Seminars in Orthodontics

VOL 16, NO 3

SEPTEMBER 2010

Introduction
vidence-based research has indicated that
most malocclusions should be treated in
the early stages of the permanent dentition stage
of development, which means that orthodontics
is the alignment of teeth that have already
erupted into the oral cavity. The teeth in these
patients may therefore be assumed to have a
normal eruption mechanism. This assumption
has enabled ease of prediction in achieving resolution of a given malocclusion and success in
the overall treatment, with a high degree of
certainty. Few disciplines within medicine and
dentistry can aspire to the degree of excellence
achievable in orthodontics with the same level of
confidence in its achievement.
The presence of an impacted tooth is the fly
in the ointment. Perhaps the impaction is
caused by some hard tissue obstruction, such as
an odontoma or a supernumerary tooth. This
finding should make treatment straightforward,
still with a high expectation for the chances of
success. However, it introduces a new dimension
into the case because surgery will be necessary to
remove the obstruction. Does elimination of the
cause guarantee that the tooth will erupt spontaneously or will it be necessary to additionally
expose the impacted tooth? Perhaps it will be
necessary to apply traction to this tooth to encourage it to erupt. If so, then an attachment will
need to be placed on the tooth, while it is accessible.
A periapical lesion or radicular cyst in a nonvital deciduous tooth or a dentigerous cyst are
each possible causes of soft-tissue impediments
to normal eruption. In contrast, there may be no
apparent obstruction, which means that other
forms of pathology may be reasons for failure of
a tooth or teeth to erupt. A general condition,
such as cleidocranial dysplasia or one of the
forms of amelogenesis imperfecta, will result in

2010 Elsevier Inc. All rights reserved.

doi:10.1053/j.sodo.2010.05.005

the noneruption of teeth, with only the former

responding well to orthodontically assisted eruption mechanics.1-3 A local flaw of the periodontal ligament (PDL) or some unknown disturbance in the eruption mechanism may interrupt
the normal eruptive progress of a tooth. Primary
and secondary retention and primary failure of
eruption are descriptive connotations rather than
etiologic definitions. They cover an area in which
definitions do not indicate the reason for the feature, although the diagnosis should provide information about the prognosis for orthodontic resolution of the tooth/teeth concerned. Aspects of
these phenomena are discussed in this issue of
Seminars in Orthodontics.
Ankylosis will prevent any attempt to orthodontically move the affected tooth because there is a
break in the continuity of the PDL at a site in
which there is a direct link between bone and
tooth cementum. Despite its being a rare occurrence, it is nevertheless often falsely blamed for
any situation in which the practitioner fails to
move the tooth.4 Invasive cervical root resorption
was first described quite recently1,5 and merits being referred to as a very specific entity in its own
right. Its character is quite different from the type
of root resorption produced by orthodontic movement or that befalling the root of a tooth resulting
from an adjacent impacted canine. Invasive cervical root resorption affects the impacted tooth and
is usually the factor responsible for its noneruption. At surgery, the tooth exhibits normal mobility, but orthodontic traction has little or no effect
on it. At repeat surgery, the recalcitrant tooth may
be seen to be very mobile because the traction may
have been unsuccessfully applied for extensive periods. However, it seems that the cervical resorption causes a loss of integrity in the PDL at this site
and this does not permit its eruption.
Clearly, then, when an impacted tooth is
present, an element of doubt enters into the
equation, undermining the confidence of the
orthodontist in being able to resolve the impaction. It also mandates the need for a careful

Seminars in Orthodontics, Vol 16, No 3 (September), 2010: pp 163-164

163

164

Becker

differential diagnosis of the particular problem

to arrive at a definitive diagnosis as to its cause.
More than ever before in dentistry, options
other than orthodontic resolution exist. In addition to removable and fixed prostheses, the past
decade or two has seen the incorporation of
artificial implants into the vade mecum of prosthetic alternatives. There will usually be a deficiency of alveolar bone in the site designated for
the impacted tooth and, should the impacted
tooth be extracted, this will often reduce the
alveolar bone profile even more.
Because placing dental implants in the growing child is contraindicated, temporary solutions
are necessary to replace a missing tooth to restore the patients appearance and function and
to see the patient through the growing period
until the appropriate age is reached for permanent prosthodontic or implant-based rehabilitation. Long-term use of removable prostheses has
adverse effects on the teeth and gingival tissues
with which they come into contact, while fixed
prostheses require tooth preparation which may
have to be restored as part of the final treatment.
Orthodontics has been referred to as the 5-mm,
10-degree profession, because this is the maximum range of tooth movement, leveling, rotation, tip, and torque that is needed in most cases
and the brackets used are specifically designed
to achieve these movements. However, when impacted teeth are present, the range of tooth
movement is often considerably more and the
ability to achieve all these types of movements
are necessarily restricted and the biomechanics
becomes more complicated.
Orthodontic graduate students are taught
to use the most up-to-date bracket systems to
optimize their treatments. Courses are provided
on self-ligation, orthodontic/surgery procedures,
early treatment, adult treatment, special needs
treatment, orthodontics in periodontal breakdown
situations, lingual appliances, as well as other areas. The Hebrew University-Hadassah School of
Dental Medicine in Jerusalem teaches a very
specialized orthodontic graduate course regarding the very special nature that is the character
of treatment of patients with impacted teeth.

This author attended a lecture when a renowned

orthodontic authority on the clinical orthodontic lecture circuit assured his audience in that
you cannot win with impacted canines in more
than 7 or 8 out of every 10 cases. The subject
has become very much the Cinderella of Orthodontics.
In this issue of Seminars in Orthodontics I have
been fortunate to be able to gather papers from
several eminent authors, whom I consider to be
leaders in their respective fields of expertise.
This issue is presented as an effort on the part of
each one of the authors to disseminate up-todate information, both in the form of original
studies and illustrated literature reviews on several aspects of the subject of impacted teeth,
from genetics, through precipitating etiologic
factors, accurate 3D positional diagnosis, surgical exposure, implant anchorage, molar retention and extreme ectopias. I am most grateful to
the authors of these articles for their scholarship
and their expertise and for their willingness for
having agreed to deliver their work within the
short time deadline that I set them. My only
hope is that this issue will gain the recognition of
a wide professional readership, which will use it
as a starting point to hone their knowledge and
skills for the benefit of their patients.
Adrian Becker
Guest Editor

References
1. Becker A: The Orthodontic Treatment of Impacted
Teeth (ed 2) Abingdon, Informa Healthcare, 2007
2. Becker A, Lustmann J, Shteyer A: Cleidocranial dysplasia.
Part 1 general principles of the orthodontic and surgical treatment modality. Am J Orthod Dentofac Orthop
111:28-33, 1997
3. Becker A, Shteyer A, Bimstein E, et al: Cleidocranial
dysplasia. Part 2a treatment protocol for the orthodontic and surgical modality. Am J Orthod Dentofac Orthop
111:173-183, 1997
4. Becker A, Chaushu G, Chaushu A: An analysis of failure in
the treatment of impacted maxillary canines. Am J
Orthod Dentofac Orthop 137:743-754, 2010
5. Heithersay GS: Clinical, radiologic, and histopathologic
features of invasive cervical resorption. Quintessence Int
30:27-37, 1999