Efficient clinical management of palatally impacted canines is truly one of the most challenging orthodontic problems that clinicians face. Traditionally, a full fixed appliance worked to a full-dimension stainless steel wire serves as the anchorage unit to apply vertical and lateral force vectors to the impacted tooth. Depending upon the original position of the impacted canine, it can be difficult to avoid a collision of the crown of the impacted canine with the adjacent roots of the central and lateral incisors during force eruption.

Alternatively, indirect anchorage can be created with a 6-mm TOMAS anchorage pin strategically placed on the palatal aspect between a second bicuspid and a first permanent molar. This is a favorable location for insertion because of the generous bone adjacent to the single palatal root of the first molar. A TOMAS system T-bar, engaging the anchorage pin cross-slot and secured with composite with its horizontal extensions bonded to the lingual of each adjacent tooth, completes the indirect anchorage unit.

A self-ligating bracket, bonded to the lingual of the second bicuspid but occlusal to the horizontal extension of the T-Bar, serves as an easy-to-manage insertion point for a .021 x .025 Beta-Titanium eruption cantilever arm. This arm can be customized to deliver distal, vertical, and lateral force vectors as determined by 3D CBCT evaluation of the original position of the canine relative to the roots of the adjacent teeth. The rate-limiting step of such cases—vertical eruption of the impacted tooth—can be addressed immediately at the beginning of treatment, coupled with a thorough exposure of the entire anatomical crown and luxation prior to force application to a bonded attachment. With this approach, it is not uncommon to observe an emergence of the impacted tooth through the palatal tissue and away from the roots of the adjacent teeth within the first 4 months of force application.

Full fixed appliance placement follows, with traditional methods to guide the canine to its appropriate place in the arch. Patients should enjoy a significantly reduced treatment time spent in full fixed appliances, while clinicians will see a significant reduction in the number of office visits required to deliver care.

—John M. Pobanz, DDS, MS, Diplomate, ABO, South Ogden, Utah