Impacted dysfunction were noted at the initial examination

 Impacted
teeth are those, which are prevented from erupting by some physical barrier, in
the eruption path and remain in the jaws, surrounded completely or partially by
hard or soft tissues. The incidence rate of 0.8 to 2.3% has been reported for
impaction of maxillary permanent canines.1 The prevalence in adult of impaction
of mandibular canines has been reported from 0.05 to 0.4%.2 The locations
of impacted mandibular canines are common in the labial aspect of the dental
arch than compared to maxillary canines.3,4 Various treatment options for impacted
mandibular canines including surgical removal, exposure and orthodontic
alignment, transplantation and observation. The
purpose of this case report is to describe the diagnosis and management of
impacted mandibular canine by surgical exposure and orthodontic treatment
mechanics. Case ReportA 16 year
old female patient presented with an irregularly placed upper and lower front
teeth. She was physically healthy and had no history of medical or dental
trauma. No signs or symptoms of temporo-mandibular joint dysfunction were noted
at the initial examination The extra
oral clinical examination revealed a straight profile with competent lips.
There were no gross asymmetries. The intraoral examination showed an Angle’s
Class I malocclusion. The mandibular left canine was impacted. The maxillary
and mandibular arch showed mild spacing with overbite of 1mm and reverse
overjet irt 11and 42. (Figure 1 and 2)Cephalometrically,
the patient had a Class III skeletal relationship (ANB angle: -1°) with
mandibular prognathism. A horizontal growth pattern was seen (SN.GoGn: 26°).
Maxillary incisors were proclined with the upper incisor – NA of 114°. The
lower incisors were uprighted with an IMPA of 93°. The panoramic radiograph
showed all permanent teeth, including the maxillary and mandibular unerupted
third molars. The mandibular left canine was impacted. (Figure 3) The commonly
used radiograph for diagnosis of impacted canine includes OPG, occlusal view
and Intraoral periapical radiograph. 
Apart from these PA and lateral cephalogram and CBCT were also used in selected
cases.Treatment
Objectives The initial
treatment objectives were surgical exposure of the mandibular left canine and
bring it into alignment. The orthodontic procedure would align the maxillary
and mandibular dental arches. Our treatment objective also included correcting
the Class I incisor relationship. The comprehensive treatment objectives were
to establish good functional and stable occlusion and to improve the smile
characteristics and dental esthetics.Treatment
plan 1.     Non extraction treatment plan followed by
surgical exposure of 33 and alignment of the same in the arch.  Treatment progressThe case
was started with MBT 0.022″ pre adjusted edgewise appliance. The initial
alignment was achieved with 0.016″ NiTi archwire. The leveling was carried out
with 0.018″ AJ Wilcock archwire and e4333impacted
mandibular canine was surgically exposed with full thickness flap under local
anesthesia. The bracket was bonded on exposed canine and ligature wire was tied
(Figure 4) Elastic traction was given from the ligature wire attached to the
bracket on the exposed canine. In order to bring the mandibular left canine in
the arch, a overlay (“Piggy Back”) wire of 0.014″ NiTi, over the 0.017 X 0.025″Stainless
steel base archwire was engaged on the bracket of the mandibular left canine (Figure
5). The alignment and leveling was completed with 0.019 X 0.025″ NiTi and 0.019
X 0.025″ stainless steel archwires. It took 14 month to bring the canine into
the arch. (Figure 6)Treatment result Intraorally,
ideal overjet and overbite was achieved with Class I molar and canine
relationship with consonant smile arc. The radiograph showed good bone support
and root parallelism.DISCUSSIONImpacted
permanent mandibular canine are detected quite regularly in the clinical and
radiographic examination of a young dental patient. The most important step in
the management of impacted teeth is the diagnosis and localization of impacted
teeth. Failure of eruption of the mandibular canine is an unusual event.4,5 There is
very few number of studies revealing the occurrence of mandibular canine
impactions.4 Delayed
tooth eruption can cause necrosis of the pulp, ankylosis and external apical
root resorption. It is difficult to predict when resorption will start. Thus,
all impacted teeth should be regarded as having a high risk of external apical
root resorption or damage to the adjacent tooth. Periodically radiographic
examinations should be used to monitor the impacted canine for above risk.6,7 Surgical
extraction appears to be the most favored treatment for impacted mandibular
canines, rather than a heroic effort to bring the tooth back to its original
place.8 In
our case, the canine was in favorable position, and since canines are
considered important keystones in the dental arch, we decided to orthodontically
bring it into most ideal position. Therefore,
a good knowledge of the clinician may improve situation in future treatment
options, which can have a significant impact on the treatment outcome.Conclusion Satisfactory
functional and esthetic results were achieved in this case with ideal skeletal
and dental relationships. The combined effect of surgical exposure of impacted
mandibular canine and orthodontically correct the major components of a
balanced smile for this patient, whose main concern was his unpleasant smile.  References 1. Thilander
B, Myrberg N. The prevalence of malocclusion in Swedish school children. Scan J
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Fonseca JR. Oral and Maxillofacial Surgery. Phailadelphia: W.B. Saunders,
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R, Mahesh G, Nikhi M. Bilateral Mandibular Canine Impaction: A Rare Case
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