Objective: The aim of the study was to evaluate patients treated for impacted mandibular canines through a combined surgical and orthodontic approach. Study Design: The cases which were made button operations of impacted mandibular canines were selected from 5100 panoramic radiographs taken from patients who made use of our oral and maxillofacial surgery services between January 1998 to April 2006. All of these selected patients were assessed radiographically. Pertinent information such as sex, age at the time of surgery, site of the unerupted tooth, space availability and any other associated pathoses were also recorded. These patients were called again, and the condition of the mandibular canines was evaluated with panoramic radiographs. If the tooth erupted in the right position and it was functional and asymptomatic, we assumed the treatment to be successful clinically. Results: In the present study, from 5100 patients, 69 patients had impacted mandibular canines and only 21 patients' teeth (a total of 23 teeth) were treated orthodontically. Sixteen impacted mandibular canine teeth of 14 patients erupted successfully. Two impacted canine were extracted, and only one canine tooth was transplanted to the normal position. Four patients ended the treatment because of failure of eruption. Conclusion: If a mandibular canine tooth is impacted, not only is surgical exposure sufficient but also traction force must be applied orthodontically after the surgical exposure. In addition, age influences the success of the treatment on impacted mandibular canine teeth more than the position and impaction level of the teeth. © Medicina Oral S. L

Aras, Hamdi

Halicio?lu, Koray

Yavuz, Muhammed Selim

Ça?laro?lu, Murat

Repositori d'Objectes Digitals per a l'Ensenyament la Recerca i la Cultura

Med Oral Patol Oral Cir Bucal. 2011 Nov 1;16 (7):e925-8.                                                                                                                                                Treatments of impacted mandibular caninese925Journal section: Oral SurgeryPublication Types: ResearchEvaluation of surgical-orthodontic treatmentson impacted mandibular caninesMutan-Hamdi Aras 1, Koray Halicioğlu 2, Muhammed-Selim Yavuz 3, Murat Çağlaroğlu 41 Assistant Professor, DDs, PhD. Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Gaziantep University, Gaziantep, Turkey2 Orthodontic private practice, Bolu, Turkey3 Assistant Professor, DDs, PhD. Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ataturk University, �rzu-rum, Turkey4 Assistant Professor, DDs, PhD. Department of Orthodontics, Faculty of Dentistry, Kırıkkale University, Kırıkkale, TurkeyCorrespondence:Department of Oral and Maxillofacial Surgery,Faculty of Dentistry, Gaziantep University. Gaziantep, 27310Turkeymutanhamdi@hotmail.comReceived: 22/04/2010Accepted: 14/11/2010AbstractObjective: The aim of the study was to evaluate patients treated for impacted mandibular canines through a com-bined surgical and orthodontic approach. Study Design: The cases which were made button operations of impacted mandibular canines were selected from 5100 panoramic radiographs taken from patients who made use of our oral and maxillofacial surgery services between January 1998 to April 2006. All of these selected patients were assessed radiographically. Pertinent information such as sex, age at the time of surgery, site of the unerupted tooth, space availability and any other associated pathoses were also recorded. These patients were called again, and the condition of the mandibular canines was evaluated with panoramic radiographs. If the tooth erupted in the right position and it was functional and asymptomatic, we assumed the treatment to be successful clinically. Results: In the present study, from 5100 patients, 69 patients had impacted mandibular canines and only 21 pa-tients’ teeth (a total of 23 teeth) were treated orthodontically. Sixteen impacted mandibular canine teeth of 14 patients erupted successfully. Two impacted canine were extracted, and only one canine tooth was transplanted to the normal position. Four patients ended the treatment because of failure of eruption. Conclusion: If a mandibular canine tooth is impacted, not only is surgical exposure sufficient but also traction force must be applied orthodontically after the surgical exposure. In addition, age influences the success of the treatment on impacted mandibular canine teeth more than the position and impaction level of the teeth.Key words: Cuspid, tooth impacted, orthodontic extrusion, mandibular canine, forced eruption.Aras MH, Halicioğlu K, Yavuz MS, Cağlaroğlu M. �valuation of surgi�-cal-orthodontic treatments on impacted mandibular canines. Med Oral Patol Oral Cir Bucal. 2011 Nov 1;16 (7):e925-8.    http://www.medicinaoral.com/medoralfree01/v16i7/medoralv16i7p925.pdfArticle Number: 17072          http://www.medicinaoral.com/© Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946eMail:  medicina@medicinaoral.com Indexed in: Science Citation Index �xpandedJournal Citation ReportsIndex Medicus, M�DLIN�, PubMedScopus, �mbase and �mcare Indice Médico �spañoldoi:10.4317/medoral.17072http://dx.doi.org/doi:10.4317/medoral.17072Med Oral Patol Oral Cir Bucal. 2011 Nov 1;16 (7):e925-8.                                                                                                                                                Treatments of impacted mandibular caninese926IntroductionIn human dentition, maxillary and mandibular canines are very important teeth from the point of aesthetic and function (1-3). The maxillary canine teeth have the long-est period of development, the deepest area of develop-ment and the most devious path to travel to full occlu-sion (4). For this reason, the most frequently impacted tooth in the anterior region of the mouth is the maxil-lary canine (5). The prevalence of impacted maxillary canines is 0.9–2.2%, but mandibular canine impaction occurs less frequently (6-9).The treatment alternatives are similar for the manage-ment of mandibular canines, and the current treatment options are as follows:1. No treatment. The deciduous canine may have good root length and may be esthetically acceptable. Alter-natively, the deciduous canine may have exfoliated ear-lier and the canine space closed spontaneously leaving a good premolar-to-incisor contact point. The canine should, however, be observed to ensure that no resorp-tion of adjacent teeth occurs. In many ways removing the impacted canine is probably better to prevent re-sorption. 2. �xtraction of the mandibular canine teeth and space closure. This may be a difficult orthodontic treatment depending on the size of the residual space and the in-clination of adjacent teeth.3. Transplantation. This procedure is relatively quick but has an uncertain long-term prognosis. 4. Prosthetic or restorative treatment.5. Surgical exposure followed by forced eruption with orthodontic treatment (3,5,10). In the past, several techniques have been described for eruption of the unerupted permanent teeth. Azaz et al. (11) proposes that these can be classified into three categories. [1]The first procedure involves the surgical exposure of the crown of the impacted teeth for erup-tion. This involves excision of all soft and hard tissues around the crown of the unerupted canine, including the dental sac, to maintain a patent channel around the crown and normal eruptive path into the oral cavity. [2]The other procedure involves the application of attach-ment to the partially exposed crown. In this situation, an orthodontist is able to apply active directional trac-tion. [3]The last technique involves surgical reposition-ing of the severely malposed or impacted tooth from its original position to an ideal position for eruption. This is accomplished by surgically exposing the unerupted crown and removing sufficient bone to create an ade-quate channel through which the tooth is gently luxated and rotated into the desired position (11). �ither an open or closed surgical approach can be used to uncover the crown of an impacted tooth and place an orthodontic attachment. Various attachments are used to erupt im-pacted teeth, including threaded pins, cast gold inlays, gold cups with cleats, wire ligation, bonded attachment, bands and extracoronal caps; some are more damaging than others to the periodontium, the impacted tooth or adjacent teeth (12). This article presents a retrospective study of the man-agement of impacted mandibular canines treated with a combined surgical and orthodontic approach. Materials and MethodsWe designed a retrospective cohort study composed of 5100 panoramic radiographs taken from patients who were presented to our department between January 1998 to April 2006. All of the cases related to button op-erations of impacted mandibular canines were selected (21 patients). These patients were assessed radiographi-cally. Pertinent information such as sex, age at the time of surgery, site of the unerupted tooth, space availability and any other associated pathoses were also recorded. Patients which had not taken pre or post-treatment ra-diographs were excluded from study.During surgery, a facial flap was raised in all cases by a maxillofacial surgeon. Bone was removed if necessary. An attachment (button) was bonded onto the crown of the tooth. The flap was replaced to its original position with a chain or wire extending from the attachment into the oral cavity. If necessary, sufficient space was created for the im-pacted canine in the mandibular arch orthodontically. An elastic thread was then attached from the silver chain to the fixed orthodontic appliances. Orthodontic force was applied in order to erupt the tooth after tissue healing. The tooth was then actively extruded orthodon-tically. In some cases, premolars had been extracted to create space for the canines.All of these patients were called again for control, and the condition of the mandibular canines was evaluated with panoramic radiographs. If the tooth erupted in the right position and it was functional and asymptomatic, we assumed the treatment to be successful clinically. ResultsFrom all of the 5100 patients, 69 patients had impacted mandibular canines and only 21 patients’ (ages 12-24) teeth were treated with forced eruption by orthodon-tic treatment. The mean age of the patient’s teeth that erupted successfully were 15.1, and the mean age of the patients’ teeth that could not erupt were 19.9. Only in two patients were the canines bilateral, the others were unilateral, and in total 23 canine teeth were evaluated. �leven canines impacted on the left side, 12 on the right. Twelve patients were female, and nine patients were male. In 13 instances inadequate space was the prob-able factor of impaction. Only five deciduous canines had retained, and there were no supernumerary teeth or any pathology in any (all) cases.Med Oral Patol Oral Cir Bucal. 2011 Nov 1;16 (7):e925-8.                                                                                                                                                Treatments of impacted mandibular caninese927Sixteen impacted mandibular canine teeth of 14 patients erupted successfully (Fig. 1A-B, Fig. 2A-B). Two im-pacted canine were extracted, (Fig. 3A-B) and only one canine tooth was transplanted to the normal site. Four patients ended the treatment because of the failure of forced eruption. DiscussionMany authors have speculated about the cause of im-pacted mandibular canines (11). These are inadequate space, supernumerary teeth, premature loss of the de-ciduous dentition, retention of the deciduous canine, excessive crown length, hereditary factors, functional disturbances of the endocrine glands, tumors, cysts and trauma (1, 13�16). Insufficient space was the most com-mon factor interfering with the normal eruption of teeth in general (11).  In the mandible, mild crowding in the buccal segments led to impaction of the lower second premolars, frequently complicated by impaction of the lower third molars. Rarely, mandibular canine impac-tions occur (17). We think that inadequate space was the main factor of canine impaction in our 15 instances. However in six instances, retained decidduous canine and inadequate space were the main contributing fac-tors. There were no supernumerary teeth or any pathol-ogy in the other cases.All attempts to expose and align unerupted canines are long and expensive. Careful patient selection and preparation therefore is essential as is cooperation be-tween the orthodontist and the oral surgeon (5).  The appropriate management of impacted mandibular ca-nines is carried out in consultation with an orthodontist. The method of surgical exposure followed by forced extrusion orthodontically has the best long-term prog-nosis (18). However, during this procedure, damage to adjacent structures (19) and periodontal health of the unerupted canine should be considered. In this study, we evaluated the eruption and treatment method of 23 impacted mandibular canines. We reported that 16 im-pacted mandibular canine teeth of 14 patients erupted successfully. Two impacted teeth were extracted, and only one canine tooth was transplanted to the normal site. Four patients ended the treatment because of fail-ure of eruption.Azaz et al. (11) states that forced eruption in four teeth from 31 impacted teeth applies a traction force result-ing in failure. Some authorities believe that the age of a patient is a very helpful factor in predicting the suc-cess of the proposed tooth movement (20). Orton et al. (21) claims that treatments starting after the end of a pubertal growth spurt are likely to be protracted. In our study, the mean age of patients treated successfully was 15.5 and the mean age of patients who could not obtain eruption was 19.9. A high mean age may be the reason of the failure.Among orthodontic patients, the number of women is higher than men (1). This sex predilection was the same in our study. Out of a total of 21 patients who were treat-ed orthodontically, 12 were female and nine were male.If there was any pathology such as odontoma or any supernumerary tooth, the first procedure might have been sufficient. But in all of our cases, any pathology or supernumerary teeth were not related to impacted canines. Observed morphologic changes in the root for-mation after the treatments illustrated two basic types: premature completion of root formation (or dwarfed roots) and dilacerations. Azaz et al. (11) reports that dwarfed roots have been seen in eight instances, seven of which were associated with repositioned teeth. In ad-dition, he reports that dilacerations of the roots were seen in eight cases, three of which were associated with exposure only and four of which were associated with repositioned teeth (11). In our study, any sequelae did not appear in the treated teeth. Probably, because we did not use a repositioning procedure this condition was not seen in any of our cases. Root resorption is a well-recognized complication of Fig. 1A-B. Pre and post treatment radiograph of the successfully erupted canine and premolar.Fig. 2A-B. Panoramic radiograph of the mandibular canine before and after forced eruption.Fig. 3A-B. Before treatment of the impacted canine tooth with anky-losis, and failure of the forced eruption after 18 months.Med Oral Patol Oral Cir Bucal. 2011 Nov 1;16 (7):e925-8.                                                                                                                                                Treatments of impacted mandibular caninese928 References with links to Crossref - DOI    impacted canines. Complicating factors that the clini-cian must be aware of and look for include evidence of root resorption of the adjacent teeth, because root re-sorption may modify the treatment plan and strategy. If it is possible and practical, the impacted tooth should be moved away from the roots of the adjacent teeth (22). In this study, tooth resorption only occurred in two cases. But, root resorption started before treatment in both cases.      Since forced eruption of impacted canines provides the best long-term results, intervention with a surgical at-tachment of an orthodontic button or bracket should be implemented (23). In conclusion, if a mandibular canine tooth is impacted, not only is surgical exposure suffi-cient but also traction force must be applied orthodonti-cally after the surgical exposure. In addition, age influ-ences the success of the treatment on impacted mandib-ular canine teeth more than the position and impaction level of the teeth.References1. Joshi MR. Transmigrant mandibular canines: a record of 28 cases and a retrospective review of the literature. Angle Orthod. 2001;71:12-22. 2. Aras MH, Büyükkurt MC, Yolcu U, �rtaş U, Dayi �. Transmi-grant maxillary canines. Oral Surg Oral Med Oral Pathol Oral Ra-diol �ndod. 2008;105:e48-52. 3. Buyukkurt MC, Aras MH, Caglaroglu M, Gungormus M. Transmi-grant mandibular canines. J Oral Maxillofac Surg. 2007;65:2025-9. 4. Ferguson JW. Management of the unerupted maxillary canine. Br Dent J. 1990;169:11-7. 5. McDonald F, Yap WL. The surgical exposure and application of direct traction of unerupted teeth. Am J Orthod. 1986;89:331-40. 6. D’Amico RM, Bjerklin K, Kurol J, Falahat B. Long-term results of orthodontic treatment of impacted maxillary canines. Angle Orthod. 2003;73:231-8. 7. Aydin U, Yilmaz HH, Yildirim D. Incidence of canine impaction and transmigration in a patient population. Dentomaxillofac Radiol. 2004;33:164-9. 8. Alaejos-Algarra C, Berini-Aytes L, Gay-�scoda C. Transmigra-tion of mandibular  canines: report of six cases and review of the literature. Quintessence Int. 1998;29:395-8. 9. Yavuz MS, Aras MH, Büyükkurt MC, Tozoglu S. Impacted man-dibular canines. J Contemp Dent Pract. 2007;8:78-85. 10. Buyukkurt MC, Aras MH, Caglaroglu M. �xtraoral removal of a transmigrant mandibular canine associated with a dentigerous cyst. Quintessence Int. 2008;39:767-70. 11. Azaz B, Steiman Z, Koyoumdjisky-Kaye �, Lewin-�pstein J. The sequelae of surgical exposure of unerupted teeth. J Oral Surg. 1980;38:121-7. 12. Frank CA, Long M. Periodontal concerns associated with the orthodontic treatment of impacted teeth. Am J Orthod Dentofacial Orthop. 2002;121:639-49. 13. Milano M, Barrett L 2nd, Marshall �. �xtraction of a horizon-tally impacted mandibular canine through a genioplasty approach: report of a case. J Oral Maxillofac Surg. 1996;54:1240-2. 14. Camilleri S, Scerri �. Transmigration of mandibular canines--a review of the literature and a report of five cases. Angle Orthod. 2003;73:753-62. 15. Mitchell L. Displacement of a mandibular canine following frac-ture of the  mandible. Br Dent J. 1993;174:417-8. 16. Brezniak N, Ben�Yehuda A, Shapira Y. Unusual mandibular ca-nine transposition:  a case report. Am J Orthod Dentofacial Orthop. 1993;104:91-4. 17. McBride LJ. Traction--a surgical/orthodontic procedure. Am J Orthod. 1979;76:287-99. 18. Gensior AM, Strauss R�. The direct bonding technique applied to the management of the maxillary impacted canine. J Am Dent Assoc. 1974;89:1332-7. 19. �ricson S, Kurol J. Incisor resorption caused by maxillary cus-pids. A radiographic study. Angle Orthod. 1987;57:332-46. 20. Machen D�. Legal aspects of orthodontic practice: risk man-agement concepts. The impacted canine. Am J Orthod Dentofacial Orthop. 1989;96:270-1. 21. Orton HS, Garvey MT, Pearson MH. �xtrusion of the ectopic maxillary canine using a lower removable appliance. Am J Orthod Dentofacial Orthop. 1995;107:349-59. 22. Kuftinec MM, Shapira Y. The impacted maxillary canine: II. Clinical approaches and solutions. ASDC J Dent Child. 1995;62:325-34. 23. Crawford LB. Four impacted permanent canines: an unusual case. Angle Orthod. 2000;70:484-9. 

Evaluation of surgical-orthodontic treatments on impacted mandibular canines

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Repositori d'Objectes Digitals per a l'Ensenyament la Recerca i la Cultura