Journal of Orthodontics, Vol.

37, 2010, 262–271

CLINICAL How to…mechanically erupt a palatal

SECTION
canine
Padhraig S. Fleming
Royal London Dental Institute and Kent and Canterbury Hospital, UK

Pratik K. Sharma
Royal London Dental Institute, UK

Andrew T. DiBiase
Kent and Canterbury Hospital, UK

Management of ectopic permanent maxillary canines represents one of the greatest challenges to orthodontists. This paper
outlines a variety of techniques and mechanics which may facilitate expedient, predictable and safe eruption of palatal canines.
While each method may be useful in isolation, the varying presentations of palatal canines ensure that the ability to apply an
array of techniques is essential if successful outcomes are to be consistently achieved.

Key words: Canine, impacted, fixed appliances, removable appliances

Received 13th November 2008; accepted 25th May 2010

Introduction Surgical exposure

With the exception of the third molars, the maxillary
canines are the most frequently impacted tooth1 with the
vast majority lying palatal to the arch.2 There are many
possible approaches to the management of palatal canines,
ranging from interceptive intervention to removal of the
impacted tooth.3 Treatment decisions are governed by a
variety of factors including: position of the canine, the
dictates of the associated malocclusion, the skill and
experience of the orthodontist and surgeon, and antici-
pated patient compliance. Where interceptive measures are
impractical or ineffective, the preferred approach typically
involves mechanical eruption of the involved tooth.
Mechanical eruption of palatally impacted canines
may lead to prolonged treatment. Treatment times are
thought to increase further with greater vertical and
mesial displacement, increased angulation of the canine
and increasing age.4–8 Deleterious effects of prolonged
orthodontic treatment are well-documented and include
the propensity for greater root resorption9 and poor
patient compliance. Additionally, root resorption of
teeth neighbouring the impacted tooth is thought to be
accelerated if mechanical eruption is undertaken.10
Consequently, there is a high premium on the efficient
management of impacted maxillary canines. This paper
highlights and appraises a variety of mechanics at our
disposal to successfully and safely mechanically erupt
impacted palatal canines.
Some research and much debate have surrounded the
merits of open versus closed eruption techniques11
(Table 112–14). Overall, there appear to be minor
differences between the two methods in relation to
treatment duration and periodontal health.15 Careless
surgery, with exposure of the cemento-enamel junction,
will have deleterious periodontal consequences; however
often the choice between using an open or a closed
procedure is based on individual preference. 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
has been erupted, reducing unwanted rotations and
prolonged treatment.
In general, the authors favour open surgical
exposure where permissible. This technique enhances
control and may allow spontaneous improvement
without resort to active forces (Figure 1). With deep
impactions, closed exposures are usually favoured
as open exposures may necessitate excessive bone
and soft tissue removal risking periodontal damage
to the impacted tooth or neighbouring roots.
Deeply impacted teeth may also become enveloped
by soft tissue with inadequate exposure particularly if
unsupervised.

Address for correspondence: Padhraig S. Fleming, Royal London

Dental Institute, New Road, Whitechapel, London, E11BB UK.
Email: padhraig.fleming@googlemail.com
# 2010 British Orthodontic Society DOI 10.1179/14653121043200
 JO December 2010 Clinical Section How to erupt a canine 263

Figure 1 (a,b) Open surgical exposure may allow spontaneous progression without orthodontic appliances

Mechanics for eruption of palatal
canines
While many of the mechanical approaches outlined
below are applicable throughout treatment, they are
often used sequentially, with more than one technique
often necessary prior to integration with a complete fixed
appliance (Table 2). Initial eruption can be achieved
in many ways; however, to align the canine within the
arch sufficient space must be available, which normally
necessitates comprehensive fixed appliance therapy.
It is inadvisable to apply buccally directed forces to
the impacted canine where the tooth is intimately related
Table 1 The influence of exposure type on treatment duration.
to the roots of the lateral incisors. Such forces may
induce unwanted rotations, resorption of the incisor,
and mechanical obstruction will cause retardation of
tooth movement. Therefore, judicious mechanics with
precise directional control are required to guarantee
predictable tooth movement (Figure 2). Typically,
eruption may be commenced with an auxiliary, e.g.
titanium molybdenum alloy (TMA) ‘fishing-rod’, prior
to placement of a complete fixed appliance. Sufficient
space to fully align the canine may be generated by distal
molar movement, extraction of permanent teeth, use of
complete fixed appliances to consolidate space in the
incisor region or by advancement of the upper labial
segment using ‘push-pull’ mechanics.

Treatment duration (months)

Early treatment: auxiliary appliances

Paper Open Closed

Trans-palatal arch (TPA) with stainless steel auxiliary

Wisth (1976)12 18 22 The use of auxiliary stainless steel projections (0.6–

Pearson et al. (1997)13 25.7 21.8 0.7 mm stainless steel) connected to a TPA has been
Iramaneerat et al. (1999)14 28.8 28.8 described previously.16 Typically, it is used early in

Table 2 Properties of selected appliance mechanics.

Appropriate stage Dependence Cost or Versatility/ability to

Mechanics Anchorage Aesthetics of treatment on compliance complexity control force vector

Titanium molybdenum alloy (TMA) Moderate Moderate Early Low Moderate Moderate
‘fishing-rod’
Trans-palatal arch with whip spring Moderate Excellent Early Low Moderate Moderate
Removable appliance Good Moderate Early High Moderate Poor
Magnet Good Good Early-mid High High Moderate
Temporary anchorage device Good Good Any Low Mod-high Poor
Elastomeric traction to fixed appliance Moderate Poor Early Low Low Moderate
Piggyback wire (NiTi) Moderate Poor Early-mid Low Low Moderate
Stainless steel archwire auxiliary Moderate Poor Mid-late Low Moderate Good
 264 Fleming et al. Clinical Section JO December 2010

Figure 2 (a–d) Injudicious movement of the canine while intimately related to the lateral incisor root may introduce moments leading to
unwanted rotation of the maxillary canine. Correct directional control with buccal movement only commencing following initial posterior
and inferior movement of the canine away from the root of the incisor results in favourable translation of the canine.

Figure 3 (a) Transpalatal arch used to initiate movement of the canine prior to placement of the complete fixed appliance; removal of
the primary canines was postponed until initial movement of the canine was confirmed. (b) Mechanical eruption is continued with
piggyback archwires. (c) Case following removal of appliances

treatment; it may also be integrated with comprehensive N soft tissue irritation, e.g. tongue ulceration.
fixed appliance therapy for final alignment of the canine
(Figure 3).
TMA ‘fishing-rod’
Advantages This method offers similar properties to the previous
N excellent aesthetics; hidden from view; approach and may also be used in conjunction with a
TPA if sufficient space for alignment of the canine is
N the TPA maintains the transverse dimension and may
present. It may be equally discreet depending on the
reinforce vertical anchorage and limit mesial tipping
location, although the auxiliary typically lies buccal to
and rotation of first permanent molars, although
the arch. TMA (0.01760.025-inch) is favoured for this
anchorage loss is still likely to occur;
design as it has inherent flexibility and is formable while
N versatile; may be adjusted to permit posterior,
being of sufficient resilience to resist deformation17
occlusal or buccal movements as required;
(Figure 4); however, this approach cannot be used in
N little impediment to oral cleansing;
isolation if the opposing mandibular canine has over-
N a ‘lingual appliance’; consequently, no risk of visible
erupted or if insufficient space exists within the arch.
decalcification.

Advantages18
Disadvantages
N minimal requirement for compliance;
N prone to breakage; N patient comfort;
N may be difficult to adjust; N favourable range of action irrespective of canine position;
N no concurrent tooth movement may occur; therefore, N acceptable three-dimensional control.
adequate space must be available for the canine
within the arch;
N speech impediment; Disadvantages
 JO December 2010
Figure 4 (a,b) TMA ‘fishing rods’ to start mechanical eruption of UR3. (c) Completed result
Figure 5 (a–c) Inter-arch traction to erupt a maxillary canine combined with class II correction using a modified twin block appliance
N distortion of the long arm;
N possible irritation of the buccal mucosa by the omega
loop.
Removable appliances
Removable appliances may be used in either the
upper19 or lower20 arch to apply traction to the palatal
canine. Placement of elastics may be simplified with
pre-formed adjuncts,21 e.g. monkey hooksTM or fab-
ricated at the chairside.
Advantages
N excellent anchorage, resisting unwanted reciprocal
forces in the maxillary arch. However, elastics to a
lower removable will tend to dislodge the appliance
and hence the effectiveness is questionable;
N ability to achieve other tooth movements concur-
rently, e.g. overbite reduction, class II correction
(Figure 5) or space redistribution;
N incorporation of an anterior bite plane eliminating
occlusal interferences that may otherwise mechani-
cally impede lateral movement of the canine.
Disadvantages
Clinical Section How to erupt a canine 265
N while upper removable appliances are retentive, they
may not offer sufficient flexibility in directional force
application;
N lower removable appliances are less retentive as
extrusive forces may unseat the appliance; however,
force vectors are ideal for canine; eruption being
inferiorly directed and distally directed if required;20
N may be complex in design;
N relatively costly;
N rely on technical assistance;
N depend on excellent patient compliance.
Magnets (Figure 6)
Magnets are rarely used in orthodontics, but can be used
in the management of impacted teeth, particularly in
conjunction with removable appliances.22,23
Advantages
N versatility;
N minimal wire manipulation;
N the application of a low continuous force increasing
over time;
N facility for directional control.
Disadvantages
 266 Fleming et al. Clinical Section JO December 2010

Figure 6 (a–d) Magnets were used in conjunction with an upper removable appliance to mechanically erupt palatal canines; reciprocal
forces on the already compromised dentition with generalized root shortening were kept to a minimum

N the inverse square law applies to magnetic fields, i.e. N may require fabrication of a second removable
force decreases with increasing distance. Consequently, appliance to complete eruption;
more than 3 to 4 mm space between Neodynium–Boron N subject to the limitations associated with removable
magnets produces insufficient force to affect tooth appliances.
movement;
N relatively expensive;
Temporary anchorage devices (TADs)
N bulky;
N prone to corrosion; TADs have gained widespread popularity being used to
N poor versatility; produce a variety of tooth movements;24,25 however,

Figure 7 (a–c) Temporary anchorage device in the mandibular parasymphysis used to apply elastomeric traction to a maxillary canine in
a compromised maxillary arch subsequent to hemi-maxillectomy. Both buccal and palatal attachments were placed to maintain correct
canine inclination
 JO December 2010
Figure 8 (a) Maxillary occlusal view of impacted UR3. (b) Movement was initiated with elastomeric traction. (c) ‘Piggyback’ NiTi
archwires were used to continue alignment of the displaced canine. (d) Eruption progressed successfully with ideal canine positioning
following integration into a complete pre-adjusted appliance
their application to address impacted canines has
received little attention. Giancotti et al.26 reported a
case incorporating an osseointegrated mid-palatal
implant to erupt bilaterally impacted canines using the
implant for indirect anchorage.
Advantages
N potentially excellent anchorage which is particularly
useful in a compromised dentition (such as hypodon-
tia) with little facility to retain fixed or removable
appliances (Figure 7);
N versatile;
N may be useful to achieve separate occlusal objectives.
Disadvantages
N difficulty in positioning the TADs in the ideal position
to permit mechanical eruption and simple application
of orthodontic forces;
N cost;
Clinical Section How to erupt a canine 267
N necessity for surgical intervention in addition to
surgical exposure of the canine;
N potential for fracture or failure of the implant.
Early treatment to mid-treatment
mechanics in conjunction with pre-
adjusted appliances
Following initial movement, space creation to allow
alignment of the canine is typically necessary. Pre-
adjusted edgewise appliances are preferred with space
redistribution usually performed on a 0.018-inch stain-
less steel archwire. This base wire may also afford
sufficient anchorage to permit simultaneous application
of active eruptive force to the misplaced canine.
Elastomeric traction to fixed appliance
Elastomeric traction is useful to initiate eruption in
conjunction with fixed appliances and stainless steel
 268 Fleming et al.
Figure 9 (a,b) A 0.014-inch SSW auxiliary used to continue vertical movement of UL3; the 0.018-inch stainless steel base archwire
minimized reciprocal effects. (c) The 0.014-inch SSW in passive vertical position. (d) A vertical and lateral force is being exerted on UR3
with the auxiliary activated to engage the tooth
archwires. Rigid stainless steel base archwires, e.g.
0.018-inch or 0.01960.025-inch SSW, are desirable to
minimize reactionary forces reinforcing vertical ancho-
rage in particular.27
Disadvantages28,29
N applied forces decay rapidly with force loss of up to
50% developing within 24 h necessitating regular re-
activation;
N precise directional control is often difficult but may be
improved with archwire adjustments or auxiliaries to
centre force application, e.g. passive coil-spring
(Figure 8b).
Piggyback NiTi archwires
Auxiliary NiTi archwires provide inherent flexibility to
continue the eruptive process.30,31 Again rigid stainless
steel base archwires with significantly higher elastic
modulus, e.g. 0.018-inch or 0.01960.025-inch SSW, are
preferred to limit unwanted effects on anchor units
(Figure 8c,d).
Clinical Section JO December 2010
Advantages
N NiTi wires are considered ideal as they provide a
relatively constant, light force with high flexibility and
range17 allowing engagement of significantly dis-
placed teeth;
N this is effectively a ‘one-phased’ approach, as separate
occlusal objectives may be achieved concurrent with
mechanical eruption, e.g. space redistribution;
N the amount of space opened for the canine may be
controlled by using round archwires, therefore the
possibility of inadvertent torquing of adjacent roots
into the impacted tooth may be avoided;
N early control of overbite may be achieved by plac-
ing a lower fixed appliance eliminating occlusal
interferences to buccal movement of palatal canines,
particularly where the mandibular canines have
overerupted;
N the use of TPAs may be avoided unless it has an
auxiliary indication;
N the direction of eruption may also be controlled
somewhat by shackling the tooth mesially or
distally.
 JO December 2010 Clinical Section How to erupt a canine 269

its extremity (Figure 9). In the passive position, the loop

points vertically downward towards the mandibular
dentition; the loop is activated by ligating the helix to an
attachment on the canine with a steel ligature generating
an extrusive force.

Advantages
N directional force; wire may be fashioned to produce
precise movements;
N long range of activation;
N allow vertical movement which may not be achievable
with nickel–titanium auxiliary wires following initial
vertical movements;
N avoid laboratory procedures;
N forces are controlled and measurable.

Figure 10 ‘Easy canine’ auxiliary for eruption of ectopic canine

(Courtesy of Professor A. Caprioglio) Disadvantages
N relative complexity;

Disadvantages N the requirement for wire bending;

N limited range of action particularly when applied to
gold chain;
N inability to apply a precise directional force;
N complexity;
N poor aesthetics.
Stainless steel archwire auxiliary
The application of buccal auxiliary wires for correction
of palatal canine position has been championed by
Becker et al.32 The auxiliary spring is formed in 0.014-
or 0.016-inch SSW with a vertical loop having a helix at
N the risk of appliance breakages.
Nickel–titanium and other customized auxiliaries
A variety of alternatives to elastomeric traction have been
developed to eliminate the problem of force degradation of
elastomeric materials. They are ligated to the canine in a
similar fashion to elastomerics; most of these are nickel–
titanium based with excellent shape memory and may be
capable of exerting continuous light forces (Figure 10).33–35
However, research confirming the value of such custom-
ized alternatives is lacking; additionally, they are more
costly and complex to use than elastomeric chains.

Figure 11 (a,b) Over-eruption of a mandibular canine opposing the unerupted maxillary right canine; this was addressed with a lower
fixed appliance permitting ideal vertical positioning of both maxillary and mandibular canines. Placement of the passive open coil spring
ensured directional control during eruption of the canine with elastomeric traction
 270 Fleming et al. Clinical Section
Final detailing of canine position
While mid-treatment mechanics greatly improve the
position of the canine, final detailing of the tooth is
invariably reliant on integration with a fixed orthodon-
tic appliance to correct vertical position of the canine
and to apply correct angulation, inclination and
rotational control. A mandibular pre-adjusted appliance
may be necessary to address separate occlusal problems,
to facilitate overbite reduction or to intrude opposing
teeth encroaching on the canine position (Figure 11).
The addition of sufficient buccal root torque is
necessary to enhance aesthetics, gingival position and
to enhance stability. Selective use of Andrew’s prescrip-
tion (27u torque) is preferred to achieve this. Buccal
root torque may also be increased with archwire bends,
e.g. in rectangular SSW or TMA, or with auxiliaries
during the finishing stages.
Conclusions
Successful and predictable correction of ectopic palatal
canines carries significant aesthetic, functional and
dental health importance. Initial eruption may often
involve distal and occlusal movement prior to bringing
the tooth buccally. This approach limits the risk of
deleterious consequences and stagnation of treatment.
Mechanical eruption may be initiated with auxiliaries
prior to integration with complete fixed appliances.
Thereafter, elastomeric traction, piggyback auxiliaries
or nickel–titanium components may be used to continue
the process. Impacted palatal canines present with many
variations; consequently, a ‘one size fits all’ approach
will not produce successful results on a consistent basis.
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