Treatment and management of impacted canine with speed appliance

Palatally displaced canineLabially impacted canine

Mandibular impacted canine

slideshare.net/sylvainchamberland

©Dr Sylvain Chamberland

Side effect of straight wire mechanics in the 2nd order• Detrimental side effect

! Intrusion and tipping of the canine and premolar toward the canine space

! Cant of the occlusal plane

• Tx objective of canine extrusion

! To avoid side effects

Sem. Ortho. 1: p24, 2001 & 3: p156, 2001


Da.Le.0309 Da.Le.0710

•Mx: 3 segments•016 Supercable in the auxilliary slot•Patient was instructed to wear ! elastic 3/3-4•He didn’t...

•Mx: 19x25 TMA, 17-22•016 Supercable in the auxilliary slot•Patient was instructed to wear ! elastic 3/3-4

Da.Le.0710


Da.Le.181010

•After 6 weeks•Occlusal plane is leveled•Box loop will continue uprigthing of #13

Da.Le.150710

Patient went to Afghanistan 10 months

Da.Le.300811

August, 10 October, 10 August, 11


Selective approach to canine eruption

• Main rigid archwire

• Flexible overlay auxiliary wire

• SPEED bracket

! Auxiliary slot and arch wire

Sem. Ortho. 1: p24, 2001


OOPS!• .016 supercable / .016 CNT •.016 CNT / .016 X .022 CNT

May 14

June 25


Segmented approach to canine eruption

• Main rigid archwire

! To prevent mesial molar tipping

• Cantilever spring

! Anterior extrusion, posterior intrusion

! Counterclockwise moment at the molar


Segmented approach to canine eruption

• RPE and coil to open the space for the canine

• Cantilever for canine extrusion

• No intrusive side effect in the anterior region


Segmented approach

• Cantilever on a removable appliance

! Excellent anchorage

! Very few, if any, side effectsFr.Tr.121107

Fr.Tr.250208

Fr.Tr.121107

Fr.Tr.120508

26 w15 w


Flexible overlay wire

• Mx: .020 x .020 HA NiTi

! Auxiliary .016SC

Ma.La.19-03-09


F.O.W.:15 weeks

Ma.La.19-03-09 Ma.La. 30-06-09


Ma.La. 30-06-09

+ 7 w

Ma.La. 17-08-09


Ma.La. 17-08-09 Ma.La. 29-09-09


Detrimental side effect in 2nd order

• High #23

• Cl II elastic to enhance extrusion + distallization of 23 + protraction of 36

• But

! Forces & moments move teeth

Al.Du. 05-08-09Al.Du. 15-05-09


• Sentalloy coil spring to open space.

• Main arch: .019 X .025 CNT.

• Auxiliary wire: .016 CNT.

Canine impaction


Canine impaction• TPA .032 X .032 TMA + mesial

out on #18 and #26.

• Elastomeric chain from molar hook to 2nd premolar.

• Coil spring to open space.


Transpose #23

• Baliste cantilever

! .017 NiTi spring

Ce.Che. 07-04-09

Ce.Che. 12-01-09

Could be used with PDC


Cantilever Arm

Che.Ce 070409

Che.Ce 210509


• Anchorage loss

! Should have been anticipated

! Poor collaboration with elastic wear did not help

Cé.Ch. 21-05-09

Cé. Ch.16-06-09


• Tooth #22 was not engaged since last 6 weeks

• Transposition is corrected

Cé. Ch.16-06-09Cé. Ch.15-09-09


• Lack of septal bone between 22-23 need to be monitored

• Root resorption is noted

Cé. Ch.05-11-07 Cé. Ch.20-01-11, 2 months into retentionCé. Ch.24-08-11, 9 months into retention


Palatally displaced canine

• Full thickness palatal flap

• Create opening through palatal mucosa

• At 4 months

! Main arch: .020 x .020 HA niti

! auxiliary wire: .016 HA niti

Ch.St-P. 0408

Ch.St-P. 27-06-08


• Ligatures are retighten

! Bonded button #23 buccal

• Canine bonded at 35 weeks

! auxiliary .016SC engaged

• At 11 months

! Canines are rebonded

Ch.St-P. 06-10-08

Ch.St-P. 08-04-09


• Transmucosa exposition «à la Kokich»

• Removable appliance & finger springcantilever

Ph.St-Pi. 22-09-09

Ph.St-Pi. 22-09-09

Ph.St-Pi. 08-04-09


• Sequence

! September: Engagement

! October:1st control

! November: 2nd control

! December, at 13 weeks: Bond 13 & 23

! February, at 19 weeks

Ph.St-Pi. 22-09-09

Ph.St-Pi. 20-10-09

Ph.St-Pi. 23-12-09Ph.St-Pi. 03-02-10


Ch.St-P. 150408 Ch.St-P. 030211

144 weeks

Ph.St-P. 080409 Ph.St-P. 310811

120 weeks

Fixed appliances only

Removable cantilever spring & fixed appliances


Surgical approachFull thickness flapOstectomyCurettage of the dental follicle

Opening window through the mucosaFlap closed + sutured

Ga.Vi. 120510


Sentalloy uprighting spring 02-000-01& 00Sentalloy rotating spring 10-003-01;02; 03;04

Ga.Vi. 230610At 6 weeksGa.Vi. 260510

At 2 weeks

Ga.Vi. 040810At 12 weeks Ga.Vi. 150910

At 18 weeks

Ga.Vi. 120510



Ga.Vi. 150910At 18 weeks

Ga.Vi. 120510

Ga.Vi.261010At 24 weeks




•Bond #13".016 SC™ aux. wire.


• Rebond 13; .016 sent. aux. wire


Ga.Vi. 120510


At 47 weeks post ligationGa.Vi.060411


• Rebond #13; .016 sent.; #13 is engaged

At 47 weeks post ligationGa.Vi.060411

At 53 weeks post ligation; 75 weeks into treatment

Ga.Vi.180511


Remarks

• Pulling an impacted canine with fixed appliance, finger spring or auxilliray wire is a good and predictable approach

• However, using a removable appliance with SS cantilever spring may be faster to bring the canine at the level of the mucosa


Remarks

• For more details about surgical exposure go to

• http://www.slideshare.net/sylvainchamberland/2-0-ruptions-ectopiques-approche-chirurgicale

• 2 0 Éruptions ectopiques_Management chirurgical des canines incluses


Ma-Ch.Po061010 Ma-Ch.Po120111

Ma-Ch.Po010910Canine ligated at 41 weeks

Evolution of the canine in 5 weeks

post ligation

Evolution at 19 weeks post ligation

• Can you explain why the canine is rotated?• In which direction?• Why the force couple is done this

way at 19 weeks?


Ma-Ch.Po120111

Evolution at 19 weeks post ligation

Ma-Ch.Po060411

31 weeks post ligation

72 weeks into tx

51 weeks post ligation

92 weeks into tx

Ma-Ch.Po240811


92 weeks

• Extraction: x, x, x, x

• Surgical exposure of 13 was delayed

• Ligation could have been done from start and traction initiated with a removable appliance and cantilever spring

X X

X X

X X


Initial

Ma-Ch.Po291009

Ma-Ch.Po240811

June 2010

92 weeks into tx• Finishing bends


Impacted Lower Canine• What is your diagnosis?

! ...

• Full thickness flap. Should have been ligate enough apically to expose the crown

! #33 engaged

• Healing at 7 weeks

! Finger spring initiated

Ch.Tr0610

Ch.Tr260810

Ch.Tr071010

Ch.Tr251010

9 weeks

Ch.Tr231110

13 weeks I let the ginviva heal for 3 months.The keratinized gingival bridge has goneA bracket was bonded in late march 2011


Impacted Lower Canine• I apologies.

• The outcome, despite nice eruption of the canine, is the worse case scenario in term of keratinized attached gingiva

Ch.Tr260810

Ch.Tr251010

9 weeks

Ch.Tr231110

13 weeks

Ch.Tr040411

•A keratinized tissue graft is necessary

• Vestibular position

• #12 & 22: displaced labially and distally

• High vestibular bulge #23

• Labial vestibular bulge #33

Fr. Tr 02-06

Impacted canine


• #13 buccal to # 12

• #23 horizontal

• #33 mesially tippedFr. Tr 02-06


• Extraction of 53, 63, 73, 83

Fr. Tr 09-06

Fr. Tr 02-06


• Extraction of 54, 64, 74, 84

• Favorable auto correction of 13 & 33

• 23 still horizontal

Fr. Tr 09-06Fr. Tr 02-06 Fr. Tr 03-07

Fr. Tr 10-07


• Tx:

! Ligature of 13, 23, 33

! Traction with removable appliance

Fr. Tr 10-07


• Closed eruption technique

• Traction with elastics & Hawley

Fr. Tr 10-07

Fr. Tr 11-07


• #13

Fr. Tr 01-08


Fr. Tr 02-08


Fr. Tr 04-08

Fr. Tr 05-08


• Ready for braces

! Tx initiated july-08

Fr. Tr 06-08

3rd order discrepancy


• Mx: .016 supercable

• Md: .019 x .025 HA niti

Fr. Tr 15-09-08


• Mx: .018 supercable

• Md: .020 x .020 HA niti

Fr. Tr 09-12-08


• Mx: .020 x.020 HA niti

! To initiate torque correction 12 & 22

• Md: .020 x.020 HA niti

Fr. Tr. 03-02-09


• Mx: .020 x .025 Niti Speed wire

• Note 3rd order problem to be corrected

Fr.Tr. 19-03-09


• Rebond #12 with special torque

• .020 x .025 niti SW

Fr.Tr.11-05-09


• Reassessment of bracket position

• Pr: exo #75 & #85

Fr.Tr.17-08-09


• May 09 to Feb 10

• Torque of 12 and 22 has improved with full dimensional 20 x 25 SW

• Delayed eruption of lower 2nd premolar extrend the treatment time

Fr.Tr.09-02-10Fr.Tr.11-05-09


• Open eruption technique

! Full thickness palatal flap

" Bonded button on canines

" Closing + suturing the flap

" Create opening through the flap

A-A Gag 1104

A-A Gag 0505

A-A Gag 0505 A-A Gag 0605 A-A Gag 0805

A-A Gag 1105 A-A Gag 1106


A-A Gag 0805

A-A Gag 1105

A-A Gag 1105


• Age: 20 y

• Extraction 53, 63

• Closed eruption approach

Palatally displaced canine

Ca-A.Bo.04-05


• Bonded button + elastomeric chain

• Correction of rotations 13 & 23

Ca-A.Bo.11-07

Ca-A.Bo.10-07Ca-A.Bo.08-07

Ca-A.Bo.01-08 Ca-A.Bo.04-08


Ca-A.Bo.10-07

Ca-A.Bo.11-07

Ca-A.Bo.08-07


Ca-A.Bo.11-07

Ca-A.Bo.01-08

Ca-A.Bo.04-08


• Tx duration: 32 months

Ca-A.Bo.11-08

Ca-A.Bo.04-05

Ca-A.Bo.08-10 21 months into retention


Au.De. 17-11-08

Transposed 23-22

Au.De. 12-01-09


• Severe ALD

Au.De. 12-01-09


• #23 was pulled distally from the removable appliance

• Removable appliance provide a good anchorage

• Root movement of the lateral incisor by fixed appliances is avoided

Au.De. 30-06-09. •md: .016 sent med

Au.De. 11-08-09. •md: .016 x.022 neost


Au.De. 30-06-09. •md: .016 sent med

Au.De. 11-08-09. •md: .016 x.022 neost

Au.De. 22-09-09.


• 8 months into treatment

• From now: treatment is easy

Au.De. 05-10-09. Mx: .016 SC

Au.De. 17-11-08

Au.De. 05-10-09.


• Easy, but it tooks times to get it done!

Au.De. 15-08-11

Au.De. 23-02-09

129 weeks

Au.De. 19-12-06


• She's happy!

Au.De. 15-08-11

Au.De. 17-11-08

2011

2008

2006


• Classe I

• Impacted #13

• Severe ALD

Pa.Be. 15-08-08


• Retained #53

• Very heigh #13

• Impacted 8's

Pa.Be. 15-08-08


• Bimaxillary protrusion

• Tx plan

!


At 54 weeks

• #13 is erupting

• Side effects are noted

! Cant of occlusal plane

! Intrusion of 12, 11

• Brackets and wires don't move teeth

! Forces and moments does


• Forced eruption was stopped from sept 09 to feb. 10

• Mx occlusal plane had to be leveled: 22 weeks

! Mx: .020 x .025 niti & .016 sent cantilever to distalize and extrude #13

Pa.Be. 24-02-10


• Cantilever was effective to distallize and erupt #13

• Elastic ! was used to promote extrusion of the canine

Pa.Be. 24-02-10

Pa.Be. 26-05-10 Pa.Be. 07-07-10 Pa.Be. 01-09-10

Mx: .020 x .025 niti

Md: .020 x .025 SS


• Lower premolar are protracted with ECPa.Be. 01-09-10 Md: .020 x .025 SS

Mx: .016 sent

• Mx: .020 x .020 neost, EC 23-o-25-26-27

• Md: HDGW to protract molars; square anterior section including premolars is recommended

Pa.Be. 06-10-10

Mx: .020 x.020 neost

Md: .021 x .021 x .020 x38 mm HDGW


• Mx: .021 x .025 TMA (6 weeks)

! Does it slide? No!

• Md: .021 x .025 SS from january 2011 to august 2011

Pa.Be. 06-04-11


• 154 weeks!!

• Retrospectively, I would use a removable appliance and a cantilever spring to erupt #13.

• It would have save me detrimental side effects and weeks of Tx

Pa.Be. 22-08-11


• Fairly good root parallelism

Pa.Be. 22-08-11


• She's happy


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Treatment and management of impacted canine with speed appliance

Health & Medicine

Transcript of Treatment and management of impacted canine with speed appliance