not permitted.

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MINERVA STOMATOL 2013;62:117-25

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Impacted maxillary canine on the position of the

central incisor: surgical-orthodontic repositioning
G. FARRONATO 1, 2, L. GIANNINI 1, 2, C. FOLEGATTI 1, 2, E. BROTTO 1, 2, G. GALBIATI 1, 2, C. MASPERO 1, 2

® A
T C
H DI
The aim of this article is to describe a case of a 1Department of Diagnostioc, Surgical,
young orthodontic patient in which an impac- Reconstructive Surgery, IRCCS Cà Granda
ted maxillary canine was repositioned in the Foundation, Maggiore Policlinico Hospital,
IG E
central incisor position. A severe resorption
of the root of the central right maxillary inci-
University of Milan, Milan, Italy
2School of Orthodontic, University of Milan,
Milan, Italy
R M
sor by ectopic eruption of the impacted right
maxillary canine is described. The canine was
repositioned in the incisor’s position to avoid
resorption of the roots of the adjacent teeth
during the disinclusion. The central incisor The functional and aesthetics importance of
P A

was extracted and the canine was extruded by

a closed eruption technique. When the canine canines requires an early diagnosis to rec-
ognize tooth displacement and to predict
O V

eruption was complete, the tip, the torque and

the morphology of the canine were modiied the subsequent failure of eruption in order
in order to make it look like an incisor. Nowa- to choose the most suitable treatment op-
C ER

days the therapy with dental implants is the tion to manage this situation.
best choice, if the position of impacted teeth
The management of impacted canines is
Y

is dificult to reach. This case report descri-

bes a successful management of an impacted almost always complex and it is based on a
upper right canine aligned in the upper right multidisciplinary approach that involves of-
IN

central incisor position. Accurate diagnosis,
conservative management of the soft tissues,
anchorage unit and the direction of the ortho-
dontic traction are important factors for the
M
ten not only orthodontist and oral surgeon,
but also pedodontist and periodontist.
In literature different therapeutic solu-
tions are described:

success treatment.
KEY WORDS: Orthodontics - Surgical procedures, — surgical extraction of deciduous ca-
operative - Early diagnosis. nine and increase of the space;2-4 For this
therapeutic solution an early diagnosis is
necessary;
T he canine is considered one of the most
or other proprietary information of the Publisher.

— surgical extraction and auto-transplan-

important teeth in terms of esthetics and
function. It has a very long root able to sup-
port heavy masticatory load and it plays an
important role of protection for posterior
teeth during mandibular lateral movements.1
Corresponding author:Prof. G. Farronato, University
ofMilan, Via Commenda 10, 20100 Milan, Italy.
E-mail: giampietro.farronato@unimi.it
tation of impacted tooth;
— surgical extraction of impacted tooth
and orthodontic closure of the space;3
— surgical extraction followed by pros-
thetic or implant-prosthetic replacement;3, 5
— surgical exposure and orthodontic
alignment of the impacted tooth;
— no treatment.

Vol. 62 - No. 4 MINERVA STOMATOLOGICA 117

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
FARRONATO IMPACTED MAXILLARY CANINE ON THE POSITION OF THE CENTRAL INCISOR
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
Surgical exposure and orthodontic align-
ment is the best choice to obtain the most
satisfactory long term results.6
This therapy requires:
— fully formed tooth apex;
— favorable topographic and anatomic
conditions;
— normal shape and structure of impact-
ed tooth;
— presence of space into the dental arch;
— lack of ankylosis;
— good integrity of periodontal tissues;
® A
— orthodontic anchorage;
— lack of barriers to surgical exposure;
T C
— bone’s quality.3
Diagnosis and position of an impacted
H DI
tooth is based on clinical and radiograph-
ic examinations 3, 7-12 as panoramic ra-
diograph, lateral headilm, occlusal radio-
graphs, intraoral radiographs according to
IG E
Clark’s technique, computed tomography
(CT). They conirm the diagnosis of impac-
R M
tion giving informations about dental dam-
age and localization of the impacted teeth,
its relations with adjacent teeth and possi-
ble apical resorption. This allows to choose
P A
the most useful treatment.13-15
Nowadays, CT is considered the diagnos-
O V
tic method of choice.
CT provides the position and the inclina-
C ER
tion of the impacted tooth, the relationship
with the adjacent anatomical structures, and
Y
in particular with the roots of neighboring
teeth.16-18
IN
Nowadays the CBCT (cone-beam com-
puted tomography) gives informations
about spatial relationship of impacted ca-
nines. The clarity image is remained very
M
similar to that of a conventional CT, but it
has additional advantages: it allows to ob-
tain a perfect reconstruction of three-di-
mensional maxillary or mandibular spaces
analyzing directly the canine’s position, the
or other proprietary information of the Publisher.
size, the follicle, the amount of bone cover-
ing the tooth. The three-dimensional recon-
struction is performed by stereolithography
models that the computer obtains directly
from the same CT.19, 20 Thus, the perfection
of the images, the possibility of getting ster-
eolithography models and reducing expo-
sure compared to a conventional CT, make
118 MINERVA STOMATOLOGICA
CBCT the gold standard for the diagnosis of
impacted canine.21
The aim of this paper was to describe a
clinical case in which a central incisor with
severe root reasorbtion was replaced by an
impacted canine. The advantages and dis-
advantages of this therapeutic choice are
analyzed.22, 23
Case report
A 17-year-old male patient came to the ortho-
dontic department of the Milan University for an
orthodontics consultation with the chief complaint
of irregular front teeth.
Extra oral examination showed a mesomorphic
face, competent lips, mild convex proile.
The intraoral examination showed the absence
in the dental arch of the irst upper right canine, re-
duced mesial-distal width of the upper right lateral
incisor, a midline deviation toward right side in the
upper jaw and a posterior crossbite in the right side,
an Andrew’s class I on the left side and a class II on
the right side, mild mandibular incisors crowding,
reduced overjet, retroinclined maxillary central inci-
sors, deep overbite, maxillary transverse deiciency
(Figures 1-3).
Cephalometric analysis showed a skeletal Class
II malocclusion with hypodivergent growth pattern,
retroinclined maxillary incisors (Table I). Frontal
cephalometric radiograph evidenced a maxillary
transversal narrowness. The panoramic ilm showed
the right upper canine impacted and a severe root
reasorbtion of the upper right central incisor.
It was decided to expand the maxilla through a
modiied palatal expander (Figure 4) realized with
two bands on the irst upper molars and a central
screw. A vestibular arm extending from the upper
right molar band to the contralateral incisor was
constructed and bonded to the incisor before the
expansion. The purpose was to gain space to the
right side of the arch and prevent anterior move-
ment of upper central left incisor in the space creat-
ed by the palatal expansion and restoring a correct
symmetry of the midlines. The right vestibular arm
was made with a distal eyelet and a mesial one,
positioned near the impacted canine area.
The central screw was actived by a quarter turn
twice daily for 14 days and then blocked with a
ligature wire (Figure 5).
The space created by palatal expansion allowed
the migration of teeth only on the side where there
was lack of space near the impacted canine. The
appliance was left in place for 6 months in order to
stabilize transverse maxillary dimension.
It was decided to position multibrackets ap-
pliance except on the right lateral and central inci-
April 2013
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is

IMPACTED MAXILLARY CANINE ON THE POSITION OF THE CENTRAL INCISOR FARRONATO

This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

A B
Figure 1.—A) Lateral right (A) and lateral left (B) intraoral view before treatment. Upper right canine is not present,

® A
deviation of upper midline to right and posterior right crossbite is evident.

T C
H DI
IG E
R M
P A

Figure 2.—Panoramic
Panoramic i ilm
lm before treatment. The reab-
sorption of the central right maxillary incisor is evident. Figure 4.—Upper occlusal intraoral view of modiied
palatal expander in situ.
O V

The arm on the right side is made with a loop to extrude

the upper right canine impacted while the left arm is
bonded in order to obtain middle lines’ symmetry using
C ER

the space created by the expander

Y
IN
M

Figure 5.—Upper occlusal intraoral view after expander’s

or other proprietary information of the Publisher.

activation. The space of intercisal diastema created by

the palatal expansor is evident.

sors to avoid the movement of its root that could

Figure 3.—Lateral headilm before treatment.
cause the resorption of the root itself and / or im-
pacted canine.24
The central incisor and the left irst premolar
were extracted. The central right upper incisor was
extracted due to severe root’s reasorbtion. The irst

Vol. 62 - No. 4 MINERVA STOMATOLOGICA 119

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
FARRONATO IMPACTED MAXILLARY CANINE ON THE POSITION OF THE CENTRAL INCISOR
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
left upper premolar was extracted to obtain the
right symmetry of maxillary arch.
When leveling and alignment of the dental arch
was obtained the right upper central incisor was
extracted and the right upper impacted canine was
surgically exposed and bonded with a button and
a ligature wire.
A mucoperiosteal lap was raised and the crown
of the impacted tooth was exposed using a round
bur on low-speed handpiece, an intraosseous route
was created to connect the tooth with the alveolar
cavity of central incisor extracted, allowing the pas-
sage of the ligature wire to the unerupted tooth.
The lap was then sutured to its original position.
® A
The surgical technique preserved a correct quan-
tity of the attached gingiva. Orthodontic traction
was directed between the inner and outer cortex,
T C
allowing the impacted tooth to follow an eruptive
path similar to the physiological one preserving the
H DI
keratinized gingival.25, 26
Orthodontic traction was performed with light
forces, activated monthly; heavy forces would have
caused hyalinized processes and ankylosis of the
IG E
periodontal ligament with extrusion of the element
without its supporting structures.
When the canine was close to the dental arch,
R M
a 014 nickel titanium wire was used to gradually
bring the element in the right position.
A bracket for upper right incisor was placed on
the canine: this allowed both the reduction of me-
P A
sio-distal size of the canine respect to incisor (from
O V
C ER
Y
IN
M
A B
or other proprietary information of the Publisher.
C of canine, lateral incisor and irst premolar.
120 MINERVA STOMATOLOGICA
a +8° tip to a to +4° tip), but also to provide a posi-
tive torque to the element, instead of a negative one
(from a -7° torque to a +17 ° torque).27
A bracket on upper left lateral incisor was also
positioned.
A bracket for an upper right canine was placed
on upper left irst premolar bracket; this allowed to
increase the tip of the upper irst premolar in order
to assume the canine’s one (from a tip to a tip of
0° to 8°).
After repositioning of the canine in the arch, the
correct occlusal relationships were obtained during
the inishing stage.28, 29
When the canine was positioned in the upper
right central incisor room, root canal therapy and
coronal reconstruction were made to let it take on
the appearance of a central incisor.
A prosthetic solution using porcelain veneers to
harmonize the color of two anterior teeth was also
proposed. The patient was so satisied with the re-
sult that he decided to postponed later any pros-
thetic solution.
A dental plastic of irst upper right premolar that
was placed in the upper right canine position was
performed to obtain a correct canine guidance and
to take the morphological characteristics of a ca-
nine.
Finally a cosmetic reconstruction of the right up-
per lateral incisor to obtain a correct mesial-distal
diameter was performed. A retention device was
then given (Figures 6, 7).
Figure 6.—Lateral right (A), frontal (B) and lateral left
(C) intraoral view after treatment. Good esthetic results
have been obtained by the conservative reconstructions
April 2013
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
IMPACTED MAXILLARY CANINE ON THE POSITION OF THE CENTRAL INCISOR
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
® A
Figure 7.—Panoramic ilm (A) and lateral (B) headilm at the end of orthodontic ixed treatment with appliance in situ.
T C
H DI
Discussion
All the therapeutic possibilities had been
considered in the planning of this clinical
IG E
case:
— surgical exposure of right upper ca-
R M
nine and orthodontic alignment. Extraction
of upper right central incisor and its pros-
thetic implant replacement;
— extraction of right upper canine and
P A
upper right central incisor and replacement
of both teeth with implants and prosthesis;
O V
— surgical exposure and reposition of
right upper canine instead of upper right
C ER
central incisor, extraction of upper right
central incisor and upper left irst premolar
Y
to obtain arch symmetry.
The irst treatment option was discarded
IN
because the orthodontic-surgical exposure
with canine’s reposition in its place, would
have not a good prognosis and also it would
lead to serious complications as resorption
M
of lateral root. In fact, according to the ra-
diographic parameters of Ericson and Kurol
9, 10 on panoramic radiograph, the cusp of
the canine was in the irst sector (between
or other proprietary information of the Publisher.
the incisor central axis and midline): the
prognosis of the reposition treatment of an
impacted tooth in its normal position in the
arch was given.11, 30-32
The cephalometric tracings showed the
angle between the axis of canine and the
one perpendicular to the Frankfurt plane
was 45°. This value conirms the negative
prognosis.3
Vol. 62 - No. 4 MINERVA STOMATOLOGICA
FARRONATO
The two other therapeutic options were
discussed and evaluated together with the
patient and his parents who were motivated
upon the possibility to recover his impacted
tooth with surgical exposure.
Consequently the canine was exposed
and repositioned in upper central incisor
position after extraction of the central in-
cisor severely compromised, closing the
space at the upper right canine and extract-
ing upper left irst premolar.
Conclusions
Maxillary canine impaction is a frequent
clinical problem. The treatment requires
frequently a multidisciplinary approach. It
is fundamental early diagnosis to intercept
clinical situation that can predispose to im-
paction.
In this case report a successful treatment
of a surgical exposure of impacted canine,
followed by orthodontic traction and align-
ment in the upper right central incisor po-
sition after extraction of this tooth is de-
scribed.
.References
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canini inclusi: approccio chirurgico-ortodontico. Mi-
lan: Ed. Sinergie; 2007.
2. Shapira Y, Kuftinec MM. Early diagnosis and intercep-
tion of potential maxillary canine impaction. J Am
Dent Assoc 1998;129:1450-4.
121
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
FARRONATO IMPACTED MAXILLARY CANINE ON THE POSITION OF THE CENTRAL INCISOR
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
3. Bishara SE. Impacted maxillary canines: a review. Am
J Orthod Dentofacial Orthop 1992;101:159-71.
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6. Becker A. Trattamento ortodontico dei denti inclusi.
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® A
9. Ericson S, Kurol J. Radiographic examination of ec-
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lary canine eruption in children with clinical signs of
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Pre-treatment radiographic features for the periodon-
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13. Farronato G, Grillo ME, Giannini L, Farronato D,
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CT based rating of unilateral impacted canines. J
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Consideration of the Upper Canines. Am J Orthod
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Disinclusione e riposizionamento ortodontico-chirurgico
di un canino mascellare incluso in posizione dell’incisivo centrale
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tanza funzionale ed estetica del canino impongono
una diagnosi di possibile inclusione il più preco-
ce possibile per scegliere la soluzione terapeutica
più adatta per il recupero in arcata dell’elemento
interessato. Il canino è considerato esteticamente
insostituibile nell’esposizione durante il sorriso. Es-
sendo, inoltre, dotato di una radice particolarmente
lunga e tale da sopportare notevoli carichi, svolge
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ization of maxillary canines with cone-beam com-
puted tomography. Am J Orthod Dentofacial Orthop
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Received on October 10, 2012.
Accepted for publication on March 11, 2013.
un ruolo primario nei movimenti mandibolari di la-
teralità 1.
Esistono differenti soluzioni terapeutiche che
possono essere attuate nei casi di inclusione dei
canini:
— estrazione del canino deciduo e aumento pre-
ventivo dello spazio 2-4;
— estrazione dell’elemento incluso ed autotra-
pianto;
April 2013
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
IMPACTED MAXILLARY CANINE ON THE POSITION OF THE CENTRAL INCISOR
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(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
— estrazione dell’elemento incluso e chiusura
ortodontica dello spazio 3;
— estrazione e sostituzione protesica 3, 5 o im-
plantoprotesica;
— trattamento ortodontico-chirurgico con recu-
pero in arcata del dente incluso (trattamento disin-
clusivo) 3.
La terapia conservativa cioè l’intervento chirur-
gico disinclusivo rappresenta la scelta terapeutica
d’elezione per ottenere i risultati più soddisfacenti
a lungo termine 6.
Tale terapia si effettua secondo precise indica-
zioni:
— dente con apice completamente formato;
® A
— condizioni anatomo-topograiche favorevoli;
— forma e struttura dell’elemento incluso nor-
mali;
T C
— presenza di spazio in arcata;
— assenza di anchilosi;
H DI
— buona integrità dei tessuti parodontali;
— presenza di ancoraggio ortodontico;
— assenza di ostacoli alla disinclusione;
— suficiente tessuto osseo 3.
IG E
La gestione del canino incluso è quasi sempre
complessa e si basa su un approccio multidiscipli-
nare che coinvolge spesso non solo l’ortodontista
R M
ed il chirurgo orale, ma anche il pedodontista ed il
parodontologo.
La diagnosi e la localizzazione dell’inclusione
dentaria si basano sull’esame clinico e radiograico
P A
3, 7-12.
Gli esami radiograici (ortopantomograia, tele-
radiograia del cranio in proiezione laterolaterale,
O V
radiograia occlusale, radiograie endorali secondo
la tecnica di Clark, TC) confermano la diagnosi di
C ER
inclusione dentaria e danno informazioni relative
alla posizione, alla sede dell’elemento ectopico, ai
Y
rapporti con i denti adiacenti e all’eventuale riassor-
bimento degli stessi permettendo di selezionare la
metodica di trattamento più appropriata 13-15.
IN
La TC rappresenta il metodo diagnostico d’ele-
zione.
Infatti mediante tale indagine è possibile osser-
vare chiaramente la posizione e l’inclinazione degli
elementi inclusi in modo da poter valutare i rappor-
M
ti con le strutture anatomiche adiacenti, e in partico-
lare con le radici dei denti attigui 16, 17.
Con l’avvento della tomograia computerizza-
ta cone-beam (cone-beam computed tomography,
CBCT) la chiarezza dell’immagine è rimasta molto
or other proprietary information of the Publisher.
simile a quella di una TC tradizionale, ma l’esposi-
zione a radiazioni ionizzanti è stata notevolmente
ridotta.
La TC cone-beam presenta degli ulteriori van-
taggi, in quanto permette di ottenere delle perfette
ricostruzioni tridimensionali del volume mascellare
o mandibolare su cui andare ad analizzare diret-
tamente la posizione del canino. La ricostruzione
tridimensionale viene effettuata mediante la costru-
zione di modelli stereolitograici attraverso l’elabo-
Vol. 62 - No. 4 MINERVA STOMATOLOGICA
FARRONATO
razione di dati che il computer ottiene direttamente
dalla TC stessa 18-20.
Quindi, la perfezione delle immagini, la possibi-
lità di ottenere modelli stereolitograici e la ridotta
esposizione rispetto a una TC tradizionale rendono
la CBCT il gold standard per la diagnosi di inclusio-
ne canina 21.
L’obiettivo di questo lavoro è stato quello di de-
scrivere un caso clinico di posizionamento di un
canino incluso in sostituzione dell’incisivo centrale
andato incontro a rizolisi e di analizzare vantaggi e
svantaggi di questa scelta terapeutica 22, 23.
Caso clinico
Un paziente di sesso maschile si presenta all’os-
servazione all’età di 17 anni. All’esame intraorale
si rileva assenza in arcata del 13, ridotto ingombro
mesio-distale del 12, deviazione della linea mediana
superiore verso destra e cross monolaterale destro
a carico degli elementi dentali posteriori (Figura 1A,
B).
Dall’esame dell’ortopantomograia (Figura 2)
e della radiograia occlusale si evidenzia la com-
promissione della radice dell’11 andata incontro a
riassorbimento a seguito della posizione ectopica
del 13.
Sono state eseguite anche teleradiograie del cra-
nio in proiezione latero-laterale (Figura 3), postero-
anteriore e assiale per poter effettuare l’analisi tri-
dimensionale della situazione scheletrica. L’analisi
cefalometrica evidenzia sia una discrepanza sul pia-
no sagittale, in quanto è presente una tendenza alla
II Classe scheletrica, sia una discrepanza sul piano
trasverso, in quanto si osserva una contrazione del
diametro del mascellare (Tabella I).
Si è deciso di iniziare la terapia attraverso un
espansore del palato modiicato (Figura 4). Tale
espansore è stato dotato oltre che delle due bande
sui sesti e della vite centrale anche di due bracci
vestibolari ancorati alle bande molari. Il braccio si-
nistro arrivava in corrispondenza dell’incisivo con-
trolaterale alla deviazione della linea mediana su-
periore al quale è stato bondato prima di effettuare
l’espansione.
Lo scopo era quello di recuperare spazio verso
il lato destro dell’arcata ed evitare la mesializzazio-
ne del 21 nello spazio creatosi in seguito alla di-
sgiunzione palatale, ristabilendo anche una corretta
simmetria delle linee mediane. Il braccio destro ve-
stibolare è stato realizzato con un occhiello distale
ed un occhiello mesiale alla posizione del canino
incluso. Lo spazio del diastema interincisivo creato
dall’espansione del palato è stato gestito in modo
da far migrare gli elementi solo dal lato dove c’era
carenza di spazio quindi dal lato dove era presente
l’inclusione del canino.
L’apparecchiatura è stata attivata con un quarto
di giro due volte al giorno per 14 giorni (Figura 5).
123
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
FARRONATO IMPACTED MAXILLARY CANINE ON THE POSITION OF THE CENTRAL INCISOR
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
La vite centrale è stata in seguito bloccata con un
ilo di legatura e l’apparecchiatura è rimasta in situ
a scopo contenitivo.
La terapia è continuata con un camoulage di II
Classe mediante bandaggio di entrambe le arcate
con estrazione di due denti dall’arcata superiore
mantenendo in situ il disgiuntore. Per scelta estetica
del paziente, il bandaggio è stato eseguito con at-
tacchi in ceramica.
Si è deciso di non posizionare l’attacco sul 12 per
evitare lo spostamento radicolare di tale elemento
che avrebbe potuto causare il riassorbimento della
radice dello stesso e/o dell’elemento incluso. Anche
l’11 non è stato bondato 24.
® A
L’arcata è stata solidarizzata con un arco a pieno
spessore.
Gli elementi che si è deciso di estrarre erano l’11
T C
ed il 24. L’11 è stato sacriicato a causa della grave
compromissione della radice. Si è proceduto quindi
H DI
in un’unica seduta all’estrazione di 11 e all’interven-
to di disinclusione del 13.
Si è proceduto con tecnica di chirurgica in gra-
do di preservare una suficiente quota di gengiva
IG E
aderente. Si è scollato un lembo mucoperiosteo ed
esposta la corona del dente incluso; con una fresa a
rosetta montata su manipolo a bassa velocità è stato
R M
creato un tragitto intraosseo che, collegando la sede
di inclusione con la cavità alveolare dell’11 estratto,
consentisse il passaggio del dispositivo di trazione
ino al dente incluso.
P A
È stato quindi bondato un bottone con occhiel-
lo al quale è stata applicata una legatura metallica
estesa ino alla supericie occlusale dell’arcata su-
O V
periore.
Il lembo è stato quindi suturato nella posizione
C ER
originaria.
La trazione ortodontica è stata direzionata tra la
Y
corticale interna e quella esterna, permettendo al
dente incluso di seguire un percorso eruttivo simile
a quello isiologico preservando la gengiva chera-
IN
tinizzata 25, 26.
La trazione ortodontica è stata esercitata con for-
ze estremamente leggere attivate mensilmente; for-
ze pesanti avrebbero infatti potuto causare processi
di ialinizzazione ed anchilosi del legamento paro-
M
dontale con estrusione dell’elemento senza le sue
strutture di supporto.
Quando il canino è stato prossimo alla linea d’ar-
cata per la trazione è stato utilizzato un ilo 014
in nichel- titanio che progressivamente ha portato
or other proprietary information of the Publisher.
l’elemento nella posizione programmata.
Si è deciso quindi di posizionare su di esso un
bracket per incisivo superiore destro: ciò ha per-
messo sia di ridurre l’ingombro mesiodistale del
canino rispetto a un incisivo (passando da un tip
di +8° a un tip di +4°), ma anche di fornire torque
positivo all’elemento, invece che negativo (passan-
do da un torque di -7° a un torque di +17°) 27-29.
Si è posizionato il bracket anche sull’elemento
12. Si è deciso di posizionare sull’elemento 14 un
124 MINERVA STOMATOLOGICA
bracket per canino superiore destro; questo accor-
gimento ha permesso di modiicare l’ingombro me-
siodistale del premolare aumentandolo come fosse
quello di un canino (si è passati da un tip di 0° a
un tip di +8°).
Completato il riposizionamento in arcata del ca-
nino si è passati alla fase di riinitura durante la qua-
le sono stati inalizzati i corretti rapporti occlusali.
Per simmetrizzare l’arcata superiore si è provveduto
all’estrazione del 24.
Una volta che il canino è stato posizionato in
sede 11, si è provveduto ad eseguire terapia cana-
lare e ricostruzione coronale per fargli assumere
l’aspetto di un incisivo centrale superiore.
Al paziente è stata proposta anche una soluzione
protesica mediante faccetta in ceramica per armo-
nizzare il colore dei due elementi centrali. Il pazien-
te era talmente soddisfatto del risultato ottenuto che
ha deciso di mantenere la situazione così come era
e ha rimandato una eventuale soluzione protesica
successivamente. Per ripristinare la corretta guida
canina dal lato destro è stata effettuata una amelo-
plastica del 14 in posizione 13 per fargli assumere le
caratteristiche morfologiche di un canino.
Inine è stata eseguita una ricostruzione estetica
del 12 perché l’elemento in questione acquistasse
un corretto diametro mesio-distale. La terapia orto-
dontica issa è stata terminata con delle meccaniche
di chiusura degli spazi estrattivi, correzione delle
rotazioni, correzione della curva di Spee e delle
meccaniche di II Classe mediante l’utilizzo di elasti-
ci intermascellari ed anse di chiusura. È stata quindi
consegnata un’apparecchiatura di contenzione (Fi-
gure 6, 7, Tabella I).
Discussione
Nella valutazione costi-beneici prima di affron-
tare questo caso clinico sono state considerate tutte
le alternative terapeutiche.
Il caso in questione poteva essere risolto secon-
do i seguenti piani di trattamento:
— disinclusione di 13 e suo posizionamento
nella corretta sede e sostituzione dell’elemento 11
estratto con un impianto osteointegrato;
— estrazione di 13, riapertura dello spazio in
corrispondenza del 13 e sostituzione di entrambi gli
elementi dentali con impianto e protesi. Sostituzio-
ne dell’elemento 11 estratto con impianto e protesi;
— disinclusione di 13 riposizionamento dell’ele-
mento in sede 11, estrazione di 11, estrazione di
24 per rendere simmetrica l’arcata e chiusura degli
spazi.
La prima soluzione terapeutica è stata scartata
perché la disinclusione ortodontico-chirurgica del
canino con riposizionamento in sede 13 avrebbe
avuto una prognosi sfavorevole ed inoltre avrebbe
portato ad ulteriori gravi complicanze come il rias-
sorbimento di gran parte della radice del laterale.
April 2013
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is

IMPACTED MAXILLARY CANINE ON THE POSITION OF THE CENTRAL INCISOR FARRONATO

This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

Infatti secondo i parametri radiograici di Ericson
e Kurol 9, 10 sull’ortopantomograia, la cuspide del
canino è nel settore 1 (tra l’asse dell’incisivo
centrale e la linea mediana): la prognosi del trat-
tamento di riposizionamento dell’elemento incluso
nella sua normale posizione in arcata si aggrava
quanto più l’elemento da disincludere si avvicina al
settore 1 11, 30-32.
Nella teleradiograia laterolaterale l’angolo tra
l’asse del canino e la perpendicolare al piano di
Francoforte è di 45°: questo valore conferma la ne-
gatività della prognosi 3. Le altre due soluzioni te-
rapeutiche sono state discusse e valutate insieme al
paziente che si è mostrato particolarmente motivato
cata, seguito da una trazione ortodontica con lo
scopo di posizionarlo in sede dell’incisivo centra-
le superiore destro, in seguito all’estrazione dello
stesso.
Riassunto
In presenza di canini mascellari inclusi, il tratta-
mento d’elezione per l’ortodontista è rappresenta-
to dalla disinclusione e riposizionamento in arcata
dell’elemento qualora vi siano le condizioni anato-
miche favorevoli. Si descrive il caso clinico di un
giovane paziente che presentava una grave rizolisi

® A
alla possibilità di disincludere e quindi recuperare il dell’incisivo centrale mascellare destro in seguito a
suo dente incluso. crescita ectopica del canino superiore destro. È sta-
Di conseguenza l’operatore ha affrontato questo

T C
to deciso di disincludere il canino incluso riposizio-
caso clinico disincludendo il canino in posizione 11 nandolo in posizione dell’incisivo per evitare pro-
previa estrazione dell’incisivo centrale gravemente babili riassorbimenti radicolari a carico dell’incisivo

H DI
compromesso, chiudendo lo spazio in corrispon-
denza del 13, ed estraendo il 24.
Conclusioni
IG E
L’assenza in arcata di un canino superiore rap-
R M
presenta un problema clinico di frequente riscontro
e richiede molto spesso un approccio multidisci-
plinare. È fondamentale una diagnosi precoce per
correggere quelle situazioni cliniche che possono
favorire l’inclusione di un elemento dentario.
P A
laterale durante le manovre di trazione in posizione
corretta. È stata quindi programmata l’estrazione
dell’incisivo centrale e la disinclusione del canino.
Una volta erotto il canino si è modiicata l’ango-
lazione, l’inclinazione di radice e la morfologia in
modo da farlo assomigliare più possibile a un incisi-
vo centrale. In epoca in cui la terapia implantare ha
fatto enormi progressi si vuole proporre una solu-
zione terapeutica alternativa che in questo caso cli-
nico ha permesso di ottenere risultati con una buo-
na estetica e con una migliore prognosi nel tempo.

In questo articolo si descrive un caso clinico di PAROLE CHIAVE: Ortodonzia - Trattamento chirurgico -
esposizione chirurgica dell’elemento assente in ar- Diagnosi precoce.
O V
C ER
Y
IN
M
or other proprietary information of the Publisher.

Vol. 62 - No. 4 MINERVA STOMATOLOGICA 125