar) care is not taken in the direction of
traction applied to the impacted canine.
78.55 years-old Patient has mobile upper anterior teeth
and a diastema is starting to develop. What will be the
differential diagnosis and its management?
1)Take a detailed medical history including:
-medications taken
-systemic disease
-prior hospitalization
-family history
-recent trauma
2)EXAMINATION
-Extraoral:
(i)Lymph nodes
(ii)lip seal
(iii)lip line
(iv)mouth opening
(v)TMJ paplation
-Intraoral
(i) check occlusion
(ii)gingival examination..inflammation, swelling
(iii)teeth..carious, mobility grade
(iv)attachment loss
(v) pockets (presence or absence), exudation, deposits
(vi) lumps on the palate or sulcus
-Investigations
(i) radiographs..IOPA and OPG
(ii)blood tests
DIFFERENTIAL DIAGNOSIS
(i)localized aggressive periodontitis
(ii) Trauma
(iii) Due to bisphosphonate theory
(iv) cyst, or tumour
can be excluded on the basis of history and radiographs
TREATMENT
1)evaluate if specialist guidance required
2)patient education about options
3)instruction in plaque control
4)subgingival scaling
5)Determination of prognosis of the remaining teeth
6)Periodontal surgery, if required
7)Extraction, if prognosis hopeless
Immediate denture provision, immediste insertion
minimal preparation bridge
8) Maintainence phase
9) extraction of remaining teeth
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10)provision of permanent prosthesis
Types:
I.Bridge: good esthetics if bone loss is minimal
check bone levels of teeth around
II.Implants: bone graft might be required
III New permanent removable prosthesis:
If periodontitis not controlled
IV.chrome cobalt framework prosthesis
11. Outline your mgt. For child in the mixed dentition
with absent permanent upper lateral incisor and lower
2nd premolars? 65.. Submerged ankylotic E when the
permanent 5 is missing. What is short and long term
management? / Congenital absence of second premolar,
management
History:
1)trauma
2)deciduous discoloured?(for dilacerations)
other causes (supernumerary, lesion, crowding, avulsion,
scarring of alveolus)
Extraoral examination:signs like thinning of hair and any
abnormalities of sweat glands should be checked for to rule
out anhydrotic ectodermal dysplasia.
Intraoral examination: assessment of occlusion
palpation of mucosa in the area of the missing teeth for the
presence of unerupted teeth or pathology
testing of teeth adjacent to the missing ones
Radiographic examination: panoramic radiograph
(orthopantomogram) to determine the presence/absence of
permanent lateral incisors and premolars, third molars,
supernumerary teeth or any other pathology
Occlusal assessment: Impressions and wax registration for
study models to assess occlusion
CHOICES IN MANAGEMENT:
1)To retain/open the space after loss of deciduous lateral
incisor and second molar and insert a prosthetic appliance
2)Orthodontic closure of space
3)use composite to build up
4)accept the space
Factors to consider in management:
Patient’s and parents’ attitude to treatment
Patient’s age
Skeletal relationship
Occlusion
Colour, size, shape, inclination of adjacent teeth
Crowding/spacing
Oral hygiene
be removed from the models and repositioned in alternative
positions in wax to determine the best result
MANAGEMENT
1)Based on the occlusion
Class I patterns: Space closure would be more appropriate
for management of missing second premolars. Other factors
will also dictate the decision. For missing lateral incisors,
space opening followed by prosthetic replacement is more
appropriate.
Class II patterns: Since the mandible is small relative to the
maxilla, closure of space in the lateral incisor region would
be a better option since it will reduce the overjet also.
However, space maintenance and prosthetic replacement of
lower premolars is more appropriate.
Class III patterns: The maxilla is proportionally smaller so
orthodontic space closure in the lower second premolar
region would camouflage the skeletal discrepancy. For the
missing lateral incisors, the preferred option would be to
maintain/open the space and replace them because it would
prevent further constriction of the arch.
2)Space retention/opening followed by prosthetic
replacement
-fixed orthodontic treatment will be required to open space
to create the space, early extraction of the contralateral
incisor or primary canine (in the case lateral incisors) may
be required
-this space needs to be maintained before a definitive
treatment like implants or FPDs can be carried out
this can be done by removable prosthesis or fixed
prosthesis like minimal preparation Maryland bridge as
interim prosthesis
-the replacement should be conservative and satisfy the
esthetic and functional objectives
-implant ,though expensive is the most conservative and
esthetic restoration
however, implant placement should be deferred till the
facial growth is completed
-FPDs are less conservative and include resin bonded,
canine cantilever or full coverage bridges
-selection of the appropriate FPDs depends on the position
and condition of the abutment tooth
3)Space closure:
-Easier in people with increased facial height.
space opening in people with reduced FMPA
-disadvantages of space closure- maxillary canines, which
would be moved into the spaces of the missing lateral
incisors, would require significant grinding or cosmetic
bonding to simulate lateral incisor
-facilitated by early extraction of primary teeth on affected
side
4)Buccal segments:
In case of mild or no crowding, open space
In case of crowding, close space
Trial setup/kesling setup: duplicate models would be used.
The teeth that would require orthodontic movement would
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Missing mandibular second premolars
Permanent
=best option is an implant
1)If the ankylosis occurs while the patient is
young and still undergoing significant facial growth,
the tooth will become submerged.
If this region will be restored with a future implant, the
alveolar ridge could be compromised vertically and require
a bone graft.
Therefore extraction of ankylosed deciduous molars is
recommended, if the patient has significant growth
remaining, the deciduous molar must be extracted to
prevent a significant ridge defect.
-also, if it remains, may cause vertical bony defect,
submergence, over-eruption of the opposing upper teeth,
food-impaction
2) If the patient has little facial growth remaining,
and the deciduous molar is submerged only slightly, the
tooth can be maintained to preserve the width of the
alveolus for the future implant.
However, 1.5-2.00mm of mesiodistal width reduction
might be required as the premolar tooth is narrower than
the primary 2nd molar
The reduced tooth might be bonded with composite to
cover the exposed dentin
Even occlusal bonding might be required to maintain the
occlusion
3) If the edentulous space is not maintained, the adjacent
permanent first molar and first premolar should erupt
together
Although this could require longer orthodontic treatment
to push the teeth apart to create the implant space,
this type of tooth movement will also result in a more
robust alveolar ridge
As the roots of adjacent teeth move apart, they deposit
bone behind that equals the width of the premolar and
molar, and will produce an excellent ridge in which to
place the implant. This process is called orthodontic
implant-site development.
3)In class II cases, space maintenance followed by
prosthetic replacement would be the preferable option.
Implant placement or fixed prosthesis to replace the
missing premolar might be considered
4)In class III cases, space closure would be better.
5) in a patient with no dental crowding and a
normal facial profile, closure of the edentulous space
produce an undesirable facial profile. In these situations,
the orthodontist requires additional anchorage, either
extraoral or intraoral, to prevent these unwanted
facial changes
Temporary option
=Maintenance of deciduous tooth
= conventional bridges or resin bonded
Bridges
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