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Received: 26 April 2021    Revised: 23 August 2021    Accepted: 6 September 2021

DOI: 10.1002/ccr3.4856

CASE REPORT

Treatment of impacted canines with aligners: An

alternative and viable option

Gianluca Mampieri1   | Tommaso Castroflorio2  | Andrea Conigliaro3  |

Aldo Giancotti1

1
Department of Clinical Sciences and
Translational Medicine University of Abstract
Rome Tor Vergata, Rome, Italy To recover impacted canines without esthetic issues, the aligners can be a resolu-
2
Department of Surgical Sciences, tive tool allowing by pontics the camouflage of absent canines during orthodon-
Dental School University of Torino,
Turin, Italy
tic treatment. Knowledge of biomechanics, correct staging of dental movements,
3
Orthodontist, Private practice Siracusa, and surgery planification are strategic to achieve a good result.
Siracusa, Italy
KEYWORDS
Correspondence aligner treatment, customized treatment, impacted canines
Gianluca Mampieri, Department of
Clinical Sciences and Translational
Medicine University of Rome -­ Tor
Vergata, Viale Tito Labieno 222 –­ 00174
Rome, Italy.
Emails: gianluca.mampieri@uniroma2.
it; gianluca.mampieri@gmail.com

Funding information
No public or private funding was
required for this work

1  |  I N T RO DU CT ION planned to surgically expose both canines to pull them di-

rectly toward their ideal position without resorting to any
Impacted cuspids represent an important challenge for external auxiliary other than direct elastic forces from the
orthodontists, particularly when we have to treat pa- canines to the aligner.
tients rejecting fixed and visible appliances. Currently, To achieve the mentioned objectives, without causing
aligners allow to face several types of malocclusions, but esthetic issues, the aligners were modified directly by the
there are few indications for impacted canines, especially orthodontist in order to allow elastic traction of the im-
without the support of auxiliaries as miniscrews or fixed pacted canines while keeping a pontic to camouflage the
sectionals. absence of the canines in the arch.
However, the combined use of aligners and elastics can The final result supports the idea that, if the position
be effective in the treatment of impacted canines as shown of the impacted canines is favorable, it is possible to re-
by this clinical report. A 17-­year-­old female patient had cover them by using simple biomechanics with aligners
upper deciduous canines in the arch and permanently im- and without auxiliaries.
pacted cuspids inside the alveolar bone. After a first phase Impacted teeth can represent one of the most chal-
of treatment aimed at recovering space in the arch, it was lenging clinical issues for orthodontists. In particular, the
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2021 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.

Clin Case Rep. 2021;9:e04856.  wileyonlinelibrary.com/journal/ccr3   |  1 of 11

https://doi.org/10.1002/ccr3.4856
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management of impacted canines is often complex and 2  |  C LINICAL REPORT

shall be associated with a careful physical and radiological
examination. According to literature, the inclusion of ca- 2.1  |  Diagnosis
nines, following third molars, occurs the most frequently,
with an incidence ranging from 1% to 5.9%.1 As a result, A 17-­year-­old female patient presented with a Class I oc-
several orthodontic techniques, including specific devices clusion, mild overbite, and missing upper cuspids with the
and surgical approaches, have been proposed to move an permanence of the respective deciduous.
impacted canine into the arch. Most techniques imply the The upper and lower incisors were slightly retrusive.
use of fixed appliances and a number of auxiliaries in order The patient's smile was not esthetic due to the presence of
to favor a guided forced eruption in the crestal bone.2-­6 Yet, deciduous canines in the arch. The maxillary midline was
in the last few years, a growing demand for orthodontic coincident with the face and the mandibular midline. As
treatment with removable esthetic appliances as aligners confirmed by the panoramic x-­ray, the upper canines were
can be noticed, especially for the adult population. impacted. All third molars were developing, and there
When the Invisalign® system was introduced, it had were no recordable periodontal alterations. (Figures  1A-­
some limits, such as the inability to control root movement H; 2A-­C; 3A-­E).
and to move larger teeth over substantial distances.7,8
Recent improvements have allowed the use of Invisalign®
also in more complex clinical conditions, thanks to inno- 2.2  |  Treatment objectives
vative material and attachments, more accurate software,
the introduction of a new force system, and the more ex- Treatment objectives were to:
tensive experience gained.9-­15 The aim of this work is to 1: align and level both arches;
share a dedicated procedure for the treatment of impacted 2: gain space in the upper arch for impacted canines;
cuspids by combining the use of aligners with a conven- 3: recover impacted canines;
tional forced eruption technique. 4: refine alignment and occlusion.

(A) (B) (C)

(D) (E) (F)

(G) (H)

F I G U R E 1   (A-­H) Extra and intraoral

pretreatment records
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2.3  |  Treatment alternatives biomechanics.20-­23 Additionally, other articles report

the use of skeletally anchored devices demonstrating
Given the clinical conditions revealing that the two im- their effectiveness for the treatment of complex canine
pacted cuspids were positioned at the center of the al- impaction.24-­26
veolar crest, meanwhile considering the minimal space However, regarding the reported case in this article,
required for their recovery, several specific devices could two considerations led us to prefer aligner treatment for
have been applied. In literature, there are hundreds of two main reasons: firstly, the awareness of having to treat
publications reporting several effective methods pur- two not deeply impacted canines; secondly, the patient's
sued in order to recover impacted canines.16-­19 The ma- great esthetic expectations. The patient was informed that
jority thereof reports the utilization of full or segmental the treatment could have lasted slightly longer if com-
fixed appliances able to exert rational forces and specific pared with conventional fixed appliance timing.

(A) (B) (C)

F I G U R E 2   (A) Pretreatment lateral X-­ray. (B) Pretreatment panoramic X-­ray. (C) Initial cephalometric tracing

F I G U R E 3   (A-­E) Initial digital casts

(A) (B) (C)

(D) (E)

(A) (B) (C)

(D) (E)

F I G U R E 4   (A-­E) Clinical
observation after using 21 aligners
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2.4  |  Treatment plan the pontics in the aligners to obtain a valid camouflage of
the cuspids' absence during the traction of 1.3 and 2.3 and
The orthodontic treatment with aligners would include 3 upon the elastic traction to guide the impacted teeth into
phases: the arch. The innovative feature of the mentioned treat-
Phase I: slight expansion of the arches, correction of ment phase was the guided eruption of 1.3 and 2.3 with-
incisor inclination, and space gain for 1.3 and 2.3; out using auxiliaries, but rather aligners only.
Phase II: surgical exposure of impacted canines (1.3 The third and last phase was aimed at finishing occlu-
and 2.3) following extraction of deciduous canines, and sion and intercuspation, by using 13 aligners.
their engagement and traction toward the arch;
Phase III: orthodontic positioning of impacted canines,
outreach of the most proper position into the arch, and 2.5  |  Clincheck virtual planning
optimal esthetics.
The first phase consisted of 21 aligners to gain enough The first treatment phase consisted of 21 aligners in each
space for 1.3 and 2.3 by expanding the arch without signif- arch (Figure 5A-­E). The planned objectives were to gain
icant incisor proclination. (Figure 4A-­E). further space for impacted cuspids by means of upper
The second phase followed the extraction of decidu- arch expansion and slightly proclining incisors. During
ous canines and consisted of 17 aligners. This treatment this stage, alignment, leveling, and coordination of both
phase was more challenging because we had to manage arches were also planned. Moreover, upper molars were

(A) (B) (C)

(D) (E)

F I G U R E 5   (A-­E) Initial virtual projection

(A) (B) (C)

(D) (E)

F I G U R E 6   (A-­E) Intermediate virtual projection

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distally derotated, whereas lower molars and premolars rectangular attachments to enable greater control of the
were tipped buccally mostly to perform relative extru- canine tip upon tooth extrusion.
sion with a strategic advantage in deep bite correction. The finishing phase of treatment consisted of 17 align-
Optimized attachments were used for this step. ers aimed at distally tipping 1.3 and 2.3, thus improving
After having completed the surgical phase, the last occlusion (Figure 7A-­E).
three upper aligners were modified directly by clinicians Optimized extrusion attachments were placed on 1.4,
in order to allow the use of intra-­arch elastics and to en- 4.4, 4.5 and 2.4, 3.4, 3.5 in order to reach the best possible
gage impacted cuspids, and then traction them toward the arch intercuspation. Moreover, the use of Class II elastics
arch. from a metallic button on 1.3 and 2.3, as well as hooks on
The second step aimed at guiding the upper canines in the aligners in 3.6 and 4.6 was planned in order to achieve
the arch was planned by including 13 aligners (Figure 6A-­ a slight extrusion and the distal tip of canines.
E). Because the active extrusion forces applied to the
cuspids were exerted by interarch elastics, we planned
precision cuts on the aligners in the 1.3 and 2.3 areas. 2.6  |  Treatment progress
These cuts were utilized to bond esthetic buttons on the
surface of 1.3 and 2.3. Hooks were projected in the lower The described innovative treatment was based on a surgi-
arch corresponding to the 3.3, 3.4, 4.3, and 4.4 areas. This cal approach combined with the management of cuspid-­
way, it was possible to use triangle elastics from the es- guided eruption by using aligners.
thetic buttons on the upper canines to the hooks on the Once cuspid space was obtained, the surgical phase was
lower aligners. carried out with the preliminary extraction of deciduous
At this stage, we preferred conventional attachments canines. Bilateral full-­thickness flaps were raised, and the
on lower premolars, as they would guarantee greater sta- cortical bone was removed until the partial exposition of
bility to the aligner once the elastics were worn by the the impacted canine cusp. A metal button was sandblasted
patient. Moreover, on the upper canines, we prescribed on its surface and bonded to the exposed canine crown.

(A) (B) (C)

(D) (E)

F I G U R E 7   (A-­E) Finishing virtual projection

(A) (B) (C)

F I G U R E 8   (A-­C) Surgical and bonding phase

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(A) (B) (C)

F I G U R E 9   (A-­C) Orthodontic traction of the cuspids

(A) (B) (C)

F I G U R E 1 0   (A-­C) Orthodontic traction from “dovetail” hooks to impacted canines

(A) (B) (C)

F I G U R E 1 1   (A-­C) Refinement stage with triangle elastics applied

After applying an adhesive film on the button's surface, a After 3  months, when the cuspid tips were more su-
horn-­shaped composite hook with a flow (Core-­× Flow perficial, the buttons were replaced, and the composite
A3, Dentsply) was created starting from the metal button arm was no longer necessary. Also, the elastics were re-
(Figure 8A-­C). The flap was then repositioned and sutured so placed with shorter ones (4  mm/180  g). Since then, the
that the composite hook would be accessible to the patient. second button in the aligners was replaced by a "dovetail"
Just 2  days after surgery, the buttons were placed in- hook created on the palatal side corresponding to areas 1.3
side pontics, where a hole had been made on the palatal and 2.3. The intraoral elastic (4 mm/180 g) was directed
side to enable their exit. They were fixed within the same from the button on the canine to the “dovetail” hook.
resin of temporary crowns that had been used to fill the (Figure 10A-­C).
pontics simulating 1.3 and 2.3 crowns. Thus, the patient During the cuspid traction phase, the pontics allowed
was instructed to apply intra-­arch elastics (6  mm/180  g) to maintain suitable esthetics. The pontics in areas 1.3
from the composite hook to the second palatal buttons for and 2.3 were filled with a thin layer of composite (Core-­×
anchorage (Figure 9A-­C). Flow A3, Dentsply) on the buccal surface only. This way,
It was indicated to wear elastics at least 12  h/day. there would be enough space to enable forced canine
Thanks to the elastic traction, the permanent canines eruption.
began to erupt guided by the aligner at the center of the After only 2  months, both cuspids were in the arch,
alveolar process. Indeed, every 20  days, this process im- after which Phase III was launched. Additional aligners
plied that the resin inside the pontics had to be gradually were planned to refine occlusion and esthetic details.
reduced in order to make space for canine crowns. (Figure 11A-­C).
MAMPIERI et al.      |  7 of 11

F I G U R E 1 2   (A-­H) Extra and (A) (B) (C)

intraoral posttreatment records.
(I) Posttreatment lateral X-­ray. (L)
Posttreatment panoramic X-­ray

(D) (E)

(F) (G)

(H)

(i) (l)

2.7  |  Treatment results considerably improved, and the treatment was com-
pleted within 18 months. (Figure 12A-­L).
Final clinical records show good esthetics and functional At the end of treatment, periodontal evaluation showed
recovery of upper canines in the arch. The patient's smile healthy marginal tissues with pale pink and firm gingivae.
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(A) (B) (C)

(D) (E)

F I G U R E 1 3   (A-­E) Final digital casts

F I G U R E 1 4   Final cephalometric tracing F I G U R E 1 5   Pre/Post superimposed cephalometric tracings

MAMPIERI et al.      |  9 of 11

T A B L E 1   Cephalometric assessment

Cephalometric morphological assessment mean SD Pre Post

Sagittal skeletal relations
Maxillary position S-­N-­A 82° + 3.5° 85° 85°
Mandibular position S-­N-­PG 80° + 3.5° 80° 81°
Sagittal jaw relation A-­N-­PG 2° + 2.5° 5° 4°
Vertical skeletal relations
Maxillary inclination S-­N/ANS-­PNS 8° + 3.0° 4° 4°
Mandibular inclination S-­N/GO-­GN 33° + 2.5° 33° 33°
Vertical jaw relation ANS-­PNS/GO-­GN 25° + 6.0° 29° 29°
Dento-­basal relations
Maxillary incisor inclination 1/ANS-­PNS 110° + 6.0° 99° 109°
Mandibular incisor inclination 1/GO-­GN 94° + 7.0° 93° 97°
Mandibular incisor compensation 1/A-­PG (MM) 2 + 2.0 mm 3 mm 4 mm
Dental relations
Overjet (MM) 3.5 + 2.5 mm 2 mm 2 mm
Overbite (MM) 2 + 2.5 mm 3 mm 3 mm
Interincisal angle 1/1 132° + 6.0° 139° 125°

Also, the gingival smile line was improved, with the gin- Our work underscores that, in certain clinical condi-
gival parabolas of the canines at the same height of the tions, one can guide impacted canines by using aligners
central incisors, contributing to the pleasant smile esthet- combined with elastic traction.
ics. (Figure 12) Occlusal results evidenced a proper bilat- An accurate preliminary study with CBCT is manda-
eral Class I relationship and a correct overbite. A mutually tory to localize the 3D position of impacted canines and
protected occlusion with canine guidance during excur- to decide how to approach them. If the canine is in a fa-
sive movements was achieved. Proper interdigitation of vorable position, at the center of the alveolar crest and not
the upper functional lingual cusps into the fossae of the too deep, the intra-­arch elastic system and aligners can be
lower teeth was achieved. (Figure 13) Moreover, upper used to guide cuspids into the arch.
and lower midlines were facially centered. (Figure 13). The advantages of this treatment are several, including:
Final tracing (Figure  14) and overall superimposed 1. Good esthetics: we can use aligners with pontics to
cephalometric tracings (initial and final; Figure 15), and obscure the absence of the canines; elastics can be worn
their quantitative values underscored the improvement of at home only.
the front teeth position. Indeed, both upper and lower in- 2. Effective management of reaction forces: during the
cisors were slightly proclined, while posterior teeth were traction of impacted canines with fixed appliances, one
maintained in the initial position. (Table 1). of the most difficult aspects is to plan the anchorage and
At the end of the treatment, dedicated thermoformed to control reaction forces which often generate undesired
retainers (Vivera®) were dispensed to the patient in order asymmetries in the maxillary arch. For this reason, it is ad-
to promote the long-­term stability of results.27 visable to use transpalatal bars, TADs, and full-­size wires,
yet several difficulties can arise while using them. With
aligners, reaction forces will be released on all upper teeth,
3  |  DI S C USSION producing only a slight intrusion.
3. No emergencies upon traction phase: the complex
Nowadays, it is possible to correct an increasing number system to extrude impacted cuspids and relevant forces
of malocclusions by using aligners, including impacted can often lead to the debonding or detachment of fixed
canines. Previously, however, impacted canine treatment appliances. This problem is overcome with the use of
was considered as being challenging and often requested a aligners.
hybrid approach featuring both aligners and sectional fixed Canine-­forced eruption technique with surgery closed
appliances.20-­23 Indeed, the traction phase of impacted ca- approach has been widely described in the literature, but
nines used to be considered possible only by adopting an it has been never associated with aligners and with elastics
auxiliary system as sectional fixed appliances or TADs.24-­26 activation system managed directly by patient. In every
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10 of 11       MAMPIERI et al.

device described in the literature are present fixed appli- usually qualify as "research" requiring approval from ethi-
ance and/or anchorage system that preview an additional cal boards designed to protect humans involved in clinical
surgery phase for insertion of miniscrews or plates.23-­26,28 research.
Our system is clearly less invasive and it guarantees es-
thetic and less stress for the patient who can decide during DATA AVAILABILITY STATEMENT
the day when is the best time to wear elastics for extruding Data openly available in a public repository that issues
impacted canines. datasets with DOIs.
Yet, there are also some limits in the use of aligners
to treat impacted canines. Hence, an accurate preliminary ORCID
study is crucial, because the indication is strictly depen- Gianluca Mampieri  https://orcid.
dent on the favorable position of the impacted canines, as org/0000-0003-3248-9237
previously explained.
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