Message Boards
Today's Active Topics Today's Active Cases Browse Forum Categories My Recent Activity My Messages Private Groups My Marked Threads My Subscriptions
Today's Active Images Today's Active Polls Most Active Topics Global Townie Map Advanced Message Board Search Message Board Terms of Use

Spring Into Action by Dr. Grant Coleman

View Comments (0)
Categories: Orthodontics;
Spring Into Action 

An efficient way to erupt impacted teeth

by Dr. Grant Coleman

Efficiency seems to be the buzzword in orthodontics these days. Our specialty is making major efforts to improve the efficiency of our treatments, and we’ve made great strides in helping our patients get to the finish line more quickly. Customized braces, new Class II correctors, improved clear aligner materials and attachments and a host of other technological improvements have helped us be more efficient in our treatment times.

This is a huge win for our patients, and it’s a win for us as orthodontists, too, because it costs us money every time we have to put a patient in our chair. In theory, the perfectly efficient case would take two visits—braces on and braces off. Every appointment we add between those two costs us money and reduces our revenue per visit.

Despite all the advancements our specialty has seen, there is one area where we have truly struggled to become more efficient—correcting impactions. Bringing in an impacted tooth is just, well … slow. A 2019 study published in the American Journal of Orthodontics and Dentofacial Orthopedics showed that, on average, bringing in an impacted canine takes 13 months.1 Obviously there are several factors that could affect how rapidly an impacted tooth comes in, including the mechanics used, severity of the impaction, surgical technique, etc. But the fact remains that correcting impactions is one of the most time-consuming and efficiency-killing things we have to tackle in orthodontics.

Traditional methods for bringing impacted teeth into the arch include the classic “gold chain” technique, ballista loops or Kilroy springs, or nickel titanium (NiTi) overlay wires. A gold chain bonded to the impacted tooth is typically tied to the archwire using some sort of elastomeric thread, which puts traction on the tooth to erupt it. Usually the doctor or assistant tying the elastomeric doesn’t know exactly how much force is being applied to the tooth; it’s just cinched down until it feels “tight,” and this is typically a bit uncomfortable for the patient because of the pressure exerted on the tissue the chain emerges from. In addition, elastomerics have a relatively rapid rate of force decay, so within a few weeks the elastic thread is passive and no longer exerting traction on the tooth. As a result, we need to bring the patient back every two to three weeks to place a new elastomeric to put new eruptive traction on the tooth.

Ballista loops and Kilroy springs are improvements in that they are more efficient and provide more constant force, but as they work they can develop occlusal interferences, and there’s also nothing to stop them from overerupting a tooth, so frequent monitoring is important. NiTi overlays also apply more consistent force than elastomerics to the gold chain, but these can be limited by how far the wire is actually deflected and can become passive relatively quickly.

Let’s look at a couple of cases I have treated where I believe the efficiency of addressing the impactions was significantly improved through the use of a different method of forced eruption.


Case 1
This patient, “HT,” was a 14-year-old male who presented in January 2019 with impacted U3s, retained UCs, crowding in both arches, excessive overbite, a slight Class II tendency on the right side, and buccal crossbite of the UR4 (Figs. 1–3). Treatment was initiated with upper and lower fixed appliances and both arches were aligned, and space was opened bilaterally at the site of the retained UCs. I referred him to have both retained UCs extracted and the U3s surgically exposed in December 2019.
Orthodontic Impacted tooth case
Fig. 1
Orthodontic Impacted tooth case
Fig. 2
Orthodontic Impacted tooth case
Fig. 3


Instead of gold chain, I requested the surgeon place Isoglide eruption springs on both canines. Isoglide is a spring device with a bonding pad on one end, a stainless steel clamp on the other and a superelastic NiTi coil spring in the middle (Fig. 4). The surgeon bonds it to the impacted tooth, then gently stretches the spring toward the archwire and clamps it into place on the wire at the site the tooth will move toward. The spring places light, constant force of approximately 60–90 g on the impacted tooth and, unlike elastomerics, it typically does not require any reactivation to erupt the tooth into the arch. Because reactivations usually aren’t needed, there are no “retie” appointments at two-to-three-week intervals, and I typically just check the patient at their normal eight-week appointment to evaluate the progress of the impacted tooth.

I saw HT in January 2020 for his first postexposure check and took progress photos (Fig. 5), just 36 days after his exposure surgery. Both U3s were already partially erupted through the tissue at this time. My plan was to schedule him for another check in approximately eight weeks to monitor the progression of the U3s.
Orthodontic Impacted tooth case
Fig. 4
Orthodontic Impacted tooth case
Fig. 5

And then COVID-19 hit.

We, like almost every ortho office in the U.S., had to shut down our office for five weeks. So instead of seeing HT again in March, I didn’t get to see him again until the end of May. At that visit, I took new photos (Fig. 6) showing that, despite the inability to see the patient, both springs had continued to place light, constant traction to continue to five months and two appointments after exposure surgery—both teeth had erupted enough that the springs were able to be removed. Note that because the surgeon had to bond the spring to the lingual of the UR3, the tooth rotated as it erupted.
Orthodontic Impacted tooth case
Fig. 6

Had these impacted cuspids been bonded with traditional gold chain tied with elastomerics, there would have been little to no progress of tooth eruption during the COVID-19 shutdown because they would not have been able to be reactivated. If ballista loops had been attached and went unmonitored, they could have become overly active and extruded the canines out of the bone. The eruption springs, however, do not stop applying traction until fully closed but are also self-limiting and cannot overerupt the teeth.

After removal of the springs, brackets were bonded to the canines and treatment proceeded as normal. The patient finished treatment with a Class I buccal segment bilaterally, normal overbite and normal overjet (Figs. 7 and 8). This was a fortunate example of efficient treatment of impactions despite an unfortunate and unexpected office shutdown.
Orthodontic Impacted tooth case
Fig. 7
Orthodontic Impacted tooth case
Fig. 8


Case 2
This patient, “CD,” presented in July 2020 at age 13 with moderate crowding in both arches, excessive overbite and midalveolar impacted U3s with insufficient room for proper eruption (Figs. 9–11). Treatment was initiated with upper and lower fixed appliances and both arches were aligned and space was opened bilaterally at the site of the impacted U3s.
Orthodontic Impacted tooth case
Fig. 9
Orthodontic Impacted tooth case
Fig. 10
Orthodontic Impacted tooth case
Fig. 11

Cases like this pose a dilemma, because as you can see in the progress records (Figs. 12 and 13), the canines now have sufficient space for eruption and are quite vertical in their orientation. Given enough time, these teeth would likely erupt on their own—but how much time is “enough”? These canines could easily take 12 or more months to fully erupt on their own, and during that time of waiting there would be little progress made in other areas of treatment. As Tom Petty said, “The waiting is the hardest part.”
Orthodontic Impacted tooth case
Fig. 12
Orthodontic Impacted tooth case
Fig. 13

It seems appropriate in such a situation to give the patient the option of having the canines surgically exposed to avoid the inefficiency of waiting. And if the teeth are exposed, the goal would be to bring them into the arch as quickly as possible to avoid the risks associated with longer orthodontic treatments. The patient agreed to having the U3s exposed, and Isoglide eruption springs were placed by the surgeon at the time of exposure.

Just 15 days after the exposure surgery, the light, constant force applied by the NiTi springs had erupted both U3s almost to the level of the occlusal plane (Fig. 14), and the eruption spring was removed at that time. At CD’s next appointment, I was able to bond brackets to the U3s and engage them in a continuous NiTi wire, and elastics were started to help bring them down into proper occlusion. Treatment proceeded as normal, and the patient finished treatment with a Class I buccal segment bilaterally, normal overbite and normal overjet (Fig. 15). Oral hygiene improved significantly after appliances were removed, and as a result gingival health improved as well. The decision to expose these teeth and utilize NiTi in their forced eruption saved the patient significant time in fixed appliances— potentially 12 months or more given their high vertical position.
Orthodontic Impacted tooth case
Fig. 14
Orthodontic Impacted tooth case
Fig. 15



Conclusion
As we strive as a specialty to improve the efficiency of our treatments, it’s important for us to look at all aspects of treatment that tend to slow things down. Impactions have been a particularly troubling area for us. It’s exciting to see that applying the benefits of NiTi to this challenging aspect of treatment can help us make the huge delay associated with impactions a thing of the past.

Reference
Shin et al. Factors affecting forced eruption duration of impacted and labially displaced canines, AJODO, 2019; 156:808–817.

Author Bio
Dr. Grant Coleman Dr. Grant Coleman is in private practice in Charlotte, North Carolina. Coleman received his dental degree from the University of Alabama School of Dentistry and completed his orthodontic training at the Virginia Commonwealth University Department of Orthodontics. In 2003, he received the Earl E. & Wilma S. Shepard Award for receiving the highest score in the nation on the American Board of Orthodontics written exam. Coleman designed, patented and sells the Isoglide eruption spring mentioned in this article. He and his wife, Katie, have two sons and one daughter.



More In Orthodontics
3 Wire Treatment - An Efficiency Game
3 Wire Treatment - An Efficiency Game
Dr. Chad Foster
CE Credits: 1.5
Custom Braces: Reflections From an Early Adopter
Custom Braces: Reflections From an Early Adopter
by Dr. David Richter
June 2024
Micro-Osteoperforation: Orthodontic Acceleration Becomes Mainstream
Micro-Osteoperforation: Orthodontic Acceleration Becomes...
Dr. Bruce McFarlane
CE Credits: 1.5
When Bonding Falls Short
When Bonding Falls Short
September 2025
Orthotown Magazine
September 2025
Orthotown Magazine September 2025 Read Current Issue Read Archived Issues
Sponsors
Townie® Poll
Do you have a dedicated insurance coordinator in your office?
  
Related Articles
Impacted Supernumerary Maxillary Premolar in Adult Female, Buccal Crossbite
Impacted Supernumerary Maxillary Premolar in Adult Female,...
October 2023
More Than a Smile
More Than a Smile
by Dr. Trevor Nichols and Alec Gallego
July/August 2025
Really Interesting Aesthetic Case
Really Interesting Aesthetic Case
October 2023
Site Menu
Message Boards Magazine Continuing Education Podcasts Blogs Classifieds News Events Townie® Poll Ebooks Townie Choice Awards
Company Info
Contact Us Advertise With Us Howard Farran DDS, MBA Policies and Agreements
Site Help
Sally Gross, Member Services Specialist
Phone: +1-480-445-9710
Email: sally@farranmedia.com
©2025 Orthotown, a division of Farran Media • All Rights Reserved
9633 S. 48th Street Suite 200 • Phoenix, AZ 85044 • Phone:+1-480-598-0001 • Fax:+1-480-598-3450