Management of

ectopic canine

Interception of displaced canine

Management of ectopic canine is difficult
Early detection of an abnormal eruption path gives the
opportunity for interceptive measures.
Essential to routinely palpate for unerupted canine when
examining child aged 10 years old and older
also important to locate position of canines before undertaking
the extractions of other permanent teeth

Buccally ectopic canine

Buccal displacement usually associated with crowding
relief of crowding prior to eruption of canine will usually
effect in some spontaneous improvement
In erupted bucally displaced canine managed by relief of crowding, if
indicated, and alignment usually with fixed appliance.
Extraction of the first premolars
distalizing the maxillary molars and premolars to create space for
accommodation of the canine

In severely crowded cases ( no additional space exists to

accommodate canine) extraction of canine itself may be
indicated

 In impacted canine
surgical exposure of impacted tooth may be indicated
Then in order to apply traction to align the canine, an
attachment can be bonded to the tooth at the time of surgery.
A gold chain or stainless steel ligature can be attached to the
tooth and used to apply traction

Replaced flap. A mucoperiosteal flap was

retracted so that an attachment could be
bonded to the crown of the maxillary right
canine. A twisted steel ligature was tied to
the attachment and left lying against the
bone. The flap was returned to its original
position and sutured around the exposed
loop of the ligature.

Displaced flap. This partial-thickness flap

was raised from the gingival crest. It was
then displaced apically and mesially so
that a portion of the blocked-out tooths
crown, with its bonded steel button and
attached ligature, remained exposed to
the oral cavity.

Palatally impacted canine

There are various treatment modalities for palatally impacted
canine. Patient and parent counseling on the various treatment
options are essential.
Factors affecting treatment decisions:
patients opinion of appearance and motivation towards orthodontic
treatment
malocclusion
position of displaced canine : is it within range of orthodontic alignment?
presence of space/ crowding
Condition of teeth

1. Interceptive Treatment by
Extraction of Deciduous
Canine
Timely extraction of deciduous canine in patients aged 10-13 years with
palatally ectopic canines has been found to normalize the eruptive path
of canines within 12 months in 78% of cases (Ericson & Kurol, 1988).
will reduce the treatment complexity involved with impacted canine,
the treatment time and cost.

Indications (Ericson & Kurol, 1988.)

Patients aged between 10-13 years
Arches are spaced
Ectopic canine root still developing
Horizontal overlap of ectopic canine with lateral incisor not mesial to
midline of incisor (Ericson & Kurol, 1988.; Powers & Short, 1993.)

2. Surgical Exposure and

Orthodontic Treatment
The purpose of surgical exposure is for alignment of the ectopic
canine with fixed orthodontic appliances.
indications for the procedure:
Patient must be willing to wear fixed appliances
Since the treatment time is normally prolonged, the general dental
health of the patient should be good
When interceptive extraction is not feasible
Favorable canine position
Space available ( or can be created)

Whether orthodontic alignment is feasible or not depends

on the three-dimensional positioned of unerupted canine
Height :
The higher a canine is positioned relative to occlusal plane the poorer the
prognosis.
access for surgical exposure will be more restricted
If crown tip is at or above the apical third of the incisor roots, rthodontic
alignment will be very difficult
Anteroposterior position :
The nearer the canine crown to the midline, more difficult alignment will be.
Positon of apex :
The further away the canine apex is from normal, the poorer the prognosis for
successful alignment
Inclination :
The smaller the angle with the occlusal plane the greater need for traction

If these factors are favorable, the usual sequence of

treatment is as follow:
Make space available

Arrange exposure

Allow the tooth to erupt for2-3 months

Commence traction
With deeply buried canine, there is danger that gingiva
will cover the tooth again. An attachment plus means of
traction ( wire ligature or gold chain) can be bonded to
the tooth at the time of exposure.

3. Surgical removal of canine

This option can be considered when :
The patient refuses orthodontic treatment
The contact between the lateral incisor and first premolar is acceptable
Pathological changes associated with the ectopic canine or radiographic evidence of
early root resorption of the adjacent teeth
The ectopic canine is ankylosed and cannot be tract into the arch or transplanted.
Prognosis for the alignment of the ectopic canine depends on its 3 dimensional
position. It is poor when (Southall & Gravely, 1989):
The canine crown is tilted towards the midline of the arch
The position of the crown tip is less than one third of the incisor roots
The inclination of the canine is more horizontal
Canine root apex is away from its normal position.

4. Transplantation
Orthodontic alignment is preferable whenever possible.
Autotransplantation can be an alternative to orthodontic treatment
and surgical removal of ectopic canines if:
a. The patient rejects orthodontic treatment because of social and aesthetics
reasons.
b. The canine is severely malpositioned and cannot be aligned orthodontically.
c. Sufficient space and bucco-palatal bone must be provided for the transplant.

Management of ectopic permanent

first molars
Ectopic eruption of permanent molars is classified into
two types:
self-correct
Sixty-six percent of ectopic eruption permanent molars selfcorrect by age seven.
others that remain impacted.
permanent molar that presents with part of its occlusal surface
clinically visible and part under the distal of the primary second
molar usually does not self-correct and is the impacted type.
Guideline on Management of the Developing Dentition and Occlusion in Pediatric Dentistry, American Academy Of Pediatric
Dentistry, revised 2014

 Treatment depends on how severe the impaction appears

clinically and radiographically.
For mildly impacted first permanent molars, where little of
the tooth is impacted under the primary second molar,
elastic or metal orthodontic separators can be placed to
wedge the permanent first molar distally. (Warren JJ et al 2001)
For more severe impactions, distal tipping of the permanent
molar is required. (Yaseen SM et al, 2011)
Tipping action can be accomplished with brass wires,
removable appliances using springs, fixed appliances such
as sectional wires with open coil springs, sling shot-type
appliances, a Halter-man appliance, or surgical uprighting.
Guideline on Management of the Developing Dentition and Occlusion in Pediatric Dentistry, American Academy Of Pediatric
Dentistry, revised 2014

orthodontic separators

Halter-man appliance

Unerupted central incisor

Neil, a 9-year-old boy, presents with 11 unerupted

 Sequence in management of unerupted 1.

Obtain oral surgical/orthodontic opinion (and possibly paediatric dental
opinion); if prognosis for 1 alignment judged satisfactory then,
Open space for unerupted 1 (may involve primary tooth extractions).
Remove supernumerary.
Bond attachment to 1.
an attachment with a length of gold chain should be bonded to 1 followed by flap
replacement (closed technique).

Do not surgically expose 1.

Align 1 with appropriate appliance. ( removable appliance)
Maintain 1 correction with bonded retainer.
Reassess malocclusion regarding further treatment needs.
It is likely that further treatment, probably loss of a premolar unit from each
quadrant and fixed appliance therapy, will be required at a later date and detailing
of 1 position can be undertaken at that stage

Upper removable appliance to open space

for 1.

Following extraction of four first premolars, fixed

appliance therapy

Refferences
Millett D, Welbury R, Clinical Problem Solving in Dentistry
Orthodontics and Peadiatrics Dentistry 2010 Elsevier Ltd. All rights
reserved.
Laura Mitchell, An Introduction to Orthodontics, Fourth Edition
Clinical Practice Guidelines, Management Of The Palatally Ectopic
Maxillary Canine , Ministry Of Health Malaysia September 2004
Guideline on Management of the Developing Dentition and Occlusion
in Pediatric Dentistry, American Academy Of Pediatric Dentistry,
revised 2014.
Hessa M Alkhal,Bakr Rabie,Ricky W K Wong, Orthodontic tooth
movement of total buccally blocked-out canine: a case report, Cases
Journal2009,2:7245