CASE REPORT Orthodontic treatment of bilaterally impacted maxillary canines in an adult Sunjay Suri, BDS, MDS, a Ashok Utreja, BDS, MDS, b and Vidya Rattan, BDS, MDS c Chandigarh, India This case report discusses the management of bilaterally labially impacted maxillary canines and a deepbite Class II malocclusion in a 21-year-old woman. An interdisciplinary approach to treatment with different mechanical strategies led to the achievement of the desired esthetic, functional, and occlusal treatment goals. The problems associated with impacted maxillary canines and the biomechanical interventions used for this patient are discussed. (Am J Orthod Dentofacial Orthop 2002;429:429-37) M axillary canines have the longest period of development, the deepest area of develop- ment, and the most difficult path of eruption of all the teeth. 1 Their normal age of emergence is between 11 and 12 years. 2 Other than the third molars, the maxillary canines are the most likely to remain unerupted or impacted. They are also the teeth that most commonly require surgical exposure and ortho- dontic guidance during eruption. 1 Maxillary canine impactions are more common in females (1.17%) than in males (0.51%). 3 The frequency of maxillary canine impaction is significantly higher than that of mandibu- lar canines. 4 Impacted maxillary canines are also situ- ated palatally more frequently than labially. 5,6 Eight percent of patients with impacted maxillary canines have bilateral impactions. 3 The incidence of impacted canines in patients over 20 years of age has been documented as 0.9%. 7 DIAGNOSIS AND ETIOLOGY A 21-year-old woman came to the Postgraduate Institute of Medical Education and Research in Chan- digarh, India, for orthodontic treatment with the chief complaint of impaired facial esthetics due to spaces and unerupted upper canines. She also had a mild lisp. As an active sportsperson and a key player on India’s national roller-hockey team, her dentition was a serious limitation that curtailed much of her social interaction. She had a grossly symmetric, mildly brachycephalic, euryprosopic face with a prominent nose and competent lips (Fig 1). Intraoral examination (Fig 2) showed a spaced upper arch with unerupted maxillary canines and a mildly crowded lower arch. In occlusion, she had a 50% deepbite and a 3-mm overjet. The molar relationship was end on. The dental midlines were concordant with each other and with the face, and no mandibular shift was detected on closure. The maxillary left second premolar was in lingual crossbite. Teeth 17, 26, 27, 36, and 46 (FDI tooth numbers) were carious. There were no signs or symptoms suggesting temporomandibular joint disorders, and the maximum incisal opening and jaw movements were in the normal range. There was no relevant history of any medical problem. Radiographic examination (Fig 3) showed that all teeth, including the third molars, were present. Both maxillary canines had well developed roots, were impacted at the level of the roof of the palate, and were mesially angulated near the roots of the maxillary lateral incisors. Both teeth had a mesial angle to the midline exceeding 25°. The maxillary right canine was positioned higher and was more severely mesioangu- lated than the left. A horizontal tube shift technique with periapical radiographs confirmed that both im- pacted maxillary canines were in the labial position. Cephalometric evaluation (Table) showed a mild skel- etal Class II pattern and a decreased lower anterior facial height. Both the maxillary and the mandibular incisors were mildly set into the face. The nose was prominent, and the soft tissue of the lips was found to be mildly excessive. TREATMENT OBJECTIVES The objectives of orthodontic treatment for the patient were to erupt the labially impacted maxillary a Assistant professor of orthodontics, BRS Dental College, Panchkula, India; former senior resident, Postgraduate Institute of Medical Education and Research, Chandigarh, India; former clinical fellow, The Hospital for Sick Children, Toronto, Ontario, Canada. b Professor and head, Division of Orthodontics, Oral Health Sciences Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India. c Assistant professor, Unit of Oral and Maxillofacial Surgery, Oral Health Sciences Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Reprint requests to: Dr Sunjay Suri, #29, Sector 24-A, Chandigarh 160023, India; e-mail, sunjaysuri@rediffmail.com. Submitted, June 2001; revised and accepted, November 2001. Copyright © 2002 by the American Association of Orthodontists. 0889-5406/2002/$35.00 + 0 8/4/126406 doi:10.1067/mod.2002.126406 429