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- W2078754588 abstract "Multiple treatment options are available for patients who have impacted canines in addition to congenitally missing lateral incisors. This article describes the treatment of a 13-year-old postpubertal girl with bilaterally impacted permanent maxillary canines, missing lateral incisors, retained deciduous canines, and a midline diastema. The orthodontic treatment plan included extraction of the deciduous canines. A lingual and labial approach (1-couple force system) was used to move the permanent canines into the arch. Through a collaborative team effort, including an orthodontist and a periodontist, the outcome was excellent esthetically and functionally. Multiple treatment options are available for patients who have impacted canines in addition to congenitally missing lateral incisors. This article describes the treatment of a 13-year-old postpubertal girl with bilaterally impacted permanent maxillary canines, missing lateral incisors, retained deciduous canines, and a midline diastema. The orthodontic treatment plan included extraction of the deciduous canines. A lingual and labial approach (1-couple force system) was used to move the permanent canines into the arch. Through a collaborative team effort, including an orthodontist and a periodontist, the outcome was excellent esthetically and functionally. Maxillary canines are important both esthetically and functionally. They are also the second most frequently impacted teeth, with a prevalence of 1% to 4%.1Ericson S. Kurol J. Resorption of maxillary lateral incisors caused by ectopic eruption of the canines. A clinical and radiographic analysis of predisposing factors.Am J Orthod Dentofacial Orthop. 1988; 94: 503-513Abstract Full Text PDF PubMed Scopus (178) Google Scholar, 2Ericson S. Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary canines.Eur J Orthod. 1988; 10: 283-295PubMed Google Scholar, 3Baccetti T. Leonardi M. Armi P. A randomized clinical study of two interceptive approaches to palatally displaced canines.Eur J Orthod. 2008; 30: 381-385Crossref PubMed Scopus (104) Google Scholar Palatally impacted canines occur twice as frequently in females as in males, and bilateral occurrence has been reported to be in the range of 8% to 45%.2Ericson S. Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary canines.Eur J Orthod. 1988; 10: 283-295PubMed Google Scholar Jacoby4Jacoby H. The etiology of maxillary canine impactions.Am J Orthod. 1983; 84: 125-132Abstract Full Text PDF PubMed Scopus (232) Google Scholar stated that 85% of the impacted canines are palatal, and they usually occur in patients with adequate arch length. Patients with impacted maxillary canines are perceived to be more difficult and time-consuming to treat than those with a routine malocclusion. From a treatment perspective, congenitally missing maxillary lateral incisors also pose significant problems for orthodontists.5Zilberman Y. Cohen B. Becker A. Familial trends in palatal canines, anomalous lateral incisors, and related phenomena.Eur J Orthod. 1990; 12: 135-139Crossref PubMed Scopus (112) Google Scholar, 6Peck S. Peck L. Kataja M. Prevalence of tooth agenesis and peg-shaped maxillary lateral incisor associated with palatally displaced canine (PDC) anomaly.Am J Orthod Dentofacial Orthop. 1996; 110: 441-443Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar, 7Kokich Jr., V.O. Congenitally missing teeth: orthodontic management in the adolescent patient.Am J Orthod Dentofacial Orthop. 2002; 121: 594-595Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar They are the third most commonly missing teeth after third molars and mandibular second premolars, and they account for 20% of all congenitally missing teeth.8Pinho T. Maciel P. Pollmann C. Developmental disturbances associated with agenesis of the permanent maxillary lateral incisor.Br Dent J. 2009; 207: E25Crossref PubMed Scopus (28) Google Scholar Jena and Duggal9Jena A.K. Duggal R. The pattern of maxillary canine impaction in relation to anomalous lateral incisors.J Clin Pediatr Dent. 2010; 35: 37-40PubMed Google Scholar stated that there is a high probability of palatal canine impaction when adjacent lateral incisors are anomalous or missing. Becker et al10Becker A. Smith P. Behar R. The incidence of anomalous maxillary lateral incisors in relation to palatally-displaced cuspids.Angle Orthod. 1981; 51: 24-29PubMed Google Scholar found that 5.5% of patients with a palatally impacted canine had a congenitally missing lateral incisor. Anic-Milosevic et al11Anic-Milosevic S. Varga S. Mestrovic S. Lapter-Varga M. Slaj M. Dental and occlusal features in patients with palatally displaced maxillary canines.Eur J Orthod. 2009; 31: 367-373Crossref PubMed Scopus (33) Google Scholar reported that 16% of patients with palatal canine impaction have peg-shaped lateral incisors, missing lateral incisors, or missing second premolars, suggesting a significant association between palatally impacted canines and missing lateral incisors. Mossey et al12Mossey P.A. Campbell H.M. Luffingham J.K. The palatal canine and the adjacent lateral incisor: a study of a west of Scotland population.Br J Orthod. 1994; 21: 169-174Crossref PubMed Scopus (51) Google Scholar stated that smaller than average crown width of lateral incisors is an important factor for palatal canine impaction; however, no statistical evidence has yet given credibility to the association between the crown width of lateral incisors and palatal canine impaction. Nevertheless, when it does happen, careful treatment planning is imperative. Strang13Strang R.H.W. Textbook of orthodontia. Lea & Febiger, Philadelphia1950Google Scholar stated that in patients with missing lateral incisors and impacted canines, the best option is to create space for the lateral incisors followed by prosthetic replacement for the missing lateral incisors. On the other hand, Carlson14Carlson H. Suggested treatment for missing lateral incisor cases.Angle Orthod. 1952; 22: 205-216Google Scholar emphasized canine substitution of the lateral incisors followed by selective recontouring of the canines. A maxillary midline diastema is a malocclusion characterized by spaces between the maxillary central incisors; it has functional and esthetic consequences. It is more prevalent in the African American population than in white people.15Cao J. Wan L. Zhang Z. Ma S. Orthodontic closure of a midline diastema with an infrabony defect.J Clin Orthod. 2011; 45: 156-159PubMed Google Scholar, 16Gkantidis N. Kolokitha O.E. Topouzelis N. Management of maxillary midline diastema with emphasis on etiology.J Clin Pediatr Dent. 2008; 32: 265-272PubMed Google Scholar The most common etiology reported in the literature is tooth size or jaw size discrepancy including missing lateral incisors.16Gkantidis N. Kolokitha O.E. Topouzelis N. Management of maxillary midline diastema with emphasis on etiology.J Clin Pediatr Dent. 2008; 32: 265-272PubMed Google Scholar Retained deciduous canines are sometimes present with palatally impacted canines. Studies have shown that the removal of a deciduous canine results in successful eruption; in some cases, it has been shown to be successful in inducing eruption and even uprighting the impacted canines.3Baccetti T. Leonardi M. Armi P. A randomized clinical study of two interceptive approaches to palatally displaced canines.Eur J Orthod. 2008; 30: 381-385Crossref PubMed Scopus (104) Google Scholar, 17Bonetti G.A. Zanarini M. Parenti S.I. Marini I. Gatto M.R. Preventive treatment of ectopically erupting maxillary permanent canines by extraction of deciduous canines and first molars: a randomized clinical trial.Am J Orthod Dentofacial Orthop. 2011; 139: 316-323Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 18Jacobs S.G. Reducing the incidence of unerupted palatally displaced canines by extraction of deciduous canines. The history and application of this procedure with some case reports.Aust Dent J. 1998; 43: 20-27Crossref PubMed Scopus (24) Google Scholar Similarly, several authors have proposed the extraction of deciduous canines to return ectopically erupting canines to normal eruption pathways, especially if the persistence of the deciduous teeth would be a mechanical obstacle for the emergence of the permanent teeth.2Ericson S. Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary canines.Eur J Orthod. 1988; 10: 283-295PubMed Google Scholar, 3Baccetti T. Leonardi M. Armi P. A randomized clinical study of two interceptive approaches to palatally displaced canines.Eur J Orthod. 2008; 30: 381-385Crossref PubMed Scopus (104) Google Scholar In this article, we report on a patient with bilaterally impacted canines, congenitally missing lateral incisors, hypertrophic and incisively placed labial frenum, and retained deciduous canines. A 13-year-old postpubertal girl came to our clinic with the chief complaint of spacing between her maxillary central incisors (Fig 1). She had no significant medical history, but her dental history included an amalgam restoration and sealants on the posterior teeth. She reported a history of crepitus in the left temporomandibular joint, but no limitations of mouth opening or pain were reported at the initial examination. The pretreatment records showed a straight to mild tendency toward a concave facial profile. She had a Class II (end on) molar relationship bilaterally. Clinical examination showed an 80% deepbite, 3 mm of overjet, U-shaped maxillary and mandibular arches, and the mandibular midline shifted toward the right by 2 mm. The maxillary labial frenum was attached to the incisive papilla. The patient had retained deciduous canines and congenitally missing lateral permanent incisors in the maxillary arch. The orthopantomogram (Fig 2) showed that both maxillary canines were bilaterally impacted, and the occlusal and periapical radiographs confirmed that the impactions were palatal. Tomographic images showed that the crowns of the canines were close to the roots of the central incisors, and the roots of the impacted canines were close to the roots of the premolars (Fig 3).Fig 2Pretreatment orthopantomogram.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3Tomograms showing the positions of the impacted canines: A, right side; B, left side.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The position of the impacted canines was evaluated with the orthopantomogram, periapical and occlusal radiographs, and tomograms. According to the method suggested by Ericson and Kurol,1Ericson S. Kurol J. Resorption of maxillary lateral incisors caused by ectopic eruption of the canines. A clinical and radiographic analysis of predisposing factors.Am J Orthod Dentofacial Orthop. 1988; 94: 503-513Abstract Full Text PDF PubMed Scopus (178) Google Scholar, 2Ericson S. Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary canines.Eur J Orthod. 1988; 10: 283-295PubMed Google Scholar the right and left canines were impacted at 55° and 58°, respectively (Fig 4, A). Mesiodistal evaluation according to the method of Baccetti at al3Baccetti T. Leonardi M. Armi P. A randomized clinical study of two interceptive approaches to palatally displaced canines.Eur J Orthod. 2008; 30: 381-385Crossref PubMed Scopus (104) Google Scholar showed a sector 5 impaction, where the impacted canine completely overlapped the central incisor crown (Fig 4, B). The etiology of palatally impacted canines is obscure and multifactorial. In this patient, we speculated on 2 possible reasons for the impaction of the maxillary canines: genetics and congenitally missing lateral incisors. Because neither her sibling nor her parents had impacted canines, heredity was ruled out as a potential factor for impaction. Therefore, the missing lateral incisors might have been responsible for the bilateral canine impaction. Previously, it was speculated that the root of the lateral incisor might play an important role in the eruption of the permanent canine by providing adequate guidance for its eruption.4Jacoby H. The etiology of maxillary canine impactions.Am J Orthod. 1983; 84: 125-132Abstract Full Text PDF PubMed Scopus (232) Google Scholar, 8Pinho T. Maciel P. Pollmann C. Developmental disturbances associated with agenesis of the permanent maxillary lateral incisor.Br Dent J. 2009; 207: E25Crossref PubMed Scopus (28) Google Scholar The patient was diagnosed with an Angle Class II malocclusion, congenitally missing maxillary lateral incisors, palatally impacted maxillary canines, midline diastema, incisively placed frenum, and 80% deepbite. The treatment objectives for this patient were to achieve an optimal soft-tissue profile and establish an ideal occlusal relationship after the eruption of the impacted canines and the attainment of normal overjet and overbite. The treatment plan to achieve these objectives was established as follows. The impacted canines would be surgically exposed on an outpatient basis under local anesthesia and brought into the arch using cantilever mechanics; the retained deciduous canines would be extracted. The congenitally missing lateral incisors and impacted canines would be replaced with the canines and the premolars, respectively. The midline diastema would be closed; to prevent the relapse, the labial frenum would be surgically resected. The deepbite would be corrected and an ideal occlusal relationship established. The second option was to distalize the molars bilaterally to achieve an Angle Class I molar relationship and to restore the space for prosthetic implants in place of the congenitally missing lateral incisors, but this option was rejected because the patient was only 13 years old, and we must wait at least 5 years before placing implants. Also, the parents opted out of it for economic reasons. The other option was to convert the deciduous canines into lateral incisors, but this option was also rejected because more than half of the roots of the canines were resorbed, and we were not sure about the longevity of the deciduous canines. Overall, the treatment progressed in 3 phases. Phase 1 was the initial banding of the maxillary molars. The maxillary right and left canines were surgically exposed, and gold chains were connected to the attaching device (button) on the impacted canines. Initial orthodontic traction was applied using a low load deflection rectangular Connecticut new archwire (Ultimate Wireforms Inc, Bristol, Conn) to prevent detrimental effects to the roots of the incisors. A transpalatal arch was used to prevent the side effects of cantilever on the molars. As the canines moved closer to the oral cavity, more gold chain was exposed through the mucosa; when necessary, the excess chain was cut. After complete eruption of the crown into the oral cavity, the buttons were removed, and brackets were placed to move the canines into the arch. The total duration of phase 1 was 15 months. It was a time between the application of orthodontic traction and eruption of the crowns of the impacted canines into the oral cavity. Phase 2 was fixed appliance therapy aimed at creating space in the maxillary arch to accommodate the palatally impacted canines. All teeth were sequentially bonded or banded with 0.022 × 0.028-in preadjusted edgewise brackets. The deciduous canines were extracted, the midline diastema was closed, and the impacted canines were brought into the arch. A frenectomy was performed immediately after closure of the diastema. Phase 2 took 12 months to complete, and it was the time for closing the midline diastema and moving the impacted canines into the arch (Fig 5). Phase 3 included orthodontic treatment to align the canine in the arch and final finishing and detailing using a 0.021 × 0.025-in rectangular Connecticut new archwire. Settling was done on a 0.017 × 0.025-in stranded stainless steel archwire using triangular seating elastics. Total duration of phase 3 was 7 months. The overall treatment time for this patient was 34 months. The impacted canines were brought to their correct positions in the arches. There was a dramatic improvement in the patient's smile. Facial balance was maintained despite extraction of the deciduous canines. The final study models show a bilateral Class II molar relationship and a Class I canine relationship. Ideal overjet and overbite were achieved (Fig 6). The panoramic radiograph showed that the roots were well aligned and angulated, but there was noticeable root resorption on both maxillary central incisors (Fig 7).Fig 7Orthopantomogram before debonding.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The periodontal evaluation at the end of the treatment showed healthy tissues, with pale pink and firm gingivae, and probing depths were not more than 2 mm. Opening the lateral incisor spaces for endosseous implants or substituting the canine for missing lateral incisor is, of course, a diagnostic decision that depends on various factors and needs a multidisciplinary treatment plan. The lingual approach for the management of the impacted canines was specifically used in this patient, because the canines were adjacent to the midpalatal suture. A modified transpalatal arch was used to make the posterior teeth a unit. A rectangular Connecticut new archwire (cantilever spring) was used from the contralateral molars, and the initial force directed on the impacted canines was vertical (extrusive force).19Fleming P.S. Sharma P.K. DiBiase A.T. How to...mechanically erupt a palatal canine.J Orthod. 2010; 37: 262-271Crossref PubMed Scopus (12) Google Scholar As the canines erupted into the oral cavity, the force direction was changed to both extrusive and labial. Cantilever-based appliances or springs (1-couple force systems) are designed to have a low load deflection rate.20Kornhauser S. Abed Y. Harari D. Becker A. The resolution of palatally impacted canines using palatal-occlusal force from a buccal auxiliary.Am J Orthod Dentofacial Orthop. 1996; 110: 528-534Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar The force systems delivered by these appliances tend to stay optimal and consistent in their magnitude, not causing any deleterious effects on the surrounding periodontium through the entire range of tooth movement.21Yadav S. Chen J. Upadhyay M. Jiang F. Roberts W.E. Comparison of the force systems of 3 appliances on palatally impacted canines.Am J Orthod Dentofacial Orthop. 2011; 139: 206-213Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Additionally, an acceptable magnitude of force is maintained in the appliance during treatment to avoid frequent reactivations. During active orthodontic treatment, attention was paid to the optimal force magnitudes of the cantilever springs and the wires to prevent any root resorption of the maxillary incisors.22Otto R.L. Early and unusual incisor resorption due to impacted maxillary canines.Am J Orthod Dentofacial Orthop. 2003; 124: 446-449Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Resorption of the incisors was consistently found in patients in whom the cusp of the maxillary canine was positioned medially to the midline of the lateral incisor in the orthopantomogram and other accessory radiographic films. In this patient, the cusp tips of the impacted canines were positioned medially to the maxillary central incisors.23Milberg D.J. Labially impacted maxillary canines causing severe root resorption of maxillary central incisors.Angle Orthod. 2006; 76: 173-176PubMed Google Scholar Three-dimensional radiography studies have shown up to 38% of root resorption for lateral incisors and 23% of root resorption for central incisors associated with an impacted canine.24Liu D.G. Zhang W.L. Zhang Z.Y. Wu Y.T. Ma X.C. Localization of impacted maxillary canines and observation of adjacent incisor resorption with cone-beam computed tomography.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 105: 91-98Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 25Alqerban A. Jacobs R. Lambrechts P. Loozen G. Willems G. Root resorption of the maxillary lateral incisor caused by impacted canine: a literature review.Clin Oral Invest. 2009; 13: 247-255Crossref PubMed Scopus (91) Google Scholar Resorption of permanent incisors is a common complication during the management of palatally impacted canines. Depending on the severity of the root resorption, it can lead to the extraction of the permanent incisors or an increase in the treatment time, or both.25Alqerban A. Jacobs R. Lambrechts P. Loozen G. Willems G. Root resorption of the maxillary lateral incisor caused by impacted canine: a literature review.Clin Oral Invest. 2009; 13: 247-255Crossref PubMed Scopus (91) Google Scholar, 26Alqerban A. Jacobs R. Souza P.C. Willems G. In-vitro comparison of 2 cone-beam computed tomography systems and panoramic imaging for detecting simulated canine impaction-induced external root resorption in maxillary lateral incisors.Am J Orthod Dentofacial Orthop. 2009; 136 (discussion 764-5): 764.e1-764.e11Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar The exact location of the palatally impacted canines is important to prevent or reduce complications. The root resorption in this patient was due to the initial location of the crown of the canines (close to the periodontal ligament space of the central incisor) and the contact relationship of the canines' crowns with the roots of the central incisors during the application of orthodontic force. Extraction of the deciduous canine is the treatment for the self-correction of palatally impacted canines, but if the impacted canine cusp tips are located medial to the lateral incisors, extraction of the deciduous canine will not help in self-correction. Studies have favored extraction of the impacted canines if the angulation of the canine to the midline is increased.27Stivaros N. Mandall N.A. Radiographic factors affecting the management of impacted upper permanent canines.J Orthod. 2000; 27: 169-173Crossref PubMed Scopus (69) Google Scholar, 28Motamedi M.H. Tabatabaie F.A. Navi F. Shafeie H.A. Fard B.K. Hayati Z. Assessment of radiographic factors affecting surgical exposure and orthodontic alignment of impacted canines of the palate: a 15-year retrospective study.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 107: 772-775Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 29Nagpal A. Pai K.M. Setty S. Sharma G. Localization of impacted maxillary canines using panoramic radiography.J Oral Sci. 2009; 51: 37-45Crossref PubMed Scopus (28) Google Scholar However, the study of Fleming et al30Fleming P.S. Scott P. Heidari N. Dibiase A.T. Influence of radiographic position of ectopic canines on the duration of orthodontic treatment.Angle Orthod. 2009; 79: 442-446PubMed Google Scholar does not support this rationale. In this patient, we can speculate that the diastema resulted from both the congenital absence of the lateral incisors and the hypertrophic and incisively attached frenum. After the impacted canines were moved into the oral cavity, the deciduous canines were extracted, the midline diastema was closed, and the frenum was surgically resected. After we achieved the desired orthodontic results, the patient was advised to have the canines reshaped to lateral incisors and the first premolars reshaped to canines, but the parents refused this for economic reasons. The total time for the moving the impacted canines into the oral cavity was approximately 15 months; this was longer than the average of 12 months reported in several studies.27Stivaros N. Mandall N.A. Radiographic factors affecting the management of impacted upper permanent canines.J Orthod. 2000; 27: 169-173Crossref PubMed Scopus (69) Google Scholar, 29Nagpal A. Pai K.M. Setty S. Sharma G. Localization of impacted maxillary canines using panoramic radiography.J Oral Sci. 2009; 51: 37-45Crossref PubMed Scopus (28) Google Scholar The reason for the longer time was the initial position of the impacted canines; both canines crossed the long axis of the corresponding central incisors, and they had an α angle of 55°. Ericson and Kurol31Ericson S. Kurol J. Radiographic assessment of maxillary canine eruption in children with clinical signs of eruption disturbance.Eur J Orthod. 1986; 8: 133-140Crossref PubMed Scopus (207) Google Scholar stated that an angle greater than 31° and a mesiodistal position of the canines (sector 5) usually takes more time to erupt into the oral cavity. Schubert and Baumert32Schubert M. Baumert U. Alignment of impacted maxillary canines: critical analysis of eruption path and treatment time.J Orofac Orthop. 2009; 70: 200-212Crossref PubMed Scopus (20) Google Scholar concluded that treatment time for bilateral impactions is approximately 5 months longer than unilateral impaction because of the metabolic process and anisotropic quality of bone. The other reason could be the increased bone mineral density because the patient was postpubertal. However, retrieving the bilaterally impacted canines into the mouth was done with minimal fixed appliances, thereby shortening the time with full fixed appliances. Orthodontic, periodontal, and esthetic outcomes are frequently compromised in a patient with bilaterally impacted canines and congenitally missing lateral incisors. These problems require careful and multidisciplinary treatment planning. The precise mechanics along with careful planning at each step helped us to achieve the desired results." @default.
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