PRACTICAL MANAGEMENT OF THE IMPACTED

MAXILLARY CUSPID

MILTON M. LAPPIN, D.D.S;, M.S.,* DETROIT, MICH.

NE of the most perplexing problems the dental practitioner has to face is

0 the proper management of the impacted maxillary cuspid. There is per-
haps no oral anomaly which requires greater ingenuity than the treatment of
this condition. After the diagnosis of “unerupted or impacted cuspid” has
been made, the immediate problem is the proper sequence necessary to vis-
ualize the tooth, or, in other words, what procedure to follow to assist in its
eruption.
An approach or rationale of treatment of this condition will be presented
for the edification of the general practitioner as well as the orthodontist. The
actual orthodontic treatment and appliance manipulation usually needed to
correct this tooth from a lingual to a normal position in the arch will also be
discussed in this article.
A typical case has been selected to simplify the discussion concerning the
“impacted cuspid.” This case is a composite of many which have been simi-
larly treated. Fig. 1 shows a plaster cast with the right and left maxillary
deciduous cuspids in position. The patient is 14 years of age. Roentgeno-
graphic examination (Fig. 2) reveals the presence of right and left permanent
maxillary impacted cuspids, both lingual to the adjacent teeth. Once the diag-
nosis of “unerupted or impacted cuspids” has been established, the patient is
referred to an oral surgeon for surgical exposure. The oral surgeon is in-
structed to expose these teeth so they will erupt into the mouth. If esthetics
is a factor, he is further advised to maintain the deciduous teeth in position,
if at all feasible.
The oral surgeon then not only exposes these permanent cuspids, but he
also removes all the overlying tissue and as much of the surroundii.ig bony
crypt as practical, i.e., without endangering the vitality of the adjacent teeth.
He relieves the incisal tips if at all possible, thus channeling a path for the
teeth to erupt into, and then places a surgical pack into the wound to prevent
surface healing and at the same time to promote the initial movement of the
teeth in the direction of least resistance, namely the channel which has been
created. It will be noted that up to this point no orthodontic treatment has
been attempted.
Following the necessary postoperative treatments, the patient is dismissed
for three months, and observed at three-month intervals for as long as neces-
This thesis was submitted to the American Board of Orthodontics in partial fulfillment
of the author’s requirements for certification.
*Instructor, Department of Orthodonttcs, University of Detroit School of Dentistry.
 770 MILTON M. LAPPIN

sary. Usually cases thus handled are ready for ort,hodontic treatment within
six months to one year. Fig. 3 shows a cast of the same patient exactly six
months following surgical exposure.
The point that should be stressed here is that adequate surgical exposure
has permitted these teeth to erupt without any mechanical assistance what-
soever. In this ease, the six months’ waiting period following surgery represents

Fig. 1. Fig. 2.
Fig. l.-Cast showing deciduous cuspids in position.
Fig. Z.-Occlusal fllm showing bilateral impacted cuspids, lingual to adjacent teeth.

Fig. 3.-Same case as Fig. 1, but six months following surgical exposure of permanent cuspids.

a saving to the patient of six months of orthodontic treatment. Many ingenious

appliances have been designed to bring these impacted cuspids into the mouth,
when the identical results could have been obtained by proper surgical expo-
sure and then just waiting for Mother Nature to do the rest-a great saving in
time, expense, sad inconvenience to the patient.
 IMPACTED MAXILLARY CUSPID 771

The placing of a hole in the cingulum for the cementation of a pin is a

needless and destructive procedure. Many cuspids have lost their vitality
through accidental exposure of the pulp while drilling for a pinhole in a bloody
field. Likewise, the placing of onlays to hasten eruption is usually not only
unnecessary, but it needlessly adds orthodontic treatment time to the case at
hand. These two methods are rarely, if ever, justified without first exposing
surgically and giving the,‘tooth a chance to erupt of its own accord. They
should be used only as a last resort.

ETIOLOGY

The etiology of impacted teeth has long been a controversial subject.

Several theories have been advanced as to the underlying cause of the im-
pacted cuspid.
The presence of supernumerary teeth may be considered an etiological
factor. However, the presence of a supernumerary tooth in the upper cuspid
area is so rare ,that this cause alone cannot be considered as having great im-
portance.
At the age of 235, the first premolar germ is above the deciduous first
molar, but already the germ of the cuspid is lying above the premolar germ.
Perhaps this position of the cuspid above all the other permanent teeth helps
explain why this tooth is so frequently impacted. From this position it has
a long and devious way to go. It must erupt mesially and occlusally, notwith-
standing the fact that most of the other teeth chronologically precede the cus-
pid in eruption time. Therefore it must assume its place in an arch where all
of the other teeth have more or less assumed their respective places and the
cuspid, so to speak, must accept whatever space is left over.
As early as the age of six the tip of the permanent cuspid may normally
be seen erupting lingually to the. apex of the deciduous cuspid. When for
some reason the resorptive forces do not attack the deciduous cuspid root, this
may cause the permanent cuspid to become impacted. Another way of saying
the same thing is that the delayed exfoliation of the deciduous cuspid is an
etiologic factor in the production of this condition. This deflects the perma-
nent cuspid and prevents it from erupting. Since these impacted cuspids are
practically always deflected lingually, it is entirely possible that the normal
eruption of the impacted cuspid may be retarded because of the character and
density of the palatal tissue. This lingual tissue is much firmer and more
fibrous than the tissue on the labial side; it serves as an obstacle to normal
eruption, and produces an impaction.
Several cases have been reported in which one parent and at least one or
more progeny revealed the presence of an impacted cuspid. There is also sub-
stantial clinical evidence to support the contention that unerupted cuspids may
be congenital in nature.
Dewel stated that “curiously, unerupted cuspids frequently occur in quite
normal arch form cases. Therefore the cause is usually not due to crowded or
contracted arches.“l Actual clinical material has substantiated this statement.
772 MILTON M. LAPPIN

DIAGNOSIS

The maxilla,ry permanent cuspid shows first evidence of calcificatiori al.

4 to 5 months of age; the crown is completed at 6 to 7 years of age and the
usual eruption time is 11 to 13 years of age. Therefore, when this tooth fails
to make an appearance by 13 years of age, one should immediately be suspicious
of an impacted or unerupted cuspid,
Before any positive diagnosis can be made, a roentgenographic examina-
tion is imperative. The usual intraoral examination will suffice for most cases.
An occlusal film may be employed in addition to the intraoral study to localize
further the unerupted tooth or teeth. (See Fig. 2.)
By applying Clark’s principle of localization, one may determine at a
glance whether the unerupted tooth is buccal or lingual. If two separate
exposures of the same area of the mouth are taken with the x-ray tube being
moved mesially or distally, and the unerupted tooth moves in the same direc-
tion as the tube is moved, then this tooth is lingual to the roots of the adjacent
teeth. On the other ha,nd, if it moves in the opposite direction to the tube, the
tooth is buccal. This briefly is Clark’s principle of localizing an unerupted
tooth. The following x-ray films will illustrate the point. Fig. 4 shows an
unerupted cuspid. In Fig. 5 the tube has been moved mesially as evidenced by
the appearance of the central incisor of the opposite side. In Fig. 4 the tip
of the cuspid just overlaps the central incisor, but in Fig. 5 the tip of the cuspid
is mesial to the central incisor and nearly touching the opposite central in-
cisor ; therefore the unerupted tooth has moved mesially or with the tube and
is lingual to the adjacent teeth.
Fig. 6 shows another unerupted cuspid, and Fig. 7, taken with the tube
moved mesially, shows that, the tooth in question has moved opposite to the
x-ray tube or distally. Therefore the unerupted tooth is buccal to the adjacent
teeth.
Figs. 8 and 9 bring out a very interesting point in angulation. Both views
of an unerupted cuspid were taken of the same patient within one minute of
each other. In Fig. 8, the permanent cuspid seems practically horizontal and
situated at the apices of the teeth in the buccal segment. At first glance, the
prognosis for the ultimate eruption of this tooth would be hopeless. In Fig. 9
the condition is seen in an entirely different light. The unerupted cuspid no
longer appears horizontal, but rather seems inclined toward the mesial, which
is a truer picture of the existing condition. This dramatically illustrates the
importance of accurate record making, in addition to making occlusal films
and even stereoroentgenograms, to determine the true positions of these teeth.
Broadbent’ demonstrated by taking a series of anteroposterior and lateral
headplates of children, starting at the age of 6, and at intervals of three to six
months thereafter, that it is possible to observe with great accuracy the path of
the permanent canine as it proceeds along its devious course of eruption. By
noting deviations from normal he can predict when the permanent maxillary
canine is being deflected lingually long before its normal eruption time. As
soon as this condition is detected, Broadbent removes the offending tooth, the
 IMPACTED MAXILLARY CUSPID 773

Fig. 4. Fig. 5.
Fig. 4.-Impacted maxillary cuspid.
Fig. B.-Same tooth as Fig. 4, but with x-ray tube moved mesially. The impacted tooth
moved mesially too, and is therefore lingual to adjacent teeth.

Fig. 6. Fig. 7.
Fig. B.-Impacted maxillary cuspid.
Fig. ‘I.-Same tooth as Fig. 6, but with x-ray tube moved mesially. The impacted tooth
moved distally, and is therefore buccal to adjacent teeth.

Fig. 8. Fig. 9.
Fig. S.-Impacted cuspid seems horizontal and in a hopeless position.
Fig. S.-Same tooth as Fig. 8, but taken from a different angle.
774 MILTON M. LAPPIN

deciduous canine, so that the permanent canine may assume its normal posi-
t.ion and thus not be deflected lingually into the dense fibrous tissue of the
pwlate.
FREQUENCY

“The upper cuspid is second only to the lower third molar in order of
frequency of impaction.“3
“Impacted upper cuspids occur more frequently in females than in males,
are rarely congenitally missing, occur much more frequently in the upper than
in the lower jaw. Also when impacted and unerupted, these teeth occur prac-
tically always lingual, rather than buccal to the adjacent teeth in the arch.
Jt is extremely rare for a deciduous cuspid to be impaeted.“4
NEED FOR EXPOSURE

Sometimes in later life, these unerupted teeth may start to move in the
direction the crown is facing. Since the crown is nearly always pointing to
the mesial, there is a distinct danger to the roots of the lateral and central
incisors. The pressure thus produced may cause resorption of the central and
lateral roots and subsequent devitalization of these teeth. Another common
condition obserqed is the displacement of the lateral incisors due to pressure
from the cuspid crown.

Fig. IO.-Destruction and loss of permanent lateral incisor by an ectopically erupting cuspid.

Frequently the membrane surrounding the crown of an unerupted tooth

becomes cystic and may lead to extensive destruction of bone. Should these
cystic areas become infected, they may be considered causative factors in pro-
ducing local or referred pain.
In rare cases, the pressure produced by a misplaced cuspid may cause
destruction of a tooth in its path. Fig. 10 shows complete destruction and sub-
sequent loss of a permanent latera, incisor by an ectopically positioned cuspid.
SURGICAL REQUIREMENTS

After the need for surgical exposure has been determined, the patient
should be assured that the operation, while quite simple, takes considerable
time to perform. The exact position of the unerupted tooth or teeth should
be ascertained by taking x-rays from several angles and applying Clark’s prin-
 IMPACTED MAXILLARY CUSPID 775

ciple of tooth localization. Since practically all cuspids requiring surgical ex-
posure are lingual, the technique5 for exposing a lingually impacted cuspid
will be described:
1. Anesthesia is obtained by infiltration in the mucobuceal sulcus and by
blocking the nasopalatine nerve and the anterior palatine nerve on the side
to be exposed.
2. The palatal mucoperiosteum is reflected at the site of the unerupted
crown. This is accomplished by incising the interproximal papillae on the
lingual surface and carrying the incision through the adjacent gingival crevice.
This incision is extended for sufficient length to permit adequate exposure of
the bone over the coronal part of the unerupted tooth. The mucoperiosteum
is reflected from the lingual embrasures of the teeth.

Fig. Il.-View immediately following surgical exposure of maxillary cuspids.

3. By means of hand chisels and small surgical burs, the overlying bone
is removed and the crown is exposed. A small surgical bur is used to cut a
definite pericoronal space, being sure the entire crown including the tip is
exposed. Extensive removal of bone is done if possible, to permit the desired
movement of the crown. Great care is taken to be sure adjacent teeth are not
injured or their radieular parts exposed.
4. The mucoperiosteal flap is replaced and with small scissors and knife
a window is cut in the flap to expose the crown of the tooth into the mouth.
This window may necessarily include the gingival crest.
5. The margins of the flap are retained by sutures from palatal to labial
mucosa.
6. A zinc oxide-eugenol type of cement is incorporated in a 1, inch strip
of gauze. (Some men prefer the use of baseplate gutta-percha.) This strip
is then. carefully packed into the pericoronal space and the remaining portion
used to cover the operative defect completely.
7. The pack is left in place until epithelization of the margins of the
wound takes place-usually ten to fourteen days. The wound is inspected at
this time. A loose similar pack is replaced if repair is not adequate. Too early
removal of the dressing may result in granulation over the wound before the
tooth has shifted close enough to the surface to prevent closure of the defect.
776 MILTON M. LAPPIN

ACTTJAL ORTHODONTIC TREATMENT

After the exposed cuspid has attained its maximum eruption (usually
three months to one year following surgery), an appliance is prepared t,hat’
will produce a labial force on t,his tooth. Of course if other orthodontic re-
quirements are to be met, such as creating space for the cuspid, common sense
would dictate completing these while waiting for the cuspid to erupt. The
mechanics for moving the cuspid arc then integrated into the over-all require-
ments of the case. It should be borne in mind, however, that while t,he tip
of the cuspid crown is adjacent to the central or lateral roots, extreme care
should be exercised in moving the central or lateral incisors because of the
likelihood of damaging their roots while the cuspid crown is in the way.
The actual appliance used is left to the discretion of the operator. It is
felt though, that the use of the renlovable Mershon type lingual wire, fitting
into l/z round tubes soldered on molar bands, merits considerat.ion. Since
the lingually locked cuspid occurs so often in cases of normal arch and jaw
relationship, the lingual appliance is usually preferred because of the ease with
which it is constructed and the simplicity of its adjustment. After obtaining
adequate separation of the molar teeth, bands are made. With the bands on
the teeth, a compound impression of the upper jaw is taken, the bands are in-
serted into the impression, sealed t.o place, and a plaster or stone model is
poured. When t,he model has been separated, 1/z round tubes are soldered
onto the lingual surfaces of the molar bands. Wire 0.038 inch in diameter is
now closely adapted to the model, following the configuration of the lingually
locked teeth. In addition, small safety pin springs, 0.022 inch in diameter, are
soldered to the arch wire opposite the cuspid teeth. Tubes are soldered on the
buccal surfaces of the molar bands in case they are needed later. The appli-
ance is now cemented to position.
It should be noted that no attempt is made to prevent the lingually erupt-
ing teeth from attaining their maximum eruption in a lingually locked position.
It is felt that when the time comes to correct these teeth from a lingual posi-
tion to the normal relationship, buccal to the lower teeth, a better mechanical
leverage is obtained if the teeth are permitted to attain their maximum eruption.
However, it is imperative in most, cases at this time to place a bite block (Fig.
13) on the lower teeth which will hold the upper and lower teeth apart while
the cuspids move from a lingual t,o a buccal relationship with the lower teeth.
Otherwise it is very time consuming to depress the canine sufficiently to jump
the bite. The actual tipping of the cuspid teeth is now obtained by adjusting
the safety pin springs.
The maxillary cuspid being a long and cone-shaped tooth makes it exceed-
ingly difficult to form a band that will stay in place. Should it be found neces-
sary to make an attachment for this tooth, the following technique of making
a cast band will prove very helpful :
Select a copper band 36 gauge by 1/2 inch ; festoon the mesial and distal
aspects and take a compound impression of the tooth. Wrap Scotch tape
around this impression. Pour a model using a good casting investment and
 IMPACTED MAXILLARY ctrs~ib m

when hard, separate the model from the impression. Now pencil an outline of
the band on the model, adapt 28 gauge pink wax to model, being very careful
not to exceed penciled outline. Secure wax in four places, two buccal and
two lingual. Using a piece of wire about 0.055 inch for a sprue, heat and
fasten this wire at right angles to the lingual surface of the tooth. With a bit
of wax, reinforce the point at which the sprue meets the wax. Invest and cast,
using a good, hard casting gold. Wi.th a Carborundum stone, machine the
inside of the band generously. Solder necessary attachments to this band, and
cement to position.

Fig. 12.-Mershon type removable lingual appliance showing springs for moving cuspids labially.

Fig. 13.-Lower acrylic bite block.

SUMMARY AND CONCLUSIONS

As a summary, the following points are noteworthy:

1. Adequate surgical exposure is the first step in the management of an
impacted cuspid.
2. A waiting period of three to twelve months is routine procedure follow-
ing surgical exposure.
3. Orthodontic intervention is rarely justified or necessary, if the impacted
tooth has been adequately exposed.
4. The delayed exfoliation of the deciduous cuspid is probably the prin-
cipal etiological factor in the production of maxillary cuspid impactions.
778 tiIL?!ON M. LAPPiN

5. Cuspid impactions are congenital in nature.

6. When a maxillary cuspid impaction occurs, it is practically always
lingual to the adjacent teeth in the arch.
7. Because of possible injury to adjacent teeth and supporting st,ructures,
impacted cuspids discovered in lat,er life should be closely watched and consid-
ered candidates for removal if surgical exposure is not practical.
8. It is entirely possible that the increased popularity of cephalometric
x-rays, taken in lateral and anteroposterior views as a routine diagnostic ortho-
dontic procedure, will detect impactions in their incipiency.
9. By detecting an impaction earl>- and removing the ofTending tooth, the
deciduous cuspid, it may be possible to prevent this condition from occurring
in a great many cases.
REFERENCES
1. Dewel, B. F.: Clinical Diagnosis and Treatment of Palatally Impacted Cuspids, D. Digest.
51: 492-497, 1945.
2. Broadbent, B. H.: Communication, Dec. 12, 1950.
3. Crver. M. H.: Retarded EruDtion of the Teeth: Their Liberation and Extraction. ,
” .f. A. M. A. 43: X22-1529.-1904. m-7--
4. Rohrer, A.: Displaced and Impacted Canines, INT. J. ORTHODONTIA 15: 1003, 1929.
5. Bloom, H. J.: Communication Dec. 1, 1950.
6. Day, A. J.: Unerupted Teeth Which Have Been Surgically Exposed and Brought Into
Occlusion, D. Record 66: 269-274, 1946.
7. Noyes, F. B. : Dental Histology and Embryology, ed. 4, Philadelphia, 1929, Lea & Febiger,
DD. 368-381.
8. Gwini; C. D.: Exposure of Unerupted Upper Cuspids for Orthodontic Purposes, J. Am.
Dent. A. 32: 265-270, 1945.
9. Leslie, S. W.: A New Method of Treating Unerupted Teeth by Means of Surgery and
Orthodontia, J. Canad. D. A. 8: 364-369, 1942.
10. Lipcomb, W. E.: Some Views on the Subject of Impacted Maxillary Canines, AM. J.
ORTHODONTICSAND ORAL S~~a.29: 550,1943.
11. Moffitt, J. J.: A Method of Bringing Impacted Teeth Into Normal Position, J. Am.
Dent. A. and Dental Cosmos 24: 1139-1141, 1937.
12. Reese, B. L.: The Unerupted Cuspid, AM. J. ORTHODONTICSAXD ORAL SURG.~~: 214-220,
1945.
13. Siegel, S. R.: Method of Bringing Into Position an Overretained Impacted Upper Cerl-
tral Incisor, J. Am. Dent. A. 29: 317-319, 1942.
14. Strock, M. S.: The Artificial Eruption of Malposed Teeth, D. Digest. 47: 10-14, 1941.
15. Viverito, J. S.: Malplaeed and Impacted Canines, Dental Items Interest 62: 950.955,
1940.
16. Dewel, B. F.: The Upper Cuspid: Its Development and Impaction, Angle Orthodontist
19: 79-90, 1949.
17. Dewel, B. F.: Clinical Observations on the Axial Inclination of Teeth, AK J. ORTHO-
DONTICS 35: 102, 1949.
18. Buchner, H. J.: Root Resorption Caused by Ectopic Eruption of Maxillary Cuspid,
INT. J. ORTHODONTIA22: 1236,1936.
19. Berger, H.: Idiopathic Root Resorption, AM. J. ORTHODONTICSAND ORAL SURG. 29: 548:
1943.
20. Strang, R. H. W.: Textbook of Orthodontia, ed. 2, Philadelphia, 1943, Lea & Febiger,
p, 82.
1002 BRODERWK TOWER.