Impacted dysfunction were noted at the initial examination

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Last updated: May 13, 2019

 Impactedteeth are those, which are prevented from erupting by some physical barrier, inthe eruption path and remain in the jaws, surrounded completely or partially byhard or soft tissues. The incidence rate of 0.8 to 2.

3% has been reported forimpaction of maxillary permanent canines.1 The prevalence in adult of impactionof mandibular canines has been reported from 0.05 to 0.

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4%.2 The locationsof impacted mandibular canines are common in the labial aspect of the dentalarch than compared to maxillary canines.3,4 Various treatment options for impactedmandibular canines including surgical removal, exposure and orthodonticalignment, transplantation and observation. Thepurpose of this case report is to describe the diagnosis and management ofimpacted mandibular canine by surgical exposure and orthodontic treatmentmechanics. Case ReportA 16 yearold female patient presented with an irregularly placed upper and lower frontteeth. She was physically healthy and had no history of medical or dentaltrauma. No signs or symptoms of temporo-mandibular joint dysfunction were notedat the initial examination The extraoral clinical examination revealed a straight profile with competent lips.

There were no gross asymmetries. The intraoral examination showed an Angle’sClass I malocclusion. The mandibular left canine was impacted. The maxillaryand mandibular arch showed mild spacing with overbite of 1mm and reverseoverjet irt 11and 42. (Figure 1 and 2)Cephalometrically,the patient had a Class III skeletal relationship (ANB angle: -1°) withmandibular prognathism. A horizontal growth pattern was seen (SN.GoGn: 26°).

Maxillary incisors were proclined with the upper incisor – NA of 114°. Thelower incisors were uprighted with an IMPA of 93°. The panoramic radiographshowed all permanent teeth, including the maxillary and mandibular uneruptedthird molars. The mandibular left canine was impacted. (Figure 3) The commonlyused radiograph for diagnosis of impacted canine includes OPG, occlusal viewand Intraoral periapical radiograph. Apart from these PA and lateral cephalogram and CBCT were also used in selectedcases.

TreatmentObjectives The initialtreatment objectives were surgical exposure of the mandibular left canine andbring it into alignment. The orthodontic procedure would align the maxillaryand mandibular dental arches. Our treatment objective also included correctingthe Class I incisor relationship. The comprehensive treatment objectives wereto establish good functional and stable occlusion and to improve the smilecharacteristics and dental esthetics.Treatmentplan 1.     Non extraction treatment plan followed bysurgical exposure of 33 and alignment of the same in the arch.  Treatment progressThe casewas started with MBT 0.022″ pre adjusted edgewise appliance.

The initialalignment was achieved with 0.016″ NiTi archwire. The leveling was carried outwith 0.018″ AJ Wilcock archwire and e4333impactedmandibular canine was surgically exposed with full thickness flap under localanesthesia. The bracket was bonded on exposed canine and ligature wire was tied(Figure 4) Elastic traction was given from the ligature wire attached to thebracket on the exposed canine. In order to bring the mandibular left canine inthe arch, a overlay (“Piggy Back”) wire of 0.014″ NiTi, over the 0.

017 X 0.025″Stainlesssteel base archwire was engaged on the bracket of the mandibular left canine (Figure5). The alignment and leveling was completed with 0.019 X 0.

025″ NiTi and 0.019X 0.025″ stainless steel archwires. It took 14 month to bring the canine intothe arch.

(Figure 6)Treatment result Intraorally,ideal overjet and overbite was achieved with Class I molar and caninerelationship with consonant smile arc. The radiograph showed good bone supportand root parallelism.DISCUSSIONImpactedpermanent mandibular canine are detected quite regularly in the clinical andradiographic examination of a young dental patient. The most important step inthe management of impacted teeth is the diagnosis and localization of impactedteeth. Failure of eruption of the mandibular canine is an unusual event.4,5 There isvery few number of studies revealing the occurrence of mandibular canineimpactions.4 Delayedtooth eruption can cause necrosis of the pulp, ankylosis and external apicalroot resorption. It is difficult to predict when resorption will start.

Thus,all impacted teeth should be regarded as having a high risk of external apicalroot resorption or damage to the adjacent tooth. Periodically radiographicexaminations should be used to monitor the impacted canine for above risk.6,7 Surgicalextraction appears to be the most favored treatment for impacted mandibularcanines, rather than a heroic effort to bring the tooth back to its originalplace.8 Inour case, the canine was in favorable position, and since canines areconsidered important keystones in the dental arch, we decided to orthodonticallybring it into most ideal position. Therefore,a good knowledge of the clinician may improve situation in future treatmentoptions, which can have a significant impact on the treatment outcome.

Conclusion Satisfactoryfunctional and esthetic results were achieved in this case with ideal skeletaland dental relationships. The combined effect of surgical exposure of impactedmandibular canine and orthodontically correct the major components of abalanced smile for this patient, whose main concern was his unpleasant smile.  References 1. ThilanderB, Myrberg N. The prevalence of malocclusion in Swedish school children.

Scan JDent Res1973;81:12-20. 2. BrownLH, Berrkman S, Cohen D, Kaplan AL, Rosenberg MA. A radiological study of thefrequency and distribution of impacted teeth. J Dent Assoc S Afr.1982;37:627-30.

3.Fonseca JR. Oral and Maxillofacial Surgery.

Phailadelphia: W.B. Saunders,2002;1:342-71. 4. MonikaR, Mahesh G, Nikhi M. Bilateral Mandibular Canine Impaction: A Rare CaseReport. Journal of Oral Health and Community dentistry. 2009;3(2):38-41.

5.Camilleri S, Scerri E. Transmigrationof mandibular canines – A review of the literature and a report of five cases.

Angle Orthod 2003;73:753-62.6. Kavadia-Tsatala S, Tsalikis L,Kaklamanos EG, Sidiropoulou S, Antoniades K. Orthodontic and periodontalconsiderations in managing teeth exhibiting significant delay in eruption. World J Orthod.

2004;5:224–229. 7. Peck S. On the phenomenon ofintraosseous migration of nonerupting teeth. Am J Orthod Dentofacial Orthop. 1998;113:515–517.

?8.. Nagaraj T, Umashree N.

Transmigrationof mandibular canine. e-Journal of Dentistry. 2011;1(3):72-74.9.

Boyd RL. Clinical assessment ofinjuries in orthodontic movement of impacted teeth. II.

Surgical ?recommendations. AmJ Orthod 1984;86:407-18. ?10. Camilleri S, Scerri E. Transmigrationof mandibular canines – A review of the literature and a report of five ?cases.Angle Orthod 2003;73:753-62. ?12.

Peck S. On the phenomenon ofintraosseous migration of nonerupting teeth. Am J Orthod Dentofacial Orthop.1998;113:515–517.

?13.Nagaraj T, Umashree N. Transmigrationof mandibular canine. e-Journal of Dentistry. 2011;1(3):72-74. ?14. Canut JA. Mandibular incisorextraction: Indications and long term evaluation.

Eur J Orthod 1996;18:485-9. ?15.Vignesh T, Senthil Kumar K. P, SenthilKumar T. Mandibular incisor extraction in orthodontics: A systematic review.Journal of Indian Academy of Dental Specialist Researchers. 2014;1(1);1-5.

?16.Riedel RA, Little RM, Bui TD.Mandibular incisor extraction-postretention evaluation of stability and relapse.Angle Orthod 1992;62:103-16. ?17. Rosenberg MA. A radiological study ofthe frequency and distribution of impacted teeth. J Dent Assoc S Afr.

1982;37:627-30. 18. Fonseca JR. Oral and MaxillofacialSurgery. Phailadelphia: W.B.

Saunders, 2002;1:342-71. 19. Monika R, Mahesh G, Nikhi M.

Bilateral Mandibular Canine Impaction: A Rare Case Report. Journal of Oral Health andCommunity dentistry. 2009;3(2):38-41. 20. Michele N, Aldo C,Roberto R, Tiziano B, Pierpaola C, Giovan PP.

Factors affecting the clinicalapproach to impacted maxillary canines: A Bayesian network analysis. Am JOrthod Dentofacial Orthop. 2010;137(6):755    

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