Multi-disciplinary management to align ectopic

or impacted teeth
Padhraig S. Fleming
The orthodontist is the central member of a team dealing with the
management of impacted or ectopic teeth with the knowledge and ability
to either avert or simplify treatment with relatively straightforward measures
such as interceptive primary extractions or orthodontic space redistribution.
However, in many cases, ectopic and impacted teeth may present complex
treatment planning decisions requiring the integrated expertise of a range of
dental specialists including periodontists, prosthodontists, and oral surgeons
to produce lasting functional and esthetic improvements with minimal shortterm or long-term biologic cost. (Semin Orthod 2015; 21:3845.) & 2015
Elsevier Inc. All rights reserved.

Introduction
mpacted teeth are those that fail to reach the
correct occlusal position due to tooth, bone,
or soft tissue impediment. While an ectopic tooth
may erupt, it develops in an abnormal position.
Maxillary canines are both commonly impacted
and susceptible to ectopic development. With the
exception of third molars, maxillary canines are
most likely to develop ectopically with a reported
frequency of between 0.8% and 3%.1 Other
commonly impacted teeth include maxillary
central incisors and those terminal in their
series including second premolars and third
molars.
Traditionally, management of ectopic and
unerupted teeth centers on the orthodontist; this
approach allows the full range of options including
interceptive approaches, space recreation, autotransplantation, and orthodontic mechanical
eruption to be considered. However, successful
management of impacted or ectopic teeth may
require an integrated approach between orthodontists, oral surgeons, periodontists, and prosthodontic specialists. Interdisciplinary input is

Institute of Dentistry, Barts and The London School of Medicine

and Dentistry, Queen Mary University of London, London, UK.
Address correspondence to Dr. Padhraig S. Fleming, BDent Sc
(Hons), MSc, PhD, MOrth RCS, FDS (Orth) RCS, FHEA, Institute of
Dentistry, Barts and The London School of Medicine and Dentistry,
Queen Mary University of London, Turner St, London E1 2AD, UK.
E-mail: padhraig.eming@gmail.com
& 2015 Elsevier Inc. All rights reserved.
1073-8746/15/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2014.12.004

particularly important in the planning stages with

implications for extraction decisions and operative
procedures, and ultimately inuencing the duration and ease of subsequent orthodontic treatment, and the longevity and esthetics of the nal
outcome. These interactions will be discussed in
this review, with particular emphasis on the
management of ectopic or impacted maxillary
canines.

Interceptive management
Seminal research by Ericson and Kurol2 indicated
that removal of primary maxillary canines is a
predictable and relatively conservative solution to
the ectopically developing palatal maxillary canine
with a reported eruption rate of 78% following
interceptive extraction over a 12-month period.
The success rate, however, declined to 64% with
medial displacement of the canine beyond the
midline of the adjacent lateral incisor. These
ndings in 1013 year olds with uncrowded arches
were mirrored in a subsequent study involving
crowded malocclusions.3
Recently, however, the merit of removing primary canines has been questioned4 on the basis
that prospective studies in this area have consistently been compromised by failure to justify the
sample size, confounding, and inadequate explanation of randomization procedures, allocation
concealment, and efforts to reduce measurement
bias. There are also instances of spontaneous
improvement of canines suggesting their behavior
can be erratic, irrespective of primary tooth
removal (Fig. 1). Furthermore, the use of a

Seminars in Orthodontics, Vol 21, No 1 (March), 2015: pp 3845

38

Multi-disciplinary management to align ectopic or impacted teeth

Figure 1. Spontaneous improvement in the position

of palatal ectopic canines despite the persistence of the
primary maxillary canines.

range of mechanics including cervical pull

headgear, straight pull headgear, rapid maxillary
expansion, or removal of multiple primary teeth
has been considered in more recent research
either as an alternative to or as an adjunct to
interceptive removal of primary canines. These
space-generating procedures have generally
demonstrated an advantage over isolated removal
of primary canines.58 However, these studies are
typically compromised by similar limitations to
earlier related clinical trials.4

Space recreation in the permanent

dentition
Based on the aforementioned research, space
creation appears to be of potential benet in
encouraging eruption of ectopic canines in the
mixed dentition. Similarly, the benet of
improving space conditions has been demonstrated in the permanent dentition. Olive9 has
advocated space redistribution to encourage

39

autonomous eruption of canine teeth; eruption

rates of 75% have been demonstrated with xed
appliances. However, in this study, active
treatment was preceded by interceptive loss of
primary canines, which may therefore have
inated the potential benet of xed
appliance-based space generation. In a followup study, the inuence of the degree of ectopia
on eruptive potential was highlighted with more
medially displaced canines less likely to erupt
without recourse to surgical exposure.10 Age was
also found to have an inuence on the likelihood
of eruption with the prognosis for eruption
poorer in subjects older than 13 years with
more medially displaced canines.
Clearly, a high percentage of impacted canines tend to respond favorably to space recreation either with or without orthodontic
extractions (Fig. 2). The buccal position of
impacted canines is a byproduct of their
developmental position, crowding, and their
propensity to follow the buccal path of least
resistance. Occasionally, however, even impacted
buccal canines without a signicant degree of
ectopia display reduced eruptive potential and
may require surgical exposure to facilitate
eruption. Typically, this may be undertaken
with a local exposure or apically repositioned
ap. Other impacted teeth including premolars
tend to respond equally favorably to space
recreation in adolescence obviating the need
for surgical intervention in many cases (Fig. 3).
Therefore, the position of the orthodontist as
the gatekeeper overseeing the coordination of
care of patients with ectopic teeth is justied, and
the necessity to resort to combined, orthodonticsurgical management of ectopic and impacted
teeth is correspondingly reduced. However,
in certain instances, joint intervention is
unavoidable and can be anticipated at initial
presentation.

Figure 2. Space recreation for buccal impacted canine following removal of heavily-restored maxillary rst molars.

40

Fleming

Figure 3. Impacted maxillary and mandibular second premolars related to premature loss of primary molars (A).
Removal of the maxillary rst premolars in conjunction with space maintenance with a Nance palatal arch (B) and
space recreation with a lip bumper (C) facilitated eruption of the permanent teeth (D).

Surgical exposure and orthodontic

alignment
When interceptive procedures fail or are considered inappropriate, combined assessment with an
oral surgeon or periodontist to facilitate orthodontic alignment of an ectopic tooth is often
indicated. There are a number of key considerations when planning this type of treatment.

Position of impacted/ectopic tooth

The position of unerupted teeth has been linked
to the likelihood of a favorable response to
interceptive extractions and space recreation;
similarly, the prognosis and treatment time for
mechanical eruption and alignment of canines is
inuenced by the degree of displacement.
In particular, vertical displacement in excess
of 14 mm above the occlusal plane11 and
pronounced medial displacement12,13 have
been shown to lead to increased treatment times.
While this difference in treatment time is related
to the distance that the object tooth is required to
move, it is compounded by greater surgical
complexity in managing more displaced teeth
and may be further complicated by anatomical
issues, including position of the lateral incisor
roots, orientation of the canine, and difculty in
accessing the displaced tooth. These issues place

greater emphasis on communication between

orthodontist and surgeon to generate realistic
plans and facilitate efcient and safe tooth
movement by performing the correct procedure,
while optimizing force delivery and vectors.
Ectopic buccal canines present a particular
challenge in negotiating the root of the maxillary
lateral incisor during alignment.14,15 Careful surgical and orthodontic planning is therefore required
to allow unimpeded and efcient movement of the
canine (Fig. 4) without inducing or aggravating
resorption of the lateral incisor. Multiple surgical
procedures are possible depending on the location
of the tooth; clear communication with surgical
colleagues is therefore paramount.
Circular open exposures of buccal canines are
rarely possible in view of the constraints placed by
the requirement for attached gingivae to provide
a predictable, stable attachment. When canines
are displaced superiorly, provision of attached
gingivae is no longer possible unless the gingival
attachment is repositioned during the exposure.
Apically repositioned aps are, therefore, typically preferred to maintain an adequate width of
attached gingivae; however, with signicant
vertical displacement, apical repositioning
would expose a large denuded area, which may
require a secondary grafting procedure. Consequently, surgical exposure and bonding may be

Multi-disciplinary management to align ectopic or impacted teeth

41

Figure 4. Buccal ectopic maxillary right canine with impacted upper right second premolar related to an infraoccluded second primary molar. The canine was erupted buccally and moved distally to limit the risk of resorption
to the maxillary right lateral incisor. The canine was aligned although the adjacent lateral incisor underwent some
resorption; a decision was therefore made to accept inadequate labial root torque of the lateral incisor.

undertaken, with the bonded attachment placed

palatally. While inferior movement of the canine
is often needed to permit eruption into attached
gingivae, this may be unfeasible due to the close
proximity of the root of the incisor. Buccal
movement of the canine can rst be undertaken
until the canine becomes more supercial buccally, and a minor secondary surgical procedure
can be performed at that point with an apically
repositioned ap to provide an adequate band of
attached gingivae.16 Consequently, close liaison
with surgical colleagues is necessary to facilitate
timely referral for the secondary procedure to
avoid the risk of eruption into friable, free gingival
attachment. Alternatively, consideration may be
given to actively moving the lateral incisor palatally
to limit the potential for obstruction to tooth
movement
and
associated
deleterious
consequences including resorption of the lateral
incisor root (Fig. 4). Moreover, the bonded
attachment on the lateral incisor can be
temporarily omitted, programmed to impart
palatal root torque during the rectangular wire
phase, or can be altered to allow free tipping of the
incisor during the initial treatment phases, for
example, using Tip-Edge brackets.

Age
Impacted teeth are a feature of malocclusion
consistently shown to prolong orthodontic
treatment.1113 There is also an exponential

increase in the likelihood of unsuccessful treatment among adult patients with ectopic teeth.17
It is believed, for example, that palatally displaced
canines lack sufcient eruptive impetus to
penetrate the palatal cortical plate and mucosa
naturally resulting in impaction.18 This inertia is
thought to become more marked with increasing
age and has been apportioned to a form of disuse
atrophy18 within the periodontal ligament. This
characteristic makes impacted teeth less likely to
erupt naturally after the third decade and similarly
more problematic during mechanical orthodontic
eruption, although exceptions do arise (Fig. 5).
The unpredictable nature of orthodontic eruption of impacted teeth in adults often warrants a
more conservative approach to orthodontic and
surgical management, with greater emphasis on the
potential merits of prosthodontic approaches.
Consequently, irreversible decisions including
extraction of adjacent permanent teeth and indeed
early loss of primary canines during treatment is
best-avoided as primary teeth are a natural space
maintainer, may aid in retention of alveolar bone,
and their presence is known to be of psychological
benet where permanent teeth are lacking.19
Moreover, prior to placement of complete labial
appliances, eruptive forces may be delivered using
lingual attachments or palatal invisible auxiliaries
(Fig. 6) due to the heightened esthetic premium in
adults. Where orthodontic approaches are considered unrealistic or inadvisable, the displaced tooth
may be replaced prosthetically with a dental

42

Fleming

Figure 5. A 22-year-old female presented subsequent to recent eruption of palatal ectopic maxillary canines, the
primary canines were retained. Both canines were aligned with xed appliances.

implant. Prior to this approach, a decision in

relation to possible removal of the impacted
tooth and the extent of the resultant bony defect
is facilitated by 3-dimensional imaging techniques.20

Type of surgical exposure

Initial observational research on the relative
merits of open and closed eruption techniques
was equivocal in terms of periodontal health and
treatment times.2123 More recent prospective
research has conrmed that open and closed

exposure of maxillary canines appears to differ

little in respect of surgical time, treatment outcomes, and periodontal health.24 Nevertheless,
there are potential indications for either
technique; however, individual preference
appears to be important in many scenarios.
Where the canine is not deeply impacted,
wide, open exposures have the obvious
advantage of allowing complete visualization of
the crown permitting accurate bond placement.
Incorrect positioning of attachments in closed
techniques may be undetected until the canine

Figure 6. A 26-year-old female was concerned in relation to the mobility of the maxillary primary canines. Both
canines were signicantly displaced and had a guarded prognosis for alignment (A). A palatal arch with auxiliaries
was placed to initiate eruption prior to removal of the primary canines and placement of labial xed appliances (B)
and complete alignment of the canines (C).

Multi-disciplinary management to align ectopic or impacted teeth

has been erupted, inducing unwanted rotations

and prolonged treatment. It is therefore imperative that if closed exposures are planned,
communication in relation to the desired
position of the attachment is clear; typically,
these should be placed near the cusp tip to
facilitate efcient tooth movement with minimal
unwanted rotation. Conversely, placement closer
to the cervical margin risks periodontal problems
and rotation of the canine rather than efcient
labial movement.
Open surgical exposure allows the orthodontist
to control the position of the attachment and may
allow eruption without resort to active forces.18
With deep impactions, closed exposures are usually
favored as open exposures may necessitate
excessive bone and soft tissue removal risking
periodontal damage to the impacted tooth or
neighboring roots. Deeply impacted teeth may also
become enveloped by soft tissue with inadequate
exposure particularly if unsupervised.

Restorative considerations
The association between canine ectopia and a
variety of dental anomalies including absence of
lateral incisors and microdont and misshapen
maxillary lateral incisors is established. As such,
management of ectopic teeth may incorporate a

43

restorative element in many cases, even when the

tooth itself can be aligned. Moreover, ectopic
canines can induce invasive root resorption of
lateral incisors potentially compromising the
longevity of these teeth. It is accepted that
resorption of teeth ceases following the removal
of the cause, potentially by orthodontically erupting or extracting the canine. Indeed, resorbed
incisors have been shown to have excellent
longevity.25 Consequently, the restorative and
periodontal implications must be balanced
against orthodontic considerations to develop a
unied approach to management of ectopic teeth
with roots shorter than 10 mm likely to exhibit
mobility.26 For these patients, a combined and
informed decision must be made as to whether to
consider maintaining the compromised tooth or
attempting to orthodontically reposition the
ectopic canine mesially to produce a more
predictable result. Where restorative problems
including signicant reduction in the mesio-distal
width of the incisor and unfavorable gingival
architecture dictate extraction of the tooth, the
canine may be repositioned mesially (Fig. 7). A
major advantage of this approach is the need for
limited active restorative intervention, with only
conservative reshaping and direct composite
buildup of the canine required. Additional
palatal root torque should be added to the

Figure 7. A Class I malocclusion with ectopic maxillary left canine and diminutive lateral incisors with mandibular
arch crowding (A). After joint consultation, a decision was made to orthodontically align the ectopic canine with
loss of the diminutive lateral incisors and 2 mandibular premolar units. The maxillary canines were reshaped
incrementally (B) and restored with direct composite (C) to simulate lateral incisors.

44

Fleming

Figure 8. Appearance 2 years following removal of orthodontic appliances; treatment involved alignment of the
maxillary left canine, which was buccally ectopic (A). A connective tissue graft and tunnel technique was
performed to restore gingival symmetry (B). (Courtesy of Dr. Ronan Allen.)

canines by selecting an appropriate bracket or by

imparting supplementary torque with an archwire
bend. When the canine is placed in the position
of the lateral incisor, it may also be extruded to
harmonize the gingival levels with respect to the
adjacent teeth,27 as the gingival zenith of a natural
lateral incisor lies 11.5 mm inferior to that of a
central incisor, while the canine and central
incisor gingival margins should lie at the same
vertical level.
Following alignment of ectopic teeth, major
considerations include both the stability of tooth
positioning and the stability of the periodontal
attachment.28,29 Short-term follow-up has demonstrated little difference in periodontal
attachment loss adjacent to maxillary canines
based on the type of initial exposure. However,
there does appear to be a minor but statistically
signicant susceptibility to recession following
surgical exposure and orthodontic alignment.
There remains, however, little long-term data on
the likelihood and possible progression over
time, necessitating further surgical advice and
interception (Fig. 8).

Conclusions
Impacted teeth are commonly encountered by
orthodontists with referrals typically made in the

mixed dentition to facilitate their correction.

Orthodontists have the potential to avert
impactions and complex associated treatment by
relatively simple means including interceptive
extractions and space recreation. However,
impacted teeth may present complex management issues and a wide range of treatment options
many of which are time-consuming and
demanding in terms of compliance. Consequently,
a team approach to formulating treatment plans
and overseeing the management of impacted
teeth is central to managing difcult cases, which
are recalcitrant to conservative measures.

References
1. Ericson S, Kurol J. Radiographic assessment of maxillary
canine eruption in children with clinical signs of eruption
disturbances. Eur J Orthod. 1986;8:133140.
2. Ericson S, Kurol J. Early treatment of palatally erupting
maxillary canines by extraction of the primary canines.
Eur J Orthod. 1988;10:283295.
3. Power SM, Short MB. An investigation into the response
of palatally displaced canines to the removal of deciduous
canines and an assessment of factors contributing to
favourable eruption. J Orthod. 1993;20:215223.
4. Parkin N, Benson PE, Shah A, et al. Extraction of primary
(baby) teeth for unerupted palatally displaced permanent
canine teeth in children. Cochrane Database Syst Rev.
2009;15:2.

Multi-disciplinary management to align ectopic or impacted teeth

5. Leonardi M, Armi P, Franchi L, et al. Two interceptive

approaches to palatally displaced canines: a prospective
longitudinal study. Angle Orthod. 2004;74:581586.
6. Armi P, Cozza P, Baccetti T. Effect of RME and headgear
treatment on the eruption of palatally displaced canines:
a randomized clinical study. Angle Orthod. 2011;81:370374.
7. Baccetti T, Leonardi M, Armi P. A randomized clinical
study of two interceptive approaches to palatally displaced
canines. Eur J Orthod. 2008;30:381385.
8. Alessandri Bonetti G, Zanarini M, Incerti Parenti S, et al.
Preventive treatment of ectopically erupting maxillary
permanent canines by extraction of deciduous canines
and rst molars: a randomized clinical trial. Am J Orthod
Dentofacial Orthop. 2011;139:316323.
9. Olive RJ. Orthodontic treatment of palatally impacted
maxillary canines. Aust Orthod J. 2002;18:6470.
10. Olive RJ. Factors inuencing the non-surgical eruption of
palatally impacted canines. Aust Orthod J. 2005;21:95101.
11. Stewart JA, Heo G, Glover KE, et al. Factors that relate to
treatment duration for patients with palatally impacted
maxillary canines. Am J Orthod Dentofacial Orthop.
2001;119:216225.
12. Fleming PS, Scott P, Heidari N, et al. Inuence of
radiographic position of ectopic canines on the duration
of orthodontic treatment. Angle Orthod. 2009;79:442446.
13. Zuccati G, Ghobadlu J, Nieri M, et al. Factors associated
with the duration of forced eruption of impacted
maxillary canines: a retrospective study. Am J Orthod
Dentofacial Orthop. 2006;130:349356.
14. Pitt S, Hamdan A, Rock P. A treatment difculty index for
unerupted maxillary canines. Eur J Orthod. 2006;28:
141144.
15. Stivaros N, Mandall NA. Radiographic factors affecting
the management of impacted upper permanent canines.
J Orthod. 2000;27:169173.
16. Becker A. Orthodontic Treatment of Impacted Teeth. 3rd ed.,
Chichester, UK: Wiley-Blackwell; 2012.
17. Becker A, Chaushu S. Success rate and duration of
orthodontic treatment for adult patients with palatally
impacted maxillary canines. Am J Orthod Dentofacial Orthop.
2003;124:509514.
18. Kokich VG. Preorthodontic uncovering and autonomous
eruption of palatally impacted maxillary canines. Semin
Orthod. 2010;16:205211.

45

19. Laing E, Cunningham SJ, Jones S, Moles D, Gill D.

Psychosocial impact of hypodontia in children. Am
J Orthod Dentofacial Orthop. 2010;137:3541.
20. Chappuis V, Engel O, Reyes M, Shahim K, Nolte LP, Buser
D. Ridge alterations post-extraction in the esthetic zone: a 3D
analysis with CBCT. J Dent Res. 2013;92:195S201S.
21. Wisth PJ, Norderval K, Be OE. Periodontal status of
orthodontically treated impacted maxillary canines. Angle
Orthod. 1976;46:6976.
22. Becker A, Brin I, Ben-Bassat Y, et al. Closed-eruption
surgical technique for impacted maxillary incisors: a
postorthodontic periodontal evaluation. Am J Orthod
Dentofacial Orthop. 2002;122:914.
23. Schmidt AD, Kokich VG. Periodontal response to early
uncovering, autonomous eruption, and orthodontic
alignment of palatally impacted maxillary canines. Am
J Orthod Dentofacial Orthop. 2007;131:449455.
24. Parkin NA, Milner RS, Deery C, et al. Periodontal health
of palatally displaced canines treated with open or closed
surgical technique: a multicenter, randomized controlled
trial. Am J Orthod Dentofacial Orthop. 2013;144:176184.
25. Becker A, Chaushu S. Long-term follow-up of severely
resorbed maxillary incisors after resolution of an etiologically associated impacted canine. Am J Orthod Dentofacial Orthop. 2005;127:650654.
26. Jnsson A, Malmgren O, Levander E. Long-term followup of tooth mobility in maxillary incisors with orthodontically induced apical root resorption. Eur J Orthod.
2007;29:482487.
27. Kokich VO Jr, Kinzer GA. Managing congenitally missing
lateral incisors. Part I: canine substitution. J Esthet Restor
Dent. 2005;17:510.
28. Zasciurinskiene E, Bjerklin K, Smailiene D, Sidlauskas A,
Puisys A. Initial vertical and horizontal position of
palatally impacted maxillary canine and effect on
periodontal status following surgical-orthodontic treatment. Angle Orthod. 2008;78:275280.
29. Parkin NA, Milner RS, Deery C, et al. Periodontal
health of palatally displaced canines treated with open
or closed surgical technique: a multicenter, randomized
controlled trial. Am J Orthod Dentofacial Orthop. 2013;144:
176184.