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ARTICLE IN PRESSIO-47; No. of Pages 8

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ase report

reatment of an upper impacted cuspid using ultrasonicurgery and a modified RPE. A case report

ittorio Grenga ∗, Mauro Bovi, Raffaele SchiavoniD, DDS, Private practice, Rome, Italy

r t i c l e i n f o

rticle history:

eceived 10 March 2011

ccepted 8 April 2011

eywords:

a b s t r a c t

This case report describes the possibility to use a modified rapid palatal expander like

anchorage to reposition an included maxillary cuspid.

Moreover it is enphasized the use of an ultrasonic device during surgery to expose the

impacted tooth.

© 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.

nchorage

lass I malocclusion

mpacted cuspid

apid palatal expander

lary right canine (Fig. 1).

ltrasonic surgery

. Introduction

he prevalence of non eruption and/or ectopic eruption of theaxillary canine has been reported to range from 0.8% to 2.3%.

here is a significantly higher frequency in females comparedo males. Unilateral impactions are the most common1.

The treatment of impacted canines is often not so easy andredictable and it may lead to failure.

The principal reasons of the failure are an inappropriateositional diagnosis and a lack of appreciation of the consid-rable anchorage requirements of the case2.

Diagnosis and treatment planning of impacted maxillaryanines can be done by using traditional radiography or moreccurately by using cone-beam computed tomography3,4.

The comparative analysis of these methods permits toeterminate the labiopalatal position of an impacted maxil-

Please cite this article in press as: Grenga V, et al. Treatment of an upper ireport. Prog Orthod (2011), doi:10.1016/j.pio.2011.04.003

ary canine.Frequently patients with impacted upper cuspids require

axillary expansion to create necessary space to reposition

∗ Corresponding author. Via Apuania 3 - 00162 Rome, Italy.E-mail address: [email protected] (V. Grenga).

723-7785/$ – see front matter © 2011 Società Italiana di Ortodonzia SIDoi:10.1016/j.pio.2011.04.003

the permanent canine5.This can involve the preliminary useof a rapid palatal expander (RPE).

The next phase of treatment involves the surgical exposureof the impacted tooth and the use of orthodontic traction tomove the tooth to the occlusion.

The present article proposes the use of ultrasonic surgery toexpose the canine in palatal position and an easy modificationof RPE to allow the orthodontic repositioning of the impactedupper canine during the stabilization period of the maxillaryexpansion.

2. Case report

A 16-year-old female presented with a Class I malocclusion,constriction of the upper arch and palatally impacted maxil-

mpacted cuspid using ultrasonic surgery and a modified RPE. A case

A RPE with a 13 mm screw was inserted to correct the mildtransverse discrepancy of the upper arch and to give anchor-age for canine repositioning.

O. Published by Elsevier Srl. All rights reserved.

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http://www.elsevier.com/locate/pio

mailto:[email protected]

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Please cite this article in press as: Grenga V, et al. Treatment of an upper impacted cuspid using ultrasonic surgery and a modified RPE. A casereport. Prog Orthod (2011), doi:10.1016/j.pio.2011.04.003

ARTICLE IN PRESSPIO-47; No. of Pages 8

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Fig. 1(a-l) – Facial and intraoral photographs of the patient at the start of treatment. Note the panoramic radiograph showingthe upper right cuspid in palatal inclusion.

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Fig. 2 – Palatal view of the upper arch with the RPEinserted. Note the 0.022 x 0.028 inch tube soldered on therc

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Fig. 4 – Palatal view of the upper arch immediately aftersurgical exposition of the canine crown using an ultrasonicdevice. Note the TMA 0.017 x 0.025 inch sectional springinserted in the tube soldered to the RPE right arm.

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ight arm of the RPE. There is also a little auxiliary arm thatan be used during orthodontic traction.

On the right arm of the expander a 0.022 x 0.028 inch tubeas soldered (Fig. 2).

After the appliance placement, the screw was activated auarter of a turn (0.25 mm) once per day for two weeks.

After that the necessary expansion was achieved, theatient underwent surgery to expose the impacted canine.

Surgery was performed under local anesthesia (Articainehloride 4% plus adrenaline 1/100000) after waiting 20 minutesor vasoconstriction to take effect.

A window of palatal mucosa was excised with a radiosurgi-al device (Ellmann Dento-Surg 90 F.F.P., Ellmann Internationalnc., Hewlett, NY, USA).


The removal of the bone covering the impacted canineas performed by using an ultrasonic surgical device (Piezonaster SurgeryR,EMS, Switzerland) without flap elevation6.he insert used was the EX 2 (Fig. 3)

Fig. 5 – Palatal view of the upper arch three months afterthe application of the TMA sectional spring and after onlyone reactivation.

ig. 3 – (a) After having done a window on the palatal mucosa with a radiosurgical device, pericoronal osteotomy has donesing an ultrasonic device (EMS with a EX2 insert). Note that the insert is parallel in relation to the dental crown, in this way

t is possible to realize an osteotomy less traumatic for the enamel.b) Exposition of the crown of the impacted canine: note reduced bleeding that permit to position an attachment on therown minimizing bonding problems.

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and
Fig. 6 (a-d) – RPE was removed, the upper arch was bonded

The choice to use an open eruption method allowedto avoid the RPE removal and to perform the orthodon-tic traction. A button was placed on the palatal surfaceof the canine and a 0.017 x 0.025 inch TMA sectional

Fig. 7 (a-d) – The canine has reached the arc

a power chain was applied to reposition the canine.


spring was applied by using a tube soldered on the RPE(Fig. 4).

After one month the spring was easily reactivated and afterthree months the canine was extruded in palatal position

h and a 0.014 NiTi archwire is applied.

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Fig. 8 (a-e) – Upper and lower arches bonded to resolve the mild crowding in the lower arch and to obtain an optimali

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eady to be moved to the arch (Fig. 5). The RPE was thenemoved and the upper arch was bonded. The upper righteciduous canine was extracted. A button was bonded on theestibular surface of the upper permanent canine to allowhe repositioning in the arch of the tooth together with theotation of the canine.

An upper 0.020 inch stainless steel archwire was applied inhe upper arch with a coil spring from the right first bicuspido the right lateral incisor to increase the space. A power chainas applied on the button of the cuspid.

Composite was placed on the occlusal surfaces of the


pper second molars to open the bite temporarily and toermit the movement of the maxillary right canine fromalatal to labial position without occlusal interferences

Fig. 6).

After 4 months the canine reached the arch and so it waspossible to put a bracket on the cuspid. An upper NiTi 0.014inch archwire was applied and the composite on the occlusalsurfaces of the maxillary second molars were removed (Fig. 7).

Three months later the canine was completely derotatedand levelled and the lower arch was bonded to resolve themild crowding of the anterior teeth (Fig. 8).

After 18 months of active treatment the patient wasdebonded and two essix retainer were applied to be wornnighttime.

Final records of the patient showed a good aesthetical and


functional result.Two little spaces distal to the lateral upper incisors were

present probably due to a discrepancy between the mesiodis-tal diameters of the upper and lower front teeth (Fig. 9).

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Fig. 9 (a-i) – Final records of the patient after 18 months of treatment.

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Fig. 10 – Panoramic radiograph showing a good position ofthe upper right canine without periodontal problems andw

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ith the root with no sign of resorption.

The panoramic radiograph showed a good periodontal sta-us with a correct position of the root of the canine withoutesorption (Fig. 10).

. Discussion

he literature reveals that palatally ectopic canines that haveeen surgically exposed and orthodontically aligned have amall and clinically insignificant reduction in periodontal sup-ort compared with contralateral canines.7–9

In addition, to remove more bone than that which isdequate for bonding a small attachment appears to benjustified.10

Disadvantages of surgical exposure of an impacted palatalanine without flap elevation include inadequate visibility andifficulty in performing a correct osteotomy to identify therown of the tooth. Moreover, haemorrhage makes bracketonding difficult.

Ultrasonic surgery with selective cutting of the tissuesllows for the performance of osteotomies through soft tis-ues for a clear identification of the impacted tooth withoutamaging the palatal mucosa. The cavitation produced by theltrasonic technique facilitates hemostasis.11–13

The osteotomy is the main aspect of the surgical interven-ion because it allows for visualization of the enamel of therown of the impacted tooth, revealing the exact position ofhe tooth and its relationship with the contiguous structures.his creates space for the correct positioning of the button.

The amount of bone removed should be as small as possi-le, consistent with the proper placement of an orthodonticppliance (button-chain) to allow pulling of the tooth. Theone removal should not damage the adjacent teeth; this mayccur when the canine is very close to the roots of the lateralnd central incisors.

Use of ultrasonic instrumentation in performing thesteotomy allows for the selective cutting of hard tissue. Itlso helps to distinguish between bone, cement, and enamel.onsequently, there is no injury to the cemento-enamel junc-

ion, which is fundamental for physiological tooth movementnd avoidance of the risk of ankylosis. Additionally, the adja-


ent dental structures are preserved. Damage to the involvedooth and to the adjacent teeth is avoided because of thextreme tactile sensitivity of the device (which allows for the

x x ( 2 0 1 1 ) xxx–xxx 7

recognition of different materials) and because of the effec-tiveness of different ultrasonic cutting tools according to theirplacement on the surface of attack. Tools are most effectivewhen they are placed perpendicular to the surface, and leasteffective when parallel.

During the pericoronal osteotomy, the inserts should beheld parallel to the tooth to be exposed so that there is almostno action on the tooth, but maximum action on the bone tobe removed. This approach allows for a safe osteotomy alongthe buccal surface of the crown of the impacted tooth.

The time required for removal of the bone overlying theimpacted tooth is minimal because of the greater ease withwhich the operator can move. Thus, the surgery time isshorter, and this is particularly pleasing to young patients.The comfort and cooperation of the patient are greatlyincreased because ultrasonic instruments are less traumaticthan rotating instruments, and the use of manual chiselsand hammers can be avoided. Finally, more effective bleed-ing control during surgery allows for the preparation of adry field, which is necessary for the success of intraoperativebonding.

The removal of the etching agent from the enamel sur-face of the tooth should be performed with the irrigation ofultrasonic instrumentation because the cavitation maintainsa bloodless field.

Conflict of interest

The authors have reported no conflicts of interests.

Riassunto

Questo caso clinic descrive la possibilità di usare un espansorepalatale rapido modificato come ancoraggio per il riposizionamentodi un canino mascellare incluso. Inoltre si utilizza un dispositivo aultrasuoni durante l’intervento chirurgico per esporre il dente incluso.

Résumé

Cette observation médicale décrit la possibilité d’utiliser unexpanseur palatal à action rapide modifié comme ancrage pour repo-sitionner une canine incluse au maxillaire.Qui plus est, l’accent est mis sur l’utilisation d’un appareil à ultrasonspendant l’opération chirgicale pour exposer la dent incluse.

Resumen

Este case report describe la posibilidad de utilizar un expansorpalatal rápido modificado como anclaje para reposicionar un caninomaxilar incluido.Asimismo, se hace hincapié en la utilización de un dispositivo deultrasonidos durante la intervención quirúrgica para exponer eldiente incluido.

e f e r e n c e s


1. Andreasen JO, Petersen JK, Laskin DM. Textbook and color atlasof tooth impactions. Copenhagen: Munksgaard;1997.

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2. Becker A, Chaushu G, Chaushu S. Analysis of failure in thetreatment of impacted maxillary canines. Am J OrthodDentofacial Orthop 2010;137:743–54.

3. Haney E, Gansky SA, Lee JS, Johnson E, Maky K, Miller AJ,Huang JC. Comparative analysis of traditional radiographsand cone-beam computed tomography volumetric images inthe diagnosis and treatment planning of maxillary impactedcanines. Am J Orthod Dentofacial Orthop 2010;137:590–7.

4. Maverna R, Gracco A. Different diagnostic tools for thelocalization of impacted maxillary canines: clinicalconsiderations. Prog Orthod 2007;8:28–44.

5. Schindel RH, Duffy SL. Maxillary transverse discrepanciesand potentially impacted maxillary canines inmixed-dentition patients. Angle Orthod 2007;77:430–5.

6. Grenga V, Bovi M. Piezoelectric surgery for exposure of


palatally impacted canines. J Clin Orthod 2004;38:446–8.7. Burden DJ, Mullally BH, Robinson SN. Palatally ectopic

canines: closed eruption versus open eruption. Am J OrthodDentofacial Ortop 1999;115:634–9.

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8. Schmidt AD, Kokich VG. Periodontal response to earlyuncovering, autonomous eruption and orthodonticalignment of palatally impacted maxillary canines. Am JOrthod Dentofacial Orthop 2007;131:449–55.

9. Baccetti T, Crescini A, Nieri M, Rotundo R, Pini Prato GP.Orthodontic treatment of impacted maxillary canines: anappraisal of prognostic factors. Prog Orthod 2007;8:6–15.

10. Becker A, Casap N, Chaushu S. Conventional wisdom andthe surgical exposure of impacted teeth. Orthod Craniofac Res2009;12:82–93.

11. Bovi M. La strumentazione ultrasonica in chirurgia orale.Cap. 7: Esposizione dei denti inclusi. Quintessenza EdizioniS.R.L. 2011.

12. Walmsley AD, Laird WR, Williams AR. Intra-vascularthrombosis associated with dental ultrasound. J Oral Pathol


1987;16:256–9.13. Williams AR. Intravascular mural thrombi produced by

acoustic microstreaming. Ultrasound Med Biol 1977;3:191–203.

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