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The Orthodontic Treatment of
Impacted Teeth

AD R IA N BECK ER BOS, LOS RCS, 000 Re ps

Clinical Asso ciat e Professo r, Depar tment of O rtho dontics, Hebrew Unive rsity-
Hadassah Schoo l of Dental Medici ne, fou nd ed by the Alpha Om ega Fratern ity,
Jerusalem, Israel

MARTIN DUNITZ
CI M.. rtin Dumtz Ltd I99S
Fi ~t published in the Unikd Kingd om in 1998 by

~1 .. rtin Dunitz Ltd

Tbcl.ivcrv House
7-9 Pratt Street
t..o ndufl NW I OAE

All rights reserved. No pari of th is publica tion milY b..• reproduced , ~tnrt-'d in .1 retrieva l
system, o r tra nsmitted, in any form o r by an y means , elect ronic, nwc h.m ic.ll, pho tocopying,
roc ...rd ing or o the rwise without the prior pe rmission of the publisher o r in acco rdance wi th
ttlt' provisions of th.., Co pyright Acl 19118, or under the• te rms of any licence pcrmitti n~
limited copymg issued by th.., Copyrigh t Licensing Agen '-1', 33-34 Alfred PIaU', London
WC IEroP.

,\ CIP catalog ue recor d for th i~ btxl k is a\'ailable from the British Library

ISBN 1115317 32f! 2

Co mposition t>y w earsct, Boldon, Tyne and Wear

Pri nted an d bo und in Singapore
 CONTENTS

Preface vii

1. Gene ral principles related to the d iagnosis an d treatment of impacted

teet h __ 1

2. Rad iograph ic met hods related to the diagnosis of impacted teeth 13

3. Surgical expos ure of impacted teeth 25

4. Treatmen t strategy 43

5. Maxillary centra l inciso rs , 53

6. Palatally impacted canines 85

7. Other sing le teeth 151

8. Impacted teet h in the adu lt 179

9. Cleido crania l d ysplasia 199

Index 231
 PREFACE

There can be littl e question th at the treatment sibility tow ard s the subject o f im pa cted teeth
of impacted teeth h as caught the imagination to others, accounting for the popularity of
of many in the den tal profession . The cha l- othe r mod alities of treatment. The sub ject ha s
lenge has, over the years, been taken up by become someth ing o f a Cinderella of den-
the general p ractitioner and by a n umber of tis try.
dental specialis ts, inclu d ing the paedodonttst, \Vith in the orthodontic /surgica l modality,
the pe riod on tist , the orthodontis t and, most much room exist s fo r d eba te as to what
of all, the o ral and max illofacial surgeon . should be done first and to wh at lengths each
Each of these p ro fessionals has mu ch "i npu t" of the two spe cialties rep resen ted should go
10 offer in the resol ution of the im me d iate in the zea lous pursuit of its allotte d portion of
problem and each is able to show some fine the proced ure. The literatur e o ffers scant
resu lts. Howeve r, no sing le ind ivid u al on th is information and guidan ce to resolve these
specialist list can completely and successfully issues, leaving th e practitioner to fen d for
treat more than a few of these cases, witho ut him / he rself, wi th a problem th at has ram ifi-
the assistance of one or mo re of others of cations in several different specialist realms .
his/her colleagues on that list. Thus, the type This boo k di scusses the many aspe cts of
of treatment prescribed may depend u po n impa cted teeth, inclu d ing thei r prevalence,
which of these d enta l specialists sees the ae tiology, d iagnosis, treatment tim ing , treat-
patient firs t an d the level of his/her experi- ment and progn osis. Since these aspects d iffer
ence with the p roblem in h is / her field. Such between incisors and can ines, and betw een
treatmen t may involve su rgica l exposu re and these and the other teeth, a separate cha p ter is
packing, it may involve or thodontic space devoted to eac h. The ma terial presented is
open ing, perhaps auto-transp lantation, or a based on the find ings of clinica l research that
surgical dentoal veolar se t-down procedure, h as been car ried out in Jeru salem by a small
or even just an abnorma lly angulated pros- grou p of clinicians, over the pa s t 15 years or
thetic crown recons tru ctio n . so, at the Heb rew Uni ve rsity - Hadassah
Experience has com e to show tha t the School o f Dental Medicine, fou nd ed by the
orthodontic /su rgical mo da lity has the poten- Alpha O mega Frate rn ity and from the glean-
tial to achieve the mo st sati sfa cto ry resu lts, in ings of clinical experience in the treatmen t of
the long term. Despite this, many or thodon- many hund red s of my patients, yo ung and
tists have ignored or ab rogated their respon- old .
viII ORTHODONTIC TREATMENT

An overall an d reco m mended approach to and Max illofacial Surgery a t H ad assah, wi th

the treatment of impacted teeth is presented whom a modus operandi has been devel-
an d emphasis is placed on the periodontal oped, in the treatment of our patients.
prognosis of the results. Among the ma ny Professor Arye Shteye r. Head of the
ot her aspects of this book, the in tention has Depa rtment and, su bse quently, Professor
bee n to propose ide as and p rinciples that ma y Josh ua Lustmann have educated me in the
be use d to resolve e ven the most d ifficult finer point s of surgical p roced ure an d ca re
im pact ions, e m p loying orthod ontic au xil- while, a t the sam e time, ha ve demonstrat ed a
iaries of many different types a nd designs. res pec t an d under s tand ing of the needs of the
No ne of these is speci fic to any particu la r or thodontist at the time of su rger y. I am
orthodo ntic appliance system or trea tmen t gra tefu l to them for their collabora tion in the
"p hilosophy", notwithsta nd in g the a u tho r's wri ting of Ch apte r 3.
own pe rsonal p references, w hich will become Dr llana Brin rea d the original manuscript
ob vious from man y of th e illustra tions. These a nd made so me use fu l suggestions, w hich
auxiliaries may be· used w ith equal faci lity in have been included in the te xt. I am gratefu l
virtually an y a pplia nce system wit h , v h ich to Dr Alexander Va rdimon for his comments
the reader may be fluent. The only limitations reg arding the use of magnets and to D r Tom
in the use of these ideas and principles are Weinberger for the discussions that we have
those im po se d on the reader by h is /her own had regard in g seve ral issues ra ised in the
im agi nation and willi ng nes s to adapt. book. My wi fe, Sheil a, read the earlier manu-
The o rthodon tic man ufacturers' catalogues scrip ts an d mad e ma ny importa nt recommen-
are replete wit h the more commonly and rou- da tions an d corrections. More than a ny one
ti nely use d attachmen ts, ar chwircs a nd auxil- else. sh e e ncour aged me to keep w ri ting d ur-
ia rics, which Me offered to the p rofession in g the many months when other a nd more
wi th the aim (If strea m lining the busy prac- press ing res ponsibilities cou ld ha ve been
tice. These cata log ue items h ave not bee n tai- used as ju stifiable excuses for putting the pro-
lored to the demand s of the clinica l issues ject as ide.
that are raised in this book. Thes e issu es, by My collea gu es, D r Monica Ba rzel. Dr
their very natu re, are exceptional, problem- Ycc heved be n Basse t, Dr Ga bi Engel, D r
at ic a nd often un ique, while occu rri ng along- Doron H are ry. Dr Tom Weinbe rge r, Professor
side and in ad dition to the routine . Among Yerucham Zilbcrman , and my former gradu-
the more common limitations self-imposed by ate stud ents Dr Yossi Abed, Dr Dror
many orthodontists has been the d isturbing Eiscnbud. Dr Syl via Geron, Dr Im ma nu el
tre nd to rely so co mpletely upon the use of Gillis, Dr Ra ffi Romano a nd D r Nir Sh pack,
p refo rmed an d p re-welded a ttachments that have provided me w ith several of the illustra-
they ha ve forgotte n the arts of weld ing and tions inclu ded he re a nd I am inde bted to
soldering a nd no longer carry the necessary the m.
mo des t equ ipment. Th is then res tricts one's [ am g ra tefu l, too, to Ms Alison Ca m pbe ll,
practice to us ing only wh at is a vailab le and Co mmission in g Editor a t Martin Dunitz
sufficiently commonly u sed to make it com - Publishers and to Dr Joanna Batragel,
mercially w orth while for the manu facturer to Te chnical Editor, for their con structive a nd
p roduce. By conse nting to this unhea lthy s itu - p rofessio nal critiq ue of the manuscrip t, w hich
at ion, the orthodontist is agreei ng to work contribu ted so mu ch to its u ltim a te forma t. I
w ith "one h and tie d behind his / he r back" also thank Naomi and D udley Rogg, of the
a nd tr ea tment results will inevitably suffer. British Hernia Centre, for the compu ter an d
I acknowledge and am g rateful for th e he lp o ffice facilities that they p laced at m y disposal
given me by se veral colleagues; in the prepa- during my short sabbatical in London, in the
ration of thi s manuscript. An e xcellen t p rofes- latter stages of the prepa ra tion of the w ork for
sional relationship has been established a nd publi cat ion.
has withs tood the tes t of time, w ith two Perm ission to use illust ra tions from my
se nio r members o f the Department of Ora l own ar ticles that were pu blished in va rious
PREFACE

learn ed jou rnals was gra nted by the publish- part 2 - a Trea tment Pro tocol for the
ers of those journals or by the owners of the Orthodontic and Su rgical Modality. A m. I.
copy right, as follows> Orthod. Dentojac. Orttiop. 111:173-183, with
Figu re 5.13 was reprinted from Peret z B, kind permi ssion o f Mosby-Year Book Inc., SI.
Becker A, Cho sak A (1982). The repositioni ng Louis, MO, USA.
of a traumatically-intruded mature rooted Figure 6.35 was reprinted from
permanent incisor with a removable appli- Kornh au ser, S., Abed , Y., Ha rary, D. and
ance. [Pcaodont, 6:343-354, with kind permls- Becker, A. (1996), The resolu tion of pa lata lly-
sion of the Jou rnal of Ped od on tics Inc. impacted can ines using pa latal-occlusal force
Figu res 5,4 & 5.12 were reprinted from from a buccal auxiliary. A m. /. Orthod.
Becker A, Stern N, Zelcer Z (Copy right 1976) Dentofac. OrthoJ'. 110:528-534, with kind pe r·
Utilizat ion of a dil acerated inciso r toot h as its mission of Mosby-Year Book lnc.. St. Louis,
ow n space maintainer. f. Dmt. 4:263·264, with MO, USA.
kind permiss ion from Elsevier Science Ltd ., I am very thankful for their coope ration
The Boule vard, Langford Lane, Kid lington and for their agreement.
OX5 1GB, UK.
Figures 9.8-9.14 were reprin ted from Ad rian Becker
Becker, A., Shteyer. A, Bimstcin, E. and [crueolein
Lustmnnn, J. (1997), Cleido cranial dys plasia:
1 GENERAL PRINCIPLES RELATED TO
THE DIAGNOSIS AND TREATMENT OF
IMPACTED TEETH

CONTENTS • Dental age • Assessing dental age • When is a t ooth co nsi dered to be
Impacted? • Imp act ed t eeth and loc al space lo s s • Who se problem? • The timi ng of
th e surgical intervent ion • Patient motivation and th e orthodo ntic option

In order to und erstand w hat an im pacted chronologie ag e, wh ich is calculated d irectly

toot h is and whether and when it sho uld be from th e birth d ate, to give furthe r info rma-
treated , it is necessary to first define our per- tion regarding a particul ar ch ild 's growth and
ception of normal development of the denti- development.
tion as a whole and the time frame within Dent al age is another of these pa rameters,
whi ch it operates. and is a particularl y relevant and importan t
assessment, wh ich is used in advisin g p roper
orthodontic treatment tim ing. Schou r and
DENTAL AGE Massier (1941), No lla (1960), Moorrce s et al
(1962, 1963) and Koyourndjis ky-Kaye et al
A patient 's growth and develop men t may be (1977) have d rawn u p tables and d iag ram-
faste r o r slower th an av erage, and we may matic cha rts of stages of development of the
assess h is or her age in line with this develop- teeth, from initia tion of the calcification
ment (Krogman, 1968). Th us a child may be p rocess th rou gh to the co mpl etion o f the roo t
rela tively tall, so tha t his mor p hological age ap ex of eac h of the teeth, together with the
milY be consid ered to be advanced. By study- av erage chronolog ie ages at wh ich each s tage
ing rad iographs of the p rogress of oss ification occur s.
of the epiphysea l cartilages of the bones in the Eru p tion of each of the va riou s groups of
han d s of a young patien t (carpal ind ex) and tee th is expe cted at a p articul ar tim e but this
comparing this w ith average da ta val ues for may be influe nced by local factors, wh ich
child ren of the same age, we are in a position may cause pn'mature or delayed eruptio n,
to assess the child 's skeletal maturity. with a w ide time-span d iscrepancy. For this
Similarly, there is a sexual age assessment reason, eruption time is an unreliable method
related to the appearance of primary and sec- of assessing den tal age.
ond ary sexu al featu res , a mental age assess- With few excep tions, ma inly related to
ment (lQ tests ), an assessment for behaviou r frank p athology, root development proceed s
and another to measure a child' s sel f-conce pt. in a fairly consta nt manner - usually reg ard -
These ind ices are used to complement the less of tooth eru ption or the fate of the
2 THE ORTHODONTIC TREATMENT OF IMPACTED TEETH

de cidu ou s p redecessor. It therefore follows ha vin g complet ed most of their expected rout
that the usc of tooth develop ment as the bas is length, then the ch ild's d ent al and chrono-
for dental egc assessment, as determined by logic ages coincide (Fig. 1.1). The dec id uous
exa mination of pe riapical or panoram ic tee th have not shed na turally, because of
Xc ravs, is a far more accurate too l. insu fficien t resorption of their roo ts. As s uch ,
Thus we may find that a chil d 11-12 years we have to presume tha t they p rovide the
old has four erupted first pe rmanent molars imped imen t to the no rm al eruption of the
and all the pe rmanent incisors only, wit h pe rmanent teeth . The ir pe rm an en t successors
deci duous can ines and mo la rs com pleting may then s trictly be defined as having de-
the erupted den tition. We re the p racti tioner lap..-d eruption. Un der these ci rcu mstances, it
merel y to run to the eruption chart, he wo uld would be a logical decision to extract the
no ll' that at this age all the pe rmane nt canine s decid u ou s tee th, on the grou nds that thei r
and premolars shoul d have erupted and he con tinued p resence defines them as over-
would concl ude that the 12 deciduous teeth retained.
are over-retained and should be extracted! The second possibility is that the radio-
Howeve r. two possibi lities ex ist in this situ- graphs reveal relatively little root d evelop-
ation, and the radiog raphs must be studied ment, corresponding more closel y perhaps to
carefully to distinguish them from each other. the p icture of the 9-year-old chi ld on the too th
In the event that the radiographs show the development chart (Fig. 1.2). The child's birth
unerupted permanent canines and p remolars certi ficate ma y indicate that he is 12 years of

Figu re 1.1
Advanced root development o f the canines and premO"
lars, de finin g thl'b\.' teeth ,IS exhibiting delayed eruption.
Extra ction uf the deciduous t"o.'Ih is indicated.

Figure 1.2
An tt -yea r-old patient wi th roo t development defining
de n ial age as 9 yea rs. Extra ction is con tra ind ica ted .
GENERAL PRINC IPLES RELATED TOTHE DIAGNOSIS AND TREATMENT OF IMPACTED TEETH 3

ag e an d this ma y well be su pported by h is

bo dy size and d eve lo pmen t an d by h is int elli-
ge nce. Never theless, his de ntition is that of a
ch ild 3 ye ars younger, defin ing h is d enta l age
at 9 years. Extraction in the se circu ms tances
wou ld be the w rong line of treat ment, since it
is to be expected tha t the se tee th will shed
normally at the ap pro pr iate delltal age, and
early extraction may lead to the unde sired
seq uelae that are characte ristic of early extrac-
tion . performed for any other reason.
From this d iscu ssion , we are no w in a posi-
tio n to d efine the terms that we shall use
th rou ghout this text. The first refers to a Figu re 1.3
retained deciduous tootu. which ha s a pos itive The mand ibular left second deciduous molar is retained
connotation an d which may be d efined as a (extraction co neremdjcated), since the roo t dt>,velopmen t
tooth tha t rem ains in place beyon d its normal of its su ccessor is ina d eq uate for normal e ruption. The
sh ed d ing time . ow ing to ab sence or retarded right ma xillary d eciduou s canine. in oonlrast, is over-
d evelopment of the pe rmanent successor. By ret ained (extra ction advised), SIf\Cl' its long-rooted SUCCl.-~

contrast, an d with a ne gat ive conno tation, an sor has delayed e ru pti on .
coer-retained decid uous tooth is one wh ose
unerupted pe rmane nt successor exhibits a
roo t developmen t in excess of three-qu art ers
of its expected fina l length (Fig. 1.3).
A perma nent toottt unth lida ycd em ptio" is an signs of the p resence of a too th are seen
uneru pted toot h whose roo t is developed in shortly after initiation of calcificatio n of the
excess o f this leng th and whose spontaneo us cusp tips . Thereafte r, o ne ma y atte mpt to
eruption ma y, in time. be expected. A too th deline ate the completed crown form ation,
tha t is not expec ted to eru pt in a reasonable variou s degrees of foo l fo rmation (u sually
time in these circumstanc es is termed an ex pressed in fractions ), through to the fu lly
impacted tooth, closed roo t ape x. By and large, orthodontic-
Den tal age is not assessed \v ith referen ce to treatment is perfo rmed 0 11 a relative ly older
a single tooth on ly, s ince some vari ation is sec tion of the ch ild popul ation , and, as such,
found within the differen t groups of teeth. the stag es of root (ormati on are u su ally the
An all-ro und assessment must be made, and onlv factor s that remain relevant.
on lv the n Gill 01 defin itive de terminatio n be The stage of too th developmen t that is easi-
off~red. However, in d oing this, one shou ld est to de fine is tha t rela ting to the closure of
be wary of includi ng the maxillary lateral the roo t apex . For as lon g as the d enta l papilla
incisor s, th e m andibular second premola rs is di scern ible at the roo t end , the apex is ope n
and the third molars, w hose de velo pm en t is and still develop ing. O nce fully close d, the
no t always in line wit h that of the rem aining papi lla d isap p ears an d a contin uous lamina
teeth (Ga rn et al, 1% 3; Sofaer, 1970). dura is seen to intimately follow the root out -
line. The accu racy w ith w hich one milY assess
fractions of an unm ea surable and merely
'expected ' final root length is far less reliable
ASSESSING DENTAL AGE and much more s ubject to ind ivid ual obse rver
variation .
When study ing fu ll-mouth pe riap ical radi o- Roo t development of the permane nt teet h is
graphs or a panoram ic film, there are seve ral comp leted approximately 25 - 3 ye ars after
criteria tha t may be used in the estim ation of normal eruption (Nella. 1960). This allo ws us
tooth development. The first radi ogr aph ic to conclude tha t, at the age of 9 yea rs, the
4 THE ORTHODONTIC TREATMENT OF IMPACT ED TEETH

mandi bula r incisors (w hich erupt at age 6) will By this method, we ma y a rr ive a t a tenta-
be the first teeth to exhib it closed apices an d tive d iagnosis for den tal age, on the ba sis of
that these will usually be closely followed by the last too th in this sequence that has a
the four first permanent molars. At 9.5 years, closed a pex (Fig. 1.4). It is no v.., important to
the mandibular lateral incisors will com plete, relate th e actual development of the remain-
while a t 10 and 11 years respectively, the max- ing teeth in the sequence to their expected
illary central and normally developing lateral development that may be d eri ved from the
inciso rs w ill be full y formed. wall chart o r from tables that ha ve been pre-
Th is be ing so, when prese nted with a se t of se nted in the literature. Th is may then pro-
radi ographs, w e may p roceed to assess denial vid e co rroborative evidence in su pport of the
age by follow ing a s im p le line o f in vestiga- dental age determination.
tion, w h ich uses the dental age o f 9 yea rs as Wh en the denta l age is less tha n 9 ye a rs,
its starting poi nt and then p rog resses for- none of the pe r ma ne nt teeth w ill ha ve com-
w ards or re-traces its s te ps bac kwards, p leted their roo t de velopment, a nd the clin i-
depending upon its find ings. cian will ha ve no choice but to rely on an
If the mandibular cen tral incisor roots a re es timation of d egree of root developmen t,
com plete, w e may presume the pa tient is at d egree of cro wn completion and, in the w ry
leas t 9 years old (de nt al age), and we may young, init ia tion of crown calcif icat ion (Fig.
then adva nce, chec kin g for closed a pices of 1.5). This is mo st conveniently done by work-
firs t mo la rs (9-9.5 years), ma ndi bul ar la teral ing backwa rds from the ex pected de velop-
incisors (9.5 years), max illary cen tral incisors ment a t age 9 ye ar s and compari ng the dental
(to years ), normally developing ma xillary lat- develop ment status of the patient w ith this,
eral inciso rs (11 ye ars ), mand ibu lar cani nes beginning w ith the mandibular cen tral
a nd first premola rs (12-13 years), ma xilla ry inciso rs a nd the first permanent mo la rs. Thus,
first p remolars (13-14 yea rs), normally devel- at d enta l age 6 years, on e wou ld find one-half
opin g second p re mola rs a nd max illary to two- th ird s root le ng th of these teeth. and
ca ni nes (14-15 years), an d second molars (15 thi s could be corroborated by stu dying the
yea rs). d evelopment of the other tee th . At the sa me

Figu re 1.-1 Figure 1.5

Root apices a re closed in all fir«t molars, all mandibu lar Xo closed apices. De ntal age assessment 7.5 }'N T'5 .
and three ma xilla ry incisors, ("'eluding the monilial)' left
late ral inciso r.
GENERAL PRINCIPLES RELATED TO THE DIAGNOSIS AND TREATMENT OF IMPACTED TEETH 5

time, one sho u ld expec t une ru pted ma xillary seco nd pr emolar has an o~1l' n root apex and
central incisors wit h one-half root leng th, d eve lopment equ ivalent to ab ou t half its
mandi bular canines with on e- third roo t eventual length . O n the basis of the informa-
leng th, first p remolars with one-qu a rter roo t tion gathered , we may assess the dental age
lengt h, and so on. of the den tition as a whole to be 14 yea rs. At
As pointed ou t earlier, va ria tion occurs, the same time, we should ha ve to note tha t
and this may lead to certain apparent contra- the d en tal age of the unerupted second p re-
d iction s. In such cases, elim ina ting the ma xil- mola r wa s approximately 10 years. Ha ving
lerv lateral incisors, the mand ib ula r second mad e th is determi nation, we may now con-
premolars and the th ird molars w ill usually fid ent ly say that the second pr emolar, in-
sim plify the p roce d ure an d contribute to its d ivid ua lly, d oes no t exhibit delayed eru ption
accu racy , since these teeth are more ind ivi- and the deciduou s secon d mo lar is no t over-
d ually va ria ble co mpa red with the res t of retained, in the terminology used here.
the dentition. Ad d ition ally, un usually small Accord ingly, it wou ld not be appropriate
teeth, cun iform premolars an d man dibular to extract the deciduous too th at this time, but
incisors, and peg-shaped lateral incisors are to wait at least a furthe r 2 years, at which
mos t often to be seen developing very much time the tooth may be expected to shed nor-
later (sometimes as much as 3 or 4, years mally.
later), and should no t bt> inclu ded in the ov er- To summarize th is d iscussion, it is essential
all estimation. O ne may then present a dete r- to d iffere nt iate be tween fou r d ifferent con di-
mination for the den tition as a whole, w ith tions th at may exist whe n we encounter a
the added not ation tha t an ind ivid ual too th de ntiti on that incl udes certain deci duou s
may have a mu ch lower den tal age. tee th, inco ns istent with the patient' s chrono-
We ma y occasionally examine a I-t-ye ar-old logic age. Becau se the ens uing classification of
pa tient wh o ha s a co mplete perman en t den ti- these con di tion s is treatment o riented, the
tion. including the secon d molars, with the labelli ng of a patient with in one of these
exception that a mand ibu lar second d ecidu- grou pings ind icates the treatment that is
ous mola r is present. The radiograp hs (Fig. req ui red.
1.6) show the apices of the first molars, cen -
tral and latera l incisors, ma nd ib ular canines A late-de7.'t'/oJ'ifl~ dentition, The dental age
and premolars to be closed , wh ile the maxil- of the pa tien t lags be hind the chr ono logie
lary canines and the seco nd mo lars are almost age, as witn essed radi ogra phica lly by less
closed . Howeve r, the u neru pt ed ma ndibular root forma tio n than is to be expec ted at a
given ag e, in the entire d entition.
Typ ically, thi s will be evide nt clinically
by the continued and sy mmetrical p res-
ence of all the decid uous m olar s and
cani nes on each side of each jaw .
Extraction o f decidu ou s teeth is con-
tr aindi cated at this time.
2 Go er-retai ned deciduous Ict'/II. The dental
age of the pa tien t ma y be posit ively co rre-
lated wit h th e ch ronolog ie age, bu t the
radi ogr aph shows an ind ividu al perma-
nent tooth or tee th with we ll-d evel oped
roots, w hich rema in une rupted . Th is
tends to be local ized in a single area and
may be d ue to an ec topic siti ng of the pe r-
Figure 1.6 mane n t tooth bud, which ha s s timula ted
A late-developing left mandibular second premolar. the resorp tion o f only a po rtion o f the
(Courtesy of Dr M Baezel.) roo t o f its d ecid uous p redecesso r, bu t
6 THE ORTHODONTIC TREATMENT OF IMPAC TED TEETH

shedd ing has not occurred becau se of the ha ve been imped ed by on e of several actio-
persistence of the remaining part of the logic possibilities . Th ese in clud e such factors
root or of a second and unresorbed root. as a failure of resorption of the roo ts of a
Neverthe less, the condition ma y occa- d ecid uous too th, an ab normal e ruptive pa th,
sio nally be fou nd symme trically in a a supe rn u me ra ry too th, d ental crow d in g or a
single den ta l ar ch or in both arches. d isturbance in the e ru pti on mechan ism o f the
Extraction of the over-reta ined teeth is too th. Howeve r, obstruc tion may also res u lt
indica ted. fro m a thickened post -ext raction or po s t-
3 A normal del/ falase , with si/Ig le or multiple tr auma repair o f the mucosa (Figs 1.8<1, b).
late-dt'!.t'lopil/g p CrIIJr1 I1t' lI f leeth. This condi- No t in freque ntly, and particular ly in the
tion is com monly found in relation to the mandibular premolar region, there may be a
maxilla ry late ral incisor and the man- h istory of ve ry ea rly extraction of one or bo th
di bula r second p remola r teeth. a nd ex- decid uous mola rs. De layed or no n-e ru ption
traction of the deciduou s p red ecessor is of the premolars will occur, owin g to a thic k-
to be a voided. ened mucosa over lying the tee th . It may be
-t A combination of the abooe. Some times one possible to pa lp at e these teeth, their d istin ct
may see featu res of each of the above ou tline being clearly seen bu lging the gum for
three alte rnat ives in a single de ntition. a pe riod of year or more, although e ru ptio n
may no t occur.
The im po rtance of inte rpreti ng the d ifferen-
tial d iagnosis fo r a gi ven pa tient cannot be
overe m phasized, sin ce it ha s fa r-reach ing
effects on all th e as pe cts of diagn osis, treat - IMPACTED TEETH AND LOCAL SPACE
ment planning a nd trea tmen t tim ing for cases
wi th impacted teeth .
LOSS
A time lapse ex ists between th e pe rformance
of a su rgical procedure to remove the ca use of
WHEN IS A TOOTH CONSIDERED TO a n impaction and the full eru ption of th e
BE IMPACTED? im pa cted tooth into its p lace in the dental
a rch. The extent of th is time spa n is de pe n-
From the work of Oren (1962 ), we lea rn that
under no rmal circumstances a too th erupts
w ith a developing roo t a nd wit h a pproxi-
ma tely three-qua rte rs of its fin al roo t length .
The man dibula r central incisors and first
molars ha w ma rg inally less root develop-
ment and the ma nd ibula r ca n ines an d se cond
molars ma rgina lly mo re when they eru p t. We
may therefore ta ke this as a d iagnostic bas e-
line fro m w hich to assess the er up tion of te eth
in general. Th us, shou ld an erupted tooth
ha ve less root development (Fig. 1.7), it
would be a ppro pri a te to label it as prematurely
erupted. This will usually be the consequence
of ea rly loss of a deciduous too th, pa rticularly
one w hose ex traction w as dictated by deep
caries, with res ul tan t pe ria pical pa thology.
At the opposite e nd of the scale. we find the
unerupted tooth that e xhibits a more com- Figure 1.7
pletely de ve loped roo t. Th e no rmal eruption The left mandibular premolars are prem atu re ly eru pted.
process of this too th must be p res u med to ....ith insufficien t root d...vclo pment.
GENERAL PRINCIPLES RELATED TO THE DIAGNOSIS AND TREATMENT OF IMPACTED TEETH 7

teeth. Th is inte rvention is no less suscep tible

to the d riftin g of neigh bou ring teeth th an is
any other factor that may prod uce inte rp roxi-
mal loss of dental tissue.
With an od ontom e or su pernumerary tooth
in the pat h o f an u neru pted permanen t tooth,
vertical (and sometimes mesial or distal or
buccal or lingual) d isplacement of the per-
manent tooth is likely to be consider able.
It wo uld be conven ient if the removal of the
space-occupying body cou ld be performed,
leaving the deciduou s tee th intact, since
the deci duou s tooth would mainta in arch
integrity d uri ng the extended period of time
needed for the permanent tooth to eru pt nor -
maUy. Unfortunate ly. o ften, in orde r to gain
(.)
access to perform the desi red surgery. one or
more deciduous teeth need to be extracted.
Thi s being so. and h avin g regard for the long
distance tha t the di splaced permanent tooth
has to tra vel. space maintenance should be
rega rded as esse ntial in most cases. It sho uld
be the first or thodontic procedure to be con-
sidered in these cases and it sho uld be
ret ained u ntil full eruption has occurred.
Impacted teeth are often associated with a
lack of space in the im med iate area. This is
frequentl y due to the d rifting of ad jacen t
teeth, alth ough crowd ing of the dentition in
genera l may be the p rime cau se. In such
cases, the spon taneo us eruption of an
(b)
impacted tooth is unlikely to occur unless
adequate or, p referab ly, excessive space is
Figu n " 1.8 provid ed. It wo u ld be convenient if the exci-
(a) Th~· righ t mand ib ular second premolar was extracted sion of the associa ted pathologic entity coul d
at age 8.5 y l',lfS. (b) Seen ill age 11. the rool o f the be com fortab ly delayed un til thi s time, to
unerupted firsl premolar is alm ost com pleted . bri ng about the desire d eruption and to per-
mit this correc tive treatment to be attempted
when the root developmen t of the unerup ted
tooth is ade qu ate. However, the su rgeon will
dant on severa l factors, such as the initial d is- insist on removi ng most forms of pathology
tance between the too th and the occlusa l as soon as a tentative d iagnosis is reached, in
plane, the stage of the de velop ment of the order to obta in exami nable biopsy ma terial
particular tooth, the age of the pati ent, andthe for the establishment of a definitive diagnosis.
manne r in which hard and soft tissue may be Odontomes and su pernumera ry tee th aTC
laid d own in the healing wound . During this gen era lly conside red to be exceptions to th is
lime period, therefore, local ch anges in the ru le, and the tim ing o f their removal may be
eru pted den tition may occur as a resu lt of the mo re leisu rely cons ide red.
break in the integrity o f the d en tal arc h
caused by the surgical proced ure, such as
space loss and tipping of the adja cent erup ted
8 THE ORTHODONTIC TREATMENT OF IMPACTED TEETH

WHOSE PROBLEM? The seco nd exception occu rs w ith a 14--15-

yea r-old patient who req uests the restorati on
Patients do not go to their den tist com plain- of an unsightly cariou s lesion on a retained
ing o f an im pa cted too th. They are freq uently maxillary deci d uous canine. Gene rally speak-
unaware tha t th is abnormality exists, since ing. the pati en t will be una ware tha t this is not
there is no pain, d iscomfort or swelling. a permanent tooth, and it will req uire suitable
Neither is it obvious to the layman that there professional advice to point ou t that restora-
is a miss ing too th, since the decid uous pred e- tion is probably no t the appropriate line of
cessor is usu ally reta ined. The vas t majority treatm en t, rat her extraction and the reso lut ion
of impacted teeth come to light by cha nce, in of the impaction of the pe rmanent canine.
rou tine dent al exa mina tion, and are not the A very s mall percentage of cases ma y
result of a patient' s d irect complaint. As a be see n initially by their genera l denta l prac-
general rule, it is the pa edodontis t or general titioner beca use of symptoms related to
den tal p ractitioner who, du ring a routine relatively rare complications of im pacted
den tal examination, discove rs and records the teeth . Am ong these symptom s ar c mob ility
existence of an ov er-retai ned de ciduous too th . or migration of ad jacent teet h (d ue to
A periap ical rad iograp h will then confirm the roo t resorp tion), pa in less bony expansion
d iagnosis. (dentigerous or radicular cys t ), or perh ap s
There are two p rincipal excep tions w here p ain and I or discharge (in fected cyst, w ith
an ab no rmal appearance may be the reason commun ication to the oral cavity) (Shafer et
why the patient seeks pr ofession al advice. al. 1983 ).
The first usu ally' brings the patien t to the In itially, the p ractition er should ascertain
office at the age of 8-10 years, when a single whet her there is a go od chance that resolu tion
maxilla ry central incisor will have eru pt ed a w ill be spon taneo us, on ce the aetiologic factor
yea r or so earlier and the pa ren t points ou t has bee n removed, or whether active appli -
that the erup ting lateral inciso r of the oppo-- ance therapy w ill be needed . To be in a posi-
site side has no t left enough s pace for the tion to d o this, the exact position , long-axis
expected eruption of the second cen tral angulation and rot ational status of the tooth
incisor (Fig. 1.9). Often, the deci duous cen tral have to be accurately visualized and an
incisor is retained . In this situation, the p aren t assessment of space in the arch must be
has recognized abnormality, bu t w ill not mad e. Followi ng this initial assessment, the
generally have the technical u nderstand ing to pedodontist or general de ntal p ract itio ner
suggest the possibility of impaction o f the now has to decid e who shou ld treat the p rob-
unerupted central incisor . lem.
Ma ny general p ractitioners will p refer not
to accept responsibility for the case, and w i11
refer the patient to an oral and maxillofacial
surgeo n, on the basis that surgery will be
needed. Many surgeons will agr ee that the
pr oblem is essen tially surgical in na ture, and
will proceed to remove retai ne d deciduous
teeth, clear away othe r possible aettolo gtc fac-
tor s, su ch as supernumerary teeth, odon-
tomes, cys ts an d tumou rs, and will also
expose the impacted pe rmanen t too th . If the
im pacted too th is buccally located, the su rgi-
cal flap may be apica lly repositioned, to pre-
vent primary closu re and to ma intai n
subsequent visua l contact w ith the im pacted
Figure 1.9
too th after healing h as occurred . This will
Une rup ted right max il1<l ry central incisor with spaa' loss. have the effect of en couraging eruption in
GENERAL PRINCIPLES RELATED TO THE DIAGNOSIS AND TREATMENT OF IMPACTED TEETH 9

ma ny cases. Un til hea ling (by ' second ary

inte ntion' ) has occu r red , the wound will usu-
ally be packed with iod oform gauze impreg-
na ted with Whitehead 's va rn ish, over a
pe riod of a few weeks. Ca reful placem ent an d
wed ging o f th e pack between an impacted
tooth and its neighbour is used by surgeons
to he lp free th e tooth to erupt na tu rally, wh en
the pack is later removed . Of ten, in more di f-
ficult impactions, wider su rgical exposure is
undertaken, in clud ing fai rly radical bone
resection, both around the crown and d own
to the C El, w ith complete rem oval of the den-
tal follicle. Figu re 1.10
Following a period of many months and A midline supern um e ra ry tooth (rnesiodens] discovered
(for some more aw kw ard ly positio ned teeth ) in routine periapica l radiograph ic view of the ma xillary
sometimes exte nd ing int o years, the su rge on incisor a rea.
will usually the n follow up the spontaneous
eruption of the impacted tooth until it reaches
the occlus al leve l. If, at that tim e, alignment is
poor or the too th still ha s not eru pted, the
patient w ill be referred to the orthod ontis t.
The paed od on tis t or ge ne ral dental practi- the no rmal and spon taneous eruption of a
tioner may alternative ly and preferably refer neighb ouri ng tooth .
the pat ien t di rectly to an orthod ontis t. Cer- At this s tage, from every point of view, it
tainl y, the orthod on tist cann ot d irectly influ- wou ld be inap prop riate to expose the crown
ence the position of the im pacted tooth until of an im matu re too th. In the first place, one
appropriate access ha s been p rovided su rgi- would no t wa n t to en courage the toot h to
cally and an attachment has bee n placed on erupt before an adequa te (half to two-t hirds )
the tooth. Nevertheless, with proper planning root len gth h ad been p roduced . Secondly , at
and mana gement , inclu d ing the refer ral for this early stage of its development. the too th
surgical exposu re at th e appropriate stage in cannot be consid ered as impacted , and, given
the treat me nt, a much high er level of quality time and freed om to manoeuvre, will prob-
care may be p rovided and in a very mu ch ab ly eru pt by itself. Early exposure risks the
shorter tim e frame . This will be d iscussed in possibility o f d amage to the crown and to the
the en suing chapters of this boo k. subsequen t root development of the tooth .
Nevertheless, with the d isco very of the
pathological con dition (Fig. 1.10), the pot en -
tial for impaction exists, an d leaving the con-
THE TIMING OF THE SURG ICAL d ition untreated will worsen the prognos is.
INTERVENTION Acco rd ingly, rem oval of the pa tho logical
en tity, withou t d istur bing the ad jacen t pe r-
From the above d iscussion, we see th at manent teeth o r the ir follicular cry p ts, should
the tim ing and nature of the s u rgica l p roce- be the aim of an y treatment at that time. It
dure are determined by the d eg ree of devel- ma y then reasonably be expected that normal
opmen t of the teeth concerned at the time development and erup tion w ill occu r in the
of initial d iag nos is. At an early stag e, a fullness of time. Wh ils t this is an obviou sly
radiographic su rvey of a very yo ung chil d desi rable co urse of action , access to the tar-
may reveal pa tholog y, s uch as a su pe rn u m- geted area may be th warted by the presence
erary too th, an odontome , a cys t or and closeness of adja cent developing st ruc-
benign tu mour , that ap pears like ly to preven t tu res, and delay may still be advised .
10 THE ORTHODONTIC TREATMENT OF IMPACTED TEETH
_ _ _ _ _ _ __ _ _"-'----'-'-C----"----=---=--'--------=--=::..--=..'-

Fig u re 1.11
Thl' p,lO<J ra mic rad iugrap h shows e rup ted maxillar y lat -
e ral incisors an d over -retained d.'cid" o us ..ental incisors.
TI1<.' une rupt ed cen tral incisors may be seen su periorly to
the two uneru pted supernumerary teet h . (Co urtesy of
Dr I Gi 11i~. )

The second scenario occurs when the con- 1986). However, even a cursory analysis of
d ition is only d isco vered much later . In th is the pa tient load of an y give n or thodontic
case (Fig. 1.11). the permanent tee th may jus- p ractice will rev eal a round three-quar ters of
tifiably be defined as imp acted, and the aims the pa tients being treated for this ma locclu-
of s urgical treatme nt become twofo ld: first, to sion. The reas on for this has to do wi th the
elim ina te the pathology, and then to create fact that a pa tien t' s ap pearance is adversel y
op timal cond ition s for the erup tion of the per- affected to a grea ter exten t by this condition
manent tooth, which is alread y lat e. Th is will than by most oth ers. In other word s, ap pear-
u sua lly involve exposure of the crown of the ance plays an inordina tely large part in the
too th. For man y teeth , giv en adequa te sp ace initiative an d motivati on on the part of the
in the dental arch an d little or no disp lace- paren t of a you ng pa tien t to see k treatmen t.
ment of the impacted toot h, spon tan eo us A signi ficant sectio n of the remaining q uar-
eruption may be expected (Dibiase, 1971; ter of the pati ents in this hypothetical ortho-
Mitchell and Bennett. 1992). As w e sha ll see dontic p ractice are being treated for various
in subsequent chapters, there arc several situ- less unsightly con ditions (crowding, single
ations and tooth types where this may not ectopic teeth, ope n bites or class 3 relation-
occur, o r it may no t occur in a reasonable ships). Thi s leaves on ly a few pa tien ts in this
time fra me, often because of severe di sp lace-- practice sample who have been refe rred fo r
ment o f the affected too th . Fo r these cases, strictly hea lth reasons, which may no t be
the natural erup tive potential of the tooth is obvious to the pa tient.
s up plemented and, if nece ssary, diver ted Appearance is not a problem for th is small
mech an ically, wit h the use of an orthodontic gro up of p atie n ts, wh o will have ag reed to
app liance. orthod on tic treatment on ly after moti vation
has been evoked by the carefu l and persu a-
sive ex pla nati ons of a dentist, o rthod ont ist,
pe riodontis t, p rosthodontist or o ral surgeon,
PATIENT MOT IVATION AND THE regarding the ills that are othe rwise likely to
ORTHODONTIC OPTION befall them and their dentitions.
Most im pactions arc symptomless, and,
Angl e's Class II ma locclus ion is present in as ide from maxillary central incisors, do not
between one- fifth and one-qua rter of the child us ua lly present an ob vious ab norma l appear-
po pu lation in most countries of the western ance. Acco rd ingly, mo tiva tion for treatment
world (Massier and Fran kel, 1951; Brin et al, in these cases is m in ima l, and much time has
GENERAL PRINCIPLES RELATED TO THE DIAGNOSIS AND TREATMENT OF IMPACTED TEETH 11

to be spent with the patien t before he or she Koy ou md jisky-Ka ye E, Ba res M, Gro ve r NB
agrees to trea tme n t. The s tory d oes no t end (1977) Stages in the emerge nce of the dent i-
there, s ince these pa tien ts ma y often require tion : an im proved classi fication and its appli-
pe riodic ' pep talks' to ma intain their level of cat ion to Israeli children. Growth 41: 285--96.
coo peration and the ir res ol ve to co mplete the
trea tment. Many of them w ill no t main tain Krogm an WM (1968) Bio log ical tim ing and
the required sta nda rd of oral hygiene, and, the den to factal com plex . J Dent Chil d 35:
while it is d ifficu lt to jus tify continuing treat- 175-85.
ment in these circumsta nces i ~ is just as d iffi- Massier M, Frankel JM (1951) Preva len ce of
cul t to rem ove applian ..o.:'~ rro m a patient in m alocclus ion in child ren aged 14-18 yes. A m J
the mid d le of treatme n t, whe n im pacted teeth Ortnod 37: 75 1-60
have bee n pa rtially erupted and large spaces
are presen t in the dental arch. For these rea - Mitchell L, Bennett TG (1992) Su pe rn u me rary
sons. wh ile ambitiou s and innovative treat- teeth caus ing delay ed eru ption - a retrospec-
ment p lan s may be suggested , it is essential to tive st udy. Br J Ort}IOO 19: 41-6.
take the moti vation factor into acco unt before
advis ing lengthy an d com plicated tr eatmen t, Moo rrees CFA, Fanning EA, O ren A-M,
since the risk of non-completion may be high. Leb ret L (1962) The timing of orthodontic
trea tment in relation to too th form ation . Trans
Eflr Ortnoa Soc 38 : 1- 14.

Moorree s C FA, Fann ing EA, Hunt EE Jr

REFERENCES (1963) Age va ria tion of for ma tion stages for
te n pe rma nent teeth. J Dellt Res 42 : 1490-502.
Brin I, Becker A, Shal hav M (1986) Position of Nella CM (1960 ) The development of pe rma-
the maxillary permanent can ine in relation to nent teeth. / Dent Child 27: 254- 66 .
anomalous or miss ing lateral incisors: a popu-
lation st udy. Ellr / Orthod 8: 12-1 6. Schou r I, Messl e r M (1941) The dev elopment
Di Hi,l SC DD (197 1) The effects of variations in of the hu man d en tition . J Alii Dent Assoc 28:
tooth morpholog y and position on eru ption . 1153-60.
Dellt Pmct Dent Rec 22: 95-108. Shafer WG, Hinc MK. Levy BM (1983) A
Gam SM, Lewis AB, Vicinus JH (1963) Third Texbook of Oral Pathology, 4th ed n. WB
molar po lym or phism and its s ignificance to Sau nders, Philad elph ia.
denta l genetics. J Delli Rt'S 42: 1344-63. Sofaer JA (1970) Dental morp holog ic varia-
Gran A·M (1962) Pred iction of tooth emer- tion and the Hardy Wei nberg law . J Dellt Res
gence. J DCllt Res 41: 573-85. 49(Sup pl), 1505.
2 RADIOGRAPHIC METHODS RELATED
TO THE DIAGNOSIS OF IMPACTED
TEETH

CONTENTS • Qual itative rad iography • Th ree-d imensional diagnosis of to oth po sit ion
• CT scann ing

It is not the purpose of this chap ter to present Q UALITATIVE RADIOG RAPHY
a complete manu al on dental radio gra phy,
but rat her 10 concisely highlight those tech- Periap ica l radiographs
nique s an d meth od s tha t are usefu l in the
clinical setting, as it pe rtains to im pacted The first, simplest and most inform at ive X-ray
teeth. The me thods offered have two ma in film is the pe riapical vie w. This view is orien-
aims (Sewa rd , 1968; Hun ter, 1981). The firs t ted to pass through the m inimum of su r-
relates to the fu rn ishing of qu ali tat ive infor- rounding tissue. in order to give accu racy an d
ma tion regard ing no rmal and abnormal qu ality of resolut ion . It is generally aimed to
condi tion s that ma y be associated w ith be perpendicular to an imaginary plane
unerupted teeth . Thu s the d ifferent ways of bisecting the angle between the lon g axis of
radiologically displ ay ing and recognizing an erupted tooth and th e film plane, to pro-
patholog ical entities, such as su pernu me rary duce the minimum of distortion. The penapt-
teeth, enl arged eruption follicles, odon tomes, cal film is designed to view the tooth itself
root resorption and other patholog ical en ti- from the angle of best advantage, without any
ties, arc dis cus sed and compared . The second relation to its position in space.
aim is to describe the var ious radiological From this film, it w ill be immediately obvi-
techniqu es that the clin ician may find helpful ous if there is an impacted tooth and if its
in accurately pinpointing the position of a stage of d evelop ment is sim ila r to that of its
clinically invisible, unerupted too th . The rela- erupted an timere, w ith at least two-thirds of
tive merits of the se techniques ar e di scussed, its root length . The presence and size of a fol-
and ind ications for their use arc suggest ed in licle will be obvious, and it will be possible to
relation to the di fferent gro ups o f teeth asce rtain crown or roo t resorp tion, roo t pat-
involved . tern and integrity . The p resence and d escrip-
tion of hard tissue obstruction w ill be evident,
allowing the observer to d istinguish connate,
in risiform and b arrel-shaped su pe rn u mer-
aries, and odontomes o f the comp lex or
14
THE ORTHODONTIC TREATMENT OF IMPACTED TEETH
...::.::.:::...::.:==:::...:.==::.::-=..:==::::..:.:::.::.:

com pou nd com posite types. Simila rly, it will

show soft tissue lesions, such as cysts. The
grea t clarity offered by the view is su perior to
that o f othe r views, and it should always be
used as the init ial film of a suspected
impacted toot h in a rad iographic exam ina-
tion. As with any radiogra phic film, however,
the periapical view is only twa-di mensional,
and gives no information in the b ucca- lingual
plane; overlap ping structu res cannot be
d ifferentiated as to which is lingual an d
which buccal.
For this film to give the most advan tageous
view of the tee th in the maxillary arch and in
the mandib ula r an terior segment, the central
ray of the periapical view is obliqu e, and w ill Figu re 2.1
vary between 20° an d 55° to the occlusa l
plane (Mason, 1982), depend ing upon the Taking a true occlusal view of the lowe r jaw: for the
region to be x -rayed. Given this oblique canine / premolar region and for the incisor region.
direction, any attempt to estimate the height
of the tooth o r its bucca-lin gual orientation.
without ad di tional info rmation, must fail.
When pe rform ing pe riapical radi ography
on the poste rior teeth in the mandibular arch, a large cyst or bucca-lin gually displaced
however, the most ad van tageou s direction tooth.
has the centra l ray very close to the horizon- In orde r to p rodu ce a true occlusal view in
tal, and, as such, also offers a true lateral view the anterior reg ion of the mandibu lar arch
of these teeth. Thu s not on ly will the observer (Fig. 2.1), the head will need to be tip ped back
see the most precise de tail of the too th and its further and the tub e po inted at the sy mp hysis
surrou nd ing tissues, bu t it will also be po ssi- menti, at an angle of 110° to the horizon tal, in
ble to accu rate ly assess its heigh t in the jaw. line with the long axes of the incisor teeth. To
achieve the same for the molar teeth, the 90°
angle to the horizontal will need to be aug-
men ted by a 15° med ial tilt of the tube, to
Occlusal radiogra phs compensate for the characteristic sligh t lin-
gua l tip ping of these teeth (Mason, 1982).
Mandibular arch
In the mandi bu lar arch, this view is properly
Maxillary arch
executed by tipp ing the patient's head back-
wards an d po intin g the X-ray tube at right- Maxillary anterior occlusal. In the m axillary
ang les to a film, held between the teeth, in the arch, the no se and fo rehead interfer e w ith the
occlusal plane (Fig. 2.1). In the low er positioning of the x -ray tube, close to the area
canine / pre molar region, the occlus al view is to be viewed . The best that can be achieved
a 'true' occlusal view an d sho uld de pict all by positioning the tube close to the face is an
the posterior standing teeth in cross-section. an terior maxillary occlusal view of the teet h,
As su ch, it shou ld also provide bu cco-lingual wh ich is perhap s bet ter described as a high or
position al in formation on the tooth and an y steeply-ang led pe riapical view (Fig. 2.2). The
associated structu res in a plan e at righ t ang les view w ill 'shorten' the actual length of the
to tha t seen on the periapical film. Because of roots, bu t it w ill be a far cry fro m the cross-
the thickness of bone trave rsed, de tail is sectional view that is so easy to achieve in the
mu ch po orer, u nless there is expansion du e to mandibular arch. Since the cen tral ray passes
RADIOG RAPHIC METHODS RELATED TO THE DIAG NO SIS OF IMPACTED TEETH 15

Vertex occluuJ ( 110" \ Anter ior occluul

to occluu l plane) (60" to ccchrsa l plane)

Periapical

\ \ !JiJ !J" Occtosat

~ " plane Figure 2.3
A trw.' vertex occlusal film usi ng On g' s pmjl'rtion, sho w-
inll) two palatal ca nines. The right canine is ChlSl' to the
arch and almost vertical. The cro wn of the Il'fl ca n ine
reaches the midlin e sut ure, while the Toot a pex is close to
Figu re 2.2 the line of the a rch.

A di ag ram showi ng inciso r inclin atio n, film pos ition a nd

cen tral X-ra y beam, d iffere ntiating the periapical " le w,
the a n lt'rior (ob liqu e) occlusal vie w and the true verte x
occlusal views. ante rior teeth will be seen in their cross-
section al view as sm all circles with a tiny con-
centric circle in the cen tre, denoting the pulp
chamber. No information is available regard-
ing the relative height of the object in the
alveolus, and it certainly cannot be used for
fine detail. A single tooth that is palatal to the
through less thickness of bone, detail is usu- line of the arch will ap pear wit hin th is arc of
ally good, alt hough no t as clear as w ith the sma ll circles. If the too th is at an ang le, not
per iapica l view . parallel to its neighbours, it will show up inits
True (i xrtex) occlusal. A true occlusal view elliptical, ob lique cross-section, repres enting a
of the anterior maxilla is a view in which the tilted long nxis. If th e tooth is horizon tal
centra l ray of the X-ray beam ru ns pa rallel to across the palate, its full length will be obvi-
the long axis of the centra l incisor s (Fig. 2.2). ous on th is view, togethe r w ith the exact
This is only possible when the cone is p laced mesio-d istal and bucco-lingual or ientation of
ove r the vertex of the skull, to p rodu ce the both the root an d the cro wn, in the hor izontal
vertex occlusa l film. Since the beam h as to plane (Fig. 2.3).
travel a great d istance through the cran ium Th e di fferen ce between the two types of
and its con tents, the base of the sk ull and the occlusal film may not seem to be very great,
maxilla, there is a conside rable loss in clarity. but it sho uld be app reciate d that, from the
Recently, an excellen t method of p rod ucing van tage po int of an anter ior occlusal film, the
this view extra-orally ha s been described an terior tee th will be fores hor tened but will
(Dog. 1994). In order to avoid the need for a still have app reciable length. In thi s situ ation,
very long exposu re, a fast film sh ou ld be used a high and mesially placed labial canine could
in a cassette with intensifying screens. For give precisely the same picture as a low and
these reason s, the method is no t popular. mesially p laced palatal canine. Th is cou ld not
Nevertheless, in this view (Fig. 2.3), all the happen in a vert ex occlusal projection.
16 THE ORTHODONTIC TREA TMENT OF IMPACTED TEETH

(a) Ibl [e)

Ie) [dl

Fig u re 2.-1
(a) The periapical v iew shows an Impacted Ie-ft maxilla ry central incisor, due to an in verted u neru pted sup,'munwr,uy
toot h. Th e decid uous too th is over-re tain ed. Accu ra te di ag nosi s o f the hd~ht of the im p.1(il'd tooth in thc, alveol us is not
possible from this view. (b) Th e anterior ma xilla, see n o n oil lateral Cl.'p haluffielric radiogra ph. shows th e high im pil(tN
centra l incisor, facing the labia l sulcus; Ic) a nd (d) representt f c SolID,' views a" (a) and (h) afte r remova l o f the SUf"?T-
numeral)' tooth an d bracket bonding to the exposed incisor. (Courl.~y o f Dr D Ha ra ry.I (e) A pa rallel in tr a-ora l photo-
gra phic view. Th is film has been lM"rally inverted to simplify comparison.
-
RADIOGRAPH IC METHO DS RELATED TO THE D IAGNOSIS OF IMPACTED TEETH 17

Extra-ora! radiographs mou th. Thu s, w hile it gives a good two-

d im ensiona l represen ta tion of the tooth, this
The panoramic view, while not showing the view ha s lim ite d value when vis ua liz ation of
same degree of detail as a periapical film, has a n unerup ted too th is req uired, in the three
the adv an tage of simply and quickly offering plan es of sp ace .
a good sca n of teeth and ja ws, from TM joint
to TM join t. It is p robably true to sa y tha t
or thodon tists a re tod ay in general agreement
that this film gives the most qu alita tive in fe r- PA RALLAX METHOD
mation. to act as a starting point from wh ich
to proceed to other forms of radiography, in By following the p rincip les in volved in binoc -
line wit h the de man d s o f the pa rt icular s itu- ula r vis ion, two pe riapical views of the sa me
ation in a ny given case. ob ject and ta ken from slightly d iffe rent angles
True a nd ob lique la teral ex tra-ora l views can provid e de pth to the flat, two-dimensional
(Figs 2.4a-e) a nd the va riousl y angu lated pictu re depicted by each of the films individ-
oblique occlusal films all pro vid e info rmation u ally (Fig. 2.5). Thi s is of considerable help
that may be used to complemen t the periapi- w ith distinguishing the bu ccal or lingual d is-
cal film, particularly when too th displace- placement of the can ine, which is low d ow n
ment is severe. However, the use of any and fairly close to the line of the arch. Th e
oblique film for the accurate localization of a p rocedure is pe rformed in the foll owing man-
bu ried too th may frequently be misleadi ng, ner (Fig. 2.6).
be it a single pe riap ical, an occlusal or a lat -
1 A periapically sized film is placed in the
eral jaw film . Th is being so, two incipient mouth, w ith the pa tient' s finger holding it
dangers exist . First, as we shall see in later against the pa latal as pect of the area
chapters, a s urgical procedure may be mis - w he re the too th wou ld no rm ally be situ-
directed a nd a flap opened on the w ro ng s ide a ted. The x -ray tu be is d irected at right-
of the alveolar p rocess. Second ly, mi sin terp re- a ng les to a ta nge nt to the line of the arch
tat ion of the too th' s position may lead the a t thi s poi nt, as for a ny peria pical view
operator to assume a very fa vou ra ble progno-
sis for biomec ha nica l resolution when, in fact,
the tooth may be in a co m pletely intractab le
posi tion. Thus the choice of trea tm ent w ill be
inap propri ate.

THREE-DIMENSIONAL DIAGNOSIS OF
TOOTH POSITION

As dentists, we arc ve ry used to seeing peri-

ap ical films of ind ivid ua l teet h, and, p rov ided
that the teeth conce rned a re in the line of the
arch, the se films ha ve ma ny advantages. Figure 2.S
Howeve r, in th is view, the x -ray tube is no t
The left periapical view. oriented for the central incisor s,
directed in th e true horizontal, true ver tical or
shows the crow n of the camne superimposed on the d is-
true late ral pla nes. As ide fro m radiogra phy of tal half of the central incisor mot. Th~' rmddlc film,
the mand ibu la r poste rior tee th, the tube is rotated 30" to the left, shows the canin e overlapping only
always tipped a t a n angle to one or more of the lat eral tnctsor roo t. By ml aling the cen tral bea m ,1 fur -
these pla nes . Th is is un im porta nt for a n ther 30", superimposition of Itll' canine over the lateral
eru pted too th, s ince the th ird di mens ion is incisor root h as been eliminated. The canine is pillol tally
supplied by the di rec t vision w ithin the displaced.
18 THE ORTHODONTIC TREATMENT OF IMPACTED TEETH
- - - - - -- - - - ----'-'-----'---------'------
fron t, the right lateral incisor root and the
cro wn of the pa latal canine will be in the mid -
d le, superimposed on on e ano ther to a much
greater deg ree.
2 Jacobs (1986, 1987) enjo ins the obse rver to
use the right eye in p lace of the x -ra y tube
23 21 23 21 and suggests the useful exercise o f hol d ing up
two fingers vertically at eye level, with one
obscu ring the o ther. If the observer now
closes th is eye and ope ns the other, h is or her
new vantage poi nt fo r inspection will have
resu lted in a visu al separation of the two fin-
gers. Th rough the left eye, the obscured finger
will ha ve ' mov ed' to the left of the forw ard
finger, to become partially visib le. Trans-
ferri ng this to the rad iographic context, in the
second pictu re, the too th furthest from the
tube [l.e. the pala tal toot h ) will ' move' in the
same d irection that the X-ray tube has tr av-
elled from the first exposure.
This method is very useful in cases where
there is a m inim al he ight d iscrepancy be-
Fig ure 2.6 tween the erupted and uneru pted ad jacent
A d iagra mma tic representa non o f the parallax method . If teeth (Fig . 2.5). However, when the canine is
the \ll.~·n·d~ '-'y t' p''t.'n; alo ng the axis of the X-ray beam in high and the periap ical view shows no su pe r-
each Col"". the image on lilt> film w ill be easy to I\'CUJ15truct. im posit ion of the canine with the roots o f the
erupted teeth, o r where the superimposition
is only in the apical area, then the overall pic-
tu re may be very m islead ing and a different
and at the appropriate angle to the hori- met hod of locali za tion should be used. The
zonta l plane. periapical view is d irec ted from above the
2 A second film is pla ced in the mouth in occlusal p lane an d in an ob lique downw ard
the identical posit ion, bu t on th is occasion and med ial d irection , wh ich di stances the
the X-ray tube is sh ifted (rotated) mesi- palatal canine from the roots of the othe r
ally or d ista lly round the arch, but held at tee th and makes it ap pear higher than the
the same angle to the horizontal p lane anatomy of the maxilla wou ld allow.
plane and di rected at the mesially or dis - Tn the incisor reg ion, an unerupted perm a-
tally adj acent tooth. To ach ieve this, the ne n t incisor may be associated with on e or
tu be should describe between 30° and 45° two supernumerary teet h (meslodcns) . The
of an Me of a circle wh ose cen tre is some- parallax met hod is insu fficiently clear in the se
where in the midd le of the p alate. cases, because of the pr esen ce of two or three
Let us assume tha t a righ t unerupted hard tissue entities in the bo ne, superimpo sed
canine is pa latall y pla ced (Fig. 2.6), then this on the outline of the root s of the d ecid uous
tooth will be close to the m iddle of the pictur e tee th and at va ry ing heig hts in the alveolus.
obt ained in both films. However, in the first
pi ctu re, where the tube was d irected over the
designated canine area of the rid ge, the lateral
incisor root will be on the right. If the cani ne Radiog rap hic views at right-angles
is also we ll fo rwar d, the re w ill be so me over-
lap of the can ine crown an d the lateral incisor Rad iogra phic views may be taken at righ t-
root. On the seco nd picture, taken from the angles (Seward , 1968; Hunter, 198] ) to one
-
RADIOGRAPHIC METHODS RELATED TO THE DIAGNOSIS OF IMPACTED TEETH 19

(.) (b) «)

Figure 2.7
(a) The trw lateral cephalometric radiogr aph shows both canines superimposed, ill a higher levelthan th., other Il'CIh.
Their axial inclination in the aotero-posterior plane is favo urable, with the crowns and "'pin'S apparontty normally
located . (b) The pos tero-anterior cephalom e tric radiogra ph shows the fwo camncs !'imilarl)' anguletcd, wifh their apices
in the line of thl' arch and thl' crowns dose.' to the mid line. From IhL~ Iwo films, we molY concl ude tha t the apices art.'
ideally ploln-d an d that the long ""lOS of the It...·!h hav e a downward, mesi al a nd palatal incli nil(ion. (0;:) The pa no ram ic
\ -il' W of the same pa ti.'nl. Th., apF"'a rancc of ca nines c!0S<' 10 the m idline is very simil.u ttl that .......n on th.· pos tero-
anterior ccphalomcutc radi og raph .

anothe r in various ways, bu t, for the met hod bucco-Hnguel relatio nsh ip only. By combin-
to be of value, it mu st be possible to deter- ing th e resu lts o f any two of these th ree films,
mine the exact o rien tation in space of both the three-d imensiona l localization may be accu-
film and the central ray, by obse rving other rately determ ined .
struc tu res on the film. Thi s requirement is Translating these p rincip les into rad io-
very difficult to satisfy when a v iew is soug h t graphi c practice p resen ts some difficulties.
at right angl es to the periapical v iew . However, th ese arc not insur moun tab le and,
Standardization, w hat is requ ired is the insofar as they present the clinician with
stand ard ization of views wit hin the confines accu rate positional visualizat ion of the
of a strict ad herence to the planes of space. A unerupted tooth, they arc ent irely worth-
true lateral view (Fig. 2.7a) will give exact infor- whil e.
mation regard ing both the antero-pos terior and In the rnandi bulnr po sterior area, we have
vertical location of an object, relative to other pointed ou t that the routine per iapi cal radio -
struct ures tha t may be seen both on that ra di- graph is also a true lateral view, with the
ograph and clinically. It will no t g ive any clue X-ray tube po in ting at righ t-angles across the
to the bucco-hngue l (tran svers e-pl ane) pic- bod y of the mandible, in the hori zontal plane.
tu re. A true occlusa l view will p rovide posi- The height and mesio-di stal position of a
tional information in bo th the an ter o- bu ried tooth may then be accu rate ly defined .
posterior an d tran sverse p lane s, but not the The occlusal rad iograp h of this area is
vertical plane. The th ird possibility is the true d irected at righ t angles to the occlusal p lane,
postero-anteri or view (Figs 2.7b,c), wh ich and adds the bu cco-Hngual d imension to
defines the he ight (vertical plane) and the com plete the three-d imensional p icture.
 THE ORTHODONTIC TREATMENT OF IMPACTED TEETH
2O ~=~===~== ===_'_

(. ) (b )

Hgure 2.8
The tru e la teral an d true occlusal view s, ta ken tog eth er, pro vide all the info rmation needed for an accu ra te positional
assessment of crown and root in the three planes of space. (ill The peria pical view (a tru e lateral in this case ) of an
impacted mandibular right second premolar shows the tooth to be tipped distally 60" from the vertical. with its incom-
plete apex at the correct height and mesio-dis talloca ticn. (b ) The true occlusal view sho ws the crown oi the tooth to be
lingua l 10 the molar, and the apex 10 be in the bucco-lingeallme of the arch. The long axis of thc tooth, proceeding from
its ide ally s ited i1f'l'J(, may be d escribed as rising at a 30" an gle in a dis tal and lingua l direction, 10 oVl'rlap th e mo la r
roots on the lingual side .

Accord ing ly. these two views will p rovide and parallel to the sagitt al p lane of the skull.
accu ra te localiza tion of the po sition of The X-ray tube is d irected horizontally above
un erupted tee th in th is area (Fig. 2.8). and parallel to the occlusal plane from the
Fo r most orthodontic cases, the lateral op pos ite side of the face, an d at righ t-angles
cephalometric rad iogra ph is an essen tial to the film . The result is called the tangenti al
prerequi site and, aside from the rou tine mea - view and h as the ad van tage of simplicity.
su rement of angles and planes, this film This view is particularly usefu l in monitor ing
sho uld also be used to gather valuable infor- progress in the resolution of impacted
ma tion regar di ng the location of unerupted incisors du ring active tre atment.
teeth. The lateral cephalogram represents a At the age at wh ich m ost pa tients first p re-
true lateral view of the skull, and, for the pre - sent wit h an im pacted centra l incisor (around
sent purposes, of the ante rior max illa in pa r- 8- 10 years), the perm anent canine teeth ar e
ticular (Fig. 2.7a). Altho ugh ther e arc many unerupted and are located both well forward
supe rimposed structures on this area, the out- and high in the anterior max illa. Thus, on the
line of a canine may be clearl y see n. The lateral ceph alometric or tangenti al view, right
d irection of the long axis of the tooth in the and left canines will be impossible to d ifferen -
an tero-posterio r and ver tical planes may be tiate ind ividually. The root s of the incisor s, at
defined, toget her with the mesiodistal posi- the same heigh t as the canines, as well as the
tions of both crow n and apex. su perim posed images of the more inferiorly
If a cepha lometr ic radiogra ph is not ava il- p laced crow ns of the erupted in cisors and
able, the same view of the an terior maxilla decid u ous canines, will all be indi stinguish-
may be obta ined on an occlusally sized film. able fro m one anot her and from sup ern umer-
This film is he ld vertically against the cheek ary teeth that may also be p resen t. For this
RADIOGRAPHIC METHODSRELATED TO THE DIAGNOSIS OF IMPACTED TEETH 21

offers the clinician the op por tunity to view

th e maxilla in a d ifferen t p lane, the true
postero-an terior view (Fig. 2.7b), w hich is at
right-angles to the latera l cephalogram. The
overlap of structures of the base of the skull
and the max illa renders detail of ind ividual
tee th less clear, bu t a good pos tero-anterior
radi ogr aph will show the height o f bo th the
crown and the root of a mark ed ly d isplaced
too th, as w ith the lateral fil m. Th is view also
shows whether the roo t apex o f an ectopic
pos terior too th is in the line of the arc h and
how far the crown is deflected in the pa latal
Figure 2.9
d irect ion . The bucca-lingual tilt of the long
A dilacerated cent ral incisor so-en in the la teral o.'phalo- axis of the too th will be p lainly visibl e (Fig.
mctri c rad iograph. 2.10). However, the view is less p ractica l in
the m andible, where the body is oblique to
the cen tral ray. There is usually excessive
overlap, mo re radio-opaque bone an d d iffi-
culty in discerning even ma rked ly bucca-
reason, the lateral view may be of limited lingu ally di splaced teeth.
value in cases where there is obst ructive An occlusal p rojection o f the anterior max-
impaction. w ith mi nimal d isp lacement. Whe n illa (Fig. 2.3) offers the po ssibility to view in
gross d isp lacem ent is p resen t, however, the the third p lane o f space, at righ t-angles to
outline of the altered axial inclination and- each of the two earlier rad iographs, and to
heigh t of the tooth can usually be delineated, record the pos ition of the d isplaced incisor or
despite the conside rab le superimposi tion of canin e without overlap . However, for it to be
other tee th. of greates t value, it is important to p roject the
Nowhere is this view a greater asset than X-ray beam th rou gh the lon g axis of the maxi-
when a dil acerated too th is presen t, since it llary teeth, as jus t described.
separates ou t this malformed too th, superi - Any two of these th ree views (the later al
orly, from the roo t apices of the other teeth cephalogram or tangential view, the postero-
and from the permanent canines, becau se of ant erior ceph alogram and the true occlusal)
its relative height (Fig. 2.9). Fu rthermore, its will p rovi de complete information reg ard ing
morphology may be seen to bes t ad vantage every aspect of the height, bucco- ling ua l and
from this aspect, wh ich allow s definitive and mesi o-dis tal location of the crown, the root,
accu rate di agn osis of the cond ition to be and the d egree of tilt of the long axis of the
made, together with its precise relations vis-a- imp acted tooth and its relation with neigh-
vis su rround ing structu res. The tang en tial bour ing teet h. The postero-anter ior and
view sho uld be con sidered an essen tial occlusal views, how ever, arc 110t always as
requirement in radi og raphically record ing the clear as is desirable, and they may need to be
dtlaccra tcd centra l incisor. repeated or di scar ded . The lateral cephalo-
For max illary can ines, the lateral v iew is metri c or tangential views in a cast' of bilat-
extremel y usefu l. It sh ould be remembered era l canine imp action may crea te conf usion,
that most im pacted maxillary canines are since one canine will be superimposed on the
d iagnosed in the full pe rmanent dent ition, other and d istingu ishing them may be a p rob-
when all the othe r tee th wi ll have erup ted. lem, alth ough othe r views will usually facili-
This dema rcates the canine at a h igher level tate di fferen tiation. Two id en tically orien ted
than the o ther tee th. and superimposed canines (Fig. 2.7) will obvi-
A post ero-anterior ceph alometric film is ously not need to be d ifferen tiated.
used less rout inely in ort hodontics, bu t it Fr"om these aspects, it is very easy to bu ild
22 THE ORTHODONTICTREATMENT OF IMPACTED TEETH

(.j (b j

Fig ure 2.10

(e.b] Extracted portion of the later al and postero-ant erior cephal o-
me tric views, to show an impacted max illary left second premolar
to be loca ted with its apex in the line of the a rch, but superiorl y
di s plaCl.·..t Th{' cro w n is displaced pa la tally, close to the m id line
and the long axis is strongly palatal, slightly dow nward and
slightly distal. (c) The periap ical film gives the misleading appear-
ana' of the crown being dis placed superiorly and anteriorly.
(Co urtesy of Dr I Gill is.)
«j

up a three-d imensional pi cture o f the exact CT SCANN ING

position and an gu lation of the im pacted tooth
and to define the type of movement that will Recen tly, the usc of comp u ted tomogra p hy
be necessary to b ring the tooth into align - (CT) scann ing h as been su ggested (Ericso n
ment. When building this compos ite menta l and Ku rol. 1988a,b) for identifying the exa ct
reconstruction o f the position of the un - position of the palatally impacted canine, par -
erup ted too th in s pace, the desig n of the ticula rly when root reso rp tion of the lateral
appliance needed to resolve the impaction is incisor is suspected (Ericson and Ku rol. 1987).
simplified and fewe r surprises are likely to be cr scann ing is a method in which clear serial
encountered . It is, however, an important p re- radi ographs m ay be taken at grad ua ted
requisite in all these cases to examine a peri- depths in any part of the human body (Fig .
apical view of the tooth, to eliminate the 2.11a). At the same time , this technique
possibility of local pa thology, which could be allows the eli m ination of the su peri m position
missed on the extra-oral vie ws. of othe r stru ctu res that we ha ve seen w ill
RADIOGRAPHIC METHODS RELATED TO THE DIAGNOSIS OF IMPACTED TEETH 23

(.) (bl (-)

(d ) (el

Figu re 2.11
(a ) The lateral skull r,ld iogr,l ph sh ow s the direction and sepa ratio n of the indiv id ua l CT "slices', (b-e) These sections
dt'p ict most clearly tht' midline slIpt' m u merar y loath a nd its rel,l tion ~hi p to the adja cent teeth in all thr ee pl ant'S o f
space. (Co u rtt'Sy of Dr 0 Eiscnbud.]

obscu re the image of the object tha t we are tooth. In th e following chapters, we sha ll
attempti ng to view in trad itional radio- describe how the relative difficulty of br ing-
graphy. In recons tructive dentistry, this ing these teeth into their proper position is
method has been developed to allow accura te depe ndent on advance knowled ge of the
placement of implants (Schwa rz et al, 1989). exact positions of bot h crown and root apex.
Although it ha s excellent pot ential for the We sha ll conclude th at variations in root apex
d iagn osis o f the position of im pacted and displaceme n t, in particular, prejudice both the
supern ume ra ry teeth , the large do sage of ability of the orthodontist to co mplete the
rad iation is difficult to justify for all excep t exer cise and the periodontal p rognosis of the
the exceptional case. tooth, when the treatment is finally co m-
By viewing seria l rad iogr aphic 's lices' of pleted . The metho d may also give accu rate
the maxilla (Figs 2.11b-c), the relationship of information regardi ng ear ly root resorp tion,
the im pacted too th to adjacent teet h, in all pa rticula rly of the bu ccal and palatal su r faces
three p lanes o f space, may be accur ately of the roo l. Th is may not be possible to d iag-
assessed , as can the positions o f CTOwn and n ose by any o ther me thod , prior to treatmen t.
apex and the inclination of the long axis of the It therefore ma kes sense that for those
24 THE ORTHODONTIC TREATMENT OF IMPACTED TEETH

pat ients in whom the re is a suspected d is- ecto pically eru pting maxillary canines - a
placement of the long axis of a tooth, due case report. Elir I Orthod 10: 115-20.
to an abnormal orientation of the rool apex
Ericson S, Kurol J (1988b) Resorp tion of maxil-
or the presence of root resorption (Ericson
and Kurol, 1988b), the use of high-resolution lary late ral incisors caused by ectopic erup-
tion of canines. Am I Orthod Dentojac Orthop
com puted tomography should be considered.
94: 503-13.
Although CT scanning units are relatively
few a nd ima ging is expensive, their us e is Hunter S6 (1981) The radiographic assess -
increasin g. a nd they a re now more freely ment of the une rupted maxillary canine. Br
availab le to the orthodontist in p ractice . It Dent 1 150: 151-5.
ma y still be d ifficu lt to just ify us ing the
Jacobs SG (1986) Localisation of the
method on a routine bas is for the occasional
unerupted maxillary can ine. AI/sf r Orthod 1 9:
and more straightforward case wit h one or
313-16.
two impacted teeth . However, its use in cases
of multiple impactions, particu larly cleidocra- Jacobs SG (1987) Exercises in the localisation
nial dysplasia, has mu ch to offer in the accu- of unerupted teeth . Austr Orthod J 10: 33-5,
rat e pla cing of the very la rge numbe r of 58- 60.
impacted teeth, both at the treatment plan-
Mason RA (1982) A Guide to Dental
ning stage and the subsequen t surgica l
Radiography, 2nd edn. Wright PSG, Bristol.
phases.
Ong A (1994) An altern ative techn ique to the
vertex / true occlusal view. Am J Orthod
Dentcfac Orthop 106: 621-6.
Schwarz MS, Rothman SLG, Cha fetz N,
REFERENCES Rhod es M (1989) Computed tomography in
dental implantation surgery. Dent Clin N Am
Ericson S, Kurol J (1987) Rad iog raphic exami- 33, 555-97.
na tion of ectopically erupting maxillary
Seward GR (1968) Radiology in general den-
canines. Am I Orthod Dentojac Orthop 91:
483-92. . tal pra ctice. IX - Unerupted maxillary
canines, central incisors and su pe rnumer-
Ericson 5, Kurol J (1988a) CT d iagnos is of aries. Br Dellt / 115: 85--91.
3 SURGICAL EXPOSURE OF IMPACTED
TEETH

In collab oration with Professor Arye Shteyer and Professo r Joshua Lustmann

CONTENTS • Aims of surgery for impacted teeth • Surgicallntervenlion without

orthodontic treatment • The surgical elimination 01 pathology • Buccal lyaccessibl e
Impacted teeth • Part ial and fu ll flap closure on the palatal side • A con servativ e
attitude to th e dental follic le • Cooperation between su rgeon and orthodontist
• The team approach to attachment bonding

AIMS OF SURGERY FOR IMPACTED case, decide and act solely in acco rd ance with
TEETH hi s own jud gemen t. In this way, man y po--
tentially re trie vable im pacted tee th were
For imp acted thi rd molars, treatment alterna- extracted.
tives and opportunities for cho ice are few, There a re no surgical methods, other than
and. in the majority o f cases, extract ion is transplantation . by which positive and active
ad vised . However, for othe r impacted tee th, align ment of an impacted tooth may be car-
this is not so, and seve ra l lines of treatment ried out. The best a su rgeon may do is to pro-
may p resen t (McDonald and Yap, 1986). vide the optimal env iron ment for nor mal and
Neverth eless, in the pa st, the deci sion as to un h indered eru ption and then ho pe and pray
how a particular im pacted tooth shou ld be that the tooth will oblige. With th is in mind,
treated was most often decided by the or al therefore, tho se teeth that were considered
surgeon, who also, by and large, deci de d wor th trying to recover we re wide ly exposed
upon and stage -managed the alternatives. and packed with gauze soa ked in White-
This situation has cha nged in recen t year s. he ad 's varnish, to protect th e wound during
Prior to the 1950s, most orthodo n tists were the healing ph ase and to prevent reheating of
unprepared to ad apt their skills and ingenu- the tissues over the tooth. For a varie ty of rea-
ity to the task o f resolving the imp action of sons, several oth er ste ps were taken, depend-
maxillary canines and incisor s. Accord ingly, in g upon the preferences and beliefs of the
the or thodo n tists them selves referred patients operator, with the aim of provid ing 't hat
to the oral su rgeon , who would decide if the extra something ' that wo uld impro ve the
chances of spontaneous eru p tion still fur ther.
impacted too th could be brought into the
dental ar ch. Where the circum stances were These measu res were o ften very emp irical in
n ature, and in clud ed one or mo re of the fol-
potentially favourable, the tooth wo uld be
lowing :
surgically exposed, and, when the su rgical
field was d isplayed fu lly, the su rgeon would (a ) clearing the follicula r sac comp letely,
make his assess ment of the p rognosis of the inclu ding in the eEJarea;
26 THE ORTHODONTIC TREATMENT OF IMPACTED TEETH

(b) clca n ng the bmw a ro und the too th, dow n

to the eEJ area, to dissect out a nd free the
entire crown an d the corona l porti on of
the roo t of the Impacted too th;
(c) 'looseni ng up' the too th, by subluxa ting it
wi th an eleva to r;
(d) bone-channelli ng in the desired direc ti on
of movement of the too th;
(e) pocking g,l uZC or hot gutta pe rcha in to
the a rea of the CEl , und e r p ressure, in
order to apply force to deflect the crop- ~
tion pa th of the tooth in a particula r d irec-
no n.
(.1
In those years. few patients were referred to
the o rthodontist until full eruption had been
achieved and the tooth then needed to be
moved horizontally into line w ith its ne igh-
bOUTS. Up to that point. the problem was con-
sidcrcd to be w ithin the realm of the oral
surgeon. In many cases. 's uccess' in achieving
the eruption o f the too th was pyrrhic and
often subordina ted to failu re of .1 d ifferent
kind . namely the period o ntal condition of the
newly eru p ted tooth a nd its poorer su rvi val
po ten tia l - its prognosis. Th is w as the
inevitable res u lt o f the aggressive a nd over
enthusiastic su rgical techniques tha t had bee n
us ed. w hic h ty p ically left the too th w ith an (hI
elongat ed clinical crown, ,1 lack of attached
gingiva an d .1 red uced alveol ar cr es t heigh t
(Odenrick MId Modcc r. 1978; Boyd , 1982,
19M; Becker ct al. 1983; Kohavi ct .11, 1984a, b).

SURGICAL INTERVENTION WITHOUT

ORTHODONTIC TREATMENT

W e COIllC a c ros s Cil SCS in which th e on ly clini -

cal pro blem rel at es to th e im pacted tooth, the
occlusion an d nllgnmcnt being otherwise
acceptable. For these pa tien ts. the follow in g
lei
question needs to be addressed : What surgi -
cal methods MC a vailable tha t may be Figuree 3.1
expected to pro vid e a more or less com plete (,1) A lo·yt'.u-ul,l k nl,llt' exhibitsa n Ullt' Tu ple,.I maxillary
solu tion , wi thou t out s id e assistan ce? To be in ldt canine, w hich h,IS been pn'St'nl in thi" povirion fur 2
a position to a nswer this question, it is neces- yt'.lTh MId h,IS not progres sed. (b) The loo th W,lS ,'xpf)';cd,
s ary to provid e a d escription of the position an d Ih,· flap , whi ch co ns ist,,,,l of thic kened mU(O"'l. was
of the teeth tha t wi ll respond to this kin d of apically repo sitioned . (c ) At 9 mon ths post-surgery. the
treatment . t"" th h,l" erupted nn rm"ll y. (Co ur t,'!'>y of L Shapira.)
SURG ICAL EXPOSURE OF IMPACTED TEETH 27

Figu re 3.3
Following exposure and packing, tlw tooth has erupted
spon tan<-'(lusly. bu t thO;' bon... l...vel is compromiso."d.

generally lead to a fairly rapid eruption of the

soft tissue impacted. too th, particularly in the
maxillary incisor area. The mo re the tooth
bulges the soft tissue, the less likely is a rebu r-
ial of the tooth in healing soft tissue and the
(b)
faster is the e ru ption .
Figu re 3.2
(a) Soft tissue impaction o f max illa ry cen tra l incisors. (b)
Apical reposi tioni ng (If bo th buccal and pa latal flap s to Exp osure with pack
leave the incisal edges e xposed . (Cou rtesy o f Professo r J
Lustma nn.) Taking this one step fur ther, we can SI,.'C that a
less super ficial toot h req u ires a more rad ical
exposure p roced ure, and may need a pac k to
Expos ure only p reven t the tissues frum rehe eling over the
too th. While the surgeon may be rewa rded
A superficially pla ced too th, palpable beneath with spon taneous eru ption, th is will take
the bulging gu m, is an obviou s candid ate. longer, and a comprom ised per iodo ntal result
This type of tooth may be seen in the maxil- should be expected (Fig. 3.3).
lary canine a rea (Fig. 3.1), but also in the We have d efined over- retained de cid uous
mand ibu lar premolar area (sec Fig. 1.8) and teeth as teeth still present in the mou th when
the maxillary centra l incisor area (Fig. 3.2), the ir permanent su ccessors have reach ed a
usually where very early extraction of the stage o f devel opment that is compa tible with
deciduous predecessor was performed wh ile their full eru ption. These decid uou s teeth
the immature permanen t tooth bu d was still ma y then be considered as obs tructing the
deep in the bone and u nready for eru ption. normal developm ent tha t wo uld be expected
Healing occurred , and the permanen t teet h to procee d in their absence, The deciduo us
are unable to pe netrate the thickened mu cosa tee th should be extracted, bu t p rov ision
(Dibiase, 1971; And reasen and And reasen, sho uld be mad e to encou rage the pe rmanent
1 99~ ) . Removing the fibrous mu cosal cove r- teet h to erupt quickly. Many of these perma-
ing or incising and resutu ring it to leave the nen t teeth wit h dela yed er u ption arc obnor-
incisal edges exposed (Figs 3.1a and 3.2b) w ill mally low in the alveolus, and Me in d anger
28 THE O RTHODONTIC TREATMENT OF IMPACTED TEETH
~~----------'------------'----
of being rebu ried by the healing tissu e of the brought abou t an improvemen t of the posi -
evacuated socket of the deciduous tooth. tions of the grossly displaced teeth, together
According ly, the crowns of the teeth sho uld with an imp rovement of the bony defect that
be exposed to their widest d iameter an d a w ill be ev ident in the anatomy of the alveolar
surgical o r pe riodon tal pack placed over them bon e in th e area, which ma y take ma ny
and su tured in p lace for 2- 3 weeks. Th is will months to occu r. Duri ng th is time, the psy-
encou rage epi thelializ ation d own the sid es of cho log ical prep aration of the patient for the
the soc ke t and , generally, pre ven t the re-fer- proposed or thodont ic treatment may be
mation of bon e o ver the unerupted toot h. und er taken, which mu st begin with seeing
po sitive results from a preventi ve dental
health programme aimed at elim inating ma r-
Exposure with pressure pack gina l gingival inflammation an d redu cing the
caries incidence for that patient. .
Mild mesial impaction of a mand ibu la r sec-
ond permanent molar be neat h the distal
bulbosity of the first permanent mo lar is a
condition that often responds to surgical Hard tissue obstruction
interven tion and packing on ly. Th is in volves
exposure of the occlusal su rface of the too th Obs tructive impaction invi tes the logical step
of rem oving the offe nd ing body causing the
and the deliberate wedging o f some form of
no n-e ruption. On many occasions, this is pe r-
pack in the are a between the two teeth an d
lea vin g it there for two o r thr ee wee ks. formed by the su rgeo n, wit hou t recourse to
Duri ng this time, the pr essure w ill often suc- orthod ontic assi st an ce, and enjoys a va rying
ceed in eliciting a di sta l mov ement of the degree of succes s. ln Chap ter 5, we sh,111 refer
to the re liability of spontaneou s erupti on,
impacted molar, which may then erupt more
freely whe n the pack is removed . The degree follow ing the va rious surgical pr ocedures
inv olved in the treatmen t of impacted
of con trol available to the operator in judging
inciso rs. For the presen t d iscu ssion, we must
the amo unt of p ress ure applied and the
extent to which the p ack interferes periodon- recogni ze th at there is a significa nt numbe r of
tally is minimal, an d lasting da mage to the cases in which e ruption does not occur in a
reasonabl e time frame .
periodontium is likely. Success in bringing
about an improved position of the too th may Undoubtedly, the position of most un-
thus not be matched by the health of its sup- erupted teeth imp roves with the passage of
po rting s tructures in the final analysis. time, following the removal of the obst ruc-
tion, be it a supern umerary tooth, an odon-
tome, res id ual decid uous roo ts or an infra-
occluded p rimary tooth. However, many o f
THE SURGICAL ELIMIN ATION OF these teeth do not erupt without assistance,
PATHOLOGY because of local dis turban ces caused by the
recen tly removed obstru ction and the healing
Soft tissue lesions tissues.
A hard tiss ue body occu pie s mu ch spa ce,
In Ch ap ter 7. we sha ll refer more sp ecifically and ma y cau se a gross d isplaceme nt of the
to be nig n tu mo urs. Surgical treatment is the developing too th bu d of the n orm al too th,
onlv trea tment tha t is indi cated for these con- both in term s of overall di st an ce from its
diti'ons in the first instance. This should be p lace and in that the o rien tation of its long
performed without delay, if only for reasons axis is also deflected. Thus the root or the
of obtaining biopsy material to confirm the crown of the too th may be deflected mesially,
innocence of a ten tat ive diagnosis. Ortho- distally, ling ua lly or buccally , comprom ising
dontic treatm en t should be suggested then - its cha nces of spontaneo us eruption. Ab-
bu t begun only afte r a filling-in o f bone h as normally sha ped root s may develop in the

B l e LJOTH~aUE' DE L'U N I 'lE R S rT ~

C ": P/I.RI S V
U.r::: .R. D" '; ' : l i '--' I:" /~! ':
1,ruO :: ;:' I , ' ~r-" '{
Q? 1 ? n ~Jl ("'I\II U , ,,. , <::
Other documents randomly have
different content
Proof of earlier As a culminating proof that the Caroline
Charter. Charter was not the first and only Royal
grant held by the Horners’ Company, we have but to turn to the
Correspondence recently found in the British Museum, and it will at
once become evident that the Horners were possessed of a Charter
long before 1638. Mr. Carmarthen, writing to Lord Burghley in 1597,
says:
“The question resteth upon one word cheefly in thyr Charter,” etc.,
or, again, “By the king’s grant in theyre Charter,” etc. This may allude
to a Charter granted by Edward IV, or, as seems probable, that in
reality the “Cornuarii” were well established as a legalized Gild
certainly not later than Richard II, and, in all probability, owned
Charters of a much earlier date, which would be in the nature of
special grants to the Guardian of the Gild, held by him, and would
therefore at a later period not necessarily be in the possession of the
Company. Moreover, on 30th of March, 1815, the Clerk of the
Company stated, as appears by an entry in the Minute Book, that he
had opened and examined the chest containing the documents
relating to the Company, and he found that it contained ... “also the
original Charters granted for establishing the Company,” etc. Had
there been but one, it is improbable that the word would have been
used in the plural.
Thus it will be seen that the Charter of 1638 is but an instrument
reiterating and once more legalizing the acts which had been in
vogue amongst the Horners for a very considerable time.
1638. Charter of The Charter of Charles I provides that the
Charles I. Horners, Freemen of the City of London and
Westminster and liberties and suburbs of the same, are incorporated
by the name of “Master, Wardens, Assistants, and Fellowship of the
Mistery of Horners of the City of London,” with power to purchase
and hold freehold and leasehold estates of every kind and all
manner of goods and chattels, and to grant, alien and dispose of the
same, and by the same name to plead and be impleaded, and to
have a Common Seal.
One of the said Fellowship is to be chosen the Master, two to be
chosen Wardens, and ten or more of the Fellowship, Assistants. The
Master, Wardens and Assistants, or the greater part of them,
whereof the Master and one of the Wardens are always to be two,
have power to make and alter, amend or make new, “reasonable
laws and constitutions touching the Trade, Art, or Mistery, and for
punishment and reformation of abuses, wrongful practices and
misdemeaners, and for defraying the charges of maintaining and
continuing the Corporation, and after what order they shall demean
themselves in their office mistery and work.” And to impose such
fines, amerciaments, or other lawful punishments upon all offenders
as shall seem necessary; such fines, etc., to be raised for their own
uses.
Robert Baker was appointed the first Master to continue in office
until the 2nd February, 1638, and until another person was elected
in his place. Christopher Peele and Thomas White were appointed
first Wardens under the new rules and Charter. Ten brethren were
appointed the first Assistants during their lives or good behaviour,
and the Master and Wardens were upon retirement from their
offices, to be assistants in the same manner. The Master and
Wardens were to take oaths before the Master in Chancery to “well
and truly execute their offices” before entering upon the same.
Power is given to the Master, Wardens, Assistants, and Fellowship to
meet in their Common Hall or other convenient place upon the 2nd
of February, if it be not Sunday, and if it be Sunday, then upon the
next day after, to elect a Master and Two Wardens for the ensuing
year; and they are to take their oaths of office before the late Master
and Wardens, or two of them; and like power of election is given
until the next 2nd of February in case of the death or removal for
misbehaviour of any Master or Warden during his term of office, and
also in like manner to elect an Assistant on the death or removal of
any of the Assistants appointed by the Charter.
Power is given of oversight, rule and search of all persons
occupying, importing, exporting, or using the art or mistery of
Horners within the cities of London and Westminster, and the
liberties and precincts thereof, and of all manner of wares thereunto
appertaining, to the intent that all delinquents may be discovered
and punished. They may purchase for ever one house for a Hall not
exceeding the yearly value of £40.
They are to elect one honest and discreet person as Clerk, and also
appoint a Beadle.
Exercise of Rights, The control continuously exercised by the
1689. Company over the trade, and finally
secured to them in the Charter just
Buying Horns, 1739.
mentioned, has never been abandoned,
though at any rate for the present it is not exercised. In the first
year of William III (1689) the Horners’ Company successfully
prosecuted a Comb maker for pressing horns, he not being a
“Horner.” Maitland, who published his work in 1739, tells us that the
Company “had of late appointed diverse of their members to attend
the market of Leadenhall & those of the neighbouring counties for
the buying of horns” to be sent to their common warehouse in
Wentworth Street, Spitalfields, where they were made up into lots
and divided amongst the several members, not omitting the widows
and orphans, who also received their several shares.
Last legal claim, The last occasion on which the Court
1745. exercised its rights against persons
infringing its monopoly was in the year
Ceases as a trading
body. 1745. Having ascertained that certain
persons not free of the Company had
bought rough horns and pressed them into lantern leaves, and were
disposing of them within the City of London and twenty-four miles
distant, proceedings were ordered to be taken against them, and, as
a result, the Company successfully established its right to the
monopoly in the manufacture of horn work in the City of London and
twenty-four miles round. From that time forward the trade in horn
declined, and during the second half of the eighteenth century, the
Company finally ceased to be a trading community. Thus ended the
operative existence of a Craft Gild which from “time out of mind”
until the present moment has had a useful and honourable career.
The Horners’ Company has been practically contemporaneous with
the history of England, and is, it may be believed, still destined to
serve many a useful purpose.
Property. In spite of legal incorporation the property
of the Company has, from time to time,
been vested in certain trustees, the last trust deed being dated
1756.
Minutes. The earliest Minute Book in the possession
of the Company covers the period 1731 to
Annual Dinner. 1796, and is extremely interesting as
showing the care taken in the apprenticing of novices to the trade, in
the appointment of its officers, and, perhaps most of all, in the
unbroken continuity of the annual dinner held generally at some
place outside the City, which though, at the time, partaken of only
by the members of the Court, represented the annual feast of the
mediæval Gilds, and finds its successor to-day in the Livery Dinner,
which has become almost a matter of civic importance.
This ancient practice has long been associated with Trade Gilds,
certainly as far back as 700 B.C. We may believe that the deipnon or
feast of the hetairoi, or Greek Trade Gilds, must have had a long
history before the time when such distinguished members as
Lysymachus, son of Milesias, and the son of Thucydides, joined in
them.
Favourite Inns. During the eighteenth and first part of the
nineteenth century the favourite inns
selected for the annual dinner seem to have been the “Crown and
Sceptre” at Greenwich, the “Plough,” or “Folly House,” Blackwall, the
“Star and Garter,” Richmond, and, in much later days, the “North and
South American Coffee House,” which latter, however, was probably
used more for the ordinary meetings of the Company than for the
annual dinner.
Aldgate the It is a little difficult to define the area in
Horners’ Home. which the Horners of London were
originally located, but it may be somewhat vaguely described as the
district of Aldgate. Many were the streets and alleys to which
Horners have given a name, and one well-known Horn Alley was,
until a comparatively late date, to be found on the East side of
Bishopsgate Street, and in Korneman’s book on “Old Street Signs
and Tablets” is an allusion to one with the following inscription:
—“This is Horn Alley, 1670.” In Stow’s “Survey of London,” 1633, the
following passage occurs:—“I read in the 26th of Henry VI (1447),
that in the parish of St. Dunstan’s in the East a tenement called
Horners Key was granted to William Harrington, Esq.” Doubtless this
alludes to a building used by the Horners for the purposes of their
trade, at a time when all was couleur de rose with them, and it is
extremely likely that upon further investigation this William
Harrington will be found to be the Guardianus or Alderman of the
Gild.
The warehouses of Time, however, brought its changes, and
the Gild. when, in 1603-4, the Horners’ Act was
repealed, it would seem likely that they found it either impossible to
continue to pay the rent, or, realising that disaster awaited them,
may have sold the property, if it were theirs to sell. It is, however,
certain that in 1604 the Company leased a house with storehouses
and sheds in Wentworth Street, Whitechapel, for the term of 1,000
years at a ground rent of £4. When, in 1789, these premises were
no longer required for the use of the trade, which had declined, they
were let for £30 a year, and in 1879 were sold to the Metropolitan
Board of Works and the money invested on behalf of the Horners’
Company.
Was there a It has been stated that the Horners’
Horners’ Hall? Company never had a Hall. It is difficult to
see quite why this statement has been made, for there is much to
make the student of Gild lore think otherwise. The Charter of 1638
expressly provides for one, and, as in every other respect, it simply
imposes the absolute conditions then existing, there would seem no
reason to doubt that the sum of £40 per annum therein mentioned
was the exact value of the property then held. The Bottlemakers
would not have joined the Horners had the latter Company not had
a hall or meeting place.
As with other Craft Gilds, the Fire of London probably proved very
disastrous to the Company, and, no doubt, very little was saved.
The fact that there are hardly any deeds of importance anterior to
1666, that the Old Book of the Company, which has recently been
recovered, after wandering so long, ceases to have an entry after
1636, together with the fact that the two or three early deeds which
ante-date the Fire of London are in a deplorable condition, as well as
the fact that the Company owned a considerable amount of silver
plate, which was sold in 1789, makes it not improbable that the
Horners, like every other City Gild, had its regular Hall or meeting
place.
Arms. The coat of arms of the Company is Ar. on a
Chevron sa., three bugles of the first
between three leather bottles of the second.
Destruction of Gild In 1835 the Municipal Corporations Act
monopolies. gave the coup de grâce to any remnants of
monopoly exercised by the extant City Gilds. That Act gave liberty to
all either to buy or sell, and, by so doing, compelled most of the City
Companies, nolens volens, to seek for a sphere of usefulness in
other directions.
1837. Revived Though, as a trading Gild, the Horners’
importance. Company declined, it has steadily risen in
reputation as one of the ancient mysteries of the City of London,
and, in 1837, the Commissioners on Municipal Corporations classed it
as fifty-fourth out of eighty-nine Companies there enumerated. In
1846 the Company petitioned the Court of Aldermen for a livery
which was granted them, the number of liverymen being limited to
sixty.
1882. Exhibition of In 1882 the Court of the Horners’ Company
Horn work. organized an exhibition of Hornwork, both
ancient and modern, which was held by the kindness of the then
Lord Mayor, Sir Henry Knight, at the Mansion House. By a strange
coincidence, and without any premeditation on the part either of the
Lord Mayor or the Company, it was held on October the 18th, St.
Luke’s Day, which was the day on which the annual Horn Fair at
Charlton took place. The exhibition of Horns and Hornwork far
exceeded, both as regards quantity and quality, the most sanguine
expectations of the promoters. So great was the interest shown by
the public that it became necessary to keep it open for an extra day,
and, during the four days of the exhibition, it was visited by no
fewer than 7,000 persons. Amongst the exhibitors was Her Most
Gracious Majesty the late Queen Victoria, who sent some interesting
specimens from her treasures at Windsor Castle. In
acknowledgment, of Her Majesty’s kind consideration, and by her
gracious permission, the Company presented to Her Majesty a print
of the descriptive catalogue and the account of the Company
mentioned in the preface, bound in horn leaves, ornamented with a
beautiful design from the South Kensington School of Art, selected
after competition by the scholars. It is now in the King’s private suite
of rooms at Windsor Castle.
1900. Royal Casket. In the course of the year 1900, at the
instance of Mr. A. W. Timbrell, C.C., it was
decided to present Queen Victoria with a horn casket in order to
fittingly commemorate the new century. On being approached upon
the subject, Her Majesty graciously accepted the offer. Before,
however, the presentation could be made, her lamented death
occurred. It was then decided to present the casket to King Edward,
and on March 28th, 1901, the late King’s Secretary wrote to the
Clerk of the Company expressing His Majesty’s pleasure in accepting
the proposed gift.
The casket was made of selected specimens of the finest British
bullock horn, mounted with massive silver and gilt straps, and
ornaments of the Early English style of chasing. It is supported upon
four pierced feet, the whole resting upon an ebony plinth, upon
which is a silver plate bearing the names of the Master, the Wardens,
and the Clerk. The whole enclosed in a handsome morocco case,
forms one of the finest specimens of the Horner’s art. Sir Francis
Knollys, in acknowledging the presentation, stated that he was
commanded by the King to renew the expressions of His Majesty’s
thanks to the Worshipful Company of Horners for the casket which
they had presented to him, and that His Majesty admired it greatly
and considered that it would form a great addition to the Horn Room
at Osborne.
Another Royal A similar casket, slightly different in design,
Casket. was presented to His Majesty King George
V on the occasion of his Coronation, and this, like the one presented
to his revered father, has been designed and carried out by Mr.
Deputy Millar Wilkinson, of Cornhill, the present Father of the Court.
It was constructed in the form of a cigar box, mounted with finely
worked silver-gilt applied strap work, chased with lions’ heads and
dolphins, chased end handles; on the front is a circular plaque
representing the arms of the Horners’ Company. The casket is
surmounted by a figure of St. George and the Dragon, the whole
resting upon an ebony plinth, upon which is a silver-gilt plate
bearing the names of the Master, the Wardens, and the Clerk.
Enclosed in a handsome red morocco case, it forms a beautiful and
unique specimen of the Horners’ art.
The deputation which made the presentation was headed by the
Worshipful Master, who, in the course of his address to His Majesty,
said:—
“The Horners’ Company, which is one of the most ancient of the City
Guilds, in tendering the casket, desire to assure Your Majesty of their
loyalty to Your Throne and Person, and convey their respectful
wishes for a long and prosperous reign.”
The King, in receiving the casket, remarked that it was a very
beautiful piece of workmanship, and that he would value it the more
inasmuch as it was presented to him during his Coronation year.
Further increase in In consequence of the continued prosperity
Livery. of the Horners’ Company, due to many
causes, doubtless, at a time when little life was being evinced, to the
work of Mr. James Curtis, but especially in the present activity of its
esteemed Clerk, Mr. Howard Deighton, it was found necessary in
1905 to apply again to the Court of Aldermen for an increase in the
livery to the number of 100, which was granted subject to the livery
fine being increased to £30.

Sic floreant Cornuarii!

 TRANSCRIBER’S NOTE

Punctuation has been normalized. Variations in hyphenation have

been retained as they were in the original publication.
*** END OF THE PROJECT GUTENBERG EBOOK A SHORT HISTORY
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