4811074 a

8/10/2019 4811074 A

1/9

BRITISH DENTAL JOURNAL VOLUME 196 NO. 6 MARCH 27 2004 319

PRACTICE

Orthodontics. Part 10: Impacted teethD. Roberts-Harry1 and J. Sandy2

This section deals with the important issue of impacted teeth. Impacted canines in Class I uncrowded cases can be improved byremoval of the deciduous canines. There is some evidence that this is true for both buccal and palatal impactions. Treatment of

impacted canines is lengthy and potentially hazardous. Interceptive measures are effective and preferred to active treatment.

Supernumerary teeth may also cause impaction of permanent incisors, their early diagnosis and appropriate treatment is

essential to optimise final outcomes. If there are any doubts about impacted teeth it is better to refer too early than too late, this

latter option may unnecessarily extend the length of treatment as well as the treatment required.

1*Consultant Orthodontist, OrthodonticDepartment, Leeds Dental Institute,Clarendon Way, Leeds LS2 9LU;2Professor of Orthodontics, Division ofChild Dental Health, University of BristolDental School, Lower Maudlin Street,Bristol BS1 2LY;*Correspondence to: D. Roberts-HarryE-mail: [email protected]

Refereed Paperdoi:10.1038/sj.bdj.4811074 British Dental Journal 2004; 196:319327

Check all 10-year-olds for the position of their permanent canines by initial clinical

examination and palpation, if necessary with further radiographs to locate possible

impactions

Check for late eruption of permanent incisors, if one incisor has erupted, the others should

not be far behind. If the permanent lateral incisors have erupted but not the permanentcentral incisors then suspicion of impaction should be heightened

Refer too early rather than too late

I N B R I E F

This section brings together the informationgeneral dental practitioners need in order todiagnose and deal effectively with impactedteeth.

IMPACTED CANINESA canine that is prevented from erupting into anormal position, either by bone, tooth orfibrous tissue, can be described as impacted.Impacted maxillary canines are seen in about3% of the population. The majority of impactedcanines are palatal (85%), the remaining 15%are usually buccal. There is sex bias, 70% occurin females. One of the biggest dangers is thatthey can cause resorption of the roots of thelateral or central incisors and this is seen inabout 12% of the cases.

The cause of impaction is not known, butthese teeth develop at the orbital rims and havea long path of eruption before they find theirway into the line of the arch. Consequently incrowded cases there may be insufficient roomfor them in the arch and they may be deflected.It seems that the root of the lateral incisor isimportant in the guidance of upper permanentcanines to their final position. There is alsosome evidence that there may be genetic inputinto the aetiology of the impaction.

Late referral or misdiagnosis of impactedcanines places a significant burden on thepatient in relation to how much treatment theywill subsequently need. If the canines are in poorpositions it will require a considerable amount oftreatment and effort in order to get them into theline of the arch and a judgement must be madeas to whether it is worth it. Sacrificing the canineis unsatisfactory since this presents a challenge

to the restorative dentist, an aesthetic problemand by definition, cannot be used to guide theocclusion. There are times when it might be sen-sible to consider its loss, but early diagnosis canmake a significant difference to how much treat-ment is needed by the patient.

DIAGNOSISIt is easy to miss non-eruption of the permanentcanines, but there are some markers whichshould increase suspicion of possible impaction.

Any case with a deep bite, missing lateral inci-sors or peg-shaped upper lateral incisors needs adetailed examination. Figure 1 shows such acase and in this instance both canines were sig-nificantly impacted on the palatal aspect. Theretained deciduous canine is self evident. Otherclues include root and crown positions. Figure 2shows a lateral incisor which is proclined. There

10

ORTHODONTICS

1. Who needs

orthodontics?

2. Patient assessment and

examination I3. Patient assessment and

examination II

4. Treatment planning

5. Appliance choices

6. Risks in orthodontic

treatment

7. Fact and fantasy in

orthodontics

8. Extractions in

orthodontics

9. Anchorage control and

distal movement

10. Impacted teeth11. Orthodontic tooth

movement

12. Combined orthodontic

treatment

Fig. 1 Typical features which should arousesuspicion of impacted canines. There is a deep

bite and a small peg-shaped lateral incisor. Theretained deciduous canine is obvious. In thispatient both upper permanent canines werepalatally positioned

VERIFIABLECPD PAPER

NOW AVAILABLEAS A BDJ BOOK

8/10/2019 4811074 A

2/9

PRACTICE

320 BRITISH DENTAL JOURNAL VOLUME 196 NO. 6 MARCH 27 2004

is a retained deciduous canine and the perma-nent canine lies buccal which moves the rootof the lateral incisor palatally and the crownlabially.

Any general dental examination of a patientfrom the age of 10 years should include palpa-

tion for the permanent canine on the buccalaspect. It is possible to locate the canines withpalpation, but this will lead to some false observa-tions. For instance, the buccal root of a decidouscanine, if it is not resorbing, can feel like thecrown of the permanent tooth. It is thereforeimportant to back up clinical examination withradiographs. Failure to make these observationswill eventually result in patients complaining ofloose incisors; inevitably some permanentcanines will resorb adjacent teeth with devastat-ing efficiency as shown in Figures 3 and 4.

WHAT ARE THE BEST RADIOGRAPHIC VIEWS

TO LOCATE CANINES?Most patients undergoing routine orthodonticscreening will have a dental pantomogram.Location of tooth position requires two radi-ographs in different positions. In the interests ofradiation hygiene it is sensible to use this asa base x-ray and to take further location radi-ographs in relation to the dental pantomogram.

An anterior occlusal radiograph allows this andthe principle of vertical parallax can be used tolocate the position of the canine. The tube has toshift in order to take an anterior occlusal and itmoves in a vertical direction. If the tooth crownappears to move in the direction of the tube shift(ie vertically) then the tooth will be positionedon the palatal aspect. If the crown appears tomove in the opposite direction it is buccal and ifit shows no movement at all it is in the line ofthe arch (Figures 5 to 7). This also provides a rea-sonably detailed intra-oral view in cases of rootresorption.

Although there are other radiographic tech-niques which can be used to locate canines, thismethod works well. If there are difficulties inbeing sure of the exact location then two peri-apicals taken of the region with a horizontalshift of the tube may give slightly better preci-sion. The periapical radiographs will also givegood detail of the roots of adjacent teeth, partic-ularly the lateral incisors. The proximity of thecanine crown to incisor roots does make them

vulnerable to root resorption. The percentage ofteeth adjacent to the crown of the canine whichundergo some form of resorption is probablyquite high at the microscopic level. No extrac-tions should be contemplated until the canineshave been located. Figure 8 shows a dental pan-tomogram of a patient who had both upper andlower first premolars removed as part of a treat-ment plan, but where the canines had not beenlocated beforehand. The dental pantomogramclearly shows the poor position of the caninesand subsequent treatment involved the removalof the permanent canines since their positionwas deemed hopeless and movement of thecanines may well have resulted in root resorp-

Fig. 2 There are clues as to the whereabouts of the upper rightpermanent canine in this patient. The upper right lateral crownis proclined because the upper right permanent canine isbuccally positioned and therefore places pressure on the rootmoving the crown of the lateral incisor labial ly and the root ofthe lateral incisor palatally

Fig. 3 Consequences of failure to diagnose impacted canines. Thisradiograph shows the roots of the upper lateral incisor to be resorbing

Fig. 4 The patient shown in Figure 3 had both lateral incisorsremoved because of the severe root resorption caused by theunerupted permanent canines

8/10/2019 4811074 A

3/9

PRACTICE


tion of the incisors. The canines had to bereplaced prosthetically and it would be difficultto see how a legal defence of this situation couldbe raised.

INTERCEPTIVE MEASURES FOR CANINES

One of the most significant publications in theorthodontic literature came from Ericson &Kurol (1988)1 who demonstrated that extrac-tion of upper deciduous canines where theupper permanent canines were developing onthe palatal aspect, resulted in nearly an 80%chance of correcting the impaction. The paperwas very specific about what types of maloc-clusions this could be applied to. Nearly all thecases were Class I with no incisor crowding.This is important to emphasise, a subsequentfollow-up paper2 confirmed their originalobservation and also indicated that the tech-nique could not be applied easily to crowdedcases and in some cases this would result in aworsening of the situation rather than animprovement. The dental pantomogram of apatient is shown in Figure 9. The canines arepalatally positioned. Since this was anuncrowded case, the deciduous canines wereextracted and Figure 10 shows that both the

Fig. 5 Orthopantomograph of patient where the two canines are clearly impacted Fig. 6 Anterior occlusal radiograph of the samepatient shown in Figure 5. Both canines are nowmore apically positioned and therefore theseteeth have moved with the tube shift and arepalatally positioned

Fig. 7 Same patient as in Figures 5 and 6 withboth permanent canines exposed surgically andon the palatal aspect

Fig. 8 Dental pantomogram of a patient who had had all four first premolarsremoved without sufficient diagnostic information. The upper permanent canines arein a very poor position and with the distinct possibility of some root resorption it wasfelt that the upper permanent canines should be removed and replaced prosthetically

Fig. 9 Dental pantomogram of a patient with palatally impacted canines

8/10/2019 4811074 A

4/9

PRACTICE


permanent canines erupted with no orthodon-tic assistance. Clearly this saved the patient aconsiderable amount of treatment and earlyappropriate referral would be wise if a generaldental practitioner is unsure. The interceptivemeasure of extracting deciduous canines

works well if carried out between the ages of1113 years. The closer the crowns are to themid-line the worse the prognosis. It is worthre-emphasising that this works best in Class Iuncrowded cases.

TREATMENT OF CANINESThe treatment of buccally or palatally impact-ed canines involves exposure and then a formof traction to pull the tooth into the correctposition in the arch. Palatally impacted teethcan be exposed and allowed to erupt. Thistends to form a better gingival attachmentsince the tooth is erupting into attached

mucosa. This cuff may be lost on the palatalaspect as the tooth is brought into line. Someoperators prefer to raise a flap, attach a bracketpad with a gold chain to the tooth in theatreand then replace the flap. Traction is subse-quently applied to the chain and the toothpulled through the mucosa (Fig. 11). There issome evidence that this procedure is less suc-cessful than a straight forward exposure. Italso has a disadvantage that if the bondedattachment fails then a further operation,either to expose or reattach, is needed. Theadvantage with this technique is that the rootusually needs less buccal torque once the

crown is in position.If the canine is moderately high and buccal,

it will not be possible to expose the tooth since itwill then erupt through unattached mucosa andan apically repositioned flap should be consid-ered. If it is very high, it is not possible to apical-ly reposition the flap and therefore it is better inthis situation to raise a flap and bond an attach-ment with a gold chain. It is critical that thechain passes underneath the attached mucosaand exits in the space where the permanentcanine will eventually be placed as in Figure 11.If it is not placed in this situation and exits out ofnon-keratinised mucosa the final gingivalattachment will be poor (Fig. 12).

Other options include:

Accept and observeLeaving the deciduous canine in place and eitherobserving the impacted canine or removing it.Long term, the deciduous canine will need pros-thetic replacement.

Extract the impacted canineIf there is a good contact between the lateralincisor and the first premolar then it has to becarefully considered whether this should beaccepted. The purists of occlusion will argue thatthe premolar is not capable of providing goodcanine guidance. Aesthetically there are prob-lems since the palatal cusp hangs down. This canbe disguised by grinding or rotating the tooth

Fig. 10 The same patient as in Figure 9. The dental pantomogram clearly shows thatboth canines have disimpacted and are now erupting in the line of the arch. The onlyactive treatment was extraction of both upper deciduous canines

Fig. 12 A bucally positioned canine has had a gold chain attachedbut in an incorrect position. The chain should exit mid alveolus andfrom keratinised mucosa

Fig. 11 Palatally impacted canines which have had a flap raised andgold chain bonded to the crowns of the permanent canines

8/10/2019 4811074 A

5/9

PRACTICE


orthodontically so that the palatal cusp is posi-tioned more distally. The placement of a veneeron the premolar is another way of improving theappearance.

Transplantation

Canine transplantation has received poor pressin the past. Many of the problems arose becausethe canines were transplanted with a closedapex. These teeth were seldom followed up withroot fillings on the basis that they would revas-cularise. This is unlikely through a closed apexand it is preferable to treat them as if they werenon-vital. Transplantation is an option whichshould only be reserved for teeth that are inalmost an impossible position and where there isextensive hypodontia or other tooth loss.

ImplantsImplants are also an option and as single tooth

implants improve, this may become morefavoured in future. It is important to rememberthat implants in a growing child will ankyloseand appear to submerge as the alveolus contin-ues to develop. These are not therefore an optionuntil the patient is at least 20 years of age.

Correction of canine positionFavourable indications for correction ofimpacted canines.Canines are moved most easily into their correctposition if the root apex is in a favourable posi-tion. If the tooth lies horizontally it is extremelydifficult to correct this and generally the closerthe tooth to the midline the more difficult thecorrection will be. Treatment is nearly alwayslengthy and can damage adjacent teeth. Figure13 shows a lateral incisor adjacent to a palatallyimpacted canine where the opposite reaction to

pulling the palatal canine out is the labial posi-tioning of the lateral incisor root. Obviously thisis not favourable and the gingival recession willworsen. The force to move the canines can beobtained from elastomeric chain or thread.Figure 14 shows elastomeric chain being used topull the canine labially. An attachment has beenbonded to the tooth, but as the tooth moves to itscorrect position it will be necessary to rebond it.Moving the tooth over the bite sometimesrequires the occlusion to be disengaged with abite plane or glass ionomer cement build ups onposterior teeth, for a few weeks.

An alternative is to use a smaller diameternickel titanium piggy back wire with a stiffbase wire to align the tooth (Fig. 15). The thickerbase wire maintains the archform by resistinglocal distortion caused by the traction on thecanine. The nickel titanium piggy back wire pro-duces flexibility and a constant low force, unlikeelastomeric chain or thread which have a high

initial force and then a rapid decay of this force.It is better not to tie the piggy back in fully as thewire needs to be able to slide distally as thecanine moves labially. If tied in fully the frictiondoes not allow this function. It also helps if the

Fig. 13 A lateral incisor adjacent to a palatallyimpacted canine. When the canine is pulledlabially the reaction will be for the lateral rootto move labially. It is essential therefore to usethick rectangular wires during the movement ofpalatally positioned canines. Further labialmovement of the lateral root would bepotentially damaging to the periodontalattachment

Fig. 15 A piggy back flexible wire has beendeflected in order to apply traction to the gold

chain which has been attached to a palatallypositioned canine. There is a stiff base wirewhich prevents unwanted reactions to thistraction

Fig. 14 Palatally positioned canine being movedwith power chain into the correct position

8/10/2019 4811074 A

6/9

PRACTICE


piggy back wires run through auxiliary tubes onthe first molar bands. One further method whichhas gained some popularity is the use of a sec-tional archwire made of beta-titanium alloy.

This wire is formable and flexible, it can bedeflected as a sectional arm and pulls the caninelabially. It is important to use a palatal archwhich cross braces the molars to prevent themmoving into crossbite as an opposite force reac-tion to the buccal movement of the canines(Fig. 16).

The use of heat activated nickel titaniumalloys has also done much to improve the effi-ciency of moving impacted canines into thecorrect position. Figures 17 and 18 show asequence of tooth movements where a nickeltitanium alloy has been deflected, after coolingwith a refrigerant, into the bracket. The length

of time between the two slides was 8 weeks and

it can be seen how much tooth movement hasoccurred. The transpalatal arch is also usefulanchorage for vertical and antero-posteriortooth movements.

WHAT CAN GO WRONG?

There are a number of problems with movingpermanent canines from either a buccal or apalatal position. By and large, the older thepatient the less chance there is of succeeding,and certainly moving canines in adultsrequires caution. If the canines have to bemoved a considerable distance then ankylosisis a distinct possibility as well as loss of vascu-lar supply and therefore pulp death. Treatmentoften takes in excess of 2 years and it is impor-tant to maintain a motivated and co-operativepatient. It is necessary to create sufficientspace for the canine to be aligned and this isusually around 9 mm.

The periodontal condition of canines thathave been moved into the correct position in thearch can deteriorate, this is particularly true ifcare has not been taken to ensure that the canineeither erupts or is positioned into keratinisedmucosa. There may also be damage to adjacentteeth during surgery, or indeed the surgeons candamage the canine itself with burs or otherinstruments. Figure 19 shows the crown of acanine which has clearly been grooved by a burwhich was used for bone removal when thecanine was exposed. It is quite easy to induceroot resorption of adjacent teeth (either the lat-eral incisor or the first premolar), particularly if

care is not taken in the direction of tractionapplied to the impacted canine. Loss of bloodsupply of adjacent teeth can also occur. It isquite common at the end of treatment to see aslightly darker crown of the permanent canine,this probably results from either a change in

vascularity and vitality of the canines, or poten-tially haemoglobin products can be producedand seep into the dentine thus changing thecolour of the overlying enamel. The worst sce-nario of all is that the canine ankyloses and willnot move. The protracted length of treatmentalso results in patients abandoning treatment.

Despite all of our improvements in treatmentmechanics and diagnosis for impacted canines,the eruption path is often unpredictable.Canines which have a seemingly hopeless prog-

Fig. 16 Beta titanium sectional arch which is bothformable and flexible can be deflected to applytraction to move the impacted canine buccally

Fig. 17 The impacted canine has had a heat

activated nickel titanium wire deflected intothe bracket

Fig. 18 Same patient as shown in Figure 17nearly 8 weeks later where significant toothmovement has taken place

Fig. 19 The crown of this canine was grooved bya bur used during bone removal when the caninewas exposed

8/10/2019 4811074 A

7/9

PRACTICE


nosis can sometimes correct their position anderupt. Nevertheless, to sit and observe a patientwhere the canines are clearly in difficulty with-out referral to a specialist would be difficult todefend legally. Hopefully the days of patientsarriving in orthodontic departments with

retained deciduous teeth at the age of 16 willdiminish as the profession takes on the chal-lenge of life long learning.

OTHER IMPACTED TEETHThe most common cause of unerupted maxillaryincisors is the presence of a supernumerarytooth. These are often typed as follows:

Conical Tuberculate Odontomes (complex or compound) Supplemental teeth

There are some conditions which have a

genetic basis where impacted teeth are seenmore frequently and this includes cleidocranialdysplasia, cleft lip and palate, gingival fibro-matosis and Down's Syndrome.

It is worth remembering that most centralincisors should have erupted by the age of 7 andlateral incisors by the age of 8. Surprisingly, mostreferrals for impacted maxillary incisors arewhen the patient is 9 years of age. This delay indiagnosis could potentially influence the out-come and it is important that when the contralat-eral incisor has erupted 6 months previouslythere is likely to be a problem. Similarly, if thelateral incisors erupt well before the central inci-sor then consideration should be given to inves-tigating further (Fig. 20).

It is perfectly possible that a supernumerarytooth may be present and not affect the erup-tion of the incisors (Fig. 21). Indeed one of theclinical signs that a supernumerary may bepresent is the evidence of spacing wherea supernumerary is in the midline and causinga diastema between the upper incisors. The dif-ferent types of supernumerary teeth seem tohave different implications for treatment.

Conical supernumerary teeth are small andpeg-shaped, they usually have a root and theydo not often affect incisor eruption (Fig. 21), butif they are in the midline they can cause a medi-an diastema. They should only be removed ifthey are adjacent to incisors which need toundergo root movement. Potentially the move-ment of the root against the supernumerarytooth could cause resorption of an incisor root.

Where the supernumerary teeth are tubercu-late these usually have no roots and developpalatally. They often prevent the eruption ofcentral incisors and if they do, they need to beremoved (Fig. 22). Complex and compoundodontomes are rare, but can similarly preventeruption of the permanent incisors and alsoneed to be removed. Obviously, radiographs areneeded to confirm any clinical observationsabout impacted teeth and parallax used in thesame way as for canines in order to locate theposition of the supernumerary teeth. Eighty per

Fig. 20 This patient has both her lateral incisors fairly well eruptedbut retained deciduous teeth. This could easily have been diagnosedsooner and may influence the outcome of final tooth position

Fig. 21 Conical supernumerary which hasnot inhibited the eruption of thepermanent incisors. The supernumeraryis in the midline

Fig. 22 Anterior occlusal radiograph which shows both upperlateral incisors to have erupted, both upper deciduous central

incisors are retained and the upper permanent central incisors areunerupted. There are two tuberculate supernumeraries presentwhich are associated with the non-eruption of these upperpermanent central incisors

8/10/2019 4811074 A

8/9

PRACTICE


cent of supernumerary teeth occur in the anteri-or part of the maxilla and there is a male tofemale ratio of 2:1. The incidence in the popula-tion as a whole varies, but is somewhere in theregion of 12%.

Treatment of impacted supernumerariesAlthough guidelines have been published fromthe Royal College of Surgeons,3 these reviewwhat the options are rather than defining whatthe best treatment is. In part this is due to alack of good research to show what the bestmethods are.

Obviously if there is an obstruction the soonerit is removed the better. Some suggest exposingthe incisor at the same time or attachment of agold chain in order to prevent re-operation if thetooth fails to erupt. However, this is potentiallydamaging, particularly if bone has to beremoved in order to expose or bond an attach-

ment to the tooth with a gold chain brought outthrough the mucosa in order to place tractionand move the impacted incisor.

If diagnosed early and the supernumerary isremoved when the apex of the incisor is openthen eruption of the tooth can be anticipated.Even if there is a need to re-operate at a laterdate, if the tooth has come further down it ismuch easier to either expose the tooth or raise aflap and place an attachment on an incisal edgethat is now much closer to its correct position.Often incisors will erupt quite a long way andthen become impacted in fibrous tissue (Fig. 23).In this situation it only requires a small exposure

usually on the palatal aspect to allow the toothto come down. Apically repositioned flaps areoften disastrous and produce poor mucosalattachment. In the main they should be avoided.

Fixed appliances are usually needed in orderto regain lost space where adjacent teeth havedrifted and these appliances are also useful iftraction does need to be applied to the impactedteeth. Removable appliances in this situation areoften cumbersome, although they have beenused with a magnet bonded to the uneruptedtooth and a further magnet embedded into theremovable appliance in order to bring the toothdown. The use of fixed appliances in this situa-tion allows alignment, space management andoverbite correction. Ultimately the early diagno-sis of unerupted teeth is the biggest contributiona practitioner can make to the management ofimpacted teeth.

IMPACTED PREMOLARSWhere crowding exists or where there has beenearly loss of deciduous molars, premolars aresometimes unable to erupt. Often relief ofcrowding (usually extraction of first premolars)allows impacted second premolars to erupt. Sec-ond premolars do seem to have enormous poten-tial to erupt and given time these teeth often findtheir way into the arch (Figs 24 and 25). Often inthe upper arch they displace palatally. There mayalso be clues from the deciduous teeth. If thedeciduous teeth become ankylosed they often

Fig. 24 Dental pantomogram of a patient who appears to havesevere impaction of her lower left second premolar

Fig. 25 The same patient as in Figure 24, 9 months later wherethere has been good eruption of the lower left second premolar.Eventually this tooth made its way fully into the line of the archand it was possible to upright the lower left first molar

Fig. 23 Typical fibrous tissue impaction of the permanent incisor. In this patient asupernumerary had been removed 9 months earlier. The tooth will only require asmall exposure on the palatal aspect to enable it to erupt. The bulge in the labialmucosa is clearly evident and this is where the crown will sit

8/10/2019 4811074 A

9/9

PRACTICE


appear to submerge as alveolar bone growthcontinues. This may indicate the absence of asecond premolar, but sometimes this submer-gence can be seen when permanent successorsare present. Most of these situations will resolve,but it is thought wise to consider removing the

second deciduous molar if it slips below the con-tact points and there is then space loss as themolar tips forward. Where first molar mesialmigration compromises the contact point rela-tionship, space maintenance might be consid-ered. Figure 26 shows a radiograph of a patientwho appears to have generalised submergencesince all second deciduous molars are seen to besubmerging in all four quadrants. In this situa-tion continued observation of the developmentof the occlusion with appropriate loss of decidu-ous molars is essential. With the extensiverestorations and caries, an argument could bemade for loss of all four first molars in this case.

OTHER IMPACTIONSThe only other impactions to be considered in ageneral form are first molars. These may impactin soft tissue and it is sometimes worth consider-ing occlusal exposure where a first molar has noterupted. This usually occurs in the upper archand can be accepted if the oral hygiene is goodwith minimal caries experience. Impacted molarsof this type quite frequently self correct before orduring eruption of the second premolar. Theremay also be primary failure of eruption and if thetooth fails to move with orthodontic traction thisis usually a good indication that the tooth will

not move. First molars may also impact into sec-ond deciduous molars as they erupt and theoptions then are to try and move the molar dis-tally with a headgear or removable appliance, toconsider using separators (brass wire) to relieve

the impaction or ultimately to remove the seconddeciduous molar if any of these methods fail torelieve the impaction.

It is clear that the biggest single contributionthat can be made to the treatment of impactedteeth is to improve diagnostic skills and definecare pathways with clinical protocols. Earlyreferral does not harm, a late referral willincrease the burden of care for patients andpractitioners.

1. Ericson S, Kurol J. Early treatment of palatally eruptingmaxillary canines by extraction of the primary canine. Eur JOrthod

1988; 10: 283-295.2. Power S, Short M B E. An investigation into the response ofpalatally displaced canines to the removal of deciduouscanines and an assessment of factors contributing tofavourable eruption. Br J Orthod 1993; 20: 215-223.

3. National Clinical Guidelines. Faculty of Dental Surgery, RoyalCollege of Surgeons of England, 1997.

Fig. 26 Dental pantomogram of a patient with all four seconddeciduous molars submerging. Those which are below the contactpoint (upper right second deciduous molar) should probably beremoved in order to aid eruption. The others should be observed

BDA Information Centre Services

Did you know?

As a BDA member you can gain access to one of

the best dental information services in the world

You donthave to be based in London to use

the service

You can borrow books, videos and information

packages

You can borrow up to eight items via the postal system

The only cost to you is the cost of the return postage.

If youre not sure what to request then telephone us

and we can advise you.

You are entitled to freeMEDLINE searches

Telephone us with a subject and we will send you a listof relevant references with abstracts.

You can request photocopies of journal articles.

There is a small charge for this service and you need to

fill in a Photocopy Request Form first. Telephone us if

you would like one of these forms.

BDA Members can view the latest Current Dental

Titles on our web site free of charge.

For further details of any of these services dial

020 7563 4545.

Contact us via e-mail at:

[email protected] the Information Centre web pages at:

http://www.bda.org

Please note: The Information Centre is temporarily relocated in the basement Lecture Theatre

during its major refurbishment please ring first if you plan to visit

4811074 a

Documents