Management of Impacted Canines

15
George Varghese

Impacted canines are one of the common problems encoun- the development of complications. An ideal management
tered by the oral surgeon. Patients may present at different protocol for impacted permanent maxillary canines should
ages and many cases will be incidental findings. Close inter- involve an interdisciplinary approach linking the specialties
action with the paedodontist and orthodontist is required to of oral and maxillofacial surgery, periodontology and
get an optimal out come. Surgical removal may not be the orthodontics.
best treatment in all the cases and particular treatement plan
will have to be tailored for the needs of the patient. Localising
the impacted canine seems not a challenge any more with the 15.2 Aetiology of Canine Impaction
advent of CBCT, in indicated cases. This chapter elaborates
on canine impaction, keeping in mind the basic principles Although the exact cause of impacted maxillary canines
mentioned in the chapter on third molar impactions. remains unknown, multiple factors may play a role. Primary
Premolars, incisors and other teeth may be impacted but causes that have been linked to impacted maxillary canines
most of the surgical principles and approaches mentioned for include the rate at which roots resorb in the deciduous teeth,
canine can be applied to them as well. any trauma to the deciduous tooth bud, disruption of the nor-
mal eruption sequence, lack of space, rotation of tooth buds,
premature root closure and canine eruption into a cleft.
15.1 Introduction Secondary reasons include febrile diseases, endocrine
­disturbances and Vitamin D deficiency. Impacted canine can
Maxillary canine is the second most commonly impacted be concomitant with other conditions.
tooth, after the mandibular third molar. The permanent max- Except the third molars, maxillary canines are among the
illary canine may be considered as impacted when the erup- last teeth to erupt. They usually develop high in the maxilla
tion of the tooth lags behind as compared to the eruption and need to travel a considerable distance before they erupt.
sequences of other teeth in the dentition. Diagnosis of maxil-
lary canine impaction may be made by clinical examination
and by radiography. Local factors may also play a role in canine impaction,
The normal path through which maxillary canines erupt and these include:
may be altered due to changes in the eruption sequence in the
maxilla, and also by space limitations due to crowding. It is 1. A longer eruption path that the tooth has to traverse
essential to diagnose and treat this condition early, to prevent from its point of development to normal occlusion
[1].
2. Thick palatal bone and mucoperiosteum, which can
obstruct eruption of palatally oriented canines.
Electronic Supplementary Material The online version of this ­chapter 3. More developed root at the time of eruption, which
(https://doi.org/10.1007/978-981-15-1346-6_15) contains supplemen-
tary material, which is available to authorized users. may minimize the eruptive force.
4. Disorder of the primary canine can affect the posi-
tion of the permanent one. This is because the
G. Varghese (*)
crown of the developing permanent canine lies just
Principal, Professor and Head, Department of Oral and
Maxillofacial Surgery, Pushpagiri College of Dental Sciences, palatal to the apex of the primary canine root.
Tiruvalla, Kerala, India

© The Association of Oral and Maxillofacial Surgeons of India 2021 329

K. Bonanthaya et al. (eds.), Oral and Maxillofacial Surgery for the Clinician, https://doi.org/10.1007/978-981-15-1346-6_15
330 G. Varghese

Mandibular Canines
5. Canines are more susceptible to environmental 1. Labial
influences as they are among the last teeth to erupt • Vertical
(except the third molars). • Oblique
6. Limited space for eruption as the canines erupt • Horizontal
between teeth which are already in occlusion. The 2. Aberrant
second molar may further reduce the space. • At inferior border.
7. The permanent canine has a greater mesiodistal • On the opposite side.
width than the primary canine. • Mental protuberance.

15.3  lassification of Impacted Maxillary

C Complications that Can Occur Due to Canine Impaction
Canines 1. Adjacent teeth may undergo internal or external
resorption.
15.3.1 T
 he Following Classification Suggested
2. Change in alignment or proclination of lateral inci-
by Archer (1975) [2] is Very Practical
sor (Fig. 15.1).
3. Odontogenic Cyst formation.
Class I: Impacted canines in the palate.
4. Development of Odontogenic Tumour.
1. Horizontal
2. Vertical
3. Semivertical
• Class II: Impacted canines located on the labial surface.
The clinical signs that indicate an impacted maxillary
1. Horizontal
canine include:
2. Vertical
3. Semivertical 1. Prolonged retention of the primary canine [4] and
• Class III: Impacted canine located labially and pala- or delayed eruption of the permanent canine.
tally—crown on one side and the root on the other side. 2. Lack of a bulge on the labial side of the alveolus in
• Class IV: Impacted canine located within the alveolar the canine region.
process—usually vertically between the incisor and first 3. Delayed eruption of the lateral incisor, or an incisor
premolar. that is tipped distally or migrated.
• Class V: Impacted canine in edentulous maxilla— 4. Loss of vitality or increased mobility of the perma-
Impacted canine can be in unusual positions like inverted nent incisors.
position.

15.3.2 F
 ield and Ackerman (1935) 15.4 Radiographic Localization
Classification [3] of Impacted Canine

 axillary Canines
M The position of the impacted canine may be determined by
1. Labial position visual inspection, palpating intraorally or by radiography.
• Crown in intimate relation with incisors. Radiographic examinations may include periapical X-ray
• Crown well above apices of incisors. with cone shift technique, occlusal radiography, anteroposterior
2. Palatal position and lateral radiographic views of maxilla, OPG, CBCT, CT scan.
• Crown near surface.
• Crown deeply embedded in close relation to apices of
incisors. 15.4.1 Radiographic Features to Consider
3. Intermediate position
• Crown between lateral incisor and first premolar roots. • Labiopalatal position of the canine relative to the erupted
• Crown above these teeth with crown labially placed teeth—either labial, palatal or directly above the teeth.
and root palatally placed or vice versa. • Orientation of the long axis of the canine in relation to the
4. Unusual position adjacent teeth.
• In nasal or antral wall. • Size and shape of the canine, and its root pattern.
• In infraorbital region. • Status and health of the adjacent teeth.
15 Management of Impacted Canines 331

a b

©Association of Oral and Maxillofacial Surgeons of India

Fig. 15.1 Bilaterally impacted maxillary canine causing proclination and spacing of incisors. (a) Frontal view, (b) Occlusal view, (c) OPG
­showing impacted canines (yellow circle)

• Location and orientation of the crown and root in relation This technique can also be performed with differing vertical
to the adjacent teeth, in three dimensions (vertical, mesio- angulations (vertical parallax). There are different combina-
distal and labiopalatal). tions of parallax techniques:
• Presence of associated cyst, odontomas or supernumerary
1. Clark technique: Two intra-oral periapical radiographs
teeth.
are taken using different horizontal angulations [5].
• Curvature of the root of impacted tooth.
2. Southall and Gravely technique: One maxillary anterior
occlusal radiograph and one maxillary lateral occlusal
Going into the fine details of localization of canine is
radiograph are taken [6].
beyond the purview of this chapter. It is an area which has
3. Rayne technique: This involves differing vertical angula-
been extensively studied with regard to the various imaging
tions, with one periapical and one maxillary anterior
modalities and their advantages.
occlusal radiograph being taken [7].
Various radiographic methods are considered routinely by
4. Keur technique: This is also a vertical parallax method, in
practitioners for localization. A few of them are mentioned
which one panoramic and one maxillary anterior occlusal
below.
radiograph are taken [8].
15.4.1.1 Parallax
This was first introduced by Clark [5], and involves two 15.4.1.2 OPG
radiographs taken at two different horizontal angles, but 1. Magnification
using the same vertical angulation. Owing to parallax error, The magnification technique depends on a principle
the object that is further away appears to travel in the same known as ‘image size distortion’. According to this, for a
direction as the direction in which the tube was shifted. The given ‘focal spot’—film distance, objects that are far
object nearer to the tube appears to move in the opposite away from the film will appear more magnified than those
direction [Same Lingual Opposite Buccal (SLOB) rule]. that are closer to the film. This has been applied using
332 G. Varghese

OPGs for the impacted canine. (Wolf and Matilla [9]; Fox
et al. [10]). In the OPG, if a canine looks bigger as com- Reason for Surgical Removal of Impacted Canines
pared to the adjacent teeth in the arch or the contralateral • Associated cyst/tumour with the impacted tooth.
canine, it is probably located closer to the tube (palatal). • Development of caries.
If it is relatively small, it is located further away from the • For prosthetic replacement.
tube (labial). This method can be applied effectively only • For orthodontic reasons.
when the canine is not rotated, does not touch the incisor • Resorption of roots in adjacent tooth.
root and the incisor is not tipped [11]. • Malalignment of adjacent teeth.
Kuftinec [12, 13] asserts that if the canine’s cusp is • Pain referred to other regions.
mesially at the root of the lateral incisor, the impaction
is probably palatal but if the cuspid is found overlap-
ping the distal half, a labial impaction is more
probable.
2. Chaushu et al. [14] stated that a single panoramic radio- Treatment Options for Impacted Canines
graph could be used to assess the mesiodistal dimensions 1. Observation.
of the canine and the ipsilateral central incisors. The 2. Surgical exposure.
canine would be palatally placed if the ratio of the sizes 3. Surgical exposure and orthodontic traction.
between the canine and the central incisors is 1.15 or 4. Surgical removal.
greater.
3. Katsnelson [15] et al. suggested a technique that used
a horizontal line that extended from the mesiobuccal
cusp tip of the right and left maxillary first molars, 15.5 Modalities of Management
along the long axis of the impacted canines. The degree of Impacted Canine
of inclination of the canine as compared to the midline
is recorded. If the inclination is greater than 65°, the The impacted maxillary canine may be managed by several
canine is 26.6 times more likely to be buccally placed different techniques. The chosen method would depend on the
than palatal. degree of impaction, age of the patient, stage of root forma-
tion, presence of any associated pathology, dental condition of
15.4.1.3 Computed Tomography the adjacent teeth, position of the tooth, patient’s willingness
Computed Tomography readily provides excellent tissue to undergo orthodontic treatment, available facilities for spe-
contrast and eliminates blurring and overlapping of adjacent cialized treatment and patient’s general physical condition.
teeth [16]. However, since CT exposes the patient to a high
dose of radiation, the unfavourable relationship between cost 1. Extraction of primary canine.
and benefit to the patient determines its use only in particular This method is as an interceptive form of management.
cases, such as in the presence of craniofacial deformities. CT Extraction of the deciduous tooth may be considered when
makes it possible to easily identify the position of impacted the maxillary permanent canine is not palpable in its nor-
teeth and evaluate precisely the location of nearby anatomi- mal position and the radiographic examination confirms
cal structures and identify any root resorption in the adjacent the presence of an impacted canine. However, this treat-
teeth. ment will not necessarily correct the problem. Surgical
intervention may be required if the permanent canine fails
15.4.1.4 Cone Beam CT to erupt within one year of the deciduous extraction.
Conventional CT imaging is associated with high radiation 2. No treatment—Leave the tooth in situ.
dose and high cost. Cone Beam Computed Tomography In some asymptomatic cases, no treatment may be required
(CBCT) have been used instead for localization of the apart from regular clinical and radiographic follow-­ up.
impacted canine. As CBCT uses cone-shaped radiation, the There is a small risk of follicular cystic degeneration,
radiation dose is significantly reduced, and a high spatial although the incidence of this is unknown. Rarely, odonto-
resolution is achieved [17, 18]. genic tumours may develop in relation to the impacted tooth.
15 Management of Impacted Canines 333

3. Surgical exposure of the tooth. 15.5.1.1 Procedure

This technique may be used in cases where there is 1. Palatally positioned canine
enough space for the canine to erupt, and where the root The location of the crown of the impacted canine may be
formation is incomplete. Surgically exposing the crown determined by radiographs. The possible position of the
of the canine may allow it to come into position by nor- crown is determined, and a cruciform incision made over
mal eruptive forces. this. Along the incision arms, flaps are elevated on four sides
4. Surgical exposure and orthodontically assisted eruption. so that the crown is uncovered. The flaps may be excised. If
This is the most appropriate approach for an impacted there is haemorrhage, it can usually be controlled by pressure
canine. For attempting this technique, the case must fulfil application. If there is any bone overlying the crown, it is
the following criteria: removed and sharp edges are smoothened so that the crown
(a) The impacted canine must be favourably positioned. lies in a saucer-shaped bony cavity. To prevent soft tissue
(b) The patient must be compliant with both surgery and regrowth over the exposed crown, a pack (such as a perio
long term orthodontics. pack or roller gauze impregnated with iodoform or antibiot-
(c) The patient must not have associated medical ics) may be inserted or sutured in place. Another alternative
problems. technique is to use a crevicular incision, expose palatally and
5. Surgical removal of the impacted tooth. place orthodontic brackets as shown in Fig. 15.2.
This technique is preferred for teeth that are in an unfa- 2. Labially positioned canines
vourable position, and which are likely to cause problems Any one of the following techniques may be employed
in the future. It may also be considered when a patient is depending on the depth and position of the impacted tooth:
not willing for orthodontic treatment or cannot afford it, (a) Creating a surgical window/Gingivectomy: This is
even if the impacted tooth is in a favourable position. done if the tooth lies just underneath the gingiva. The
6. Surgical repositioning/Autotransplantation. overlying soft tissue is simply excised to expose the
Impacted canines that are malpositioned, but have a crown.
favourable root pattern (without hooks or sharp curves) If the impacted canine is close to the alveolar crest,
may be considered for autotransplantation into the dental or if a broad band of keratinized tissue covers the
arch. This may be done by utilizing the socket of decidu- tooth, a surgical window may be created. Gingivectomy
ous canine or first premolar, depending on the amount of may be done when it is possible to uncover at least one
space needed and available.

15.5.1 Surgical Exposure of Impacted Canines

Surgical Exposure Techniques

• Gingivectomy and exposure of crown/ surgical

window.
• Closed eruption method (Repositioned flap) [19, 20].
• Apically repositioned flap technique (window flap)
[19, 20].
• Tunnel Technique [21].

Various studies have compared the effects of the different

exposure techniques in the periodontium; however, a consen-
sus is yet to be reached [22–24].
Chapokas et al. in 2012 have brought out a useful classifi- ©Association of Oral and Maxillofacial Surgeons of India
cation of maxillary canine impactions based on which the
exposure technique may be decided [25]. Fig. 15.2 Exposure of a palatally impacted canine
334 G. Varghese

half to 2/3 of the crown, leaving at least 3 mm of gin- applied as needed for the tooth to erupt. Drawback of
gival collar. Usually in these cases, the tip of the this technique is that the tooth cannot be inspected
impacted tooth lies near the cemento-enamel junction directly once the flap has been sutured (Fig. 15.4).
of the adjacent tooth (Fig. 15.3). (c) Apically positioned flap: In cases where the cervical
(b) Closed eruption technique: If the impacted canine portion of the crown does not lie within the attached
lies in the middle of the alveolus, near the nasal spine, gingiva, removal of the soft tissue may cause the
or high in the buccal vestibule or the palate, this tech- attached gingiva to be lost. Later on, this can lead to
nique may be indicated (Vermette et al., 1995) [19]. periodontal problems. In such a case, it may be better
A flap is first elevated over the area of the impacted to use an apically repositioned flap.
tooth. If necessary, the crown is then exposed after The flap is designed in such a way that vertical
removal of the overlying bone. An orthodontic incisions are placed on the soft tissue at the distal
bracket may be bonded to the crown and to the side of the lateral incisor and at the mesial side of the
bracket, a traction wire is affixed. The flap is then first premolar. Then a horizontal incision is made that
sutured, with the traction wire left exposed to the oral links the two vertical incisions. Subsequently, after
cavity. Sufficient time is given for the flap to undergo locating the crown of the impacted tooth, the flap
initial healing. Later on, the traction wire may be may be sutured back into at the apical end, while the
connected to an archwire and optimal force may be crown is exposed to the oral cavity (Fig. 15.5a, b).

©Association of Oral and Maxillofacial Surgeons of India

Fig. 15.4 Closed eruption technique for labially impacted canine

©Association of Oral and Maxillofacial Surgeons of India

Fig. 15.3 Exposure of labially impacted canine by surgical window

technique

a b

©Association of Oral and Maxillofacial Surgeons of India

Fig. 15.5 (a, b) Schematic diagram of apically positioned flap for exposure of a labially positioned crown. (a) Incision, (b) Suturing
15 Management of Impacted Canines 335

15.5.2 S
 urgical Removal of Palatally Impacted 15.5.2.2 Procedure (Fig. 15.7a–d) (Fig. 15.8a, b)
Maxillary Canines The incision is initiated in the gingival margin on the palatal
side from the ipsilateral first premolar and, depending on the
If the impacted maxillary canine is in an unfavourable posi- position of the impacted tooth, is extended up to the contra-
tion, and cannot be brought into normal occlusion, it should lateral lateral incisor or premolar.
be removed earlier rather than later. This is because increas- In cases of unilateral impaction, instead of extending the
ing age increases the difficulty of the procedure, and by incision to the contralateral side, a vertical incision may be
removing early, damage to the adjacent structures may be given in the mid palatal region. In situations where there is
minimized. bilateral canine impaction and both teeth are close to the
midline, the incision should always extend between the first
15.5.2.1 Surgical Anatomy or second premolars of both sides (Fig. 15.8). Elevation of a
The impacted canine is separated by a thin layer of the bone single palatal flap not only avoids sloughing but also pro-
from the maxillary sinus and nasal cavity (Fig. 15.6). vides adequate visualization. This method may pose a risk of
Infrequently, this bone may be absent. In these cases, the risk haemorrhage from the nasopalatine vessels which can, how-
of tooth or root displacement into the maxillary sinus is high. ever, be controlled by pressure pack or by electrocautery.
It is also not uncommon to have the likelihood of creating a The mucoperiosteal flap is then reflected to reveal the
communication between the oral cavity and antrum, which palatal bone and the tooth. Division of the nasopalatine ves-
may lead to post-operative nasal bleeding. sels and nerve may be done for further exposure.

Fig. 15.6 Surgical anatomy

of maxillary canine area. Note Nasal cavity
the close relationship of the
root of the impacted canine to
the floor of the maxillary
sinus and nose
Maxillary sinus

Palatine nerves & vessels

©Association of Oral and Maxillofacial Surgeons of India

336 G. Varghese

Fig. 15.7 (a–d) Schematic

diagram showing steps in the a b
surgical removal of palatally
positioned impacted maxillary
canine (a) Reflection of the flap,
(b) Removal of bone to expose
the crown, (c) Sectioning of the
crown, (d) Removal of the root

c d

©Association of Oral and Maxillofacial Surgeons of India

Fig. 15.8 (a, b) Palatal flap a b

elevation for exposure of
bilaterally impacted palatally
positioned canine. (a) Flap
outlined from the second
premolar on one side to the
second premolar of the opposite
side, (b) Following reflection of
the mucoperiosteal flap, multiple
drill holes are placed in the bone
overlying the crown. These drill
holes are then connected together
to remove the bone thereby
exposing the crown

©Association of Oral and Maxillofacial Surgeons of India

15 Management of Impacted Canines 337

a b

©Association of Oral and Maxillofacial Surgeons of India

Fig. 15.9 (a, b) Incisions for removal of labially placed canine. (a) Semilunar incision, (b) Trapezoidal (3 sided) incision

The crown of the tooth may be visible occasionally, or 15.5.3 S

 urgical Removal of Labially Positioned
a bulge may be felt. Bone around the area is removed with Impacted Maxillary Canine (Fig. 15.9a, b)
bur, taking care to protect the roots of the adjacent teeth (Video 15.1)
from damage. Once adequate bone is removed, a groove is
prepared on the mesial side and an elevator may be 15.5.3.1 Incision
inserted into it. An attempt is made to luxate the tooth. A semilunar incision (Fig. 15.9a) is usually used, and it pro-
Once the crown is moved out, it may be grasped using an vides good exposure. The lower part of the incision must lie
upper anterior or premolar forceps. Dislodgement of the at least 0.5 cm away from the gingival margin.
root apex may require a certain amount of torsion, as this For cases that are deeply impacted, triangular flaps (­ 2 sided)
is often curved. or trapezoidal flaps (3 sided) may be used, with incisions
If the tooth is resistant to elevation, more bone removal along the gingival margin and relieving incisions. (Fig. 15.9b).
is done to enlarge the opening. Tooth sectioning (odontot-
omy) may be carried out using a straight fissure bur if there 15.5.3.2 O  perative Procedure (Fig. 15.10a–f )
is any obstruction to movement (Fig. 15.7c, d). The crown (Fig. 15.11a–i)
portion is removed first. A portion of the root may then be The mucoperiosteal flap is elevated and the bone with the tooth
visualized. If not, bone is removed to expose the root. A bulge is exposed. Using a bur, a window is created over the crown
hole is created in the root and an elevator is used to engage prominence. The window is enlarged so that the entire crown is
this and remove the root. exposed, taking care not to cause damage to the adjacent tooth
Meticulous debridement and curettage is done to roots. The tooth is then luxated using an elevator.
remove the tooth follicle. Saline irrigation is used to clear If there is any resistance during elevation, the tooth must
out bone debris. The flap is replaced and sutured into be sectioned, so that the fragments can be removed easily. If
position. It is held in close contact with the palatal bone three fragments are created, the middle one may be removed
by pressing a gauze pack with the dorsum of the tongue, first, and the remaining two fragments may be elevate using
for an hour or two. Healing follows without any the resultant space (Fig. 15.10a–f).
complications. The area is carefully debrided and checked for a residual
To decrease chances of hematoma formation, a prefabri- follicle, which must be removed. The mucoperiosteal flap is
cated clear acrylic plate may be used to cover the palate repositioned and sutured (Fig. 15.11a–i) shows the localisa-
post-­operatively. tion and surgical removal of a labially positioned impacted
maxillary canine.
338 G. Varghese

Fig. 15.10 (a–f): Schematic diagram

a b
showing surgical removal of labially
impacted maxillary canine. (a) Impacted
maxillary canine. Note the relationship of
the cuspid to the roots of the adjacent teeth,
nasal cavity and maxillary sinus. (b)
trapezoidal mucoperiosteal flap reflected.
(c) Drill holes placed in the cortical plate
overlying the crown so as to expose the
crown, after the full exposure of the crown,
elevator is applied beneath the crown to
mobilize the tooth, (d) If the tooth is
resistant to elevation, the crown is sectioned
using bur and it is removed, (e) Cavity
created following removal of crown, (f) The
root is moved into the space created by the
removal of the crown and it is then removed

c d

e f

©Association of Oral and Maxillofacial Surgeons of India

15 Management of Impacted Canines 339

15.5.4 Removal of Maxillary removing an impacted canine that has its root oriented labi-
Canine in an Intermediate ally and crown palatally.
Position (Fig. 15.12a–h)

The impacted maxillary canine may be located in an inter-

mediate position, with the root oriented labially and the Complications of removal of maxillary canines:
crown palatally, or vice versa. Removing a maxillary canine • Perforation through the nasal or antral mucosa.
in the intermediate position may be challenging and may • Tooth or root displacement into the maxillary sinus
take more time as it may require a labial and palatal • Haemorrhage
approach. The risk of damaging adjacent teeth is also • Adjacent tooth root damage
higher with teeth in an intermediate position. CBCT or CT • Fracture of apical third of the root of the impacted
scan is very useful to locate the exact position of such a tooth.
tooth. Figure 15.12a–h illustrates the steps involved in

a b

Fig. 15.11 (a–l) show the clinical and radiographic images of the steps structures such as maxillary antrum, nasal floor and nearby teeth. (c)
in removing a labially impacted canine by odontectomy. Bilaterally Sagittal view, (d) Coronal view, (e) Axial view, (f) 3-D view. Steps in
impacted maxillary canines (a) Intra-oral right lateral view, (b) OPG the surgical removal of impacted 13. (g) Incision marked, (h)
showing 13 in inverted position (yellow circle) with close proximity to Mucoperiosteal flap reflected, (i) Tooth division done, (j) Tooth
maxillary sinus and impacted 23 (in red circle). CT of the same patient removed and debridement (k) Suturing completed, (l) Specimen
showing the relationship of the inverted 13 (yellow circle) to adjacent
340 G. Varghese

e f

g h i

j k l
©Association of Oral and Maxillofacial Surgeons of India

Fig. 15.11 (continued)

15.5.5 M
 anagement of Impacted Mandibular these teeth retain their original innervation, which is
Canines important to consider while administering local
anaesthesia.
Impacted mandibular canines are not as frequent as maxil- The diagnosis of an impacted mandibular canine is simi-
lary canines, and are usually found in a labial position. lar to that of the impacted maxillary canine, and it presents
However, they may occasionally migrate to the mental with similar features. These include retained primary teeth,
protuberance or even the lower border of mandible, where proclination/displacement of adjacent incisors or clinical
they can lie in a transverse position. They can also drift to features associated with cyst formation. Impacted canines
the opposite side of the mandible, referred to as transposi- may not be associated with any symptoms, and may be acci-
tion/transmigration of the canine. It must be noted that dentally discovered during the routine radiographic exami-
15 Management of Impacted Canines 341

Fig. 15.12 (a–h) Schematic a b

diagram showing the steps in the
surgical removal of impacted
maxillary canine with root on the
labial side and crown on the
palatal side. (a) Outline of the
impacted canine and its relation
to the roots of the adjacent tooth.
Note the semilunar incision
marked, (b) Outline of the crown
of the impacted canine on the
palatal aspect, (c)
Mucoperiosteum reflected on the
buccal side overlying the bone to
be removed and the root of the
impacted tooth sectioned. An
elevator is being used to dislodge
the root, (d) Empty socket after c d
removal of the root. (e) Palatal
flap is outlined and reflected.
Bone covering the crown of the
impacted tooth is removed using
bur. (f) Using a blunt instrument
placed in the socket of the tooth
on the buccal side, pressure is
exerted on the cut end of the
crown (see black arrow) to push
the crown palatally, (g) Empty
socket on the palatal side after
removal of the crown, (h) Flap is
replaced back and suturing
completed

e f

g h

©Association of Oral and Maxillofacial Surgeons of India

342 G. Varghese

nation, or during the investigation of other dental conditions.

Sometimes, however, these teeth can cause recurrent pain Tongue

and infection.
Dalessandri et al. in 2017 opined that the most common Submandibular duct
treatment strategies for the treatment of mandibular canine
impactions are surgical extraction and orthodontic traction.
Surgical extraction and radiographic monitoring were sug-
gested for transmigrant mandibular canines: The authors pro- Sublingual gland

posed a decision tree in order to guide practitioners through

the treatment plan of impacted mandibular canines [26].
Mylohyoid muscle

15.5.5.1 Treatment Options

The impacted mandibular canine may be treated using one of
the following strategies:
Mentalis muscle
1. Observation ©Association of Oral and Maxillofacial Surgeons of India

2. Exposure and orthodontic repositioning Fig. 15.13 Surgical anatomy of mandibular canine area
3. Surgical repositioning
4. Surgical removal of the tooth—The impacted mandibular
canine may be removed if one of the following conditions
15.5.5.4 Complications of Surgical Removal
is present:
These Include the Following
(a) Pathology such as follicular cyst or tumour in rela-
tion to the impacted tooth.
1. Injury/mobility of the adjacent tooth—This can occur
(b) Orthodontic reasons, such as the need to move an
during bone removal, if the supporting bone of the lateral
adjacent tooth into the area of impaction.
incisor is removed accidentally. This is managed by
splinting the lateral incisor to the adjacent tooth.
15.5.5.2 Surgical Anatomy (Fig. 15.13) 2. Mental nerve injury—If the distal vertical incision is
The bone in the mandibular canine region consists of a thick extended too far backwards and inferiorly, the mental
lingual cortex and a thin buccal cortex. The impacted tooth nerve may accidentally be severed.
usually lies mesial or distal to the actual canine region. A
buccal flap must ideally be used for surgical access, as a lin-
gual flap may not provide adequate access, and is associated 15.6 Summary
with increased post-operative morbidity. While raising the
buccal flap, the mentalis muscle insertion (at the mental The management of impacted canine teeth requires skilful
fossa) and incisive muscle insertion (at the height of the handling and careful observation on the part of an oral and
canine alveolus) are divided. maxillofacial surgeon. If any tooth is absent in the dental
arch after the normal time of eruption has lapsed, the surgeon
15.5.5.3 R  emoval of Mandibular Canine must investigate. The management of an impacted tooth is
(Figs. 15.14 and 15.15) simple if the basic principles of surgery are followed appro-
For tooth exposure, a trapezoidal (3 sided) flap is used. priately for all the teeth. The case must be evaluated care-
Alternately, a horizontal incision may be made below the fully for proper diagnosis and treatment planning. Treatment
attached gingiva. If the tooth lies close to the lower bor- planning requires a multidisciplinary approach, and the gen-
der of the mandible, an additional incision may be needed eral dental surgeon must consult with the oral and maxillofa-
extra-­orally for proper exposure. As in the case of maxil- cial surgeon, orthodontist and paedodontist for achieving
lary canine in the labial position, bone removal is done optimal results.
with bur. The tooth may be elevated in toto, or may
require sectioning if resistance is met (Figs. 15.14a–h
and 15.15).
15 Management of Impacted Canines 343

a b

c d

Fig. 15.14 (a-h) Schematic diagram showing steps in the surgical elevation unsuccessful tooth division is performed using bur, (f) Crown
removal of impacted mandibular canine. (a) Incision to raise a trapezoi- removed and more of the root exposed to create a purchase point on the
dal flap, (b) Mucoperiosteal flap reflected and the bone overlying the root using bur, (g) Root removed using an elevator applied at the pur-
crown removed using bur and chisel, (c) Crown of impacted canine chase point, (h) Closure of the incision
exposed, (d) Elevator is applied in an attempt to luxate the tooth. (e) if
344 G. Varghese

e f

g h

©Association of Oral and Maxillofacial Surgeons of India

Fig. 15.14 (continued)

15 Management of Impacted Canines 345

a b

c d

e f

Fig. 15.15 (a–m) Shows the clinical and radiographic images of the Overlying odontome exposed, (h) Odontome removed and crown of 33
steps in removing a labially impacted canine by odontectomy. Impacted exposed. (i) Sectioning of crown of 33, (j) Removal of crown and root
left mandibular canine (yellow circle) with an associated odontome (a) of 33 followed by debridement, (k) Suturing completed (l) Specimen of
OPG showing impacted 33, (b) CT Axial view, (c) Coronal view, (d) 33 with follicle and odontome, (m) Pressure dressing applied to reduce
Sagittal view. (e) Intra-oral view, (f) Mucoperiosteal flap reflected, (g) oedema
346 G. Varghese

g h

i j

k l

Fig. 15.15 (continued)

15 Management of Impacted Canines 347

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