Download The Treatment of a Palatally Impacted Maxillary Canine

OLGU RAPORU (Case Report)
Hacettepe Dişhekimliği Fakültesi Dergisi
Cilt: 30, Sayı: 2, Sayfa: 48-58, 2006
The Treatment of a Palatally Impacted
Maxillary Canine by Tunnel Traction
Method
Palatinalde Gömülü Maksiller Kanin Dişin Tünel
Traksiyon Yöntemiyle Tedavisi
*Müge AKSU DDS, PhD, *Tülin (Uğur) TANER DDS, PhD
* Hacettepe University, Faculty of Dentistry, Department of Orthodontics
ABSTRACT
ÖZET
The patient was a 15-year-old boy who had an Angle
15 yaşındaki erkek hastada Angle Sınıf I malokluz-
Class I malocclusion with a right palatally impacted
yona eşlik eden palatal olarak gömülü sağ maksiller
maxillary canine. The right deciduous canine was
also persisted in the mouth. The treatment involved
the tunnel traction method, by which the impacted
kanin varlığı teşhis edildi. Sağ süt kaninin de ağızda
olduğu tespit edildi. Tedavisinde gömülü kanin dişi-
canine was pulled toward the center of the alveolar
nin süt dişi soketi içerisinden sürdürülmesini sağla-
ridge via the deciduous canine socket. The duration
yan tünel traksiyon yönteminin uygulanması plan-
of the traction was 11 months and the total treatment
landı. Traksiyon 11 ay, toplam tedavi 31 ay sürdü.
time was 31 months. At the end of treatment, an
Tedavi sonunda, sürdürülen sağ maksiller kanin
apically repositioned flap operation was performed to
correct the low gingival contour on the buccal side of
the maxillary right canine to improve esthetics.
The tunnel traction method is an advantageous treat-
dişin labial dişeti bölgesine apikale repozisyone flep
cerrahisi uygulanarak gingival konturu düzeltildi ve
daha estetik bir görüntü sağlandı. Tünel traksiyon
ment technique in maxillary canine impaction cases
metodu, süt dişlerinin varlığında, doğal intraosseoz
with retained deciduous canine by providing a natural
tünel oluşturması bakımından gömülü maksiller
intraosseous tunnel toward the dental arch.
kaninlerin tedavisinde avantajlı bir yaklaşımdır.
KEYWORDS
ANAHTAR KELİMELER
Impacted maxillary canine, Tunnel traction
Gömülü maksiller kanin, Tünel traksiyon
49
INTRODUCTION
CASE REPORT
The palatal impaction of maxillary permanent
Diagnosis:
canines is a frequently encountered clinical problem. Genetic factors are largely responsible for
this anomaly1,2. Other causes suggested for canine impactions are usually the results of any one
or combination of the following factors: Tooth
size-arch length discrepancies, prolonged retention or early loss of the deciduous canine, abnormal position of the bud, dilacerations of the root,
ankylosis, cystic or neoplastic formation and the
absence of the maxillary lateral incisor3-5.
A 15 year-old boy was referred to the orthodontic clinic for the unaesthetic appearance of
his crowded maxillary anterior teeth. The clinical examination revealed an Angle Class I molar
relationship, a highly positioned maxillary left
canine on the vestibule and a persistent right deciduous canine. The permanent right canine was
not seen in the arch. There was also a total of 2
mm diastema between the central incisors and
the right lateral incisor. Mandibular teeth were
The presence of the impacted canine may
aligned reasonably well with a 2 mm diastema
cause some effects such as migration of the ne-
between left canine and first premolar (Fig 1A-
ighboring teeth and loss of arch length, internal
L). The radiological examination showed that the
resorbtion, dentigerous cyst formation, external
right permanent canine was impacted palatally
root resorbtion of itself as well as the neighbo-
(Fig 2A-C).
ring teeth and combinations of the above squelae. Potential complications emphasize the need
for close observation of the development and
eruption of these teeth during the examination
of the growing child6.
The orthodontic treatment of a palatally impacted canine is aimed at bringing the tooth into
its correct position in the dental arch without causing any periodontal damage. To achieve this
goal, a variety of surgical7-11 and orthodontic
15
3,12-
techniques have been proposed in relation to
the position of the impacted tooth and to the
treatment method used for traction16,17. Tunnel
traction is one of the approaches for orthodontic
treatment of the deep infraosseous impacted canines by providing an osseous tunnel toward the
centre of the alveolar ridge18. This method can
be valid when the deciduous canine is persisted
in the mouth, so that the socket of the deciduous canine can be used to form a tunnel for
movement of the impacted canine. In this case
report, we describe the surgical and orthodontic
treatment of a palatally impacted canine by using
the tunnel traction method.
A
50
D
E
B
F
G
FIGURE 1
C
(A) Pretreatment extraoral facial photograph (B) Pretreatment
extraoral lateral photograph (C) Pretreatment smiling
photograph (D-G) Pretreatment intraoral photographs
51
H
L
FIGURE 1
(H-L) Pretreatment study models
I
A
J
B
FIGURE 2
(A) Pretreatment panoramic radiograph (B) Pretreatment
occlusal radiograph
K
52
Surgical procedure:
A full thickness mucoperiosteal flap was raised to expose the cortical plate and the deciduous canine was extracted. Cortical bone was
removed to provide access to the crown. With a
low speed bur, a perforation on to the bone from
the socket of the deciduous canine was performed to reach the crown of the impacted canine.
The socket of the deciduous canine was then formed like an osseous tunnel that would be used
for traction. A gold-chain bonded on the impacted tooth was passed through the tunnel. The
flap was sutured back into its original position.
C
Treatment progress:
FIGURE 2
(C) Pretreatment lateral cephalometric tracing
Treatment:
The objective of treatment was to prepare
adequate space for the upper canines and properly positioning the impacted right canine into
the arch to obtain a good alignment of the teeth.
Because the lower teeth were in good alignment,
no treatment was planned in the lower jaw.
A transpalatal arch was used for providing
anchorage during the traction of the impacted
canine. .018 x .025 inch Roth brackets were
bonded to the maxillary teeth. Initial leveling was
accomplished with a .016 x .016-inch nickel titanium wire, followed by a .016 x .022-inch stainless steel wire. Open-coil springs were used to
gain spaces for the maxillary canines. Then, .016
x .022-inch stainless steel wire with a helix on
the right canine side was inserted. The helix was
bent to be used for tying the gold chain during
traction of the impacted canine. The deciduous
right canine was not removed and kept in place
during the preoperative orthodontic treatment.
Following 10 months of orthodontic therapy, the
patient was referred to the surgeon for exposure
of the impacted canine.
One week after surgery, the sutures were removed and the traction phase began. Elastic thread was placed through the first link of the gold
chain and tied to the helix on the arch, applying
a traction force to the impaction canine. The direction of the traction was directed toward the
center of the alveolar ridge (Fig 3A-D). During
the traction phase, the movement of the impacted tooth was guided through the tunnel. As the
canine moved closer to the designated position
more gold chain became exposed through the
mucosa. Excess chain was then cut. This was
repeated every 2 weeks until the impacted canine and the attached part of the chain became
exposed in the oral cavity and the cusp of the
impacted canine emerged at the center of the
alveolar process. The postsurgical panoramic radiograph shows the canine in its proper position
(Figure 3E). The gold chain was eventually removed and the canine bracket was bonded to the
upper right canine..016-inch and .016 x .016inch nickel titanium arch wires were used to level
the right canine sequentially. When the canine
was completely aligned within the dental arch,
a finishing arch wire of .016 x .022-inch stainless steel was placed and the patient was seen at
monthly intervals. The brackets were debonded
after good alignment and interdigitation of teeth
were achieved (Fig. 4A-C). As the gingival contour of the right canine was lower then the left
53
E
FIGURE 3
A
At the start of traction phase: (A) Intraoral lateral photograph
(B) Occlusal photograph (C) Occlusal radiograph (D)
Panoramic radiograph (E) During traction: Canine directed
into its proper position
B
A
B
C
C
D
FIGURE 4
(A-C) Posttreatment intraoral photographs
54
one, an apically repositioned flap was performed
to correct the gingival contour.
Results:
At the end of treatment, the palatally impacted maxillary right canine was positioned into
proper alignment, resulting in a pleasing smile.
(Fig. 5A-L) Radiographically, the right canine
displayed proper root inclination and the incisors remained stable at the end of treatment
(Fig. 6A-C). The duration of the traction was 11
months which elapsed between the application
of the traction and the eruption of the cusp of
the impacted canine. Total treatment time was
31 months. For retention, a Hawley retainer was
placed and the patient was instructed to wear it
24 hours a day.
The impacted canine was brought into the
arch and properly without complaints of significant discomfort. There was no attachment loss
at the site of the impacted canine during the treatment, and the maximum probing depth was 3
mm. The pseudo- pocket on the buccal side of
the right canine tooth was corrected by a flap
B
C
FIGURE 5
A
(A) Posttreatment extraoral facial photograph (B)
Posttreatment extraoral lateral photograph (C) Posttreatment
smiling photograph
55
D
H
E
I
F
J
G
K
FIGURE 5
FIGURE 5
(D-G) Posttreatment intraoral photographs
(H-K) Posttreatment study models
56
L
C
FIGURE 5
(L) Posttreatment study models
FİGURE 6
(C) Posttreatment lateral cephalometric tracing
operation. No root resorption of the adjacent
teeth was seen on the periapical radiographs during the traction of the impacted canine.
DISCUSSION
Maxillary permanent canines are important
for an attractive smile and are also essential for a
A
functional occlusion. Therefore, extraction of the
canines should be avoided, if at all possible. In the
case of maxillary impaction, surgical exposure of
the related tooth and the use of fixed orthodontic
appliances is the most frequently used treatment
alternative as long as the tooth position is favorable. Various methods have been used for moving
the canine into proper alignment3,7-18. Fournier et
al15 have proposed the use of a removable plate.
B
Becker and Zilberman12 have recommended the
use of a flexible palatal arch slotted into horizonFİGURE 6
(A) Posttreatment panoramic radiograph (B) Posttreatment
periapical radiographs
tal, soldered, palatal tubes on the molar bands
of any type of fixed multibonded appliance. Jacoby14 has suggested his ballista spring to direct a
palatal-occlusal force from the buccal side.
57
In this report, the successful treatment of a
palatally impacted maxillary canine using the
tunnel traction method was presented. The only
study presenting the long-term effect of the tunnel traction method was reported by Crescini et
al18. The advantage of this technique was that
the impacted canine was moved through an osseous tunnel to its proper place on the dental
arch. However, this method could be used in the
presence of a retained deciduous canine tooth
on the affected side.
The duration of the traction needed to resolve the impaction was 11 months and the total
treatment time was 31 months in this case. Crescini et al18 also reported 11 months of tunnel traction time. However, their total treatment time
was 22 months. Becker and Chaushu19 revealed
that in young patients, the duration of canine
traction took about one third of the overall treatment time. The duration of the treatment for
the impacted canines was reported to change
due to age, gender, molar relation, severity of
impaction, amount of crowding, unilateral and
bilateral impactions. Thus, individual treatment
times for the impacted canine teeth showed a
large range20.
This case report showed that with the use
of the tunnel traction method, the right palatally impacted maxillary canine was erupted in its
proper place on the dental arch without giving
any damage to the neighboring teeth. It has been
reported that the orthodontic treatment of palatally impacted canines may cause root resorption
of the adjacent lateral incisors21 or premolars22.
After the completion of the orthodontic treatment, the buccal gingival height of the impacted
teeth often needs correction8 though some authors18 suggested no gingival augmentation procedure after treatment of impacted canines with
the tunnel traction method. In presented case,
an apically repositioned flap was performed to
increase the clinical crown height of the right canine. The patient’s smile esthetics was improved
following the procedure.
CONCLUSION
The impacted canine associated with the persistent deciduous canine was treated successfully
by tunnel traction method. The extraction of the
deciduous tooth provided a natural osseous tunnel for movement of the impacted tooth. Traction
through the osseous tunnel ensured an eruption
path that closely follows the physiologic pattern
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CORRESPONDING ADDRESS
Müge AKSU DDS, PhD
Hacettepe University, Faculty of Dentistry, Department of Orthodontics 06100 Sıhhiye-Ankara/TURKEY
Business: +90 312 311 64 61, Fax: +90 312 309 11 38, E-mail: [email protected]