|INDIAN BOARD OF ORTHODONTICS CASE REPORT
|Year : 2018 | Volume
| Issue : 2 | Page : 127-132
Nonsurgical, nonextraction management of impacted maxillary canine
Dr., Private Practice of Orthodontics, New Delhi, India
|Date of Submission||06-Apr-2018|
|Date of Acceptance||06-Apr-2018|
|Date of Web Publication||13-Apr-2018|
Dr. Jasneet Singh
A-3/150 Paschim Vihar, New Delhi - 110 063
Source of Support: None, Conflict of Interest: None
NS, a 12 year 2 months old female patient, presented with the chief complaint of irregular teeth. Diagnosis revealed skeletal Class II jaw base relation, with average (toward vertical) growth pattern, dentoalveolar angles Class I molar relationship with severe crowding in upper and moderate crowding in the lower arch, normally positioned maxillary incisors but proclined lower incisors, “V” shape constricted maxillary arch with first premolar in crossbite, overretained deciduous molar and a high placed buccoversion canine in the first quadrant and an impacted canine in the second quadrant, constricted mandibular arch with first premolar blocked out in the third quadrant. Treatment with a nonsurgical, nonextraction treatment plan by expansion of the upper arch and taking advantage of natural eruptive forces of the tooth was planned. The final outcome solved the patient's complaints and achieved an esthetically pleasing and functionally adequate occlusal result.
Keywords: Impacted maxillary canine, Indian Board of Orthodontics case report, nonsurgical nonextraction treatment
|How to cite this article:|
Singh J. Nonsurgical, nonextraction management of impacted maxillary canine. J Indian Orthod Soc 2018;52:127-32
| Pretreatment Assessment|| |
NS, a 12 years and 2 months old patient, presented with a chief complaint of irregular and mal-aligned teeth. There was no relevant medical or dental history. Extraoral examination [Figure 1] revealed an oval facial form with straight divergence, no gross facial asymmetry, and an obtuse nasolabial angle with competent lips. The temporomandibular joint was normal on functional examination.
Intraoral examination [Figure 2] revealed a permanent dentition except the third molars in all the four quadrants, the permanent 2nd premolar in the first quadrant with overretained deciduous molar, and a permanent canine in the second quadrant. Maxillary arch was constricted with severe crowding with high placed buccoversion of maxillary right canine, impacted maxillary left canine, and a crossbite with respect to first premolar in the second quadrant. Mandibular arch was also constricted with moderate crowding with first premolar blocked buccally in the third quadrant. Oral hygiene was good with no underlying active gingival or periodontal disease; however, mild stains were present without calculus in the lower anterior region. The incisor relationship was Class I with 3 mm overjet and 25% overbite. Buccal segment relationship was Class I molar relationship on both sides, but premolar was in KATZ +5 and +4 for left and right side, respectively. Upper and lower midlines were coincident with the facial midline, and there was no displacement in the mandibular path of closure.
Pretreatment radiographs taken were orthopantomogram [Figure 3] and lateral cephalogam [Figure 4]. Radiographic examination revealed developing tooth germs for third molars in all the four quadrants, unerupted second premolar with overretained deciduous second molar, partially erupted canine in the first quadrant, and an impacted canine in the second quadrant. Cephalometric analysis [Table 1] revealed a Class II skeletal pattern account of normally positioned and size maxilla and retropositioned mandible, with average (toward vertical) growth pattern, dentoalveolars angles Class I molar relationship, normally placed upper incisors and proclined and forwardly placed lower incisors. Model analysis showed overall Bolton's excess in the lower arch.
| Diagnosis and Etiology|| |
Diagnosis revealed skeletal Class II jaw base relation, with average (toward vertical) growth pattern, dentoalveolar angles Class I molar relationship with severe crowding in the upper and moderate crowding in the lower arch, normally positioned maxillary incisors but proclined lower incisors, “V” shape constricted maxillary arch with first premolar in crossbite, over-retained deciduous molar and a high placed buccoversion canine in the first quadrant, and an impacted canine in the second quadrant, constricted mandibular arch with first premolar blocked out in the third quadrant. Etiology was probably hereditary as the mother showed a similar pattern of dentition with crowded teeth and buccoversions of both the maxillary canines.
| Problem List|| |
- Severe crowding in the upper and moderate crowding in lower arch
- Buccoversion of 13
- 23 completely blocked and in bone
- Crossbite 24
- Narrow and tapered upper and lower arches
- Rotations in multiple teeth.
| Aims and Objectives of Treatment|| |
- Alleviation of crowding
- To create space for 23 to utilize its inherent eruptive capacity to bring it into alignment
- To expand the upper lower arches
- Achieving Class I canine relationship with normal overjet and overbite
- Maintenance of existing Class I molar relationship
- Correction of rotations
- Correction of crossbite
- Leveling of curve of spee
- Maintenance of harmonious, soft tissue profile.
| Treatment Plan|| |
It was decided to treat the case nonextraction with a preadjusted appliance (MBT prescription, 022 slot). Gaining of space in the upper arch was planned by expansion by Quad Helix with extended arms and slight proclination of the upper anteriors. The quad helix would provide slow expansion and would also take care of the torquing and rotation of the molars by its double back-end wire. The extended arms of the quad helix will provide expansion in the anterior segment where it is required the most and would help in slight proclination of upper anteriors to gain space. This would also convert the arch form into ovoid from existing anterior tapered form. The first quadrant space would also be gained by extraction of the overretained deciduous molar. It was decided to utilize the inherent eruptive capacity of the maxillary left canine to guide it into the arch rather than the surgical uncovering of the tooth. In the second quadrant, open-coil spring would be required to establish the exact space for the maxillary left canine. Lower space gaining would be achieved by interproximal reduction in lower posteriors which would satisfy the Bolton's discrepancy also.
It was planned to retract on a heavy rectangular SS wire (19 × 25 SS) if any residual spaces were left after the stage of leveling and aligning in the upper arch. Inclusions of second molars would be done in later stages of the treatment to avoid any unusual bite opening along with box elastics.
Finishing and detailing would be done by taking a mid-treatment orthopantomogram to assess the root status.
Proposed retention strategy – upper and lower fixed bonded retainers. Upper Hawley's additionally to be worn during night time to prevent any relapse of the expanded maxilla.
Prognosis for stability – since the treatment was carried out in the growth years, stability of treatment should be good. Moreover, the canine-guided occlusion and proper interdigitation are less likely to relapse. By achieving root parallelism and giving the patient-fixed bonded retainers, the relapse tendency is reduced. The patient will be given upper Hawley's retainer to be worn during night time to prevent any relapse in transverse direction of the expanded maxilla. The patient, however, will be called for follow-ups every 6 months for regular assessments and dental check-ups.
Additional dental treatment – removal of stains by polishing and extraction of 3rd molars in future
| Treatment|| |
The patient was strapped up with upper and lower preadjusted appliance (MBT prescription, 022 slot). Treatment progressed through initial leveling and alignment with flexible NiTi archwires followed by 0.018 premium plus Australian stainless steel archwires for consolidation of spaces and for creating and maintaining space for the permanent canines in the first and second quadrants. An upper right deciduous molar was extracted after the alignment phase so as to maintain space for the permanent second premolar. Although IPR was performed in the leveling stages to create space for the lower right first premolar. Quad helix with extended arms was engaged following the insertion of Australian wires and was activated intermittently till the desired archform was achieved with prerequisite space requirement [Figure 5]. However, an open-coil spring was also required during the treatment to achieve the exact space dimension for maxillary left canine to erupt. The space created by this method drove the impacted canine right into its position and was later bonded. This was followed by heavy rectangular 19 × 25 SS wires for expression of bracket prescription. Second molars were banded later during the treatment to avoid any bite opening since the patient has a vertical growth tendency. This was supplemented by box elastics when these were included.
Finishing and detailing were done after taking a mid-treatment orthopantomogram [Figure 6] to assess the root status which required repositioning of a few brackets and use of spaghetti, serpentine, and triangular elastics.
Active treatment lasted 2 years following which patient was given fixed bonded retainers both in the upper and lower arches along with Hawley's which was supposed to be worn only during night to prevent in relapse in the expanded maxilla.
| Posttreatment Assessment|| |
Posttreatment assessment [Figure 7] and [Figure 8] revealed a Class I incisor relationship with 2 mm overjet and 25% overbite and all the individual malalignments corrected. Buccal segment occlusion was Class I bilaterally, with a mutually protected occlusion. Bilateral functional canine-guided occlusion was achieved with Class I Canines and premolars were in KATZ 0 and +1 for the left and right, respectively. There were no crossbites and displacements; however, lower dental midline was slightly off to the right.
Correct interdigitation and bilateral canine-guided occlusion will have lesser relapse tendency. The patient was however kept on 6 months follow-up for regular dental checkups and case assessment.
Posttreatment radiographs [Figure 9] and [Figure 10] revealed good root parallelism and the cephalometric values have remained more or less the same as pretreatment values. Mandible has very slightly rotated down.
Comparison of pretreatment and posttreatment [Figure 11] reveals good esthetic and functional result.
| Complications Encountered during Treatment|| |
Torque expression of the upper laterals was insufficient regarding the case. Additional torque was given in the wires initially with respect to 12 and 22 and later supplemented with Goodman torquing springs to achieve the desired finish of the case.
| Critical Appraisal|| |
The lower midline should have been better aligned and slightly toward the left.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]