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Multiple tooth impaction in the young adult

Published: September 2016

Bulletin #58 September 2016

Multiple tooth impaction in the young adult

Possibly the single most important attribute of teeth is that they normally erupt into the oral environment by themselves, without outside assistance. Nevertheless, failure of the teeth to erupt is not uncommon and is due to failure of one or more of the various mechanisms, intrinsic and extrinsic factors that control eruption. This provides justification for a website dedicated to the many aspects of the problem.

Under normal circumstances, what determines when eruption should occur is the stage of the calcification and development of the teeth and it is well documented that a tooth will be spurred on to its greatest eruption potential when one half to two thirds of its final root length will have been reached.1-4 A tooth with a fully apexified root end will generally exhibit a much reduced or absent eruptive potential. At the opposite end of the scale, the potential for eruption of a tooth with less than half its root and a wide open apex, will also be limited.5 In these cases, therefore, the orthodontic preparation of space within the affected dental arch, alone, may well not result in eruption.

It should be added, in relation to unerupted teeth with markedly underdeveloped roots, that premature surgical exposure may damage further root development and, additionally, may rob the tooth of the physiologic process of enamel maturation.6 These well-known characteristics are among the factors to be considered when evaluating the timing of an orthodontic intervention aimed at mechanically assisting eruption.7

In the present bulletin, we shall discuss 2 cases in which the patients were young adults, each with multiple impacted teeth in the canine/premolar areas bilaterally in both jaws. In both cases, the ideal timing for orthodontic treatment had passed several years earlier, as demonstrated by the full apexification of all the impacted teeth. However, the attitude and the approach to treatment of the practitioners concerned could not have been more different.

My interest in this particular area of orthodontics, both in clinical work and in teaching, is well known in my country and it manifests itself in my private practice becoming the depository for all those cases that are considered “impossible” and which almost nobody else is prepared or knows how to treat. Close to half my patient load is made up of individuals with impacted teeth of one sort or another. As the natural consequence of this, I also have radiographs and CT’s of a wide variety of clinical oddities sent to me, simply for the “Wow factor” and with the added notation “….. I’ll bet you have never seen anything like this!” In the spirit of the recently finished Olympic Games in Rio de Janeiro, I have no doubt that I could justify a claim for a world record in this regard. Some of these films I use as illustrative material in my lectures and some in my textbook and journal publications – always acknowledging the courtesy of the source. The first case reported here is an example taken from this group of patients, and while the 2 cases share many common clinical features, the approach of the practitioner to treatment in the second case was diametrically opposed to that taken in the first and, accordingly, their outcomes and prognoses were strikingly disparate.

Case 1 – an orthodontic/surgical approach


Fig. 1. Panoramic view of the dentition in July 2010, at age 15 years. Note that all premolars, canines and mandibular second molars are unerupted, despite full closure of their root apices.

The first case was a young female aged 16 years, who had been entirely unaware that she still had many over-retained deciduous teeth in her mouth until her dentist brought it to her attention and had discussed the need for treatment. She was a normal, healthy and non-syndromic individual. At the time, July 2010, her erupted dentition comprised only the permanent incisors and the first permanent molars, together with the full complement of deciduous canines and molars. A panoramic radiograph revealed unerupted permanent canines, premolars and second molars in the mouth – 12 teeth in all, with fully closed root apices (Fig. 1).


Fig. 2. Panoramic view 17 months later in December 2011, shortly before commencement of treatment.

      The unerupted third molars were at a very early stage of development. The general dental practitioner referred the patient to an oral and maxillo-facial surgeon for advice and for extraction of the deciduous teeth, two of which he had extracted beforehand (Fig. 2). As a first step, the oral and maxillo-facial surgeon referred the patient on to me for an orthodontic evaluation, although much time was wasted by the patient, due to social, geographical, educational and motivational issues. The surgeon and I considered that although one or two of the premolars might erupt as the result of extraction of the deciduous teeth, we agreed that this could take a very long time, in view of the closed apices and that this would not provide a solution for the canines, in view of their extreme displacement. Furthermore, orthodontic appliances would be needed to treat the overall malocclusion and for the traction and alignment of the 4 difficult canines. It was argued that proactive premolar traction and alignment would significantly reduce treatment time, enhance efficiency and achieve a superior result.

Pre-treatment records were taken in November 2011, although appliances were only placed in March 2012, when the patient was almost 18 years of age, about to leave school and about to be drafted into the army to commence her 2 years of compulsory national service. At this time, the mandibular right second premolar had erupted. There were also positive signs also of right maxillary premolar eruption, more than 2 years after the deciduous teeth had been extracted. All four canines and four of the remaining unerupted premolars were displaced deep into basal bone. The left mandibular second premolar had developed a 900distally-pointing root apex dilaceration.


Fig. 3. Intra-oral views of the teeth in occlusion on the day the fixed appliances were placed. Brackets are present on all deciduous and permanent teeth in the mandible and a Nickel-Titanium round leveling archwire is in place. Brackets were placed only on the incisors in the maxilla and the modified Johnson twin wire arch is tailored to be totally passive in the incisor region. Note the rigid round buccal “tube-within-a-tube” slotted into the round molar tubes. See text for explanation.Sept_16_Fig._4._Surgical_plan

Fig. 4. Occlusal views of the dentition with deciduous teeth labeled. Note the presence of soldered lingual arches in both jaws. The list of surgical aims is detailed on the right side.

The appliances consisted of molar bands with soldered lingual arches in both jaws and Tip-Edge Plus brackets (TP Orthodontics, LaPorte, Indiana) on the permanent incisors in both jaws. In the maxilla, brackets were only placed on the incisors and, in order to circumvent the potential problems associated with long unsupported spans between first molars and lateral incisors, a modified Johnson twin wire combination archwire was placed (Figs. 3, 4).8 No attempt was made to align the maxillary incisors because of the close proximity of the canine to the incisor roots and the possibility that this would cause root resorption. The anterior portion of the combination archwire was tailored to provide the required passive engagement of the incisor teeth with posterior supporting rigidity, suitable as a platform from which extrusive forces could be mounted. In the mandible, brackets were also placed on all 5 over-retained mandibular deciduous teeth, to provide a similar degree of stability for the initial leveling and aligning archwires. Once anterior alignment and leveling were completed in the mandibular arch, a heavy 0.020” round base arch was substituted.


Fig. 5. Surgery performed by Prof. Refael Zeltser in November 2012. Intra-oral views of the labial approach to exposure of the right mandibular canine (a), the left mandibular canine and premolars (b) and the left maxillary canine and premolars. Note small bonded eyelets with their braided soft steel ligature connectors.


Fig. 6. With the full surgical flaps re-sutured into their former places, the braided steel ligatures are turned over the 0.018” round archwires under mild extrusive tension, prior to the patient leaving the operating theater.


Fig. 7. The right maxillary canine was palatally displaced and very high up on the root of the lateral incisor. The connector wire may be seen exiting the middle of the resutured flap, close to the soldered palatal arch (arrow). The original intention had been to draw the tooth down into the palate, to clear the incisor root, once the other premolars and canines were in place. See text for explanation.

Surgical exposure of the unerupted premolars and canines was performed in all four quadrants simultaneously under general anesthesia in the operating theater of the Hebrew University-Hadassah Hospital in Jerusalem, in November 2012. The surgeon removed only a portion of the dental follicle surrounding the crown of each tooth, steering well clear of the CEJ. He maintained hemostasis while I bonded the small eyelets in the optimal available location on the enamel surface of each of the 9 unerupted teeth concerned. A closed exposure procedure was used, due to the extreme depth of several of the teeth (Figs. 5-7). The re-approximated edges of the replaced soft tissue surgical flaps were re-sutured leaving only the braided steel ligatures visible (Fig. 6). The maxillary right premolars had partially erupted at the time, but these were nevertheless further exposed to their maximum circumference and were left uncovered to erupt spontaneously.

Due to its very high but palatal location, the right maxillary canine was exposed in the palate and its twisted steel ligature was brought through the palatal flap to lie passively curled on the palatal mucosa (Fig. 7). Initially, it was not possible to apply a palato-vertical force9 on the palatal side because there were too few erupted teeth to stabilize an auxiliary spring mechanism and this tooth was left until a later stage in the treatment, when the other impacted teeth would be aligned and could serve as supports. Sept_16_Fig._8._nov_2012_post_surg

Fig. 8. 1-day post-surgery panoramic view, November 2012.

The braided ligatures that were threaded through the eyelets bonded to the other teeth were shortened and rolled into short helices at the point where they emerged through the sutured edges of the flaps and, in the absence of brackets in these posterior areas, the light archwires were threaded through these helices to provide vertical traction (Fig. 6, 8). Tension was then progressively renewed by rolling the helices towards the gingivae, as they became more protruded with the eruptive progress. Once the teeth had erupted adequately, Tip-Edge brackets were placed on them to rotate, upright and torque as needed and to complete the finer artistic finishing.


Fig. 9a. Surgery in December 2013 performed by Dr. Harvey Samen. The right maxillary canine has autonomously migrated and becomes very palpable on the labial side following eruption and alignment of the adjacent teeth.

Fig. 9b. At re-exposure, the original attachment can be seen on the lingual side of the canine.

Fig. 9c. A labial attachment is substituted.

When the premolar teeth erupted in the right maxillary quadrant, the braided ligature that belonged to the right canine had disappeared into the soft tissue of the palatal mucosa. The tooth became more and more palpable on the labial side in the succeeding months (Fig. 9a), illustrating a spontaneous response of the tooth to the environmental change produced by increasing the space. Thus a second surgical exposure of this tooth became necessary and it was carried out with a closed labial approach (Fig. 9b, c).

During the entire period that extrusive forces were being applied to the impacted teeth, the patient was instructed to wear vertical “up-and-down” elastics to reinforce the anchorage of the molar and incisor teeth. It will be readily understood that the extrusive forces in the maxilla are directed vertically downward, while in the mandible they are vertically upward. Thus, it is logical to pit the two opposing force vectors against one another, by harnessing the one to the other and making the extrusive forces of the one jaw provide the anchor base for the extrusive forces of the other. Sept 16 Fig. 11_1

Fig. 10. The open bite created by the reactive force on the anchor teeth by the multiple extrusive forces on the impacted teeth and due to non-compliance with vertical up-and-down elastics.

However, the patient was almost totally non-compliant with this efficacious biomechanical concept for many months, with the result that a considerable anterior open bite developed (Fig. 10). Only when the all the teeth had come into the line of the arches did the patient begin to cooperate, albeit under considerable duress. In line with her negative attitude throughout the 29 months of mechanotherapy, treatment was terminated prematurely due to patient and parental pressure, before adequate torque and uprighting had been completed, particularly in relation to the maxillary canines. Nevertheless, a satisfactory result was achieved post-treatment (Figs. 11-13).

Sept 16 Fig. 10. Pan Sept 2014_2

Fig. 11. Panoramic view on day of appliance removal, September 2014.


Fig. 12. Intra-oral views of the dentition in August 2016, 2 years after completion of all treatment.


Fig. 13. The smile at 2 years post-treatment, showing good alignment and an esthetic smile line.

A braided wire splint was bonded lingually from canine-to-canine in both jaws on the day the orthodontic appliances were removed. These were prepared from superhard flexible 5-strand wire formed on a plaster cast of the teeth and using a labial acrylic positioning jig, as we have described elsewhere.10

Case 2 – a prosthodontic/endodontic/surgical approach

I guess that it is not everyone who is prepared to wear braces and undergo extensive alveolar surgery as integral parts of treatment that extends over a 29 months period. Many will look for the “quick fix”…… and sometimes there is one. More likely, however, there is no quick fix. The patient may well seek a dentist prepared to succumb to his demands and conditions. Whether the practitioner is prepared to throw caution and ethics to the wind by permitting him/herself to being conned into treating the patient to make the “fast buck”. is another matter.

It is quite remarkable how similar the 2 cases in this bulletin must have been, before “treatment” was instituted.

I never saw the patient who is presented here, nor can I guarantee that the panoramic view has not been photoshopped, although I believe this to be highly unlikely, if not impossible to achieve in this case. To concoct a picture like this would require the evil mind of a dentally-educated but highly mischievous person. The film was sent to me as a “double WOW factor” case by a former graduate student of mine who came across it serendipitously, with the now familiar mantra “….. I’ll bet you have never seen anything like this!” I hasten to add that he was not the treating dentist! Sept_16_Fig._14._Elisha_Reichenberg__bridge_over_troubled_waters

Fig. 14. Case 2 (courtesy of Dr. Elisha Reichenberg).

If we study the panoramic film carefully (Fig. 14), we should be able to discern the following features:-

1. Judging by the closed apices of both erupted and unerupted teeth, probably including the stunted roots of the 2 third molars, the patient is at least 18 years of age, but could be considerably older.

2. In the mandible and aside from the left third molar, there are 2 unerupted canines and 4 unerupted premolars.

3. On the right side of the maxilla, the second premolar is erupted, but the canine and first premolar are impacted, with a markedly infraoccluded deciduous first molar directly in the eruption path of the premolar. The third molar is also unerupted.

4. On the left side of the maxilla, there is an impacted canine. There is also a large area where the alveolar bone is missing, which one may be permitted to assume is the result of an earlier and very radical and damaging surgical attempt to remove similarly impacted premolars.

5. Apart from the left maxillary premolars, the right maxillary lateral incisor and the left mandibular central incisor are also absent.

6. The mandibular incisor has been replaced with an implant, which has failed and all bone support has given way to a broad periodontal/osseous lesion, in the immediate area.

7. All the erupted permanent teeth have been endodontically treated, most probably as elective procedures to provide maximum retention for them to serve as abutments for the “ear-to-ear” prosthodontic rehabilitation.

8. 2 deciduous canines and 2 deciduous molar (on the right side) in the mandible have also been included as abutment teeth for the reconstruction, despite the fact that there is precious little left of their resorbed roots and what remains appears to be periodontally involved.

I have titled this film “Bridge over troubled waters” (with apology to Simon and Garfunkle) because the corono-ponto-prosthodontic construction has been superstructured over a veritable Pandora’s box of impacted permanent and deciduous teeth in various states of deterioration, decay and putrefaction, with and without root canal treatment, any one of which portends potential major disaster…… for which I shudder to think how much the patient was charged!

Further comment or discussion of this case is superfluous, although I would expect the horror represented by this film to “go viral”.


1. Schour I, Massler M. The development of the human dentition. J Am Dent Assoc 1941;28:1153–1160.

2. Moorrees CFA, Fanning EA, Hunt EE Jr. Age variation of formation stages for ten permanent teeth. J Dent Res 1963;42:1490–1502.

3. Demerjian A, Goldstein H, Tanner JM. A new system of dental age assessment. Hum Biol 1973;45:211–227.

4. Koyoumdjisky-Kaye E, Baras M, Grover NB. Stages in the emergence of the dentition: an improved classification and its application to Israeli children. Growth 1977;41:285–296.

5. Nolla CM. The development of permanent teeth. J Dent Child 1960;27:254–266..

6. Robinson C. Enamel maturation: a brief background with implications for some enamel dysplasias. Front Physiol. 2014;5:388.

7. Moorrees CFA, Fanning EA, Grøn A-M, Lebret L. The timing of orthodontic treatment in relation to tooth formation. Trans Eur Orthod Soc 1962; 38: 1–14.

8. Becker A. Orthodontic Treatment of Impacted Teeth 3rd ed. 2012, Oxford,Wiley-Blackwell Publishers, Chapter 5 Page 88

9. Kornhauser S, Abed Y, Harari D, Becker A. The resolution of palatally-impacted canines using palatal-occlusal force from a buccal auxiliary. American Journal of Orthodontics and Dentofacial Orthopedics 1996,110:528-534.

10. Becker A, Goultschin J. The multistrand retainer and splint. American Journal of Orthodontics, 1984;85:470-474.