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Bayoumi's lecture Lec #3 Impaction


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

Frequency :
Maxillary canine is 20 times more than mandibular canine More frequent in females than males Palatal impaction is 3 times more than buccal impaction

Localization of impacted maxillary canine:

clinical examination Radiographic examination Clinical examination: By palpation: a) Presence of distinct bulge b) Deflection of crowns: mostly of lateral incisors pr premolars.

Radiological examination: a) Intra-oral periapical films

b) Occlusal radiographs ( topographical & cross sectional ): Canine will appear as a round radioapaque structure.

c) Shift sketch technique: 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).

d) Stereoscopic technique: It is old fashion technique m the film is translated into 3-D image by special device. e) 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. f) Extra-oral oblique or true lateral:

g) Panoramic films: To determine relation to maxillary sinus.

Classification of impacted maxillary canine:

ARCHER,S CLASSIFICATION Class I Palatally Impacted canine a) Horizontal b) Vertical c) semivertical Class II Buccally impacted canine a) Horizontal b) Vertical c) Semivertical Class III Impacted canine located in both the palatal and labial surfaces. Class IV Impacted canine located in the alveolar process. Class V Impacted canine located in an edentulous maxilla.

Contra-indications for the removal of an impacted maxillary canine:

When it can be brought into normal position either by surgical repositioning or a combination of surgery and orthodontic treatment..

Factors complicating the removal of the impacted canine:

1. 2. 3. 4. 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.


Planning the operative procedure 1. X-ray examination 2. Classify the impaction 3. Extent of the flap 4. 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

1. Usually open the flap in the area where the crown is present (mostly buccally),So a buccal flap is reflected first. 2. 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. 3. After opening a buccal flap, decapitate & remove the crown, follower them by the root. 4. If you open the buccal flap finding the root remove it first then do a palatal flap & remove the crown (keep the buccal flap open because you might need it). 5. 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 buccal flap. 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. N.B: Replantation can be done i.e. remove the canine & create a socket where you like to place the tooth then do endo ttt or retrograde filling , be sure that the replanted tooth is in vertical position & out of occlusion.

Treatment Options: 1. Extraction. 2. Reposition. 3. Surgical exposure & orthodontics. 4. Replantation.

Complications during or after the removal of impacted teeth:

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

Wishing you all the best