DEPARTMENT OF ORAL &

MAXILLOFACIAL SURGERY

CANINE IMPACTION
 CANINE IMPACTION
INTRODUCTION:
The word IMPACTION is derived from
latin word “impactus”.
DEFINITION:
Impacted tooth is the tooth that has
failed to erupt completely or partially to its
correct position in the dental arch and its
eruption potential has been lost.
Maxillary canines are usually more
commonly impacted than mandibular
canines.
 FACTORS RESPONSIBLE
FOR CANINE IMPACTION
1. Delayed resorption of the primary canines may
lead to impaction of permanent canine.

2. As canines erupt between the teeth already in

occlusion,these have to compete for space in the
oral cavity, moreover mesio-distal diameter of the
primary canine is much less than that of permanent
canine.

3. The bone of the hard palate offers more resistance

than the alveolar bone on the ridge for a lingually
erupting canine.
4. The muco-periosteal tissue covering the
anterior 1/3rd of the palate is very thick, dense
and firmly adherent to the bone and as such
offers resistance to eruption of canine.

5. The greater the distance a tooth is supposed to

travel from the point of development to its place
of normal occlusion, greater will be the
possibility of its misdirection and impaction.
Canines have a greater distance of all the teeth
to travel , so are more prone to be impacted.
INDICATIONS FOR REMOVAL
OF IMPACTED CANINE:
1. Change in position of the adjacent teeth
because of pressure exerted due to the attempt
for eruption of the canine.

2. Resorption of the roots of adjacent teeth

because of pressure exerted by the impacted
canine.

3. Cyst formation from the follicle around the

canine. Attempt should be made to remove the
cyst and facilitate the eruption of impacted
canine.
4. Repair of cleft palate may cause scarring and
narrowing of the arch leaving no place for
canine to erupt.
5. In edentulous jaw, an impacted canine can
be left unnoticed. It starts erupting with
denture irritation and needs to be removed.
6. Pain in eye, ear, side of the head, entire face
and back of neck can be attributed to
impacted canine and calls for its removal.
7. Canines lying in unusual positions like naso-
antral wall or floor of the orbit are indicated
to be extracted as they may not start
erupting in the nasal cavity or on the face.
 CONTRAINDICATION FOR
REMOVAL OF IMPACTED
TOOTH
 All impacted teeth should be removed
unless specific contraindications
justify leaving them in position.

 Contraindication for the removal of

impacted teeth primarily involve the
patient’s physical status
1. The Extremes of age:
Most common contraindication for the
removal of impacted teeth is advanced
age.
As the patient ages the bone becomes
highly calcified, therefore less flexible
and
The less likely
result to bend
is that more under the forces
bone must be
surgically removed to displace the
of tooth extraction.
tooth from its socket.
2. Compromised medical status:
If the impacted tooth is
asymptomatic, its surgical removal must
be viewed as elective.
if the patient is medically compromised ,
the surgeon must consider leaving the
tooth in the alveolar process.

If the tooth becomes symptomatic, the

surgeon must work carefully with the
patient’s physician to remove the tooth .
3. Probable excessive damage to tooth structure:
If the impacted tooth lies in an area in
which its removal may seriously damage
adjacent nerves, teeth or previously
constructed bridges, it may be prudent to leave
the tooth in place, if the tooth is aymptomatic.

If the tooth is symptomatic tooth should be

removed while taking special measures to
prevent damage to adjacent structures.
CLASSIFICATION OF IMPACTED
MAXILLARY CANINE:
Class 1: Palatally placed maxillary canine-
a. Horizontal
b. Vertical
c. Angulated

Class 2: Labially or buccally placed maxillary canine-

a. Horizontal
b. Vertical
c. Angulated

Class 3: Involving both buccal and palatal bone-

Eg: crown is placed on the palatal aspect and
the root is toward the buccal alveolar
process or vice versa.
Class 4: Vertically impacted canine in alveolar
process between lateral incisor and
first premolar.

Class 5: Canine impacted in the edentulous

maxilla.

Class 6: Maxillary canines in unusual positions.

Eg: in naso-antral wall or
infraorbital margin.
CLASSIFICATION OF IMPACTED
MANDIBULAR CANINE:
 LABIAL  ABERRANT
a. Labial a. At inferior
b. Oblique border
c. Horizontal b. On the opposite

side.
c. mental

protuberance
 CLINICAL FINDINGS FOR
IMPACTED TOOTH
 RADIOLOGICAL EXAMINATION:

1 Intraoral x-ray:
These are possible if the tooth is in
the alveolus and not in the ramus.
Possible if oral opening is adequate.
If there is no gagging.
Useful to study the relation with adjoining tooth.
Useful to study the configuration of the roots and
status of crown.
Useful to record the relationship with inferior
alveolar canal.
 TUBE SHIFT TECHNIQUE:

 For bucco or linguo version tube-shift method should be used or

occlusal film is taken.

 Occlusal radiographs are used because they allow full

visualization of the root structure and the relationship of canine to
the maxillary alveolus and nasal cavity.

 The first radiograph is taken directly in the midline, and Second is

taken with the beam shifted toward the side of the impacted
tooth.
 Using clark’s rule otherwise known as tube
shift or buccal shift technique, an impacted
canine located on the palate will appear to
move in the same direction as the x-ray beam,
while one on the labial aspect will move in the
opposite direction.
 The impacted canine located in the middle of
the alveolus will not appear to change its
location in the two radiographs . This is
because the alveolar ridge is the center about
which the beam is rotating.
 The axial orientation may be demonstrated nicely on a
radiograph.
 Computed tomographic scan is helpful if the canine is very
high and plain films cannot localize it definitively.

2. Extra oral x-ray:

Indicated in:
a. Trismus
b. Impacted tooth in aberrant position
c. For ruling out associated pathology
 TECHNIQUE FOR SURGICAL
REMOVAL OF IMPACTED
MAXILLARY CANINE

A. OPERATIVE PROCEDURE FOR

MAXILLARY CANINE IN LABIAL
POSITION:
Two types of incision are designed:
1.SEMILUNAR INCISION
2.ANGULATED FLAP INCISION
1. SEMILUNAR
INCISION:
It is designed on
the alveolar mucosa.
- It starts from the
frenum keeping the
bulge of the tooth in the
centre and extend in
the premolar region.
- The lower margin of
the incision should be
5mm away from the
gingival margin.
2.Angulated flap
incision
It is given
in the gingival crevice of
incisors and premolars
with :
vertical arm going into the
muco-buccal fold.
-Even two vertical
incisions can be made on
each side of the
impacted canine.
1. Raise muco-periosteal flap.
2. Drill holes in the bone covering the tooth.
3. Join these holes to remove the bone in the bulge
area exposing the crown fully.
4. Make a deep cut on mesial side of the crown
elevate the tooth with crier or straight elevator.
5. If tooth can’t be luxated and there are chance of
damage to the adjoining tooth, the bone from
the root should also be removed, alternately the
tooth can be removed by sectioning.
6. After removing the tooth, the socket should be
examined.
7. Remove the tooth follicle, loose piece of bone
and tooth etc.
8. Smoothen the sharp edges of bone.
9. Irrigate the socket with normal saline.
10. Replace the flap after obtaining the hemostasis.
11. Suture by interrupted sutures.
12. Stitches should be removed on seventh post
operative day.
13. Note: When canine is lying below the apices of
the roots of the lower teeth on the buccal side ,
it is approached intraorally.
 B. OPERATIVE PROCEDURE FOR REMOVAL
OF MAXILLARY CANINE IN PALATAL
POSITION

1. PALATAL INCISION:
Incision
is started from first
molar region around
the neck of the teeth
upon the central
incisor.
COMPLETE PALATAL INCISION:

 If both he maxillary canines are impacted

and plan to be removed in a single sitting ,
the incision is extended across the midline
upto the first molar region of opposite
side. In this case the naso-palatine vessels
are caught with hemostats and
ligated/cauterised.
 Raise the mucoperiosteal flap with periosteal elevator.
 A stay suture is passed through the flap for retraction.
 Most of the time the bulge bone is present.
 Make holes in the bone covering the canine.
 Join these holes to cut the bone, thereby exposing crown
and part of the root of the tooth.
 Make a deep cut on the exposed crown, try to elevate the
tooth taking bone as a fulcrum.
 Examine the socket, remove the tooth follicle and bone
chips.
 Wash the cavity with normal saline, replace the flap by
suturing with interrupted sutures after obtaining complete
hemostasis.
 Note: If there is danger of luxating the adjoining teeth, the
impacted tooth should be removed by sectioning.
PROCEDURE FOR REMOVAL
OF IMPACTED CANINE IN AN
UNUSUAL POSITION:
 Canine lying at the infraorbital margin is
removed intraorally by exposing the
infraorbital margin through an incision given in
the vestibule.
 Canine in nasoantral wall, if erupting in the
maxillary antrum has to be removed by going
into the antrum through Coldwell Luc
approach. If the tooth is erupting in the nasal
cavity the same can be approached through
an intra-nasal approach.
 The impacted maxillary canines in
class 3 position can be removed by
approaching from the buccal side as
well as palatal side conveniently
exposing crown from one side and
the root from the other.
 When the canine is impacted in the
mental protuberance it can be
removed by intraoral approach.
 A canine impacted at the inferior
border of mandible is best removed
by extra oral approach.
 TECHNIQUE FOR SURGICAL
REMOVAL OF IMPACTED
MANDIBULAR CANINE
 of the lower teeth on the buccal side is Canine
when lying below the apices of the roots
approached intra orally.
 Raising large flap cutting through the gingival
margins of the standing teeth and making two
angulated vertical incision into the vestibule.
 Reflect the flap and cut the muscle origin that
comes in the way.
 Drill holes in the bone through the labial cortex around the
crown.

 Join these holes to remove the overlying bone and expose

the crown.

 Elevate the tooth by drilling a hole in the cervical line for

positioning the elevator.

 Examine the socket , remove the tooth follicle and bone

chips.

 Wash the cavity with normal saline, replace the flap by

suturing with interrupted sutures after obtaining comlete
hemostasis.
 OPERATIVE PROCEDURE FOR
REMOVAL OF MANDIBULAR
CANINE IN UNUSUAL POSITION
 When the canine is impacted in the mental
protuberance it can be removed by intraoral
approach.
 A canine impacted at the inferior border of
mandible is best removed by extra oral
approach.
 The incision is made in the creases of the skin
along the lower border of the mandible at a
distance of 2 cm. below the lower border to
save the mandibular branch of facial nerve.
 Periosteum is incised and reflected with a heavy periosteal
elevator.

 The bulge of the crown is exposed by drilling holes in the

cortex and joining these holes.

 The tooth is elevated out of the socket.

 Remove the tooth follicle and bone chips, flush with normal
saline.

 The wound is sutured in layers .

 Stitches are removed on the 5th post operative day

 POST EXTRACTION
INSTRUCTIONS
1. The patient are told to keep the gauze
sponge firmly held between the jaws
over the extraction site for half an hour
after the extraction.
2. No mouth wash to be used for 6 hours
post-operatively.
3. A cold liquid diet is recommended for 24
hours post-operatively.
4. Stress on oral hygiene should be
given.cleanliness of the oral cavity and
remaining teeth if any, is essential by
using mouth wash and tooth brush etc.
5.A cold liquid diet for first 24hours should
be followed by semi-solid food till such
time the patient finds it difficult to
masticate the normal food.

6.Warm saline mouth rinses 24 hours post-

operatively facilitate healing, help in
cleansing the wound and minimise
trismus.The diet should be supplemented
by high protein and multivitamin capsules.

7.The antibiotics, if started preoperatively

are required to be continued for 3-5 days
post-operatively.
 COMPLICATIONS
 OPERATIVE  POST
OPERATIVE
COMPLICATIONS COMPLICATIONS
1.HEMORRHAGE 1.OEDEMA
2.FRACTURE OF ROOT
2.SECONDARY
3.INJURY TO ADJACENT TOOTH HEMORRHAGE
4.BREAKING OF INSTRUMENTS
3.PAIN
5.ASPIRATION OF TOOTH
6.FRACTURE OF MANDIBLE 4.DRY SOCKET
7.INJURY TO SOFT TISSUE 5.OSTEOMYELITIS
8.OPENING INTO NASAL 6.TRISMUS
CAVITY 7.SOFT TISSUE NECROSIS
8.ECCHYMOSIS
 OPERATIVE COMPLICATIONS

1.HEMORRHAGE:

 When there is bleeding from soft tissue,blood vessel can be caught with a
hemostat and ligated or a stick tie may be applied.

 The bleeding from the bone can be controlled by crushing the bone on the
bleeding point.

 Adrenaline pack kept for sometime in the socket will also stop the hemorrhage.

2.FRACTURE OF ROOT:

 It may take place either due to wrong technique or due to injudicious use of
elevators.
Fractured root have to be removed surgically.
 3. INJURY TO ADJACENT TOOTH:
It may occur due to injudicious use of
elevators.
Proper precautions should be taken while cutting the bone
and elevating the third molar during removal.

 4. BREAKING OF INSTRUMENTS:
Use of old and rusty elevators should be
avoided as these may beak during elevation of tooth.

5. ASPIRATION OF TOOTH:
It is a serious complication unless tooth is
coughed out by the patient with a forceful reflex cough.
 6. FRACTURE OF MANDIBLE:
It is a rare complication that occur due to excessive
force during elevation of the tooth .
It can occur because of fragility of the bone and ankylosis of the tooth to
the bone.

7. INJURY TO SOFT TISSUE:

Soft tissue can be injured by the sharp elevators,
especially when they slip across the tooth.
Bleeding should be controlled with pressure pack and repair done by
suturing.

8. OPENING INTO NASAL CAVITY:

The unfortunate accident can occur due to injudicious
use of fine elevator during removal of impacted maxillary canine.
POST OPERATIVE COMPLICATIONS

 1. OEDEMA:
Swelling of face after every surgical procedure is a common
observation and disappears mostly within 5-7 days.

2. SECONDARY HEMORRHAGE:
Hemorrhage seen after 24-48 hours of operation is mostly due
to incomplete hemostasis during surgery.

When there is bleeding from soft tissue,blood vessel can be caught with a
hemostat and ligated or a stick tie may be applied.

The bleeding from the bone can be controlled by crushing the bone
on the bleeding point.
Adrenaline pack kept for sometime in the socket will also stop the
hemorrhage.
 3.PAIN:
The pain of surgical trauma which is normally experienced in the
post operative period disappears within 24 hrs.
Proper antibiotic and analgesic therapy should be given.

4.DRY SOCKET:
It is also called localised alveolar osteitis and is one of the most
common post operative complication.
there is severe neuralgic pain sensitive to any food and foul smell
from the socket.
Treatment consist of sedative and analgesics dressings locally.

 5. OSTEOMYELITIS:
It may follow localized alveolitis.
There may be pus discharge or granulation tissue extruding from
the bone
6. TRISMUS:
Acute trismus is seen following the removal
of a difficult impaction.

7. SOFT TISSUE NECROSIS:

Interruption of blood supply to the palatal flap while
doing the maxillary impactions can result in
necrosis of the soft tissue of the palate.

8. ECCHYMOSIS:
Discoloration of the soft tissues beneath the eye , in
the cheek, under the mandible and floor of the mouth is
seen as a result of post operative bleeding.
 References
 COLIN YATES : a manual of oral and maxillofacil
surgery.
 KABAN TOULIS: pediatric oral and maxillofacial surgery.
 PETERSON: textbook of oral and maxillofacial surgery.
 KRUGER: textbook of oral and maxillofacial surgery.
 NEELIMA ANIL
MALIK: textbook of oral and maxillofacial surgery.