齒顎矯正協會-TJO

*
Review Article

Diagnosis and Management of Impacted Maxillary Canines

Yu-Cheng Hsu, Chia-Tze Kao, Chih-Chen Chou, Wen-Ken Tai, Po-Yu Yang
Orthodontic Department, Chung Shan Medical University Hospital, Taichung, Taiwan
College of Oral Medicine, Chung Shan Medical University, Taichung, Taiwan


Running title:Impacted Maxillary Canine
Maxillary canines play an important role in facial esthetics, since the canine eminence can support the alar and the upper lip. Impacted maxillary canines is a common problem which requires multidisciplinary diagnosis and treatment in dental clinic. The aim of this review is to integrate the studies that include clinical diagnosis and guidelines for management of canine impaction.

Keywords: canine impaction; surgical exposure; orthodontic biomechanics.
GO

INCIDENCE OF CANINE IMPACTION

The incidence of maxillary canine impaction was reported as second to the third molar.1 The incidence was reported varies, from 0.92% to 2.2%, higher in some races. Dachi and Howell reported an incidence of 0.92%, while Thilander and Myrberg reported 2.2% in 7-13 years of age.2,3 Ericson and Kurol also reported an incidence of 1.7%, more common in women (1.17%) than in men (0.51%) as a ratio about 2:1.4
Bilateral impactions present in about 8% of people with maxillary impacted canines. Palatally impacted canine occurs more than labially impacted canine by the ratio of 2:1 to 3:1.5 Jacoby believed that most labial impactions could erupt to a relatively labial and superior position.6 He declared that 85% of palatally impacted canines have enough space for eruption, whereas only 17% of labially impacted canines have enough space. There were 83% of labially impacted canines cases who had arch length deficiency, a primary etiologic factor for labially impacted canines. However, palatally impacted canines seldom erupt without surgical or orthodontic intervention due to the thick cortical bone and dense palatal mucosa. Moreover, palatally impacted canines are often in a horizontal or oblique direction.
The prevalence of impacted maxillary canines in Chinese people was different from Caucasians.7 The ratio of labially and palatally impacted canines is 2.1: 1, and the ratio of male to female having maxillary canine impactions is 1.8:1.
GO

ETIOLOGY AND DEVELOPMENTAL CONSIDERATION

Maxillary canines take the longest period to develop and the longest course to travel into dental occlusion.8 During the development, the crowns of canines are close to the roots of lateral incisors. Early correction of the root position in maxillary lateral incisor with distal tipping and flaring might either cause the impaction of canines or root resorption of lateral incisors.9
The etiology of maxillary canine impaction may be genetic, generalized or localized (Table 1). The labial impaction is often the result of crowding or shifting of the maxillary dental midline,10 whereas the etiology of palatal impaction is hypothesized to be multifactorial and genetic.11
Two main theories have been proposed to explain the presence of palatally impacted canines: the guidance theory and the genetic theory.1 The guidance theory suggested that the length and timing of root formation of the lateral incisors is crucial for guiding the mesially erupting canine to a more favorably distal and incisal direction.12 Becker et al. reported an increase of 2.4 times of incidence of palatally impacted canines if absence of lateral incisors.13 The genetic theory suggested that the genetic factors are primary origin of palatally displaced maxillary canines, resulting in the familial and bilateral occurrence as well as gender preference.14

Table 1

Table 1

The etiologic factors of canine impaction.45,46

View Hi-Res Image
GO

SEQUELAE OF IMPACTION

According to the study of Shafer et al., there are some following sequelae of canine impaction:15
  • Labial or lingual malpositioning of the impacted tooth
  • Migration of the neighboring teeth and loss of arch length
  • Internal resorption
  • Dentigerous cyst formation
  • External root resorption of the impaction or the neighboring teeth
  • Infection particularly with partial eruption
  • Referred pain
GO

DIAGNOSIS

The diagnosis and localization of impacted maxillary canine should be based on clinical and radiographic evaluation.
Clinical Evaluation
The amount of space for eruption, the morphology and position of the adjacent teeth, the contour of the bone, the mobility of teeth should be considered through clinical evaluation. Clinical signs of canine impaction are listed as followings:16
  1. Delayed eruption of the permanent canine or prolonged retention of the primary canine
  2. Absence of a normal labial canine bulge On the other hand, the absence of the canine bulge at earlier ages should not be considered as an only indicator of canine impaction. According to study of Ericson and Kurol, 29% of children had nonpalpable canines at age of 10; but only 5% at age of 11, and only 3% at later ages.17
  3. Presence of a palatal bulge
  4. Delayed eruption, distal tipping, or migration of the lateral incisor
Radiographic Evaluation
Radiographic evaluation includes periapical radiographs, occlusal films, panoramic radiographs, lateral cephalograms and cone-beam computed tomography (CBCT).18
  1. Periapical films: A second periapical film is required. The lingual object moves in the same direction of the cone; the buccal object moves in the direction opposite to the direction of the cone, as "same-lingual, opposite-buccal (SLOB)" rule.19
      (1) Tube-shift technique or Clark's rule
           Two films are taken at different horizontal angulation of the cone.
      (2)Buccal-object rule
           Two films are taken at different vertical angulation of the cone.
  2. Occlusal films can also help to determine the buccolingual position of the impacted canine.20
  3. Panoramic films
    Katsnelson et al. revealed 26.6 times of chances for labially impacted canine if the angulation of the impaction and the horizontal reference line is more than 65°.21
  4. Frontal/lateral cephalograms can sometimes be used to determine the position of the impacted canine in relation to adjacent structures such as the maxillary sinus and the floor of the nose.
  5. CT/CBCT is an accurate technique for identifying and locating the position of the impacted canine, and assessing if any damage to the roots of adjacent teeth and the amount of bone surrounding the teeth, yet increasing the costs, time and radiation exposure.22,23
GO

CONSIDERATION OF TREATMENT PLANNING

A number of factors can affect the prognosis and should be considered before making the treatment decision, including the patient’s age and cooperation, general and dental health, skeletal variation and dental spacing or crowding (Table 2).
Treatment options
Various treatment options are available including:24
  1. No treatment
    No active treatment is recommended when:25
    • the patient does not request treatment
    • there is no sign of resorption or other pathology of the adjacent teeth
    • the canine is severely displaced with no evidence of pathology
    • the canine is remote from the dentition with a good contact between lateral incisor and first premolar
    • the primary canine provides good esthetics/prognosis
    In this case, periodical monitoring is suggested in the cases of cystic degeneration, root resorption and the other possible complications. In most cases, the root of primary canine will eventually resorb and need extraction.24
  2. Interceptive treatment
    The primary canine is usually extracted to facilitate the eruption of the permanent canine or to let the permanent canine move to a favorable position; it avoids excessive duration, expense, and complex treatment.
    Williams suggested extraction of the primary canines at the age of 8 or 9 in Class I uncrowded cases for self-correction of a labial or intra-alveolar canine impaction.26 Ericson and Kurol suggested that extraction of the primary canine before the age of 11 will normalized the position of the canines in 91% of the cases if the crown tip is distal to the midline of the lateral incisor, while only 64% of the cases can be normalized if the crown tip is mesial to the midline of the lateral incisor.27 Baccetti et al. declared that the extraction of the primary canine is an effective way to normalize the eruption of maxillary canine by 2 times the possibility than in untreated cases.28
    Therefore, extraction of the primary canine before the age of 11 as an interceptive approach to prevent canine impaction can be concluded. Then clinical and radiographic re-evaluation should be taken at 6-month intervals. If there is no improvement within 12 months, an alternative treatment is indicated.27
  3. Extraction
    The extraction of the impacted canine is seldom considered for the functional occlusion might be compromised, yet it might be an alternative, only if:29
    • it is ankylosed and cannot be transplanted
    • it is undergoing external or internal root resorption
    • its root is severely dilacerated
    • the impaction is severe
    • the occlusion is acceptable, with the first premolar in the position of the canine and well-aligned
    • there are pathologic changes
    • the patient does not desire for orthodontic treatment
    If the impacted canine is going to be extracted, then the decision should be made whether to replace the canine with first premolar or to restore the canine space with prosthesis.
    If the canine space is going to be replaced with the first premolar by orthodontic protraction, several factors should be taken into consideration; such as the lingual cusp interference of premolar, tooth size discrepancy, the unilateral mechanics, the smile esthetics. For orthodontic alignment, it may need to intrude the first premolar and restoring the premolars with composite resin or porcelain prosthesis, or to apply negative crown torque and mesiopalatal rotation to imitate the appearance of a canine. The canine guidance can be replaced by premolar guidance or group function.30
  4. Autotransplantation
    The ideal stage for autotransplantation is at 50-75 % of the root formation.31 The prognosis of transplantation of the impacted canine in adult is poor, most of them need endodontic treatment.32
  5. Surgical exposure and orthodontic treatment
    Considerations for exposing the impacted canine should be emphasized, including surgical technique, marginal gingival placement, control of inflammation, magnitude of force, atraumatic surgery, and proper gingival attachment.
    Three main techniques may be performed:33
    • Excisional uncovering (gingivectomy)
    • Apically positioned flap (APF)
    • Closed technique
      Including vestibular incision subperiosteal tunnel access (VISTA) technique.34, 35

    Kokich had proposed 4 criteria for surgical exposure:33
    • Labiolingual position of the crown
      If the canine is impacted labially, then the 3 techniques are viable; if the canine is impacted at the center of the alveolus, then APF and gingivectomy might not be feasible for the extensive bone removal.
    • Vertical position of the tooth relative to the mucogingival junction (MGJ)
      If the crown is positioned apically to MGJ, then closed technique is the most appropriate approach.
      If the crown is slightly apical positioned, then APF is used.
      If the crown is positioned coronally to MGJ, then any of the 3 techniques can be used.
    • Amount of attached gingiva
      The amount of 2-3 mm of attached gingiva should be sufficient after eruption. If there is no sufficient attached gingiva, APF could bring out to preserve the attached gingiva for periodontal health.
    • Mesiodistal position of the crown
      If the crown is positioned mesially, APF is recommended for it could be difficult to move the tooth through the alveolus unless complete exposure.
Table 2

Table 2

Factors influencing the treatment decision of an impacted maxillary canine.47

View Hi-Res Image
GO

ORTHODONTIC CONSIDERATIONS

Which biomechanics to be used depends on several factors, such as the location and the angulation of the canine relative to the dental arch, the adjacent teeth and the occlusal plane.36
The appliances such as ligature wires, brackets, buttons or eyelets may be used to attach onto impacted tooth. Various traction methods has been proposed, including light wires, auxiliary springs or arms from main the archwire or transpalatal arch, mousetrap loops, K-9 spring, ballista loops and Kilroy I, II springs.33,37,38 Also, temporary anchorage devices (TADs) can be reliable and then brackets bonding can be delayed until canine eruption.39 Hawley type removable appliances can be used as anchorage unit; however, the need for patients’ cooperation, limited control of tooth movement and the inability to treat complex malocclusions are the disadvantages.24
Initially, the arch should be leveled and aligned until a rigid rectangular wire is placed. Then enough space is required before the surgical exposure. Whatever materials are used, the direction of the force applied on the impacted tooth should first move the impaction away from the root of the adjacent tooth. The force should be light, no more than 2 oz (60 g).24
When a palatally impacted canine is encountered, the tooth surface available for bonding is often on the palatal side. However, Becker reckoned that the palatal surface is an undesirable site for applying traction force from main archwire, for it could embed the buccal surface of the crown and produce periodontal problems and make it harder to move the canine to a better position and angulation.40 Therefore, it would be better to let the canine erupt vertically until the buccal surface could be bonded.41 As for the labially impacted canines, periodontal conditions such as bony dehiscence and recession of labial gingival margin should be prevented by guide the impacted tooth to erupt between the alveolar cortical plates.42
GO

RETENTION

Becker found an increase incidence of rotations or spacings on the impacted side (17%), as compared to the control side (8.7%).43 Besides, the rebound of canine extrusion might happen in some cases as well, therefore, circumferential supracrestal fiberotomy is recommended to prevent relapse of these conditions.44
GO

CONCLUSION

Impacted maxillary canine is the second most frequent impaction, early diagnosis and intervention make the best solution. The keys to treat the impacted canines successfully include accurate localization, use of appropriate surgical procedure and orthodontic biomechanics.
GO

REFERENCES

  1. Litsas G, Acar A. A Review of Early Displaced Maxillary Canines: Etiology, Diagnosis and Interceptive Treatment. Open Dent J 2011;5:39-47.
  2. Dachi SF, Howell FV. A survey of 3,874 routine full mouth radiographs. Oral Surg Oral Med Oral Path 1961;14:1165-9.
  3. Thilander B, Myrberg N. The prevalence of malocclusion in Swedish school children. Scand J Dent Res 1973;81:12-20.
  4. Ericson S, Kurol J. Radiographic assessment of maxillary canine eruption in children with clinical signs of eruption disturbances. Eur J Orthod 1986;8:133‑40.
  5. Fournier A, Turcotte J, Bernard C. Orthodontic considerations in the treatment of maxillary impacted canines. Am J Orthod 1982;81:236-9.
  6. Jacoby H. The etiology of maxillary canine impactions. Am J Orthod 1983;84:125-132.
  7. Zhong YL, Zeng XL, Jia QL, Zhang WL, Chen L. Clinical investigation of impacted maxillary canine. Zhonghua Kou Qiang Yi Xue Za Zhi. 2006;41:483-5.
  8. Dewel BF. The upper cuspid: its development and impaction. Angle Orthod 1949;19:79-90.
  9. Broadbent BH. Ontogenic development of occlusion. Angle Orthod 1941;11:223-41.
  10. Kokich VG. Surgical and Orthodontic Management of impacted maxillary canines. Am J Orthod Dentofac Orthop 2004; 126:278-283.
  11. Pirinen S, Arte S, Apajalahti S. Palatal displacement of canine is genetic and related to congenital absence of teeth. J Dent Res 1996;75:1742-1746.
  12. Brin I, Becker A, Shalhav M. Position of the maxillary permanent canine in relation to anomalous or missing lateral incisors: A population study. Eur J Orthod 1986;8:12-16.
  13. Becket A, Smith P, Behar R. The incidence of anomalous lateral incisors in relation to palatally displaced cuspids. Angle Orthod 1981;51:24-9.
  14. Peck S, Peck L, Kataja M. Site-specificity of tooth maxillary agenesis in subjects with canine malpositions. Angle Orthod 1996;66:473-476.
  15. Shafer WG, Hine MK, Levy BM, Editors. A Textbook of Oral Pathology. 2nd Ed. Philadelphia: WB Saunders; 1963.
  16. Ngan P, Hornbrook R, Weaver B. Early timely management of ectopically erupting maxillary canines. Seminars in Orthodontics 2005;11:152–163.
  17. Ericson S, Kurol J. Longitudinal study and analysis of clinical supervision of maxillary canine eruption. Community Dent Oral Epidemiol 1986;14:172-176.
  18. Bishara SE. Clinical management of impacted maxillary canines. Seminars in Orthodontics 1998;4:87-98.
  19. Langland OE, Francis SH, Langlois RD. Atlas of special technics in dental radiology. In: Textbook of Dental Radiology. Springfield, IL: Charles C. Thomas Publishes; 1984.
  20. Ericson S, Kurol J. Radiographic examination of ectopically erupting maxillary canines. Am J Orthod Dentofac Orthop 1987; 91(6) 483-492.
  21. Katsnelson A, Flick WG, Susarla S, Tartakovsky JV, Miloro M. Use of panoramic x-ray to determine position of impacted maxillary canines. J Oral Maxillofac Surg. 2010;68:996-1000.
  22. Liu DG, Zhang WL, Zhang ZY, Wu YT, Ma XC. Localization of Impacted Maxillary Canines and Observation of Adjacent Incisor Resorption with Cone-Beam Computed Tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:91-98.
  23. Alqerban A, Jacobs R, Keirsbilck P, Aly M, Swinnen S, Fieuws S, Willems G. The effect of using CBCT in the diagnosis of canine impaction and its impact on the orthodontic treatment outcome. J Orthodc Sci 2014;3:34–40.
  24. Bishara SE. Clinical management of impacted maxillary canines. Seminars in Orthod 1998;4:87-98.
  25. Mc Sherry PF. The ectopic maxillary canine: a review. Br J Orthod 1998;25:209-216.
  26. Williams BHJ. Diagnosis and prevention of maxillary cuspid impaction. Angle Orthod 1981;51:30-40.
  27. Ericson S, Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary canines. Eur J Orthod 1988;10: 283-295.
  28. Baccetti T, Leonardi M, Armi P. A randomized clinical study of two interceptive approaches to palatally displaced canines. Eur J Orthod 2008;30:381–385.
  29. Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofac Orthop 1992;101:159-171.
  30. Mirabella D, Giunta G, Lombardol. Substitution of impacted canines by maxillary first premolars: a valid alternative to traditional orthodontic treatment. Am J Orthod and Dentofac Orthop 2013; 143:125-33.
  31. Kristerson L. Autotransplantation of human premolars. Int J Oral Surg 1985;14:200-213.
  32. Ahlberg K, Bystedt H, Eliasson S, Odenrick L. Long-term evaluation of autotransplanted maxillary canines with completed root formation. Acta Odontologica Scandinavica 1983;41: 23–31.
  33. Kokich VG. Surgical and orthodontic management of impacted maxillary canines. Am J Orthod and Dentofac Orthop 2004;126:278-283.
  34. Zadeh HH. Minimally invasive treatment of maxillary anterior gingival recession defects by vestibular incision subperiosteal tunnel access and platelet-derived growth factor. Int J Period Rest Dent 2011;31:653-660.
  35. Chen CK, Chang CH, Roberts WE. Class I II multiple gingival recession: vestibular incision subperiosteal tunnel access (VISTA) and platelet-derived growth factor. Int J Orthod Implantol 2014;35:22-36.
  36. Kokich VG, Mathews DA. Impacted teeth: surgical and orthodontic considerations. In: JA McNamara Jr. (ed.) Orthodontics and Dentofacial Orthopedics. Ann Arbor, Michigan: Needham Press; 2001.
  37. Bowman SJ, Carano A. The Kilroy spring for impacted teeth. J Clin Orthod 2003;37:683-688.
  38. Shastri D, Nagar A, Tandon P. Alignment of palatally impacted canine with open window technique and modified K-9 spring. Contem Clin Dent 2014;5:272–274.
  39. Park HS, Kwon OW, Sung JH. Micro-implant anchorage for forced eruption of impacted canines. J Clin Orthod 2004;38:297-302.
  40. Becker A, Shpack N, Shteyer A. Attachment bonding to impacted teeth at the time of surgical exposure. Eur J Orthod 1996;18:457-463.
  41. Sinha PK, Nanda RS. Management of impacted maxillary canines using mandibular anchorage. Am J Orthod Dentofac Orthop 1999;115:254-257.
  42. Crescini A, Nieri M, Buti J, Baccetti T, Pini Prato GP. Pre-treatment radiographic features for the periodontal prognosis of treated impacted canines. J Clin Period 2007;34:581-587.
  43. Becker A, Kohavi D, Kohavi D, Zilberman Y. Periodontal status following the alignment of palatally impacted canine teeth. Am J Orthod 1983;84:332-336.
  44. Edwards JG. A long-term prospective evaluation of the circumferential supracrestal fiberotomy in alleviating orthodontic relapse. Am J Orthod Dentofacial Orthop 1988;93:380-7.
  45. Bedoya MM, Park JH. A review of the diagnosis and management of impacted maxillary canines. J Am Dent Assoc 2009;140:1485-1493
  46. Manne R, Gandikota C, Juvvadi SR, Medapati Rama H, Anche S. Impacted canines: etiology, diagnosis, and orthodontic management. J Pharm Bioall Sci 2012;4:234-8.
  47. Charles A, Duraiswamy S, Krishnaraj R, Jacob S. Surgical and orthodontic management of impacted maxillary canines. J Res Dent Sci 2012;3:198-203.
Table 1

Table 1

The etiologic factors of canine impaction.45,46

View Hi-Res Image
Table 2

Table 2

Factors influencing the treatment decision of an impacted maxillary canine.47

View Hi-Res Image
  1. Litsas G, Acar A. A Review of Early Displaced Maxillary Canines: Etiology, Diagnosis and Interceptive Treatment. Open Dent J 2011;5:39-47.
  2. Dachi SF, Howell FV. A survey of 3,874 routine full mouth radiographs. Oral Surg Oral Med Oral Path 1961;14:1165-9.
  3. Thilander B, Myrberg N. The prevalence of malocclusion in Swedish school children. Scand J Dent Res 1973;81:12-20.
  4. Ericson S, Kurol J. Radiographic assessment of maxillary canine eruption in children with clinical signs of eruption disturbances. Eur J Orthod 1986;8:133‑40.
  5. Fournier A, Turcotte J, Bernard C. Orthodontic considerations in the treatment of maxillary impacted canines. Am J Orthod 1982;81:236-9.
  6. Jacoby H. The etiology of maxillary canine impactions. Am J Orthod 1983;84:125-132.
  7. Zhong YL, Zeng XL, Jia QL, Zhang WL, Chen L. Clinical investigation of impacted maxillary canine. Zhonghua Kou Qiang Yi Xue Za Zhi. 2006;41:483-5.
  8. Dewel BF. The upper cuspid: its development and impaction. Angle Orthod 1949;19:79-90.
  9. Broadbent BH. Ontogenic development of occlusion. Angle Orthod 1941;11:223-41.
  10. Kokich VG. Surgical and Orthodontic Management of impacted maxillary canines. Am J Orthod Dentofac Orthop 2004; 126:278-283.
  11. Pirinen S, Arte S, Apajalahti S. Palatal displacement of canine is genetic and related to congenital absence of teeth. J Dent Res 1996;75:1742-1746.
  12. Brin I, Becker A, Shalhav M. Position of the maxillary permanent canine in relation to anomalous or missing lateral incisors: A population study. Eur J Orthod 1986;8:12-16.
  13. Becket A, Smith P, Behar R. The incidence of anomalous lateral incisors in relation to palatally displaced cuspids. Angle Orthod 1981;51:24-9.
  14. Peck S, Peck L, Kataja M. Site-specificity of tooth maxillary agenesis in subjects with canine malpositions. Angle Orthod 1996;66:473-476.
  15. Shafer WG, Hine MK, Levy BM, Editors. A Textbook of Oral Pathology. 2nd Ed. Philadelphia: WB Saunders; 1963.
  16. Ngan P, Hornbrook R, Weaver B. Early timely management of ectopically erupting maxillary canines. Seminars in Orthodontics 2005;11:152–163.
  17. Ericson S, Kurol J. Longitudinal study and analysis of clinical supervision of maxillary canine eruption. Community Dent Oral Epidemiol 1986;14:172-176.
  18. Bishara SE. Clinical management of impacted maxillary canines. Seminars in Orthodontics 1998;4:87-98.
  19. Langland OE, Francis SH, Langlois RD. Atlas of special technics in dental radiology. In: Textbook of Dental Radiology. Springfield, IL: Charles C. Thomas Publishes; 1984.
  20. Ericson S, Kurol J. Radiographic examination of ectopically erupting maxillary canines. Am J Orthod Dentofac Orthop 1987; 91(6) 483-492.
  21. Katsnelson A, Flick WG, Susarla S, Tartakovsky JV, Miloro M. Use of panoramic x-ray to determine position of impacted maxillary canines. J Oral Maxillofac Surg. 2010;68:996-1000.
  22. Liu DG, Zhang WL, Zhang ZY, Wu YT, Ma XC. Localization of Impacted Maxillary Canines and Observation of Adjacent Incisor Resorption with Cone-Beam Computed Tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:91-98.
  23. Alqerban A, Jacobs R, Keirsbilck P, Aly M, Swinnen S, Fieuws S, Willems G. The effect of using CBCT in the diagnosis of canine impaction and its impact on the orthodontic treatment outcome. J Orthodc Sci 2014;3:34–40.
  24. Bishara SE. Clinical management of impacted maxillary canines. Seminars in Orthod 1998;4:87-98.
  25. Mc Sherry PF. The ectopic maxillary canine: a review. Br J Orthod 1998;25:209-216.
  26. Williams BHJ. Diagnosis and prevention of maxillary cuspid impaction. Angle Orthod 1981;51:30-40.
  27. Ericson S, Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary canines. Eur J Orthod 1988;10: 283-295.
  28. Baccetti T, Leonardi M, Armi P. A randomized clinical study of two interceptive approaches to palatally displaced canines. Eur J Orthod 2008;30:381–385.
  29. Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofac Orthop 1992;101:159-171.
  30. Mirabella D, Giunta G, Lombardol. Substitution of impacted canines by maxillary first premolars: a valid alternative to traditional orthodontic treatment. Am J Orthod and Dentofac Orthop 2013; 143:125-33.
  31. Kristerson L. Autotransplantation of human premolars. Int J Oral Surg 1985;14:200-213.
  32. Ahlberg K, Bystedt H, Eliasson S, Odenrick L. Long-term evaluation of autotransplanted maxillary canines with completed root formation. Acta Odontologica Scandinavica 1983;41: 23–31.
  33. Kokich VG. Surgical and orthodontic management of impacted maxillary canines. Am J Orthod and Dentofac Orthop 2004;126:278-283.
  34. Zadeh HH. Minimally invasive treatment of maxillary anterior gingival recession defects by vestibular incision subperiosteal tunnel access and platelet-derived growth factor. Int J Period Rest Dent 2011;31:653-660.
  35. Chen CK, Chang CH, Roberts WE. Class I II multiple gingival recession: vestibular incision subperiosteal tunnel access (VISTA) and platelet-derived growth factor. Int J Orthod Implantol 2014;35:22-36.
  36. Kokich VG, Mathews DA. Impacted teeth: surgical and orthodontic considerations. In: JA McNamara Jr. (ed.) Orthodontics and Dentofacial Orthopedics. Ann Arbor, Michigan: Needham Press; 2001.
  37. Bowman SJ, Carano A. The Kilroy spring for impacted teeth. J Clin Orthod 2003;37:683-688.
  38. Shastri D, Nagar A, Tandon P. Alignment of palatally impacted canine with open window technique and modified K-9 spring. Contem Clin Dent 2014;5:272–274.
  39. Park HS, Kwon OW, Sung JH. Micro-implant anchorage for forced eruption of impacted canines. J Clin Orthod 2004;38:297-302.
  40. Becker A, Shpack N, Shteyer A. Attachment bonding to impacted teeth at the time of surgical exposure. Eur J Orthod 1996;18:457-463.
  41. Sinha PK, Nanda RS. Management of impacted maxillary canines using mandibular anchorage. Am J Orthod Dentofac Orthop 1999;115:254-257.
  42. Crescini A, Nieri M, Buti J, Baccetti T, Pini Prato GP. Pre-treatment radiographic features for the periodontal prognosis of treated impacted canines. J Clin Period 2007;34:581-587.
  43. Becker A, Kohavi D, Kohavi D, Zilberman Y. Periodontal status following the alignment of palatally impacted canine teeth. Am J Orthod 1983;84:332-336.
  44. Edwards JG. A long-term prospective evaluation of the circumferential supracrestal fiberotomy in alleviating orthodontic relapse. Am J Orthod Dentofacial Orthop 1988;93:380-7.
  45. Bedoya MM, Park JH. A review of the diagnosis and management of impacted maxillary canines. J Am Dent Assoc 2009;140:1485-1493
  46. Manne R, Gandikota C, Juvvadi SR, Medapati Rama H, Anche S. Impacted canines: etiology, diagnosis, and orthodontic management. J Pharm Bioall Sci 2012;4:234-8.
  47. Charles A, Duraiswamy S, Krishnaraj R, Jacob S. Surgical and orthodontic management of impacted maxillary canines. J Res Dent Sci 2012;3:198-203.
TOP