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Impacted mandibular canine

 

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Impacted mandibular canine

Question

Hi Doctor Chamberland,
We consulted an oral implantology and maxillofacial surgeon (Dr D.. L. A.) in P… Fr. He was recommended to us by the orthodontist (Dr Leco…) who we consulted for our daughter who is 12 years and 4 months of age. The mandibular panoramic X-ray indicates 2 impacted canines. We have an appointment at the end of the month for the extraction of an impacted canine in the lower jaw which presses on the roots of 3 front teeth (incisors). After reading your article, I wonder if this extraction is necessary and if there are other methods to correct her dentition. The orthodontist told us that it was necessary before any treatment.

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The pictures are real X-rays, I will however try to scan them so you can see clearer. I am not a physician, but if it is possible to avoid surgery for my daughter, then I am ready to try.

I thank you for your response.

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Response

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I identified the teeth following the universal numbering system on the panoramic X-ray provided and indicated by a white arrow the position of the impacted lower canine crown with regard to the roots of the lower incisors (black arrow).

Teeth #43 (lower right canine) and #23 (upper left canine) are the impacted ones.

 

I confirm that I would not extract the lower right canine (#43) on the pretext that it is in front of the roots of the lower incisors. I was able to spare, more than once, this type of canine and I learned to be creative as much in the mechanics of treatment to use as in the finishing of such treatment. People have to accept that this kind of treatment can last 36 months, but efforts are worth it.

An additional reason not to extract the impacted canine is that the analysis of the picture of the lower dentition and the panoramic X-ray does not show a lack of space. If a lack of space had been noted (> 8 mm), it could have been justified to foresee the extraction of the impacted canine and of 3 other premolars, but it is not the case.

 

Here is what I would have done if I had treated this case:

  1. Extract the residual primary canines (identified by a “c”) and the primary first molars (#54, #64, #74). These are the teeth that are aligned with the first premolars identified by a “4 “.
  2. Request surgical exposure by using the exposition technique for vestibular canines recommended by Vanarsdall.
  3. Use a removable appliance: Hawley retainer, Adams clasp on teeth #36 and #46, cantilever armspring with a hook with rounded end to pull using a short elastic connecting the hook and the metal ligature bonded to the canine. The cantilever could also be a spring with helices near the Adams clasp.
  4. After some 4-6 months, control the evolution with a new panoramic X-ray.

 

Here is an example:

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The lower canine #43 shows an impaction similar to your daughter’s. Its relative position to the roots of the lower incisors is identical to your daughter’s (black and white arrows). The canine crown was palpable in the oral vestibule where indicated by the circle.

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After 6 months of traction with a removable appliance, the canine significantly straightened up, but we observed a side effect of a forward shift of the posterior teeth. The canine was almost vertical, but transposed between the central incisor and the lateral incisor. I decided to finish the treatment by keeping this canine-lateral incisor transposition.

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This picture shows the evolution of the position of the canine after 7 months of traction (picture on the left, black circle) and after 11 months of treatment with fixed appliances (X-ray on the right). The teeth sequence is identified. The #43 is between the #42 and #41 instead of being between the #42 and #44. The treatment ended 15 months later.

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The above pictures show the quality of the occlusion 9 years after the fixed appliances were removed. Notice the good gingival health. The mandibular arch midline does not fit with the maxillary midline, but does it matter since the impacted tooth is spared and that no implants were necessary to replace the tooth which would have been extracted?

Consult the Keynote called “Éruption ectopique-dystopie dentaire” slides 30 à 35 (in French).

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Another more recent case:

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Notice the traction initiated with an elastic on the left and the cantilever on the right. The cantilever spring on the left was not engaged at the beginning, because the canine must be posteriorly straightened up before making it erupt vertically. When the cleat was visible on the right, we continued the treatment with fixed appliances.

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Notice how parallel the roots are and the absence of radicular resorption.

Mechanotherapy

Removable appliance for the traction of the impacted mandibular canine

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Here is an example of a removable appliance used to apply traction to the canine. On the January 08 and April 08 pictures, a simple 3/16″ 3,5oz elastic connects the hook to the ligature wire. This ligature wire was shortened during the visit in April, because the visible part had become too long, which means that the impacted tooth had straightened up. At the visit in May 08, the appliance was modified and a cantilever spring with a .020 SS wire was used. Notice that exceptionally, the helices are distal to the Adams clasp to lengthen the lever arm. Generally, the helices are mesial to the hook where indicated by the white arrowhead.

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Etiology

Among impaction causes, of course there are genetic causes, meaning hereditary. Like it is demonstrated that the impaction of upper canines can be explained genetically.

But there are at least 2 other causes to mandibular canine impaction.

The primary canines indicated by a green “c” all have pulpotomies. Cystic lesions are marked by arrows. Absence of resorption of primary dental roots is obvious.

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Iatrogenic cause: pulpotomies on primary canines that cause a chronic apical lesion and constitute an obstacle to the resorption of the roots and consequently, the exfoliation of the primary canine does not occur.

Odontoma indicated by the 2 white arrows. The lower canine deviates toward the back and cannot erupt.

Supernumerary tooth: An odontoma is a misshaped supernumerary tooth and constitutes an obstacle to the eruption of the permanent tooth. The extraction of this odontoma allows the auto-eruption of the canine.

 

Questions and comments

Leave a comment

  1. Laine says:

    My son has an impacted horizontal bottom tooth #27
    under his bottom, front teeth. The Dentist who did his exam told me that on the X-ray, there is a dark pocket around the tooth. They are concerned about this and have set up an appointment with an oral surgeon. Please tell me anything that would be helpful in informative. He’s 15 and being his Mother and only Parent, I of course, am concerned. Please get back to me. Thank-you.
    Ms.Maxson

    1. I am not familiar with numbering system adopted by the ADA, so I had to search to understand whcich tooth are you talking about.

      In Canada and most other countries of the worl utilze the Fedreation dentaire internationale numbering system. Therefore tooth #27 is the upper left second molar, but in the ADA system tooth #27 is a lower right canine.

      The dark pocket is likely a follicular cyst that surround every crown of an unerupted tooth. If the tooth is impacted this follicular cyst may enlarge. The question now would be if it is possible to do a surgery to bond a ligature and try to bring the teeth into the mouth. I recommend that you consult an orthodontist to get his opinion.

      Do you have a panogram that we could share in the page. If so, i will get you a link to upload the xray.

      1. Laine maxson says:

        I have the X-ray please give me the link or E-mail
        to send it so you can tell me what you think. I appreciate your help very much.
        Laine

        1. Mandibular-impacted-Canine-Chamberland-Orthodontiste-a-Quebec Thank you for sending me the xray of the impacted canine of your 15 years old son.

          It is quite deeply impacted and horizontal. Moreover, it seem to cross the midline as i can see the crown in front of the lower left incisors.

          It is difficult to assess what would be the best approach.

          If there is moderate to severe crowding of his occlusion, i would consider the extraction of the canine and 3 other premolars.

          If there is no crowding, I would consider surgical exposure and ligature and orthodontic traction. However, the mechanics may be challenging. I used a removable appliance to begin with of most of the case, but in this case, i would consider miniscew and a system of cantilever beam fixed onto the screw to get bone anchor.

          That is all I can say. I would visit your orthodontist first or get his opinion if the surgeon elect to extract the canine which would be my last choice if no other extraction are necessary.

          My first would be to design the adequate mechanical plan and get the best surgeon which is easy here.

          Case exemple

          Mandibular-impacted-canine-initial-and-post-traction-CHamberland-Orthodontiste-a-Quebec

          This is an exemple of a canine that was pulled from its impacted position. It took about 7 month to see the toth into the mouth. The second xray show the progress at 12 months at the end of the first phase of treatment. Other exemple are shown in the french version of this page.

      2. Kim Sav says:

        Oral surgeon and orthodontist advise that we extract deeply impaced madibular canine from our 14 year old daughter (turned 14 July 2017).
        The canine is horizontally positioned and there is an odontoma and primary canine above it.
        We dont know if we should extract adult canine, it is not pointed up at all.
        Completely horizontal low in her jaw. Odontoma has no symptoms.

        1. Complex Odontoma

          .Thank you for sending me the panogram of your 14 years old daughter.

          The white arrow indicate a complex odontoma, which mean more than one supernumary tooth in one follicle.

          There is absoulutely no doubt that the complex odontoma and the primary canine HAVE to be extracted.

          You sent me the writtent reports of your orthodontistQUote:

          1- the location of the root of the horizontal canine is positioned about two teeth BEHIND where it normally would reside.

          2-The mechanics of bringing in the canine without damage would involve sliding the tooth horizontally forward through the lower jaw bone and then uprighting it 90 degrees once it passes the roots of the premolar, this is physiologically/orthodontically impossible to do.

          I understand his concern and yes it may be very difficult, may be impossible to bring the canine without some damage to the roots of the adjacent premolars.

          I understand your concerns about losing the permanent canine and this mean that an implant will be necessary when she turn 18 or so.

          The question are:

          Is there an orthodontist who will be willing to try to bring this canine in?

          Personnaly, I would be willing to try if you accept that I may not succeed. If I succeed, I am a king. If I failed, you were told that it may failed

          Are you willing to pay the extra fee for this difficult treatment?

          I would likely charge 1,5 to 2 k over the regular orthodontic treatment fee.

          How long would it take?

          It is a minimum of 12-18 months for the canine. Likely 36-40 months total treatment time.

          I understand the surgeon’s reason to extract the canine:

          1. Association of this tooth with Cyst and tumor,

          Yes, this is possible, but he can take the decision “in situ” once he open the field. If he can dissect the odontoma from the canine follicle. He can have access to bond a button to the canine and a chain or a ligature to use for pulling the tooth.

          2. Severe deep impaction in the inferior border of the mandible.

          A surgeon do not move teeth. He may not know if he did not see an orthodontist who would try.

          At such far distance, it is difficult for me to tell you what you should do and more difficult to tell your orthodontist or the surgeon that they should try to bring the canine in.

          I would try to bring the canine in, but there is an expression “gérant d’estrade” that means it is easy to say it should be done this way if you are not the one who will do it.

          In my area, I would tell to the parents and the surgeon to let me try it. we have very few to loose. We may gain a lot.

          It is your call. I am quite sure your orthodontist is a good orthodontist even if I don’t know who he is.

          I hope that help.

          I will watch you reply.

  2. Kay says:

    Hello,
    I have been told that my daughter’s canine tooth needs to be extracted as there is no chance of saving it. It has a cyst around it, and is close to the sinus cavity heading in the opposite direction than the front of her mouth. The oral surgeon recommends removing it, and bone grafting for a future implant. My child is 12 years old. Any thoughts on this? Thank you very much! I can’t seem to attach the X-ray.

    1. I recommend that you consult an orthodontist. It is very rare that we can’t bring an impacted canine into the dental arch in a 12 years old kid. I hope my answer don’t come too late.
      For more information, read the web page Impacted teeth canine. Look at both english and french version. Read all the comments.

  3. Kal says:

    Hi I have been told by the orthodontist that my 12 year old daughters impacted, displaced lower canines 33 and 43 need to be surgically removed. The orthodontist also wants to extract 73 and 83 before fitting braces. She has said it is a ‘hopeless’ case and extraction is the only option.
    I can send you the X-ray. Please can you advise if there is any other way
    Thank you
    Kal

    1. You can send me the panogram via my Facebook professional page. I will reply here and post the panogram with my comments.

      I am bias toward bringing the permanent canines in, but the situation of you daughter may be different. We will see.

    2. Bilateral mandibular impacted canines

      Thank you Kal for sending the xray.

      Your daughter has impaction and transposition of both mandibular canines (33 and 43),  retained primary canines (73, 83), maxillary crowding as I can see the the upper canines are ectopic and vestibular near the 1st premolars.

      I agree with the extraction of both lower impacted canines and lower primary canines. In order to obtain a class I occlusion, normal overjet and normal overbite, I suggest the extraction of the upper 1st premolars (14, 24), but one could extract both maxillary canines intead of the 1st premolars since in the mandibule, it is the canines that will be extracted.

      Conclusion

      I would agree with the following treatment plan:

      1-extraction of 4 permanents canines + 2 lower primary canines

      Or

      2- extraction of upper 1st premolars and lower permanent canines + 2 lower primary canines.

       

      1. Kal says:

        Hi thank you for your prompt and comprehensive reply. Regarding the maxillary crowding the treatment plan we have been given is:
        A)Fitting of a Rapid Palatal Expander
        B)Extraction of 13 only
        The orthodontist is not in favour of extracting the canine on the opposite side as she believes my daughter is having too many extractions already.
        She has informed us that the discrepancy in the midline will not be corrected.

        However after reading your advise I believe the extraction of both maxillary canines or 1st premolars would have been a better option. I’m a bit stuck now as my daughter has had the expanders in for over a week now!

        Thank you
        Kal

        1. Hum! It is worse than I expected…

          I can’t imagine doing an orthodontic treatment and tell to my patient (or the parents) that I would not be able to fit the maxillary midline with the facial midline. This is non sense!

          What is the indication of maxillary expansion? Was there a posterior cross bite or was it for gaining space?

          You are good for a thorough discussion with the orthodontist and tell him/her that you will not accept unfitted midline to the facial midline. If not, I would recommend that you ask a 2nd opinion to a certified orthodontist.

          1. Kal says:

            The expansion was to correct the cross bite and for space because she didn’t want to extract 23.

            Do you think I can still opt for extraction of 23 now that my daughter has had the expanders fitted for over a week?

            1. Yes you can, but your orthodontist should understand why. Is he a certified orthodontist or a general dentist who do orthodontics?

  4. Idris says:

    My daughter has impacted lower canines….can u pls give your opinion.

    1. I may be able to give an opinion if you send a panogram to my professional page: facebook.com/drsylchamberland. If you send the xray, it means uou accept it will be published.
      Write the detailed question following this comment on the site.

  5. Kate Harwood says:

    My daughter is 12 years and 9 months, and we were recently advised by our dentist to have an OPG taken as she still had two baby canines.
    We received the results today, and the OPG shows both upper canines are impacted and one lower canine is impacted in the jaw horizontally.
    Our dentist has recommended we find an orthodontist, but I don’t know how to find one who is competent in treating what we have been told is a very complicated issue.
    Can you advise on what we should be looking for? I have sent a copy of her OPG to your facebook page.
    Thank you so much for your time.

    1. Mandibular impacted canine & Maxillary impacted canine

      Thank you for sending me the panogram.

      Tooth #33 is deep impacted in the symphysis. Tooth 23 (upper left) is high impacted. There is 2 remaining primary canines (c) and 1 missing lower right 2nd premolar (X).

      I would definitely recommend the extraction of the remaining 2 primary canines.

      I hope you will find an oral surgeon that would accept to bond a chain on the crown of the tooth #33 and an orthodontist that will do the orthodontic traction. The same apply for tooth #23.

      That is what I would do.

      I understand that some orthodontist may say it will take too long but it is worth giving it a try. I did many.

      I don’t know where you live, but I would assume there are many good orthodontist in your area.

      1. Kate says:

        Thank you so much for your response. I am very appreciative of the advice you have provided, as we now have an idea of an appropriate course of treatment. We live in regional Australia, and their are no orthodontists local to us. I have made an appointment with our nearest orthodontist (1.5hrs travel) and will see if he is willing to ligate the tooth. If not, we may need to travel further! 🙂
        Thank you once again,
        Kate

      2. Mrs Lamia AlMidfa says:

        Good afternoon Dr Sylvain

        I really need your help and your advise for my 11 years old daughter who have an impacted lower canine laying horizontal under middle teeth. Plus the top center tooth issue that did not fall yet.
        I went 4 doctors in Dubai – UAE and they told me that the lower impacted canine must extracted asap :’(
        Please provide me with your email to send you my daughters recent Xray, as i am really concerned 🙁

        1. Many orthodontist will not try to a mandibular impacted canine into occlusion. It takes times and it may be difficult mechanically. It is also possible that the canine position that it may not be possible to manage a forced eruption.You can send the panogram via my professional FB page facebook.com/drsylchamberland

  6. Rebecca Dunbar says:

    Hello dr, my daughter is 11 she was diagnosed with an open bite in 2014.
    When she was 7 or 8 she has first phase braces problem t on her teeth she had those removed last year 2016.
    she is getting ready to get phase 2 braces and she was having her regular dental work done and the dentist found an impacted canine.
    now I feel like how could this be missed she has been under regular dental care forever with ortho I have a picture to show you as I believe most of her adult teeth are I.
    Except this impacted tooth it is completely horizontal past the midline to the opposite side that it not suppose to be on first off I feel this should have been caught earlier way earlier being she has been under care since she was 7 or 8
    but now what is going to happen with this I am so concerned that she is not going to be able to keep the canine and she will have an unsemetrical lower denture
    IMG_1668.JPG

    1. The impacted canine may have developped during phase 1 therapy.

      I have a few concerns. 1- The phase 1 treatment was quite long. 2- What was the type of treatment that she received? 3-Did she had braces on her upper front teeth? 4-Did they took progress pranogram during phase 1? 5- Were they able to close the open bite?

      I don’t understand how they could have missed an impacted canine over 2 year period.

      The image did not upload. Try to send it to my professional facebook page facebook.com/drsylvainchamberland

      I will try to help.

  7. Rebecca dunbar says:

    You know I don’t know if they did…
    I know she had X-rays for check ups but I don’t know if they took progress panoramic or if they took a end of phase 1.
    She was suppose to have the phase one on 17-18 months she had them a little over 2.
    she only broke one bracket during the time. She was very compliant with cranking her palatal expander and with wearing her rubber bands if I remember correctly she may have had the palatal expander removed and it may have colapsed and they had to repeat that. But yes in the end her teeth looked great but we knew we would have to do the phase 2 after she got all her adult teeth.
    The dr. took those off her braces last year he said: in about 1 year we would put them on again.
    I am very upset because from what I see this is not something that just happened over the last year.

  8. Rebecca dunbar says:

    Am I correct in thinking He should have been taking X-rays during the treatment making sure all was errupting correctly and filling in on target he is an orthodontist that is part of the treatment correct?

  9. Rebecca Dunbar says:

    She had a palatal expander and a crib and yes upper and lower braces.
    he was a specialist and I wanted to be sure I had someone good to do the job. Yes the open bite was closed they looked beautiful when we took them off a year ago.
    I believe he said the last panaramic was 2014 that would have been at the beginning of treatment.
    there was no others just the new one taken yesterday.

  10. Mandibular impacted canine that crossed the lower midline

    It is quite impressive that after doing maxillary expansion, tongue crib, braces on upper and lower front teeth, placing upper and lower holding arch, an orthodontist do not question himself why the lower right permanent canine has erupted and the lower left primary canine was retained.

    I am speechless.

    At this stage, the prognosis to bring the canine in its position is poor. Many orthodontist will recommend its extraction because it may take 2 to 3 years to bring it into the mouth. If this is an extraction case, then it would be logical to extracted the impacted caine, the primary canine and 3 other premolars to obtain symmetric class I occlusion.

    If it is not an extraction case, one can try to do orthodontic traction. Chances are that the canine will finish transpose with the lower left lateral incisor. This is not a bad solution and I did to one patients many years ago and I am currently doing it to another patients.

    This case came in my office in february 2016. I initiated orthodontic traction and the teeth moved. However, last month, it was quite obvious that I could not get the canine into its position. So I decided to treat it transposed. I am curently opening a space between the cental and the lateral incisor.

    This is better than nothing and better than an implant.

    You have to know that the treatment time may be 30 to 36 months for such a case and it is costly. But the solution is defenitive and no further cost will occur during the life time like crown replacement, implant replacement, bone graft.

    I don’t know if you can find an orthodontist in your area that would be willing to try such treatment.

    Bonne chance.

  11. Jules Lemay, orthodontist says:

    UNBELIEVABLE!!! 🙁

  12. Rebecca Dunbar says:

    Hello Dr.
    we will be going back on December 8 to see what they have to say they would like to do with this impacted cainine and get further X-rays and what not.
    my husband and I are grateful for time you have spent on this and giving us some direction on what has happened in this case!
    Our question is when we take a look with a 3 D X-ray to see where this tooth is lying in respect to the roots of her front teeth..:.if it is not in the roots what do you think about leaving it alone for now?
    Watching it to see if it remains stable and do nothing with it….
    what is the likelihood that it would continue to travel….is there a good chance that it will surface through the gums into the linguial gum line on its own eventually?
    Here is the thing… she has had dental work… she is not the most comfortable in the chair… she has had braces…
    she has to have them again because the open bite is opening back up as the orthodontist said it would which really effects her ability to bite through food but we are all fearful of having to put her through surgery now as well and she doesn’t want to have to do it….
    not to mention we are concerned for the possibility of something not being best case senerio.
    We worry about bone loss in an extraction case would the bone come back when they dig in there to pull it we also worry about possible nerve damage this is her face you know! We are parents so we do worry about what if everything doesn’t go perfect!

    Thank you Rebecca Dunbar

    1. I apologies for the delay in responding.

      There are several aspect with your questions.

      I would not keep the canine for a long period of time if no one attemps orthodontic traction, but you can monitor it every year.

      SHe has an open bite and at 11, she is still growing. It  may be a wise idea to monitor her groth for 2 -3 years. Any orthodontic treatment to close the open bite is prone to relapse because she is growing.

      If extraction is done, do not worry about bone loss. It will fill in. Except at the site of the primary canine.

      Sorry, I have to go. I hope I was of some help.

      Best regards

       

  13. Georgi says:

    Dear Dr. Chamberland,

    I am writing to you with a concern of a tooth of mine. I am almost 17 now and about four years ago I discovered that I have an impacted mandibular canine (left). The tooth is completely horizontal outside of the root canal and does not show any signs to interfere with the incisors soon. (If you give me your e-mail I will be able to send you an X-Ray and Panoramic images to see my case in more detail)

    I had braces for 3 years now which were taken off few months ago. Now I have a transparent retainer with a filling on the space of the missing tooth, so that the space can be kept if an implant or a teeth bridge needs to be placed.

    My questions are:
    Should extraction be considered? (Is the location of the Marginal Mandibular Branch nerve problematic for extraction)

    If the tooth does not cause any problems should it be extracted or I can leave it there hoping that it will stay still without causing any problems in the future?

    Which is better an Implant or a teeth bridge placement on the missing tooth?

    Thank you in advance,
    Best Regards,
    Georgi Dimitrov

    1. I can’t believe that you had braces for 3 years and that your orthodontists did not attempt to bring the canine in occlusion or informed you of the different possibilities.
      When you were 14, this would have been a not so difficult thing to do and in 3 years of treatment, this is a realistic treatment time to bring such canine into the mouth.
      You can send me the xray via my professional facebook page (facebook.com/drsylvainchamberland/).
      I am departing for a sicentific meeting today. May take some time to reply.
      Best regards

  14. Sum says:

    Hi, My son is 11 years and 5 months. He has impacted canines one in lower jaw and other in upper jaw opposite side. The orthodontist first recommended to take out baby teeth to create space for the permanent teeth to erupt normally and the impacted canine may get the space sense to straighten on it’s own. He has already got lingual arch to maintain the space after extraction of baby teeth in lower jaw. However another orthodontist suggested extraction of that impacted canine in lower jaw. We are quite concerned about the two opinions. Will extraction of impacted canine cause danger to the roots of front permanent teeth? And will extraction of impacted canine means confirm implant in future? Is there another way to save the two impacted canines? Please let me know how to share the X-ray.
    Thank you

    1. I agree that the removal of the primary teeth will favor eruption of the permanent canine, but he may still need further intervention.

      That is a good thing to have a lingual arch to maintain space while checking the evolution of the impacted mandibular canine.

      I did not see the severity of the impaction, extraction would be my very last choice. Yes it may mean an implant for the future unless it is possible to extract 3 other teeth (3 first premolar) to achieve the equivalent of 4 dental unit extraction and close all space for camouflage.

      You can share the panogram via message to https://www.facebook.com/drsylvainchamberland/

  15. M. Michaelidis says:

    Hello Dr. Chamerland, My son is almost 8 years old and he lost his lower canine prematurely because his lower lateral adult incisor ate into the root of his baby canine. It does not appear that he currently has enough room for the adult canine to erupt. Should this be treated early with phase 1 orthodontics to minimize complications with the adult teeth or can we wait until he is older. His insurance won’t pay for interceptive orthodontics unless it is proven that the adult teeth will not be able to emerge without treatment. Attached are a couple of pictures. Thank you!!
    https://imgur.com/vrb3hjg
    https://imgur.com/XLk1EMm

    1. I would place a lower lingual arch to maintain arch space and make annual recall. I would not do comprehensive interceptive treatment at this age.

      See example below:

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