American Journal of ORTHODONTICS

Volume 69, Number 4, April, 1976

ORIGINAL ARTICLES

Management of imppactedcanines
Samir E. Bishara, D.D.S., D.Orth., MS., Dennis D. Kommer, D.D.S.,
Michael H. McNeil, D.M.D., Louis N. Montagano, D.D.S.,
Larry J. Oesterle, D.D.S., and H. Warren Youngquist, D.D.S.
Iowa City, Iowa

A n impacted or unerupted canine tooth is usually easy to diagnose, but

the skill and expertise of the orthodontist, the oral surgeon, and the general prac-
titioner are needed to bring it to its proper position.
Since maxillary permanent canines are more frequently impacted than are
mandibular ones, the emphasis of this article is on the management of maxillary
canines. The same general principles can still be applied to both maxillary and
mandibular canines.
Normal eruption of maxillary canines

According to Moyers, 7 “The maxillary cuspid follows a more difficult and

tortuous path of eruption than any other tooth. At the age of 3 years it is high
in the maxilla, with its crown directed mesially and somewhat lingually.” The
canine changes its position in the bone: at first, its crown lies in close proximity
to the distal aspect of the root of the lateral incisor. As it erupts farther into
the oral cavity it tends to upright itself and finally assumes its position in the
arch.
Records from the Bolton study taken on 5,000 children in the first 12 years of
their lives were used by Br0adbent.l He investigated the developing occlusion in
the primary and permanent dentitions. Of particular interest was his discussion
of the “ugly duckling” stage. He explained that at 7 years the central incisors
usually start to erupt while in the maxilla the lateral incisor crowns are flaring
distally. The size of the maxilla at this age is sufficient to permit the canines to
Orthodontic Department, College of Dentistry, University of Iowa.
This investigation was supported in part by United States Public Health Service
Research Grant DE-00853, National Institute of Dental Research, Bethesda, Md.

371
372 Bishara et al.

Image of lingual object

moves in same direction
as source of radiation

FILM

LINGUAL

Mesial

Source shifted
Y Source of rays

A
Fig. 1. Tube-shift technique to localize the buccolingual position of an impacted tooth.

BUCCAL LINGUAL BUCCAL LINGUAL

FILM FILM

Source I
moved
down
B
Fig. 2. Buccal-object rule to localize the buccolingual position of an impacted tooth.

assume their normal position. With the normal development of the maxilla the
upper canines erupt away from the root ends of the lateral incisors.
Broadbent finally stated, “It is obvious that to correct the ‘ugly duckling’
incisor alignment between 8 and 12 years of age is fraught with hazards that are
greater in the underdeveloped face than in one that is normal for its age.”

Etiology of impacted canines

Moyers7 summarized the etiology for impaction as being due to either: (1)
primary causes, e.g., (a) rate of root resorption of deciduous teeth, (b) trauma to
the primary tooth bud, (c) disturbance in tooth eruption sequence, (d) avail-
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Management of impacted canines 373

Fig. 3A. Eruption or movement of the canine can be measured on standardized periar Gcal
films.

Fig. 36. Clinically, in the oral cavity, movement is measured from the tip of the cusp to a
relatively fixed position.

ability of space in the arch, (e) rotation of tooth buds, (f) premature root clo-
sure, (g) canine eruption into the cleft area in cleft-palate individuals ; or (2)
secondary causes, e.g., (a) abnormal muscle pressure, (b) febrile disease, (cl
endocrine disturbances, and (d) vitamin D deficiency.
Sequelae of impaction

Shafer, Hine, and Levy9 listed seven possible sequelae which can be rel ated
to the unerupted canines : (1) labial impaction, usually vertically impacted; (2)
374 Bishm-a et al. Am. J. Orthod.
April 1976

Fig. 4. Postoperative surgical pack (photographed through a reflecting mirror).

Fig. 5. Band with bracket cemented to the impacted canine at the time of surgical ex-
posure. Traction on the canine is done with a Kl Alastik.

lingual impaction, usually horizontally impacted; (3) root resorption of im-

pinged teeth ; (4) referred pain ; (5) infection from partial impaction resulting
in pain and trismus ; (6) dentigerous cyst which can possibly become an amelo-
blastoma ; and (7) self-resorption-which radiographically resembles caries and
begins usually in the crown portion of the impacted tooth.
On the other hand, the impacted canine may cause no untoward effects during
the lifetime of the individual.
Rantas examined 105 patients with clefts of the lip and palate. He found that
the crown-root development of the maxillary canines was retarded in about 6.7
per cent of the subjects. Whether this retarded development would also increase
the incidence of impacted canines in these individuals was not determined.
Diagnosis cmd localization of impacted canines

Diagnosis is usually made on the basis of both clinical and roentgenographic

examinations.
 Management of impacted canines 375

Fig. 6. Dead-soft stainless steel wire, twisted in a pigtail shape, to be used as an attach-
ment for force application.
Fig. 7. When the impacted canine is in close proximity to the neighboring teeth, the use of
pigtail attachment is contraindicated.

1. Clinical. Any one or a combination of the following signs may be present:

(a) delayed eruption of one or more of the permanent canines after 14 years of
age; (b) prolonged retention of a primary canine; (c) elevation of the soft tissue
of the palatal or labial mucosa (depending on canine location) ; (d) distal migra-
tion of the lateral incisors with or without a midline shift.
2. Roentgenographic. Impacted canines may be diagnosed during routine
dental examination, which usually includes either a full-mouth survey or a
Panorex film.
Radiographic localization. Different roentgenographic techniques have been
advocated to localize the position of unerupted canines. The most common are as
follows.
1. PERIAPICAL FILMS.~ (a) Tube-shift technique or Clark’s rule : Two periapical
films are taken of the same area, with the horizontal angulation of the cone
changed when the second film is taken. If the object in question moves in the
same direction as the tube head it is lingually positioned. If it moves in the op-
posite direction it is situated closer to the source of radiation and therefore is
buccally located (Fig. 1).
(b) Buccal-object rule : If the vertical angulation of the cone is changed by
approximately 20 degrees in two successive periapical films, the buccal object will
move in the direction opposite to the source of radiation (Fig. 2). On the other
hand, the lingual object will move in the same direction as the source of radiation.
The basic principle of this technique deals with the foreshortening and elongation
of the images of the films.
In summary, a single periapical film can give information as to the relative
376 Bishara et al. Am. J. Orthod.
Am-i2 1976

Fig. 8. Bracket directly bonded to the impacted canine; the arch wire is stepped down op-
posite to the canine to facilitate force application between the soldered hook and the at-
tachment on the canine.
Fig. 9. Threaded pin used as a method of attachment to an unerupted incisor. The same
method can be used for impacted canines. It is preferable to have the pin on the incisal
edge or cusp tip rather than in the area of the cingulum to avoid inadvertently exposing
the dental pulp.

mesiodistal and superior-inferior positions of the object and the use of two peri-
apical films can add the buccolingual dimension.
2. OCCLUSAL FILMS. These also help to determine the buccolingual position
of the impacted canine in conjunction with periapical films, provided that the
image of the impacted canine is not superimposed on the other teeth.
3. EXTRAORALFILMS. (a) Frontal and lateral cephalograms can sometimes be
of aid in determining the position of impacted canines, especially in relation to
other facial structures-particularly the maxillary sinus and the floor of the
nose.
(b) Panorex films are also used to locate impacted teeth in all three planes of
space (much the same as using two periapical films in the tube-shift method or
Volume 69 Management of impacted caxines 377
Number 4

RESTORATION

Fig. 10. Wire loop (0.016 inch round wire) partly incorporated in a restoration and used
as a method of attachment. This method is not advocated.

Fig. 11. The use of the lower arch as a source of anchorage and to transmit vertical vec-
tors of force to the impacted tooth.

Clark’s rule)-with the exception that, since the source of radiation comes from
behind the patient, the movements are reversed for position ; e.g., a palatal impac-
tion will move left to right roentgenographically when the tube head moves from
the patient’s right to his left. A labially impacted or positioned tooth will move
roentgenographically in the same direction as the tube head because it is farther
from the source of radiation than the reference point.lO
The importance of localization of impacted teeth is that it is necessary in
order to determine both the surgical approach and the feasibility of managing
the condition orthodontically. Accurate determination of the relation of the im-
pacted tooth to the adjacent teeth and/or structures is essential if injury to other
dental units or facial spaces is to be avoided.
378 Kish~ara et al. Am. J. Orthod.
A?wil1976

Fig. 12. Case 1. A girl with a palatally impacted maxillary right canine. Dental findings
included a normal mesiodistal molar relation, acceptable overbite and overjet, and little
crowding in the lower arch. Skeletal, dental, and soft-tissue relations were within normal
cephalometric limits. The impacted canine was surgically uncovered and then covered
with a celluloid crown. After 31/2 months the celluloid crown was removed and replaced
by a band (with a lingual button). Light elastic force between the canine and an 0.018 by
0.025 edgewise wire brought the canine into the line of the arch. The case was treated in
one arch in approximately 14 months.

Surgical exposure and methods of attachmenlt to the impacted canine

There are two methods of bringing impacted canines into the line of occlusion :
(1) surgical exposure, allowing natural eruption to occur, and (2) surgical ex-
posure with the immediate placement of an auxiliary attachment through which
orthodontic forces can be applied to move the impacted tooth to its proper posi-
tion in the line of arch.
Xurgical exposure to allow natural eruption to occur. This method has many
advantages and is most useful when the canine has a correct axial inclination and
does not need to be uprighted during its eruption. The progress of canine erup-
tion should be monitored with frequent roentgenograms, using reference points
either on an adjacent erupted tooth or on the arch wire (Figs. 3‘1 and 3B).
Clark2 treated 2,000 cases successfully by the above method but he used poly-
carbonate crowns placed over the impacted tooth. His technique can be sum-
marized as follows : (1) A palatal flap is laid back and overlying bone is removed
to expose the crown. It is essential that all bone and soft tissue be removed from
around the canine crown. (2) The impacted canine is luxated. (3) A polycar-
bonate crown is fitted to cover the entire crown of the canine and should be made
 Maruxgement of impacted canines 379

Fig. 12 (Cont’d). For legend, see opposite page.

380 Bishara et al. Am. J. Orthod.
Awil 197G

Fig. 13. Case 2. A girl with a palatally impacted maxillary canine and a congenitally miss-
ing maxillary left second premolar. Dental findings included a normal mdsiodistal molar
relation on the right and an end-to-end relation on the left. The midline had shifted and
the lower left canine was in cross-bite. Crowding in the lower arch was estimated to be
about 6 mm. Cephalometrically, there was a tendency toward bimaxillary dental protru-
sion. An attempt was made to uncover the impacted canine surgically but a decision was
made to extract it for fear of damaging the neighboring teeth. Two lower first premolars
were removed and the maxillary right first premolar was used as a canine, resulting in
good interdigitation on this side. Spaces reopened on the opposite side. The case was
treated in both arches in approximately 18 months.

long enough to extend through the window cut in the palatal tissue. The crown
is then cemented with surgical paste or regular cement. (4) Prior to suturing the
palatal tissue, a trough is cut through the cortical plate from the impacted canine
to the alveolar ridge to ease tooth movement.
Usually 6 months to a year must elapse before the impacted tooth has erupted
sufficiently to permit removal of the polycarbonate crown and replacement of it
with a band. If the tooth fails to erupt it is necessary to remove any cicatricial tis-
sue surrounding its crown. Clark indicated that, after a palatally impacted ca-
nine has been brought into the line of arch, lingual drift can be prevented by re-
moving a halfmoon-shaped wedge of tissue from the lingual aspect of the canine
down to the bone.
Surgical exposure with the placement of an auxiliary. After surgical exposure
of the impacted tooth, an auxiliary is attached to its crown, either directly to the
enamel or indirectly to a band or crown. Orthodontic forces can be transmitted
to this attachment for the purpose of moving the tooth into the line of the arch.
Two methods are generally accepted.
1. Lewis6 preferred a two-step approach. First the canine is surgically un-
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Management of impacted canines 381

Fig. 13 (Cont’d). For legend, see opposite page.

covered and the area packed with surgical dressing to avoid filling in of tissues
around the tooth (Fig. 4). When, after 3 to 8 weeks, the wound has healed, the
pack is removed and a band or other attachment is placed on the impacted tooth
(Fig. 5).
2. The second method is actually a one-step approach: the attachment is
placed onto the tooth at the time of surgical uncovering (Fig. 6).
Methods of attachment. Different methods of attachment to the impacted
canine are used, and a few of them are discussed here.
1. Wire: A dead-soft 0.020 inch brass or stainless steel round wire is passed
below the cingulum of the impacted canine, with the ends of the wire twisted in
a pigtail form and allowed to extend through the palatal tissue (Fig. 6). This
method sometimes demands considerable surgical skill and is at times impossible
because the impacted tooth is too close to adjacent teeth (Fig. 7).
2. A variation of the above method is to attach a gold chain (with soldered
links) to the wire wrapped around the tooth. A light round wire (0.014 inch) is
then soldered to the main arch wire (0.020 inch or preferably edgewise). The end
of the auxiliary wire is bent in the form of a hook. To activate the system the
302 B&ma et al. Am. J. Orthod.
April 1976

Fig. 14. Case 3. A girl with a palatally impacted maxillary canine. Dental findings in-
cluded a normal mesiodistal molar relation on the left side and an end-to-end relation
on the right, with acceptable overbite, overjet, and minimum crowding in the lower arch.
Cephalometrically, the patient was within normal limits. The impacted canine was un-
covered surgically and a celluloid crown was inserted which was later replaced by a dead-
soft stainless steel wire twisted around the neck of the tooth. Alastiks and multilooped
arch wires were used to bring the tooth into the line of occlusion. Treatment did not in-
clude removal of teeth and both arches were banded. The treatment time was 22 months.

hook at the end of the auxiliary wire is attached to one of the links of the chain,
thus applying tension on the tooth. Another use of the chain is to monitor the
movement of the impacted tooth by counting the number of links coming out of
the tissues in consecutive visits.
3. Band : Many times a band can be fitted and cemented at the time of surgery
(with a bracket, hook, or button welded to it) if all the surfaces of the crown of
the impacted canine are uncovered. The corresponding tooth in the same arch
can be used as a guide in choosing a suitable band for the unerupted tooth (Fig.
5).
4. Cast gold crown or onlay : After the canine has been uncovered and packed,
and the tissues have been allowed to heal, an impression is made of the exposed
portion of the canine and a gold onlay with a hook or eyelet is constructed and
cemented to it. The impression for the crown could also be taken on the opposite
tooth in the same arch if the crown is to be fabricated before surgically exposing
the impacted canine.
5. Direct bonded attachment: Adhesives can be used to band an attachment
directly to the tooth at the time of surgery or after its partial eruption (Fig.
8). One problem with this method [as well as with any method using a cement or
 Management of impacted canines 383

Fig. 14 (Cont’d). For legend, see opposite page.

adhesive) is the difficulty in obtaining a dry field for bonding at the time of sur-
gery.
6. Threaded pin: A hole of appropriate size is drilled in the tooth and a pin
is threaded or cemented into it (Fig. 9). Care must be taken to avoid placing
the pin in the pulp chamber. The primary disadvantage of this method is that
the tooth will need a restoration after the pin is removed.
7. Wire loop, made of 0.016 inch round wire, may be embedded into a pre-
pared cavity in the crown of the impacted tooth; the cavity is then filled with
amalgam or Adaptic (Fig. 10).
Dewe13 cautioned against any permanent destruction of tooth structure. The
authors agree with this concept and feel that in most cases such destruction of
sound tooth structure is neither needed nor warranted.
Johnston,4 in an excellent review of the problem of impacted canines, stated
that palatal impactions occur almost 50 times as often as labial impactions and
the incidence is three times greater in females than in males. He felt that impac-
tions are rare in those cases in which serial extraction procedures have been initi-
ated. He also advocated surgical exposure of the impacted canine and the applica-
tion of an Orahesive bandage. In 4 to 6 months the tooth will have erupted suf-
384 Bishara

Fig. 15. Case 4. A girl with a labially impacted maxillary right canine. Dental findings in-
cluded a Class II molar relation and minimum crowding in the lower arch. Cephalometric
findings were within normal limits. The impacted canine was uncovered surgically and a
band was cemented; a ligature wire was attached to an eyelet welded on the band. Intra-
arch elastics were used to move the canine to a position where it was engaged with a
continuous arch wire. Both arches were banded, no teeth were extracted, and the treatment
time was 23 months.

ficiently to permit taking a compound impression on which a cast onlay can be

made with small loops as a source of attachment. The onlay is then cemented and
traction is applied.
Johnston further noticed that labially impacted canines are more difficult to
manage because ordinarily there is lack of room in the bony trough for one tooth
to pass the other. In very few instances, when there is a normal arch form and
the deciduous canine is still present, no treatment may be indicated ; when the
deciduous canine has been lost a bridge can be inserted.

Orthodontic management of impacted canines

A. One-arch vs. two-arch treatment. Most orthodontic cases do require band-

ing of both maxillary and mandibular arches in order to achieve the desired bio-
mechanical control necessary for optimal results.
The lower arch can often be used to great advantage in helping to position
the impacted canine in proper occlusion. This is especially true in horizontal im-
pactions. By utilizing the more vertical type of force vectors the canine may be
“guided” down from its impacted position. This is best achieved by building the
lower arch wire to a heavy rectangular arch wire (0.018 by 0.025 inch or larger).
These wires resist gross distortion when forces are applied to them. Heavier arch
wires will also distribute the reactive forces over the whole lower arch and there-
fore minimize adverse tooth movement (Fig. 11).
 Mhagement of impacted canines 385

Fig. 15 (Cont’d). For legend, see opposite page.

On the other hand, treating one arch only, particularly if light arch wires
are used, can lead to both undesirable tooth movements and difficulties in properly
coordinating and interdigitating the upper and lower arches together. To prevent
some of the undesirable sequelae of one-arch treatment, four considerations
should be kept in mind: (1) light forces should be used for canine extrusion;
(2) continuous tie or stop of the teeth mesial and distal to the canine area may
be indicated ; (3 ) a rectangular arch wire should be present before the extrusion
386 Bishara et al.

mechanics are started (such an arch wire resists to a greater extent the dcforma-
tion caused by the extruding force) ; and (4) the lower arch should be reasonably
well aligned and leveled (Fig. 12).
B. Cuspid vs. pre??zolar estmctios. The prognosis of successfully exposing and
guiding the canine to its proper position is often guarded; therefore, in those
cases requiring upper premolar extraction, it is desirable to delay this until the
prognosis of the impacted tooth is more certain. The prognosis will depend on
the position of the impacted canine in the bone, the relationship of the impacted
tooth to the roots of the adjacent teeth, ant1 the skill of the oral surgeon. Xost
clinicians agree that permanent canines arc important from both esthetic and
functional points of view and therefore should bc preserved whenever possible.
In difficult impactions, however, it. might be necessary to surgically remove the
canine. B decision has to be made as to whether to move the premolar into the
ca.nine position or to fill the canine space with a fixed prosthesis. When the ortho-
dontist is considering replacing the canine by a. first premolar, problems related
to tooth-size discrepancies and unilateral mechanics must be carefully assCssCC1
for each case before extraction decisions are made. If the decision is maclc to ~los(~
the canine space orthodontically, the first and second prcmolars can be protracted
and the case finished in a Class II molar relation on the affected side(s)-unless
lower first premolars arc also extracted arnl the molars can then be finished in a
Class I relation (Fig. 13). Such a choice of treatment alternatives is possible only
if the first premolars are not extracted until the prognosis of the impacteil
canine (s) is determined.

Summary

In this article an overview of the problem of impacted canines has been pre-
sented ancl some of the clinical considerations related to surgical management
and types of attachments have been discussed. In the orthodontic management of
impacted canines the clinician has to make certain decisions regarding one-arch
vs. two-arch treatment and canine vs. first premolar extraction. The factors which
might influence such decisions were also discussed.

REFERENCES
1. Broadbent, B. H.: Ontogenic development of occlusion, Angle Orthod. 11: 223-241, 1941.
2. Clark, D.: The management of impacted canines: Free physiologic eruption, J. Am. Dent.
Assoc. 82: 836840, 1971.
3. Dewel, R. F. : The upper cuspid: .lts development and impaction, Angle Orthod. 19: 79-90,
1949.
4. Johnston, WN. D.: Treatment of palatally impacted canine teeth, A&f. J. ORTHOU. 56: 58%
596, 1969.
5. Landland, 0. E., and Sippy, F.: Manual of dental radiology, Ames, 1969, Tinivesrity of
Towa Publications.
6. Lewis, P. D.: Preorthodontie surgery in the treatment of impacted canines, AM. J. ORTHOD.
60: 383-397, 1971.
7. Noyers, R. E.: Handbook of orthodontics, ed. 2, Chicago, 1963, Year Book Medical Pub-
lishers, Inc., pp. 83-88.
8. Ranta, R.: On the development of central incisors and canines situated adjacent to the
cleft in unilateral total cleft cases. An orthopantomographic and clinical study, Suomen
Hammaslaakariseuran Tomituksia 67: 345-349, 1971.
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Management of impacted canines 307

9. Shafer, W. G., Hine, M. K., and Levy, B. M.: A textbook of oral pathology, ed. 2,
Philadelphia, 1963, W. B. Saunders Company, pp. 2-75.
10. Turk, M. H., and Katzenell, J.: Panoramic localization, Oral Surg. 29: 212-215, 1970.

Dental Science Bldg. (56648)

THE JOURNAL 60 YEARS AGO

April, 1916
To extract an irregular tooth would answer but little purpose, if no alteration could be
made in the situation of the rest; but we find that the very principle upon which teeth are
made to grow irregularly is capable, if properly directed, of bringing them even again.
This principle is the power which many parts (especially bones) have of moving out of
the way of mechanical pressure.

The best time for moving the teeth is in youth, while the jaws have an adapting dis-
position; for, after a certain time, they do not readily suit themselves to the irregularity
of the teeth. This we see plainly to be the case when we compare the loss of a tooth
at the age of fifteen years, and at that of thirty or forty. In the first case we find, that
the two neighboring teeth approach one another, in every part alike, till they close; but
in the second, the distance in the Jaw, between the two neighboring teeth, remains the
same, while the bodies will in a small degree incline to one another from want of lateral
support.

And this circumstance of the bodies of the teeth yielding to pressure upon their base,
shows that, even in the adult, they might be brought nearer to one another by art properly
applied. (Hunter, John: Natural History of the Teeth, ed. 1, London, 1771, J. Johnson.
In Weinberger, Bernard. W.: History of Orthodontia. Internat. J. Orthod. 2: 205, 1916.)