CLINICIANS CORNER

Management of impacted maxillary canines using mandibular

anchorage
Pramod K. Sinha, DDS, BDS, MS,a and Ram S. Nanda, DDS, MS, PhDb
Spokane, Wash and Oklahoma City, Okla

rthodontic management of impacted

maxillary canines can be very complex and requires a
carefully planned interdisciplinary approach. These
teeth are surgically exposed and moved toward the arch
wire after the maxillary arch is stabilized by progressing to a rigid arch wire. This movement is accomplished by bonding some form of orthodontic attachment to the exposed tooth and application of traction to
move the impacted tooth in a desired direction.
Frequently, when the palatally impacted canine is
surgically exposed, the lingual surface of the tooth is
visible and hence presents as the only available surface
for bonding attachments. The orthodontic force to be
applied to this bonded attachment requires careful planning for the following reasons:
1. An orthodontic force applied from the adjacent maxillary teeth will tend to embed the facial surface of the
crown and may create periodontal problems. This can
be prevented by first erupting the tooth vertically and
once a facial attachment can be bonded, forces should
be applied to position the tooth facially.
2. Initial leveling and aligning followed by progression of
wires to reach a rigid rectangular arch wire in the maxillary arch is required before uncovering the impacted
tooth and application of traction as described above.
3. In cases where additional room is required for the
impacted tooth, space has to be created during the
process of arch wire progression prior to the uncovering procedure.
4. Anatomic obstructions may involve the fabrication of
auxiliaries numerous times during the traction process
to redirect forces and therefore the path of eruption, or
may require frequent adjustments to do the same.

A variety of techniques have been used in the vertical movement of these teeth.1-4 Most techniques1-3 have
used the maxillary arch as anchorage for traction, which
may be unsuitable in many clinical situations. Different
clinical situations present with impacted canines being
positioned in a variety of angulations and locations.
From the Department of Orthodontics, University of Oklahoma. aClinical Assistant Professor.
bProfessor and Chairman.
Reprint requests to: Dr. Pramod K. Sinha, E 936 Calkins Drive, Spokane, WA
99208
Copyright 1999 by the American Association of Orthodontists.
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254

Therefore, appliances designed to erupt these teeth

should have the versatility to allow a change in direction
of traction quickly and easily. This may prevent deleterious effects like resorption of roots of adjacent teeth
and physical obstruction as a result of anatomic limitations from slowing the progress of treatment.
Hence, the purpose of this article is to describe a technique using the mandibular arch as an anchorage unit to
vertically erupt impacted maxillary canines. This technique utilizes a mandibular fixed lingual arch as opposed
to a removable appliance presented in an earlier report.4
The lingual arch can be prepared with a vertical hook
bent in the lingual arch during its fabrication before soldering, or hooks can be soldered to the arch for the same
purpose (Fig 1). Elastics are engaged in these vertical
hooks and to the attachment on the impacted teeth for the
required traction. In addition, directional forces can be
used by applying elastics in a Class II direction as
required. One case will be presented to demonstrate this
technique for the impacted maxillary canine.
TECHNIQUE

A thorough evaluation of the pretreatment orthodontic records should accompany clinical examination
for every patient. These patients require additional
radiographs to properly locate the impacted teeth. In
some cases, the impacted canine may lie close to the
roots of the lateral incisors where it is prudent to move
the canine away from the root of the incisor before
engaging the lateral incisor bracket.
After consultations with the surgery team and formulation of a treatment plan, the following sequence of
events are planned for these patients:
1. The maxillary and mandibular teeth are banded and
bonded. A mandibular impression is made to fabricate
a mandibular lingual arch to be soldered from the first
molar band on one side to the first molar band on the
other side. The mandibular lingual arch is cemented in
place after fabrication.
2. After adequate space is opened, it is maintained with a
closed/open coil spring. In some cases, the space for the
unerupted tooth may be available and traction may be
applied from the first day because other teeth are not
involved in the anchorage unit. Alternatively, space
opening and traction may be applied simultaneously.

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Fig 1. Fixed lingual arch with soldered hooks.

Fig 3. Intraoral right lateral view of dentition in occlusion

shows retained right maxillary primary canine.

Fig 4. Panoramic radiograph shows impacted right maxillary canine.

Fig 2. Elastic traction applied to bonded attachments.
CASE PRESENTATION
Diagnosis
3. Surgical exposure is performed and a button with a hook
fabricated from 0.010 or 0.012 inch stainless steel ligature wire is bonded using composite resin. For areas that
are difficult to isolate, recently introduced hydrophilic
primers can be used to successfully attach appliances.
4. Traction with light forces is applied via directional elastics as shown in Fig 2. The elastic size can vary to ensure
the delivery of forces that range from 40 to 60 g based
on the movements of the mandible. The elastic application is demonstrated to the patient, and a proficiency
check is done a week after the surgical procedure.
5. The canine is guided vertically toward the occlusal
plane. An orthodontic bracket should be bonded on the
labial surface of this tooth as soon as possible.

The lingual arch is fabricated with 0.036 inch

stainless steel wire. Vertical hooks (5 to 6 mm in
length) can also be fabricated by bending the 0.036
wire on itself. It is important to avoid excessive forces
to erupt the tooth. Hence, elastics should be carefully
monitored for the magnitude of forces applied.

A Caucasian female presented with a chronologic

age of 17 years 10 months (Figs 3 and 4). She had an
anterior divergent, straight facial profile (facial angle of
94, angle of convexity of + 0.5). Her SNA value was
89 and her SNB value was 86 leading to an ANB
value of + 3. She had a Class I molar relationship, with
the right maxillary canine impacted palatally. Her right
and left maxillary primary canines were overretained.
Treatment objectives

The treatment objectives were to bring the right

maxillary canine into proper position and maintain the
Class I molar relationship and facial profile.
Treatment plan and sequence

A treatment plan that involved the extraction of the

primary canines and surgical exposure of the impacted
right maxillary canine followed by directional forces to
bring it into occlusion was presented and accepted. A

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Fig 6. Intraoral frontal view of dentition in finished

occlusion.

Fig 5.Three-quarter smile photograph shows finished

occlusion.

Fig 7. Intraoral right lateral view of dentition in occlusion.

consultation was done for the surgical exposure of the

permanent canine before starting treatment. The primary canines were extracted after which appliances were
bonded on the maxillary and mandibular arches. A
mandibular lingual arch similar to the one described
earlier was placed in the mandibular arch. Surgical
exposure was performed, and an appliance identical to
the one shown in Fig 2 was bonded on the exposed surface of the unerupted teeth. Because the crown of this
tooth was in close proximity to the roots of the lateral
incisors, it was decided to replace the flap over the
crown and allow the hook to be exposed for force application. Light orthodontic forces were applied with elastics hooked to the mandibular lingual arch. The patient
was directed to use the elastics at all times except while
eating. Sequential arch wire changes were done in the
upper and lower arches and, vertical elastics were used
as needed. The canines were erupted in the palate and
were moved in the space opened for it in the maxillary
arch. The case was completed and the final result is
presented in Figs 5-7.

DISCUSSION

Palatally impacted canine teeth present unique

challenges to orthodontists. These ectopically placed
teeth have generated an array of treatment mechanics
to facilitate successful eruption of these teeth into
proper occlusion.
The mandibular lingual arch can be cemented
before the placement of any other orthodontic appliances; this allows traction on impacted teeth independent of the leveling and alignment of the arches. The
button that is bonded to the unerupted tooth has a 0.012
inch ligature wire twisted to form a hook for elastic
engagement. The maxillary and mandibular arches are
banded and bonded, and sequential arch wire changes
progressing to rigid stainless steel wires are achieved in
both arches. Spaces are opened in the maxillary arches
for the final positioning of the impacted teeth. These
spaces are maintained by using closed-coil springs.
Once the canine is erupted, an orthodontic bracket is

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bonded on the labial surface of the tooth. Different

methods can be used to bring the palatally positioned
tooth toward the buccal surface. Elastic threads or elastomeric chains can be used from the rigid maxillary
arch wire. We used a flexible arch wire such as 0.014
nickel titanium that is engaged in the canine bracket and
is tied over the rigid maxillary arch wire. This flexible
wire can extend from an auxiliary tube on the first molar
or can be tied over the conventional buccal molar tube.
The canine tooth is allowed to approach the rigid maxillary wire until the bracket touches the rigid arch wire.
The maxillary wire is then replaced with a flexible arch
wire to achieve the desired position of the tooth.
The purpose of this article is to present a technique
used successfully by the authors in their day to day
practice. It is relatively simple to use requiring no complex wire bending and, with relatively few side effects.
The advantages of this technique are in its simplicity in
appliance design and application. Further, forces can be
used before the alignment of arches, which may significantly reduce overall treatment time. However, careful
monitoring of the unerupted tooth is required to change
the direction of the forces as required. As is evident, the
practitioner has the ability to easily change the direction of the force by demonstrating the use of elastics
from molar hooks.
Another clinical situation that presents a variety of
problems involves cases in which the maxillary canines
are impacted and crowding is sufficient to decide on an
extraction treatment plan. The clinician is confronted
with the following questions: Which teeth should be
extracted? Is the canine ankylosed? or, Is the tooth
going to respond favorably with elastic traction? To
answer these questions, the practitioner has to ensure
that the canine will move on the application force. However, this is difficult to do when leveling and aligning is
not accomplished. In these situations, we have found

that this technique is very useful in that the lingual arch

can be cemented and elastic traction can be applied
after the surgical uncovering of the canines. The decision to extract or not to extract the impacted tooth
becomes clear on evaluating movement of the tooth.
We have not experienced problems with this technique; however, a few potential problems can be suggested as possible in treatment. One of the key elements
in any form of tooth movement is the magnitude of
forces. Similarly, in this technique the force magnitude
is important and should not exceed 40 to 60 g. A high
force level may produce unwanted movements of the
mandibular teeth, particularly the molars. This technique
also involves the use of elastics controlled by patient
compliance, which may pose a problem in some cases.
CONCLUSIONS
1. The mandibular fixed lingual arch can be an effective
anchorage source for vertical eruption of impacted
maxillary canines.
2. The technique presented can be used in all cases with
impactions.
3. It may be particularly useful in the following situations:
in cases when a confirmation of ankylosis of the
impacted tooth is suspected and extraction decisions need to be made.
The movement of the impacted tooth monitored on
radiographs can provide cues to diagnostic decisions, and, in cases where the maxillary arch is
unsuitable for providing anchorage.
REFERENCES
1. Fournier A, Turcotte J-Y. Bernard C. Orthodontic considerations in the treatment of
maxillary impacted canines. Am J Orthod 1982;81:236-9.
2. Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofacial Orthop
1992;101:159-71.
3. Kornhauser S, Abed Y, Harari D, Becker A. The resolution of palatally impacted
canines using palatal-occlusal force from a buccal auxiliary . Am J Orthod Dentofacial Orthop 1996;110:528-34.
4. Orton HS, Garvey MT, Pearson MH. Extrusion of the ectopic maxillary canine using
a lower removable appliance. Am J Orthod Dentofacial Orthop 1995;107:349-59.