By Dr.Muhammad ATHAR Khan

PGR OMFS Nid,Multan.

Thick and Dense palatal mucoperiostium

Thick hard palate Bone

Long Distance to eruption

Last ant.tooth to erupt

Retained Primary canine

Inadeqaute space

Root development completed before eruption

Eruption of Tooth is dependent on increase in apical development.

A Tooth wich Fails to Erupt into its Functional

position within expected time is called impacted

tooth.

The surgical removal of a deeply seated

maxillary canine in relation to the maxillary sinus

and the nasal cavity is one of the most difficult

oral surgical procedures

•Maxillary canine is 20 times

more than mandibular canine

• More frequent in females than

males

• Palatal impaction is 3 times

more than buccal impaction

•Classification of impacted maxillary canine:ARCHER,S CLASSIFICATION1) Class IPalatally Impacted canine

a) Horizontalb) Verticalc) semivertical

2)Class II Buccally impacted canine

a) Horizontalb) Vertical c) Semivertical

3)Class IIIImpacted canine located in both the palatal and labial surfaces.

4)Class IVImpacted canine located in the alveolar process.5)Class VImpacted canine located in an edentulous maxilla.6) Class VI in aberrant position.

•

◦ Localization of impacted maxillary canine:

clinical examination

Radiographic examination

Clinical examination:

By palpation:

Presence of distinct bulge

Deflection of crowns:

mostly of lateral incisors or premolars.

Radiological examination:

a) Intra-oral periapical films

b) Occlusal radiographs

Canine will appear as a round radioapaque

structure.

In This technique, the films are in the same position while the cone is shifted,

if the canine moves with same direction of the cone ,

it indicates that it is located far (palatally),

while if the canine moves opposite to the direction of the cone ,

it indicates that it is near (buccally).

(SLOB Rule)

d) Tomograms:

Sections are taken, if the

canine is impacted buccally ,

it's tip will appear first ,

while if impacted palatally,

the apex will appear first.

To determine relation to maxillary sinus.

•..

•Contra-indications for the removal of an impacted maxillary canine: When it can be brought into normal position

either by

surgical repositioning or

surgery and orthodontictreatment

Factors complicating the removal of the impacted canine:

Close relationship to the roots of the neighboring teeth.

Intimate relation to the maxillary sinus.

Curvature or hypercementosis of the root.

Difficulty in localization most important factor.

◦ SURGICAL REMOVAL OF IMPACTED MAXILLARY CANINE

Planning the operative procedure

X-ray examination

Classify the impaction

Extent of the flap

Sectioning of the tooth is needed or not

Removal of palatally impacted canine:

1- If unilateral:

1. Reflection of flap from mesial of central incisor to distal of first molar. The flap is better to be envelop.

2. Bone removal by post stamp technique.

3. Decapitation removal of the crown.

4. A cryer elevator is used to push the root to the empty space then remove it.

2- If bilateral: - The flap will result in cutting of nasopalatine

vessels & nerves leading to hemorrhage & numbness in order.

- However, regeneration of the nerve fibers will occur later so if you don't have anyother option, do it.

- Anther solution is to make the flap crossing around the incisive papilla to avoid injury to the neurovasculature.

- Upon suturing a palatal flap always place the knots buccally to prevent irritation of the tongue.

Removal of labially impacted canine:

Easier since the buccal plate of bone is thinner & better accessibility.

A pyramidal flap is preferred , followed by similar steps as before..

Removal of impacted canine from intermediate position

Usually open the flap in the area where the crown is present (mostly buccally),So a buccalflap is reflected first.

The type of the flap differs according to the height of the impacted tooth e.g. if the tooth is very high, do semilunar flap or pyramidal.

After opening a buccal flap, decapitate & remove the crown, follower them by the root.

open the buccal flap finding the rootremove it first then do a palatal flap & remove the crown (keep the buccal flapopen because you might need it)If the other half of the tooth can't be reached, push it from the buccal side to the palatal side or vice versa until it can be held & removed.

Removal of impacted canine in edentulous ridge:

The problem here is the pneumatization of the maxillary sinus & should be in mind while doing such impaction.

If the tooth need the buccal side, do buccalflap.

If the tooth need the palatal side do palatal flap.

Removal of impacted canine from unusual position:

These situations will be managed according to the position.

The canine could be in: Zygoma, below orbit, inferior turbinate of the nose, maxillary sinus.

For example: if canine is impacted in maxillary sinus then Caldwell-Luck operation will be performed

Surgical exposure of the impacted maxillary canine for orthodontic treatment :

A flap is opened to expose the canine then a bracket is placed over the exposed canine with arch wire over the adjacent teeth

Replantation can be done i.e. remove the canine & create a socket where you like to place the tooth then do endo or retrograde filling , be sure that the replanted tooth is in vertical position & out of occlusion.

Treatment Options:

Extraction.

Reposition.

Surgical exposure & orthodontics.

Replantation.

Exposure of the inferior alveolar canal. Injury or compression to the inferior alveolar nerve resulting in

paraesthesia. Injury to inferior alveolar vessels resulting in Hemorrhage

Fracture of roots and displacement into the maxillary sinus or submandibular space

Necrosis of the flap due to improper placement. Fracture of large segment of bone Traumatization or dislodgement of adjacent teeth Injury to the soft tissues from the instruments Forcing a tooth into the maxillary sinus Forcing maxillary third molar into the ptergopalatine fossa

Opening into the nasal cavity oro-nasal communication. Fracture of the alveolar process Fracture of the lingual plate of bone Fracture of maxillary tuberosity. complete fracture of the mandible

Extensive laceration of the soft tissues Extensive exposure of the roots of the adjacent teeth Acute trismus Pain of dry socket Discoloration of the soft tissue due to ecchymosis Necrosis of large segment of bone

THANX