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References

Ericson S, Kurol J Radiographic assessment of maxillary canine eruption in children with signs of eruption disturbance. Eur J Orthod. 1986; 8:133-140
Crescini A, Clauser C, Giorgetti R, Cortellini P, Prato GP Tunnel traction of infraosseous impacted maxillary canines. Am J Orthod Dentofacial Orthop. 1994; 105:61-72
Woloshyn H, Årtun J, Kennedy DB, Joondeph DR Pulpal and periodontal reactions to orthodontic alignment of palatally impacted canines. Angle Orthod. 1994; 64:257-264
Becker A, Brin I, Ben-Bassat Y, Zilberman Y, Chaushu S Closed-eruption surgical technique for impacted maxillary incisors: a postorthodontic periodontal evaluation. Am J Orthod Dentofacial Orthop. 2002; 122:9-14
Crescini A, Nieri M, Buti J, Baccetti T, Mauro S, Paolo G, Prato P Short and long term periodontal evaluation of impacted canines treated with a closed surgical – orthodontic approach. J Clin Periodontol. 2007; 34:232-242

Tunnel traction of impacted maxillary canine: a case report

From Volume 10, Issue 1, January 2017 | Pages 28-30

Abstract

This case report describes a surgical approach for the orthodontic treatment of deep infra-osseous impacted canines. This technique allows for orthodontic traction of the impacted tooth to the centre of the alveolar ridge, which results in a better periodontal outcome.

CPD/Clinical Relevance: Use of a tunnel traction technique to treat deep infra-osseous canines.

Article

The maxillary canine is commonly displaced or impacted. Labial impaction of a maxillary canine is due either to ectopic migration of the canine crown over the root of the lateral incisor or shifting of the maxillary dental midline, giving rise to insufficient space for the canine to erupt.1

The surgical orthodontic treatment of impacted canines is aimed at bringing the tooth into its correct position in the dental arch without causing periodontal damage. To achieve this goal, a variety of surgical and orthodontic techniques have been proposed. There are three techniques for uncovering a labially impacted maxillary canine:

  • Excisional uncovering (Figure 1);
  • Apically positioned flap; and
  • Closed eruption technique (Figure 2).
    • Figure 1. Excisional uncovering of impacted canine.
    Figure 2. Closed eruption technique.

    According to Crescini et al, one of the fundamental indicators of the success of treatment of impacted maxillary canines is the final periodontal outcome.2

    The literature shows that the most severe periodontal damage occurring in the treatment of impacted canines is the loss of supporting bone and it is associated with more radical surgical procedures involving exposure of the tooth underneath the cemento-enamel junction.3,4 Therefore, a part of the keratinized gingiva must be preserved or an apically positioned flap should be used. In deep infra-osseous impaction cases, although the removal of a significant portion of cortical bone favours eruption of the tooth, removing tissue may result in the loss of bone support. In the case of deep infra-osseous impaction, these techniques cannot always be used safely and other steps are required to achieve a satisfactory periodontal outcome.

    Here a surgical approach for the orthodontic treatment of deep infra-osseous impacted canines is described. This technique allows for orthodontic traction of the impacted tooth to the centre of the alveolar ridge, which results in a better periodontal outcome.

    Case report

    A 16-year-old patient presented with the main complaint of irregularly arranged teeth (Figure 3). There was no relevant medical history. Clinical examination revealed an ectopically erupted canine in the first quadrant and a retained deciduous canine and missing permanent canine in the second quadrant (Figures 3, 4). Radiographic examination (an orthopantomogram) showed a deep infra-osseous impaction of the canine (Figure 5).

    Figure 3. Frontal intra-oral view.
    Figure 4. Lateral intra-oral view showing retained deciduous canine in second quadrant.
    Figure 5. Pretreatment OPG showing impacted canine.

    Technique

    Tunnel traction2 of the impacted canine was planned as the permanent canine is situated just above the retained deciduous canine (seen in the maxillary occlusal radiograph – Figure 6). A full thickness flap was raised to expose the cortical plate, and the deciduous canine was removed. Cortical bone was removed to provide access to the crown, and the follicular socket was eliminated. The deciduous socket formed a tunnel that was used for the traction (Figure 7). A handmade wire chain of rings (approximately 1.5 mm in diameter) was prepared with 0.011” ligature wire. The chain was passed through the osseous tunnel and fixed as closely as possible to the cusp of the impacted canine by means of an attaching device, a bonded bracket base with a soldered ring (Figure 8). The chain passed through the bone tunnel and emerged from the socket of the deciduous tooth. The flap was then repositioned and sutured in its original position. One week after surgery, the sutures were removed and the traction phase began (Figure 9). A force of approximately 100 grams was applied, while care was taken to maintain the chain at the centre of the socket. The elastic traction was directed to the centre of the alveolar ridge. During the orthodontic treatment, the patient was recalled every 4 weeks to activate the traction force and reinforce oral hygiene measures.

    Figure 6. Maxillary occlusal radiograph.
    Figure 7. Tunnel preparation.
    Figure 8. Bonded attachment on canine and placement of traction hook through tunnel.
    Figure 9. Tunnel traction started.

    The cusp of the impacted canine thus emerged in place of the deciduous canine, at the centre of the alveolar process, after 3 months and was surrounded by keratinized gingiva (Figures 10, 11). The canine was aligned into the arch through routine orthodontic mechanics within 5 months (Figure 12).

    Figure 10. Progression of tunnel traction on IOPA.
    Figure 11. Eruption of canine into the arch.
    Figure 12. Alignment of canine completed.

    Discussion

    In deep infra-osseous impaction cases, although the removal of a significant portion of cortical bone favours eruption of the tooth, removing tissue may result in the loss of bone support. So these techniques cannot always be used safely and other steps are required to achieve improved periodontal outcome.

    When an impacted canine is situated near or above the roots of a retained deciduous canine, satisfactory results could be expected if the physiologic eruption pattern is restored. It was believed that ‘When a permanent tooth erupts, ideally it will break through the gingiva near the crest of the ridge so that some gingiva will be present on the facial surface.’5

    Tunnel traction allows for orthodontic traction of the impacted tooth to the centre of the alveolar ridge with preservation of alveolar bone, which results in a better periodontal outcome for the erupted canine.